West Byfleet Dialysis Unit is operated by Fresenius Medical Care Renal Services Limited. The service has 25 dialysis stations which includes four isolation rooms. The unit is built on two levels and is a purpose built facility for the treatment of chronic kidney failure. The unit has the capacity to dialyse 120 patients.

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

The main referring renal unit is St Helier Hospital Renal Department, which is part of the Epsom and St Helier University Hospitals NHS Trust. The trust’s consultant nephrologists visit the dialysis unit four times per month. The wider multi- disciplinary team include: a dietician, transplant nurse, blood transfusion nurse and the vascular access team also visit at varying times.

The unit operates from Monday to Saturday. Treatment is delivered across five treatment sessions. On Monday, Wednesday and Friday they operate between 6.30am and 23.30 pm (three treatment sessions) and on Tuesday, Thursday and Saturday between 6.30am and 18:30pm (two treatment sessions).

Staff within the clinic have direct access to St Helier’s renal unit data base allowing for ease of access to all relevant patient information and referrals. The Fresenius data base links information with the trust’s database.

The arrangements for emergency patient care, for example cardiac events are directed via 999, and all Fresenius staff complete the appropriate basic life support training.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 26th June 2017, along with an unannounced visit to the centre on 10th July 2017.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

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.

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:

• There were effective systems in place to keep patients safe. This included appropriate management and reporting of incidents, effective cleaning schedules and maintenance programmes. All staff were aware of their roles and responsibilities in ensuring patient safety.

• Staff completed competencies according to the Fresenius medicine management policy.

• Patients’ medical and nursing records were secure. Staff had access to all relevant records ensuring patients’ care was as planned and not delayed.

• Staff worked collaboratively with the trust to monitor and assess patients regularly. Patients and their GP’s were provided with written updates on their condition and treatment plans.

• Staffing levels were maintained in line with the trusts contract arrangements. Nursing staff had direct access to a consultant nephrologist who was responsible for patient care. In emergencies, patients were referred directly to the local acute NHS trust or the local commissioning trusts renal unit.

• Staff were aware of their roles and responsibilities to maintain the service in the event of a major incident. Patients were able to continue their treatment at alternative centres.

• All policies and procedures were based on national guidance and compliance was monitored through an effective audit programme.

• Patient’s pain and nutrition were assessed regularly and patients were referred to appropriate specialists for additional support as necessary.

• There was a comprehensive training and induction programme in place to ensure staff competency.

• There were processes in place to ensure effective multidisciplinary team working, with specialist support provided by the referring trust.

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

• Patients were treated with respect and compassion. Staff took care to maintain patient dignity and confidentiality when delivering care and treatment.

• Staff were familiar with and worked towards the organisational vision of providing the best possible care for renal patients.

• There were effective processes in place to monitor risks associated with the service and individual patients.

• Quality assurance meetings occurred regularly and included the wider multi-disciplinary team.

• All staff and patients were positive about the service.

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

• Best practice guidelines advise two registered nurses check at the point of administration of intravenous medicines. We saw the sodium chloride (0.9%) ampules were not checked by two nurses at the point of administration.

• The unit was in poor decorative repair. We saw cracks on walls and parts of the flooring covered by tape. This could harbour dirt and dust and make cleaning difficult.

• Outside the unit the grounds were in poor repair which made it difficult for people disabled or in wheelchairs to safely move from the car park to the unit.

• Chairs in the clinic out patients department were not made of wipe clean material to prevent the spread of infections.

• On the inspection day, the outside waste disposal area was not locked; we also found three bulk storage bins in the disposal area to be unlocked.

• Not all waste bins were labelled to indicate the type of waste to be disposed in accordance with HTM07-01.This meant there was potential for waste not to be segregated properly.

• The unit did not review the personal emergency evacuation plans to ensure information about the patient was up to date in the event of an emergency.

• The number of patient records audited each month was inconsistent and did not constitute 10% of records being audited.

• The unit did not have an up to pathway or tool kit for managing suspected infections, and sepsis.

• The competency assessment document for dialysis assistants, who were able to administer anticoagulants (a medicine that thins the blood), were not fit for purpose. The competencies referred to a medicine which was no longer in use on the unit.

Professor Ted Baker

Chief Inspector of Hospitals

We found that the unit was operating at nearly full capacity with patients who attended three days per week, at times that they told us they chose to fit with their life style. Some patients had attended for up to four years.Some patients showed us how they had been taught to set up their own machines for dialysis, which meant they were actively engaged and participated in their care and treatment. Patients told us that they felt safe and knew the staff well because there was rarely a change of staff.

The patients had a television and music available for the four hour sessions, beverages were provided. Most patients had patient transport services to bring them to the centre. They liked the location of the service as it was close to where the majority of patients lived.

We found that there were systems and processes in place to monitor and review the care standard and improve practice. Each member of staff had a training account and was directed by an online system to keep updated professional portfolio's.

During this follow up inspection we did not speak to people using the services of the dialysis centre, as we were checking improvements made by the provider only. We had received many positive comments about the service during our previous inspection, carried out on 12 May 2011.

We spoke to ten patients who were attending the dialysis centre for treatment on the day of our visit. During our discussions, we received positive feedback about the centre and the staff providing care. Many of the patients told us that they had been receiving treatment from the staff for a considerable period and because of this, they were familiar with staff and the procedures carried out. Patient’s were very happy with their care and treatment and said that they were involved in discussions and decisions about this. They advised us that, staff had provided information, verbally and in writing. Patients said they felt able to ask questions and have their concerns listen and responded to by staff. Patients told us that the dialysis centre was clean and that they saw staff cleaning equipment prior to and after use.