We saw the clinic staff and patients had a good rapport and appeared to be relaxed in each other’s company. We saw people who used the service were encouraged to assist with their own care. We spoke with seven of the 11 patients who were using the service at the time of our visit. They all told us that they were extremely satisfied with the care and treatment provided at Stockton Dialysis Clinic.

Patients told us, “I have been coming for dialysis for 11 years and the staff here are fantastic”, “The staff are marvellous and you couldn’t ask for better” and “I’m extremely satisfied with what the staff do here”.

We saw there were on-going assessments and evaluation of treatment through screening tests such as regular blood tests. We saw that although these had been agreed with medical staff no changes were implemented until a discussion had been held with the patient. We found that the staff worked closely with the renal team at James Cook University Hospital and followed their directions at all times.

We found that the clinic had policies and procedures in place to ensure people were treated in a safe environment. We saw that the building was well-maintained.

We found that staff were recruited appropriately and regular checks were completed to make sure their nursing registration remained current. We also found that there were sufficient staff on duty to meet patient’s needs.

We saw the clinic staff and patients had a good rapport and appeared to be relaxed in each others company. We saw people who used the service were encouraged to assist with their own care.

We saw there were ongoing assessments and evaluation of treatment through screening tests such as regular blood tests. We saw that although these had been agreed with medical staff no changes were implemented until a discussion had been held with the patient. One person told us “My care was explained thoroughly.”

We saw the clinic had policies and procedures in place to ensure people were treated in a clean environment. We saw a list of daily tasks the cleaning staff were required to complete. The work carried out by cleaning staff was closely monitored by the clinic manager and regular audits were carried out to check cleaning had been completed to a high standard. We spoke with some of the patients being treated. One of the people we spoke with told us “It’s very clean, very good.”

We saw a training and development programme was in place to ensure staff were suitable qualified to care people who used the service.

We saw the clinic operated a quality assurance system. People who used the service, their representatives and staff were asked for their views about the standard of care provided. We also saw the unit had a suggestions/comments box in the reception area of the clinic.

Stockton Dialysis Unit is operated by Diaverum UK Ltd, an independent healthcare provider. The unit is a ‘standalone’ dialysis clinic located within the grounds of North Tees Hospital NHS Trust and commissioned by the South Tees NHS foundation trust to provide renal dialysis to NHS patients. The NHS trust referred patients to the clinic. The service commenced in 2004 with 15 stations (located in two bays and one side room). Providing haemodialysis for clinically stable patients with end stage renal disease/failure.

There are on average 903 dialysis treatment sessions delivered a month. The service delivered 10,839 haemodialysis sessions in the 12 months prior to inspection. Adults aged 18 – 65 received 4989 sessions and adults aged 65+ received 5891 session during April 2016 to March 2017. There were 71 people in total using the service. The service provides dialysis for patients over the age of 18 years only. The clinic does not provide peritoneal dialysis or services to children.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 6 June 2017, along with an unannounced visit to the hospital on 22 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? 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 was a positive culture regarding reporting of incidents. Staff understood the incident reporting policy and understood the principles of ‘being open’ and ‘Duty of Candour’
• Staff were competent and were proactively supported with their training and development needs and mandatory training compliance was high for the majority of required modules.
• The clinic had systems and processes in place to keep vulnerable patients safe from harm. Staff were aware of their roles and responsibilities for reporting and escalating adult safeguarding concerns.
• Staff followed current evidence based guidance, including National Institute of Health and Care Excellence (NICE) and The National Service Framework for Renal Services in providing care for patients.
• Patient feedback was very positive and patients told us that staff went out of their way to meet their needs.
• The service offered different dialysis sessions to meet individual needs including an overnight service where patients had dialysis treatment during the night. The clinic is one of very few clinics in the UK to offer nocturnal dialysis, which is associated with both improved patient outcomes and improved quality of life. The clinic had received extremely positive patient feedback for this service and demand for nocturnal dialysis was increasing.
• There was no waiting list for treatment at the clinic and the clinic had not cancelled or delayed any dialysis sessions for non-clinical reasons in the 12 months prior to the inspection.

• The clinic had a corporate vision, mission and values for the service to improve the quality of life for renal patients and “to be the first choice in renal care”.

• Staff we spoke with said they had positive working relationships with the management team. The manager was described as approachable and supportive and staff and patients felt the clinic was well managed.
• The clinic had recently received an excellence award for retention of staff.
• The organisation was described as supportive for staff development and there was a no blame culture evident when incidents occurred, which encouraged reporting.

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

• We were not assured that incidents were investigated thoroughly. We saw that not all contributory factors had been considered during the investigation of a medicine incident. It was not clear how the themes and trends of all the incidents were shared from the different clinics in the company to all staff.
• Staff did not always check patients’ identity before administering dialysis medicines / treatment.
• Compliance with infection prevention and control training, water quality and testing, and training regarding female genital mutilation (FGM) was poor.
• Staff at the clinic had not received training regarding sepsis and there was no sepsis protocol in use
• There was no policy regarding safeguarding children and staff had not received safeguarding children training.
• Effective weekly treatment time data for January 2017 to March 2017 showed that 53.4% patients were dialysed for the prescribed four hours treatment time. This is less than the minimum standard of 70%.
• The clinic was not meeting the ‘Accessible Information Standard’ (2016) or the Workforce Race Equality Standard (WRES) (2015) at the time of our inspection.
• The risk register was not reflective all of the current risks relevant to the clinic.
• We did not see how performance information or learning from incidents and complaints was shared across the organisation.

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 two requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)