During the inspection we spoke with three people who were having dialysis that day. We also spoke with the clinic manager, the regional director, a nurse and a dialysis assistant. People spoken with told us that they were very happy with the care and treatment they received. One person said, “They look after us brilliantly. The team and care is excellent.” Another person said, “The staff are good.”

There were systems in place to gain consent and review consent from people.

We were able to observe the experiences of people. We saw that staff treated people with dignity and respect. Staff were attentive and interacted well with people and their relatives/representatives. We saw that people had been assessed and that care plans were in place.

People were protected from abuse, or the risk of abuse and their human rights were respected

We saw that people received care and treatment in safe, accessible surroundings that promoted their wellbeing.

We found there was an effective complaints system in place at North Ormesby Dialysis Unit.

During the inspection we spoke with seven patients who were having dialysis that day. Patients spoken with were very happy with the clinic and treatment that they received.

Patients spoken with said:

"I have been coming here three years in June. I prefer coming here to the hospital, they are more organised."

"The quality of care is excellent and very consistent. The new manager is brilliant you can talk to her about any problem and she will sort it out for you."

"I come here three times a week. This service is very good and you can be flexible with your appointment times. When the doctor visits I am taken to the consultation rooms so that we can speak in private."

"This service is excellent. I get picked up at home by the driver who brings me to the unit. I come in pick up my card, weigh myself and find my chair. We have the same chair on each visit which I like. I only have to wait a maximum of 15 minutes before I go onto dialysis. They stagger the times that people arrive to avoid people waiting. After my dialysis I wait about 20 minutes and the driver takes me home."

"We have our bloods checked very regularly and staff go through the results with you."

"The clinic does maintain my privacy, no areas where I think they could improve. Just four of us in a bay usually, I prefer it as it's quiet."

"I didn't look around before my treatment started but I was given the choice to come here. My treatment options were discussed, they are very good at explaining and I know myself. Every year we sign a new consent form."

"My consultant comes monthly, doesn't always see me sometimes just discusses my bloods. I had some choice; I can come here at 7:10am and get straight on. The nurse sets it up and if I ask questions I get good answers regardless of who I ask here. It's a good unit now, the last two months big changes as previous problems with staff shortage. We were not getting on and off early enough. Completely changed since the new manager took over, in two months she has changed it around."

Another patient spoken with during the inspection informed that they didn't see or hear from the consultant as often as they would like.

North Ormesby Dialysis Clinic is operated by Fresenius Medical Care Renal Services Ltd, an independent healthcare provider. It is contracted by NHS England to provide renal dialysis to NHS patients. Patients are referred to the unit by the local NHS trust. The service is on the site of North Ormesby Medical Village in Teesside. It is an 18 station unit (comprising of 12 stations in the main area, two side isolation rooms and a four bed bay) providing haemodialysis for stable patients with end stage renal disease/failure.

We inspected this service using our comprehensive inspection methodology. We carried out an announced comprehensive inspection on the 4 April and an unannounced inspection on the 24 April.

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.

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 areas of good practice:

• We found that the clinic was visibly clean, arrangements for infection prevention and control were in place and there was no incidence of infection. Theenvironment met standards for dialysis clinics and equipment maintenance arrangements were robust. Staff were aware of their responsibilities in keeping the patient safe from harm and record keeping was thorough. Mandatory training was completed by all staff.

• Effective arrangements and support from a dietitian was in place and the nutritional need of dialysis patients was a priority. There was effective multidisciplinary working and collaboration with the NHS trust renal team helped support patients’ treatment and positive outcomes.

• There was a good range of comprehensive policies in place to support staff; these were accessible and understood by staff we spoke with. Policies were based on national guidance and an audit programme was in place to monitor compliance. Key performance indicators for 2016/17 showed comparable performance against other Fresenius units nationally.

• Staff described the Fresenius incident reporting system and were aware of changes being made to transfer from a paper to an electronic system. Staff reported incidents as clinical, non-clinical and Treatment Variance Reports (TVR’s).

• We observed staff working with competence and confidence and the training available in the clinic supported all staff to perform their role well. Nursing staff were experienced and qualified in renal dialysis. Over 50% of nursing staff had a specialist renal qualification. One hundred percent of staff had received induction and appraisal.

• We observed that consent processes were in place and documentation was accurate. Easy access to complex patient information in the clinic and across the trust supported treatment and care of patients in the unit.

• Effective processes were in place for the provision of medicines. These were stored and administered in line with guidance and staff completed competencies annually to ensure they continued to administer medicines correctly.

