quality standards: services for people with progressive ... · west midlands renal network ....

West Midlands Renal Network

Quality Standards:

Services for People with Progressive and

Advanced Chronic Kidney Disease

(Version 2.4)

These Quality Standards are beyond their review date

so should be used with caution as they may not be up to date

Renal QS V2.4 final 20170110 1

© April 2012 West Midlands Quality Review Service & West Midlands Renal Network

These Quality Standards may be reproduced and used freely by NHS and social care organisations in the West Midlands

for the purpose of improving health services for residents of the West Midlands and those who use West Midlands’

services. No part of the Quality Standards may be reproduced by other organisations or individuals or for other purposes

without the permission of the West Midlands Quality Review Service. Organisations and individuals wishing to reproduce

any part of the Quality Standards should email the West Midlands Quality Review Service on: swb-tr.SWBH-GM-

[email protected] .

Whilst the West Midlands Quality Review Service has taken reasonable steps to ensure that these Quality Standards are

fit for the purpose of reviewing the quality of services in the West Midlands, this is not warranted and the West Midlands

Quality Review Service will not have any liability to the service provider, service commissioner or any other person in the

event that the Quality Standards are not fit for this purpose. The provision of services in accordance with these Standards

does not guarantee that the service provider will comply with its legal obligations to any third party, including the proper

discharge of any duty of care, in providing these services.

Review by: December 2016 at the latest

Version No. Date Change from previous version V2.2 01.04.2016 Paragraph added about organisation’s clinical governance arrangements

UKAS accreditation logo added V2.3 23.11.2016 UKAS logo removed - previously added in error as this set of Standards were

developed prior to accreditation being obtained. V2.4 10.01.2017 Text added to the front page - “These Quality Standards are beyond their

review date so should be used with caution as they may not be up to date”

mailto:[email protected]



CONTENTS Introduction......... ............................................................................................................................................... 3

Scope of the Quality Standards ...................................................................................................................................... 4

Structure of the Quality Standards ................................................................................................................................ 5

Comments on the Quality Standards ............................................................................................................................. 6

Quality Standards ............................................................................................................................................... 7

Primary Care... .................................................................................................................................................... 7

Guidelines and Protocols ............................................................................................................................................... 7

Renal Services.. ................................................................................................................................................... 7

Information and Support for Patients and their Carers ................................................................................................. 7

Staffing ......................................................................................................................................................................... 12

Support services ........................................................................................................................................................... 15

Facilities and Equipment .............................................................................................................................................. 17

Guidelines and Protocols: All Patients ......................................................................................................................... 20

Guidelines and Protocols: Pre-Dialysis Care ................................................................................................................ 22

Guidelines and Protocols: All Dialysis .......................................................................................................................... 26

Guidelines and Protocols: Haemodialysis .................................................................................................................... 28

Guidelines and Protocols: Peritoneal Dialysis .............................................................................................................. 29

Guidelines and Protocols: Transplantation and Post-Transplant Care ........................................................................ 30

Service Organisation and Liaison with Other Services ................................................................................................. 33

Governance .................................................................................................................................................................. 35

Renal Network .................................................................................................................................................. 37

Guidelines .................................................................................................................................................................... 37


Governance .................................................................................................................................................................. 39

Commissioners of Renal Services ..................................................................................................................... 41


Governance .................................................................................................................................................................. 42

Appendix 1 References ................................................................................................................................ 43

Appendix 2 Cross-References to Care Quality Commission and NHS Litigation Authourity Standards ...... 47

Appendix 3 Evidence Preparation................................................................................................................ 52

Appendix 4 Abbreviations ............................................................................................................................ 56


INTRODUCTION

These Quality Standards have been developed by the West Midlands Renal Network, working with the West Midlands Quality Review Service (WMQRS), in order to help improve services for people with progressive and advanced chronic kidney disease within the network. They aim to improve the quality of services for these patients and their carers, and improve access to renal dialysis and transplantation.

The Quality Standards (QSs) are based on the National Service Framework (NSF) for Renal Services and a range of other guidance (Appendix 1). National Service Frameworks can be interpreted in different ways and may not yet be implemented in full. The QSs therefore clarify the service that is expected throughout the West Midlands within two to five years. They help to provide the answer to the question: “For each service, how will I know that the NSF and other guidance have been implemented?” The National Service Framework for Renal Services describes the objectives which these Quality Standards are supporting and should be referred to for any queries over their interpretation.

The Transplant Forum of the West Midlands Renal Network led the development of the Quality Standards relating to renal transplantation. A working group, including patient and carer representatives supported development of Version 1 of the Quality Standards for Services for People with End Stage Renal Failure. Comments from the Renal Network’s Patient and Carer Forum were taken into account throughout in order that the Quality Standards reflected the views of local service users. Version 1 Quality Standards were used for peer review visits during 2009. Version 2 incorporates learning from these visits and updates the Quality Standards to reflect more recent guidance.

These Quality Standards cover the patient pathway through primary care to satellite and hospital-based services. They also apply to all providers commissioned by the NHS to provide care for patients with renal disease. The Quality Standards are suitable for use in self-assessment or peer review visits. They are cross-referenced to the Care Quality Commission’s Regulatory Requirements so that they can support providers’ and commissioners’ submissions to the Care Quality Commission (Appendix 2). Appendix 3 explains all abbreviations used in the Standards.

In developing these Quality Standards, the Renal Network has tried to find the balance between clear, unambiguous requirements and reasonable flexibility and responsiveness to local circumstances and settings. The Network has tried to avoid duplication with other review systems and with other systems for supporting implementation of general health service guidance. Although based on the NSF and other guidance, some Quality Standards reflect the Network’s view about the way in which this guidance should be implemented.

We hope that through using these Quality Standards:

• People with renal disease and their families and carers will know more about services they can expect.

• Commissioners will have better service specifications.

• Service providers and commissioners will work together to improve service quality.

• Quality review visits will give an independent view of service quality.

• Reviewers will learn from taking part in review visits.

• Good practice will be shared.

• Service providers and commissioners will have better information to give to the Care Quality Commission and Monitor (Appendix 2).


These Quality Standards should be implemented within two to five years by all services within the West Midlands. The Quality Standards will be reviewed by December 2016 at the latest and may be revised earlier based on experience of use for peer review visits or following changes to national guidance or evidence of effectiveness.

The quality of service described can be achieved only by cooperation between users, providers and commissioners of services. The West Midlands Renal Network provides the forum and leadership for this cooperation. Many Quality Standards can be achieved without additional funding but others will require investment. Commissioners of services are committed to implementation of the National Service Framework for Renal Services and, in agreeing these Quality Standards, commissioners are restating this commitment. The additional investment needed to achieve the QSs will still be subject to assessment and discussion with each service. The timing of additional investment will depend on the availability of funding and competing priorities from other services.

The contribution of the Working Group which developed Version 1 of these Quality Standards and everyone who commented on draft versions is gratefully acknowledged.

SCOPE OF THE QUALITY STANDARDS

These Quality Standards cover the pathway of care for people with established kidney disease, including those with progressive Chronic Kidney Disease (CKD) who are likely to progress to established CKD within 12 months. This pathway includes transplantation, preparation for renal replacement therapy, dialysis, conservative kidney management and end of life care. They do not cover care of patients with acute kidney injury, although Quality Standards may be added when NICE guidance on this has been published.

