KC Dialysis Centre

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

At our last assessment we rated this key question as requires improvement. 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.

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 demonstrated a structured approach to learning from patient safety incidents. Staff completed patient safety incident reports following incidents, creating a clear audit trail to support investigation, review and organisational learning. Incident reporting processes had recently been reviewed and strengthened, with revised documentation introducing a formal after-action review completed by senior staff. These reviews considered the impact of the incident, identified lessons learned, and documented actions and recommendations to reduce the risk of recurrence.

Incident records were maintained within a dedicated incident folder and were reviewed to identify themes and trends, particularly those relating to medicines management. Records demonstrated incidents were investigated thoroughly, with duty of candour requirements considered and documented where relevant. We also reviewed examples of incidents involving patients who deteriorated following dialysis treatment and required emergency transfer to hospital. These incidents had been recorded, reviewed and used as opportunities for reflection and learning.

The service had an incident management policy which outlined how patient safety incidents were reported, investigated and learned from in line with NHS England’s Patient Safety Incident Response Framework (PSIRF). Staff were required to record incidents using a patient incident form, ensuring a clear audit trail was maintained.

The system supported the identification of learning opportunities, enabling incidents to be reviewed, lessons learned to be shared, and improvements implemented to reduce the risk of recurrence and enhance patient safety.

Although no suspected or confirmed cases of sepsis had required activation of the policy during the review period, the service had arrangements to undertake case reviews following significant deterioration events. These reviews considered the effectiveness of the response, identified learning opportunities and supported improvements to practice. The provider also planned to introduce periodic retrospective reviews of deteriorating patient and sepsis management as part of its continuous quality improvement programme when sufficient cases were available to provide meaningful assurance.

The evidence showed a good standard. The service 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 service had clear admission, referral and discharge processes to support the safe delivery of haemodialysis and continuity of care. Referrals were accepted only from established renal services and included comprehensive clinical information, such as dialysis prescriptions, blood-borne virus and MRSA screening results, vascular access details, medical history, allergies and infection risks. All referrals were reviewed by the clinical team and, where necessary, discussed with the patient's home renal unit before treatment was confirmed.

An admission policy outlined the systems and processes for the selection and acceptance of patients referred for holiday dialysis treatment. The policy covered the patient pathway from referral through to treatment and discharge, helping to ensure patients received care which met their clinical needs and information was shared effectively between services.

The service had established discharge processes to support continuity of care. Prior to discharge, staff completed checks to ensure dialysis treatment records were fully completed, any treatment variations or clinical concerns had been communicated to the patient's home renal unit, medicines information had been documented where required, and any follow-up actions had been completed. Discharge documentation was reviewed by managers before being filed, and any omissions or discrepancies were addressed immediately. This real-time verification process provided assurance that discharge procedures were consistently followed and reduced the need for separate retrospective audits.

The service maintained ongoing communication with patients' home renal teams throughout their stay and provided a discharge summary on completion of treatment, supporting safe transitions, effective information sharing and continuity of care between providers.

Arrangements also supported the safe transfer of patients when escalation of care was required, including the use of a transfer letter for hospital admissions. Following completion of treatment at KC Dialysis Centre, patients were discharged back to the care of their usual renal team. Patients were provided with contact details for the service and advised how to seek advice if they had any questions or concerns relating to the treatment received.

Patients requiring urgent medical attention were advised to contact their renal unit, attend the emergency department, or call emergency services as required. Post-discharge concerns, complaints and incidents were documented and reviewed through the service's clinical governance processes. These arrangements supported effective communication, safe transitions between services and continuity of care for patients receiving holiday dialysis treatment.

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. The service shared concerns quickly and appropriately.

The service had a safeguarding policy which provided staff with clear guidance on how to recognise, respond to and escalate concerns where an adult or child may be at risk of harm. Staff received safeguarding training and had completed safeguarding training to level 3 in adults.

Additionally, the service was fully compliant with training and/or supervision for all staff that was required to their role to enable them to provide support in the best way to people with learning disability and autism.

Staff were supported to develop the competencies required to assess, plan and evaluate care where safeguarding concerns were identified. The service sought external advice when safeguarding concerns arose and provided an example where guidance had been obtained from the local authority safeguarding services regarding the attendance of a patient who posed a potential risk to others. This demonstrated that staff recognised safeguarding issues and were willing to seek specialist advice to support safe care delivery.

Patients and carers were signposted to support services, and there were arrangements to escalate urgent concerns through safeguarding or emergency procedures where necessary. Any concerns relating to a patient's mental wellbeing were documented and shared with the referring renal unit to support safe, coordinated care.

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.

The service had a policy on the recognition and management of the deteriorating patient, including sepsis, which provided staff with guidance on the early identification, assessment and escalation of patients who may deteriorate whilst receiving dialysis treatment. Patients were routinely monitored throughout treatment, including the use of NEWS2 observations and established escalation processes to identify and respond to changes in a patient's condition.