• We observed a caring and compassionate approach taken by the nursing staff and named nurses during inspection. The detail in written individualised care plans was thorough and updated.

• Nurse staffing levels were maintained in line with national guidance to ensure patient safety. There was use of a specialist nurse agency when required. Staff provided additional cover during peaks in activity or during staff shortage. Nursing staff had direct access to the consultant responsible for patients care.

• The clinic provided opportunity for patients to visit prior to starting dialysis treatment as part of pre-assessment. Twice a month new patients were supported to visit to ask questions; anxieties could be alleviated by nursing staff.

• Patients were supported with self-care opportunities and a comprehensive patient education process was in place. Holiday dialysis for patients was arranged to provide continuity of treatment and support the wellbeing of patients.

• The clinic provided a satellite local service, with flexible appointment system for patients requiring dialysis and the service contract obligations were clear to senior staff. We observed a responsive approach to arranging appointments with the needs of the patient at the centre. Arrangements for contingency for appointments in an emergency was in place.

• The clinic had detailed local risk assessments in place and we observed a new operational risk register; this was being developed by the national senior team and would be reviewed through the governance committee structure prior to implementation and training to clinic staff.

• Activity was monitored closely for non-attendances of patients. The team worked flexibly to accommodate patients individual appointment needs to avoid non-attendance. Any unavoidable or emergency transfers to the NHS trust renal unit were appropriately managed by the nursing team.

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

• The grading of harm from incidents was not clearly described by staff. It was also not clear on the reporting forms. This would not support a clear trigger for the requirements of the duty of candour regulation. The incident management policy was not consistently applied in practice. Staff we spoke with told us that incident reporting was discouraged by senior staff in the clinic. Senior staff we spoke with told us that they supported incident reporting and had delivered training and support to staff.

• The classification of clinical and non-clinical incidents did not reflect the reported events, for example patients falling in the clinic were reported under ‘non-clinical’ incidents, to the health and safety manager, rather than the chief nurse. We did not see any investigation or sharing of lessons with clinic staff to support prevention of falls in the clinic.

• Observations were recorded regularly to assess the patient’s condition, before during and after dialysis. We noted however that the clinic did not use a recognised national early warning score (NEWS) system to support the recognition of the deteriorating patient. There was inconsistent recording of temperature and no recording of respiratory rate as directed by the care plan.

• There was no formal way for staff to identify patients who were not familiar to them. We recognised that most patients were well known to the clinic team. There was frequent use of agency nurses and recruitment of new patients or holiday patients to the clinic. Staff would not always be able to identify patients when administering medicines or commencing dialysis treatment. We observed that staff did not consistently ask patients for identification formally or informally during inspection.

• Clinic staff did not have access to a designated member of Fresenius staff who had appropriate level 4 safeguarding training for advice. This training requirement was also not included in the Fresenius policy.

• We did not observe a system for reporting of pain assessment for patients in the clinic who receive dialysis treatment.

• The clinic did not measure or audit any patient travel or waiting times.

• Appraisal was performed for all staff however we reviewed that the quality of the appraisal process needed improvement. In the employee survey 2016/17, over half of the staff in the clinic had reported that they did not feel their work was valued or that their training and development was identified through the current appraisal process. In five records we reviewed the appraisal notes were very brief.

• We reviewed concerns and complaints from patients with particular regard to the temperature of the clinic and comfort of patients. We reviewed action plans from the patient survey which lacked detail, timescales and responsibilities were not allocated or communicated across the team.

• The issues reported to us from a range of sources indicated that there was a culture of unprofessional display of behaviours such as shouting and confrontation in the clinic.We reviewed a range of information that indicated escalation of staff concerns in the organisation had not been acted upon. The morale of nursing staff was observed to be low at all levels during our inspection, and this was also evident in the employee survey responses..

• The 2016/17 employee satisfaction survey results showed an overall poor satisfaction response in all questions related to feeling supported by line management, or feeling stressed about work or feeling valued. We reviewed a five point action plan that did not sufficiently acknowledge or address the issues in the survey. There was a reduction in performance from 2015 to 2017 against a number of indicators in the survey.

• The clinic local team meeting was inconsistent and the agenda and content did not support governance of risk and quality at a local clinic level. The meeting briefly focussed on tasks or duties to be allocated to the team.

• The Fresenius risk management policy did not reflect the introduction of an operational risk register.

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.

Ellen Armistead

Deputy Chief Inspector of Hospitals