These Quality Standards link with other WMQRS Quality Standards, in particular those for:

• Urgent Care Services

• Care of People with Vascular Disease

• Care of Vulnerable Adults in Acute Hospitals

The latest versions of these Quality Standards are available on the WMQRS website: www.wmqrs.nhs.uk

These Quality Standards apply to all types of renal dialysis – home and hospital / satellite unit haemodialysis (HD) and peritoneal dialysis (PD) including continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). The QSs also refer to all types of transplantation, including cadaveric, live donor, antibody incompatible and deceased donor transplantation. Antibody incompatible transplantation includes both HLA and ABO incompatible transplantation.

Some QSs apply only to Birmingham Children’s Hospital as the sole West Midlands provider of renal services specifically for children and young people. Other services may care for young people aged 16 and 17 and services should be sensitive to the needs of these patients and their carers.

Policies, Protocols, Guidelines and Procedures:

The Quality Standards use the words policy, protocol, guideline and procedure based on the following definitions:

Policy: A course or general plan adopted by an organisation, which sets out the overall aims and objectives in a particular area.

Protocol: A document laying down in precise detail the tests or steps that must be performed.

Guidelines: Principles which are set down to help determine a course of action. They assist the practitioner to decide on a course of action but do not need to be automatically applied. Clinical guidelines do not replace professional judgement and discretion.

http://www.wmqrs.nhs.uk/


Procedure: A procedure is a method of conducting business or performing a task, which sets out a series of actions or steps to be taken.

For simplicity, some standards use the term ‘guidelines and protocols’ which should be taken as referring to policies, protocols, guidelines and procedures. All clinical guidelines should be based on national guidance, including NICE guidance where available. Local guidelines and protocols should specify the way in which national guidance will be implemented locally and should show consideration of local circumstances. Guidelines and protocols should be organised in the way which is most helpful to the local service, for example, one guideline may cover several Quality Standards or several guidelines may relate to one Quality Standard.

The Quality Standards for Services for People with Progressive and Advanced Chronic Kidney Disease should sit within organisations’ overall clinical governance arrangements. The WMQRS Clinical Governance Quality Standards describe the clinical governance arrangements which should be in place. Compliance in NHS provider organisations will usually be assured through NHS Litigation Authority Standards. Non-NHS organisations may wish to use the WMQRS Clinical Governance Quality Standards to assure themselves of the robustness of their overall clinical governance arrangements.

All WMQRS Quality Standards are available on the WMQRS website www.wmqrs.nhs.uk

STRUCTURE OF THE QUALITY STANDARDS

The Quality Standards are structured as follows:

Reference Number and Applicability

This column contains the reference number for the standard and, for some standards, the type of service to which it is applicable. The reference number is unique to these standards and is used for all cross-referencing. Each reference number is composed of two letters (the first identifying the care pathway and the second the service to which a standard applies) and three digits (the first identifying the relevant section and the last two being unique to that Quality Standard). Some Quality Standards are not applicable to all types of service. Details of the applicability are given under the reference number.

The reference also includes a guide to how the Quality Standard will be reviewed:

The shaded area indicates the approach that will be used to reviewing the Quality Standard.

BI Background information to review team

Visit Visiting facilities

MP&S Meeting children, young people, families and staff

CNR Case note review

Doc Documentation should be available

Quality Standard This describes the quality that services are expected to meet.

Demonstration of Compliance (DoC)

This describes how organisations may show that they are meeting the standard. This is not prescriptive and organisations may have other ways of demonstrating compliance.

Notes The notes give more detail about either the interpretation or the applicability of the standard.

The Quality Standards are in the following sections:



Section Reference Number Primary Care RA - Renal Services

• Children’s Renal Service (CRS) • Satellite Unit (SU) • Renal Unit (RU) • Transplant Centre (TC)

RN -

Renal Network RY - Commissioners of Renal Services RZ -

Each section covers the following topics:

Section Reference Number Information and Support for Patients and their Carers - 100 Staffing - 200 Support Services - 300 Facilities and Equipment - 400 Guidelines and Protocols - 500 Service Organisation and Liaison with Other Services - 600

Governance - 700

COMMENTS ON THE QUALITY STANDARDS

These Quality Standards will be updated as new evidence of effectiveness is published and as a result of the experience of using them in practice. Any comments on the Quality Standards should be sent to Carol Willis, Acting West Midlands Renal Network Manager, on [email protected] or the West Midlands Quality Review Service on 0121 507 2891 or [email protected] . These comments will be taken into account when the Quality Standards are updated.

More information about WMQRS and its Quality Standards and reviews is available at www.wmqrs.nhs.uk





QUALITY STANDARDS

PRIMARY CARE

Ref Standard

GUIDELINES AND PROTOCOLS

RA-501 BI

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Primary care guidelines

Guidelines on the primary care management of patients with chronic kidney disease should be in use, covering at least: a. Information and advice for patients and their carers, including lifestyle advice in order to slow down the

rate of kidney damage b. Indications for referral to the renal service

Cross Reference CQC : 16E Cross Reference NHSLA: 2.8

RENAL SERVICES

Ref Standard

INFORMATION AND SUPPORT FOR PATIENTS AND THEIR CARERS

RN-101 All

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General Support for Service Users and Carers

Service users and their carers should have easy access to the following services. Information about these services should be easily available:

a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. HealthWatch or equivalent organisation

Notes: 1 Information should be written in clear, plain English and should be available in formats and languages appropriate to the needs of service users and their carers. 2 This QS is about ‘signposting’ to relevant services. The actual services available may be different in different areas. Cross Reference CQC : 1A, 1H Cross Reference NHSLA: 2.3, 2.10


Ref Standard RN-102

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Information: All patients

Information should be offered to all patients and, where appropriate, their carers covering: a. Chronic kidney disease, including its causation, and physical, psychological, social and financial impact b. Treatment options available c. Pharmaceutical treatments and their side effects d. Promoting good health, including diet, fluid intake, exercise, smoking cessation and avoiding infections e. Symptoms and action to take if become unwell f. Support groups available, for example, Kidney Patients Association g. Expert Patients Programme (if available) h. Staff and facilities available, including facilities for relatives i. Who to contact with queries or for advice j. Where to go for further information, including useful websites

Notes: 1 Information should be available in formats and languages appropriate to the needs of the patients and carers. This may include large print and tape, video or CD / DVD information. 2 Age-appropriate information as well as information for parents / guardians should be available in units caring for children and young people. Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2

RN-103 CRS RU TC

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Information: Pre-dialysis

Information should be offered to all patients receiving pre-dialysis care covering at least: a. What are the reasons for starting dialysis b. Conservative management c. Types of dialysis available and locations of these services d. Changing dialysis modality and possible consequences e. Self-care options f. Potential complications of each type of dialysis g. Access types and access surgery h. Transport options and eligibility for free transport i. Availability of, and eligibility for, temporary dialysis away from home j. Arrangements for six monthly holistic review with named nurse k. Who to contact with queries or for advice l. Where to go for further information, including useful websites

