Bodmin Dialysis Unit

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This service was previously inspected but not rated in 2017. At this inspection we rated safe as requires improvement. We found gaps in the documentation of care plans and risk assessments. The service detected and mitigated potential risks in the care environment. However, the estate was ageing and maintenance issues were not being fixed in a timely manner by the local Trust due to budget constraints. The unit had enough staff. However, some staff were unaware of the training provisions offered by the parent company and not all staff had received an appraisal. People were safe and protected from bullying, harassment, avoidable harm, abuse and discrimination and there was a good incident reporting culture.

The service was in breach of legal regulation in relation to people's safe care and treatment. We issued a Warning Notice for Regulation 12 around the gaps in the documentation of care plans and risk assessments. Following inspection, we received information from the provider these gaps in documentation had been rectified.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were confident to report incidents and knew what to report and when. Staff had effective systems to raise concerns both formally and informally. We reviewed incidents which staff described to us at the site visit. We found these were appropriately reported and investigated as necessary. Staff saw incidents as an opportunity to learn and improve but said learning from the incident was not always fed back. Staff said changes to practice were not implemented in a timely and co-ordinated manner following investigation of an incident.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care.

The service had a freedom to speak up guardian. Staff were aware of how to contact them. We were told no staff at the unit had contacted the guardian.

The service’s referral and admission process did not ensure that all essential information about the patient was recorded to ensure their needs could be safely met.

There were gaps in the documentation of care plans and risk assessments, in particular for patients who had other co-mobilities such as diabetes. For example, we reviewed 4 patient records and found none had a completed care plan. Care plans would usually document how their specific medical needs would be managed. We found a falls risk assessment which did not include diabetes as a potential falls risk and none of the files reviewed had a completed sepsis document. The lack of structure found in care plans did not ensure optimal management of kidney disease, which posed a risk to patient outcomes and quality of life. We raised this issue with the service at the time of inspection and were told post inspection that these gaps in care plans and risk assessments had been rectified.

People who used the service were seen regularly by the same staff members. We observed patients were comfortable talking to the nurses during their procedures.

The service worked with the local trust to regularly review the patient’s care and treatment via a multi-disciplinary meeting.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Clinic Managers were appointed as Local Safeguarding Leads and provided with level 3 safeguarding training for both adults and children. All staff had completed mandatory safeguarding training for children and adults to level 2. All staff we spoke with understood their responsibility to report safeguarding incidents. Numbers of who to contact in the event of a safeguarding concern were clearly displayed on a notice board for all staff to access. Staff said they could access safeguarding information and policies on the electronic system.

The service worked well with people to understand and provide care which met their needs in a safe and supportive manner. However, risks were not always documented and managed, and patients did not always feel fully informed about their care.

Patient feedback from a survey stated there was some improvement work needed around the metric ‘My care team pays attention to my needs’. The service had an action plan to improve communication with patients which included explaining the results of monthly blood tests to patients, and for the nurses to talk to patients to identify any problems and other health issues. This was due to be completed in August 2025 but we could not ,identify whether any progress had been made against this action plan.

The service was a satellite dialysis unit. People who required treatment were referred to the service by the local NHS trust. Patients’ appropriateness for the service was assessed. For example, patients requiring a bed were not suitable for the service as only dialysis chairs were available. Clinical risk was managed via the regular multidisciplinary meeting (MDT) between local consultants at the NHS trust and the provider. However, the service did not always document risks to patients in care plans as previously mentioned under safe systems.

If there was a medical emergency the protocol was to phone 999 and wait for an ambulance to transfer the patient to the local hospital. Staff were aware of this policy and we reviewed incidents where this policy was implemented in a timely manner.

The service detected and mitigated potential risks in the care environment. However, the estate was ageing and maintenance issues, such as a leak in the roof, had not been fixed in a timely manner by the local trust. There was a list of works to complete but due to funding issues, not all maintenance items on the list had been carried out.

The layout of the unit did not allow staff to maintain the privacy of patients receiving haemodialysis. The unit did not have curtains around each station to use when privacy was required. Instead, there were screens stored in a separate room which could be used in emergencies. These were not routinely used. We were told consultants spoke to patients whilst they were on dialysis chairs and screens were not used for these conversations. One patient commented he would prefer more privacy.

The service had space for 14 dialysis patients and had 3 spare dialysis machines. Technical support was available for the dialysis machines and the water treatment plant. The provider was in discussion with the local Trust regarding replacement of dialysis machines due to their age.

