We spoke with eight of the patients receiving dialysis on the day of our inspection. The patients all understood the care and treatment they were receiving. Patients said "I received information leaflets and the doctor also clearly explained the treatment to me" and "I can ask the nurses anything”.

Patients told us that the nurses looked after them well and they were happy with the care provided. We were told “The nurses are on the ball. They come quickly when my alarm sounds”; “The care is excellent. It’s just like a family, everyone looks after you”. Our observations confirmed what patients had said.

Only the registered nurses were allowed to administer the dialysis treatment and medication. We spoke with three nurses and they told us they had received training in dialysis treatment and administration of medicines. This ensured that medicines were safely administered by staff who were competent to do so.

Patients we spoke with said “Staff clearly know what they are doing” and “They are very good at their jobs. I feel perfectly safe when I come in here”. We observed staff supporting patients. All of the interactions we observed were timely, caring and professional. Staff displayed competence in what they were doing.

A copy of the company’s complaints policy was on display in the reception waiting area at the entrance to the unit. We found that complaints were fully investigated and resolved where possible to people’s satisfaction.

We observed the care and treatment provided and spoke with four of the patients who were receiving dialysis on the day of our inspection. Patients had been given appropriate information and support regarding their care or treatment. One patient said “They explain things and if I have a problem they will talk it through with me”. Another person said “They explain everything to me although a lot of it goes over my head”.

Patients told us that the staff treated them with dignity and respect. We were told “They asked if it was OK to call me by my Christian name” and “They are all very pleasant and respectful”. They said the nurses looked after them well and they were happy with the care provided. We were told “The nurses never pass you by without asking if you are alright” and “They always come quickly when I need them”.

At our last inspection patients raised issues about staffing levels and the temperature in the treatment area. At this inspection we found that improvements had been made. Patients told us “There are always enough staff to see to me”, “I am very well looked after. Staff are very friendly and efficient” and “Staff are happy and jolly. You couldn’t have better”. We observed that the temperature in the treatment area was consistently warm and comfortable. One patient told us “Some people say they feel cold but I’m always too hot”. Another patient said “Sometimes it’s a bit chilly but mostly it’s OK. I can pull up my blanket if I need to”.

We spoke with six of the patients receiving dialysis on the day of our inspection. All told us that their hospital consultant and the dialysis nurses on the unit had explained the treatment and support that they would receive. Patients told us that they had also received information leaflets prior to admission explaining what they could expect. We were told “If I want to know anything I can ask the doctor when I see him but usually the nurse can answer my questions”.

We observed that staff carried out their roles in a caring, competent and confident manner. The unit was busy but patients were not being rushed and their needs were being met promptly. Patients told us, “It’s brilliant the nurses always make sure I’m alright” and “The nurses are very caring and respectful”. However we were told that on occasions the nursing staff were stretched. The results of the unit’s 2011 patient questionnaire showed that respondents were either very satisfied or quite satisfied with the dialysis unit in general. The results showed a high level of patient satisfaction with the approachability and professionalism of staff. There was some dissatisfaction with the temperature in the dialysis room and waiting times to get on and off the dialysis machines when there were staff absences.

All of the patients we spoke with said the equipment was satisfactory and most felt that the dialysis chairs were “reasonably comfortable”. We were told “The chairs here are much more comfortable, and the equipment is more modern than in the hospital”; “The chairs are fine, I can press a button to adjust the position myself”; and “The comfort is alright, I can normally have a sleep”. One patient told us they were comfortable enough for the first two hours but then found the chairs became uncomfortable. All patients were able to bring in their own pillows and blankets if they wished.

We observed that each of the dialysis stations had a ceiling mounted television with headset facilities for patients to use. Due to the construction of the building there were no windows or natural light in the dialysis area. The dialysis stations at the far end of the room faced toward the wall. One patient said this made them feel “a bit isolated” as they couldn’t observe what was going on.