The service monitored compliance with the policy through its clinical governance arrangements. This included mandatory sepsis awareness training, competency assessments for registered nursing staff, and the review of incidents, near misses and episodes of patient deterioration to identify learning and ensure appropriate management. The policy was also reviewed regularly to ensure alignment with current national guidance and best practice.

Patients were encouraged to report any concerns, symptoms or changes in their condition during treatment, supporting their involvement in the early identification and management of clinical risks.

Additionally, patients receiving haemodialysis had personalised mental health care plans which documented their individual needs, treatment goals, risks, co-morbidities and agreed interventions, including how staff could support their comfort and wellbeing during dialysis sessions.

Patients were referred to the service with key clinical alerts and risk information clearly identified. Referral documentation included important considerations such as whether patients were prescribed anticoagulant medication (blood thinners), known allergies, and the prescribed volume of fluid to be removed during treatment. During the inspection, we observed staff reviewing and acting upon this information to ensure treatment was delivered safely and in line with individual patient needs.

Staff demonstrated a good understanding of patient-specific risks and could identify and respond to deterioration promptly. Risks were monitored through regular assessment of patients’ vital signs, observation throughout treatment, and continuous monitoring of dialysis machine alarms. Staff responded to changes in patients’ condition or equipment alerts, taking timely action to maintain patient safety and minimise the risk of harm.

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.

The dialysis unit was visibly clean and well maintained. The unit had eight dialysis chairs, with five patients receiving treatment on the day of inspection. Staff told us it was uncommon for all eight chairs to be in use simultaneously, which helped ensure sufficient space and staffing capacity to support patients during treatment. The service reported activity levels were typically higher during the summer months due to increased demand for holiday dialysis.

Dialysis machines were located within the treatment area and all equipment observed had up-to-date servicing records. Staff completed safety checks before equipment was used and had access to a contracted technician for maintenance, servicing and repairs. Dialysis consumables were single-use, CE marked and within expiry dates.

Clinical waste and sharps were managed safely, with waste bins and sharps containers available, closed and correctly positioned within the treatment area. Clinical consumables and stock were stored within a dedicated storage area on pallets and off the floor.

Emergency equipment was available and securely stored, including oxygen, a defibrillator, grab bag and suction equipment. The accessible toilet was fitted with an extended emergency pull cord and location indicator to enable people to summon assistance if required. Weekly testing of emergency call systems provided additional assurance that staff could respond promptly in an emergency.

During the assessment, we identified some items within the anaphylaxis kit had exceeded their expiry date. This was raised with the leaders at the time of inspection. The service took immediate action to remove the expired items and replace them with in-date stock, ensuring the kit was fully replenished and fit for use.

The provider invested in equipment and infrastructure to support safe and effective care. This included the installation of a new reverse osmosis water treatment system and replacement water pumps to help maintain reliable water quality for haemodialysis treatments.

A comprehensive fire risk assessment had been completed and was last reviewed in February 2026. The assessment considered risks across different areas of the premises and detailed the controls to mitigate identified hazards. A fire procedure was in place, fire exits were clearly marked and kept unobstructed, and smoke detectors were installed throughout the premises.

The fire alarm system was checked weekly, with records maintained, and both the fire alarm system and firefighting equipment were tested and serviced every six months by a qualified contractor. Annual inspections of the premises were undertaken by the fire authority. Electrical equipment was subject to annual portable appliance testing (PAT) by a qualified electrician.

The service monitored environmental safety through regular health and safety audits and had a range of policies and risk assessments in place, including waste management, the safe use and disposal of sharps, water quality management, and legionella risk assessments. We reviewed the legionella risk assessment completed in August 2025 and found controls were in place. Water quality analysis was undertaken three times a year, with reports reviewed for 2025 and April 2026 demonstrating satisfactory results. In addition, dialysis water quality audits were completed, with the May 2026 audit showing 100% compliance.

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 arrangements to ensure staff had the skills, knowledge and experience required to deliver safe care. A mandatory training programme covered key topics including manual handling, infection prevention and control, and sepsis recognition and management. Training records showed staff were up to date with all mandatory training requirements, with overall compliance of 100%.

The clinical workforce consisted of two registered nurses who held current nursing and midwifery council (NMC) registration. Due to the small size of the service, the two registered nurses undertook each other's competencies and annual appraisals, which included discussion of performance, clinical practice, learning needs and professional development. The provider recognised the limitations of this arrangement and, following the inspection, committed to introducing annual appraisals undertaken by a qualified external professional to provide greater independence, oversight and assurance.

Staff were supported to develop and maintain their professional competence. Registered nurses undertook continuing professional development and met Nursing and Midwifery Council revalidation requirements. Training needs were reviewed regularly to ensure staff remained up to date with dialysis practice and emergency procedures.

