Clacton-on-Sea Dialysis Unit

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• 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

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 rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service was managed to meet patient’s needs. Leaders and the culture created promoted integrated, person-centred care.

The service was in breach of regulation for governance at the service.

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.

We scored the service as 3. The evidence showed a good standard. The service 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.

The organisation had a mission statement, vision, strategy culture and set of values, which were defined and centred around providing life enhancing renal care for all patients. Not all staff knew the values of the organisation, but we saw the culture and values demonstrated by all the staff we observed and spoke with during our onsite assessment. For example, staff were passionate in their language and actions towards one another as well as patients they cared for.

Staff could explain how they were working to deliver high quality care and the impact their care had on those they cared for. For example, staff used the same systems as the NHS medical team which further supported shared care of people they cared for.

Staff appraisals were aligned with the company values and objectives which ensured that staff were engaged. At the time of the assessment, staff appraisal compliance was 100%.

We scored the service as 3. The evidence showed a good standard. The service 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.

Managers and deputy managers were supported in completing competency training when new to the role to ensure that they had the necessary skills to perform their role. The manager described their roles and responsibilities for the unit and knew the current issues it faced such as transport delays, capacity issues and missed appointments.

Staff reported they felt supported and were given appropriate training and shadowing experience to consolidate their learning. We heard how staff requested further training as they did not feel confident at the end of their induction and this was supported by the manager. Staff told us that the culture was open, honest and inclusive. All staff we spoke to were happy to work at the unit.

Staff told us that they had opportunities to make suggestions on how to improve the service and bring staff together such as team meals and quizzes for patients.

Senior leaders were contactable if the manager or senior staff faced challenges whilst on duty. They told us that senior leaders were approachable and transparent. We observed kind, supportive and respectful interactions between senior leaders and staff whilst on site.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service through a variety of ways such as formal surveys, raising concerns or complaints and at monthly reviews with their named nurse. The last 2025 patient perception of care survey showed 3 areas of improvement, and this was displayed within the waiting area of the unit to inform patients of how their feedback had been used.

Managers used complaints to make improvements and feedback to system partners. For example, the number of transport delays and complaints were discussed at monthly review meetings with the ambulance provider to demonstrate if local action taken was effective. Staff told us that they were informed of complaints and themes at their monthly team meetings.

The provider’s Speak Up policy supported and encouraged staff to report concerns. There were no concerns reported by staff at this unit in the last 12 month. We were provided evidence of processes in place to support a thorough investigation and how this had been completed in the wider organisation.

We had not received any concerns reported from staff in the last 12 months. Staff we spoke to told us that they felt comfortable to raise concerns and could do so without fear of retribution.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were policies and processes in place to promote equality, diversity and inclusion in the workforce such as uniform and equal opportunities policies. The provider was developing a global equal opportunities, diversity and inclusion policy to support equal opportunities for all employees.

The 2025 staff survey, ‘my opinion counts’, highlighted that 20% staff at the unit felt that there was limited progression and intended to leave. An action plan was in place to address the findings.

The uniform policy promoted equality and diversity, ensuring they did not discriminate against any individual based on protected characteristics. For example, where wearing of items arising from a particular religious or cultural norm a risk assessment would be carried out to ensure the health and safety of staff and patients was not compromised.

Staff were able to apply to work flexibly. For example, flexible working agreements were made to accommodate personal circumstances, such as caring responsibilities or health issues.

The provider undertook national equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

We did not see equality impact assessments for policies and procedures we reviewed to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

We scored the service as 2. The evidence showed some shortfalls. The service had clear roles and responsibilities and systems for accountability. However, there were shortfalls in good governance.

There was a governance structure in place which supported management processes within the organisation. Unit managers were supported by clinical leads at local level and regional business and health and safety managers. The organisational structure was displayed in the unit and staff told us that they were visible and approachable.

There was a clear framework to support the management of risk, issues and performance. The service had several dashboards which could be filtered to show compliance locally, and comparison both regionally and nationally. Unit managers produced monthly integrated performance reviews to ensure that essential information, such as learning from incidents and complaints, was shared and discussed with the general manager and clinical leads.

The unit manager undertook local clinical audits such as hand washing, risk assessments and use of personal protective equipment to provide assurance. On one occasion we saw the sample of audits was not always in line with policy. For example, we saw that only 8 care records were reviewed in January 2026 instead of a minimum of 14.

