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Inspection Summary


Overall summary & rating

Updated 24 August 2017

Since 2008 Fresenius Medical Care Renal Services Ltd has provided haemodialysis for stable patients with end stage renal disease or failure at Scunthorpe NHS Dialysis Unit. The dialysis unit is located on the Scunthorpe General Hospital site. The service is a satellite service of Hull NHS Dialysis Unit and patients are referred from this hub and the local NHS trust. It is a 16-station dialysis unit, comprising of four side isolation rooms and a 12 station main bay.

We inspected this service using our comprehensive inspection methodology. We carried out an announced comprehensive inspection on 23 May 2017 and an unannounced inspection on 12 June 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 no 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 record keeping was thorough. Mandatory training was completed by all staff.

  • Effective arrangements and support from a dietitian and social worker were in place and the individual need of dialysis patients was a priority. There was effective multidisciplinary 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 reported incidents as clinical, non-clinical and 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 50% of nursing staff had over 10 years renal experience and one had a specialist renal qualification. One hundred percent of staff had received induction and appraisal.

  • 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. The detail in written individualised care plans was thorough and updated.

  • Nurse staffing levels were maintained in line with national guidance to ensure patient safety. There was use of a specialist nurse agency when required. 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 was arranged to provide continuity of treatment and support the wellbeing of patients.

  • The unit provided a satellite 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 for 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. Any unavoidable or emergency transfers to the NHS trust renal unit were appropriately managed by the nursing team.

  • The unit monitored waiting and travel times for patients and they did not have long waits pre and post treatment.

  • Staff had introduced a formal process for identification (ID) of patients as action from previous inspection feedback. A signed document with photograph in the patient record had been introduced. We observed nurses asking patients for ID prior to treatment and administration of medicines on both visits. This process needed embedding to ensure safe identification of patients, with particular regard to safe administration of medicines and treatment by staff.

  • Team meetings gave evidence of local leadership sharing lessons learnt from incidents and audit findings. Nursing staff we spoke were very positive about the clinic managers open approach to leadership and governance.

  • 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.

  • Patient satisfaction surveys showed consistent 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 harm from incidents was not clearly described by staff. It was also not clear on the reporting forms or in the unit policy. This would not support a clear trigger for the requirements of the duty of candour regulation.

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

  • 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.

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

  • The unit did not have processes or policy in place to ensure staff could identify and manage patients at risk of developing sepsis.

  • Unit staff did not have access to a designated member of Fresenius staff who had appropriate level 4 safeguarding training for advice. This training requirement was also not included in the Fresenius policy.

  • We looked at a range of policies, these all had included a date they became effective, but did not have a date to indicate when the policy expired or would be revised.

  • The arrangements for the workforce race equality standards (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 24 August 2017

We do not currently have a legal duty to rate dialysis services

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 no 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 and record keeping was thorough. Staff could describe the incident reporting system.
  • ID processes had been recently introduced to support the safe identification of patients prior to treatment and administration of medication.
  • Nurse staffing levels were maintained in line with national guidance.
  • Mandatory training was completed by all staff.
  • Risk assessments were carried out for patients and staff were aware of escalation policies and processes for transfer of patients to NHS hospitals.
  • 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 or in unit policy. This would not support a clear trigger for the requirements of the duty of candour regulation.

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

  • Unit staff did not have access to a designated member of Fresenius staff who had appropriate level 4 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.

Effective

Updated 24 August 2017

We do not currently have a legal duty to rate dialysis services

We found the following areas of good practice:

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

  • 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.
  • We looked at a range of policies, these all had included a date they became effective, but did not have a date to indicate when the policy expired or would be revised.

Caring

Updated 24 August 2017

We do not currently have a legal duty to rate dialysis services.

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.

  • We spoke with patients who told us that ‘staff were fantastic’, and ‘would go out of their way to help with anything.’ Of 28 ‘tell us about your care’ cards, there were 22 positive responses with detailed comments from patients praising the care and treatment they received in the unit.

  • During inspection we observed nurses make arrangements to help celebrate a patient’s birthday with friends and family. A birthday cake had been ordered and other patients in the unit were involved in celebrations. We observed nursing staff supporting a patient with sight impairment to listen to the radio during treatment.

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

Responsive

Updated 24 August 2017

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • The unit provided a satellite 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. Nurses took into account the complex care needs for vulnerable and elderly patients.

  • 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.

  • The unit staff had a good understanding of patient travel and waiting times. Patient transport was organised to reduce waiting times for patients before and after treatment.

Well-led

Updated 24 August 2017

We do not currently have a legal duty to rate dialysis services.

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 Scunthorpe 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 a nominated lead consultant 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.

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

  • The unit was not meeting the Workforce Race Equality Standard (WRES) (2015) at the time of our inspection.

Checks on specific services

Dialysis Services

Updated 24 August 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

.