Gloucester Royal Hospital Renal Units

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

This service was previously inspected and rated under a previous provider but has not yet been rated under the new provider.

At this inspection we rated Safe as Good.

In safe, we found a strong learning-based culture with an emphasis on patient and staff safety. Safeguarding responsibilities were understood actively and identified. The unit had enough suitably skilled staff who responded well in an emergency. Staff received meaningful supervision, education and appraisals. Medicines were managed well and every environment we visited was visibly clean. Equipment was well maintained.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Staff were confident to report incidents and knew what to report and when. Staff had effective systems to raise concerns both formally and informally. We reviewed incidents which staff described to us at the site visit. We found these were appropriately reported and investigated as necessary. Staff saw incidents as an opportunity to learn and improve and we saw this learning disseminated through meetings, handovers and safety updates across the whole business, not just the 3 renal units. For example, following an emergency on Severn, staff had held a debrief and identified the need for a lead to be designated in future emergencies. On Cotswold unit staff described an incident using a hoist, so leaders had arranged additional training as a direct response.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care.

The service had a freedom to speak up guardian. Staff were aware of how to contact them. We were told no staff at the unit had contacted the guardian.

The service’s referral and admission process ensured all essential information about the patient was recorded to ensure their needs could be safely met. Staff could access both Diaverum and Trust records to obtain essential information such as monthly blood results.

Patients’ records were clear and complete and contained up to date care plans and medication information. We reviewed 10 records across all three units and saw all essential information was complete including pre and post treatment national early warning system (NEWS2) scores (on ward 7b), which was a relatively new process introduced by the current provider. Staff explained NEWS2 was only completed on the other units if there was concern about a patient.

People who used the service were seen regularly by the same staff members. We observed patients were comfortable talking to the nurses during their procedures.

The service worked with the local trust to regularly review the patient’s care and treatment through a multi-disciplinary quality assurance meeting, although staff acknowledged it was challenging to document when consultants had undertaken face to face visits due to the sporadic nature of visits to the units. This meant that whilst patients were being seen, it was sometimes not captured in their records.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Clinic Managers were appointed as local safeguarding leads and provided with level 3 safeguarding training for adults and level 2 for children. All staff had completed mandatory safeguarding training for children and adults to level 2. All staff we spoke with understood their responsibility to report safeguarding incidents. Numbers of who to contact in the event of a safeguarding concern were clearly displayed on a notice board for all staff to access. Staff said they could access safeguarding information and policies on the electronic system.

Additionally, staff had access to both a safeguarding lead for Diaverum and a safeguarding team within the trust.

The service worked well with people to understand and provide care which met their needs in a safe and supportive manner. Risks were documented and managed, and patients felt fully informed about their care. Risk assessments included falls risk and Waterlow (pressure ulcer) scoring.

Clinical risk was managed through regular multidisciplinary meetings (MDT) between local consultants at the NHS trust and the provider. The service discussed and documented risks to patients in care plans.

If there was a medical emergency on either the Cotswold or Severn units, the protocol was to phone 999 and wait for an ambulance to transfer the patient to the local hospital. Staff were aware of this policy, and we reviewed a debrief following an incident where this policy was implemented in a timely manner.

The service detected and mitigated potential risks in the care environment. As the estates were owned and managed by a third party, there had been some historical challenges in getting repair works completed in a timely manner. Senior staff stated this was much improved and showed us some of the recent improvement to external windows on ward 7b and planned works to replace doors.

The layout of the unit did not always allow staff to maintain the privacy of patients receiving haemodialysis. Severn and Cotswold units did not have curtains around each station to use when privacy was required. All bed spaces on ward 7b had curtains for privacy. Instead, there were screens stored in a separate room which could be used in emergencies and were easily accessible although not routinely used. We were told consultants spoke to patients whilst they were on dialysis chairs and screens were not used for these conversations, although no patients we spoke to raised this as an issue.

