Basingstoke 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

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the service management and governance was not consistently ensuring oversight and safe, evidenced based practice.

The service was in breach of Regulation 17 for governance due to repeat breaches in regulation 12 (safe care and treatment) 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 clear vision and culture that supported safe, effective care, and staff were engaged in delivering service objectives. Some improvements were needed to strengthen understanding of community needs and further embed equity, diversity, inclusion and human rights within the service.

The service had a clear vision and staff demonstrated awareness of expectations relating to safe, effective care and operational delivery. Leaders reinforced standards through staff meetings and communications, including expectations around infection prevention, documentation and maintaining audit readiness. For example, meeting records showed staff were reminded to adhere to infection prevention standards and maintain audit compliance, including completing documentation and following correct processes for patient care. Staff were also involved in discussions about adapting dialysis session allocation to prioritise clinical need and manage demand.

Staff also felt positive and proud about working for the provider and their team. Staff feedback described a supportive and collaborative environment, and positive relationships between staff and people using the service were observed and reflected in survey data, which showed high levels of satisfaction with staff helpfulness and care.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. Although leaders were visible, engaged and responsive to concerns, audits and performance data identified repeated non-compliance with key clinical, safety and safeguarding processes. Leaders did not consistently ensure actions led to sustained improvement, reducing assurance that people always received safe and effective care.

Shared direction was not consistently embedded into practice. Internal audit findings identified repeated non-compliance with key clinical and safety processes. For example, audits found staff did not consistently follow infection prevention procedures, including removing gloves before completing patient care and leaving clinical areas during treatment. Audits also identified clinical documentation was incomplete, including missing batch numbers, expiry dates and signatures for dialysis consumables, which reduced traceability. This said, Leaders were visible, engaged and knowledgeable about the service. They monitored performance data, including dialysis adequacy, treatment time and missed sessions, and discussed these regularly with external partners. For example, leaders reviewed data showing dialysis adequacy below target and implemented clinical reviews to address this. Leaders also used staff meetings to provide clear direction, including reinforcing infection control standards and responding to operational pressures.

Performance data identified a number of missed dialysis sessions requiring active management by the service. Leaders monitored missed session data and offered additional dialysis sessions where appropriate. Data showed that while some missed sessions related to planned or unavoidable circumstances, such as hospital admission, holiday, transplantation or death, there remained a cohort of patients who did not attend scheduled treatment without prior arrangement. Leaders had implemented processes to mitigate risks associated with missed treatment, including patient education, escalation and offering replacement sessions where appropriate.

Staff were supported through structured appraisal processes, with all staff having goals set and mid-year reviews underway, demonstrating ongoing performance management. Staff were able to raise concerns in meetings, including workload and administrative pressures, and leaders responded by adjusting processes such as patient allocation.

However, leaders did not maintain effective oversight of quality and safety. Audit findings identified concerns including a safeguarding process not being followed, failure to complete required clinical assessments and unsafe practices such as leaving used syringes on machines after administration rather than disposing of them immediately. Internal audits also identified repeated non-compliance in some areas, including pre-cannulation assessments not consistently being completed in line with policy, such as failing to use a stethoscope to assess vascular access.

Although actions were taken, these were not consistently effective, with repeated findings showing the same issues continued. This demonstrated leaders were aware of risks but did not ensure these were consistently addressed, reducing assurance people received safe and effective care.

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.

Staff were able to raise concerns and contribute to discussions about service delivery and operational issues. Minutes from staff meetings showed staff openly discussed challenges, including workload pressures and service processes, and leaders responded by reviewing and adjusting aspects of service delivery where appropriate. This demonstrated a culture where staff were encouraged to speak openly and contribute to improvement.

The service also used structured mechanisms to gather feedback, including patient experience surveys and engagement processes, which were shared with stakeholders for analysis. Leaders discussed patient feedback, including transport issues, in partnership meetings and sought to address concerns through collaborative approaches.

While not all feedback resulted in sustained improvement, there was no evidence staff were discouraged from speaking up or concerns were not taken seriously. Staff engagement, open discussion in meetings and leadership responsiveness indicated a culture where people felt able to raise concerns and share their views.

Staff felt respected, supported and valued. Staff said there was a good team culture, and they felt supported by leaders and colleagues. Staff described feeling able to speak up without fear of repercussion, and leaders were visible and approachable.

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.

The service had systems to support workforce management and development. Staff had access to appraisals, training and performance reviews, and were supported to develop through structured objectives and ongoing feedback.

There was evidence equality considerations were included within governance processes, including risk assessment frameworks. Workforce information demonstrated the team was diverse, with staff from a range of ethnic backgrounds, reflecting a varied workforce.

However, there was limited evidence to demonstrate how equality, diversity and inclusion were actively promoted or how outcomes were monitored and improved. There was no clear evidence of targeted initiatives, staff experience analysis or leadership actions specifically addressing inclusion or inequity. As a result, it was not possible to determine how effectively the service ensured equitable experiences for staff or addressed potential disparities.

