Hull NHS 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 key question looks at whether people were protected from abuse and avoidable harm.

At our last assessment, we did not rate this key question. At this assessment, the service was rated as requires improvement.

This rating means some aspects of the service were not consistently safe. There was limited assurance about safety and an increased risk of harm to people.

The service was in breach of regulation, in relation to the safe management of medicines.

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 provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff did not consistently feel encouraged to report incidents. Some told us they would report concerns to the nurse in charge rather than complete a formal report.

The registered manager (RM) described an incident involving a defibrillator shortly before our assessment but could not recall any actions taken as a result. The service had notified CQC of a cardiac arrest in September 2025, however most staff we spoke with could not describe any learning from this or other incidents. Staff could only describe general themes, such as the number of patient falls.

We reviewed clinic staff meeting minutes from January 2026. These recorded 5 incidents between October and December 2025 where no treatment variance reports (TVRs) were completed, including 2 unexpected admissions. Minutes from November 2025 grouped lessons learned from incidents together, so it was not possible to link learning to specific incidents or confirm that staff had learned from them.

The RM was not aware of NHS England’s Patient Safety Incident Response Framework (PSIRF), introduced as national best practice by autumn 2023. However, staff could access incident reporting systems. One staff member described reporting an incident involving a patient with suicidal thoughts and requesting support from a social worker.

Leads shared incidents and learning points at bi-monthly team meetings. Staff were expected to read and sign meeting minutes, and managers followed up with those who had not done so.

Minutes from March 2026 summarised incidents from the previous 3 months and graded them by level of harm. Incidents rated as moderate or above were escalated to senior leaders.

Unexpected admissions were the most commonly reported incident. These covered a wide range of situations, as staff often referred patients to accident and emergency to investigate potential risks.

The provider did not demonstrate compliance with the duty of candour. Only 10% of staff had completed this training. This was a repeat breach from our inspection in April 2017.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

All staff could access a user-friendly electronic patient record (EPR) system. They could contact a regional lead for support if needed. Staff recorded all cannulation attempts on the system. We saw that patient referral records included relevant medical history and background information.

Staff checked patients were safe to start dialysis. They assessed patients’ condition, recorded observations and reviewed fluid status. Staff continued to monitor patients throughout treatment, completed safety checks and responded to any changes in their condition. Patients attending the twilight shift could not always enter the clinical area before their appointment time to keep them safe.

In October 2025, the service transferred patients to another local unit for 4 days due to a disruption to the water treatment supply. During this time, staff held ‘hot debriefs’ with senior colleagues, including the medical director and area business managers.

The service had an up-to-date emergency preparedness plan, which the registered manager reviewed annually. Copies were available for staff across the unit.

However, the service did not have a completed business continuity plan. Leaders told us this was due to ongoing discussions with the host hospital trust. Staff described how they would respond to disruption, for example by informing patients of delays and arranging treatment at other units where needed.

Clinic staff meeting minutes did not include findings from nursing documentation audits. This meant staff did not receive feedback on performance or learning to support improvement.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff we spoke with could not give examples of safeguarding concerns they had raised or discussed in the previous 12 months. They were not able to describe common types of abuse or risks relevant to their patients. We reviewed minutes from the last 3 month’s clinic staff meetings before our assessment. These did not record any safeguarding concerns or learning.

Some staff were not clear who the safeguarding lead was or how to contact them. Safeguarding contact information displayed behind nursing stations was incomplete. Key contact details for local authority and police services for adults and children were missing.

However, staff could contact the registered manager (RM) or a provider lead, both trained to safeguarding level 4. The RM told us staff raised concerns when needed. Staff could record safeguarding alerts on the provider’s system, although this differed from the system used by the host hospital trust.

All care staff working in patient-facing roles had completed level 2 safeguarding training for adults and children. We reviewed the service’s 6 most recent safeguarding notifications, which described risks to people using the service. Staff referred patients at risk of harm to external safeguarding teams and multi-agency meetings. They could also refer patients to local drug and alcohol services or to the renal counsellor within psychological medicine.

The service had an up-to-date safeguarding policy, reviewed annually by provider leads. This set out staff responsibilities to protect patients and colleagues. It included guidance on safeguarding children, although children were rarely treated at the unit. It also covered the government’s PREVENT strategy.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs that was safe or supportive. However, they enabled people to do the things that mattered to them.

All staff had completed basic life support (BLS) training. They knew where emergency resuscitation trolleys were located and how many were available on the unit. If a patient needed transfer to the emergency department, staff first contacted the on-call consultant. They then informed the acute dialysis team to ensure a safe transfer and handover.

Staff understood risks within their patient group. For example, they followed clear procedures for managing fistulas. Staff educated patients to check their fistulas on non-dialysis days.

We reviewed 10 assessments of patients’ mobility. Staff updated these yearly or when a patient’s needs changed. For example, staff prepared appropriate equipment, such as an evacuation chair or wheelchair, for a patient who required assistance. Staff were trained in evacuation procedures and knew the nearest fire exits.

