Castle Vale Renal Unit

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected from bullying, harassment and avoidable harm. We checked equipment and premises were suitable for the treatment and care delivered and there was appropriate maintenance.

This was our first assessment of this service, and we rated it good for this key question. This meant people were safe and protected from avoidable harm.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. Equipment met the needs of people, and facilities were clean and well-maintained. There were effective health and safety and fire safety preventative actions. However, the fire safety risk assessment had not been reviewed, therefore it was not clear that all fire safety risks were up to date. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed safety incidents well and learned lessons from them. We saw examples of where the duty of candour had been applied, where people and their family members were informed of incidents and involved in the process of investigation and improvement. Staff understood how to report incidents and near misses and felt confident raising concerns. We viewed examples of incidents and saw these were investigated and addressed and lessons were identified and improvements implemented. For example, an increase in low harm falls, as well as falls in other units, saw the service develop a falls pathway with support from the trust's falls team. This was in the process of being implemented at the time of our visit. Incidents of aggression or unacceptable behaviour from people had resulted in the use of behaviour contracts to ensure everyone understood the responsibilities of staff, what to expect from the service and the type of behaviour expected of them.

We saw evidence lessons were learned and shared from other dialysis units. We viewed a lesson of the month notice from December 2024 about restricting the use of haemodialysis catheters. This was sent to all hospital departments along with a new protocol for `red' labelling of haemodialysis catheters to prevent non-haemodialysis use. We saw use of this labelling system in practice and staff we spoke with demonstrated an understanding of this change to practice. We also saw improvements in relation to the implementation of a sepsis pathway and the implementation of an emergency `grab box' for disconnecting dialysis in an emergency. Both of these initiatives were as a result of incidents in external dialysis units.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

There was a named nursing approach to care to ensure continuity. Named nurses were responsible for undertaking risk assessments and reviewing care plans. There was good multidisciplinary working, with a monthly multidisciplinary team (MDT) meeting held. MDT meetings were attended by consultants, members of the dialysis nursing team, a dietitian and where possible a member of the vascular access clinical nurse specialist team. Additional MDT specialist support was available in relation to end of life care, occupational therapy and social services.

Where people moved between services there was good communication. This included regular communication with a patient's GPs, as well as other dialysis units and services involved in a people's treatment and care. Where people needed to be transferred in an emergency, information about their dialysis treatment and other relevant information was sent with them.

We saw examples of the service working closely with other services to ensure continuity. There were approved business continuity plans for use in the event of interruptions to the service at Castle Vale Renal Unit. This included working with other dialysis units within the trust to ensure limited delays to treatment and that all patients had access to dialysis when they needed it.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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.

Staff understood how to access the service's safeguarding adults and children's policies which were up to date and available on the hospital intranet system. The policy included clear guidance on reporting and escalation of safeguarding concerns. Staff told us they could raise safeguarding concerns with senior staff and felt these were taken seriously. They also felt confident accessing the trust's safeguarding team for advice and support.

Almost all staff had completed level 3 safeguarding for both children and vulnerable adults, with achievement at 98% against a trust target of 90%.

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.

There were comprehensive assessment processes, and all people had a named nurse who took a lead with ensuring risk assessments were routinely completed. These included routine assessments around the risk of falls, moving and handling, tissue viability, nutrition, and diabetic foot checks. Nursing assessment and care plans included the identification of problems, goal setting and an agreed care plan with the patient to minimise risks and improve outcomes where possible.

Common dialysis risks had been included on the service's risk register and action was taken to minimise the risks. This included the risk of air embolism, low blood pressure during dialysis and the risk of needle dislodgement. Actions were taken to minimise the risks of these events, including taping, monitoring pressures and observations to address the risk of needle dislodgement in line with UK Kidney Association guidance.

Staff monitored the stability of patients, using the National Early Warning Scores (NEWS2). Staff we spoke with were aware of escalation protocols for deteriorating patients. They routinely increased the frequency of observations when NEWS2 indicated this.

The service followed the trust's procedure for the recognition and management of the deteriorating adult patient (NEWS2) and the recognition of sepsis in the community policy. Following an incident of sepsis in another dialysis unit, leaders had implemented the `sepsis six' bundle. They had implemented a process where all patients had antibiotics prescribed for such circumstances where sepsis may be recognised, so these could be administered within one hour, therefore improving patient outcomes. There was a specific screening tool in use for people on haemodialysis and staff had received training in the use of this. Staff had a good understanding of the risk of sepsis and the actions to be taken when this was suspected.

Emergency drugs and equipment were available, checked and maintained in case of the event of acute events such as anaphylaxis or cardiac arrest. These were in date, sealed and tamper evident.

Staff involved people to support managing risks to their health and wellbeing. For example, providing education in relation to foot care and the risk of skin damage.

The service did not always detect and control potential risks in the care environment. However, staff made sure equipment, facilities and technology supported the delivery of safe care.

There were not fully effective systems and processes to ensure regular review of all health and safety risk assessments. We viewed a fire safety risk assessment dated 2022 with a review date of February 2024. However, this had not been carried out. We were told discussions had been held with the fire safety officer about prioritising a risk assessment review. Following our visit, the service provided evidence that a fire safety advisor had undertaken the risk assessment review and identified actions to be completed relating to improving fire safety signage.

The design of the environment followed national guidance. There was enough space between dialysis stations to prevent the risk of cross-infection and access in an emergency while ensuring patient’s privacy was protected with the use of privacy screens if needed.

