We spoke with the registered manager, deputy manager, one registered nurse and a health care assistant. We also spoke with three patients. The patients told us they had been satisfied with their care; the staff were ‘’Friendly’’ and ‘’They know what they are doing!’’ We were told they had been kept informed about their treatments and had been given choices in how their treatments were delivered.

Staff we spoke with confirmed that staff recruitment processes were robust and as such ensured people were cared for by staff that had the appropriate skills and experience. The recruitment information we saw for a new registered nurse demonstrated that recruitment processes had been robust.

Patients' needs had been assessed, risks identified and personalised plans of care developed. We saw evidence of patient involvement in consent processes and guidance available should a patient not have the capacity to consent to treatment. The provider may like to note that we were told that staff had not received any training in the Mental Capacity Act (2005) or best interests assessments.

We reviewed cleanliness and infection control processes and practices during the inspection and noted that the environment was clean, although we did observe a build up of dust on two portable fans and some media display units. We observed staff hand hygiene and treatment practices and noted them to be satisfactory.

We asked four people who use the service and four staff their views about the care and treatment provided at Stratford Dialysis Centre (the centre). The patients we spoke with had been long term patients at the centre.

People said their experiences at the centre had been positive; one person said ‘we are very spoilt over here; we receive a good service.’ Other patients comments included ’can’t knock the care’ and ‘staff are competent, know what they are doing and are very friendly.’

People told us that sufficient staff had been available during their treatments and new staff members had been supervised. People said they ‘felt safe’ when receiving care and treatment at the clinic.

People told us before receiving care and / or treatment they had been asked for their past medical history. They said they had also agreed consent to treatment prior to treatment starting and when treatment plans changed. One person told us before starting treatment staff had asked questions about her health, background, medication and general condition. She said these areas had been reviewed by the staff member each time she had visited the centre for treatment.

People said they had been given appropriate information and support regarding their care and treatment. They said staff had regularly spoken to them about their treatment and had encouraged questions. One person told us the multi-disciplinary team had reviewed her treatment plans monthly. Following these reviews she said she had been given verbal feedback and a letter for her GP.

Two other patients described how they had been involved and informed of their treatment. The first patient said he had been kept informed of his blood results and had received a monthly printout of the blood results to take away. These blood results had been monitored by his consultant who had discussed them with him during outpatient appointments.

The second patient said she had been trained to receive home dialysis. Part of the training involved her attendance at an identified training session at her local hospital.

People also spoke about a monthly newsletter which informed them of any changes at the centre and specific social events. Two people said they had given feedback in the 2011 transport survey. They told us this survey had included questions about their consultant and nurse and whether they were happy with their care and treatment.

People told us they were aware of how to complain and where they could access information about complaints. People said they felt comfortable raising concerns with a staff member or the Patient Advice Liaison Service.

Stratford Dialysis Unit is operated by Fresenius Medical Care Renal Services Limited. The service has 12 dialysis stations. Facilities include two isolation rooms.

Dialysis units offer services which replicate the functions of the kidneys for patients with advanced chronic kidney disease. Dialysis is used to provide artificial replacement for lost kidney function.

The service provided over 8,700 dialysis treatment sessions per year and had 59 patients.

All the patients were over 18 years old:

• 44% of patients were aged 18 to 65 years.

• 66% of patients were over the age of 65.

  We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 3 May 2017, along with an unannounced visit to the unit on 10 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 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:

• The unit and equipment were visibly clean, with evidence of effective cleaning regimes and schedules in place. Staff were observed using effective precautions to maintain patient safety and reduce the risks of infection.

• There were systems in place for recording and escalating incidents both internally and externally.

• Equipment was maintained according to the manufacturer’s guidance, with an adequate supply to cover maintenance or breakages.

• There were processes in place to ensure that medicines were ordered, stored, and used, in line with guidance.

• Patients’ records were held securely, and staff had access to all relevant information.

• At the time of our inspection, 100% of staff had completed their mandatory training.

• Nursing staff were aware of their roles and responsibilities in the escalation of safeguarding concerns. However, the units’ safeguarding lead had not completed training in line with national guidance.

• Nursing staffing levels were maintained in line with national guidance and there was a structured handover process between shifts.

• Medical advice was available during opening times, with direct access to the consultant or renal team at the NHS trust.

• Staff were aware of their roles and responsibilities to maintain the service in the event of a major incident.

• Staff completed a detailed competency assessment on commencement to post and were reassessed annually. At the time of our inspection, 100% of staff had received their annual appraisal.

• Patients received regular support regarding nutrition from the renal dietitian from the NHS trust.

• There were effective processes in place for gaining patient consent for treatment.

• Patients who required dialysis were assessed by the parent NHS trust staff for suitability to dialysis in a satellite unit and then referred to this unit.

• The unit provided three dialysis sessions per day including a twilight session. Staff supported patients changing dialysis days and or times as far as possible to accommodate external commitments, appointments or social events.

• Patients were treated in a calm, caring and friendly manner. This was reflected in the positive local annual patient satisfaction scores and patient feedback we received during the inspection. Nursing staff gave patients time to ask questions during treatment.

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

• We found a patient receiving medicine from a transcribed unsigned prescription. However, the service took action to rectify this concern and staff received targeted training regarding this aspect of medicine management.

• Staff were using a cannulation technique called ‘dry needling’. This was not in line with the provider’s policy, which stated that ‘wet needling’ was the recommended technique. The service and provider took immediate action to ensure that staff complied with this policy.

• While patients were observed closely during treatment, the service did not use the national early warning score system for monitoring a patient’s risk of deterioration.

• Some risks identified on this inspection had not been fully recognised by the unit leaders. Patients’ individual risk of falling was not formally assessed by the nursing staff.

• The provider was not responsible for the building where the service was delivered, and the facilities were established prior to the Health Building Note 07, 01: ‘Satellite dialysis unit’ (2013) guidance. However, they did not meet all aspects of this guidance including, lack of space in reception for patients, lack of reception desk, dedicated consulting or exam room, treatment and training room. There were no risk assessments regarding this.

• We found that some items were stored inappropriately, for example sterile items in the dirty utility room. There were no risk assessments regarding this.

• We found that some governance systems were not fully established. For example, the unit’s patient concerns’ register and risk registers were recently commenced. This meant that there was not a fully embedded risk management process to capture risks and drive improvements.

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.

Edward Baker

Deputy Chief Inspector of Hospitals

Central Region