Dearne Valley NHS Dialysis Unit

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

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. 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 were safe and protected from avoidable harm.

There was no risk people could be harmed.

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.

3. The service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

However, the service did not grade or categorise safety events.

Staff knew what incidents to report and how to report them. All staff were encouraged and supported to report incidents using an incident reporting system. Some said they would inform the RM or nurse in charge.

Staff raised concerns, reported incidents and near misses. We reviewed the service’s last 6 incidents from January to May 2026; they averaged one per month. The most recent 3 incidents had no lessons learnt but what staff did well. 2 of these were staff’s early recognition of a deteriorating patient using the national early warning score (NEWS).

The service had no never events.

Managers and leads investigated incidents thoroughly, in line with best practice. They graded the harm levels of incidents when reporting as no, low, moderate or severe.

Managers debriefed and supported staff and other patients after distressing incidents. Staff managed a medical emergency on the unit in accordance with emergency response procedures pending the arrival of emergency services.

Staff received feedback from investigation of incidents, both internal and external to the service. Leads had notified CQC of an unexpected death. Staff we asked could provide examples of learning, team building and debriefing from this and other incidents.

We heard about a shared learning example from an incident at another unit. A patient’s central venous catheter (CVC) line was accidentally disconnected without staff knowing. In response staff ensured all patients wore open clothing so they could access their chest and arms while dialysing. This meant they could see and monitor CVCs and fistulas during treatment which reduced the risk.

Staff escalated incidents graded moderate or above to the Area Head of Operations and Associate Director of Nursing in line with the provider’s policy.

The service could demonstrate staff learned lessons from reported incidents. These were clearly summarised in governance minutes.

We saw evidence changes had been made from feedback. February, March and April 2026’s clinic team meeting minutes outlined previous incidents and feedback for staff. For example, one patient had a needle dislodgement. In response staff moved them to a dialysis chair nearer the nurses’ station for closer observation.

Staff met to discuss the feedback and look at improvements to patient care. All staff could access incident and treatment variance reporting systems. Staff heard about updates and actions taken in response to reported incidents.

Staff understood and adhered to the duty of candour. However, not all staff recognised this definition. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. Managers told us they kept patients informed of any open or ongoing discussions. Staff would apologise on the clinic’s behalf if an error was not directly their fault and inform the consultant.

However, during our assessment staff’s duty of candour training compliance was 60%. This did not meet the provider target of 96%.

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 RM was unaware of NHS England’s patient safety incidents response framework (PSIRF). This was rolled out across all health and social care organisations as a standardised best practice requirement by autumn 2023. This meant their incident investigations were not necessarily capturing all required learning.

3. The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider’s referral and admission processes ensured staff received all essential information about the patient. All staff could access a electronic patient records (EPR) system. They had a regional provider lead they could contact with any issues. Staff documented all cannulation attempts on this system.

Patient records were comprehensive, secure and all staff could access them easily. We reviewed 5 sets of patient notes. Staff had completed all documentation and individualised care plans. We saw the provider’s patient referrals for admission into the EPR system contained all relevant medical history and background information.

Staff involved all the necessary healthcare and social care services.

They ensured patients had continuity of safe care, both within the service and post-discharge. Staff ensured patients were safe to dialyse before starting treatment. They would assess a patient’s general condition, and record observations and fluid status. They also assessed and observed patients during treatment, completed safety checks and monitored any changes in their wellbeing.

Leads and staff felt well prepared in the event of a major incident, adverse event or scenario. For example, they would inform patients promptly of any delays, and check nearby units had free slots before transferring them if they preferred.

3. The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff were trained in safeguarding. All care delivery staff in patient contact roles were trained to level 2 in safeguarding adults and children. Staff undertook mandatory training and e-learning for people with a learning disability and autistic people. This was a statutory requirement since July 2022. All staff we asked had completed tier 1 e-learning training. They were awaiting available dates for the full day face to face tier 2 course.

Staff knew how and when to make an appropriate safeguarding alert. Staff could give examples of safeguarding referrals, concerns or issues they had raised or discussed related to patients on the provider system. They were aware of the most common forms of abuse or risk of harm their patients faced. Safeguarding contacts including local authority and police were displayed at the nursing station and around the unit.

Staff we asked could give us examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff referred patients at greater risk of harm to safeguarding for multi-agency risk management meetings. They could also refer to a local drug and alcohol service, or a renal counsellor.

All managers and staff knew who their safeguarding lead was and how to contact them. Staff could access or contact the RM or a provider lead both trained to safeguarding level 4. The RM told us staff were proactive at raising any related concerns.

Staff followed safe procedures for children visiting the service. The provider’s in-date safeguarding policy covered how staff should safeguard children. Children could occasionally attend the unit with carers to pick up patients, but would only wait in reception.