Staff were not aware of the unit’s performance against the provider key performance indicators. We reviewed staff meeting minutes for the last 3 months and found that this information was not discussed with staff at the monthly staff meeting.

Where compliance fell short of the target staff were informed to act on the results when needed. For example, audit data showed that IV infusions were not being signed by 2 nurses in line with policy with a compliance of 73% in January to 100% in May and June 2026. However, action taken to address review of risk assessments was not as effective. We found that risk assessments were not reviewed and completed in line with policy. There was a lack of audit to support the management of medicines stored at the unit. For example, there were not stock inventory lists to be assured that there were sufficient medicines to support service delivery and identify potential misuse of medicines.

Staff we spoke to told us they had access to the equipment and information technology needed to do their work. However, the 2025 staff survey for the unit showed that 47% of staff stated there were poor resources, equipment or tools. There was an action plan in place to address this which included a staff led equipment and resource audit.

The service did not always keep records of all relevant meetings and service level agreements in line with good governance. For example, we requested a copy of the pharmacy service level agreement with the local NHS trust to review the roles and responsibilities for the service and those of the trust. This was not kept by the provider which meant there was no formal document to demonstrate defined expected scope, quality, and timelines of pharmacy provision. Leaders told us that going forward, the service would ensure consistent recording by the unit for all relevant meetings and retained in line with their governance and record-keeping procedures.

We reviewed a range of policies and procedures which were in date and version controlled. These ensured clinical safety, standardised treatment and supported working with other teams, both within the provider and external, to meet the needs of the patients.

Staff maintained and had access to the risk register within the unit and this was discussed at the monthly staff meeting to update all staff. Staff concerns raised, such as capacity and patient transport, matched those on the risk register.

We saw evidence the service had individual personal emergency evacuation plans in place for patients and a business continuity plan.

Information governance systems included confidentiality of patient records. All patient records were stored in a lockable cabinet, and computers were locked when not attended. Staff completed mandatory training on information governance and compliance was 100% at the time of the assessment.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Senior leaders engaged with external stakeholders such as the local NHS trust and ambulance service. Consultants and dieticians from the trust regularly visited the unit and staff from the unit attended virtual weekly meetings to discuss patients receiving dialysis and those awaiting admission to the unit. Nurses discussed changes in health or treatment based on the individual patient performance scores (IPPS) to highlight any potential changes to treatments that may be required.

Staff we spoke to told us that they had good working relationships with their NHS partners and could contact colleagues via email or phone between meetings when needed. We observed staff contact the team whilst on site.
The unit worked in collaboration with the Kidney patient association whereby they encouraged patients to communicate with them via phone, email or use the red post-box in reception.

The senior leaders met with the commissioned ambulance service monthly to discuss and improve transport complaints and delays impacting on treatment sessions. An action log was set up to monitor and demonstrate the improvements made.

We scored the service as 3. The evidence showed a good standard. The service 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. They actively contribute to safe, effective practice and research.

Following our previous assessment in February 2020 we issued a requirement notice for breach of safe care and treatment, good governance and registered manager. At this assessment we found that the service had addressed all the concerns identified during that assessment. However, we found that there was a lack of good governance for oversight of medicines management and record keeping.

The 2025 staff survey showed that staff felt there was a lack of opportunity for professional development and training. Staff were now given protected time every month for their named nurse role and for professional development.

Learning was shared both regionally and nationally across the organisation. We saw ‘Nursing Nuggets’ teaching posters displayed in the staff areas for staff to support best practice and themes from reported incidents. Compliance and attendance was monitored by the manager.

All staff knew how to report incidents, near misses and adverse events which were reviewed in line with policy. Themes and trends were identified, and action was taken to reduce the risk of reoccurrence. For example, there had been an increase in falls at the unit in the last 6 months. Staff were now encouraging patients who were frail or had limited mobility to use a wheelchair to transfer to the reception area if they were fatigued following their dialysis treatment.

Incidents were discussed at handover and monthly team meeting as well as the morning huddle.
All staff we spoke to told us that they had received an induction and further role specific competency training.
We saw evidence of involving staff on areas of improvement such as equipment needs within team meeting minutes following the 2025 ‘My Opinion Counts’ staff survey 47% of staff reported poor resources, equipment and tools.