People who used the service told us they were given options about their treatment. One person said, “The staff explained my treatment plan and gave me time to discuss it.” Another person said, “Staff involve me in my treatment and I feel comfortable here.”

People who used the service told us they felt the clinic was very welcoming and relaxing. One person said, “The staff are very pleasant and approachable.” Another said, “The staff are very friendly and easy to talk to.”

People we spoke with said that the environment was always clean and tidy. Processes were in place to ensure equipment used were clean and safe. We spoke with four people who used the service and they were all satisfied with the cleanliness of the unit. One person said, “It’s spotless here all the time.”

We found that people who used the service were supported by enough qualified, skilled and experienced staff to meet their needs.

The service had a process in place to monitor people’s views about the service offered. People we spoke with told us that they had never had to complain about the service.

We found that people who used the service consented to their care and treatment. People felt in control of their own treatment. One person said “If I need to end my treatment earlier than planned, I talk to the manager and sign a consent form.”

People had care records which reflected the needs of each individual. People were able to contribute to their care and treatment record. One person said, “The staff discuss my treatment with me and explain what is happening.” Another person said, “Staff support me and meet my needs.”

People who used the service felt safe and told us that the staff were very caring. We observed staff interacting with people and they were calm and polite in their manner. One person said, “The staff are really nice here.”

The provider worked well with other professionals. Appropriate information was passed to others in a confidential manner.

Appropriate checks were undertaken before staff began work. We looked at the employment records of staff which were kept electronically.

People knew how to complain if they needed to. The complaints procedure was available in the patient guide book. One person said, “I have never had to complain but if I had a problem I would tell the staff.” Another person said, “Staff would sort anything out if I needed them to.”

We were unable to speak with people regarding their care during the inspection.

Dialysis was the only service provided. We regulate this service but we do not currently have a legal duty to rate it. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following issues that the service provider needs to improve:

• We were not assured in regards to the grading of harm from incidents, the application of the duty of candour requirements and the learning from incidents to improve patient outcomes. The classification of clinical and non-clinical incidents should reflect the level of harm. Incidents were not reported clearly to ensure that the requirements of duty of candour regulation were met for example the non-clinical incident reporting form did not trigger duty of candour requirements for example patients falling and receiving an injury.

• There was no formal way for staff to identify patients prior to medication been administered. We acknowledged that most patients were well known to the clinical team, however nursing staff must always adhere to Nursing and Midwifery Council (NMC) standards for medicines management. This includes being certain of the patients identity, checking the allergy status of the patient and expiry date of the medicines.

• We were not assured there was an effective governance framework in place. Systems were not in place to effectively manage risk and safety. There was evidence incidents had not been reported or investigated effectively and as such, duty of candour requirements had not been implemented.

• We were not assured that the clinic had a current up to date risk register that reflected all of the current risks to the unit. The clinic showed us a risk register, however post the inspections it was clear that this was a draft document. Failure to place risks on the register results in risks not being rated and the possibility of no one taking responsibility for taking actions forward.

• The emergency drug tray was located on the bottom shelf of the resuscitation trolley and the trolley was not sealed. This does not provide assurance that the correct medication would be available during an emergency. It had been noted on the checklist that the drug box was not sealed as a point of observation by the pharmacist and staff, but no actions taken.

• The clinic did not use a recognised early warning score system to support the recognition of the deteriorating patient. There was no sepsis policy and staff had not received training to recognise or manage this life threatening condition.

• There was no process or protocol available to admit patients safely onto the dialysis unit to continue their dialysis treatment whilst they were an inpatient in the neighbouring organisation.

• There was no process for audit of medicines management in the clinic. The policy did not outline that audit should be performed by the clinical team.

• We were not assured that all performance and audit information was used to benchmark the unit’s performance against other dialysis clinics to improve patient outcomes including patient transfers and admissions into hospital.

• The average number of patients with the recommended haemoglobin levels was 48.6%, April 2017. This meant that a number of patients had haemoglobin levels outside of the recommended range. Anaemia can be a complication of renal failure and dialysis associated with increased risks of mortality and cardiac complications.

• There was no evidence the unit met National Institute for Health and Care Excellence (NICE) quality standards about patients being collected from home within 30 minutes of the allotted time and collected to return home within 30 minutes of finishing dialysis.

• There was no unit patient involvement group where patients could make suggestions about the service or care of patents on the unit, or where staff could share information about the service with patients.

• We saw none of the corporate policies had review dates on them. This meant up to date guidance and legislation may not be incorporated into the organisations policies.

However, we also found the following areas of good practice:

• We found that the clinic was visibly clean and well maintained.
• Staff worked flexibly and the rota was planned to ensure safe numbers of staff were available to meet patients' needs.
• Nursing staff were experienced in providing dialysis care and training and competence records we reviewed showed that staff were well trained and competent to level the level of care expected.
• We saw that policies and procedures were developed in line with guidance and standards from the UK renal association and these had been incorporated into the organisations standard for good renal care.
• We observed that staff caring for patients were compassionate, caring and passionate about providing high quality dialysis care.
• Patients we spoke with were consistently positive about the level of care they received.
• The clinic provided a local satellite service, with flexible appointments for patients requiring dialysis. We observed a responsive approach to arranging appointments and the individual needs of patients.
• The building met the core elements of provision for dialysis patients. This included level access and dedicated parking facilities.
• The unit operated at around 94% capacity and so had spaces to accommodate for holiday treatment sessions for people staying in the local area, provided this had been approved and the patient accepted.
• The registered manager was knowledgeable about the service, knew all the staff by name, and was clearly passionate and dedicated to the unit. The staff we spoke with spoke very positively about the registered manager and said that they felt able to speak with the manager and raise any concerns that they may have about the service. Staff also said the registered manager was visible and accessible and that they could speak with them at all times. Staff we spoke with also said they when they raised concerns that they felt listened too.
• There was an overall organisation vision and strategy used in the unit. The unit had specific business objectives to achieve. The staff understood the organisational vision of “delivering the right care to the right patient at the right time”.