Scarborough 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 means we looked for evidence that people were protected from abuse and avoidable harm.

Our overall rating of safe is inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of safe care and treatment, for this question. This included incident management and learning, ensuring safe systems of care, safeguarding from harm, risk identification and management, providing safe environment, competent and trained staff, infection prevention and control and medicines management.

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

The service did not consistently identify, investigate, or learn from incidents. Staff were unable to describe recent incidents or the learning arising from them, and leaders were unable to access incident reporting systems when required.

Near-miss events were not consistently recognised or escalated. For example, we observed a patient safety incident, which involved a patient who was given the wrong patient treatment card. This meant there was a risk of starting another persons treatment. This was not identified, investigated, or used to inform service learning and improvement.

We also identified examples of patients experiencing serious adverse events, including when their blood pressure dropped and requiring emergency transfer to hospital. These events had not been reported as incidents and, as a result, were not subject to formal investigation or review to identify learning opportunities and reduce the risk of future harm.

The providers incident reporting policy did not include the identification, investigation and management of near-miss incidents and therefore there were missed opportunities to mitigate and avoid possible further incidents. We saw an example of this during our assessment, with an incorrect patient treatment card.

We also saw further missed opportunities when reviewing the Treatment Variation Record (TVR), covering the period of February 1 to 24 April 2026. Within this document we identified multiple incidents, some of which had resulted in patient harm. We noted opportunities to prevent avoidable patient harm, but they were not identified, investigated or mitigated due to poor processes and a lack of effective governance oversight.

We saw no evidence that these incidents had been escalated to the medical renal team as they occurred or through multi-disciplinary team communication pathways, as required by provider policy.

We noted that all these incidents had been rated as “no” or “non-serious harm” and had not generated an incident report.

We requested evidence of thematic learning which had been carried out within the provider's own network, however this was not provided.

All staff however had completed duty of candour training.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Systems to recognise and respond to deterioration were inconsistent and ineffective. National Early Warning Scores (NEWS) 2 scores were miscalculated and not applied in line with national guidance.

We reviewed 5 patient records whilst on site.

Systems to identify and respond to patient deterioration were inconsistent and ineffective. National Early Warning Score (NEWS2) assessments were incorrectly calculated and were not applied in accordance with national guidance. For example, we saw Patient A, NEWS2 scores were miscalculated on 28/03/26 and 09/04/26, meaning early deterioration requiring escalation to the Nurse‑in‑Charge under local guidance was not recognised. This resulted in missed monitoring actions, increasing the risk of delayed recognition and response to deterioration.

Escalation processes lacked clarity, with conflicting pathways creating uncertainty for staff and increasing the risk of delays in obtaining clinical review when patients deteriorated. We found examples where patients experienced clinical deterioration and were not appropriately escalated to neighboring NHS renal consultants for specialist review. Patients were not always hemodynamically stable, and opportunities to seek timely clinical support had been missed.

For example, we saw Patient B on 02/04/26, Patient B experienced hypotension resulting in a NEWS2 score of 3 in a single parameter. Under the providers local escalation pathway, this required notification of the Nurse‑in‑Charge and consideration of sepsis but did not mandate urgent senior clinical review or escalation beyond the unit. This local response was insufficient for a NEWS2 red‑flag presentation and did not align with national NEWS2 guidance, which requires prompt senior clinical assessment. As a result, escalation, comprehensive repeat observations, and appropriate clinical review were not effectively facilitated, increasing the risk of delayed recognition and response to deterioration.

Staff we spoke with were not able to clearly describe the service's patient acceptance criteria or identify which patients may not be suitable for treatment at the unit. Staff told us decisions regarding patient suitability were determined by referring renal consultants from the neighbouring NHS trust. However, they were unable to provide examples of patients who would be excluded from receiving dialysis care at the service. This meant we were not assured that staff had a consistent understanding of the service's admission criteria or the risks associated with accepting patients whose needs may exceed the capabilities of the unit.

Patients also experienced delays in treatment delivery, including delays in being disconnected from dialysis, which impacted their experience and general health as a consequence. Patients told us this was a regular occurrence, which they had escalated several times to managers. We observed this during our assessment.

These failures increased the risk of delayed recognition and response to deterioration, which could result in preventable clinical deterioration, emergency events, or hospital transfer. Delays in treatment also increased the risk of complications and negatively affected patient outcomes and experience. We brought this to the immediate attention of the provider and took enforcement action, to ensure immediate improvements were made. The provider also took steps to improve staff training, and improved auditing of patient records.

The service 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. They did not always share concerns quickly and appropriately.

