Scarborough NHS Dialysis Unit

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

Our overall rating of effective is inadequate.

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of safe care and treatment in relation to assessing needs, delivering evidence-based care and treatment monitoring and improving outcomes. The service was also in breach of good governance, in relation to, monitoring and improving outcomes and staff, teams and services working together.

We have not awarded this service a score for Effective.

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

The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Assessment processes did not reliably identify or respond to patient risks. For example, a Waterlow score is used to check a patient's risk of getting pressure ulcers. Waterlow assessment pathways did not clearly define review timeframes for differing levels of skin integrity risk, limiting assurance that assessment frequency was adjusted in response to the service user’s needs.

We reviewed 5 patient care records during the assessment. Staff completed initial patient assessments; however, assessment processes did not reliably identify, assess, or respond to individual patient risks.

Patient care plans had been introduced but were not individualised, and key details were missing. This meant patients were at risk of not being managed safely and in a person-centred way. Care plans were not consistently developed to reflect needs identified during assessment. In all records reviewed (100%), care plans were either incomplete, generic, or lacked sufficient detail to support the management of individual risks and clinical needs. Patient records lacked individualised goals, priorities, and interventions, and did not always reflect patients' current circumstances, communication needs, or risk profiles. Named nurse reviews, falls risk assessments, and Waterlow assessments were not always completed within required timescales.

Clinical observations and risk assessments were not consistently completed or reviewed. Known risks, including falls and skin integrity risks, were not always assessed in line with provider expectations, increasing the risk that deterioration or changing needs would not be identified or acted upon.

We found patients requiring consultant review had not always been escalated appropriately. Some patients reviewed were not haemodynamically stable in line with the provider's own acceptance criteria.

Communication needs were not consistently identified, recorded, or supported. In 1 record reviewed, a patient's language needs were inconsistently documented, interpretation services were not routinely used, and communication aids were not available. This limited the patient's ability to communicate needs and contributed to observable distress.

As audits were completed on a selective and limited basis, governance arrangements did not ensure sufficient coverage to provide assurance that all patient care plans would be reviewed within a reasonable timeframe. We were not assured that care needs were consistently identified, escalated, or acted upon to support improvements in record quality and risk management.

The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Systems for recognising and responding to clinical deterioration were not consistently implemented. We observed multiple local escalation pathways in use, including an adapted National Early Warning Score (NEWS2) emergency assessment pathway, a suspected sepsis pathway, and separate training based on a pre-hospital sepsis model. These pathways contained differing escalation criteria and approaches, introducing additional subjectivity into clinical decision-making. As a result, staff were not supported by a single, clear, and consistent framework for identifying and escalating deteriorating patients.

During our review of active patient records, we found outdated Suspected Sepsis Risk Assessment Pathways in use. These documents had been superseded by a revised version that came into effect on 27 June 2025. This meant the provider could not be assured that staff were consistently using the most current clinical guidance when assessing and managing patients with suspected sepsis.

The provider's annual audit programme was not effective, in providing oversight of clinical quality and safety. We requested the annual audit schedule and evidence of actions taken in response to audit findings. Information submitted by the provider demonstrated limited audit activity, including one month of nursing documentation reviews that had no associated action plan, and 2 months of multidisciplinary team handover reviews without evidence that audits had been completed.

The lack of a comprehensive and effective audit programme meant the provider did not have sufficient oversight of care plan reviews, prescription accuracy checks, multidisciplinary team actions, and virology status updates.

Audits completed, did not ensure that current, evidence-based documents were in use and audit activity was limited and in some cases, we saw this had ceased completely following the period of absence by the Registered Manager.

The provider had developed a clinical competency training plan. However, we were not assured that staff were assessed appropriately against this plan as we found example of staff self-declaring themselves as appropriately trained. We issued enforcement action, to ensure swift improvements were made.

The service did not always work well across teams and services to support people.

Staff team meetings within the service had not been held consistently in the absence of managers. We requested copies of local staff meeting minutes; however, these were not provided. Staff told us that information was shared verbally at the start of each shift and after significant meetings, including regional and national governance meetings.

Leaders could not demonstrate that the unit had received consistent managerial support during managerial absence. Acting management staff had not received formal training or documented support to undertake the role effectively.

We found gaps in the recording and sharing of information across multiple areas, including patient records, staff training records, audit activity, staff communications, and meeting documentation. This limited assurance that important information was being communicated, monitored, and acted upon consistently. For example, we reviewed 3 Safety Huddle Templates, which were intended to be used as a checklist for staff handovers and document the checks that required to be undertaken throughout the day. It included blood and water sampling, isolation status and incident discussions. Of the 54 safety huddle forms reviewed, only 14 had completed actions documents.

External healthcare partners told us the unit's senior nursing leadership had a standing invitation to a weekly operational meeting attended by dialysis units and the kidney care nursing team to discuss service capacity, new patients, and operational pressures. However, staff told us there had been no recent attendance at these external meetings, reducing opportunities for coordination, oversight, and escalation of service issues.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Dietary advice was offered to patients attending, via the visiting dieticians. We saw posters advising patients of safe vascular access management and needle positioning.

We requested evidence of health promotion offered to patients, but it was not submitted.

The service did not always monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We requested audit reports specifically relating to patient outcomes. The provider submitted 90 day report data but it did not show the percentage of patients achieving the renal association standards.

This reduced the service’s ability to identify and manage individual patient risks, increasing the likelihood that changes in patient condition may go unnoticed, with unmet clinical needs leading to deterioration.

We also requested any outcome measures data that the provider was collating or sharing with external parties, but we received a staff vaccination email only.

A healthcare partner told us the unit did not share any local audit data.

Audit processes were inconsistent and incomplete. They did not meet sampling requirements or provide assurance that care and risks were monitored effectively.

The provider held a monthly multi-disciplinary meeting attended by the clinic manager and/or the deputy clinic manager, along with the patient’s named consultant, pharmacist of the trust and the dietitian. At these meetings care and treatment was discussed and adjusted to meet treatment goals determined by the NHS consultant in conjunction with the patient.

However, leaders could not consistently demonstrate effective oversight of outcomes, risks, or improvement actions. This meant risks persisted over time, reducing opportunities for improvement and increasing the likelihood of repeated harm.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff received training in relation to consent and mental capacity. However, governance systems did not always ensure communication needs were identified or supported to fully support informed consent.

Interpretation services were not consistently used, and staff relied on family members for communication. We observed patient anxiety as a result of communication barriers, which meant patients may not have understood their care or been able to provide informed consent.

We did observe consent was recorded in the records we reviewed, however due to the above, there was an increased risk of inappropriate treatment decisions and reduced patient autonomy and safety.