The dialysis chairs were located close together. However, there was sufficient space to enable staff to gain rapid access in case of an emergency. The service only took patients on chairs due to the lack of space for patients on beds who may require extra assistance such as using a hoist. At the last patient survey in September 2014, one of the lowest scoring areas was around the comfort of treatment chairs where the service scored 3.5 out of a possible 5.

Staff carried out daily safety checks of specialist equipment, including the resuscitation equipment. Staff checked the water used for dialysing regularly.

At the time of inspection, the service had experienced an internet problem with half of the patients unable to connect to the internet. This caused distress to patients who relied on internet use during their long treatment periods (approximately 4 hours). The service was trying to fix the issue. However, this problem continued for at least a month and had not been fixed at the time of our last interview with the service on 16 April 2025.

The emergency eye wash station was located in the water treatment room, which was not an appropriate location for this facility. It was located too far away from the treatment area. However there was eye wash available in the first aid box which was located in the clinical area.

All patients faced in the same direction and were able to look out of the windows of the unit onto green space. There was ample free car parking spaces for people to use.

The service had enough nursing staff to keep patients safe. Managers accurately calculated and reviewed the number and grade of nurses needed for each shift in accordance with national guidance.

Staff kept up to date with mandatory training. However, only 44% of staff had completed an annual appraisal at the time of inspection. We reviewed 9 appraisals and found they did not document a meaningful conversation between the manager and the employee. Some staff we spoke with were not confident about associated conditions relating to kidney disease and were not aware of the training provision offered by the Fresenius group. Staff we spoke with said they would like more support with their learning and development.

The service had low sickness rates, with no staff on medium or long term absence during the period 1 January 2025 to 8 April 2025.

We reviewed recruitment files and found the service was compliant with Schedule 3 of the Health and Social Care Act.

Staff shared infection concerns with appropriate agencies promptly. There were policies and procedures for infection control, however, the service did not always assess or manage the risk of infection.

The service required staff to do a deep clean of their station area once a week, as per the agreed cleaning schedule. We found significant gaps where the cleaning had not been carried out, sometimes for a period of 4 weeks. There was not sufficient governance oversight of this process. When a member of staff was on leave, there was no cover arrangement for another staff member to clean their assigned dialysis station. However, staff told us they cleaned the dialysis machines and chairs between patients. We observed this happening on the day of inspection .

Staff wore personal protective equipment in line with regulations. Staff were observed to follow good hand hygiene practice. We observed staff using appropriate aseptic non touch technique to reduce the risk of infection spreading from staff to patients.

There were suitable furnishings, which were easily cleaned between patients and were well-maintained. The areas we visited in the unit were visibly clean at the time of the inspection. A third-party company undertook routine domestic cleaning.

Hazardous and clinical waste was disposed of safely and responsibly managed.

The service ensured medicines and treatments were safe and met people's needs, capacities and preferences.

Staff stored and managed medicines and prescribing documents in line with the provider's policy. Staff stored medicines appropriately and monitored fridge temperatures.

Staff followed current national practice to check patients had the correct medicines. Consultants at the referring hospital updated prescriptions every 3 months for each patient. If changes were required sooner than this following monthly blood tests, the consultants actioned these and shared the information with the staff at the clinic at the monthly quality meeting.

Prescribed fluids were stored off the floor on pallets, in a clean and secure storeroom and in line with good practice. Medicines were locked away securely.

The service had a hypoglycaemia box available to staff should a patient blood sugar (glucose) levels drop too low. However, we found there was no intramuscular glucagon stored on site. Intramuscular glucagon is used for the immediate treatment of hypoglycaemia. This is recommended by national guidance. The Fresenius Diabetes Management Policy contained clear instructions for the immediate treatment of hypoglycaemia,. which can be serious if left untreated. In severe cases, the policy indicated calling for an ambulance and administering intravenous dextrose (a simple sugar that is identical to glucose). Although national guidance states that intramuscular glucagon (a hormone that helps regulate blood sugar levels) should also be available in case intravenous access is not possible. The Fresenius Country Medical Director UK & Ireland explained this guidance had been purposefully adapted to better reflect the circumstances of the outpatient setting. The service had recently had an incident with a patient experiencing an episode of suspected hypoglycaemia where staff called 999 for an ambulance as per policy.