Clacton-on-Sea Dialysis Unit

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to management of infection prevention and control, medicines management and staff knowledge of the management of deteriorating patients.

The service has made improvements in relation to infection control practices and staff were aware of the processes to manage deteriorating patients. However, they remained in breach for medicines management. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a proactive and positive learning culture of safety supported by a provider ‘reporting and follow-up of clinical events policy. All staff we spoke to knew how to report incidents and felt leadership was receptive to new ideas on how to improve patient safety. A total of 352 incidents had been reported in the last 12 months demonstrating a good reporting culture within the unit.

At our previous assessment in February 2020, we found a lack of effective processes in place to provide staff with feedback and learning from incidents to improve patient care. During this assessment we saw that there was an effective system in place. Staff we spoke to were able to tell us about reported incidents, learning and changes made.

Incidents were reported digitally and investigations were completed to identify potential learning and prevent future occurrence. Learning was shared locally at daily huddles, through teams chat as well as regionally with other Diaverum sites and with community partners. For example, there had been an increase in falls since February 2026 which resulted in local ‘nursing nuggets’ training as well as staff encouraging patients to use a wheelchair when being transported to the ambulance following dialysis. Nursing nuggets training was provider led weekly training with focused learning designed to support practice, build confidence and keep knowledge fresh.

Staff received feedback from investigation of incidents, both internal and external to the service. Following incidents any identified learning and training was shared electronically to all staff to access. The manager received a notification when staff had completed the online training. Staff were allocated time to access training and learning every month.

Mandatory and role specific training was completed by staff in line with policy. The service had an overall compliance of 98% against a target of 90% at the time of the onsite assessment. New staff were mandated to complete competency reviews prior to working clinically. Further learning and development were offered through several ways such as supervision, mentorship and support visits conducted by the regional clinical lead.

Patient feedback was captured through annual patient perception of care survey, suggestion box and requesting feedback during care plan reviews to drive service improvement. However, a review of 5 my care documents showed that staff were not completing monthly feedback reviews to ensure that experience was captured promptly.

Patients told us that they felt comfortable to raise a complaint should they need to. The service had received 8 complaints in the last 12 months. Themes of complaints received in the last 12 months related to delayed transport and distance travelled to receive dialysis at the unit. These were logged and discussed at the monthly service review meetings with the ambulance service.

We scored the service as 2. The evidence showed some shortfalls. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, staff did not always review risk assessments to ensure there was continuity of care.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

Weekly multidisciplinary meetings were held to collaboratively review patient cases ensuring safe care. For example, referral to dietician and adjustment in dialysis prescriptions were discussed amongst all team members.

The service had a clear process in place to identify and escalate unwell patients. This included the use of the National Early Warning Score 2 (NEWS2) for identification, support from the on-call consultant at the referring trust or phoning 999 if required. All staff we spoke to knew how to seek support in the event of an acute patient deterioration.

Monthly blood tests and face to face consultant reviews were completed to ensure that care was tailored for each patient. Appropriate staff had access to the patient’s hospital records such as blood tests and upcoming appointments to ensure patients had continuity of safe care, both within the service and post-discharge. Patient’s we spoke to told us that the transfer of care to the unit was seamless, they were informed of changes in their treatment and received regular monthly reviews.

The service had a process in place for managing missed or shortened dialysis sessions. This included informing the renal consultant and contacting the patient, their next of kin and if unable to make contact working with the emergency services to carry out a welfare check to ensure the patient was safe.

Patients were able to access dialysis support whilst on holiday. Essential information about the patient’s care needs was provided and confirmed by the unit with oversight from the named renal consultant.

