Chandlers Ford 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 means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had policies and procedures to guide staff in reporting, managing, investigating, and learning from incidents. Staff understood the types of incidents they were required to report and how to record these on the electronic incident reporting system. The service operated an incident management process through its reporting systems. Incidents were categorised by harm level and managed through clear review, escalation and closure processes. Information was shared with the local NHS trust to support effective oversight, learning and continuous improvement.

Between November 2025 and April 2026, the service reported 4 incidents; 1 no harm, 2 low harm and 1 moderate harm. Evidence showed the moderate harm incident had been reviewed and appropriate learning and actions had been identified. Discussions with staff demonstrated learning had been effectively shared and embedded into practice, with staff able to describe how they would respond to signs of deterioration and undertake additional monitoring where concerns arose.

The service used multiple mechanisms to share incidents and learning, including daily safety huddles and staff meetings. This supported a positive learning culture where incidents were recorded, investigated and used to improve patient safety.

Staff also demonstrated a good understanding of their responsibilities under Duty of Candour. This is a legal requirement for health and social care providers to be open and transparent with patients when harm occurs. Staff had access to a Duty of Candour policy which outlined their roles and responsibilities. We saw evidence within incident investigation reports that Duty of Candour had been applied. This showed that leaders acted in line with their legal obligations to ensure patients and their families were informed, supported and kept updated when things went wrong.

The service had established systems and processes to support safe patient pathways, including referral, admission and transition between services. Chandlers Ford Dialysis Unit provided dialysis for NHS patients and worked in partnership with a local NHS trust to ensure continuity of care when patients transferred from hospital-based dialysis to the unit. This collaborative approach supported safe and effective transitions, with clear communication between services to ensure patients’ needs were understood and could be met prior to transfer.

The service operated a defined admission and acceptance criteria to ensure only patients whose needs could be safely managed were accepted for treatment. Referrals were reviewed by senior clinical staff and were subject to consultant approval where required. This included patients with more complex clinical histories, such as recent cardiac or psychiatric events. Any exceptions to the admission criteria required formal agreement from the consultant and documented within patient records. This helped to ensure effective oversight and management.

Detailed pre-admission checks were undertaken to support safe care delivery. This included confirmation patients were stable, had functioning dialysis access, and did not require clinical interventions or equipment beyond the competence of staff at the unit. Infection prevention and control requirements were also assessed, including blood-borne virus status and the ability to safely accommodate isolation where required. Additional considerations included oxygen requirements, medication needs and resuscitation status, ensuring all relevant clinical information accompanied the patient.

The service had clear processes to ensure all required documentation was received in advance of treatment, typically less than 24 hours prior to admission. This supported staff reviewing patient information, planning care safely and reducing risks associated with incomplete or missing information.

The service had effective systems and processes in place to protect patients from abuse and neglect. Staff received safeguarding training appropriate to their roles and demonstrated a clear understanding of their safeguarding responsibilities. All staff had completed level 3 safeguarding adults training and level 2 safeguarding children training, while the manager and deputy manager had completed level 3 safeguarding children training. Compliance with safeguarding training requirements was monitored through the service’s governance arrangements, with records showing 100% completion. Safeguarding training was delivered regularly and included scenario-based learning to support staff in recognising, responding to, and appropriately escalating safeguarding concerns.

Staff were able to describe safeguarding principles and demonstrate how they would identify and respond to concerns involving adults or children at risk of harm. They were aware of local safeguarding referral processes and understood the actions required to escalate concerns and seek advice when needed. There were clear safeguarding pathways and reporting arrangements to support staff in following the required procedures. Staff provided examples that demonstrated their understanding of safeguarding practice and their responsibility to protect patients from harm.

There was a clear organisational commitment to protecting children, young people and adults at risk from harm. Safeguarding was recognised as a collective responsibility across all roles within the organisation, with an emphasis on preventing harm, abuse and neglect. Safeguarding arrangements were overseen through governance processes, including regular review at integrated clinical governance meetings, supervision, and annual reporting.

Patients were supported to understand their rights. Staff demonstrated an understanding of the Mental Capacity Act 2005 and the Equality Act 2010, and ensured care was delivered in a way that respected patients’ rights, dignity and protected characteristics. Staff described how they adapted care to meet individual needs, reflecting an inclusive approach to safeguarding and equality.

The service had systems and processes to involve people in identifying and managing risks related to their care and treatment. Staff completed individual risk assessments for each patient. These covered areas such as falls, pressure ulcers and evacuation needs. Care plans clearly set out the actions needed to reduce risks. They also outlined the responsibilities of both staff and patients. Patients told us they were involved in these assessments and agreed with the planned actions. This showed a person-centred approach to risk management.

