North Ormesby Dialysis Unit

On this page

• 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

At our last assessment we rated this key question inadequate. The unit was in breach of legal regulation in relation to Good Governance. The unit had made improvements and is no longer in breach of this regulation.

At this assessment, the rating has changed to good.

We assessed 7 quality statements from this key question. There was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of service users who used services and wider communities. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of service users and their communities.

The unit had a vision and mission statement focused on patients’ experience and care.

We saw examples of the ‘True Care’ values on posters around the unit covering inspiration, passion, and competence. Staff we able to point these out to us and tell us what this meant for them and the patients.

We saw a poster in the reception area with the unit’s philosophy of care and observed staff providing care using this model.

Leaders told us staff appraisals were based on the unit’s values and appraisals were undertaken routinely once a year and reviewed routinely after 6 months.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge, and experience to perform these roles. The registered manager was an experienced and skilled manager currently covering two units, working 2 – 3 days and North Ormesby. The Registered Manager received support from an experienced manager. Both had the necessary leadership qualifications for this role. A new Registered Manager was to commence in post soon.

The regional managers visited the unit often and were visible to all staff.

Staff could tell us who the managers were, and we observed both the registered manager and regional managers popping in and out of the unit to talk to staff and service users whilst we were visiting.

Leaders could explain how the teams worked and had a good knowledge of all staff and how to support them and individuals as well as a team.

Leaders were able to provide us with evidence of the audits and reports in place to ensure they were aware of the standard of quality care provided and how they worked with the staff to improve this.

We reviewed staff meetings, handovers, the nursing nugget weekly training and shared folder available for all staff which discussed the quality of care and any improvements currently in place to improve quality.

Leaders were able to meet regularly with their counterparts from other units to share any quality initiatives.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Service users had opportunities to give feedback on the service they received in a manner which reflected their individual needs by using either using a suggestion box in reception, talking to a member of staff, telephoning one of the directors or by the patient satisfaction survey. Managers and staff had access to this feedback, or via an experience portal. Any comments were discussed at team meetings and handovers to make improvements.

The unit had a policy in place and an intranet App called ‘SpeakUp!’ This was used to raise questions or concerns. Staff had received training on ‘SpeakUp!’ Staff were encouraged to first talk to their manager, talk directly to senior leadership or use the App.

There had been no concerns received from staff in the past 12 months.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for service users who work for them.

Staff received training in equality, diversity, and human rights. 88% of staff had completed the training. Staff told us there was a supportive culture with opportunities available for further training.

We saw evidence that staff were supported to apply for internal vacancies.

Leaders told us staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. We saw evidence of this in staff records.

The unit undertook a yearly staff satisfaction survey and produces an action plan for any areas below average. We saw actions which included celebrating different cultures every 3 months and discussing interesting facts from different countries.

The unit undertakes equality monitoring of staff within the service.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The organisational chart was visible both in reception and the staff room.

Staff we spoke with were able to describe the induction programme and the support provided to ensure they had the required skills and experience.

There were structured meetings at all levels, including local team meetings, multidisciplinary team meetings with the trust, and governance meetings.

There was a clear framework of what must be discussed at unit and team level in meetings to ensure essential information, such as learning from incidents and complaints, was shared and discussed. Recommendations from incidents and complaints had been implemented.

There was a yearly audit schedule and staff participated in these, actions were shared at both individual and team level.

The unit had a risk register, which highlighted current risks to the service and any controls in place to mitigate risks. This was visible in staff room it included risk from falls, medication errors and risk from service users shortening their treatment.

Leaders described the process within the region to ensure the unit had enough staff to keep safe and provide treatment to the number of service users who were due. The unit employed more staff than required, and if there were short term staff issues, staff were moved from one unit to another as the units were close together. This provided continuity in treatment processes.

Business continuity plans were in place to support with emergencies such as adverse weather or increased sickness.

Staff had access to the equipment and information technology needed to do their work, with spare equipment on site if needed.

There was a Data Protection Policy in place which included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing, and patient care. However, leaders did not have oversight of DBS, mandatory training or appraisal compliance for staff working on site employed by the local NHS Trust.

Sustainability was described as a part of the units plans with an aim to minimise their environmental footprint by reducing carbon emissions, optimising water consumption and minimising waste.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The unit worked in partnership with the local Trust and Trust Specialist Renal staff to support service users with their care and treatment. Service users told us they regularly saw their doctor and dietitian who are based at the Trust when they attended the unit for their treatment.

Unit leaders told us they held regular meetings with the local NHS Trust to discuss any issues. We saw examples of this collaboration.

Partners told us there was good team working between themselves and the unit and any issues had been resolved.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The unit monitored quality regularly and discussed these findings at governance meetings.

There was a culture of learning and improvement across the service. Incidents and complaints were investigated. Audits were routinely completed. Learning was shared with staff to improve the service.

Leaders told us staff were supported to help with innovations and quality.

Leaders told us the unit participated in research. The unit was part of the Randomised Evaluation of SOdium dialysate Levels on Vascular Events (RESOLVE) Study, which was looking into the best levels of salt in dialysis fluid.

Leaders told us, and we saw evidence, that they undertook an unannounced audit of the unit once a year and fed back both good findings and issues to the unit to ensure improvements were made.