The Forest Dialysis Unit was opened in September 2012 to provide haemodialysis facilities to people who lived in the Forest of Dean and surrounding areas. They were able to accommodate 12 people at each session. We spoke with five people who were receiving treatment. They all said how pleased they were to have a facility local to them as it reduced their travelling time greatly. Two people told us they drove themselves there. All five people praised the staff saying they were very good at their job. One person said they were able to have "a laugh and joke with them". All five people said they liked their new facilities as they were bigger than the other unit they used to use. Staff told us it was a good place to work and they were well supported by each other and the management of the unit.

Records were in place regarding consent from people to receive treatment and these were also kept under review.

Appropriate arrangements were in place for the management of medications.

A system was in place for monitoring equipment used by staff and people to make sure it was safe to use and properly maintained.

Arrangements were in place for assessing and monitoring the quality of the service provision.

B. Braun Avitum UK Limited operates Forest Dialysis Unit. The service has 12 dialysis stations for patients and operates two sessions daily. The service is open six days a week and operates 144 sessions in total for a maximum caseload of 48 patients. The service is a nurse led unit, which provides outpatient satellite dialysis to NHS funded patients.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 9 May 2017 and followed this up with an unannounced visit on 17 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 of how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this unit was dialysis. Where our findings on dialysis – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the dialysis core service.

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 issues that the service provider needs to improve:

• Reported incidents were investigated but the process did not always ensure learning and action points were identified.
• The service did not have a sepsis policy/standard operating procedure to follow if patients displayed signs of sepsis.
• Medicines management did not always meet national recommendations. Intravenous fluid boluses were administered without prescription or other guidance.
• Staff did not check patients' identity prior to administering medicines or commencing haemodialysis treatment.
• There was a damaged headrest and damaged footrests on the dialysis chairs, which compromised effective cleaning and posed an infection control risk.
• Not all patients felt involved in their care and treatment.
• Governance processes were not effective to ensure a robust approach to managing quality and performance. There were no action plans from review meetings and these were not minuted.
• There was not an effective process to monitor risks and understanding of efficient risk management processes was not clear.
• Staff did not receive feedback from corporate operational management meeting or from meetings with the local NHS trust.

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

• The service had a good incident reporting culture.
• The service demonstrated good practices for effective infection control and prevention.
• The environment complied with national guidance for satellite dialysis units. The unit appeared visibly clean and tidy.
• All equipment was regularly serviced and maintained. Consumables were all in date and well managed.
• Nursing staff levels ensured safe and efficient patient treatment.
• There was a good working relationship between the unit and the consultant nephrologist, who was responsible for patients’ treatment. There was effective multidisciplinary working and a close working relationship with the local NHS trust.
• Staff completed contemporaneous documentation about care and treatment given to patients.
• Policies and procedures reflected current evidence-based guidance.
• The service monitored key performance indicators. These demonstrated the service performed similar to other dialysis centres.
• Staff treated patients with respect and compassion.
• Patients were complimentary about the care and treatment they received at the unit.
• The service met the needs of the local population and the needs of individuals attending for dialysis.
• There were no waiting lists for patients who wished to receive dialysis at the unit.
• There were processes to support patients who missed their dialysis.
• Staff felt valued and there was a positive culture. We observed team working and respect for others.

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 five requirement notices that affected Forest Dialysis Unit. Details are at the end of the report.

Professor Edward Baker

Chief Inspector of Hospitals