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Inspection Summary


Overall summary & rating

Updated 2 October 2017

Epsom Dialysis Unit is operated by Fresenius Medical Care Renal Services Limited (FMC). The unit is contracted by Epsom and St Helier University Hospitals to provide haemodialysis to adult patients.

The unit is a nurse led unit, comprising of a clinic manager, deputy clinic manager, two team leaders, a registered nurse and two dialysis assistants. The clinic manager, deputy manager and team leaders also provided clinical care. The unit has 20 haemodialysis stations, including four isolation rooms.

Dialysis units offer services, which replicate the functions of the kidneys for patients with advanced chronic kidney disease. Dialysis provides an artificial replacement for lost kidney function.

The unit provides haemodialysis treatment to adults aged 18 years and over, who have non-complex needs. The unit does not provide home treatment. At the time of our inspection, Epsom dialysis unit catered for nine patients aged 18 to 65 years old and 43 patients aged over 65 years old.

There are two ‘treatment sessions’, one in the morning and one in the afternoon, for patients dialysed on Monday, Wednesday and Friday. There is one ‘treatment session’ in the morning for patients dialysed on Tuesday, Thursday and Saturday. The unit delivers appropriately 560 treatments per month.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 21 June 2017, along with an unannounced visit to the unit on 7 July 2017.

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.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate this service but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • There was a clear governance strategy and staff knew their role and responsibilities in reporting risks and incidents. Incidents were investigated and actions taken in response to share learning.

  • The service had enough staff, with the appropriate training, they had regular supervision and managers supported them.

  • Staff were trained to the correct safeguarding levels for adults and children in accordance with national guidance.

  • The unit and equipment were visibly clean, with evidence of effective cleaning regimes and schedules in place. Staff were observed using effective precautions to maintain patient safety and reduce the risks of infection.

  • Equipment was maintained according to the manufacturer’s guidance, with an adequate supply to cover maintenance or breakages.

  • Staff escalated deteriorating patients appropriately. They had access to medical advice at the local NHS hospital and there was effective multidisciplinary team working.

  • Patients care and treatment was planned, recorded and delivered in line with current evidence-based guidance, standards, best practice and legislation.

  • Epsom dialysis unit had met all its key performance indicators between January and March 2017. The unit measured patients’ outcomes and used them to make improvements.

  • There were effective processes in place for gaining patient consent for treatment.

  • People were treated with dignity, respect and kindness. Staff encouraged patients to be partners in their care and in making decisions.

  • Staff supported patients’ changing dialysis days and or times and made arrangements when the patient went on holiday.

  • Facilities and premises were appropriate for the services being delivered.

  • A link nurse monitored vascular access and supported discussions with the referring NHS hospital.

  • There were monthly quality assurance meetings to assess and monitor the effectiveness of treatment and tailor individual patient’s dialysis plans.

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

  • Although the service had systems in place to grade the severity of clinical incidents we found that the grading system was not consistently used by staff.

  • The waste room and commercial waste bin were unlocked.

  • There were illegible labels on the sharp bins.

  • There was not a standardised way of identifying clean and ready to use dialysis stations.

  • There were omissions in the recording and actions taken following out of range room and fridge temperatures.

  • Staff did not always follow the Fresenius Medical Care Renal Services Limited medicines management policy.

  • FMC did not have a sepsis toolkit or care pathway.

  • Only the clinic manager had completed training in how to use the evacuation chair.

  • The FMC policies we reviewed did not contain a review date.

  • The unit failed to comply with the Accessible Information Standard (2016).

  • The service did not monitor patient wait times for treatment and ambulance response times.

  • The timeliness of the unit’s response to complaints was not clear.

  • The provider had not implemented the Workforce Race Equality Standards (WRES).

  • Staff did not know the organisation’s visions and strategy.

  • The risk register did not show risks specifically encountered at Epsom dialysis unit.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements to help the service improve. We also issued the provider with two requirement notices. Details are at the end of the report.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Updated 2 October 2017

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • Staff reported incidents and these were fully investigated. There was evidence of shared learning from incidents.