3. The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe or supportive. They enabled people to do the things that mattered to them.

Staff recognised and responded promptly to any sudden deterioration in a patient’s health. Training records confirmed that staff had completed mandatory training relevant to emergency situations, including basic life support (BLS), emergency response procedures, resuscitation awareness, and the use of emergency equipment where appropriate. This supported staff to respond effectively to medical emergencies.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. Staff started using the national early warning score (NEWS) a year before our assessment. They monitored patients throughout treatment sessions. Staff undertook observations and, where concerns were identified, arranged ambulance transfer to the patient’s parent acute hospital for inpatient dialysis.

Staff knew about the risk factors in their patient cohort. Staff followed established guidance to check fistulas (A fistula is a surgically created connection between an artery and a vein used for dialysis) before each needle insertion. This included looking, listening and feeling for signs that the fistula was functioning correctly, helping to identify any concerns at an early stage.

Staff dealt with any specific risk issues. Staff identified and managed patient-specific risks appropriately. They followed recognised assessment and escalation pathways to identify signs of deterioration, completed relevant observations, and took timely action when concerns were identified, including arranging urgent transfer to acute services where required. The unit had only had 1 slip, trip or fall from March 2025 to April 2026. This occurred in December 2025. Documentation did not confirm if any patient harm was caused, or if any actions were taken or learning arose from this fall.

Staff routinely undertook safety checks after connecting patients to their dialysis machines. They checked the line, needle connections, and that blood pressure monitoring was secure. The safety checks flagged any errors.

Staff shared key information to keep patients safe when handing over their care to others. They prompted patients to inform their named nurse or support staff if they had suffered a fall at home or anywhere outside the unit or were taking antibiotics. Staff could complete a ‘confidential patient concerns’ register if they were worried about a patient.

Team meetings and handovers included all necessary key information to keep patients safe. Any patient concerns were reported to the renal consultant by email or during multi-disciplinary team (MDT) meetings.

2. The provider did not always detect and control all potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

We found governance omissions around fire safety at the service. The RM had not completed sections of the two latest annual fire risk assessments from May and December 2025. This included questions about fire protection measures and safety management. The service also could not demonstrate if all actions and recommendations from previous plans had been satisfactorily addressed. The RM had scored the unit’s fire risk as 3 graded low, based on incomplete information. December’s risk assessment was poorly formatted with grammatical errors. Managers did not follow the provider’s fire safety policy which stated they must ensure ‘a suitable and sufficient FRA (Fire Risk Assessment) is in place and reviewed annually with all identified actions being completed using template’. This meant the service could not evidence all necessary fire hazards and mitigations had been acted upon.

The service’s fire drills and evacuations paperwork missed key information. A fire drill conducted in December 2025 identified gaps in the evacuation process. Staff were unable to account for all patients in clinical and communal areas during the exercise, and essential information, including next of kin details, was not readily available because patient records remained within the clinic. Leaders took prompt action to address these issues by ensuring key patient information, including next of kin details, was included in the records kept on the evacuation trolley.

Fire meeting points and first aid box locations were blank on wallcharts. This meant the service could not ensure staff knew where these were.

Not all equipment used by the service had been serviced as safe for use. We found 7 dialysis machines were slightly past their servicing date in mid-May 2026. One was overdue a service since January 2026. Manufacturer’s instructions stated the servicing was done every 2 years. The RM notified the technicians and were awaiting the servicing log. They planned to attend in the few weeks after our assessment.

The service’s medical equipment servicing chart with all the last servicing and due dates did not identify the servicing oversights we found onsite.

However, the design of the environment followed national guidance. Waiting and patient area furnishings were spaced out appropriately.

All areas and furnishings were visibly clean, tidy, well maintained and free from clutter.

There was suitable facilities for the services being delivered. These met the needs of patients, visitors or carers. Staff maintained good oversight of all treatment room areas from the nursing station. All clinical areas of the unit had secure entry codes to prevent unauthorised access and ensure people’s safety. This supported easier staff and patient flow and reduced cross-contamination risks.

The environment had adaptations to suit the needs of service users. For example, hand sanitiser dispensers were lower in disabled toilets. Staff checked toilets regularly during the day.

Staff checked emergency resuscitation trolleys were fully stocked and ready for use daily and weekly. We reviewed the daily and weekly resuscitation trolley checks by staff from January 2026 up to our assessment date. No checks were missed. They could all access the main trolley in the treatment area with an automated external defibrillator (AED). The deteriorating patient policy was to call 999 and commence CPR until the ambulance crew arrived. All trolley drawers were sealed and dated.

The service had enough suitable equipment to help them care for patients. All staff could order stock. They maintained stock management and rotation. The RM confirmed they could always access and order new supplies or equipment when needed. Oxygen cylinders were in date, and securely chained to the wall. During our assessment staff were awaiting the provider’s new machines rollout to improve dialysis efficiency.

