Blackburn Dialysis Unit is operated by Fresenius Medical Care Renal Service Limited. It has been operating since April 2013. Patients are referred by their local trust to the specialist renal and dialysis services provided by Lancashire Teaching Hospitals NHS Foundation Trust, the service’s commissioning trust. The unit functions as a satellite unit for the dialysis services provided by the commissioning trust, and treats patients in the Blackburn and Accrington areas.

The unit is a nurse led unit, comprising of a manager, deputy manager, a team leader and three registered nurses. The manager, deputy manager and team leader also provided clinical care. It has six haemodialysis stations and provides three treatment sessions per station per day (108 sessions per week). The unit is temporarily housed in a suite of portacabins in the grounds of the Royal Blackburn Teaching Hospital. Facilities include a patient waiting area with a disabled access toilet, a patient treatment and weighing area, office, clean utility, waste utility, staff changing room and kitchen, storeroom, and water treatment plant.

The unit provides haemodialysis treatment to adults aged 18 years and over, who have non-complex needs. Currently the unit provides treatment to 13 patients between the ages of 18 and 65 (2885 sessions between February 2016 and January 2017) and to 23 patients aged over 65 years (2733 sessions in the same period). The unit does not support patients on home treatment.

We inspected this unit using our comprehensive inspection methodology. We carried out the announced part of the inspection on 26 April 2017, along with an unannounced visit on 8 May 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate dialysis services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary. We found the following areas of good practice:

• There were reliable systems and processes in place to keep patients safe. These included staff training, incident reporting, infection prevention and control, water quality monitoring and treatment, disinfection and maintenance of equipment, and screening procedures for blood borne viruses.
• The unit’s layout, and staff use of equipment including prompt response to machine alarms, kept people safe. Patient records were managed appropriately. Medicines were stored and managed safely. Staff followed the provider’s medicines management policy, and a process was in place for review of patient medicines by the medical team when required.
• Patients were assessed for suitability for treatment to ensure the service was able to accommodate their care needs. The multidisciplinary team reviewed individual treatment prescriptions monthly. Patients' vascular access sites were regularly monitored.
• Patients were assessed for risk of deterioration and processes were in place to request urgent medical assessment or resuscitation. Dietitians provided advice monthly to each patient, and there was access to psychological and social work support if needed.
• Staff rarely cared for patients with dementia or learning disabilities, but staff received training in and were aware of the principles of the Mental Capacity Act and the Deprivation of Liberty Safeguards.
• Appointment slots were allocated to patients taking into account their individual needs and staff worked to accommodate requests to change appointments as required. Staff supported patients to go on holiday through co-ordinating care at other clinics in the UK, Europe and other countries.
• Care and treatment was evidence based in line with appropriate guidance. Staff were competent to provide the right care and treatment, and competencies were regularly reviewed. New staff were supported through an induction and mentoring programme.
• There were no written complaints in the reporting period; but there was evidence of shared learning from complaints and incidents that occurred in the provider’s other clinics.
• A named nurse for each patient helped to ensure continuity of care. The annual patient survey indicated  patients felt staff were caring, treated them with dignity, and explained things in a way they could understand.
• Staff supported families who were bereaved and ensured attendance at patient funerals.
• A clear management and reporting structure was in place. The clinic manager and deputy manager had the appropriate skills, knowledge, and experience to lead and engage effectively with their staff and patients.
• The unit’s clinical governance strategy supported the provider’s strategic aims; effectiveness against this was monitored through clinical and governance benchmarking audits.

However, we also found the following issues that the service provider needs to improve:

• Access to the treatment area was secure; however, there was unlocked access to the clean and waste utilities, the water plant and staff rooms.
• There were sufficient staff to care for patients; however, the unit reported a high number of shifts covered by bank or agency staff. This was due to staff sickness and one nurse vacancy.
• We were concerned that not enough was done to adequately communicate with those whose first language was not English. For example, although the patient guide was available in Punjabi, Urdu and Hindi and staff had access to telephone interpreter services, one staff member told us that sometimes ‘hand gestures’ were used to communicate with patients who did not speak English. The unit did not have access to information in other formats such as easy-read or braille.
• The risk register, which identified clinical, operational and technical risks, had only recently been introduced and did not include details such as who was responsible for managing each individual risk.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North

We talked with six patients who attended the unit several times a week. They all said staff were respectful and treated them properly, including when carrying out the dialysis procedures. Patients were satisfied with the level of privacy afforded to them. There were privacy screens on each 'station' which were used in accordance with patients' wishes.

People told us they understood their treatment options and the procedures involved. One patient said, "They explain everything to me". Patients told us they had consented and agreed to treatment/dialysis, and recalled signing a consent form. Patients also felt they had sufficient choices in the days and time of the sessions.

People were very satisfied with all aspects of the treatment and the service, and said they felt safe. The following comments were made: "We are nicely looked after whilst we are here", "It's right nice; it's lovely here" and "The staff are wonderful; they are always close at hand".

The unit looked clean and hygienic and we saw staff following the correct procedures to help prevent the spread of infection.

Staff and patients told us the unit had a good staff team made up of skilled and qualified nurses and who were well managed. One member of staff said, "We are experienced, professional and organised".

We saw day to day checks were done to ensure patients received safe and appropriate treatment. However the overall system to monitor all aspects of the unit's processes could be improved.