North Ormesby Dialysis Unit

On this page

• 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

At our last inspection we rated this key question inadequate. The unit was in breach of legal regulation in relation to safe care and treatment. The unit had made improvements and is no longer in breach of this regulation.

We assessed 8 quality statements for this key question.

Patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff had the required training and skills. Staff assessed and managed risks for patients and themselves well. There was a process in place for managing deteriorating patients. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

At this assessment the rating has remained/changed to good, however there was one breach identified relating to premises and equipment.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Service users were encouraged and supported to raise concerns. A poster was visible advising service users how to complain. We also saw posters detailing directors’ mobile telephone numbers so people could contact them directly.

Concerns and complaints were used alongside other safety information to help to proactively identify, manage and control risks before safety events happen.

Staff told us they knew what incidents to report how to report them and received feedback from managers. Staff could give examples of shared learning.

Leaders said there was a culture of safety and learning which was based on being proactive, open, and transparent. Incidents were thoroughly investigated, and lessons shared both internally and externally. Leaders provided daily safety briefings at handover and governance meetings. Staff were encouraged to read the minutes if they had missed the meetings. The leaders shared leaning/training using weekly ‘nursing nuggets’ to all staff via the staff intranet.

An incident policy and process was in place which was embedded into practice. There were 465 incidents between July 2024 and June 2025. There were no serious incidents. The top 4 incidents were shortened treatments, missed treatments, medication errors and complications of treatment. 100% of managers and 64% of nurses had received training in how to investigate incidents. This was below the unit’s compliance training target of 90%. 100% of staff were up to date with duty of candour training.

Leaders provided evidence that duty of candour was being used as part of the complaints process. A full explanation was given when things went wrong. Incidents were reviewed to ensure duty of candour had been applied where required. Duty of Candour was audited and any gaps identified were used as learning for the staff.

We scored the service as 3. The evidence showed a good standard. The service worked with service users 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 service users moved between different services.

The service collaborated closely with the local NHS trust as part of the referral process. There was a robust process in place for service users who required emergency care with a detailed handover provided. The unit and Trust shared some electronic patients’ records.

Service users told us care and support was planned and organised with them at first assessment. Staff regularly asked service users if any needs had changed. Service users saw the specialists, including the medical and diabetic team routinely.

Leaders told us safety and continuity of care was a priority throughout Service users’ care journey.

Safety policies and processes were aligned with other key partners, this enabled consistency of safe care and shared learning to drive improvement.

Partners told us the unit worked well with them, and they communicated well. Any issues raised were resolved, for example the unit is now following the correct procedure for high potassium levels.

The unit provided services to service users referred from the local NHS Trust. The consultants and dieticians who visited the unit worked at the Trust. There was a good working relationship, staff contacted the Trust when needed and multi-disciplinary meetings were held to ensure service users were safe.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was an up-to-date Safeguarding policy in place. Staff were trained in safeguarding adults and children level 1 and 2. Nurse compliance was 100% for adults and 82% for children training. Health care staff compliance was 100% for both adults and children training. Managers had level 3 training as per the safeguarding policy. Staff knew how to identify adults and children at risk and how make a safeguarding alert, and did so when appropriate. Staff and leaders could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Service users were protected from abuse using effective processes and practices. Leaders used a tracker system to monitor disclosure and barring service checks to ensure these were up to date.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

We observed staff interacting with service users and discussing their care and treatment so they could make informed decisions. Service users were asked to give feedback on the service via a comment box easily accessible in reception and via Perception of Care patient satisfaction surveys twice a year. Results of these surveys were available for staff and service users to see via posters on display. The unit had devised an action plan following the survey to improve service users’ experience.

Call bells were available in each station unit. We observed these being answered promptly.

Service users said they regularly saw the same staff when visiting the unit, which meant they were able to get to know them.

Risks to service users were assessed on first visit and every subsequent visit. Staff we spoke with were well informed about and understand the risks relating to service users they support.

Staff were able to describe what to do if a patient deteriorates or if their observations (blood pressure, pulse, temperature, respirations) were not within normal levels. There was a process in place for managing the deteriorating patient. On the day we were at the unit we observed a patient deteriorating and saw the process involved to transfer the patient to the local hospital as per the units’ guidelines.

Service users were seen by medical staff who visited the unit twice a week and service users were seen as needed if there was an issue identified. Service users who wanted to come off treatment were referred to their consultant for discussion, so that service users were aware of the risks involved in making this decision.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff and leaders told us about the technology available to support them in the delivery of safe care. The service used a treatment guideline system (TGS) which automated the treatment provided, using up to date information from the patient, such as their current weight. Patients logged onto the system in reception and weighed themselves and this calculation was automatically recorded onto the TGS system. Service users could see this result at their station unit. Staff checked the information at the station unit with the patient to confirm what treatment and supplies were required. Staff had access to some NHS systems. They could access blood results and any admissions the patients may have had.

The equipment we saw was clean, well maintained and within the service, calibration, and electrical safety test due dates. Equipment such as beds, trolleys and stands were visibly clean, and staff used disinfectant wipes to clean and decontaminate equipment.

The service had enough suitable equipment to help them provide safe care and treatment. There were enough machines for the station units, with 4 spare in case of breakdown. There was a planned maintenance schedule in place which listed when equipment was due for servicing. Equipment servicing was managed by an inhouse team from the provider. Staff told us equipment needed for care and treatment was readily available and any faulty equipment could be replaced promptly. Cleaning audits were undertaken daily. In the dirty utility room fridge temperatures were checked and recorded correctly daily. Any harmful substances were in a locked cupboard.