Risk assessments were carried out on admission and reviewed every month by a named nurse to ensure that they reflected any changes in needs. At our previous assessment in February 2020, we found falls assessments were not fully accurate. During this assessment we reviewed 5 care records for patients and found that risk assessments were not always reviewed on a monthly basis in line with the service policy for all 5 records. Audit results for the last 6 months showed some inconsistency with risk assessment reviews with an overall compliance reducing to 75% from April 2026 to June 2026. We saw evidence that staff had been reminded to review and update all risk assessments for patients.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

All staff were trained in level 1 and 2 safeguarding for adults and children as part of their mandatory training. The Clinic Manager and Deputy Clinic manager with support from Practice Development Nurse (PDN) and Clinical Lead (CL) were safeguarding level 3 trained with access to a level 4 trained nurse within the organisation, in line with national guidance. At the time of the assessment, safeguarding training compliance was 98% against a target of 90%. Not all staff knew who the safeguarding lead was, but staff told us that they would escalate any concerns to the manager and knew how to access the safeguarding policy online. There had been no safeguarding concerns reported by staff in the last 12 months.

We requested clinical staff compliance for training on learning disabilities, autism and dementia. Training compliance was 94% for both topics, against a target of 90%.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The provider's level 4 safeguarding lead liaised with the NHS trust safeguarding lead if required to ensure that concerns were shared appropriately.

We reviewed 4 staff files and saw that all staff had the appropriate disclosure and barring service (DBS), professional registration and visa checks. Regular interval checks were completed by the central human resource team.

We saw a zero-tolerance policy poster displayed throughout the service to protect healthcare staff and patients from any forms of abuse – physical or verbal.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw evidence of policies and processes in place to document patient assessment and treatment at each dialysis session. Staff and patients told us that they supported individuals to lead on the setting up of dialysis sessions should they wish. At the time of the assessment there were 4 patients that had completed the shared care competency booklet to ensure that they were safe.

Patients who chose to shorten treatment times were informed of the potential risks and impact to their health and were supported with additional treatment time at another time where capacity allowed. Decisions were documented and an internal incident form was completed in line with policy. The service monitored individuals that were repeatedly missing or refusing treatment and took action to protect them. For those at significant risk the unit added them to their local risk register to ensure risks were mitigated as far as possible. A poster highlighting the risks was also displayed in the waiting area to educate patients and carers. Staff told us that patient transport was not always timely and at times resulted in shortened treatments for patients. The regional manager for the service attended monthly service review meetings and kept an action log of complaint to track progress.

Patients told us that they felt supported with finding alternative dates and times for their dialysis sessions if required. For example, a patient told us that nurses swapped a time for their session with another patient to be able to make another hospital appointment.

At our previous assessment in February 2020, we found that not all staff were familiar with the service’s policy for using a nationally recognised tool to monitor deteriorating patients. At this assessment, all staff we spoke to were aware of the use of NEWS2 to identify and escalate a deterioration in those they cared for.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were effective systems in place for checking environment and equipment. The building was managed by the commissioning NHS trust however the provider was responsible for the maintenance of equipment and water treatment monitoring.

The entrance to the building was monitored through CCTV and had intercom access. The dialysis unit and staff areas were all restricted with swipe or keycode access. The dialysis unit had 12 stations with a side room dedicated for patients requiring isolation.

The service had 15 dialysis machines at the clinic, which included 3 spare machines in case of infection control or mechanical problems. We reviewed servicing and equipment fault logs. Evidence showed that the support was effective in repairing any reported faults within 24 hours to avoid service disruption. Staff were aware of how to report equipment faults and told us that they had access to equipment needed to carry out care and treatment. The service had reported 2 medical equipment incidents in the last 12 months indicating that system in place was robust.

We reviewed 10 items of electrical equipment whilst on site and found them to be calibrated and visible stickers were in place to indicate next test due dates.

During the onsite visit, we found cleaning chemicals stored within a lockable cupboard in line with Control of Substances Hazardous to Health (COSHH) regulations. Daily monitoring logs were completed for resuscitation trolley, water treatment and reported faulty equipment.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

We requested copies of service level agreements for services such as waste disposal and building maintenance but these were not available following the assessment. The manager did not report any concerns with regards to the management of the building by the NHS trust.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had a robust recruitment process in place to ensure that staff were appropriately qualified, checked and vetted prior to starting employment. We reviewed 4 staff files that supported these processes were followed by the provider.