Notes: 1 As QS RN-102. 2 Information on types of dialysis available should cover haemodialysis and peritoneal dialysis and should include information on home haemodialysis. 3 This QS is not applicable to Satellite Units. 4 Information should also be offered to carers, where appropriate. Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2


Ref Standard RN-104

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Information: Patients with dialysis access

information should be offered to all patients with dialysis access covering at least: a. Care of their dialysis access b. Management of pain and complications c. Emergency admission to hospital d. What to do if problems occur

Notes: 1 As QS RN-103. 2 Information on emergency admission to hospital should include unexpected admission to a hospital without an in-patient renal service and contact details for the patient’s ‘home’ renal service. 3 Information should also be offered to carers, where appropriate Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2

RN-105 All

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Information: Patients considering transplantation

Information should be offered to all patients being considered for transplantation covering at least: a. Different types of transplantation1 available and locations of these services b. Potential complications of each type of transplantation, including the risks of infection and malignant

disease c. Likely outcomes of each type of transplantation d. Tests and investigations that will be carried out e. What will happen if they are accepted for inclusion on the transplant list f. Annual review while on the transplant list. g. What will happen if they are not accepted onto the transplant list h. Who to contact with queries or for advice. i. Where to go for further information, including useful websites

Notes: 1 As QS RN-102. 2 Information on deceased kidney donors should not be included in information for children and young people. 3 Transplant Centres should work together to ensure that consistent information is available for all patients in the network. 4 Information should also be offered to carers, where appropriate. Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2

1 Different types of transplantation include live donor, antibody incompatible and deceased donors.


Ref Standard RN-106

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Information: Patients considering live donation

Information on kidney donation should be offered to all patients considering live donation and to all potential live donors covering at least: a. What is live donation b. Antibody incompatible transplantation c. Potential complications for the donor d. Payment of expenses, including the time within which payment should be received and a contact

point for queries over payments

Notes: 1 Information should be available in formats and languages appropriate to the needs of potential donors. This may include large print and taped information. 2 Information on payment of expenses should be based on the network-agreed guidelines (QS RY-508). 3 Information should also be offered to carers, where appropriate Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2

RN-107 CRS RU TC

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Information: Post-transplant patients

In addition to the information in QS RN-105, information should be offered to all patients following transplantation covering at least: a. Anti-rejection medication b. Symptoms and action to take if these occur, including what to do in an emergency c. Pregnancy and contraception

Notes: 1 Information should be available in formats and languages appropriate to the needs of the patients. This may include large print and taped information. 2 Age-appropriate information as well as information for parents should be available in units caring for children and young people. 3 Transplant Centres should work together to ensure that consistent information is available for all patients in the network. 4 This QS is not applicable to Satellite Units. 5 Information should also be offered to carers, where appropriate. Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 5.2

RN-108 CRS RU TC

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Information: Transition to adult care

Information should be available on transition to adult care. This information should cover all aspects of the transition (QS RN-538).

Note: This QS is not applicable to Satellite Units.

Cross Reference CQC : 1E, 1H Cross Reference NHSLA: 2.8, 4.9, 4.10


Ref Standard RN-109

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Education and awareness: All patients

An education and awareness programme should be offered to all patients with progressive and advanced chronic kidney disease and, where appropriate, their carers. In addition to a general programme appropriate to all patients and covering all points in QS RN-102, specific programmes for particular groups of patients should cover: a. Patients being considered for dialysis (QS RN-103) (Not applicable to Satellite Units) b. Patients needing immediate dialysis at presentation c. Patients with dialysis access (QS RN-104) d. Patients on the transplant list (QS RN-105) e. Education and training in the competences needed for self-care (for patients opting for self-care)

Notes: 1 The programme may consist of seminars, individual discussions or other arrangements. There should be flexibility in the delivery of programmes to meet the needs of different patient groups 2 The programmes for particular groups of patients may be run separately or may be combined. 3 If children and young people are cared for in the unit then the education and awareness programme should be age-appropriate and should be run separately from the programme for adult patients. 4 The programmes should involve members of the multi-disciplinary team and existing patients Cross Reference CQC : 4E Cross Reference NHSLA: 2.8

RN-110 All

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Care plans and key worker

All patients should be offered: a. A written individual care plan b. A permanent record of consultations at which changes to their care plan are discussed c. Access to clinical results and relevant clinical information through Renal Patient View (or an

equivalent system) d. A key worker / named contact

Notes: 1 The organisation’s arrangements for achieving this QS are covered in QS RN-501. 2 The Care Plan and updates may take a variety of forms including letters, copies of GP letters and service-user held records. Cross Reference CQC : 4A, 4B, 4E, 6F Cross Reference NHSLA: 1.8, 2.8

RN-111 All

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Food

Food should be offered to all patients who are away from home for more than six hours to attend clinic or receive dialysis.

Note: The NSF suggests that food such as a ‘snack box’ should be provided. Cross Reference CQC : 4A, 4B, 5A

RN-112 All

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Car parking

Free or reduced price car parking should be available close to the dialysis unit for haemodialysis patients attending for dialysis.

Note: This QS is not applicable to services which do not provide haemodialysis. Cross Reference CQC : 1A


Ref Standard RN-113

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Patient Transport

Patients travelling by hospital transport should arrive within 30 minutes of their starting time for dialysis and should be picked up within 30 minutes of finishing dialysis. Adult patients should not travel for more than 30 minutes or 25 miles (whichever is less) unless by choice. Cross Reference CQC : 4A

RN-199 All

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Involving Patients and Carers

The service should have:

a. Mechanisms for receiving feedback from patients and carers b. A rolling programme of audit of patients’ and carers’ experience c. Mechanisms for involving patients and, where appropriate, their carers in decisions about the

organisation of the service Cross Reference CQC : 1J, 16E Cross Reference NHSLA:2.3, 2.10

STAFFING

RN-201 All

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Lead Consultant and Nurse

The service should have a nominated lead consultant nephrologist and nominated lead nurse with responsibility for ensuring implementation of the Quality Standards for the Care of Patients with End Stage Renal Failure.

Note: Satellite Units which accept patients from more than one renal service should have a lead consultant and lead nurse with governance responsibility for the Satellite Unit service. Cross Reference CQC : 13A Cross Reference NHSLA: 1.9

RN-202 All

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Leads for particular aspects of care

The service should have a nominated lead consultant and lead nurse / coordinator for: a. Pre-dialysis care (Not applicable to Satellite Units) b. Dialysis care c. Transplant-related issues, including live kidney donation and Renal Unit / Transplant Centre liaison d. Transition to adult care (Not applicable to Satellite Units) e. End of life care

Notes: 1 The nominated leads may be the same as those in QS RN-201. One person may be the nominated lead for more than one aspect of care. 2 The nominated leads may delegate aspects of these duties so long as they maintain oversight and overall responsibility. Cross Reference CQC : 13A, 14A Cross Reference NHSLA: 1.9

RN-203 CRS RU TC

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Consultant Nephrologists

A consultant nephrologist should be on call at all times and available to attend to care for patients within 30 minutes.

