Bodmin Dialysis Unit

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• 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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. We found gaps in the documentation of care plans and risk assessments.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

1. We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

At our previous inspection we scored this quality statement 1. At this inspection the score remained the same. We found the service had introduced care plans for patients. However, care plans did not include all essential information about the patient to ensure their needs could be safely met.

We reviewed 5 patient records. Care plans for patients with diabetes lacked explicit instructions for treatment protocols during hypoglycaemia (low blood sugar) or hyperglycaemic (high blood sugar) episodes and omitted contact information for patients’ diabetic nurses. The monitoring and recording of blood sugar levels for some patients during dialysis was inconsistent with their care plans. This hindered staff's ability to provide effective support and collaborate efficiently with other healthcare professionals when blood sugar levels fell outside safe limits.

Risks associated with anticoagulant medication and bleeding had not been assessed and actions to mitigate this risk were not documented. A patient at high risk of developing pressure ulcers were not referred to a tissue viability nurse. A patient with sleep apnoea had a falls risk assessment, however these risks were not mitigated in the patients care plan. A patient at risk of amputation had nothing documented in the foot care section of the care plan. One patient was waiting for a gastric band operation, however there was no documented evidence in the patient care plan about the dietetic input they were receiving, also the obesity chart in the care plan had not been completed. We found one patient had a fluid balance care plan, but the rationale was blank. This had been implemented in June 2024 and not reviewed until July 2025.

However, 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 through a multi-disciplinary meeting.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.