Taunton Renal Unit is operated by B. Braun Avitum Limited. The service has 16 dialysis stations, which included two side rooms for patients and operates three sessions daily. The service is open six days a week, between Monday and Saturday and carries out 252 dialysis sessions a week for a caseload of 84 patients. The dialysis service is provided to NHS funded adults between the age of 18 years and above and has carried out 13,556 dialysis sessions in the last year prior to our inspection. The Royal Devon and Exeter Hospital commissioned B Braun to provide a haemodialysis service at Taunton Renal Unit.

The service is a nurse led unit which provides outpatient satellite dialysis provision to patients.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 20 June 2017 and carried out an unannounced visit on 28 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 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 issues that the service provider needs to improve:

• Staff did not receive feedback after reporting incidents.
• Staff were not fully compliant with mandatory training in line with corporate policy.
• Nurses did not check patients’ identity prior to commencing haemodialysis treatment.
• The unit needed to ensure the safe management of all patient medicines which includes the administration of fluid boluses during haemodialysis, the safe administration of intravenous medicine in line with the Nursing and Midwifery Council Guidelines (2013), and ensuring dialysis prescriptions were up to date, signed and dated by the lead consultant for the unit.
• Nurses at the unit were transcribing the patient’s dialysis prescription which was not in line with guidance from the Nursing and Midwifery Council (NMC, 2015).
• There was no policy or guidance available to staff about the early recognition or management of sepsis. Staff had received no specific training for the early identification of sepsis and management (infection) in line with national guidance (NHS England, 2015).
• There was no assurance actions following the continuous quality improvement meeting had been completed. Nurses were not signing and dating documents to identify when actions had been completed.
• Learning objectives set by staff over one year ago had not been signed off to demonstrate the staff member was competent and had achieved the objective.
• There was no awareness of and evidence of compliance with the Workforce Race Equality Standard (WRES) which became mandatory in April 2015.
• We were unable to find evidence in staff meeting minutes about discussions which should have taken place as a result of the patient satisfaction questionnaire, which had been signed off as completed in the action plan.
• We were not assured that risk, quality and performance was monitored for trends and learning.
• The processes to share learning, risk, quality and performance information with staff was not consistent or thorough.
• There was not an effective process to monitor ‘live’ risks which included evidence of how local service risks were identified, mitigated and acted upon.
• However, we found the following areas of good practice:
• There was a good incident reporting culture and the staff were aware of the procedure to follow when reporting an incident or an adverse patient incident. Staff followed company policy with regards to infection, prevention and control.
• The unit had clear processes to ensure regular servicing and maintenance of equipment, and there were policies and procedures to follow in case of a failure in the water supply or power failure. Staff were aware of their roles and responsibilities to maintain the service in the event of a major incident.
• Evidence based practice and the Renal Association guidelines were used to develop how care and treatment was delivered. All policies and procedures were based on national guidance and updated when required to reflect change to national guidance and then distributed to staff. Patient outcomes were monitored in line with best practice guidelines.
• There was a comprehensive training and induction programme in place to ensure staff competency.
• There was good multidisciplinary working and strong communication links with the lead consultant and the local NHS trust.
• There were effective processes for gaining informed consent, which was sought and documented prior to treatment.
• Patients were treated with dignity, compassion and respect, and on the whole maintained their privacy and dignity in all aspects of care.
• Staff understood the impact of the treatment on patient’s emotional wellbeing and actively supported patients.
• Services were planned and delivered to meet individual patient needs and improve their quality of life.
• There was a system to monitor and deal with complaints. There had been no formal complaints at the unit in the year prior to our inspection.
• Leaders had the skills and experience to lead and the senior management team were visible and accessible.
• Staff felt valued and supported in their roles and reported a positive working culture.
• There was a replacement programme for the dialysis machines, in line with the Renal Association guidelines.

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 

Chief Inspector of Hospitals