Dearne Valley NHS Dialysis Unit

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

3. The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff understood and shared the provider’s purpose, vision, values and behaviours. The provider’s purpose was to improve the quality of life for nephrology patients by the provision of superior quality products and services. Their vision included critical success factors and overall objectives.

Leaders ensured staff in all areas knew, understood and supported the shared strategy and strategic goals and how their role helped achieve them. The provider had launched a new ‘Reignite’ strategy in autumn 2025. This was to lead kidney care through exceptional patient care and innovation. The strategy was founded on 3 strategic priorities. These guided staff in their daily work to achieve the provider’s purpose. Provider leads held collaboration discussions with staff ahead of this 5-year strategic plan. All staff had the chance to attend sessions and discussions to feed into the process.

Leaders demonstrated a positive, compassionate, listening culture. This promoted trust and understanding between them, staff and patients. It was focused on learning and improvement. The provider had a culture in which leaders encouraged staff to achieve through development and promotion in 4 policies; communication, training and development, teamwork and commercial focus. Staff attended monthly town hall meetings as part of the national provider network. They could raise any concerns, issues or ideas in confidence. We heard leaders promptly followed up and fed back any responses to staff.

All staff felt respected, valued, listened to, part of a close team and well supported by the RM. Staff told us their colleagues and team were the best thing about the job. Some described their team as being ‘like a family’. They felt this helped to foster a culture of safety.

Senior leads and managers could articulate the vision for their service. The unit displayed the provider’s commitment across 7 areas. These were to prioritise safety and compliance, put patients first, continuously improve, foster trust and transparency, deliver exceptional care, engage with the community and sustainability.

The RM understood their strategic priorities and how they related to wider sector and partner services. They monitored and reviewed progress against delivery of the strategy and relevant local plans.

3. The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered and risks were well managed. The service had long-term consistent managerial oversight from the same RM since January 2024. We saw their certifications of completion from November 2025 for various leadership training courses. This meant they were suitably trained, qualified and competent for their RM role.

Leaders at every level were visible and lead by example, modelling inclusive behaviours. The RM was onsite most days the unit was open, and a deputy or nurse in charge was always available in their absence. Managers covered responsibilities such as workforce management, rostering and complaints handling.

Leaders are knowledgeable about issues and priorities for the quality of services and can access appropriate support and development in their role. The RM said they were well supported by responsive provider and regional leads. They and staff told us leaders regularly visited the unit to conduct audits and offer support to staff. The area head of operations had attended the unit the day before our assessment.

High-quality leadership is sustained through safe, effective and inclusive recruitment and succession planning. We saw the provider’s organisational chart for senior management. All clinic and registered managers were supported by a team consisting of an Area Manager, Quality Matron and a Senior Clinic Manager.

Staff told us leaders and especially their manager were highly visible. They would always make themselves available when required and resolve any issues within their remit. Following a specific induction, the service’s deputy manager felt well supported by and learnt from the manager.

3. The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Leads actively promoted staff empowerment to drive improvement. Staff were encouraged to raise concerns. Staff knew how to contact the provider’s designated Freedom to Speak Up (FTSU) guardian or deputy. The guardian owned the provider’s FTSU policy document. They made themselves available to all staff. The ‘Speak Up. Because It Matters’ policy hard copy was displayed and available to staff. No one we spoke with said they had needed to use the guardian, as their manager and team shared and discussed any concerns.

The service had a culture of speaking up where staff actively raise concerns and were supported, without fear of detriment. The provider had a transformation and patient experience manager. They encouraged unit staff to contact them about improvements, comments and suggestions (about the patient service or ways of working).

Leaders investigated concerns raised sensitively and confidentially, and they shared and acted on lessons. The service’s governance structure and several other channels gave staff the opportunity to raise any concerns or issues. They held individual team meetings, mediation meetings with any conflicts or interest, as well as twice weekly human resources catch-ups. Leads brought staff together to promote teamwork and encourage them to share good news and reflection.

All staff are confident that their voices will be heard. Staff told us the service had a positive, friendly and inclusive culture. They and their household members could access confidential phone counselling support and health insurance as part of their employee assistance programme (EAP). The EAP was always available. This also entailed a subsidised laptop scheme and other discounts and benefits.

3. The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

However, they did not value diversity in their workforce.

Leads took action to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act. They reported any incidents involving staff abuse for investigation. The provider had a code of conduct policy with a corresponding code of behaviour for all dialysis units. This helped staff work in accordance with the provider’s core values. It also outlined how patients were expected to behave and treat staff in relation to each value. This meant the RM ensured staff were protected from violence or aggression.

Leaders ensure effective and proactive ways to engage with and involve staff. They focused on hearing their voices. Senior leads and managers reminded staff to complete the provider’s yearly global employee engagement survey. The last one was in November 2025, with results shared in January 2026. Managers completed 4 actions in response to staff feedback.

Staff were empowered and confident their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation. They could submit ideas and nominate colleagues for employee of the month awards.

The provider’s workforce race equality standard (WRES) policy demonstrated their progress against the WRES indicators. It helped them identify their current situation and potential for improvement.

However, leads were unaware of their workforce’s diversity. The provider’s WRES policy from 2020-1 showed they did not know the ethnicity of 65.8% of their staff. They were also unaware of over half the training courses their staff had completed. This meant their data gave limited insights for improving equality and was over 5 years out of date.

