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Inspection Summary


Overall summary & rating

Updated 25 August 2017

Grimsby NHS dialysis unit is operated by Fresenius Medical Care Limited (FMC), an independent healthcare provider. The unit has 12 stations (comprised of ten stations in the main area and two side rooms which can be used for isolation purposes) providing haemodialysis for stable patients with end stage renal disease/failure. It is contracted by Hull and East Yorkshire Hospitals NHS Trust, to provide renal dialysis to NHS patients. Patients are referred to the unit from Hull and East Yorkshire Hospital Trusts Renal Service.

The service is situated as a ‘standalone’ dialysis unit on the site of the Diana Princess of Wales NHS hospital. There are plans to increase to 18 stations later this year. The service commenced in 2008 and does not treat children at the unit.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 5 May 2017, along with an unannounced visit to the unit on 22 May 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 issues that the service provider needs to improve;

  • We saw ‘missed opportunities’ within incident investigation documentation including escalation of the deteriorating patient and lessons learnt were not consistently collated.
  • Patient identification policies and processes were not in place in accordance with national guidelines and Nursing and Midwifery Council (NMC) standards in relation to medicines management.
  • The unit appeared untidy, with litter and bins reaching full to capacity.
  • Initial assessments lacked detail and care plans were not developed to support the care and treatment of patients with specific health needs.
  • There was no clear system to ensure staff could consistently identify and manage deteriorating patients, which included sepsis identification.
  • One of the water treatment plants had not been serviced according to the manufacturer’s instruction and documentation to mitigate against this was not available on the unit.
  • The unit was not meeting the ‘Accessible Information Standard’ (2016) or the Workforce Race Equality Standard (WRES) (2015) at the time of our inspection.
  • Staff training compliance was lower than the provider’s internal target in several areas and the unit staff had not received training in accordance with the intercollegiate guidance document "Safeguarding Children and Young People" (2014).

However, we found the following areas of good practice:

  • Staff were clearly able to describe the incident reporting system and were able to provide examples of incidents and how to report them. Staff understood the classification of incidents as clinical, non-clinical and Treatment Variance Reports (TVR’s).
  • We observed staff working with competence and confidence in the unit. Nursing staff were experienced and qualified in renal dialysis. We saw 100% of staff had received induction and appraisal and four staff were completing a renal qualification.
  • We observed a caring and compassionate approach taken by the nursing staff and named nurses during inspection.
  • We observed that consent processes were in place and documentation was accurate. Easy access to complex patient information in the unit and across the trust supported treatment and care of patients in the unit.
  • Performance indicators for 2016/17 showed comparable performance against other Fresenius units nationally.
  • The unit was able to provide haemodiafiltration 100% of the time during the last three months reviewed prior to inspection.
  • Patients were supported with self-care opportunities and a comprehensive patient education process was in place. Holiday dialysis for patients was arranged to provide continuity of treatment and support the wellbeing of patients.
  • Morale at the unit was high and staff spoke positively about the support they received from the clinic manager.

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 three requirement notices that affected dialysis. Details are at the end of the report.

Ellen Armistead​

Deputy Chief Inspector of Hospitals (North region)

Inspection areas

Safe

Updated 25 August 2017

We do not currently have a legal duty to rate dialysis.

We found the following issues that the service provider needs to improve:

  • There was no patient identification policy, which failed to comply with national and Nursing and Midwifery Council (NMC) guidance.
  • We were not assured that incidents were reported or investigated thoroughly. We saw ‘missed opportunities’ which related to communication around the escalation of a deteriorating patient.
  • The unit did not collate lessons learnt in a consistent manner and staff were not able to give any examples of lessons learnt as a result of an incident.
  • There was no sepsis toolkit or pathway in use at the unit and staff had not received training in this area.
  • Initial impression of the unit was poor due to litter on the floor around the dialysis chairs and bins reaching close to capacity.
  • A water treatment plant had not been serviced according to its due date and the associated risk assessment was not available on the unit to mitigate for this.
  • Initial assessment of patient needs, including medical history was not completed in full and care plans were not developed for patients with a specific medical concern.
  • There was a lack of audits to provide assurance regarding medicines management.
  • The unit manager had not received any additional safeguard training as the safeguarding lead for the unit.

However, we also found the following areas of good practice:

  • Staff demonstrated a clear understanding of the clinical incident reporting processes and were able to provide examples of incidents reported under the three categorisations.
  • Safety bulletins were shared with staff and we saw high levels of compliance in relation to staff understanding.
  • There was an open and transparent culture on the unit and staff were clear when to apply duty of candour when things went wrong.
  • All staff were proactively supported with their training and development needs and in the majority mandatory training compliance was high.
  • We saw there were some completed care plans in place for specific medical conditions such as anaemia.
  • Staff were able to explain what they would do in situations where vulnerable adults needed safeguarding.
  • Staff worked flexibly and the rota was planned to ensure safe numbers of staff were available to meet patient need.

Effective

Updated 25 August 2017

We do not currently have a legal duty to rate dialysis.

