Crewe Dialysis Unit is operated by Fresenius Medical Care. The service has 18 stations for dialysis. There are on average 780 treatments sessions delivered a month. The service provides dialysis services for people over the age of 18, and does not provide treatment for children.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 7 June 2017 along with an unannounced visit to the clinic on 13 June 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.

We regulate dialysis 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:

• Staff had been trained in the safeguarding of adults and children and were aware of their responsibilities in this regard.
• The unit was visibly clean and tidy and we observed good infection prevention and control procedures to be followed.
• There were adequate staff to meet the needs of the patients.
• Care and treatment at the unit was evidence based and provided in line with the provider’s Nephrocare Standard Good Dialysis Care. The unit’s policies and procedures took into account professional guidelines, including the Renal Association Guidelines and research information.
• Data relating to the unit’s treatment performance was submitted to the commissioning trust for inclusion in the renal registry, and the unit was benchmarked against the provider’s other units across the country.
• A monthly clinic review was completed and actions were taken where the expected targets were not achieved.
• All staff were trained in intermediate life support.
• Staff received an annual appraisal of their work and set objectives for the year ahead.
• There was a thorough induction for new staff.
• There was a good system of multi-disciplinary working through weekly review meetings.
• The annual patient survey indicated that patients felt that staff were caring, treated them with dignity, and explained things in a way they could understand.
• Where issues had been raised by patients these had been addressed by the clinic manager.
• Patients were supported to deliver their own care within the unit, or progress to home dialysis.
• The individual needs of patients were taken into account for example changes to times and length of treatment for social events.
• Individual plans were in place to help patients coming from other units or transitioning from children’s’ services.
• Family members were supported to be present if a patient wished this to occur.
• Staff addressed any dissatisfaction from patients quickly to prevent it escalating into a formal complaint.
• The unit had effective systems to monitor and action areas of governance and risk.
• The clinic undertook some staff and patient engagement and acted on feedback they received.
• Staff felt their leaders were visible and listened to them.
• Staff felt able to raise any concerns or issues they had.

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

• Incidents which required notification to the Care Quality Commission under the (Registration) Regulations 2009: Regulation 16 had not been reported.
• Not all staff were up to date with mandatory training.
• Medicine storage for one frequently used medicine was not secure and the administration of medicines by dialysis assistants did not meet the provider’s policy. This was brought to the attention of the manager during the inspection.
• A process for providing medicines to people other than patients at the unit had been established. The storage and provision of these medicines did not meet with safe medicine management guidance. This process was stopped during the inspection.
• Patient observation records were not consistently completed on both the paper and electronic systems.
• There was no escalation process should a patient’s condition deteriorate. There was no sepsis management pathway.
• The records for staff competency assessments had not been fully completed.
• The procedure for obtaining consent from patients with impaired mental capacity was not understood by staff. We found one example of where this had been done incorrectly. This was brought to the attention of the manager during the inspection.
• There was no access to psychological support through the clinic or the commissioning trust. This had to be accessed via the GP. Also there was no advocacy service representative at the clinic.
• There was no audit of the transport arrangements and no patient transport group in the clinic.
• There was no patient changing area or storage facility for outdoor clothing or bags.
• There was no procedure to audit the rate or reasons for patients not attending the clinic.
• The senior staff were unclear about any admission criteria for the clinic.
• Staff were not able to articulate the organisation vision and values.
• There was limited patient engagement and there was no patient group.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North West

We carried out this inspection to follow up on moderate concerns we had about the care and welfare of patients on the Unit.

On our previous visit patients told us that they were concerned that dialysis machine alarms could not be hear by staff when they were in the single or four bedded bays. When we looked at care files we found that the majority had not been completed in line with the provider’s own policies and procedures and contained blank documents.

The provider sent us an acceptable action plan to address both these issues.

During this inspection we found that that care plans had undergone a substantial improvement and were to an acceptable standard.

We also found that the provider had carried out improvements to ensure all alarms could be heard.

When we carried out our unannounced visits we spoke to eight patients. All were complimentary about the care that they received and in particular the nursing staff. One person said “staff conduct themselves excellently” and another told us that “staff are brilliant”.

Most patients told us they found the unit to be less satisfactory than the one that it had replaced in terms of the opportunity for social interaction while dialysing. This was because the unit was built with regard to best practice in the separation between bed spaces.

Many patients told us of concerns that they had that machine alarms could not be heard by staff when they were in the single or four bedded bays.

Patients told us the food that they were provided with was fine and they had access to a dietetics service.

The arrangements for responding to emergencies should patients become ill on the unit were robust and aligned with those of the NHS hospital in which the unit was situated.

Infection prevention and control procedures were appropriate, followed and the standard of cleanliness was high.

There were sufficient quantities of suitable medical devices in use on the unit and they were maintained appropriately.

When we looked at the care files for patients we found that the majority had not been completed in line with the providers own policies and procedures and that in many there were blank assessment documents and risk assessments.