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Inspection Summary


Overall summary & rating

Updated 4 October 2017

Since 2008 Fresenius Medical Care Renal Services Ltd has provided haemodialysis for stable patients with end stage renal disease or failure at Hull NHS Dialysis Unit. The service is located within the Hull Royal Infirmary site. Hull NHS Dialysis Unit takes referrals from Hull and East Yorkshire NHS trust. It is a 39 station dialysis unit, with five side isolation rooms. Hull and East Yorkshire NHS trust contracted the unit to provide renal dialysis to NHS patients in April 2016. Fresenius Medical Care Renal Services Ltd also provided care and around 200 ‘in-reach’ dialysis treatments to renal patients in a four bed bay inpatient area located in the nephrology ward of the Hull Royal Infirmary. In addition five patients are supported to receive home dialysis by the service, by the ‘home dialysis’ nurse who is based at Hull unit. The home dialysis service was not within the scope of the inspection.

We inspected this service using our comprehensive inspection methodology. We carried out an announced comprehensive inspection on 10 May 2017 and an unannounced inspection 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 said to 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 areas of good practice:

  • We found that the unit was visibly clean, arrangements for infection prevention and control were in place and there was low incidence of infection. The environment met standards for dialysis units and equipment maintenance arrangements were robust. Staff were aware of their responsibilities in keeping the patient safe from harm and mandatory training was completed by all staff.

  • Effective arrangements and support from a dietitian and social worker were in place and the individual needs of dialysis patients was a priority. There was effective multidisciplinary team (MDT) working and good collaboration with the unit consultant and the NHS trust renal team which helped support patients’ treatment and positive outcomes.

  • There was a good range of comprehensive policies in place to support staff; these were accessible and understood by staff we spoke with. Policies were based on national guidance and an audit programme was in place to monitor compliance. Key performance indicators for 2016/17 showed comparable performance against other Fresenius units nationally.

  • Staff described the Fresenius incident reporting system and were aware of changes being made to transfer from a paper to an electronic system. Staff in the Hull Dialysis Unit recorded incidents in the Hull NHS electronic system as well as using the Fresenius Medical care systems. Staff reported incidents as clinical, non-clinical and documented additional information thoroughly in Treatment Variance Reports (TVR’s).

  • We observed staff working with competence and confidence and the training available in the unit supported all staff to perform their role well. Nursing staff were experienced and qualified in renal dialysis. Over 30% of nursing staff had a specialist renal qualification. One hundred percent of staff had received induction and appraisal at the time of 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 NHS trust supported treatment and care of patients in the unit.

  • Effective processes were in place for the provision of medicines. These were stored and administered in line with guidance and staff completed competencies annually to ensure they continued to administer medicines correctly.

  • We observed a caring and compassionate approach taken by the nursing staff and named nurses during inspection.

  • Nurse staffing levels were maintained in line with national guidance to ensure patient safety. There was use of a specialist nurse agency when required and block booking of agency nursing staff had improved consistency of staff working in the unit since 2015/16. Staff provided additional cover during peaks in activity or during staff shortage.

  • Nursing staff had direct access to the consultant responsible for patients care.

  • Patients were supported with self-care opportunities and a comprehensive patient education process was in place. Holiday dialysis for patients is arranged to provide continuity of treatment and support the wellbeing of patients.

  • The unit provided a local service, with flexible appointment system for patients requiring dialysis and the service contract obligations were clear to senior staff. We observed a responsive approach to arranging appointments with the needs of the patient at the centre. Arrangements for contingency for appointments in an emergency was in place.

  • The unit had detailed local risk assessments in place and we observed a new operational risk register; this was being developed by the national senior team and would be reviewed through the governance committee structure prior to implementation and training to unit staff.

  • Activity was monitored closely for non-attendances of patients. The team worked flexibly to accommodate patients individual appointment needs to avoid non-attendance.

  • Staff had an informal process for identification (ID) of patients as patients were well known to staff. We observed nurses asking patients for ID prior and during treatment and administration of medicines on both visits. However there should be greater assurance, through policy and audit, that all staff working in the unit consistently ID patients to ensure safe identification of patients, with particular regard to safe administration of medicines and treatment by staff.

  • Local leadership shared lessons from incidents and complaints with the team and we saw good evidence of local leadership. Nursing staff and patients we spoke were consistently positive about the clinic manager overall and the open approach to leadership and governance in the unit.

  • Employee surveys were performed annually and action plans supported the team to address any issues where required. Staff morale was good in the unit at the time of inspection and there was an improved picture over all survey results in 2016/17.

