We visited this location at a time when we were able to talk to people who used the

service (patients) on a regular basis. People were satisfied with the service and

appreciated it was available to help them carry on with their lives. They told us staff were 'excellent', 'efficient' and 'respectful' when carrying out the necessary procedures. One person said, "It's an excellent service. The nurses are excellent; you couldn't wish for better people". Another patient said, "There's a really good atmosphere; it's a happy place".

Patients spoken with were satisfied with the level of privacy afforded to them. The

treatment area was open with some screens available for use around individual stations. However people told us they did not want a screen used throughout their treatment as they liked to see people and talk to those they had got to know due to attending the same sessions over a period of time.

People told us staff explained the treatment, and what was happening, especially if non

routine procedures were required. Information leaflets were available and patients

recalled being asked for their views on the service. One patient said, "They (the staff) will answer your questions when needed". Another said, "Things are explained when procedures are carried out".

We were also told people were given some choices in the day and time of the sessions,

and there was an evening session for those at work. However people recognised the

essential nature of their treatment and agreed to fit in when there were sessions available. One person said, "There is not much choice of morning or afternoon sessions at the beginning of treatment, but sometimes later on".

Diaverum UK Limited (Burnley) is operated by Diaverum UK Limited. The unit is nurse led, comprising of a manager, deputy manager, five senior nurses, seven nurses, four dialysis assistants, and four healthcare assistants. The manager, deputy manager and team leader also provided clinical care.

The service has 15 haemodialysis stations (one of which is in a side room) and provides two to three treatment sessions per station per day (225 individual treatment sessions in total per week). Other facilities within the unit include a patient waiting area including male and female toilets, a weighing area, offices, clean utility, dirty utility, staff changing room and kitchen, storeroom, and water treatment plant.

The unit is located within Burnley General Teaching Hospital (the host trust) and functions as a satellite unit for the dialysis services provided by Lancashire Teaching Hospitals NHS Foundation Trust (the commissioning trust). It mainly treats patients in the Burnley area. Patients attending the unit are referred by the host trust to the specialist renal and dialysis services provided by the commissioning trust.

The unit provides haemodialysis treatment to adults aged 18 years and over, who have non-complex needs. Currently the unit provides treatment to 42 patients between the ages of 18 and 65 (6048 individual treatment sessions between February 2016 and January 2017) and to 34 patients aged over 65 years (4896 individual treatment sessions in the same period).

We inspected this unit using our comprehensive inspection methodology. We carried out the announced inspection on 7 June 2017, along with an unannounced visit to the unit 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? 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:

• The unit had designated patient parking, access ramps, and secure but automatic doors, and was accessible to patients with mobility problems. It opened six days a week and appointment slots were allocated taking into account patients’ individual needs.

• There was a culture of incident reporting amongst staff with lessons learning shared.

• Staff completed mandatory training which included the recognition and reporting of safeguarding concerns and we saw this process work during our inspection.

• The areas we inspected were visibly clean and tidy. Records showed hand hygiene and water cleanliness were regularly monitored and maintained. Staff observed infection prevention and control measures.

• Pain relief, food and refreshments were available if required and dietetic advice was available to patients from the dietitian who visited the unit twice weekly.

• Patients spoke highly of the staff that cared for them and were happy with the treatment they provided. This was reflected in the patient survey and the very low number of formal complaints received.

• Staff we saw displayed a compassionate friendly approach to patients, and provided evidence based care in line with national professional guidelines. Staff had access to all relevant information to provide effective care and treatment.

• Treatment was individualised to each patient’s prescription and was reviewed monthly by the multidisciplinary team. Staff were able to convene case conferences with other health and care professionals to understand and support patients’ emotional and psychological needs.

• The unit implemented a holistic care package approach to assess patients’ psychological as well as physical needs. Patients were included in discussion about their care and needs.

• The clinic manager implemented a ‘memory board’ to remind all staff of recurring governance actions that needed to be carried out each month.

• The provider had a clear vision and strategy with objectives to meet key aims. This supported the close working relationship between the unit, the commissioning trust and the local trust that owned and maintained the building.

• A risk register held details of risks and actions to mitigate them.

•The unit’s service specification was defined and agreed with the commissioning trust to meet the need of local people, and took into account the trust’s policies. Monitoring meetings with the trust reviewed the unit’s performance against its service contract.

• There was a clear staffing structure and staff told us told us the organisation was ‘a good company to work for with friendly supportive staff’.

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

• Incidents were not categorised in terms of level of harm sustained.

• We were not assured that staff consistently checked patients’ identification before commencing treatment or administering medication.

• Staff at the unit did not follow up patient deaths unless they occurred within the unit itself. Instead they relied upon the commissioning trust to contact them on an ad hoc basis. This meant managers were not proactively assuring themselves that deaths were not related to care and treatment provided by staff on the unit for every patient death that occurred.

• Staff were not trained in safeguarding children level two.

• Sepsis training was not provided, which posed a risk staff may not always identify signs of sepsis. Necessary patient observations, including temperature, were not always fully recorded before, during and after the treatment sessions.

• The unit did not have a patient call buzzer system in place.

• Staff used relatives to help translate conversations with patients, which risked misinterpretation of information.

• Governance of policies, procedures and pathways was difficult to understand with expired and inconsistent review dates and processes, and staff sign-off sheets were unclear as to which staff members needed to read updates.

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 with one requirement notice. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North