Each station unit had its own TV for the patients to use. Free Wi-Fi was available. Most patients had brought their own entertainment with them to pass the time. There were no curtains around the station units for privacy and dignity, however, staff and leaders told us screens were used if required.

However, we found the back corridor where equipment and the water filtration system was located did not have a lock on the door. The equipment store and water filtration rooms in this corridor did not have a lock on their doors. The external door to the outside found in this area had the key in the door. The meant these areas were not secure and patients and visitors could access these areas easily. This was a risk as there was access to sharp devices and patients' blood products in these areas. No risk assessment had been undertaken. This was escalated immediately to the service.

Following the onsite visit the unit provided CQC with a risk assessment and an action plan to reduce this risk, with a completion date of Spring 2026.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met service users’ individual needs.

Service users told us the staff were professional, informative, and knowledgeable.

Leaders told us there were no vacancies on the unit, but sickness was an issue which was being managed by the Registered Manager, who was supported by the wider management team. There was 1 staff vacancy, which had been filled, and they were due to start in August 2025. Sickness absence was 5.3% for the month of June 2025.

We observed there were enough qualified and support staff in the unit on the day of the visit to support all the patients.

The provider had a process in place of over recruitment in each unit where it provided a service. The units were located close together in the region and staff were moved as needed to support gaps and to help with the induction of new staff and when a different skill mix was required.

Induction and mandatory training were managed centrally, this meant staff who were moved to support a different unit were familiar with how the service worked.

Qualified staffing was calculated as 1 nurse to 4 patients. With support staff also working in the unit. Staff worked 2 shifts per day when the unit was open for morning and afternoon treatments or for 3 shifts when the unit opened for evening treatments.

Service users were supported by NHS medical staff and dieticians, who undertook clinics at the unit. Appointments were scheduled on a regular basis, staff and service users could ask to be seen if and when required. Staff could access NHS medical staff as needed directly via a telephone call or email for advice.

Staff had received and were up to date with a comprehensive mandatory training programme. The training was appropriate for the patient group using the service including such topics as Basic Dialysis Practices and Machine Handling, The Dialysis Treatment and Vascular Access and Dialysis delivery. Mandatory training compliance for all staff was 95%, which was above the unit’s compliance training target of 90%.

Out of 47 training modules: adult basic life support face to face training, completing RCA’s in relation to incidents, managing a safe clinic environment, quality and compliance induction, were below 75% compliance. The unit used real time tracking of training compliance with monthly reviews taking place. Any instances of non-compliance were promptly actioned through direct follow-up, scheduling support, and escalation.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The unit had two Infection prevention and control link nurses who supported the staff.

Leaders told us the provider had a yearly Infection Prevention and Control week across all its units, with the last one being in May 2025. An infection control booklet had been produced, and copies were available in the staff room which celebrated the week and identified what the units had done, and to share good practice. The NHS infection control team attended the unit to complete environmental audits.

The unit was clean with the required furnishing available for all patients, these were well-maintained.

We observed 7 patients having treatment on the day of inspection. Staff undertook the correct sterile procedure to ensure people were kept safe from an infection when connecting and removing the treatment infusions or lines. All staff were bare below the elbow. Staff wore appropriate personal protective equipment. Clinical waste bins were available at each bed space. We observed staff cleaning equipment and bed spaces in between patient use. We observed good hand hygiene, with good access to sinks and alcohol gel.

The unit had an up-to-date General Infection Control policy in place, with sepsis guidelines being part of the Early Detection and Management of the Deteriorating Patient in Adults guidelines.

Audits were undertaken in waste management and cleaning. Weekly hand hygiene audits were undertaken. All staff were able to do this audit, so they were all aware of the importance of these audits. The most recent result in June 2025 reported 94% compliance. Results were fed back at handover and via the provider’s governance meetings. All sharps’ bins were signed and closed when not in use.

Legionnaires disease water sampling reports and risk assessments were up to date. Water plant service records were up to date.

Care of the Central Venous catheters (to administer treatment) and antiseptic non touch technique training was 100% compliance and Infection control training compliance was 95%.

We scored the service as 3. The unit made sure that medicines and treatments were safe and met service users’ needs, capacities and preferences. They involved service users in planning, including when changes happened.

Renal consultants based in the NHS trust prepared haemodialysis prescriptions in advance of treatment.

We reviewed six prescription charts and saw that records were fully completed and were clear and legible.

Service users did not wear wristbands by way of an identifier. We observed staff complete verbal checks such as confirmation of name and date of birth prior to medicines being administered. Some medicines were prepared for service users in advance of their treatment, all had computer generated labels and were double checked at point of clinical administration.

We observed a medicine round during inspection. Staff wore aprons stating do not disturb to ensure the safe dispensing of medicines

Medicines, including medical gases, were stored securely. and at the right temperatures. Emergency medicines were available should they be required and there was a process in place for date checking these medicines to ensure they are fit for use. The clinic did not store any controlled drugs. Lead responsibility for the safe and secure handling and control of medicines was the clinic manager. The nurse in charge, usually the team leader or more senior nursing staff, would be allocated duties as key holder for the medicine cabinet on a day-to-day basis.

Medicines requiring refrigeration were stored in a fridge, which was locked, and the temperatures were checked daily. Staff were aware of the action to take if the temperature recorded was not within the appropriate range.

Comprehensive policies and procedures were in place to support the administration of medicines.

The manager told us about the variety of medicines audits completed. We reviewed the results of medicine audits from March to June 2025. Compliance was above 90%. Action plans were in place following each audit.

Staff told us they had completed medicines training and had been assessed as competent.

There was a process to report and investigate medicine errors and near misses for learning.