There were seven patients using the service at the time of our inspection. We looked at seven patient care records and spoke with three members of staff and the manager.

We considered all the evidence we gathered under the outcome we inspected. We used the information to answer the five questions we always ask. Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Patients' personal records were accurate and fit for purpose.

Is the service effective?

Staff were appropriately trained in record keeping and had access to relevant policies and procedures.

Is the service caring?

We saw where patients had given written consent for their prescribed treatment.

Is the service responsive?

This inspection was a follow-up inspection to look at previous non compliance. During a previous inspection in January 2014 we saw where patients were given regular opportunities to give feedback about the quality of the service they had received.

Is the service well-led?

We found the manager had made improvements to meet the required action for compliance.

There were eight patients using the service at the time of our inspection. We looked at ten patient care records and spoke with four members of staff and the manager.

We considered all the evidence we gathered under the outcome we inspected. We used the information to answer the five questions we always ask. Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Patient records were stored securely. However, there were still outstanding issues from our last inspection. Patients personal records did not always contain the information that was required.

Is the service effective?

Staff were appropriately trained in record keeping and had access to relevant policies and procedures.

Is the service Caring?

We saw where patients had given written consent for their prescribed treatment.

Is the service responsive?

This inspection was a follow-up inspection to look at previous non compliance. During our last inspection in January 2014 we saw where patients were given regular opportunities to give feedback about the quality of the service they had received.

Is the service well-led?

We found the manager had made some improvements to meet the required action for compliance. However, not all the systems and processes in place had been fully embedded. We judged that further action was required to meet this regulation.

We spoke with five patients who were receiving dialysis treatment on the day of our inspection and asked if they were happy with the treatment they had received. One patient said, “No complaints. It’s very good here.” Another patient told us, “[They are a] good set of nurses.” Each of the patients we spoke with told us they were happy with the treatment they had received.

We spoke with two members of staff who displayed an understanding of their role in protecting vulnerable adults from the risk of abuse. Staff were aware of the procedures in place to report any matters of concern. People were protected from the risk of infection because appropriate guidance had been followed.

We spoke with two members of staff who told us that they felt very well supported by the manager and provider in relation to their duties. Staff said that they received all of the training they needed to perform their duties competently.

Patients were given regular opportunities to fill in a survey about the quality of the service they had received. We saw that the results were mainly positive. Where any concerns had been raised by patients there was an action plan in place to ensure that necessary improvements were made.

Patient's care plans did not always contain all of the information that was required and were not always kept securely.

Diaverum Dialysis Clinic – Lings Bar is operated by Diaverum UK Limited. The service has 12 treatment stations and is open Monday, Wednesday and Friday 6.15am to 11pm and Tuesday, Thursday and Saturday 7.30am to 6.30pm. Facilities include three side rooms and designated parking including two disabled parking bays.

There is a service level agreement with Nottingham University Hospitals NHS Trust to provide haemodialysis (HD) to adults over the age of 18. Haemodialysis is a type of renal replacement therapy offered to patients with chronic kidney disease and is the most common form of renal replacement therapy.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 27 June 2017, along with an unannounced visit to the clinic on 5 July 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 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 issues that the service provider needs to improve:

• Staff had not received training in safeguarding children and young people in line with intercollegiate guidance: Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014). Guidance states all non-clinical and clinical staff that have any contact with children, young people and/or parents/carers should be trained to level two.
• Staff had not received training on the use of specific medical devices; weighing scales, intravenous volumetric pumps, blood pressure monitors, vascular access monitor and the electrocardiography (ECG) machine.
• Effective arrangements were not in place for identifying, recording and managing risks. Concerns identified by the inspection team had not been identified on the risk register. We raised our concerns with the clinic manager who was not aware of the risks or concerns we had identified

• Not all staff understood the requirements of the duty of candour regulation.
• Some provider policies had no review date specified. We could not be assured therefore that policies reflected evidence based guidance and that the content has been reviewed in line with current national guidance.
• At the time of our inspection the patient call bell system was out of order.
• The registered manager at the time of our inspection could not tell us if there was a replacement programme for dialysis machines.
• The ‘medication preparation and administration’ policy was not specific to the UK regulations and good practice guidance and did not include reference documents to assist staff in safe medicines preparation and administration.
• The service did not have specific processes in place to manage challenging behaviours for example, acute confusion, delirium or worsening dementia.

• The provider did not have a policy in the clinic for the positive identification of patients.
• We did not see personal emergency evacuation plan’s (PEEP) in place for individual patient's. A PEEP is a bespoke 'escape plan' for individuals who may not be able to reach an ultimate place of safety unaided or within a satisfactory period of time in the event of any emergency.
• Pain assessments were not undertaken at this clinic.
• Staff morale was ‘low’ and the team appeared ‘fragile'. Concerns were raised around the leadership of the clinic and we were formally notified before our inspection that the registered manager would no longer be in post from 11 August 2017.

• Not all staff felt they were supported or encouraged to develop in their role. Results from the February 2017 staff survey and more recent peer review suggested staff felt there were limited opportunities for further training.
• Not all action plans had a ‘due date’ as well as a completion date in order to monitor that actions were addressed in a timely manner. Following our inspection we received a copy of the action plan developed as a result of the recent staff survey. We saw where actions had been identified for all concerns raised. However, as of 1 July 2017 none of the actions had a ‘due date’.
• The provider did not collect data to monitor transport services against the National Institute for Health and Care Excellence (NICE) quality standard (QS72): adults using transport services to attend for dialysis are collected from home within 30 minutes of the allotted time and collected to return home within 30 minutes of finishing dialysis.
• The service did not audit the time patients were taken off dialysis.
• The provider did not have an active ‘patient user group’ who met to share their views to positively influence change.
• A Workforce Race Equality Standard (WRES) report was not produced at this location.

However, we found the following areas of good practice:

• Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses and incidents had been reported appropriately.
• Performance showed a good track record in safety, patient outcomes and access to treatment.
• Despite the high turnover of staff, consideration had been given to mandatory training and dialysis specific training. Where additional support had been required to support the clinic team we saw a robust plan in place.
• Systems and processes in infection prevention and control, medical records and safeguarding vulnerable adults were given sufficient priority and patients were protected from avoidable harm and abuse.
• Patient’s care and treatment was planned and delivered and clinical outcomes monitored in line with evidence-based guidance, standards, best practice and legislation. This included the management of a patient’s pain, nutrition and hydration needs and individual physical health needs.
• There was effective multidisciplinary working between clinic staff and the referring NHS trust.
• Feedback from patients was consistently positive about the nursing staff delivering day to day care and the service had only received one formal complaint in the 12 months preceding our inspection.
• A range of haemodialysis sessions were available taking into consideration the working, cultural and family responsibility needs of the patients currently receiving treatment at the clinic.

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.

Heidi Smoult

Deputy Chief Inspector of Hospitals