Staff followed provider guidance when managing haemodialysis emergencies or adverse events. They used established protocols for both prevention and management.

After connecting patients to dialysis machines, staff completed routine safety checks. These included checking lines, needle connections and blood pressure monitoring. A safety checklist highlighted any errors.

The service had an up-to-date sepsis risk assessment pathway. This identified patients at higher risk and included a screening tool.

Staff could raise concerns through a confidential patient concerns register. They shared these with the renal consultant by email or at multidisciplinary team (MDT) meetings.

Patients were asked to tell staff if they had experienced a fall or had taken antibiotics since their last treatment. However, staff did not always complete or review risk assessments promptly. For example, they reviewed Waterlow assessments every 6 months. Care plans did not always include review dates, including for diabetes management. This meant staff may not respond quickly to changes in patients’ needs.

Signage for resuscitation equipment was not always clear. This could delay access to emergency equipment for new or temporary staff.

The provider detected and controlled potential risks in the care environment. They did not always ensure equipment, facilities and technology supported the delivery of safe care.

Staff checked resuscitation trolleys daily and weekly to make sure they were fully stocked and ready for use. Trolleys with automated external defibrillators (AEDs) were available on both floors. If a patient deteriorated, staff followed the protocol to call 999 or the host hospital trust’s crash team.

Each bay of 6 or 12 dialysis stations had its own drug trolley. These were stored securely on the main clinical floor.

Staff were trained to use specialist equipment safely. They supported patients to transfer onto dialysis chairs, for example by adjusting armrests.

On-site technicians maintained all dialysis machines and equipment. Following changes to UK servicing regulations in 2025, machines required servicing every 2 years. Records showed all machines were last serviced on 16 July 2025, with the next service due by 16 July 2027.

The registered manager (RM) told us staff could order equipment and supplies when needed. Stock shortages were rare and mainly related to national availability.

The reception area displayed the provider’s health and safety policy. Only patient transport service (PTS) crews were allowed in clinical areas to reduce disruption.

The service carried out mock fire evacuations every 6 months. We reviewed records from August 2025 and January 2026, which showed staff followed procedures and communicated well with each other and patients. Portable appliance testing was up to date and fire alarms were working.

However, records for resuscitation trolley checks were incomplete. We reviewed daily and weekly checks from January to 10 April 2026 and found missing weekly checks for February 2026 and 2 missing daily checks in April 2026.

When we raised this, the RM could not provide the missing records during our inspection. They sent additional records after the inspection visit. Previous audits had already identified gaps in these checks. This meant we could not be assured that staff consistently carried out all required checks of emergency equipment.

Clinic staff meeting minutes from January 2026 showed 7 outstanding estates or facilities issues. It was not clear when these would be resolved.

The provider could not ensure staff were fully trained and skilled to fulfil their competencies. We could also not ensure absent staff’s clinical responsibilities and tasks were always safely delegated.

However, the provider ensured there were enough qualified and experienced staff. Leads ensured staff received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

Staff did not always complete mandatory training or role-specific e-learning. The training dashboard showed an overall completion rate of 70%, below the provider’s target of 80%. None of the 40 staff, who were required to undertake all training, were fully compliant and 11 staff had not completed any mandatory training. The registered manager (RM) said these were new starters from February 2026 and expected compliance to improve.

The clinic had a training schedule. Seven of the 98 mandatory or corporate training modules had 0% compliance. Modules with no compliance included sepsis training, medicines administration and prevention of medication errors. Only 10% of eligible staff had completed duty of candour training, and 30% had completed medication safety. This meant we could not ensure staff were fully trained and skilled to fulfil their competencies.

Long-term staff sickness affected continuity of care. For example, some staff did not review blood test results or complete monthly patient reviews.

Two healthcare assistants were absent during our assessment. Staff told us this affected day-to-day tasks, such as water flushing, and could lead to delays. This meant we could not be assured that responsibilities were always safely covered when staff were absent.

However, 96% of staff had completed Tier 1 training on supporting people with a learning disability and autistic people. This has been a statutory requirement since July 2022. Some staff had also completed training in hepatitis B vaccination, anaphylaxis, resuscitation, automated external defibrillators (AEDs), and patient group directions for safe medicines management.

The service had a training plan from February 2026 covering monthly modules for the year. Training and education leads focused on specific topics, and link nurses had defined responsibilities, such as vascular access and body composition monitoring. This supported accountability and oversight.

Staff followed the provider’s care delivery training manual to support their development. All 53 staff had completed or were due an appraisal. Managers used personal development reviews to assess competencies. Staff confirmed they had read updated policies, and managers checked that professional registrations were valid. We saw evidence that enhanced Disclosure and Barring Service checks were completed and up to date.

Leads used a safer staffing tool to maintain appropriate staff-to-patient ratios. Each shift included at least one registered nurse, and a proportion of staff had to be directly employed by the provider. Staff assessed each shift for risk. If they identified unacceptable risks, they did not start treatment and escalated concerns to managers.