  • Patient satisfaction surveys showed positive results and we spoke with patients who expressed high regard for the care and treatment they received from the team in the unit.

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

  • The grading of moderate harm from incidents was not clearly described by staff. It was also not clear on the reporting forms. This would not support a clear trigger for the requirements of the duty of candour regulation. We did however see an example of the application of duty of candour for an incident that had been graded by senior staff in the Hull unit as moderate.

  • The classification of clinical and non-clinical incidents did not reflect the reported events, for example seven incidents of patients falling in the unit were reported under ‘non-clinical’ incidents, to the health and safety manager, rather than the chief nurse.

  • We observed one nurse and one dialysis assistant not strictly follow IPC policy in regard to aseptic non touch technique (ANTT) and this was reported to the clinic manager.

  • We listened to concerns from patients and staff around the arrangements for transport in the unit. Patients were subject to inconsistent waiting times before and after dialysis treatment which had an impact the quality of service delivered to patients who attended three times a week for treatment. The unit monitored the delays and met with the provider through, however improvement for patients experience was yet to be achieved.

  • We observed the waiting room to be overcrowded during peak times of activity, especially at session handover times. Patients in wheelchairs were particularly affected as there was limited space for the numbers of patients needing to access the unit. When delays with transport occurred this exacerbated the overcrowding in the waiting area, which was otherwise adequate for the needs of the size of the unit.

  • It was noted that the access code to the main unit from the waiting room had been restricted to a limited number of staff to improve security and prevent patients or visitors having unsupervised access. The majority of nursing staff did not have access to the code. A system needed to be in place where all staff had easy security access to the main unit through the main doors, to reduce the risk of not being able to get access in an emergency situation.

  • Staff and patients we spoke with complained of a lack of control over the temperature of the unit, with patients having consistent concerns of being too cold and staff being unable to regulate or access the system to regulate temperature control in the unit.

  • Documentation was inconsistently organised and not all completed in line with the Nurse and Midwifery Council (NMC) Code of Professional Conduct in relation to record keeping. All entries were legible. This was reported to the deputy clinic manager and clinic manager for immediate action. There was some improvement during the unannounced inspection to the overall organisation of the patient folders, however we observed some care record sheets had not been signed by staff.

  • Observations were recorded regularly to assess the patient’s condition, before during and after dialysis. We noted however that the unit did not use a recognised national early warning score (NEWS) system to support the recognition of the deteriorating patient. There was inconsistent recording of temperature and respiratory rate as directed by the care plan.

  • We did not observe a system for reporting of pain assessment for patients in the unit who receive dialysis treatment.

  • Unit staff did not have access to a designated member of Fresenius staff who had appropriate level 4 child safeguarding training for advice. This training requirement was also not included in the Fresenius policy. However we did see examples of adult safeguarding practice that had been thoroughly managed by the team.

  • The arrangements for The Workforce Race Equality Standard (WRES) were not embedded in the unit.

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. Details are at the end of the report.

Ellen Armistead.

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Updated 4 October 2017

We found the following areas of good practice:

  • We found that the unit was visibly clean, arrangements for infection and prevention were in place and there was a low incidence of serious infection.
  • The environment met standards for dialysis clinics and equipment maintenance arrangements were robust.
  • Staff were aware of their responsibilities in keeping patients safe from harm. Staff could describe the incident reporting system and staff were positive about the reporting culture in the unit.
  • Nurse staffing levels were maintained in line with national guidance.
  • Mandatory training was completed by all staff.
  • Effective processes were in place for the provision of medicines. These were stored and administered in line with guidance and staff completed competencies annually to ensure they continued to administer medicines correctly.
  • Risk assessments were carried out for patients and staff were aware of escalation policies and processes for transfer of patients to NHS hospitals.
  • We saw examples of staff providing thorough safeguarding support for patients in their care.
  • Arrangements for contingency in an emergency were in place.

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

  • The grading of harm from incidents was not clearly described by staff. It was also not clear on the reporting forms. This would not support a clear trigger for the requirements of the duty of candour regulation. However we did see examples of the application of the duty of candour for two incidents that had been categorised as moderate by senior staff.

  • The classification of clinical and non-clinical incidents did not reflect the reported events, for example seven patients falling in the clinic were reported under ‘non-clinical’ incidents, to the health and safety manager, rather than the chief nurse.

  • One nurse and one dialysis assistant observed did not strictly follow IPC policy in regard to aseptic non touch technique (ANTT) and this was reported to the clinic manager.

