Dearne Valley NHS Dialysis Unit

Ratings - Dialysis services

• Overall

  Good

• Safe

  Good

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Good

Our view of the service

Good practice

• Leads encouraged shared care across the service. Staff clearly explained the process to patients, along with how to access and competently document their shared care. The service had shared care tasks of the month.

Areas for improvement

• The service did not always follow the provider’s clear responsibilities, roles, systems of accountability or good governance. For example, the RM had not completed sections of both the latest annual fire risk assessments from May and December 2025. They had scored the unit’s fire risk as 3; graded low, based on incomplete information. This meant they could not evidence all necessary fire hazards and mitigations had been acted upon.
• We found 7 dialysis machines were slightly past their servicing date in mid-May 2026. One was overdue a service since January 2026. The RM notified technical support who would service these within a few weeks of our assessment.
• Documentation did not always grade incidents by severity or categorise them into different themes. This meant the service could not evidence staff knew the service’s most severe and common incident types
• The service did not investigate incidents in line with NHS England’s patient safety incident response framework (PSIRF). This contractual requirement was rolled out across all health and social care organisations up to autumn 2023. This meant service leads could not maximise learning opportunities across the organisation.
• Service leads did not maintain their local risk register. This meant managers could not evidence that all potential risks to the service were considered, reviewed or updated to mitigate harm to patients, staff and visitors.

Improvement actions

The service should ensure infectious patients are always barriered to fully mitigate potential risks of exposure to unaware patients or visitors.

The provider should ensure leads and managers implement a formal or effective system in place to identify, address and monitor risks so managers and staff are aware of those which affect their service.

People's experience of this service

Patients gave very positive feedback about the service. We spoke to 7 and their family or carers. All were very satisfied and complimentary about the service.

We observed compassionate, personalised care, positive interactions and in-depth exchanges between staff and patients. Overall patients told us they were treated with kindness, empathy and compassion. They were happy and well cared for. They told us staff made the unit welcoming and calmer.