We scored the service as 1. The evidence showed significant shortfalls. Although the service had clear responsibilities, roles, systems of accountability and governance, these were not consistently effective. Repeat breaches of regulation evidenced systems were not working to ensure improvements were implemented and embedded in practice.

Whilst the service had governance systems and processes in place, these were not effective in maintaining the safety and quality of the service. Governance arrangements did not provide leaders with sufficient assurance that risks were being effectively managed or that required standards of care were consistently maintained. Internal audits identified widespread non-compliance across key areas of clinical care and patient safety, including infection prevention and control practices, treatment procedures, documentation standards, sharps management, vascular access assessments and adherence to policies and procedures. Although action plans were developed in response to these findings, several were subsequently assessed as ineffective. Follow-up reviews identified that staff continued removing gloves prior to completion of reinfusion, documentation remained incomplete, used anticoagulant syringes continued to be left on dialysis machines, sharps bins remained open when not in use, and staff were not consistently undertaking required vascular access assessments before cannulation. Similar concerns were identified repeatedly despite corrective actions, demonstrating that known risks were not being effectively addressed and improvements were not embedded or sustained in practice.

Performance data identified ongoing risks associated with missed and shortened dialysis treatments. Leaders monitored missed session data and had processes in place to mitigate the impact of missed treatment, including offering additional dialysis sessions where appropriate. While some missed sessions related to planned or unavoidable circumstances such as hospital admission, holidays, transplantation or death, performance remained significantly above the service target throughout the reporting period. Leaders recognised this as an ongoing risk and escalated it through governance processes; however, the risk persisted over time, indicating that actions taken had not resulted in sustained improvement.

Leaders were aware of ongoing concerns regarding compliance with safe clinical practice. Staff meeting records demonstrated that infection prevention and control concerns, including risks relating to blood contamination and cross-infection, continued to be raised and discussed. Staff required repeated reminders regarding correct glove use, ANTT compliance, incident escalation and the documentation of treatment deviations, including shortened dialysis sessions and treatment refusals. This reflected ongoing concerns regarding compliance with established standards despite previous governance actions and monitoring arrangements.

Inspection and corroboration findings also identified environmental and safety risks that had not been adequately mitigated. These included concerns regarding the storage and access controls for medicines and treatment-related products, patient records being accessible to unauthorised individuals and obstructed emergency equipment.

. Risks of this nature had not been identified or addressed prior to the inspection despite established governance and oversight processes. This reduced assurance that leaders had an effective understanding of risks within the service and were taking timely action to address them.

The service maintained governance structures including performance monitoring processes, internal audits, risk management systems, escalation pathways and a risk register which included significant risks such as missed dialysis sessions and infrastructure concerns. Leaders collected and reviewed a range of information, including clinical key performance indicators, audit outcomes and patient activity data. The service also had comprehensive contingency arrangements, including emergency planning processes covering service disruption, equipment failure, staffing shortages and adverse events.

However, the persistence of repeat audit findings, ineffective corrective actions, ongoing treatment-related risks and environmental safety concerns demonstrated that these governance arrangements were not operating effectively in practice. While risks were identified, discussed and recorded through established systems, leaders could not demonstrate that actions taken resulted in sustained improvement or consistent compliance with required standards. As a result, governance systems failed to provide reliable oversight of quality and safety, and leaders could not be assured that risks to patients were consistently identified, mitigated and managed appropriately.

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.

The service worked in partnership with external stakeholders to support the coordination and delivery of care. Leaders engaged regularly with NHS partners through structured contract review meetings, where clinical performance, patient outcomes and service challenges were discussed. This ensured there was transparency and shared oversight of the service.

The service collaborated with partners including consultants, transport providers and wider system stakeholders to address issues affecting patient care. For example, missed dialysis sessions were escalated to consultants, and discussions were held around improving patient attendance and managing clinical risk.

While some system-wide challenges, such as transport delays and missed sessions, persisted, there was clear evidence the service worked collaboratively with partners to address these issues and support patient care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Learning was not consistently embedded. Audits repeatedly identified similar issues, including failure to follow infection control practices, incomplete documentation, and inconsistent clinical assessments. For example, despite previous actions, staff were still observed removing gloves prematurely during patient treatment and failing to complete required assessments before cannulation.

Performance data also demonstrated limited impact of improvement actions. Missed dialysis sessions remained high over several months despite repeated interventions, including patient education and escalation.

The service had processes to support learning from audits and performance data. Internal audits identified issues and actions were implemented. For example, following audit findings, the service introduced processes to improve documentation compliance and ensure correct stock management, including replacing outdated forms and updating labelling systems for consumables.

Learning was not consistently embedded. Audits repeatedly identified similar issues, including failure to follow infection control practices, incomplete documentation, and inconsistent clinical assessments. For example, despite previous actions, staff were still observed removing gloves prematurely during patient treatment and failing to complete required assessments before cannulation.

Performance data identified ongoing missed dialysis sessions requiring active management by the service. Although leaders had implemented measures including patient education, escalation processes and replacement sessions where appropriate, missed treatments continued to require ongoing monitoring and intervention.