Scarborough NHS Dialysis Unit

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We rated this question as inadequate.

This meant the evidence showed significant shortfalls. The service was not well managed. Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this and leaders and the culture they created did not support high quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

We have not awarded this service a score for Well-led.

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

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff were aware of the service’s ethos and vision but were unable to articulate or consistently demonstrate the underpinning values in practice. For example, how these aligned to staff appraisals and outcomes within the service.

Staff knew the ethos and vision for the service but were unable to articulate and at times demonstrate the underpinning values.

The provider`s values were;

We Care: We show empathy and support to our patients and employees.

We Connect: We foster collaboration, open communication and trusting relationships.

Commit: We take ownership, stay focused and drive results.

The provider had 3 strategic priorities which were: strengthen core operations; drive profitable growth and innovation; and develop together and strengthen our culture.

Governance systems underpinning these values did not support safe or effective care. Communication gaps were evident, due to inconsistent management arrangements and risks were not consistently identified, escalated, or managed. This created a weak safety culture, where risks were not proactively managed, increasing the likelihood of harm and reducing organisational learning.

We found no evidence that the service worked with local communities to understand the needs of their local area or address issues regarding equality and diversity. The service did not collate any information, to enable promotion of inclusivity.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider appointed a covering manager, in the main managers absence, who received support from a regional manager. However, arrangements did not ensure effective leadership oversight of the service. Senior leaders were not always visible within the unit and could not demonstrate sufficient oversight of key operational, clinical, and governance systems.

We found that governance processes and audit activity were not maintained during periods of leadership absence. As a result, oversight of key risks deteriorated, reducing the service's ability to identify, monitor, and respond to emerging concerns in a timely manner.

Leaders described a development pathway that enabled staff to progress into more senior roles, and we reviewed documentation supporting this approach. However, the training programme did not adequately prepare staff for key leadership responsibilities. For example, it did not include training in incident investigation, complaint management, coordination of care and treatment, or oversight of personalised care planning and risk assessment processes.

Leaders did not consistently demonstrate an understanding of, or compliance with, their regulatory responsibilities. The provider failed to notify CQC that the Registered Manager had been absent for more than 28 days, as required. This notification was only submitted after inspectors identified the omission during the assessment.

The absence of effective leadership oversight contributed to gaps across several areas of the service, including governance, auditing, staff support, record keeping, and quality assurance processes. This increased the provider's risk exposure and limited assurance that risks to patients were being consistently identified and managed.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to actively raise concerns. The provider had a Freedom to Speak up Guardian (FTSUG) to support staff to speak up/raise concerns about anything that got in the way of patient care or affected their working life.

Staff provided examples of adjustments made to support them in their role.

Staff we spoke with knew about the Freedom to Speak Up process and how to contact the Freedom to Speak Up Guardian. They felt they would be supported to raise concerns without fear of detriment; they had not however had to do this.

Patients told us they were able to raise concerns openly and felt able to approach staff freely.

However, records did not capture these concerns or demonstrate consistent reporting, limiting assurance that issues were acted upon.

We were told of concerns raised repeatedly, which had not been investigated or acted upon by leaders. Patients expressed frustration by this and felt the lack of action demotivated them to express further concern.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had completed equality, diversity and human rights (EDI) training, although compliance was below the providers target at the time of assessment. We were not provided with an EDI policy or strategy.

The workforce was diverse, and it was evident from conversations with staff and from observation that staff respected each other’s cultural and social differences. Staff spoke positively about the support the manager gave to enable them to work flexibly around their personal circumstances.

The service did not have any defined staff network groups, such as disability, LGBT and race equality networks. There were no equality and diversity champions or link nurses within the service.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems did not provide sufficient oversight of care planning and risk management. Audits were limited in scope and frequency and did not provide assurance that deficiencies in care plans, risk assessments, and reviews were consistently identified, escalated, or addressed.

Governance arrangements did not reliably identify, monitor, or mitigate risks. As a result, unsafe practices remained unidentified or unaddressed, increasing the likelihood of systemic failures and ongoing patient harm. Governance systems did not ensure that known risks and concerns were consistently escalated, monitored, and translated into action plans to reduce their impact. Although leaders told us risk was regularly discussed and themes were used to support learning and improvement, documentation reviewed after the assessment did not support this.

The service's risk register did not accurately reflect current risks within the service and did not include several significant risks identified during our assessment. For example, leaders had not identified or mitigated risks associated with infection prevention and control practices and the management of blood-borne infections in line with the provider's policy.

Leaders did not maintain effective oversight of key safety and quality systems. We found limited governance oversight of incident management, environmental risks, infection prevention and control, patient records, medicines management, and staff competence.

Provider audits were not effective in ensuring that current evidence-based guidance and documentation were being used. During our review of patient records, we found outdated Suspected Sepsis Risk Assessment Pathways remained in use despite having been superseded by a revised version effective from 27 June 2025. Auditing across the service was poor, with gaps evident throughout. Patient care plan audits lacked sufficient detail to provide assurance including in areas such as anti-coagulant management and falls management.

In 2 audit periods we reviewed, fewer than 53 individual patient records were audited and audit activity during these 3 month cycles did not meet the provider’s minimum sampling requirement. There was also no provider-level oversight mechanism to prevent repetition or to ensure systematic progression through the full caseload. 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. Patient care plan audits lacked sufficient detail to provide assurance including in areas such as anti-coagulant management and falls management.

This posed a risk to patient safety and weakened provider level governance arrangements, as systems intended to provide routine oversight and assurance of improvement and mitigation from further patient harm were not in place.

Leaders did not always provide effective clinical supervision and oversight of less experienced staff. We reviewed treatment variation records and found multiple examples where entries had been inappropriately closed without the required action being taken. In some cases, records indicated a patient required medical review, but there was no evidence this had occurred.

Mandatory training records supported our findings that staff had not received training in some key patient safety areas. Furthermore, during the assessment leaders were unable to provide assurance regarding staff training, professional registration, or competency records within a reasonable timeframe, demonstrating limited oversight of workforce safety and suitability.

Records relating to incident management did not clearly identify learning, actions, accountability, or timescales for improvement.

We requested evidence of learning from deaths and mortality reviews; however, this was not provided. As a result, we could not be assured that the provider had effective systems for reviewing deaths, identifying learning, and implementing improvements where required.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The service could not demonstrate effective coordination with external systems, including access to clinical and screening data.

Following our assessment, we requested evidence of an agreed process or standard operating procedure outlining the arrangements between the service and the parent trust for the monitoring and assurance of screening and vaccination checks, however this was not provided.

We also requested a copy of any Service Level Agreement, Memorandum of Understanding, or other formal arrangement in place between Scarborough Dialysis Unit and the NHS Trust that sets out the commissioned services. This was not provided.

In 3 patient records we reviewed, we saw no evidence that 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 found no evidence of recent attendance to the weekly sitrep meetings which are the touch point for operational dialysis teams.

The service did not share data with neighbouring healthcare partners and communities.

The service did not focus on continuous learning, innovation and improvement. 

The service did not demonstrate consistent learning from incidents or audits, and improvement actions were incomplete without effective learning, the same errors were more likely to recur, increasing the risk of repeat incidents and preventable harm to patients.

We found no evidence of innovation.