Patients were supported to understand their conditions and associated risks. They told us they felt confident raising concerns or reporting changes in their condition. Patients also received education and support on how to manage their renal care. This helped them understand their treatment and recognise potential risks. It also enabled them to take an active role in managing their own health and safety.

Staff used the National Early Warning Score (NEWS2) to assess and respond to patient deterioration. Records showed NEWS2 scores were completed accurately, with observations undertaken at regular intervals. Where observations fell outside the patient’s normal range, staff acted on this and increased monitoring as required.

Staff demonstrated a clear understanding of how to recognise and escalate concerns. This helped ensure patients were monitored effectively and any changes in their condition were identified and quickly responded to.

Medical staff were not based on site. However, staff had access to remote advice from renal physicians at the local NHS trust. This meant additional clinical support was available when needed. In urgent situations, patients were transferred promptly to acute services. Emergency equipment, including an automated external defibrillator, was available to respond to medical emergencies.

The service ensured staff were trained to manage risks, including life-threatening situations. Clear roles and responsibilities supported safe practice. The clinic manager ensured only trained staff carried out resuscitation and life-saving procedures. Staff completed mandatory training, including intermediate life support for those leading shifts. A structured training programme included regular simulation exercises. This helped maintain staff competence and confidence.

We identified some environmental security concerns. Although access to the patient treatment area was controlled through a keycode entry system, the rear doors of the unit were found to be unlocked. This allowed access to other areas of the building, including areas where sodium chloride and acid concentrate were stored. We also observed some clinical storage areas were unsecured. Although we found no evidence patients had come to harm, unlocked access points and unsecured storage areas created a potential risk unauthorised individuals could gain entry to clinical areas. We escalated these concerns to the manager during the inspection. Following our feedback, the provider acted quickly to mitigate the identified risks. A work order was raised immediately to install locks on the doors, and evidence provided after the inspection confirmed the locks had been fitted.

The facilities, premises and equipment were suitable for the delivery of safe care. The dialysis unit was located on the ground floor, providing accessible facilities for patients. The unit had a waiting area with a range of seating, including chairs with armrests, and drinking water was readily available. We observed there were 6 wheelchairs in the waiting area should patients need support with mobility. There were 18 dialysis stations in total, comprising of 16 treatment stations within the main ward area and 2 side rooms. Staff told us the rooms were prioritised for patients with a suspected or confirmed infection status. Individual stations were equipped with a fully reclinable dialysis chair (allowing patients to sleep or staff to deal with patient emergencies), a side table, a television and internet access. Privacy screens were available to maintain patients’ dignity when required.

The environment was visibly clean and well maintained. External cleaning contractors attended the service daily, including an early morning cleaning schedule and additional daytime cleaning. Environmental cleanliness was monitored through routine cleaning audits. During the inspection, clinical areas, including the clean utility room were observed to be clean, spacious and well organised. Staff were observed following good infection prevention and control practices, including effective hand hygiene.

The service had suitable arrangements for the safe management of waste and hazardous substances. Clinical and domestic waste were segregated using colour coded waste streams, and sharps bins were available at patient treatment stations. Clinical waste was stored securely within a locked external compound.

Equipment was maintained and available to support safe care. Each dialysis station had its own dialysis machine and staff completed safety and functional checks before use. Three spare dialysis machines were available to maintain continuity of treatment in the event of equipment failure. We observed one machine had been clearly labelled as out of service pending repair, preventing inadvertent use. Staff reported faults promptly and described receiving timely support from renal technicians, who regularly attended the unit to undertake servicing, maintenance and repairs.

Records showed medical equipment was maintained, calibrated and within servicing dates. This included blood pressure monitors, chlorometers, defibrillators, fridge thermometers, hoists, infusion pumps, pulse oximeters, scales, suction equipment and ultrasound equipment. All dialysis machines, treatment beds and chairs, 2 Body Composition Monitor (BCM) machines had all been serviced within required timescales and had future maintenance dates scheduled. BCM machines are used to assess a patient's fluid status and body composition, supporting clinicians to optimise dialysis treatment and manage hydration levels safely.

Emergency equipment was readily available and maintained. The resuscitation trolley was fully stocked, consumables and emergency medicines were within expiry dates, there were no gaps in documented checks, the suction machine was connected and operational, and the defibrillator was within its testing schedule. Four full oxygen cylinders were available within the unit. These were stored in a designated area next to the nurses’ station and secured with chains and brackets to prevent them from falling. Oxygen cylinders in use were kept on an oxygen trolley and returned to the designated storage area when not required. Daily checks of emergency equipment, including oxygen supplies, were completed and documented.

