Stockport NHS Dialysis Clinic is operated by Fresenius Medical Care Renal Services. Nephrocare is the service brand of Fresenius Medical Care. Stockport NHS Dialysis Clinic has been operating since July 2013. Patients attending the clinic are referred by their local trust to the specialist renal and dialysis services provided by the service’s commissioning NHS trust . The clinic functions as a satellite clinic for the dialysis services provided by the commissioning trust, and treats patients in the Stockport area. Stockport NHS Dialysis Clinic is purpose built and is located close to Stockport centre. The clinic is a nurse led clinic, comprising of a manager, deputy manager, a team leader, 6.2 registered nurses ( a further registered nurse was undergoing pre employment checks), 3.1 dialysis assistants and one clinic secretary 0.53 whole time equivalent (wte). The manager, deputy manager and team leader also provide clinical care. The clinic has 20 haemodialysis stations and provides two treatment sessions per station per day, Monday to Saturday (240 appointments per week). The service provides dialysis services for adults aged 18 years of age and over. At the time of our inspection the unit facilitated treatment for 80 patients per week. There are no services provided to children and young people. Facilities include a patient waiting area with two disabled access toilets, two consultation rooms, a patient resource room, technicians workshop, linen room, reception office, centre managers office, patient treatment and weighing area, two single rooms that could be used as isolation rooms, one double room for patients to self dialyse, a consultation room, office, clean utility room, waste utility, staff changing room, staff rest, kitchen, storeroom, water treatment plant and a seminar/meeting room.

We last inspected this service on 22 June and 3 July 2017 but did not have a regulatory duty to rate the service at that time. However, we told the provider the actions that they need to undertake to improve the service.

Action the provider MUST take to improve

• The provider must implement a system that ensures in the event of a patient death, notifications are routinely notified to CQC in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 (part 4).

• The provider must take action to ensure mortality reviews are undertaken to review whether there are any lessons to be learned or any omissions in the care and treatment of that patient.

• The provider should take action to provide staff with procedures and training with regards to the identification, process, and management of patients with sepsis.

Action the provider SHOULD take to improve

• The provider should undertake reviewing its compliance with the Workforce Race Equality Standard evaluation in accordance with the NHS standard contract.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 28 November 2018.

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 rate

We rated Stockport NHS Dialysis Unit as Good overall.

We found examples of practice that had improved since our last inspection such as:

• Since the last inspection we had seen an improvement in the reporting of statutory notifications to the CQC in accordance with the legislation.

• We saw evidence that mortality reviews were being undertaken to review whether there were any lessons to be learned or any omissions in the care and treatment of patients.

• We saw that all staff had been trained in the identification, process, and management of patients with sepsis.

• We saw evidence that the provider was complying with the Workforce Race Equality Standard evaluation in accordance with the NHS standard contract.

We found the following areas of good practice:

• All staff had completed mandatory training and knew how to protect patients from harm or abuse.

• Staff understood their roles and responsibilities in relation to consent and the mental health act.

• Staff treated patients with care and compassion.

• There were high patient satisfaction scores.

• Staff supported and met the needs of individuals.

• There was a positive culture and staff engagement was good.

• There was a clear governance structure.

• We saw evidence of a comprehensive audit programme that was used to drive improvements and provide assurance.

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

• We were not assured that the procedure for dispensing and administering Tinzaparin sodium intravenously was robust enough to prevent medication errors.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North region).

Stockport NHS Dialysis Clinic is operated by Fresenius Medical Care Renal Services. Nephrocare is the service brand of Fresenius Medical Care. Stockport NHS Dialysis Clinic has been operating since July 2013. Patients attending the clinic are referred by their local trust to the specialist renal and dialysis services provided by the service’s commissioning trust (Central Manchester University Hospitals NHS Foundation Trust). The clinic functions as a satellite clinic for the dialysis services provided by the commissioning trust, and treats patients in the Stockport area.

Stockport NHS Dialysis Clinic is purpose built and is located close to Stockport centre. The clinic is a nurse led clinic, comprising of a manager, deputy manager, a team leader and 9.3 whole time equivalent (wte) registered nurses. The manager, deputy manager and team leader also provided clinical care. The clinic has 18 haemodialysis stations and provides two treatment sessions per station per day (216 appointments per week). The service provides dialysis services for adults from 18 to 65 and adults who are over 65 years of age. There are no services provided to children and young people. Facilities include a patient waiting area with a disabled access toilet, a patient treatment and weighing area, two single rooms that could be used as isolation rooms, a consultation room, office, clean utility, waste utility, staff changing room, kitchen, storeroom, and water treatment plant.

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 when they are provided as a single specialty service. 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:

• There were reliable systems and processes in place to keep patients safe. These included staff training, incident reporting, infection prevention and control, water quality monitoring and treatment, disinfection and maintenance of equipment, and screening procedures for blood borne viruses.
• The clinic’s layout and staff use of equipment, including prompt response to machine alarms, kept people safe. Patient records were managed appropriately. Medicines were stored and managed safely. Staff followed the provider’s medicines management policy, and a process was in place for review of patient medicines by the medical team when required.
• Patients were assessed for suitability for treatment to ensure the clinic was able to accommodate their care needs. The multidisciplinary team reviewed individual treatment prescriptions monthly, and patient’s vascular access sites were regularly monitored.
• Patients were assessed for risk of deterioration and processes were in place to request urgent medical assessment or resuscitation if needed. Dietitians provided advice monthly to each patient, and there was access to psychological and social work support if needed.
• The clinic had processes in place to ensure higher risk patients, including those with dementia, were referred back to the commissioning trust in accordance with their contract. Staff had received training in and were aware of the principles of the Mental Capacity Act and the Deprivation of Liberty Safeguards.
• Appointment slots were allocated to patients taking into account their individual needs and staff worked to accommodate requests to change appointments as required. Staff supported patients to go on holiday through co-ordinating care at other clinics in the UK, Europe and other countries.
• Care and treatment was evidence based in line with appropriate guidance. Staff were competent to provide the right care and treatment, and competencies were regularly reviewed. New staff were supported through an induction and mentoring programme.
• The clinic had no written complaints in the reporting period; but there was evidence of shared learning from complaints and incidents that occurred in the provider’s other clinics.
• The clinic had a named nurse for each patient, which helped to ensure continuity of care. The annual patient survey indicated that patients felt staff were caring, treated them with dignity, and explained things in a way they could understand.
• Staff supported families who were bereaved.
• The clinic had a clear management and reporting structure. The clinic manager and deputy manager had the appropriate skills, knowledge, and experience to lead and engage effectively with their staff and patients.

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

• In the event of a patient death, notifications were not being routinely notified to CQC in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 (part 4).
• Mortality investigations were not being undertaken so lessons learned and reviews of omissions in care and treatment were not taking place.
• The service did not have a policy or provide training for nursing staff with regards to identification or process for sepsis management. This was not in line with the NICE guideline (NG51) for recognition, diagnosis, or early management of sepsis. (Sepsis is a life-threatening illness caused by the body’s response to an infection).
• The clinic did not undertake a Workforce Race Equality Standard evaluation in accordance with the NHS standard contract.

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 one requirement notice that affected dialysis. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)