Staff were appropriately trained and skilled in how to use any specialist equipment. They helped patients safely transfer onto dialysis chairs from wheelchairs using a hoist or appropriate manual handling techniques. They quality checked the glucometer daily and calibrated the body composition monitor (BCM) monthly, as per manufacturer’s recommendations. All chairs were fully equipped and had pressure-relieving mattresses to mitigate the risks of patients developing pressure sores.

3. The provider ensured there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

However, the service could not demonstrate staff were fully trained.

Staff did not always complete mandatory and role-specific training. At the time of the assessment, 23 of 45 mandatory training modules were below the provider’s 96% compliance target, including seven modules with no staff completion. Overall compliance was 91% in May 2026, below the provider’s target. This meant the service could not demonstrate all staff had completed the required training.

The mandatory training was comprehensive and met the needs of patients and staff. This included the basic life support and adult choking simulation, and IPC in the dialysis setting modules. Managers reminded staff to complete outstanding modules by email and at team meetings.

Onsite we found staff were experienced, qualified and had the right skills and knowledge to meet patients’ needs.

Clinical staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism and dementia. They adhered to the provider’s care delivery competency framework for their first year onwards. This ensured all staff possessed the essential skills, knowledge, and behaviours required to provide high-quality care to patients undergoing haemodialysis treatment.

Managers monitored mandatory training and alerted staff when they needed to update their training. They documented all competencies on a training matrix.

The service had enough nursing and support staff to keep patients safe. Nurse and healthcare assistant numbers matched those planned. Three staff members covered each shift; two registered nurses and a dialysis assistant. The unit had one part-time healthcare assistant (HCA). They were important at supporting various manual handling tasks to facilitate patients’ dialysis. For example, hoisting, transferring and assisting less mobile patients with wheelchairs. This meant the service could demonstrate staff clinical responsibilities and tasks were always safely delegated.

Managers accurately calculated and reviewed staff numbers for each shift in accordance with national guidance. They could adjust staffing levels daily according to the needs of patients. Leads used the provider’s safer nursing care tool to ensure safe and appropriate staff to patient ratios. Nurses in charge had minimum staffing requirements when allocating staff such as 2 qualified registered nurses per shift. Leads employed a safe staffing ratio of 4-1; 1 registered staff member to every 4 patients. This ensured a nurse for both bays, and staff shared patient oversight of the side or isolation rooms.

The service had low and reducing vacancy, turnover and sickness rates. Leads promptly advertised and filled any vacancies to mitigate any staff shortages. We heard 12 months before our assessment the unit had few permanent staff. The RM had ensured all vacancies were since filled with dedicated staff. During our assessment no staff were on sick leave.

Managers ensured all staff had a full role-specific induction and understood the service. Staff told us they had completed a comprehensive induction programme appropriate to their role. We reviewed records for 10 clinical and non-clinical staff, including managers, and found all had up-to-date enhanced Disclosure and Barring Service (DBS) checks. This provided assurance that staff were suitable for their roles and met fit and proper person requirements.

Managers identified poor staff performance promptly and supported staff to improve. Staff understood they were expected to comply with requirements set out in the employee handbook.

The service had out of hours cover from resident doctors, physiotherapists and pharmacists. Staff would contact their parent trust switchboard. All staff knew how to access hospital telephone numbers.

2. The provider and staff could not ensure infectious patients were always barriered.

However, the provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. IPC audit performance showed high compliance.

Staff did not always follow infection control principles. They could not ensure infectious patients were always barriered. One infectious patient in an isolation cubicle on the afternoon of our assessment had no signage outside warning people not to enter. Staff told us they would stop anyone from entering, and they oversaw all areas of the secure unit. The two isolation rooms were used for regular renal patients when none were infectious. This informal arrangement did not sufficiently mitigate potential risk of infection to unaware patients or visitors.

Staff did not always correctly record their disposal of clinical waste. We found two sharps bins (on the emergency resus trolley and in the drugs storage room) for infectious waste open and in use where staff had left labels blank. This meant we were unsure when and by whom they were opened. We raised this with managers who planned to immediately rectify the oversight.

Some service IPC audit performance and compliance had declined. For example, the monthly external and internal hand hygiene audit results and action plan. Staff did not adhere to the five moments for hand hygiene during the latest months of April and May 2026.

However, staff carried out daily safety checks of specialist equipment. We found all stock and supplies were stored appropriately. Equipment including the resuscitation trolley had labels indicating it had been cleaned. Cleaning staff used ‘I am clean’ stickers to clean equipment after cleaning. No boxes of supplies and consumables were stored on the floor.