We found the following issues of good practice:

  • We saw that policies and procedures were developed in line with guidance and standards from the UK Renal Association and had been incorporated into the organisations standard for good dialysis care.
  • The average number of patients with an AV fistula was 92%. This was higher and better than the Renal Association guidance of 85%.
  • Patients who did not attend appointments were monitored as part of the Treatment Variance Reporting system.
  • All staff on the unit were proactively supported with competency and development needs.
  • We saw 100% of staff had received an appraisal in the last 12 months.
  • In the December 2016 report we saw that the Grimsby unit was in the top 10% when benchmarked against other Fresenius units within the area.

However, we also found areas where the provider needs to improve:

  • It was not clear if policies were reviewed and updated regularly as policies only showed the date in which they came into effect.
  • We saw within the management reports, in December 2016, 42% of patients did not have the prescribed four hours of treatment.
  • The provider did not monitor arrival and pick up times for patients receiving dialysis.
  • Pain was not formally or routinely assessed.

Caring

Updated 25 August 2017

We do not currently have a legal duty to rate dialysis.

We found the following areas of good practice:

  • We saw positive interaction between staff and patients. Staff interacted with patients in a respectful and considerate manner.
  • Patients received treatment in shared areas; however we saw sufficient space between each patient to maintain privacy and dignity.
  • We saw staff speaking with patients about their treatment and blood result in a way they could understand.
  • When patients first started treatment they could come to visit the unit first with a family member or friend for a look around.
  • There was a variety of information available to patients including dietary information, holiday provision and shared care.
  • All of the patients comment cards we received had positive comments about the care patients experienced.
  • Patients we spoke with said staff were friendly and had a caring approach.

Responsive

Updated 25 August 2017

We do not currently have a legal duty to rate dialysis.

We found the following areas of good practice:

  • The building met most of the core elements of provision for dialysis patients. This included level access and dedicated parking facilities.
  • The unit was accessible by people who used wheelchairs. There was a hoist available, which staff used if patients were unable to transfer on to the dialysis chair.
  • The unit operated at around 90% capacity and so had spaces to accommodate for holiday treatment sessions for people staying in the local area, provided this had been medically approved and there was session availability and all relevant information was available.
  • Work was in place to extend the number of dialysis chairs in response to the growing number of referrals to the unit.
  • There was no waiting list for referrals.
  • Appointment sessions were offered to patients in accordance with their personal needs and circumstances.
  • Staff told us adjustments could be made for someone with learning disabilities or who were living with dementia; for example they could have someone with them during treatment.

However, we also found areas where the provider needs to improve:

  • There was no evidence the unit monitored against The National Institute for Health and Care Excellence (NICE) quality standards in relation to the arrival of patients within 30 minutes of the allotted time and collected to return home within 30 minutes of finishing dialysis.
  • Senior staff told us any concerns would be discussed at the weekly team meeting so that staff could learn from these and improvements could be made; however they were not able to provide evidence of this.
  • There was no patient involvement group where patients could make suggestions about the service or care of patents on the unit, or where staff could share information about the service with patients.

Well-led

Updated 25 August 2017

We do not currently have a legal duty to rate dialysis.

We found the following issues that the service provider needs to improve:

  • There was evidence that incidents investigated by senior managers had not captured ‘missed opportunities’ in relation to escalation processes.
  • There was a lack of systems and processes to ensure the effective and consistent recording, investigation, and learning from incidents.
  • Systems were not in place to follow national guidance around the observation of and management of deteriorating patients.
  • There were failures to develop and follow policy and procedures in relation to confirming patient identity in relation to medicines management.
  • We saw none of the corporate policies had review dates on them. This meant up to date guidance and legislation may not be incorporated into the organisations policies. For example the FMC medicines management policy referred to NMC guidance which had been updated eight years previously.
  • The unit had not produced workforce data which was part of the NHS contract to ensure staff equality and fair treatment in the workplace. We acknowledged the local area had low numbers of black and minority ethnic population (BME).
  • There was no process to ensure that people who have a disability, impairment, or sensory loss were provided with information that they can easily read or understand and with support so they could communicate effectively with staff. From August 2016 onwards, all organisations were legally required to follow the Accessible Information Standard.

However, we also found the following areas of good practice:

  • Morale in the unit was good and staff felt supported by local managers.
  • There was a friendly culture, and the manager was visible and approachable.
  • The unit manager carried out patient rounds on all shifts to ensure all patients had the opportunity to speak to them regarding any concerns or questions they had.
  • All staff placed patients at the forefront of everything they did and were aware of the vision of the company.
  • The unit manager had developed a strategy to develop services and improve patient outcomes.
  • The unit staff worked together and seemed to have supportive relationships.
  • We saw views and experiences of patients had been sought through the national patient survey 2016 and 91% of patients said they had complete confidence in the nursing staff.
Checks on specific services

Dialysis Services

Updated 25 August 2017

The unit provided only dialysis treatment for adults. We did not rate the service but found that most patients were happy with the care and treatment they received and felt the unit was friendly with competent staff available to provide haemodialysis treatment.