Overall, people were happy with the service they received. One person told us, "The whole unit is very good, modern, up to date and clean". Another said, "I've dialysed elsewhere. This is about the best. The cleanliness is good - their procedures are better than other places I've been to. I feel safe here." We also received comments such as, "I wouldn't change anything, the general care is good", "The staff are very caring," and, "The staff are quite good. They are helpful, very good people."

People told us they were involved in making decisions about their care and treatment. People that we spoke with confirmed that they received treatment at a time that suited them and fitted in with their lifestyle.

People were able to express their views and told us that they had taken part in the service’s annual satisfaction survey. Everyone we spoke with knew who they would speak to if they had a problem or wanted to raise an issue. People told us that staff respected their privacy and dignity.

People told us that staff gave care and treatment in line with their individual needs. They said they would be able to speak to any of the nursing staff and that staff would be aware of their needs. One person said, "They all know about my case pretty thoroughly."

People also told us that they felt cared for by the staff. One person said, "If you say something to the nurse they'll do whatever is in their control". Another said, "If you raise something they try to do something about it." People told us that the registered manager and staff came round to check if they were alright.

People told us that they felt safe using the service and that they were aware of how to complain. One person said, "There is a leaflet with the complaints procedure, though in the first instance I'd complain to the manager. I've had no reason to complain."

We received mixed views about staffing levels from people that used the service. One person said there were enough staff on duty. Another said there were generally enough staff on and that the situation had improved over the last few months. A third

said the unit had been short staffed but the current week was good.

Some people told us that on occasions they felt that there had not been enough staff on duty to meet their needs. One person said, "There always seems to be a shortage of staff." Another person said, "The manager does her best. There are not enough staff to help here. There should be more helpers. The unit is fantastic. It's a shame there are not enough staff to run it. Apart from that, I can't fault it."

Worcester Dialysis Unit is operated by Fresenius Medical Care Renal Services Limited. The service opened in 2009 and provides haemodialysis to patients from the local area of Worcestershire. This is a satellite dialysis service, which has a contract with University Hospitals Birmingham NHS Foundation Trust.

The service provided over 11,200 dialysis treatment sessions per year and had 72 patients at the time of the inspection.

All the patients were over 18 years old:

• 31% of patients were aged 18 to 65 years.
• 69% of patients were over the age of 65.

The service is located away from an acute hospital site. Facilities included 20 dialysis stations (four of which were in isolation rooms), three consulting rooms, and a meeting room.

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

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection 6 June 2017, along with an unannounced visit to the unit on 19 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. 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.
• The facilities were purpose-built and met Department of Health guidance.
• There were systems in place for reporting, investigating 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.
• Patients’ records were held securely, and staff had access to relevant information.
• Nursing staffing levels were maintained in line with national guidance.
• There was a walk round handover process, which was inclusive of the patient.
• Systems and processes were generally in place to ensure that patients received safe care and treatment. Medical advice was available, with direct access to the consultant or renal team at the NHS trust.
• 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 assessment and support regarding nutrition.
• There were effective processes in place for gaining patient consent for treatment.
• Patients who required dialysis were assessed by the NHS trust’s staff for suitability to dialysis in a satellite unit and then referred to this unit.
• The unit provided two dialysis sessions per day.
• Patients were treated respectful, caring manner. This was reflected in the positive local annual patient satisfaction survey and patient feedback we received during the inspection.
• There was appropriate monitoring of patient outcomes and the service’s performance.
• Patients were encouraged to take part in their care, with two patients fully competent to self-care.

However:

• Not all staff had completed safeguarding adults and children training in line with national guidance and corporate policy at the time of the inspection. However, we found that nursing staff were aware of their roles and responsibilities in the escalation of safeguarding concerns. The provider took action to address this lack of training after we had raised it as a concern.
• We found that there were gaps in compliance with training, including practical manual handling, preventing medicine errors and link nurse training.
• Not all senior staff had had Duty of Candour training in line with the provider’s policy.
• Staff did not consistently follow best safe practice regarding timing of second checks prior to administration of medicines.
• We were not assured from records that appropriate actions were being taken when fridge temperatures, including the medicines’ fridge, were out of recommended range. This was raised during the inspection and actions were taken.
• The service did not provide patients with easy to read information in line with the Accessible Information Standard.
• 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. This was on the unit’s risk register.
• We found that some items were stored inappropriately, for example, sodium chloride solutions in a general storeroom. Subsequent to the inspection, this issue was resolved.
• The services risk register was set corporately and did not describe risks found at a local clinic level.

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.

Heidi Smoult

Deputy Chief Inspector of Hospitals, Central Region