Staff facilitated treatment of infectious patients with other units. We heard about one patient who was C-difficile positive when they returned to the unit. The team could not accommodate them as all side rooms were in use. Staff escalated then arranged their transfer to an inpatient ward at the parent trust hospital to be safely dialysed.

Staff maintained a clean safe sterile field. We observed staff completing 7 patient disconnections from the dialysis machines. All used appropriate IPC techniques. They were suitably trained in how to use all invasive equipment, consumables and appropriate tasks.

Staff were compliant with safe hand hygiene and aseptic non-touch technique (ANTT). They were bare below the elbows and cleaned their hands before and after any patient contact. Staff maintained the ANTT in line with standards, and the National Institute for Health and Care Excellence guidance. Dialysis machines were cleaned and disinfected between all episodes of patient treatment.

The service generally performed well for cleanliness. Leads undertook monthly infection prevention control (IPC) audits. Results showed very high compliance. We saw performance charts displayed by the unit entrance from April 2026. Unit and hand hygiene results for February and March 2026 had scored 100%.

Cleaning records were up-to-date and showed all areas were cleaned regularly. A contracted cleaning company was responsible for cleaning all areas, patient bays and machines. They cleaned all machine areas daily, and deep cleaned weekly, signing and dating a checklist.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Dialysis machines were cleaned, disinfected and decalcified between all episodes of patient treatment as per provider policy.

All staff wore suitable personal protective equipment (PPE). For example, when treating and disconnecting patients or cleaning down stations. Any chemical bottles were clearly labelled to remind staff to use PPE. For example, when preparing cleaning solutions.

In practice, Staff disposed of clinical waste safely. They recorded waste disposal daily, maintained a clinical waste log and recorded the weight of any weekly bags. The dirty utility’s control of substances hazardous to health (COSHH) cupboard was stored separately and locked as per regulations.

Staff followed the provider’s management of sharps safety process. They were prompted to ‘think sharp’ to reduce and prevent sharps-related injuries.

3. The service ensured medicines and treatments were safe and met people’s needs, capacities and preferences. They always involved people in planning.

Medicines were stored securely in clean and well organised treatment areas. The drugs trolley was kept near the patient bays on the main clinical floor securely locked.

Medications staff prescribed were safe and effective. We reviewed 9 medicines records for patients. All records matched the dialysis prescription charts with no discrepancies. Documentation was clear and legible with no variable doses, units added or crossed out. Where changes to doses had occurred, these were clearly re-prescribed. Staff could evidence they numbered, logged and tracked any private or post-procedure prescriptions patients had.

Staff completed medicines records accurately and kept them up-to-date. The service had paper drug cards in place. Staff completed clear documentation around prescribing and administration in line with provider policy and processes. We found complete and detailed prescribing charts onsite. This meant staff fully used and reviewed relevant guidance to ensure prescriptions were safe and appropriate.

Staff reviewed each patient’s medicines regularly and provided advice to patients and GPs about their medicines. They followed provider policies for administering intravenous (IV) drugs. These required a second member of staff to check and sign the patients’ drug cards. This ensured they administered the correct drug, dose and route. We found all entries were cross or double-signed on patients’ records. This meant we were assured this was being completed correctly.

Staff clearly documented any allergies patients had on all paperwork. This ensured they were aware of any potential contra-indications. They checked if patients had any allergies before each medicines administration, even if patients had ‘no known allergies’ stated on their drugs card. 

Managers maintained oversight of medicines management. Staff completed temperature monitoring checks for the medicines stock room cupboards and drugs fridge in the technician’s room. There was no pharmacy service to support daily activities. However, clear medicines ordering, audits and stocks were readily available.

The service could evidence staff managed medicines safely and effectively. Managers or team leaders completed medicines management audits at least bi-annually using audit tool instructions. They addressed, updated and completed any actions from an action plan. We reviewed the audit tool from May 2026. All areas were compliant and no actions were required.

Staff followed national practice to check patients had the correct medicines when they were admitted or they moved between services. The unit had a system and process in place for patients to order their dialysis medicines. Staff knew how to follow this process and patients stated this worked well.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff followed the provider’s latest in-date medicines management policy. For example, they documented all dose units, route or second registered nurse signatures on drug charts we checked. This ensured any medicines prescribed or administered were clinically needed and accounted for.

Staff learned from safety alerts and incidents to improve practice. Leads shared external communications and updates about medicines. They were subscribed to receive medicines and healthcare products regulatory agency safety alerts. We saw notes for all staff to read about a procedural update for the supply of nasal ointment prepacks for patients who needed decolonisation treatment of Staphylococcus Aureus (MRSA or MSSA).

However, staff did not always store medicines safely. We noted the temperature where medicines were stored had exceeded national guidance. These medicines were subsequently disposed of. The manager explained the department was in the process of getting more cupboard space. They planned to store medicines in an air-conditioned room. This would mitigate future risk.