Notes: 1 The consultant nephrologist in the Transplant Centre should have responsibility for the care of patients in the Transplant Centre and for advice to Renal Units. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 13A Cross Reference NHSLA: 1.9


Ref Standard RN-204

CRS TC

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Transplant Surgeons

A consultant transplant surgeon should be available at all times for the care of patients in the Transplant Centre and for advice to Renal Units.

Notes: 1 In units caring for children and young people, the transplant surgeons should have the competence to undertake renal transplants in children. 2 This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 13A Cross Reference NHSLA: 1.9

RN-205 TC

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Lead Consultant: Transition

Transplant Centres with lead responsibility for the care of young people aged up to 25 years (QS RZ-601) should have a nominated lead nephrologist with responsibility for liaison with the network’s Renal Service for Children (CRSs) in relation to transfer to adult care.

Note: This QS applies only to Transplant Centres with lead responsibility for the care of young people aged up to 25 years. Cross Reference CQC : 13A Cross Reference NHSLA: 1.9

RN-206 CRS

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Lead Surgeon and Urologist

The service should have: a. A nominated lead surgeon for paediatric transplantation with responsibility for transplant-related

issues, including coordination of all transplant surgeons involved with the care of children or living related donor transplants to children

b. A nominated lead paediatric urologist with responsibility for liaison with the paediatric renal transplantation service in relation to the care of children with complex bladder anomalies

Note: This QS applies only to children’s renal services Cross Reference CQC : 13A Cross Reference NHSLA: 1.9

RN-207 CRS RU TC

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Staffing: In-patient wards

The in-patient ward should have sufficient renal nurse and HCA staff with appropriate competences. Staffing levels should be based on a competence framework covering the skill mix, staffing levels and competences expected for the usual number and dependency of patients. The competence framework should cover, at least, care of patients with renal disease, procedures staff are expected to undertake and equipment they are expected to use.

Notes: 1 Newly appointed staff may not yet have the expected competences in the care of patients with renal disease but their training should be organised or have already started. 2 The Skills for Health Renal National Workforce Competences may be helpful in designing role profiles and developing and reviewing competence. 3 This QS is not applicable to Satellite Units. Cross Reference CQC : 13A, 14A Cross Reference NHSLA :1.9, 3.1, 3.2


Ref Standard RN-208

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Staffing: Dialysis services

The dialysis service should have sufficient renal nurse and HCA staff with appropriate competences. Staffing levels should be based on a competence framework covering the skill mix, staffing levels and competences expected for the usual number and dependency of patients. The competence framework should cover, at least, care of patients with renal disease, procedures staff are expected to undertake and equipment they are expected to use.

Notes: 1 As QS RN-207. 2 Where the service is also supporting patients on home haemodialysis, these patients should be included in the calculation of staffing levels. Cross Reference CQC : 13A, 14A Cross Reference NHSLA: 1.9, 3.1, 3.2

RN-209 RU SU TC

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Specialist Nurses

The service should have an identified lead nurse with specialist expertise in each of the following areas: a. Vascular access b. Anaemia management c. Home therapies d. Conservative management (Not applicable to Satellite Units)

Notes: 1 One person may be the specialist nurse for more than one of the areas identified. 2 Satellite units should have access to nurses with specialist expertise in each area and may have a nurse with a particular interest in vascular access and anaemia management. 3 This QS is not applicable to children’s renal services. Cross Reference CQC : 13A, 14A Cross Reference NHSLA: 1.9, 3.1, 3.2

RN-210 All

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Clinical Technologists

Sufficient clinical technologist staff with appropriate competences should be available to support equipment maintenance, breakdown and replacement, including water treatment equipment. All clinical technologists should have regular assessment of competence in the maintenance of equipment appropriate to their role.

Notes: 1 Where the service is also supporting patients on home haemodialysis, these patients should be included in the calculation of staffing levels at a ratio of 1 wte per 20 home haemodialysis patients. 2 Recommended clinical technology staffing level for general hospital services is 1 wte: 50 in-patients with a maximum of 1wte: 65 patients, and 1 wte: 20 home patients. A minimum of 3 technicians should be available. 3 Recommended staffing levels are currently being reviewed by the Association of Renal Technologists. Revised recommendations should be used when available. 4 Clinical technologists should be included on the Voluntary Register of Clinical Technologists unless there is an appropriate reason why voluntary registration is not appropriate. 5 Clinical technologist staff may be based on the same site as the renal service or may be based elsewhere. Cross Reference CQC : 13A, 14A Cross Reference NHSLA: 3.1, 3.2


Ref Standard RN-211

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On-call Clinical Technologist

A 24 hour clinical technologist on call service should be available.

Note: This QS is not applicable to Satellite Units. Cross Reference CQC : 13A Cross Reference NHSLA: 3.1, 3.2, 5.4

RN-212 All

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Support Staff

The service should have: a. A nominated lead for coordinating holiday haemodialysis b. Sufficient staff to ensure data collection as required for relevant QS RN-700s c. Administrative and clerical support

Note: The amount of data collection and administrative and clerical support is not defined. Clinical staff should not, however, spending unreasonable amounts of time which could be used for clinical work on administrative tasks. Cross Reference CQC : 13A

SUPPORT SERVICES

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Support Services

The following services should be available to provide support to patients with renal diseases: a. Dietetics b. Pharmacy (Not applicable to Satellite Units) c. Psychological support d. Social worker e. Play specialist and youth worker (CRS only) Staff providing these services should have specific time allocated in their weekly job plan to their work with the renal service and specific training or experience in caring for people with renal diseases.

Notes: 1 Nominated individuals may spend only part of their time working with patients with renal disease. 2 All staff should have the competences needed for their role. The Skills for Health Renal National Workforce Competences may be helpful in designing role profiles and developing and reviewing competence. 3 These staff should be available to support out-patient as well as in-patient care (where applicable). 4 Psychological support may be from counsellors and / or clinical psychology services. 5 Support to Satellite Units may be through ‘drop-in’ sessions or outreach from another renal service. Cross Reference CQC : 13A Cross Reference NHSLA: 2.8


Ref Standard RN-302

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Access surgery

Emergency and elective surgical services should be available to provide: a. Elective access surgery b. Emergency surgery for failed vascular access and removal of infected peritoneal dialysis catheters

Notes: 1 Guidelines covering referral for and timeliness of access surgery are covered in QS RN-507. 2 National recommendation is one session per week for every 120 adult patients on dialysis. 3 This QS is not applicable to Satellite Units. Cross Reference CQC : 4D Cross Reference NHSLA: 4.8

RN-303 CRS RU TC

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Dermatology services

Access to dermatology services with expertise in the management of patients on long-term immuno-suppresive therapy should be available.

Note: This QS is not applicable to Satellite Units. Cross Reference CQC : 6A Cross Reference NHSLA: 2.8

RN-304 CRS RU TC

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Transplant Coordinator: live kidney donors

There should be a nominated transplant coordinator with lead responsibility for live kidney donors.

Note: This QS is not applicable to Satellite Units. Cross Reference CQC : 13A Cross Reference NHSLA: 3.1, 3.2

RN-305 TC

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Transplant Coordinator

A renal recipient transplant coordinator should be available at all times.