Staff we spoke with were unable to provide examples of recent safeguarding alerts made, or give any historic examples where patients were appropriately safeguarded.

Access arrangements into the location were unsafe. We saw during the assessment that not all visitors were recorded, including clinical staff. This meant the service could not identify who was onsite at any given time, which increased safeguarding risks for both patients and staff. Patients told us that they were often allowed into the building by domestic staff, prior to clinical staff arriving on duty. We brought this to the immediate attention of the provider, who took steps to stop this practice immediately.

However, staff received training in safeguarding adults and children level 2 and we saw completion rates were in line with the provider’s target. Some staff requiring additional level 3 safeguarding, also received the appropriate training and there was a designated safeguarding lead, training to safeguarding adults’ level 4.

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 service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Not all staff had completed basic life support (BLS) training. Staff 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.

Patients' needs were not consistently identified or supported.

Systems to recognise and respond to clinical deterioration were not operating effectively and did not consistently support compliance with national guidance. During the assessment, we reviewed the Care Delivery Emergency Assessment Forms, which were a provider-adapted National Early Warning Score (NEWS2) assessment and escalation pathway. The National Early Warning Score (NEWS2), developed by the Royal College of Physicians, provides a standardised approach to recording, scoring, and responding to changes in routinely measured physiological observations in acutely ill patients. However, the provider's systems were not being used effectively to ensure patients at risk of deterioration were identified and managed in line with this guidance.

We found emergency assessment processes did not reliably support the identification and escalation of clinical deterioration and were not fully aligned with national NEWS2 guidance. This resulted in missed red flag indicators, delayed escalation, and a lack of timely clinical review.

We identified examples where NEWS2 scores had been calculated incorrectly. As a result, some patients who met local escalation thresholds were not recognised as deteriorating and did not receive the enhanced monitoring or escalation required under the provider's guidance. This increased the risk of deterioration not being identified and acted upon promptly.

Communication needs were not consistently assessed or recognised. This limited some patients' ability to express their symptoms, concerns, risks, or immediate needs. As a result, there was an increased risk that deterioration or unmet needs would not be identified in a timely way. Patients with communication barriers were particularly affected and were at greater risk of harm.

The service did not always detect and control potential risks in the care environment, which supported the delivery of safe care.

The environment did not consistently support safe care. Clinical areas were cluttered, restricting movement around the service and reducing staff ability to supervise patients and respond effectively in an emergency.

The provider's fire safety arrangements were not effective. We found escape routes obstructed by stored items and fire doors propped open, increasing risks to patients, visitors, and staff in the event of a fire. These conditions could delay emergency evacuation and reduce staff's ability to safely manage patients who were deteriorating or required assistance during an emergency.

We requested a copy of the provider's current fire risk assessment for the building. In response, the provider submitted a fire safety report which identified that the fire risk assessment required updating. However, the updated fire risk assessment was not provided. This meant the provider could not demonstrate that fire risks had been fully assessed, reviewed, and managed.

We brought fire safety concerns to the immediate attention of the provider. The provider took steps and decluttered all areas within the service swiftly, to ensure fire exits were clear.

During the assessment, we reviewed temperature monitoring records for the patient kitchen area. These showed temperatures had exceeded the provider's maximum acceptable threshold of 25°C on each of the eight days recorded. We also found a refrigerator used to store perishable items did not have an internal thermometer and there were no records of temperature monitoring.

A refrigerator used to store perishable items had no internal thermometer and no temperature monitoring records. This showed that systems intended to identify environmental risks, implement mitigation, and confirm that risks had been resolved were not operating effectively.

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. If a patient deteriorated, staff followed the protocol to call 999 or the host hospital trust’s crash team.

Each dialysis station 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.

We reviewed 3 portable medical devices, which had been appropriately tested in line with the providers policy.

On-site technicians maintained all dialysis machines and equipment. Following changes to UK servicing regulations in 2025, machines required servicing every 2 years. All machines we reviewed had been serviced in line with these regulations.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Although staffing numbers were sufficient at the time of our assessment, the provider could not demonstrate that staff were appropriately trained or competent to carry out their roles safely. During the assessment, leaders were unable to access or provide assurance regarding staff training records or competency assessments. Following the assessment, we requested mandatory training compliance data. Mandatory training compliance was initially reported at 78%. This was significantly below the service target of 95%.

Information provided following our onsite visit, showed compliance in several areas was below the provider's target, and some training records were incomplete.

The service maintained a mandatory and corporate training programme; however, compliance was poor across several key subjects. Seven mandatory training modules had recorded low staff compliance. For example, compliance with adult basic life support was 63% and Oliver Mcgowan was 67%. The training dashboard showed an overall completion rate below the provider's target at 81%. This meant the provider could not be assured that staff had the knowledge and skills required to deliver safe care and treatment.