The service had a safe staffing policy which outlined how staffing levels were determined, how staff competency was maintained, and the actions to be taken if safe staffing levels could not be achieved. Staffing levels were monitored regularly to ensure the unit could safely meet patient demand.

During the previous 12 months, the service had not used any bank or agency staff. Staffing requirements were met entirely through the permanent workforce, providing continuity of care and enabling patients to receive treatment from staff who were familiar with their individual needs, treatment plans and unit procedures. Staff told us this supported effective communication, patient safety and a positive patient experience.

The service also had a recruitment and selection policy which provided a framework for the recruitment of suitably qualified and experienced staff. Recruitment processes pre-employment checks to ensure staff were fit for their roles. The provider also undertook fit and proper person requirement (FPPR) audits and had a structured process for the recruitment and appointment of directors. This included assessment of skills, experience, values, potential conflicts of interest, background checks and consideration of diversity, ensuring leaders were suitable to carry out their responsibilities and support the long-term strategic needs of the organisation.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff followed infection prevention and control procedures during care delivery. We observed good hand hygiene practices, use of personal protective equipment (PPE), and the use of aseptic non-touch technique (ANTT) when undertaking clinical procedures. Staff responded promptly to equipment alarms and completed cleaning and decontamination processes in accordance with local procedures following treatment. These practices supported the safe delivery of care and helped minimise infection risks.

The service had arrangements to support infection prevention and control (IPC), including colour-coded cleaning equipment, cleaning schedules, hand hygiene information and readily available personal protective equipment.

Following treatment, dialysis machines underwent an automated heat disinfection process and were cleaned externally when required. Deep cleaning was undertaken as necessary to maintain environmental hygiene.

Cleaning arrangements were well established, with schedules covering all areas of the unit, including clinical areas, waiting areas and storage facilities. These included daily weekly and monthly cleaning tasks to support infection prevention and control. Control of substances hazardous to health (COSHH) assessments were undertaken every three years, and all were up to date at the time of inspection.

IPC risk assessments were undertaken to identify potential hazards and the controls required to mitigate risks. These were supported by a range of infection prevention and control policies and procedures that provided staff with clear guidance on maintaining a safe environment and reducing the risk of infection.

Staff received regular infection prevention and control training and were expected to follow written procedures for the management of spillages, decontamination of reusable medical equipment, and cleaning of the clinical environment.

The service also used single-use medical devices which were appropriate to minimise the risk of cross-contamination. These arrangements supported the delivery of safe care and helped protect patients, staff and visitors from the risk of healthcare-associated infections.

Hand hygiene audits reviewed for January to May 2026 demonstrated 100% compliance, providing assurance that standards were consistently monitored and maintained.

The service had arrangements to reduce the risk of infection. Patients were screened through referral information, including consideration of infections such as MRSA, HIV and Hepatitis C, with clear communication and handover arrangements between referring renal units. Staff demonstrated aseptic non-touch technique (ANTT) during care delivery.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had systems to support the safe management of medicines. Medicines were stored in a locked cupboard with access restricted to designated managers. During the assessment, medicines held on site were found to be in date and stored securely.

Medicines brought to the service by patients were labelled and stored. The service relied on prescribing information and prescriptions provided by the referring dialysis unit, and staff confirmed medicines were not administered without appropriate authorisation. Where prescriptions were not available, staff contacted the referring unit to obtain the necessary documentation before treatment proceeded. Some patients were supported to self-administer their medicines where appropriate, promoting independence and maintaining established treatment routines. No controlled drugs were stored on site.

Medicines requiring refrigeration were stored in a locked refrigerator, and consumables reviewed during the assessment were found to be in date. Staff monitored refrigerator temperatures and had processes to respond to temperature excursions, including resetting the unit and escalating concerns to the supplier if required.

The service had a medicines management policy which provided staff with guidance on the ordering, receipt, storage, administration, documentation and disposal of medicines. Systems supported the safe management of medicines throughout the patient pathway. This included maintaining a record of medicines brought into the unit by patients, with documentation of any medicines returned to the patient on discharge.

Medicines reconciliation was completed for all patients on arrival to the unit. Information received from the referring renal unit, including current medicines, allergies and relevant treatment information, was reviewed and verified prior to treatment. Patients were also involved in confirming their medication details where required, and any discrepancies were clarified and documented before dialysis commenced. This helped ensure accurate and up-to-date medicines information was available to support safe care.

The service undertook a medicines management audit every three months as part of its quality assurance and governance programme. Audits reviewed compliance with medicines management policies and procedures, including medicine storage, administration practices, record keeping, disposal processes, staff competency, patient identification procedures, allergy documentation and medication safety arrangements. We reviewed the audit completed in May 2026, which demonstrated 100% compliance across audited areas. One area for improvement identified was the availability of a hard-copy British national formulary (BNF); however, staff had access to the current online version and no further corrective actions were required.