North Devon Satellite Dialysis Unit

North Devon Satellite Dialysis Unit is operated by Fresenius Medical Care and opened in November 2016.The service has 16 dialysis stations. This includes 12 stations containing either a bed or a chair and four side rooms. The unit can operate 32 sessions daily. The service is open six days a week and can operate 192 sessions weekly. The unit had a caseload of 52 patients at the time of our inspection. The service also accepts patients for dialysis who holiday in the region. The Royal Devon and Exeter NHS trust commissions the haemodialysis services provided by North Devon Satellite Dialysis Unit.

The service is a nurse led unit which provides outpatient satellite dialysis provision to patients.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 5 July 2017, along with an unannounced visit to the unit on 10 July 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 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 issues that the service provider needs to improve:

• There was no evidence of learning from the serious incident or actions taken to ensure this did not occur again at the unit.

• Staff did not receive feedback from incidents they reported.
• Not all staff were compliant with the mandatory training course infection, prevention and control.
• There was no assurance that actions regarding patient care and treatment were completed following the quality assurance meeting.
• There was not an appropriate policy and specific staff training for the early identification of sepsis (infection) in line with national guidance (NHS England, 2015).
• Nurses at the unit were transcribing the patient’s dialysis prescription which was not in line with guidance from the Nursing and Midwifery Council (NMC, 2015).
• Non-tamper evident anaphylaxis medicine was stored on the resuscitation trolley.
• Some staff were not compliant with infection prevention and control policies and procedures and the unit was not meeting organisational compliance targets for hand hygiene audits.
• There was no assurance specific actions following the outcome of the documentation audit completed by the individual nurse responsible.
• Clinical staff we spoke with did not know which patients had a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) in place and there was no system to ensure staff could access this information easily in an emergency situation.
• Staff were not compliant with the Department of Health document Confidentiality: NHS Code of Practice (2003) and were sharing login and password details to access patients full record from the local acute NHS trust.
• There was no evidence of compliance with the Workforce Race Equality Standard (WRES) which became mandatory in April 2015.
• Staff lacked understanding regarding best practice for end of life care, when this might be appropriate to discuss with medical staff and how staff could best support patients.
• There was no assurance the risk register was monitored, regularly reviewed and a named person had ownership of the actions. The risk register was not a live document and did not have some local risks on it aligned to the unit. For example, hand hygiene and lack of compliance with organisational targets and recruitment.
• There was not an effective communication process to ensure in the provision of quality and risk information to the staff
• The audit schedule did not identify how actions following audits were to be carried out and who would oversee their implementation.

We found the following areas of good practice:

• The unit met and also exceeded the requirements of the Department of Health: Health Building notes 07-01 (2013).
• The unit had clear processes to ensure regular servicing and maintenance of equipment.
• There were policies and procedures to follow in case of a power failure or disturbance with the water supply during a dialysis session.
• Evidence based practice and the renal association guidelines were used to develop how patient care and treatment was delivered. Patient outcomes were monitored against best practice guidelines.
• The unit monitored patient outcomes and presented these to the local acute NHS trust on a monthly basis for review and discussion.
• There was a comprehensive training programme to ensure new nurses were competent to carry out their role at the haemodialysis unit. Staff were supported to develop their knowledge and skills.
• There was good multidisciplinary working and strong communication links with the lead consultant and the local NHS trust.
• Informed consent was sought and documented prior to commencing treatment.
• Patients were treated with dignity, compassion and respect and staff interacted with patients in a considerate and respectful manner.
• Staff took the time to interact with patients, and patients found staff to be supportive.
• Patients’ privacy and dignity was respected in all aspects of care.
• Staff understood the importance of involving close family when they had concerns as partners in patients care.
• Staff understood the impact of the treatment on patients’ emotional wellbeing and actively supported patients. This had been much appreciated by patients.
• Services were planned and delivered to meet individual patient needs and aimed to improve patients’ quality of life.
• Patients had flexibility and choice as to when they could attend their dialysis session.
• Patients had access to entertainment during their haemodialysis session.
• There was a system to monitor and deal with complaints. There had been three complaints (two formal and one informal) made at the unit since January 2017.
• The clinic manager and senior management team understood the challenges to good quality care and were able to identify actions to address them.
• The clinic manager was visible, supportive and approachable.
• The unit had an initiative for succession planning, to ensure the unit maintained the right skill mix of nurses in the future and was able to promote from within.

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, even though a regulation had not been breached, to help the service improve. We also issued the provider three requirement notices. Details are at the end of the report.

Edward Baker

Chief Inspector of Hospitals