Note: This QS applies only to Transplant Centres. Cross Reference CQC : 13A Cross Reference NHSLA: 3.1, 3.2

RN-306 TC

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Expert advice on antibody incompatible transplantation

The Transplant Centre should have arrangements for access to expert advice on antibody incompatible transplantation.

Notes: 1 These arrangements should ensure advice is available each day (7/7) but 24 hour access to advice is not expected. 2 This QS applies only to Transplant Centres. Cross Reference CQC : 6B, 13A Cross Reference NHSLA: 3.1, 3.2

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Histocompatibility service

The Transplant Centre should have access within a two hour travel time to a consultant led, accredited histocompatibility service.

Note: This QS is not applicable to Satellite Units and Renal Units.


Ref Standard Doc

Cross Reference CQC : 6B Cross Reference NHSLA: 1.9, 5.7

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Histopathology service

The Transplant Centre should have access to a histopathology service with expertise in the interpretation of renal transplant biopsies.

Note: This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 6C Cross Reference NHSLA: 5.7

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Theatres for transplantation

The Transplant Centre should have 24 hour a day, 7 days a week access to operating theatres for renal transplantation.

Note: This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 6C Cross Reference NHSLA: 2.8

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Plasmapheresis

The Transplant Centre should have 7 days a week access to plasmapheresis.

Notes: 1 This QS is only applicable to Transplant Centres providing an antibody incompatible service. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 6C Cross Reference NHSLA: 2.8

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Support Services: Transition

Transplant Centres with lead responsibility for the care of young people aged up to 25 years (QS RN-601) should have the following services available: a. Youth worker service b. Psychological support service with expertise in the care of young people with renal disease

Notes: 1 Staff providing these services should have specific time allocated for this work. 2 This QS applies only to Transplant Centres with lead responsibility for the care of young people aged up to 25 years. Cross Reference CQC : 6C, 6M Cross Reference NHSLA:2.8, 4.10

FACILITIES AND EQUIPMENT

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Haemodialysis facilities

Appropriate facilities for the provision of haemodialysis should be available. All new facilities should meet the requirements of HBN 53 (Volumes 1 or 2 as applicable) and other services should be working towards these standards. In-patient services should ensure reasonable separation of patients receiving in-patient and out-patient care.

Note: The section of the QS relating to in-patient services is not applicable to Satellite Units. Cross Reference CQC : 10A, 11A Cross Reference NHSLA: 2.8


Ref Standard RN-402

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Haemodialysis: Equipment

All equipment used in the delivery and monitoring of therapy should comply with the relevant standards for medical electrical equipment.

Note: Latest standards are given in DB2006(05), IEC 62353 and CE 93/42/EEC. More recent standards should be applied as guidance is revised. Cross Reference CQC : 11A Cross Reference NHSLA: 5.4

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Haemodialysis: Equipment replacement

Each unit should have a programme of equipment replacement.

Note: Renal Association guidance is that machines should normally be replaced after between seven and ten years’ service or after completing between 25,000 and 40,000 of haemodialysis. Cross Reference CQC : 11A Cross Reference NHSLA: 5.4

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Haemodialysis: Concentrates

All haemodialysis concentrates should comply with European quality standards.

Cross Reference CQC : 11A Cross Reference NHSLA: 5.10

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Haemodialysis: Water

A routine testing procedure for product and feed water should be in use which ensures water used in preparation of dialysis fluid meets the requirements of BS EN 13959: 2002.

Note: If treatments other than conventional haemodialysis are used, water should meet the more stringent requirements applicable to these treatments (Renal Association Guidelines for Haemodialysis, 4th Edition, 2006, section 3.2). Cross Reference CQC : 16A Cross Reference NHSLA:5.4

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Haemodialysis: Membranes

A protocol on haemodialysis membranes should be in use covering: a. Use of low flux synthetic and modified cellulose membranes b. Membranes for patients at risk of developing symptoms of dialysis-related amyloidosis c. Membranes for patients with increased bleeding risk d. Membranes in patients on ACE inhibitor drugs

Notes: 1 This QS is not applicable if only one type of dialyser is used. 2 If patients from more than one renal service are cared for at the Satellite Unit then the protocol should be agreed by all services whose patients normally use the Satellite Unit. Cross Reference CQC : 4B, 4M Cross Reference NHSLA: 5.4

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Peritoneal dialysis: Equipment

All equipment used in the delivery and monitoring of therapy should comply with the relevant standards for medical electrical equipment.

Notes: 1 Latest standards are given in DB2006(05), IEC 60601-2, IEC 60601-16 and CE 93/42/EEC. More recent standards should be applied as guidance is revised. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 11A Cross Reference NHSLA: 5.4


Ref Standard RN-408

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Isolation facilities

Appropriate facilities for isolation of patients should be available. Cross Reference CQC : 10A Cross Reference NHSLA: 2.8

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Weighing scales

All weighing scales should comply with Non-Automatic Weighing Instrument (NAWI) Regulations 2000, part III, section 38.

Note: This QS applies to all scales in, or supplied by, the renal service. Cross Reference CQC : 11A Cross Reference NHSLA: 5.4

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Home therapy training facility

Facilities for training patients in home therapies should be available.

Cross Reference CQC : 11A


Ref Standard

GUIDELINES AND PROTOCOLS: ALL PATIENTS

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Operational Policy

The unit’s operational policy should ensure: a. Allocation of a key worker / named contact at each stage of the patient’s care b. Arrangements for handover of key worker / named contact between stages of the patient’s care c. Ensuring all patients and, where appropriate, their carers are offered information (QS RN-102) and

education programmes (QS RN-109) d. Ensuring all patients have a written care plan that is discussed with the patient and, where

appropriate, their carers: o following significant changes in circumstances o at least once a year

e. Offering patients a copy of their care plan f. Offering patients a permanent record of consultations at which changes to their care plan are

discussed g. Communicating changes to the care plan to the patient’s GP, including information about changes in

drug treatments and what to do in emergencies h. Arrangements for ensuring patients have up to date information on their blood results

Notes: 1 The key worker may be any member of the multi-disciplinary team and will usually be the clinician or nurse with responsibility for the patient during a stage of their care. The key worker may change over time. 2 For children, communication will be with the parents as well as the child. 3 A copy of the care plan should be offered to all patients but is particularly important for patients going on holiday or transferring between units. 4 In addition to current treatment, the care plan should include, where applicable: • Suitability for dialysis and preferred dialysis modality (QS RN-505) • Transport arrangements for dialysis (QS RN-505) • Interest in and fitness for transplantation (QS RN-508) • Willingness to receive a kidney from a deceased donor (adults only) • Acceptance onto the transplant list for different types of transplantation (QS RN-509) Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 4.9

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Guidelines: Lifestyle advice

Guidelines covering responsibilities, advice to be given and actions to be taken, including referral to other services, should be in use for: a. Lifestyle advice and information, including:

o Support for smoking cessation o Dietary advice, including salt reduction and alcohol o Programmes of physical activity and weight management o Sexual health, contraception and pregnancy o Travel and holidays o Risks and implications of having haemodialysis abroad

b. Monitoring of growth and development (children and young people only)

Note: The guidelines should be based on national guidance, including NICE guidance where available. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RN-503