  • Staff were up to date with mandatory training requirements to fulfil their roles.

  • Staff were trained to the correct safeguarding levels for adults. However, although all staff had completed safeguarding children training level one intercollegiate guidance states that all non-clinical and clinical staff that have any contact with children, young people and/or parents and/or carers should undertake safeguarding children level two training.

  • All staff were observed using effective precautions to maintain patient safety and reduce the risks of infection.

  • The environment was designed and maintained to keep people safe. Equipment was serviced and fit for purpose.

  • Records were detailed and included risk assessments for each patient.

  • Staff escalated deteriorating patients appropriately and had access to medical advice at the local NHS hospital.

  • Staff levels and skill mix were planned, implemented and reviewed to keep people safe at all times.

  • Plans were in place to respond to emergencies and major situations.

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

  • Although the service had systems in place to grade the severity of clinical incidents, we found that staff did not consistently use the grading system. There was no severity rating recorded for 26% of reported clinical incidents.

  • The waste disposal room door and a commercial waste bin were both unlocked.

  • The labelling of sharp bins was illegible.

  • There were omissions in the recording and actions taken following out of range room and fridge temperatures.

  • There was no standard way of identifying clean and ready to use dialysis stations.

  • FMC did not have a sepsis toolkit or care pathway.

  • Staff did not always follow the Fresenius Medical Care Renal Services Limited medicines management policy.

  • There was an out of date copy of the British National Formulary (BNF).

Effective

Updated 2 October 2017

Are services effective?

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • Patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

  • The unit measured patients’ outcomes and used them to make improvements.

  • Epsom dialysis unit had met all its key performance indicators between January and March 2017.

  • New starters completed a detailed competency assessment and were reassessed annually.

  • There were effective processes in place for gaining patient consent for treatment.

  • Staff referred patients to a social worker or a psychologist if required.

  • Effective multidisciplinary team working was evident between staff on the unit and the local NHS hospital.

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

  • FMC policies we reviewed did not contain a review date.

  • Not all staff were up to date with their mandatory training.

  • The use of family members for interpreting and lack of easy read leaflets was not in line with the Accessible Information Standard (2016).

Caring

Updated 2 October 2017

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • The 27 comment cards we received contained extremely positive feedback about the unit and its staff.

  • People were treated with dignity, respect and kindness during all interactions with staff.

  • People were involved and encouraged to be partners in their care and in making decisions.

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

  • Not all patients knew who their named nurse was.

Responsive

Updated 2 October 2017

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • Patients who required dialysis were assessed by the local NHS renal unit for suitability to dialysis in a satellite unit, and then referred to the unit.

  • Staff supported patients’ changing dialysis days and or times as far as possible to accommodate external commitments, appointments or social events.

  • Facilities and premises were appropriate for the services being delivered.

  • A link nurse monitored vascular access and supported discussions with referring NHS hospital.

  • The service made arrangements for patients to continue their dialysis treatment when they went on holiday.

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

  • The service did not monitor patient wait times for treatment and ambulance response times.

  • The complaints log did not always contain information regarding the response time to complaints.

Well-led

Updated 2 October 2017

We do not currently have a legal duty to rate dialysis services.

We found the following areas of good practice:

  • There was a clear governance strategy and staff knew their role and responsibilities in reporting risks.

  • Local leadership was effective and staff felt very well supported.

  • The unit worked closely with the referring NHS hospital.

  • There were monthly quality assurance meetings to assess and monitor the effectiveness of treatment and tailor individual patient’s dialysis plans.

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

  • Staff were unable to describe the organisation’s vision and strategy.

  • The risk register did not show risks specifically encountered at Epsom dialysis unit.

  • The Workforce Race Equality Standards (WRES) 2015 had not been implemented by the provider.

Checks on specific services

Dialysis Services

Updated 2 October 2017