Competency assessments were not consistently completed, recorded, or formally verified. As a result, the provider had limited oversight of whether staff had maintained the competencies necessary to perform their roles safely. We saw staff signed themselves as competent across several areas of clinical care. For example, we reviewed the physical training and competency records of a Registered Nurse delivering haemodialysis treatment. These records showed the nurse had signed themselves as competent; however, there was no evidence of formal competency assessment or signoff by an appropriate assessor within the setting. This posed a risk to patients as provider systems could not assure that staff delivering complex dialysis treatment had been objectively assessed as competent to practice.

Leaders could not demonstrate consistent support to the unit, to ensure effective communication across all areas. Acting management had not received any recorded formalised support or training to fulfil this role, and we saw gaps in recording of information across all areas. This included patient records, staff training, general staff updates including meetings and auditing.

However, staff had completed some core role-specific training. This included fundamentals in dialysis and anaphylaxis. Some staff had also completed training in areas including hepatitis B vaccination, anaphylaxis management, resuscitation, automated external defibrillator (AED) use, and patient group directions for medicines management.

The provider had a training plan in place which identified monthly training topics throughout the year. Training and education leads were assigned responsibility for specific subjects, however leaders at the time of assessment were unable to provide evidence of link nurse training at this location.

All clinical staff were subject to enhanced Disclosure and Barring Service checks, which were monitored and maintained.

The service did not assess or manage the risk of infection. They did not always detect or control the risk of it spreading.

Infection prevention and control practices were not consistently followed. Cleaning was insufficient and areas of blood contamination increased the risk of infection and cross contamination. The environment was visibly dirty, with areas of significant deterioration, including damaged flooring in the patient’s toilet.

We saw examples of poor clinical practice including the management of aseptic technique and barrier nursing, inconsistent hand-hygiene practices, non‑adherence to bare‑below‑the‑elbows principles and inappropriate use of personal protective equipment. We brought this to the immediate attention of the staff on duty, to ensure they followed best practice and to keep patients safe.

Infection prevention and control (IPC) practices were not consistently followed. We found evidence of inadequate cleaning, areas of blood contamination, and a visibly unclean environment. Parts of the premises showed significant wear and deterioration, including damaged flooring in a patient toilet, which could not be effectively cleaned and increased the risk of infection and cross-contamination.

During our assessment, we observed poor hand hygiene practices, inappropriate use of personal protective equipment (PPE), and inconsistent application of isolation procedures. We also identified examples of poor clinical practice relating to aseptic technique and barrier nursing. Single use antiseptic products were reused without appropriate controls, increasing the risk of infection and harm. These concerns were raised immediately with staff on duty to ensure appropriate action was taken to protect patients.

The provider took steps to improve the cleanliness of the environment, including a deep clean of all areas and improved staff training and adherence to IPC policies and processes.

We observed unsafe sharps handling practices, which indicated that systems, training, and safe working practices intended to prevent sharps injuries and exposure to blood-borne viruses were not consistently embedded or followed.

The service had IPC and blood-borne virus policies that were accessible to staff. There were arrangements for the safe management of patients with infectious conditions, including treatment scheduling designed to reduce transmission risks. However, there was no evidence to demonstrate that enhanced cleaning was undertaken following the use of isolation rooms by patients with transmissible infections. In addition, patients receiving barrier nursing did not always have appropriate signage in place. For example, a risk had been identified that all patients testing positive for blood-borne viruses or with an unknown status should be treated in the isolation room. We observed unmanaged risk during our assessment, as patients were not treated in isolation rooms when required.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always safely prescribed, stored, monitored, or administered. We were not assured that medicines management processes consistently protected patients from the risks associated with unsafe medicines practices.

Staff told us they had completed medicines management training, and records provided by the service supported this. However, medicines administration processes were not consistently followed in practice. Although second check signatures were in place, we observed no physical medicines checks carried out by the second nurse.

During the assessment, we observed anticoagulant medicines left unattended on the nurses' station and collected by staff as patients were connected to dialysis machines. These practices increased the risk of unauthorised access, administration errors, and potential harm to patients. Patients may also have received medicines that were ineffective or unsafe due to improper storage. Failures in administration increased the risk of medication errors, infection, and avoidable harm.

Arrangements for medicines storage and monitoring were not consistently effective. Medication refrigerator temperatures exceeded the maximum recommended limits on six of seven recorded checks, and ambient room temperatures exceeded the maximum recommended range on all seven recorded checks. There was no clear documentation to demonstrate timely mitigation, escalation, or protective action.