  • It was observed that the access code to the main unit from the waiting room had been restricted to a limited number of staff to improve security and prevent patients or visitors having unsupervised access. A system needed to be in place were all staff had easy security access to the main unit through the main doors, to reduce the risk of not being able to get access in an emergency situation.

  • Unit staff did not have access to a designated member of Fresenius staff who had appropriate level 4 child safeguarding training for advice.

  • We noted that the unit did not use a recognised national early warning score (NEWS) system to support the recognition of the deteriorating patient. There was inconsistent recording of temperature and no recording of respiratory rate as directed by the care plan.

  • Staff did not use a recognised sepsis assessment tool and had not received any training or guidance on the management of patients with sepsis.

  • Record keeping was inconsistent and care records were not organised well in the patient folders. We noted that these findings were consistent with unit audit data and that action had not resolved the issues at the time of inspection.

Effective

Updated 4 October 2017

We found the following areas of good practice:

  • There was effective multidisciplinary working and collaboration with the NHS trust renal team helped support patients treatment and positive outcomes.

  • There was a good range of comprehensive policies in place to support staff; these were accessible and understood by staff we spoke with. Policies were based on national guidance and an audit programme was in place to monitor compliance.

  • Activity was monitored closely for non-attendances of patients and the team worked flexibly to accommodate patients individual appointment needs. Any unavoidable transfers to the NHS trust renal unit were appropriately managed.

  • We observed staff working with competence and confidence and the training available in the unit supported all staff to perform their role well. Nursing staff were experienced and qualified in renal dialysis.

  • Consent processes were in place, policy was robust and documentation was accurate.

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

  • We did not observe a system for reporting of pain assessment for patients in the unit who receive dialysis treatment.

Caring

Updated 4 October 2017

We found the following areas of good practice:

  • We observed a caring and compassionate approach taken by the nursing staff, MDT and named nurses during inspection.

  • Patients we spoke with knew their named nurse and described good relationships with the nursing staff. Patients told us that the ‘were well looked after, couldn’t be better looked after’ ‘they’re first class, all of them’.

  • Patients spoke highly of the team overall with specific references to individual named nurses, dialysis assistants and the clinic manager.

Responsive

Updated 4 October 2017

We found the following areas of good practice:

  • The unit provided a local service, with a flexible appointment system for patients requiring dialysis. We observed a responsive approach to arranging appointments. These were arranged with the needs of the patient at the centre, taking into account their work and social commitments.

  • Senior staff were committed to attending business and clinical meetings at the NHS trust to manage the achievement of contract obligations and key performance indicators.

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

  • We listened to concerns from patients and staff around the arrangements for transport in the unit. Patients were subject to inconsistent waiting times before and after dialysis treatment which had an impact on delays and quality of service delivered to patients who attended three times a week for treatment. The unit monitored the delays, and had met with the transport provider, however improvement for patients experience was yet to be achieved.

  • We observed the waiting room to be overcrowded during peak times of activity, especially at session handover times. Patients in wheelchairs were particularly affected as there was limited space for patients needing to access the unit. When delays with transport occurred this created overcrowding in the waiting area.

  • Some staff and patients we spoke with complained of a lack of control over the temperature of the unit, with patients having consistent concerns of being too cold and staff being unable to regulate or access the system to regulate temperature control in the unit.

Well-led

Updated 4 October 2017

We found the following areas of good practice:

  • There was a clear leadership structure in the Fresenius Medical Care organisation and that was applied regionally to the Hull NHS Dialysis unit. The clinic manager was highly regarded by the team and staff morale was good at the time of inspection.

  • Leadership was reflected in three nominated lead consultants from local NHS renal services, a regional business manager, area head nurse and clinic manager, who was based in the unit for 100% of the job role. The clinic manager liaised closely with the local NHS trust.

  • We observed positive support in the unit team and nursing staff spoke highly of one another. This was reflected in our observations of their teamwork and communication and in the employee survey responses.

  • The Fresenius governance framework was detailed and supported with a range of comprehensive policies, a structured committee and meeting system, a strategy and vision that directed the team to deliver ‘the right care to the right patient at the right time’. Senior staff were conversant with these elements of their service and senior business and governance meetings were consistently attended.

  • The implementation of the new local risk register was making good progress at the time of inspection. This work should continue to be embedded in practice.

  • The clinic manager held regular team meetings that were well attended; minutes were recorded and demonstrated examples of sharing of learning and good practice.

Checks on specific services

Dialysis Services

Updated 4 October 2017

We regulate this service but we do not currently have a legal duty to rate it. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary

.