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Clinical guidelines: Management of CHD risk factors, anaemia and diabetes

Clinical guidelines should be in use covering: a. Monitoring and management of CHD risk factors, including:

o Anti-platelet therapy o Lipid reduction therapy o Control of hypertension o Calcium and phosphate control

b. Management of diabetes mellitus (adults only) c. Management of anaemia

Notes: 1 All clinical guidelines should be based on national guidance, including NICE guidance where available. 2 Clinical guidelines for CHD management may be the same as for patients post-transplantation (QS RN-529). 3 Guidelines for management of diabetes and anaemia should cover patients at all stage of their disease, including post-transplant patients. 4 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Referral for psychological support

Clinical guidelines should be in use covering indications and arrangements for referral for psychological support. Cross Reference CQC : 1D, 4B Cross Reference NHSLA: 2.8

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Referral to specialist palliative care

Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering, at least: a. Arrangements for accessing advice and support from the specialist palliative care team b. Arrangements for shared care between the renal service and palliative care services c. Indications for referral of patients to the specialist palliative care team for advice

Notes: 1 Guidelines should address the needs of patients with complex symptom control problems; patients with complex psychological, social or spiritual needs and patients with young children or elderly carers in need of support. 2 Guidelines will need to reflect the local availability of palliative care services in all areas from which the service normally accepts patients. Cross Reference CQC : 1D, 4B Cross Reference NHSLA: 2.8

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End of life care guidelines

The renal service should be aware of local guidelines for the end of life care of patients. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard

GUIDELINES AND PROTOCOLS: PRE-DIALYSIS CARE

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Operational Policy: Pre-dialysis care

A policy should be in use cover pre-dialysis care. This policy should ensure: a. Patients and, where appropriate, their carers, are offered information (QS RN-103), education

programmes (QS RN-109) and psychological support to enable them to make an informed choice of dialysis modality

b. Assessment of suitability for dialysis c. Assessment of home environment for those patients considering home dialysis (HD & CAPD) d. Assessment of the economic impact of dialysis and possible sources of financial support e. Discussion of transport arrangements with each patient f. Recording of the agreed transport arrangements in the patient’s care plan g. The patient’s preferred choice of dialysis modality is recorded in the patient’s notes / electronic

patient record and care plan The policy should cover arrangements for patients:

i. With 12 months or more preparation ii. Presenting less than 12 months before starting treatment

iii. Needing immediate dialysis at presentation iv. With failing transplants

Notes: 1 Pre-dialysis education takes time and, whenever possible, should begin at least 12 months prior to the start of dialysis treatment. 2 This policy should be based on Renal Association Standards. 3 The policy should cover situations where the patient’s preferred dialysis modality is considered sub-optimal by the multi-disciplinary team. 4 The policy should cover ‘fast-track’ education and urgent peritoneal dialysis catheter insertion for suitable patients needing immediate dialysis at presentation who wish to avoid temporary haemodialysis. 5 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 5.2

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Control of infection

Clinical guidelines should be in use covering: a. Screening for blood born viruses b. Hepatitis vaccination if required c. Monitoring of hepatitis B and C antibodies d. Screening for staphylococcus aureus and MRSA carriage and treatment of carriers The guidelines should cover arrangements for patients presenting less than 12 months before starting treatment and those needing immediate dialysis at presentation as well as arrangements for patients with 12 months or more preparation.

Note: The guidelines should be based on the latest NICE, Renal Association or network-agreed guidelines (QS RY-501). Cross Reference CQC : 4B, 8 Cross Reference NHSLA: 2.8


Ref Standard RN-507

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Access surgery protocol

Guidelines should be in use covering: a. Referral for assessment and investigation of suitability for access surgery b. Referral for surgery c. Indications for antibiotic prophylaxis d. Ensuring patients are given information about their dialysis access (QS RN-104) The guidelines should ensure that, whenever possible, access is established and functioning three months before haemodialysis and two weeks before peritoneal dialysis.

Notes: 1 The guidelines should be based on the latest NICE, Renal Association or International Society of Peritoneal Dialysis guidelines. 2 Compliance with this QS will be determined by the presence of a written protocol and audit of timeliness. The actual waiting times may be identified as an issue of risk / concern when the QSs are used in self-assessment or peer review. 3 The audit of timeliness should have been completed not more than a year preceding the self-assessment / peer review visit. 4 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Referral for consideration of suitability for transplantation

Guidelines should be in use covering referral to the Transplant Centre for consideration of suitability for transplantation. This protocol should ensure that: a. A discussion with the patient, where appropriate their carer, and nephrologist takes place about their

interest in and fitness for transplantation b. The patient is considered against the network criteria for each type of transplantation (QS RY-502) c. The resulting decision is recorded in the patient’s notes / electronic patient record and care plan d. Clinically appropriate patients are normally placed on the transplant list six months prior to the

predicted start of dialysis

Notes: 1 The guidelines should be based on BTS guidance (with the exception of discussion with a transplant surgeon – see note 3) and network-agreed guidelines (QS RY-502). 2 Units may have a variety of systems for predicting the start of dialysis but should be considering documenting and formalising these systems. 3 Discussion with a transplant surgeon at this stage is not considered essential for all patients and inclusion of this requirement could lead to delays in referrals. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.2


Ref Standard RN-509

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Acceptance on transplant list

A protocol should be in use covering acceptance onto the transplant list. This protocol should ensure that: a. A discussion with the patient, where appropriate their carer, and a transplant nephrologist and / or

transplant surgeon takes place about their fitness for transplantation b. The patient is considered against the network criteria for each type of transplantation (QS RY-502) c. A discussion takes place about the patient’s suitability for and interest in:

o Antibody incompatible transplantation o Combined kidney / pancreas transplantation (adults only) o Deceased donor transplantation

d. The availability of potential living related donors is discussed e. Clinically appropriate patients are normally placed on the transplant list six months prior to the

predicted start of dialysis f. The resulting decision is recorded in the patient’s notes / electronic patient record and care plan, and

communicated in writing to the patient and the referring Renal Unit (if applicable) within 10 working days

Notes: 1 This protocol should be based on BTS guidance and the network-agreed guidelines (QS RY-502). 2 Transplant Centres may have a variety of systems for predicting the start of dialysis but should be considering documenting and formalising these systems. 3 Audit of timeliness of communication is covered in QS RN-705. 4 For children and young people, the discussion should involve both a paediatric nephrologist and a transplant surgeon. 5 For children, the discussion will involve the parents as well as the child. 6 Some aspects of this QS will not be applicable to all children and young people. 7 This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.2

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Referral for combined kidney and pancreas transplantation

Guidelines should be in use covering criteria and arrangements for referral of patients with diabetes for combined kidney and pancreas transplantation.