The service aimed to fill vacancies promptly. However, managers said same-day sickness was harder to cover.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some patients told us that some nurses did not respond well to being challenged about poor hand hygiene. We raised this with the registered manager (RM), who told us staff were encouraged to be open to challenge. The service had responded to concerns by increasing the frequency of infection prevention and control (IPC) and hand hygiene audits to monthly.

We reviewed these audits and saw that performance had fallen by 13.3% between September and October 2025. Results for October showed some staff did not use hand gel or follow policy after touching patient surroundings. Meeting minutes from the same month did not record any actions or improvement plans.

During our assessment, 2 patients in isolation cubicles did not have clear signage to restrict access. This created a risk of infection to staff, patients or visitors. We raised this with the RM, who arranged for new laminated signs and recorded the concern as an incident.

We found issues with storage and cleaning processes. Clean linen was stored in the dirty utility room. Two commodes appeared clean but did not have labels to confirm when they were last cleaned. Some supplies were stored on the floor, increasing the risk of contamination. Non-clinical waste bins were full and had not been emptied. Staff were reminded to label cleaned equipment clearly.

However, we also saw many examples of good IPC practice. Staff followed the ‘5 moments of hand hygiene’ and cleaned their hands before and after patient contact, aseptic tasks and exposure to fluids. They used appropriate personal protective equipment and followed aseptic non-touch technique.

IPC audits from October 2025 to April 2026 generally showed compliance above 90%, although actions from the most recent audit were not complete. The service’s home haemodialysis link nurse led IPC and carried out regular audits.

Staff were trained to use equipment safely and followed procedures to reduce infection risks. For example, they checked central venous catheter (CVC) access at every treatment and had a second staff member confirm connections. They also monitored patients to ensure effective treatment and early identification of issues.

The service had policies for infection control and blood-borne viruses, which staff could access. Staff followed processes to manage patients with infectious conditions safely, including scheduling them to reduce risk to others.

Teams cleaned their own clinical areas and equipment. They completed daily and weekly cleaning checklists, and records showed these were completed. Disposable curtains were in use and had been replaced within the last 6 months.

Staff followed waste management processes and recorded waste disposal daily. Sharps safety procedures were in place, and staff were trained to prevent injuries.

The service did not always ensure medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

We were not assured that prescribing was always safe or effective. We reviewed 9 patient medicine records. Some documentation was unclear or illegible. In some cases, doses recorded on dialysis prescription sheets did not match those recorded on patients’ drug charts. Doctors used variable dose prescribing and abbreviations for units, which reduced clarity. Two patients had 3 medicines prescribed incorrectly across the 8 drug charts reviewed (25%). There was no pharmacist oversight of prescribing on the unit, so these discrepancies were not routinely identified.

Staff did not always follow policy when administering intravenous medicines. A second member of staff should check and sign drug charts, but we found missing entries. This meant we could not be assured that medicines were administered safely.

Meeting minutes from November 2025 reminded staff to check prescriptions at each administration. However, we still found incomplete and unclear prescribing records. This meant governance processes were not effective in improving practice.

Staff did not consistently complete temperature checks for the medicines fridge. We saw a staff member add entries retrospectively for 9 and 10 April 2026. Staff could not locate records for the previous month during the inspection. When we raised this, the registered manager (RM) later provided additional records. This meant we could not be assured that monitoring records were reliable.

Pharmacy support was limited. Outside weekly renal clinics, staff did not have consistent access to a pharmacist. Most staff we spoke with did not understand the pharmacist’s role. There was no clear contingency for medicines support when the pharmacist was not available. This meant there was limited oversight of medicines management.

Medicines were not always stored securely. Keys were left in drug trolleys during the day, which meant unauthorised people could access them.

The provider’s medicines policy required staff to check prescriptions clearly detailed the drug, dose and route, and to verify doses with a second registered nurse. We found these checks were not consistently recorded. This meant staff were not following the provider’s policy.

Records sent after the inspection were incomplete. Emergency medicines checks were not recorded, and a pharmacy delivery note lacked signatures and dates. This meant we could not be assured that records were completed accurately.

However, some processes supported safe medicines use. Staff used paper drug charts and followed variable dosing guidance by referring to dialysis prescription sheets. They monitored patients’ haemoglobin and iron levels and adjusted anaemia treatment appropriately.

Staff supplied pre-labelled medicines for patients to take home. Records showed the prescribing doctor and included 2 staff signatures, to confirm safe supply.

The service carried out medicines audits at least twice a year. These identified issues such as unsigned delivery notes. However, leaders did not complete all actions. For example, earlier audits identified gaps in resuscitation trolley checks, and we found these issues continued.

Staff shared external medicines alerts and recalls at team meetings, including information from the Medicines and Healthcare products Regulatory Agency.

The service reported one medicines error in the 12 months before our assessment. This did not result in harm.