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Archived: St Anne's - Emsworth

Inspection Summary

Overall summary & rating

Updated 9 October 2018

St. Anne’s Dialysis Unit, Emsworth is operated by West London Hospitals Holiday Dialysis Trust. The service has three dialysis stations and one isolation room. The unit was nurse-led and staffed by one registered nurse and three part time healthcare assistants. The service provides dialysis for one session per day with three appointment slots available for patients requiring temporary dialysis away from a base while on holiday.

We conducted this inspection on the 25 April 2018 to follow up on issues identified during our comprehensive inspection on 7 June 2017 when a warning notice was served detailing the improvements required . Therefore, we only inspected and reported on these areas.

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.

Services we do not rate

We regulate dialysis services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

The provider had made significant progress in addressing the issues identified at the last inspection in June 2017, these are detailed throughout report. While further works is required to ensure changes are met we consider the requirements of the warning notice to have been met.

We found the following areas of good practice:

  • There was a system in place for the reporting of incidents that included the details of any investigation and action taken.
  • The staff had a basic understanding of the principles of duty of candour and their application. Incident report forms had been amended to include a prompt to staff to consider the duty of candour. However, no formal training had been sourced and staff had gained their knowledge from reading about the subject.
  • Medicines were safely stored and managed.
  • Staff had completed safeguarding children training to the required level.
  • A review of the governance arrangements had been completed and a new structure implemented. This included a named person on the charity’s committee with responsibility for governance, a quarterly meeting between the governance lead and the manager, a manager’s report to the charity’s committee, an audit plan and support in the review of incidents. This was new and it was not possible to access the impact of the new structure and processes.

  • The manager had put a risk register in place since our previous visit to document and monitor risks to the service.

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

  • The manager reviewed the local policies and standard operating procedures; but there was limited information to indicate that these were evidence based. Some of the policies were from an acute trust, but had not been adapted formally, and were past their review date at the time of our inspection.
  • The manager was capturing actual and potential risks on a register; but the format used, did not provide detail on how the level of risk was assessed, or the impact of any mitigating action taken to reduce the level of the risks.

Following this inspection, we told the provider that it must take some actions to comply with the regulations even though a regulation had not been breached; and other improvements it should make, to help the service improve.

Amanda Stanford

Deputy Chief Inspector of Hospitals on behalf of the Chief Inspector of Hospitals

Inspection areas


Updated 9 October 2018


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Updated 9 October 2018

Checks on specific services

Dialysis Services

Updated 9 October 2018

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.