At the time of the assessment, the unit was run by a manager, deputy manager, 7 registered nurses, 3 dialysis assistants, 5 healthcare assistants and 1 ward clerk. Medical staff and allied health professional support was provided by the local NHS trust . The unit did not use agency staff, gaps in rosters were filled by internal Diaverum registered bank staff; who were required to complete the clinical introduction to Diaverum Handbook to ensure they were familiar with the providers systems and processes.

Managers planned staffing based on a 1:4 ratio of nurse to patient, a 1:5 ratio was considered safe if 2 trained nurses were on shift for safe medication administration. This was in line with national guidance. Staff rosters reviewed showed that there was no use of internal bank staff in the last 3 months, indicating their staffing levels were sufficient to meet the demand on the service.

The service had systems and processes in place to support continued learning and development. For example, staff received an annual appraisal and mid-year review to discuss personal development and learning needs. At the time of the assessment compliance was 100%.

Staff were provided with protected time to complete necessary training specific to their role such as cannulation principles, blood borne viruses as well as more generic skills such as basic life support and data protection. At the time of assessment, mandatory training compliance was 98% against a target of 90%.

Current sickness rate for the unit was 2.9% and there were no vacancies.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff maintained equipment well and kept it clean. Dialysis machines were externally cleaned by staff and logged digitally to confirm completion.

At our previous assessment in February 2020, we found that staff did not practice good hand hygiene practice or management of sharps. During this assessment, we observed staff washing their hands and the use protective personal equipment where indicated. Weekly hand hygiene audits were completed through observation of staff to ensure compliance in line with policy. Audit results showed 100% in June 2026.

All areas were visibly clean, had required furnishings that were wipeable and were well-maintained. Bay cleaning checklists were seen to be completed on a daily basis.

Domestic cleaning services were managed by an external company which had changed the week of the assessment. Monthly infection prevention control (IPC) audits were completed to ensure that hygiene and infection control was managed in line with policy. During the last 3 monthly audits it was found that domestic cleaning was not sufficient and resulted in a change of domestic cleaning company.

Processes were in place to screen and isolate patients who had been on holiday to high-risk destinations. During our on-site assessment, we saw evidence of 2 dialysis machines isolated for named patients to reduce potential spread of infection. Each machine was clearly labelled with the date the isolation was started and due to finish.

There were processes in place to prevent and reduce the risk of cross-contamination to other patients in care records we reviewed. For example, blood results were printed and filed in care records to show that they were tested for Hepatitis C and B prior to commencing their first treatment session at the unit.

There had been no healthcare acquired infections (HAIs) identified within the service during the past 12-month reporting period.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs. However, patients were involved when changes happened.

Medicines were stored securely in a lockable room, however systems in place were not effective in ensuring safe prescribing and stock management.

The service had a provider level medication administration policy which outlined the processes and checks to ensure that medicines were safely stored and administered. However, this policy did not reflect local procedures. We checked a range of medicines on-site, which were all appropriately stored and in date.

The commissioning NHS trust were responsible for all medicines ordering and stock inventory. We requested and reviewed the current inventory stock list and found that this was not reflective of items within the cupboards. The service did not have any processes in place to ensure there was uninterrupted access to medicines required, prevent too much stock and maintain transparency to deter theft or misuse.

We found that prescription charts were not always completed in line with policy. For example, a drug was not cancelled on a prescription chart when dosage had increased, and 2 signatures were not always recorded at the point of administration on medicines.

Changes in medicines were communicated through email by the medical team to the service. Charts were updated by the visiting consultant monthly. This process did not ensure robust and accurate recording of current medications, which could result in errors. We were told that a new process had been implemented where prescription charts would be scanned and emailed for updating to the medical team to avoid potential errors or missed recording. This was not evidenced in the current medication administration policy.

At our previous assessment in February 2020, we found that oxygen was being administered without being prescribed. During this assessment, we found oxygen was prescribed on charts for patients.

We observed the administration of medicines for 2 patients and found that staff followed policy. For example, staff peer checked medicines, dosage and checked the patient details prior to administration.

Patients we spoke to during our onsite assessment told us that all medications were explained to them and in line with their needs. For example, a patient told us that she was prescribed medication to address skin irritation during her monthly review.