Notes: 1 The guidelines should be based on BTS guidance and the network-agreed guidelines (QS RY-505). 2 This QS is not applicable to Children’s Renal Services or Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 4.10


Ref Standard RN-511

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Suspension and reinstatement on transplant list

A protocol should be in use covering suspension and reinstatement of patients on the transplant list. This protocol should cover at least: a. Regular review of patients suspended from the list b. Informing the Transplant Centre that a patient has been suspended c. Reinstatement of patients onto the list as soon as clinically appropriate d. Informing the Transplant Centre when a patient is to be reinstated onto the list

Notes: 1 This protocol should be based on BTS guidance and network-agreed guidelines (QS RY-503). 2 Sections of the QS relating to informing the Transplant Centre are not applicable to Transplant Centres, although the Transplant Centre protocol should ensure that relevant staff are kept informed about patients suspended from the list. 3 The protocol should specify the frequency with which the details of suspended patients will be reviewed. This review does not require the patient to be seen. 4 The protocol should be clear about which staff should be involved in the regular review of patients on the transplant list. 5 This QS links with QS RN-521. 6 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.2

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Annual review of patients on transplant list

Guidelines should be in use covering annual review of patients on the transplant list. The annual review should cover at least: a. Current fitness for transplantation b. Risk factors for coronary heart disease c. Anaesthetic risk d. Co-morbidity e. Availability of potential living related donors f. Consent for virology and storage for tissue typing

Notes: 1 The guidelines should be based on BTS guidance. 2 Fitness for transplantation should include consideration of all types of transplantation. 3 Advice and treatment of CHD risk factors may take place within dialysis services. 4 Some aspects of this QS will not be applicable to all children and young people. 5 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.2


Ref Standard RN-513

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Removal from transplant list

A protocol should be in use covering removal from the transplant list. This protocol should ensure that: a. A discussion takes place with the patient and, where appropriate, their family or carers about the

reason for removal b. A decision to remove the patient from the transplant list temporarily or permanently is recorded in

the patient’s notes / electronic patient record c. The Transplant Centre is informed of the decision to remove the patient from the transplant list

temporarily or permanently

Notes: 1 This protocol should be based on BTS guidance and the network-agreed guidelines (QS RY-503). 2 The section of this QS relating to informing the Transplant Centre is not applicable to Transplant Centres although the Transplant Centre protocol should ensure that relevant staff are informed. 3 For children, discussion will be with the parents as well as the child. 4 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.2

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Cardiovascular work up pre-transplantation

A protocol should be in use covering cardiovascular work-up prior to transplantation. This protocol should ensure that cardiac investigations are normally completed within six weeks of referral.

Notes: 1 This protocol should be based on BTS guidance and the network-agreed guidelines (QS RY-504). 2 Compliance with this QS will be determined by the presence of a written protocol and audit of timeliness. The actual waiting times may be identified as an issue of risk / concern when the QSs are used in self-assessment or peer review. 3 The audit of timeliness should have been completed not more than a year preceding the self-assessment / peer review visit. 4 This QS is applicable only to some children and young people. 5 Cardiovascular work-up may take place at the Transplant Centre or Renal Unit. 6 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

GUIDELINES AND PROTOCOLS: ALL DIALYSIS

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Operational Policy: Self-care and home therapies

A policy should be in use covering: a. Self-care options offered by the service, including home haemodialysis, CAPD, self-care within a

dialysis unit, APD and assisted PD b. Assessment of patient suitability for self-care and home therapies c. Training for self-care and home therapies d. Arrangements for assessing and monitoring competence of patients opting for self-care e. Assessment of home environment for patients choosing a home therapy f. Arrangements for water testing for patients on home haemodialysis

Note: This QS applies to Satellite Units for patients doing self-care haemodialysis on the Satellite Unit. If this is not offered then the standard is not applicable. Cross Reference CQC : 4B Cross Reference NHSLA: 3.5, 5.2


Ref Standard RN-516

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Monitoring

Guidelines should be in use which ensures: a. Arrangements for multi-disciplinary review of blood results b. Monitoring of hepatitis B and C antibodies c. Frequency of out-patient review d. Arrangements for six monthly holistic review with named nurse e. Indications for change of dialysis modality f. Arrangements for changing dialysis modality

Notes: 1 The guidelines should ensure that appropriate aspects of QSs RN-505, RN-506 and RN-507 are implemented. Protocols may be combined / cross-referenced as appropriate locally. 2 The guidelines should be based on Renal Association Standards. 3 The guidelines should apply to all patients, including patients on self-care. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.7

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Six monthly holistic review

A protocol should be in use which ensures a six monthly holistic review with the patient’s named nurse covering at least: a. Review of biochemistry and referral to members of the multi-professional team if required b. Current medication, compliance and referral to the renal pharmacist if required c. Consideration of nutritional status and indications for referral to the dietician for assessment (QS RN-

518 & RN-519) d. Psychological well-being and indications for referral for psychological support (QS RN-504) e. Lifestyle advice (QS RN-502) f. Transport arrangements g. Need for temporary dialysis away from home the outcome of the holistic review should be

documented in the patient’s care plan

Note: This protocol may be combined with the protocols and guidelines required by QSs RN-502, RN-504, RN-518 & RN-519. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8, 5.7

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Nutrition while on dialysis (adults)

A protocol should be in use which ensures that: a. An interview with the dietician takes place within one month of starting dialysis b. An annual nutritional assessment is undertaken c. Indications for referral to the dietician at other times

Note: This QS is not applicable to children’s renal services. Cross Reference CQC : 4B, 5B Cross Reference NHSLA: 2.8

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Nutrition while on dialysis (children and young people)

A protocol should be in use which ensures that: a. An interview with the dietician takes place within one week of starting dialysis b. A nutritional assessment is undertaken every three months c. Indications for referral to the dietician at other times

Note: This QS is not applicable to renal services for adults. Cross Reference CQC : 4B, 5B Cross Reference NHSLA: 2.8


Ref Standard RN-520

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Dialysis away from ‘base’

A protocol on ‘dialysis away from base’ should be in use covering at least: a. Isolation dialysis b. Use of dedicated machines c. Suspension from and re-instatement to the transplant list d. Informing the Transplant Centre of suspension from and re-instatement to the transplant list

Note: This protocol should be based on network-agreed guidelines (QS RY-501). Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Withdrawal of dialysis

A protocol should be in use covering withdrawal of dialysis. This protocol should ensure that: a. A discussion takes place with the patient and, where appropriate, their family or carers about the

reason for withdrawal b. A decision to withdraw dialysis is recorded in the patient’s notes / electronic patient record / care

plan c. Referral to palliative care services is made if appropriate (QS RN-598 & RN-599)

Note: This protocol should be based on Renal Association Standards. Cross Reference CQC : 4B Cross Reference NHSLA: 5.2

GUIDELINES AND PROTOCOLS: HAEMODIALYSIS

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Haemodialysis: Regimes

Guidelines should be in use covering: a. Frequency of haemodialysis b. Duration of haemodialysis c. Measurement of adequacy of haemodialysis d. Pre- and post-dialysis blood sampling e. Exception reporting arrangements for haemodialysis patients dialysing for less than four hours, three

times a week

Note: These guidelines should be based on Renal Association Standards. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Haemodialysis: Control of infection

Guidelines should be in use covering: a. Care of temporary and cuffed dialysis lines and arterio-venous fistulae, including locking solutions and

dressings b. Preparing vascular access for haemodialysis c. Decontamination of equipment after each treatment session d. Decontamination of equipment after use by patients with blood born viruses

