Dearne Valley NHS Dialysis Unit

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we did not rate this key question. At this assessment the rating was Good.

This is the first assessment for this service. This key question has been rated Good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

3. The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff ensured patients achieved their prescribed dialysis treatment times. They checked this on the machine’s patient data menu under ‘effective dialysis time’. Staff could also review these times in their provider’s electronic patient records (EPR) system, as part of the post-dialysis information.

Staff completed patient manual handling and fall risk assessment tools (FRATs) for all patients. This was six monthly or more often if stipulated as a parent trust requirement. For example, after any relevant falls or clinical incidents, new diagnosis or if a patient’s significant overall health or mobility status changed.

Staff ensured FRAT assessments did not conflict with a patient’s Personal Emergency Evacuation Plan (PEEPs). If staff identified changes during assessment review, they also updated the patient’s PEEPs.

Staff completed treatment variance reports (TVRs) if patient’s dialysis was disrupted or incomplete. For example, if a patient’s treatment had to be stopped early (before achieving their prescribed dialysis time), or they were not dialysed on their normal machine. The service’s total number of TVRs in the 12 months before our assessment from May 2025 to May 2026 was 4065. 545 of these were early terminations. The most common reported reasons were patients requesting to have shorter sessions than their prescribed times. This was due to either being brought in late by transport, family commitments or hospital appointments.

3. The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver high-quality care according to best practice and national guidance. The service used the national early warning score tool to assess and manage patients at risk of deterioration. They included temperature and oxygen saturation checks whilst monitoring patient scores. Staff completed Waterlow assessments for haemodialysis patients to assess their risk of pressure damage, and patient manual handling and FRATs.

Staff followed provider procedures and guidance in the event of any haemodialysis emergencies or adverse events. When these clinically presented or were diagnosed, they had management and prevention protocols in place.

Staff checked patient’s vascular access as per the National Institute of Care Excellence (NICE) renal guidelines.

3. The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary meetings to discuss patients and improve their care. Here they routinely referred to the psychological and emotional needs of patients, their relatives and carers. We observed good multidisciplinary team (MDT) working through the monthly meetings. Staff reviewed and updated all patients’ specific needs.

The service always shared information about patient consent, concerns and treatment changes. Multi-disciplinary meeting notes from January to April 2026 showed staff recorded any decisions and actions, including any medications administered. Nurses confirmed patient and family decisions around consent. They highlighted any patient concerns, their and any specific requirements or instructions.

Specialist support from staff such as consultants and dietitians was available for patients who needed it. Consultants gave all patients a full medical assessment yearly. Staff had direct access to a registrar at their parent trust hospital for any issues. We heard they felt well supported by medical staff. Staff could refer patients to dieticians for prompt review at MDT meetings.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. For example, if they wanted to improve their potassium levels. The unit had a multipurpose clinical room dieticians could use for consultations. Staff fully and accurately completed patients’ fluid and nutrition charts where needed.

Staff held safety huddles for every shift; twice daily to keep patients safe. Huddles had a set agenda completed by the nurse in charge. They discussed all current patients, safety checks, followed up any blood tests and allocated tasks. We heard these were helpful, informative and all attendees contributed.

3. The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff ensured patients with specialist nutrition and hydration needs had enough to eat and drink. Dieticians visited the unit monthly and could educate patients with how to develop a proper renal diet at home. Their department had accompanying information with ideal foods. The unit had renal nutrition displays produced by their parent trust’s renal dieticians.

Staff provided support for any individual needs to live a healthier lifestyle. The service had relevant information promoting healthy lifestyles and support in patient areas. Patients could sign up for online on-demand exercise, education and wellbeing classes led by physiotherapists. The classes helped people with kidney disease keep active.

3. The provider routinely monitored people’s care and treatment to continuously improve it. Staff actioned learning from audits to improve compliance. They ensured outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

However, provider and senior leads demonstrated poor governance of some reports and audits. Some service IPC audit performance and compliance had declined.

Outcomes for patients were positive, consistent and met expectations, such as national standards. Staff undertook quarterly annual benchmarking against their previous year’s outcomes. Staff tracked and reviewed monthly key treatment and performance indicators (KPIs) such as reinfusion rates. This data fed into their contract meetings.

Managers and staff used the results to improve patients' outcomes. We were sent the service’s percentage of patients achieving 21 litre infusions with fistulas, grafts and CVCs from January 2024 to March 2026. Scores had improved to achieve 89.3% and 68.4% respectively by March 2026.Staff adjusted patient’s treatment to improve outcomes. For example, by advising bigger needles.

Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. The provider’s EPR system manager checked individual patients met certain targets and addressed any missing data. The RM had monthly meetings with their medical director who reviewed and acted on any underperforming targets.

The service participated in relevant national clinical audits. The service undertook patient record audits at least quarterly. Staff reviewed a 10% sample of active patient records to ensure trends were identified. We reviewed the latest audit from February 2026. Good practice was observed, for example staff documented reasons drugs were not administered. There were no actions or areas for improvement.

Managers shared and made sure staff understood information from the audits. Audit findings were reported to managers and the named nurse upon completion. They signed off any required actions within 7 days.

Managers checked and monitored improvements. They used audit information to improve care and treatment. They fed back any results and outcomes at unit meetings and ensured it was documented in minutes.

However patient record audits were not always consistently formatted and, in some cases, illegible due to a mixture of printed and handwritten entries. This limited evidence that findings had been reviewed and used to support learning.

3. The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Patients told us staff routinely checked consent before starting treatments. They clearly identified, explained and answered questions to any changes in individual medications or procedures. This ensured patients gave informed consent to treatment with all relevant information.

Staff received and kept up to date with training in the Mental Capacity Act and Deprivation of Liberty Safeguards. All care delivery staff received training on the mental capacity act policy. They refreshed their e-learning every two years.

Staff understood how and when to assess if a patient had the capacity to make decisions about their care. When patients could not give consent, staff made decisions in their best interest. Staff did not routinely complete capacity assessments for patients. If they suspected patients had fluctuating capacity, they referred to GPs to carry out assessments in a familiar primary care setting.

Staff clearly recorded consent in the patients’ records. Consent audits demonstrated good staff compliance. We reviewed the service's most recent electronic patient record (EPR) consent audit from April 2026, which sampled at least 10% of active records across a range of named nurses to identify trends, recurrent issues, and examples of good practice. The audit provided evidence that staff were consistently obtaining and recording patient consent appropriately.