The Care Quality Commission
  • Hospital
  • Independent hospital

Bodmin Dialysis Unit

Overall: Requires improvement read more about inspection ratings

St Lawrences Hospital, Boundary Road, Bodmin, Cornwall, PL31 2QT (01208) 834292

Provided and run by:
Fresenius Medical Care Renal Services Limited

All Inspections

During an assessment of Dialysis services

We completed a focused inspection on 13 October 2025 and held virtual meetings on 20 October 2025 to follow up concerns raised within the Section 29 Warning Notice issued on 1 May 2025.

As part of this focused inspection, we reviewed 2 quality statements: Safe Systems, Pathways and Transitions and Governance, management and sustainability. The ratings for safe and well led remain the same.

We found some improvements had been made in relation to safe care and treatment. However, at this inspection we found breaches of the regulations in relation to governance.

Care plans were not individualised and key details were missing. The service did not have clear governance oversight of patient care plans, medication required for use in an emergency or accessibility of lavatories for patients with a disability. Audits were not effective in identifying or addressing areas for improvement.

During an assessment of the hospital overall

We completed a focused inspection on 13 October 2025 and held virtual meetings on 20 October 2025 to follow up concerns raised within the Section 29 Warning Notice issued on 1 May 2025.

Bodmin Dialysis Unit is a satellite dialysis unit with 14 stations treating patients with renal conditions in conjunction with the local NHS trust. This focused assessment looked at dialysis services, which remains requires improvement. In our assessment of dialysis services, we identified breaches of regulations in relation to Good Governance.

During an assessment of Dialysis services

Date of Assessment: 26 March to 14 April 2025.

We conducted an onsite assessment visit of Bodmin Dialysis Unit. We assessed quality statements from the safe, effective, responsive, caring and well-led key questions.We rated the service as Requires Improvement. In safe, we found care plans, for patients, did not always include all relevant information and some risk assessments were not fully completed. We also noted not all staff had a yearly appraisal in a timely manner. The documentation of a meaningful discussion between manager and staff member was not always recorded. In well-led, we found there was a lack of management oversight and governance to ensure that tasks were being completed. However, patients found staff to be caring and supportive and the service was rated good for the responsive, caring and effective key questions.

At this inspection we found the service was in breach of the legal regulations in relation to safe care and treatment and good governance. We issued a Warning Notice for the breach of regulation in safe care and treatment and we have asked the provider for an action plan in response to the concerns found at this assessment under governance.

During an assessment of the hospital overall

We assessed Bodmin Dialysis Unit on 26 March 2025 and held virtual meetings on 16 April 2025 with members of staff.

Bodmin Dialysis Unit was registered with CQC in 2010 to deliver the regulated activities: Treatment of disease, disorder or injury and Diagnostic and Screening services. The service had a Registered Manager/ Nominated Individual.

At this assessment we assessed dialysis services where we assessed 33 quality statements.

We visited the following areas as part of the assessment:

Bodmin Dialysis Unit.

At this assessment we identified breaches of regulations: 12 Safe Care and Treatment and 17 Good Governance.

We rated the location as Requires Improvement. We found breaches of regulations in relation to incomplete care plans and risk assessments and a lack of management oversight and governance to ensure compliance with good practice.

6 & 16 June 2017

During a routine inspection

Bodmin Dialysis Unit is operated by Fresenius Medical Care Renal Services Limited. The treats NHS patients on behalf of the Royal Cornwall Hospital NHS Trust. The service has 14 dialysis stations (two in side rooms) for patients and operate two sessions daily. The service is open six days a week and can operate 168 individual sessions weekly. The unit has a current caseload of 47 patients. The service also accepts patients for dialysis who holiday in the region.

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

We inspected the dialysis 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 16 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 areas of good practice:

  • There was a clear incident reporting process Staff received feedback from incidents they reported. Organisation wide learning from incidents was recognised and implemented.

  • Staff were fully compliant with mandatory training and safeguarding training and there was a reliable system to monitor this. There was a comprehensive training programme to ensure trained nurses were competent to carry out their role.

  • There were systems and process in place to safely manage medicines and to ensure regular servicing and maintenance of equipment was in place. .

  • Staff demonstrated good practice with infection, prevention and control processes.

  • There were safe nursing staff levels to ensure safe and effective patient care.

  • There were business continuity policies and procedures to follow in case of a power failure or issues with the water supply.

  • Pain was assessed and managed well and patient’s hydration and nutritional needs were monitored and managed well.

  • There was good multidisciplinary working and strong communication links with the nephrology consultants from the referring trust.

  • Staff had access to information about patients which enabled effective care and treatment, including access to NHS patient record computer systems. Informed consent was sought and documented prior to commencement of treatment.

  • Staff took the time to interact with patients and had a good rapport with them. Patients said staff were kind and helpful and generally spoke very highly of the unit.

  • Staff understood the impact of the treatment on patient’s emotional wellbeing and actively supported patients.

  • Patients had access to entertainment during their haemodialysis session.

  • There was a system to monitor and deal with complaints. There had been three complaints at the unit in the 12 months prior to the inspection, none had been upheld.

  • Leaders had the skills and experience to lead and staff spoke highly of the unit manager and senior management team telling us they were visible and approachable.

  • There was an effective systematic governance system and programme of audit which was shared with the consultants and contracting team.

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

  • Not all care plans had been regularly reviewed, in line with organisational policy, to ensure the welfare and safety of the patients who attended the unit.

  • Staff were not aware of the visions and values of the organisation.

Edward Baker

Deputy Chief Inspector

24 January 2013

During a routine inspection

People who used the service told us they thought Bodmin Dialysis Unit was 'like one big family' and 'we get looked after really well'. We saw they had detailed care records that included consent to treatment. We were told their care was discussed with their consultant on a regular basis.

On the day of the inspection the unit was busy with an organised but relaxed atmosphere. We saw staff making sure people were comfortable and had access to drinks and snacks. As the people who used the service were at the unit three times a week it was clear everybody knew each other well and we heard ongoing general conversation between the staff and people who used the service whilst staff were continually monitoring the equipment in use.

We found that Fresenius Medical Care Renal Services Limited had robust systems in place for monitoring the quality of the service and supporting and training their staff. We saw staff had access to up to date policies and procedures and had regular staff meetings to ensure they were up to date with their practice.