The service had space for 29 dialysis patients on Cotswold unit, 16 on Severn and 5 on ward 7b, plus 1 side-room (6 in total). In house technical support was available for the dialysis machines and the water treatment plant. Upon acquiring the 10-year contract and as part of a 10 year rolling programme, Diaverum replaced all the dialysis machines, so they were standarised. This was done to allow staff across all its Gloucester units to move freely between units. Technical staff told us these units were more reliable and had considerably less down time for breakdowns than the previous machines.

The dialysis chairs were located in bays, close together. However, there was sufficient space to enable staff to gain rapid access in case of an emergency. Patients we spoke to did not complain about the comfort of the chairs, which had been replaced at the start of the contract in December 2023. Severn clinic had access to pressure relieving cushions and mattresses, but had no beds. Cotswold and 7B had beds and access to more specialised pressure relieving mattresses.

Staff carried out daily safety checks of specialist equipment, including the resuscitation equipment. Staff checked the water used for dialysing daily.

All patients have access to an individual television which was ceiling mounted and could connect to Wi-Fi for internet access or to work remotely.

All patients faced in the same direction and were able to look out of the windows of the unit onto green space. However, chairs could be moved to allow patient to have quiet time or to help manage behaviour which challenged.

There were ample free car parking spaces for people to use for both Cotswold and Severn dialysis units.

The service had enough nursing staff to keep patients safe. Managers accurately calculated and reviewed the number and grade of nurses needed for each shift in accordance with national guidance.

Staff kept up to date with mandatory training. Data submitted showed all three units had between 94-96% compliance.

The units had low bank staff use and had not needed to use bank staff in the four months prior to our inspection. Short term absences were covered by overtime from within substantive staff.

We reviewed recruitment files and found the service was compliant with Schedule 3 of the Health and Social Care Act.

Staff on all 3 units were engaged in the appraisal process and 100% of staff had set their individual objectives.

Staff received a comprehensive induction and ongoing training and support, including supervision and mid and end of year appraisals. Staff explained how many of them had started as support workers and described how Diaverum had supported them to access further education including in one case, funding to access the OSCE (practical assessment) examination required to hold NMC registration in the United Kingdom.

Staff shared infection concerns with appropriate agencies promptly. There were policies and procedures for infection control and the service assessed and managed the risk of infection.

Cleaning was provided by the trust domestic cleaners and took place daily with enhanced cleans happening weekly. Deep cleans could be arranged on request and staff said the cleaning team was very responsive. On Severn unit, the registered manger explained cleaning had not quite been up to the standard expected, so she had arranged a walk round with domestic staff to explain what needed to improve. The unit had also added cleaning to its risk register which was reviewed monthly alongside the NHS Trust. We saw all staff cleaning the dialysis machines and chairs between patients.

Staff wore personal protective equipment in line with regulations. Staff were observed to follow good hand hygiene practice. We observed staff using appropriate aseptic non touch technique to reduce the risk of infection spreading from staff to patients.

There were suitable furnishings, which were easily cleaned between patients and were well-maintained. The areas we visited in the unit were visibly clean at the time of the inspection.

Hazardous and clinical waste was disposed of safely and responsibly managed which included an enhanced programme of recycling to minimise the impact of generating too much rubbish in a service which had a high usage of consumables.

The service ensured medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff stored and managed medicines and prescribing documents in line with the provider’s policy. Staff stored medicines appropriately and monitored fridge temperatures.

Staff followed current national practice to check patients had the correct medicines. Consultants at the referring hospital updated prescriptions as and when needed for each patient. If changes were required following monthly blood tests, the consultants actioned these and shared the information with the staff at the clinic at the monthly quality meeting.

Prescribed fluids were stored off the floor on pallets, in a clean and secure storeroom and in line with good practice. Medicines were locked away securely.

The service had a hypoglycaemia box available to staff should a patient blood sugar (glucose) levels drop too low.

All resuscitation trollies were stocked with appropriate emergency medicines but were overseen and remained the property of the trust. In an emergency, medicines would be given by the trust emergency team or attending paramedics. Diaverum staff were trained in basic life support, in line with trust requirements and Resuscitation Council national guidance.