The Care Quality Commission
  • Hospital
  • Independent hospital

Great Bridge Kidney Treatment Centre

Overall: Requires improvement read more about inspection ratings

Unit A4-A5, Link One Industrial Park, George Henry Road, Tipton, DY4 7BU (0121) 557 5538

Provided and run by:
Diaverum Facilities Management Limited

All Inspections

02 April 2019

During a routine inspection

Great Bridge Kidney Treatment Centre is operated by Diaverum Facilities Management Limited. It was awarded the contract as part of a partnership agreement with the local NHS trust. It provides haemodialysis services for adult patients living with end-stage kidney failure. The centre has 24 dialysis stations including four isolation rooms.

The nurse-led centre was supported by renal consultants employed by the NHS trust. The centre’s manager was responsible for the day to day management of the centre and dealt with all daily nursing and patient queries. The nursing director for Diaverum Facilities Management Limited has overall responsibility for nursing staff.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on the 2 April 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

Although this service has been inspected previously it was not rated. This is the first rated inspection for Great Bridge Kidney Treatment Centre.

We rated it as Requires improvement overall because:

  • The service had suitable premises and looked after them well. However, did not ensure that spare essential equipment was provided for the safe delivery of dialysis.

  • Staff kept detailed records of patients’ care and treatment. However, not all paper records had been updated with the most recent information available in the electronic versions.

  • The service did not always manage patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers did not always thoroughly investigate incidents and lessons learned were not always shared with the whole team and the wider service.

  • Leaders had the integrity, skills and abilities to run the service. However, they did not always understand or manage the priorities and issues the service faced.

  • The provider had a vision, values and a strategy for what it wanted to achieve. The vision and values had been adopted at local level however, we saw no local level strategic plans.

  • Processes were in place to provide a systematic approach to governance however, we found the documentation and completion of these processes to be limited.

  • The service had systems for identifying risks however, these were not always effective.

  • The service did not always have documented evidence that staff had learnt from when things went well and when they went wrong. However, the service was committed to promoting training, research and innovation.

However

  • The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.

  • Staff completed risk assessments for each patient.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • The centre planned and provided services in a way that met the needs of local people.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements. We also issued the provider with three requirement notices.

Nigel Acheson

Deputy Chief Inspector of Hospitals

31 May 2017 and 13 June 2017

During a routine inspection

Great Bridge Kidney Treatment Centre is operated by Diaverum Facilities Management Limited. It was awarded the contract as part of a partnership agreement with University Hospitals Birmingham NHS Foundation Trust. It provides haemodialysis services for adult patients living with chronic kidney failure. The centre has 24 dialysis stations including four isolation rooms.

The nurse-led centre was supported by renal consultants employed by the NHS trust. The centre’s manager was responsible for the centre and dealt with all daily nursing and patient queries. The nursing director for Diaverum Facilities Management Limited had overall responsibility for nursing staff.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 31 May 2017, along with an unannounced visit to the centre on 13 June 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate dialysis services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • Nursing staff treated patients with care and dignity.

  • The centre was one of the best performing centres within Diaverum Facilities Management Limited during April 2016 and March 2017.

  • The whole centre was visibly clean and tidy.

  • IT systems between the centre and NHS trust allowed healthcare professionals to communicate easily and coordinate care effectively.

  • The centre held monthly quality assurance meetings with the NHS trust to discuss all issues relating to service delivery.

  • All patients knew how to complain, the centre responded to complaints in line with its local policy.

  • We saw staff worked well together and supported one another during busier periods.

  • The consultant nephrologist and dietitian from the NHS trust regularly held clinics at the centre to review patients’ medical and nutritional needs.

  • Patients and staff told us the centre’s manager was accessible, supportive and responsive.

  • The centre’s opening hours were appropriate to allow patients to attend for their regular treatment.

However, we also found the following issues that the service provider needs to improve:

  • Not all staff including the manager had completed their yearly clinical competency for aseptic non touch technique.

  • Compliance with aseptic non touch technique and hand hygiene was variable.

  • One nurse used a technique called dry needling incorrectly.

  • Staff were not always performing the correct identity checks before commencing dialysis or administering medicines. One patient did not have a signed consent form for dialysis.

  • Storage of sodium chloride and antiseptic solution was not adequate.

  • There was out of date stock in the storeroom, and there were no supplies of intravenous administration sets on the announced inspection.

  • Staff did not check the emergency equipment trolley each day it was in use and were not aware the emergency medicines had expired on the day of the announced inspection.

  • Staff were not recognising the risks we saw during our inspection or escalating them appropriately.

  • The centre did not offer staff safeguarding childrens training, despite allowing children onto the unit.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements to help the service improve. We also issued the provider with two requirement notices. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals