Diaverum Dialysis Clinic - Rotherham

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

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 inspected the service in 2017 but at the time we did not rate dialysis services.

At this assessment we have rated Well-Led as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We assessed 7 quality statements from this key question.

We found that leaders promoted an open culture of continuous learning and improvement. There were governance systems and processes in place to ensure that services were safe and effective. Staff worked with NHS colleagues to deliver care that was person-centred and integrated.

Staff told us that the clinic management team were visible and supportive and we witnessed that during our visit.

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 provider 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 people and their communities.

At our site visit, we observed a culture which was patient focused. The service cared well for its patients and staff were able to suggest ideas for improvement in practice. These were welcomed and considered.

Staff we spoke with felt very supported by the leadership in the unit. Questions and queries were responded to, which made them feel valued and seen as members of the team.

Staff knew and understood the providers values and how they applied in the work of their team. We saw a notice board which had values such as putting patients first, prioritising patient and staff safety and delivering exceptional care.

Unit managers and staff were aware of succession plans for the unit, including for the environment and specialist equipment used.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us they felt supported in their roles by the unit’s management team. They had also been given appropriate shadowing and supernumerary working times in which to familiarise themselves with the role and complete any bespoke training that was needed.

Managers told us they could contact senior leaders at any time if they had any challenges and described communication and visibility as good and improving. Managers accessed training and support to enhance their skills and knowledge.

Patients told us the unit was well organised with the manager and deputy manager making sure any issues were dealt with, so the unit ran smoothly.

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

Staff told us they felt able to raise concerns, voice opinions and have open discussions about any challenges they faced within the service and feel listened to and supported without fear of repercussion or detriment. They were also aware of how to raise concerns anonymously.

The provider managed whistleblowing using its "SpeakUP!" policy. This framework promoted a culture of openness, allowing employees and partners to report suspected misconduct, legal violations, or breaches of the Diaverum Code of Conduct safely and anonymously via an online whistleblower platform.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff received training in equality, diversity and human rights.

Leaders told us the workforce included international nurses who had integrated into the existing team and were valued for their skills and knowledge. Staff told us they felt valued. Staff we spoke with spoke positively about career opportunities available within the team and were encouraged to develop their skills and knowledge.

There were no concerns raised to us about discrimination, bullying, harassment or people being treated differently because of any protected characteristic such as age, gender, sexual orientation, race, religion or disability. Reasonable adjustments had been put in place to support staff who had long term health conditions or personal circumstances to support them to continue working.

The provider had clear responsibilities, roles, systems of accountability and governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We reviewed the committee structure that included the dialysis unit and when we reviewed meeting minutes, saw regular meetings and discussions about quality and patient safety took place. The clinic manager and deputy reviewed incidents and attended a monthly national governance and quality meeting. This ensured the location was held accountable for investigations into falls, safeguarding reports and serious incidents. Incidents were discussed and actions were taken to improve safety and prevent future similar events from happening. Meeting actions were shared with staff in the unit to promote learning.

The unit undertook clinical audits and where shortfalls were identified, such as in the hand hygiene audit, action plans were created to support staff and the unit to improve.

Staff were clear about the policies they were following. We reviewed some policies, however, it was unclear from their title sheets when they would be reviewed by. All policies observed, had been published within the previous 12 months.

There was a risk register in place which was reviewed and updated regularly. It contained 7 risks with the highest level of risk being moderate for communication challenges with the trust estates team and poor cleaning standards by the trust cleaning team. The risk register showed updates and actions taken to mitigate or resolve risks.

The unit had business continuity plans in place to manage unplanned events such as water, electricity or machine failures to enable them to continue to deliver safe care to patients.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The clinic worked in partnership with NHS trusts which commissioned their services. Consultants and dieticians from the commissioning trusts regularly held clinics and visited the unit. Staff from the unit attended monthly multi-disciplinary meetings with trust staff. During these meetings each patient receiving dialysis was discussed to include treatment changes, health changes and amendments to any treatment plans that may be required.

Staff at the unit told us that they had good working relationships with their NHS partners and could contact colleagues via email or phone between meetings when needed.

The provider met regularly with trust colleagues to ensure training and support opportunities were available as part of ongoing clinical skills development for staff.

The provider 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.

Incident reporting was embedded in daily operations. All staff were trained to report all incidents, near misses and adverse events, which were reviewed regularly. Thematic analysis of incidents were conducted to identify trends and inform proactive interventions.

We reviewed incidents from the previous 12 months which included near misses through to critical level incidents. Each had been reviewed and where appropriate, investigations had taken place.

Each morning staff huddles discussed key risks including recent incidents.

All staff we spoke with received protected induction time, which could be extended, should further support be required. Induction was further supported by bespoke training, designed in accordance with individual staff clinical competencies and operational processes.

Staff followed best practice guidelines to deliver care and treatment but also looked at how they could improve the experience of patients and their outcomes.