Staff carried out daily, weekly and monthly environmental safety checks. These included checks relating to fire and water safety. Planned maintenance of the water treatment room was carried out and we viewed records that showed an up-to-date schedule of works and planned servicing.

Staff carried out daily safety checks of specialist equipment. There were daily checks of dialysis machines, resuscitation equipment, water and oxygen safety. Records showed relevant checks had been carried out.

We reviewed preventative maintenance records for dialysis machines and saw these were completed by the provider’s maintenance team. Annual servicing was carried out and all machines used on the unit had been serviced in the last 12 months. Annual calibration and maintenance were in place for other equipment including dialysis chairs and beds, scales and clinical equipment.

The service had enough suitable equipment to help them to safely care for people.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs.

The service had enough nursing and support staff to keep people safe. They operated a 1 in 4 ratio of dialysis staff to patients which was in line with national guidance. We reviewed staffing rotas and saw the number of nurses and healthcare assistants matched the planned numbers. Managers accurately calculated and reviewed the number and grade of nurses and healthcare assistants needed for each shift in accordance with national guidance. We saw there were 2.42 registered nurse vacancies. Managers told us the staffing establishment was set against a plan to increase staffing in line with increasing the capacity of the twilight shift which was not yet fully embedded. There was a process to increase twilight capacity from 24 to 32 sessions. This was happening over time, with cover provided by staff working additional bank shifts. There were plans to recruit to additional posts when the process was embedded.

The manager could adjust staffing levels daily according to the needs of people. Where patient dependency increased, for example, where they were dialysed in a side room due to infection risks, then 1 to 1 care was given. Additional shifts were covered by regular staff undertaking bank shifts where necessary. The service did not use agency staff. In the event of the required staffing ratio not being met, this would be recorded on the trust incident reporting system. There had been no incidents reported in the 12 months prior to our assessment.

Medical cover was provided by 2 renal consultants who shared the patient caseload. They were available, including out of hours by phone, and carried out weekly ward rounds where people were reviewed.

The service manager ensured staff completed mandatory training. Mandatory subjects included health and safety, fire safety, manual handling and infection control. Mandatory training completion was at 95% for the service against the trust target of 90%. Staff had protected time to complete training and received reminders when training required completion.

There was a 12-week induction programme for new staff. This included role specific training and competency assessments. Staff had opportunities to develop their competencies. For example, staff had attended workshops or had shadowed vascular access clinics to learn about ultrasound guided canulation in the event of a difficult to canulate fistula.

Staff received an annual appraisal. At the time of our assessment 97% of staff had received their appraisal in the last year against the trust target of 90%.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Clinical areas were visibly clean and had suitable furnishings, with the exception of a consulting room that was carpeted. However, risks to this were mitigated by no clinical activity such as blood taking or wound care happening in this room. We were told there were plans to build a new unit over time. The environment was routinely monitored. We observed staff wiping down equipment and dialysis stations and there were clear cleaning schedules and records for all areas of the unit.

The service performed well for cleanliness. Results from infection prevention and control audits showed compliance with cleanliness and infection control was high. Results showed the service regularly scored above 96% on environmental checks and 100% for hand hygiene and high-risk procedures in relation to appropriate infection control standards. We saw there had been one episode of a bacteraemia (as a result of an access line infection) in the last year.

Staff followed infection control principles including the use of personal protective equipment (PPE). We observed staff wearing appropriate PPE when on the unit. Staff regularly washed their hands, and all were bare below the elbow in line with the infection prevention and control policy.

There were protocols for regular screening for infections. People were routinely screened for blood borne viruses, such as hepatitis or HIV and other infections, in line with national guidance. There were arrangements to dialyse people who tested positive to infections in isolation using a dedicated dialysis machine.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Dialysis machines were cleaned using a heat disinfection cycle and manual disinfection in line with manufacturer guidance. There were clear arrangements for labelling and segregating machines. Single use equipment including dialysis lines and needles was regularly checked and within date.

There were clear protocols for checking water safety within the unit. This included water temperature checks, outlet flushing and microbiology sampling. Results showed temperatures were in range and sampling showed no bacteria growth.

The service made sure medicines and treatments were safe and met people's needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Medicines were administered by trained staff using individual patient prescriptions. Prescriptions were authorised, and we observed nursing staff administering medicines safely. There was a clear checking system at the bedside and patient identity checks were carried out by verifying their name and date of birth.

Staff reviewed each patient's dialysis medicines regularly and provided advice to people and their carers about their medicines. Prescriptions relating to dialysis treatment were reviewed by the renal consultants in line with changes to requirements, for example blood test results. Consultants visited the clinic on a weekly basis and reviewed prescriptions as necessary and remotely in between visits.

Staff had up to date comprehensive medicines information for all people receiving dialysis. Patient's requiring time critical medicines prescribed by their GP were encouraged to bring their medicines with them and administer them themselves while receiving dialysis. The unit did not provide these medicines. However, current up to date medicines prescribed by the patient's GP were recorded within their dialysis unit record.

Staff completed medicines records accurately and kept them up to- date. Medicines audits were carried out every 3 months and this included the records relating to medicines administration.

Medicines were stored securely. Temperature checks of the storage areas for medicines were carried out daily, including the medicines fridge.

Staff learned from safety alerts and incidents to improve practice. The service had a process for receiving and acting on relevant safety alerts.