2. The service did not always follow the provider’s clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The RM and staff were not aware of all the risks which affected their service. We reviewed the service's most recent risk register. The register showed no new risks had been identified or assessed since August 2024, and no new risks had been added since May 2021. The only risk added since August 2024 was rated as low and related to WRES reporting, with no additional controls required. Risks were reviewed infrequently, in some cases up to three years after they had first been identified. We also found several high-rated risks did not have clear action owners, mitigating controls, or target completion dates. All risks on the register had been identified by the provider's head office and none were specific to the service. This limited assurance local risks were being identified, monitored, and effectively managed.

Service leads did not maintain or review their local risk register. We asked the RM about the service’s top risks. They told us they felt assured all were captured by other means than a register. However, they could not provide any examples. No mitigations or controls were in place to address risks we found onsite around, for example, dialysis machine servicing or incomplete fire risk assessments. This meant the provider or RM could not demonstrate a formal or effective system in place to identify, address and monitor risks.

There were not always clear and effective governance, management and accountability arrangements. We found several examples of poor or outdated governance at the service. For example, during our assessment the service’s bespoke emergency preparedness plan had not been reviewed for over five years. This should be reviewed yearly by the RM. This meant we were unsure if it was still relevant to the service, or had been superseded. The provider’s safeguarding policy did not mention female genital mutilation (FGM). Clinical waste governance records were not always completed appropriately. For example, the clinical waste log was not signed or dated, meaning the service could not demonstrate who had completed the checks or when they had been carried out.

Provider and senior leads demonstrated poor governance of some audits, reports and surveys. Infection prevention and control (IPC) audit performance had declined, and the unit's performance dashboard report dated 10 June 2026 contained incomplete IPC related information. The report lacked clear narrative and detailed analysis, making it difficult to understand performance trends and outcomes.

The service's patient satisfaction survey also lacked key information, including the reporting period and qualitative feedback from patients. As a result, it was not clear how feedback was analysed, shared, or used to drive service improvement. Although a provider summary and key drivers chart accompanied the survey, the information was poorly presented, and some results did not appear to align with the corresponding survey questions. This limited assurance regarding the accuracy and use of patient feedback.

However, leaders and staff understood their role and responsibilities. The RM attended all meetings relevant to their role. These included monthly contract and governance, policy, mortality and morbidity and vascular access meetings with the parent trust hospital. They shared all the unit’s reported incidents with the trust’s governance lead.

Managers could account for the actions, behaviours and performance of staff. Any new or updated policies were shared and recorded. Attendees reviewed incidents and subsequent lessons learned from the previous few months. Each meeting had actions summarised at the end for staff awareness. Clinic staff meeting minutes included results and findings from IPC and hand hygiene audits. This meant improvements or any feedback were shared with staff.

Leaders implemented some relevant quality frameworks, recognised standards, and best practices to improve patient’s equity in experience and outcomes. They completed a monthly balance score card report for the provider’s governance review. The unit fed into their parent NHS trust’s data. For example, numbers of patients dialysed monthly. The provider had a balanced scorecard and key performance indicators (KPIs) policy. This outlined the process required for clinics to effectively use and review electronic patient records data to improve medical KPIs.

The provider had relevant clinical governance policies, including a review and reporting policy. This ensured the service adhered to clinical governance effectiveness and requirements for professional reporting. They also had a clinical risk management policy. This ensured risk management and risk assessment was an integral element to daily management practice.

All staff could access the provider’s policies and procedures on a bespoke platform. The provider had a quality policy which acknowledged their responsibility to patients, employees, shareholders and the community. This was underpinned by 4 quality objectives.

Staff could access funds for new equipment. Managers had an allocated budget when there was clinical need. The clinic secretary would gain a quote, then request and source equipment onsite. Support staff knew which stock was most used and how often, so they ordered accordingly. This meant financial pressures did not compromise patient care.

3. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders were open and transparent. They worked in partnership with key organisations to support care provision, service development and joined-up care. They used these networks to share ideas that could led to better patient outcomes. The service’s deputy manager set up meetings with their equivalents at other provider units. This helped them debrief and learn from each other.

Staff and leaders engage with people, communities and partners to share learning. This resulted in continuous improvements to the service. For example, leads shared and incorporated any learning from external reviews into staff meetings, after action reviews and clinic-level safety huddles.

Staff signposted patients to relevant organisations and fundraised for local charities. Patients were prompted to consider the national kidney sharing scheme if they had a living donor willing to donate with which they were incompatible. The unit had raised money for Doncaster and Bassetlaw Kidney association (DaBKA) by selling Christmas cards in December 2025.

3. The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The service ensured learning occurred both when things went wrong, and from examples of good practice. Leaders encouraged reflection and collective problem-solving. Staff attended a quarterly after action review provider presentation from March 2026. The session reviewed the background of incidents to encourage group discussion and reflection. This helped staff outline immediate and further actions taken. Lessons learnt from both incidents were then shared. Provider leads had also given presentations on clinical practice guides for vascular access for haemodialysis, vascular access management of clinical risks and duty of candour.

The provider recognised and celebrated success as part of a positive and supportive learning culture. Leads awarded the clinic team a team recognition certificate of achievement in January 2025.

The service has strong external relationships that supported improvement and innovation. Leads attended the Yorkshire and the Humber kidney network and kidney quality improvement partnership meetings. These helped shape the future of kidney care in the region. They also shared learning around reducing missed dialysis in the North-East and wider region to improve medical key performance indicators.