Management of the water treatment system was well controlled and reflected the importance of water quality in haemodialysis services. Staff completed and recorded daily monitoring of the reverse osmosis water treatment plant, including pressure readings throughout the system, water conductivity, temperature monitoring and rejection-rate testing. Records reviewed from March to June 2026 showed no gaps in testing, and all results were documented with staff signatures. The service had clear escalation procedures for responding to water quality concerns, including access to specialist support outside normal working hours. These arrangements helped ensure water used for haemodialysis met the high safety standards required for treatment.

The service had sufficient staffing levels to meet the needs of patients. Planned and actual staffing data from December 2025 to April 2026 demonstrated the unit consistently met the expected nurse to patient ratio of 1 registered nurse (RN) to 3 patients. Where shortfalls in non-registered staff were identified, these were mitigated by the presence of additional RNs, who were able to provide cover and maintain safe care delivery.

Staff were safely recruited and monitored. There were Disclosure and Barring Service (DBS) checks for staff, and professional registrations were reviewed monthly, with 100% compliance. Annual appraisals were completed for all staff, supporting oversight of performance and development.

Staff had the skills and training required to deliver safe and effective care. Mandatory training compliance was 95%, meeting the provider’s target. Core training such as basic life support, infection prevention and control, manual handling, information governance and use of automated external defibrillators were 100% complete. This ensured staff were equipped to respond to patient needs and risks.

The provider had a structured approach to staff training and development. The Care Delivery Manual clearly set out training expectations and development pathways. New staff completed a comprehensive induction, which included an 8-week supernumerary period. This helped staff to develop competence in a structured and supported way, aligned with the provider’s competency framework and professional development workbook. Staff competencies were reviewed annually to ensure ongoing suitability for their roles.

There were opportunities for staff to further develop their skills, and staff were encouraged to undertake specialist training relevant to the service. This helped to support continuous development and service improvement.

The service maintained a clean environment and had effective infection prevention and control (IPC) systems. All areas were visibly clean, and furnishings were well maintained and suitable for effective cleaning. There was a comprehensive provider level IPC policy which provided clear guidance for staff, including procedures specific to renal dialysis.

Staff followed good infection control practices. Equipment was cleaned and disinfected between each patient dialysis session. Staff adhered to Aseptic Non-Touch Technique (ANTT) when connecting and disconnecting patients from dialysis machines, in line with provider guidance. This reduced the risk of healthcare-associated infections and protected both patients and staff from exposure to blood and bodily fluids. Staff consistently washed their hands before and after patient contact and used appropriate personal protective equipment (PPE) in accordance with national guidance.

The service monitored IPC standards through regular audits. Hand hygiene audit results from January 2025 to May 2026 showed 100% compliance. This demonstrated strong adherence to infection control practices. Environmental IPC audits generally showed high levels of compliance, with most clinical areas consistently achieving 100%. However, some areas of non-compliance were identified, particularly in the waiting area and cleaners’ store. For example, audits in March and April 2026 identified reduced compliance scores of 89%, and a lower score of 50% in the cleaners’ store. The service took timely action to address these issues, including raising concerns with cleaning staff and addressing specific issues such as dust and toilet cleanliness.

Although there were no medical staff on site, there were clear escalation processes for infection concerns. Staff could access support from an on-call renal registrar at the NHS trust if they suspected an infection related to a patient’s dialysis access line. Staff reported receiving timely advice and support, which helped ensure patients received appropriate clinical oversight when required.

Staff followed good practice in medicines management and managed medicines in line with national guidance to ensure patients received safe and effective treatment. Medicines management systems supported the safe ordering, storage, administration and disposal of medicines and were designed to meet patients’ individual needs.

Staff had access to the provider's medicines management policy, which gave clear guidance on the safe ordering, storage, administration and disposal of medicines. The policy also included guidance for supporting patients who brought their own medicines into the service.

Medicines were stored securely and in accordance with national best practice. Medicines inspected during the assessment were within expiry dates and medicine cupboards were organised appropriately, with no evidence of overstocking. Staff completed and recorded daily temperature checks of medicine refrigerators, and records demonstrated these were consistently maintained within required parameters.

All staff completed mandatory training in the safe management of medicines. Staff administered and recorded medicines in line with national guidance and professional standards, including those set by the Nursing and Midwifery Council.

Dialysis-related medicines were prescribed by the NHS renal consultant and included medicines such as oxygen and paracetamol where required. Patients' dialysis prescriptions were reviewed regularly through multidisciplinary discussions involving the NHS renal consultant and staff from Chandlers Ford Dialysis Unit to ensure treatment remained responsive to patients' clinical needs.

Medicines management audits demonstrated high levels of compliance with the provider's medicines management policy and associated processes, providing assurance that medicines were managed safely and effectively.