We spoke to 13 people who were receiving treatment on the day we visited. People felt they were well informed about their treatment and kept up to date with any developments. All people said the staff treated them well. Some people said they liked to have a laugh and a joke with the staff as it helped to pass the time during their treatment.

Records were in place regarding consent. Staff were informed if any person had an advanced directive or living will in place.

Detailed records were in place about the treatment each person received. These were updated as required with any changes. People had access to other health care professionals as part of their care and this included their consultant, dieticians, psychologists and pharmacists.

A complaints procedure was in place for people if they wished to make a complaint.

Staff told us it was a good place to work as they had a supportive team and management.

Gloucester Royal Hospital Renal Units is operated by B. Braun Avitum UK Limited. The service has a total of 50 stations across three units providing haemodialysis treatment for adults (those aged18 years and above). Two of the locations; Cotswold and the Severn units operate on an outpatient basis and are open six days a week. On three days a week the outpatient units remain open until midnight. Ward T7B provides five beds for patients with more complex needs who require 24 hour treatment and care. A holiday haemodialysis service was available to patients living out of the county and a home haemodialysis service was available to patients who were deemed suitable for this by their treating consultant.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 23 and 24 May 2017 along with an unannounced visit to the service on 1 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

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 area of outstanding practice:

• Patients were supported to actively engage with their disease and treatment plans as much as they wanted to in order to achieve good outcomes and maintain quality of life. This was supported through continuous discussion, and shared care planning with staff. For example: patients were enabled to access their blood test results remotely and to complete clinical procedures related to haemodialysis treatment. Also, if deemed suitable by their consultant, patient’s were provided with training and specialist equipment to be able to independently have haemodialysis treatments at home.

We found the following areas of good practice:

• Effective systems were in place to ensure all haemodialysis equipment was regularly serviced and maintained in accordance the organisations policies and manufactures recommendations.
• The water plant treatment systems were checked twice a day and consistently exceeded safety standards recommended for haemodialysis treatments.
• Adequate stocks of consumable equipment were available to meet service needs. Stock rotation processes were followed to ensure consumables used in the delivery of treatment and care were in date.
• Staff had the right skills and experience and were supported with professional development. This included accessing specialist renal training with university level accreditation.
• The majority of staff were supported to have annual appraisals and complete both the organisations and local trust mandatory training. There were a range of in date policies and procedures which staff knew how to access.
• Positive and collaborative working practices were established between NHS consultants and dietitians and B. Braun clinical staff. This partnership working enabled the promotion of coordinated patient treatment and care.
• Detailed patient records were maintained and regularly reviewed. A combination of electronic and written patient records were completed. These included a descriptive documentation of the treatment and care provided to patients.
• Positive patient outcomes were well established. Gloucester Royal Renal services monitored key performance indicators (patient outcomes). Senior staff attended meetings every two months to report these back to commissioners. These consistently demonstrated the service performed as well as other similar haemodialysis services.
• Patients’ were overwhelmingly positive regarding how they were provided support by staff. Patients’ told us they felt involved with their treatment and care and that staff demonstrated compassion, dignity and respect at all times.
• The service was responsive to the needs of local people. There were no waiting lists for haemodialysis treatment and if patients were deemed suitable by their treating consultant, there was the option of a home dialysis service.
• Patients were supported with access to holiday haemodialysis. This included support to organise this in other haemodialysis services nationwide or worldwide, and also to provide haemodialysis to patients not local to the Gloucestershire area.
• Patients’ records were clear and organised and stored safely. Regular audits were completed and actions taken to maintain good record keeping standards.
• Clinical care was consultant led and regularly reviewed. There were effective processes in place to respond to patients who unexpectedly deteriorated. All staff had in date resuscitation training and the service promptly transferred patients to the local NHS trust when required.
• There was a positive working culture and staff told us they were proud of the patient care provided and enjoyed working for the organisation.

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

• The registered person must ensure the proper and safe management and use of all medicines. Gloucestershire Royal Renal units did not have a relevant policy or patient group direction (PGD) or use prescriptions for all fluids. This was not in line with national guidance (Standards for Medicines Management, Nursing and Midwifery Council, 2007, National Institute for Health and Care Excellence, CG 174, 2013).
• There was no policy, standard operating procedure or specific staff training to promote the early identification of sepsis (infection) in line with national guidance (NHS England, 2015).
• The registered manager should ensure they have knowledge of and evidence compliance with the Workforce Race Equality Standard (WRES) and Equality Delivery System (EDS2) which became mandatory in April 2015.
• Improvements were required to show how incidents were interrogated for safety and quality improvements. How actions were completed and learning shared was not always evident.
• The processes to fully share and learn from serious incidents required improvement. Meetings between B. Braun and NHS staff had been facilitated to explore learning without all the relevant staff being invited to meetings.
• Most of the clinical staff we spoke with did not know which patients had a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) in place. This included acute patients admitted from other wards within the local NHS trust to ward T7B.
• Improvements were required to governance processes. There was a lack of documentation to show how quality and performance information had been scrutinised for trends and learning. Meeting minutes lacked action plans and timescales and staff did not routinely receive feedback from management meetings or from those meetings held with the local NHS trust.
• Whilst senior staff demonstrated they escalated any identified issues to other relevant organisations, this was not always done in a timely manner. This included notifying the Care Quality Commission (CQC) and the local NHS trust.
• Staff lacked understanding regarding best practice for end of life care, when this might be appropriate to discuss with medical staff and how staff could best support patients.

Professor Edward Baker

Chief Inspector of Hospitals