Note: The guidelines should be based on ‘Safer Practice in Renal Medicine’, DH (2006), ‘Saving Lives’ High Impact intervention No. 3 ‘Renal Dialysis Catheter Care Bundle’ and network agreed guidance (QS RY-501) and cover, at least, wearing of gloves, use of sterile dressing packs and preparations used to clean lines. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


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Haemodialysis: Access management

Guidelines should be in use covering access care and performance. This should cover at least: a. Arrangements for monitoring access performance b. Management of access infections c. Management of dysfunctional access d. Investigation of AV fistulae or grafts for evidence of stenosis e. Indications for secondary AV access after each episode of access failure f. Management of anxiety and pain

Note: The guidelines should be based on Renal Association Standards. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

GUIDELINES AND PROTOCOLS: PERITONEAL DIALYSIS

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Peritoneal dialysis: Regimes

Clinical guidelines should be in use covering: b. Modality of dialysis used (CAPD, APD) c. Disconnect systems d. Type of fluid used including:

o Solutions for patients experiencing infusion pain o Solutions for patients likely to remain on peritoneal dialysis for more than four years o Indications for use of specialist fluids

e. Dialysis dose f. Monitoring dialysis adequacy, peritoneal dialysis function, residual urine and peritoneal ultra-filtration

volume

Notes: 1 These guidelines should be based on Renal Association Standards and International Society of Peritoneal Dialysis guidelines. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Peritoneal dialysis: Access management

Clinical guidelines should be in use covering access care and performance. This should cover at least: a. Peri-operative catheter care b. Care of peritoneal dialysis catheters c. Management of exit site and tunnel infections d. Management of catheter complications (leaks, obstruction) e. Management of anxiety and pain

Notes: 1 These guidelines should be based on Renal Association Standards and International Society of Peritoneal Dialysis guidelines. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RN-527

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Peritoneal dialysis: Management of complications

Clinical guidelines should be in use covering management of: a. Peritonitis b. Hernias c. Encapsulating peritoneal sclerosis

Note: This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 4.8

GUIDELINES AND PROTOCOLS: TRANSPLANTATION AND POST-TRANSPLANT CARE

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Post-transplant clinical guidelines

Clinical guidelines should be in use for patients who have had renal transplantation covering: a. Treatment of acute rejection episodes b. Management of chronic allograft damage, including chronic rejection

Notes: 1 All clinical guidelines should be based on national guidance, including NICE guidance where available. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Post-transplant follow up

Clinical guidelines should be in use covering follow up of patients following transplantation, including at least: a. Monitoring transplant function using eGFR b. Monitoring blood pressure c. Monitoring other CHD risk factors d. Skin surveillance e. Consideration of need for referral to pre-dialysis / pre-ESRF programmes f. Switching to a generic preparation g. Contraception and sexual health h. Care of mother and baby during pregnancy (adults only) i. Monitoring of growth (children and young people only)

Notes: 1 These guidelines should be based on BTS guidance and network-agreed guidelines (QS RY-508) 2 Some aspects of the guidelines may be the same as for pre-dialysis care (QS RN-503) 3 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RN-530

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Live donor work-up

A protocol should be in use covering: a. Live donor work-up b. Arrangements for organising the transplant c. Communication with Renal Units about their patients This protocol should ensure that transplantation takes place within three months of completion of the work-up.

Notes: 1 This QS is in addition to QS RN-514. 2 For adult patients, this protocol may involve some or all of the work-up being undertaken at a Renal Unit. This QS is not applicable to Renal Units which are not involved in live donor work-up. 3 The protocol should be based on network-agreed guidelines (QS RY-504) 4 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B

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Pre-operative protocol

Clinical guidelines should be in use covering pre-operative care of patients undergoing transplantation covering at least: a. Psychological preparation b. Blood and tissue matching c. Antibody screening d. Pre-transplant vaccination e. Management of patients with blood born viruses f. Use of immunosuppressive therapy g. Counselling and advice for patients called for transplantation but where the operation does not take

place (for whatever reason)

Notes: 1 All clinical guidelines should be based on national guidance, including NICE guidance where available. 2 This QS is not applicable to Satellite Units and Renal Units. 3 Some aspects of pre-operative care, including pre-transplant vaccination, may be undertaken in Renal Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Pre and peri-operative care: antibody incompatible transplantation

Clinical guidelines should be in use covering pre- and peri- operative care of patients undergoing antibody incompatible transplantation.

Notes: 1 Clinical guidelines should be based on network-agreed guidelines (QS RY-506). 2 This QS is applicable only to Transplant Centres. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RN-533

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Post-operative care

Clinical guidelines should be in use covering post-operative care of patients covering at least: a. Pain control b. Prevention of post-transplant CMV infection c. Use of immunosuppressive therapy d. Post-transplant vaccination e. Treatment of acute rejection episodes f. Antibody screening

Notes: 1 In units operating on children, all guidelines should be specific to children, including guidelines on pain control. 2 All clinical guidelines should be based on national guidance, including NICE guidance where available. 3 This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Discharge following transplantation

A protocol should be in use covering discharge of patients following transplantation. This protocol should ensure that, immediately following discharge, the patient’s GP has information on: a. The type of transplantation undertaken b. The patient’s medication and likely side effects c. Action to take should problems occur

Note: This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 4B Cross Reference NHSLA: 4.9, 4.10

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Post-transplantation referral back to Renal Units

A protocol should be in use for referral of patients back to Renal Units. This protocol should ensure that before the transfer of care takes place: a. All patients have been offered a copy of their care plan b. All patients have a named contact for advice and support c. The Renal Unit and the patient’s GP have received a copy of the patient’s care plan

Notes: 1 This protocol should be based on network-agreed guidelines (QS RY-507). 2 This QS applies only to Transplant Centres. Cross Reference CQC : 4B, 6C Cross Reference NHSLA: 4.9, 4.10

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Live donor follow up

A protocol should be in use covering follow up of live donors. This protocol should ensure that donors are followed up at least annually, including checks of blood pressure, urinalysis and renal function. There should be written hand-over from the Transplant Centre before live donor follow-up is undertaken by Renal Units.

Notes: 1 This protocol does not need to cover follow up of overseas donors. 2 This protocol should be based on BTS guidance. 3 This protocol may involve some or all of the follow-up being undertaken at a Renal Unit. 4 This QR applies to TCs and to Renal Units and CRS which undertake live donor follow-up. This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 4.9


Ref Standard RN-537

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Payment of live donor expenses

The network-agreed protocol (QS RY-509) for payment of expenses to living donors should be easily available within the Transplant Centre.

Note: This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 4B

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Transfer to adult care

The network-agreed guidelines for transition to adult care should be in use, covering: a. Age guidelines for timing of the transfer b. Involvement of the young person in the decision about transfer c. Involvement of primary health care, social care and adult services in planning the transfer d. Joint meeting with the young person’s paediatric and adult nephrologist and nursing representative e. Allocation of a named coordinator for the transfer of care f. A preparation period and education programme relating to transfer to adult care g. Arrangements for monitoring during the time immediately after transfer to adult care

Notes: 1 The named coordinator may change during the young person’s transition to adult care and will normally be the same as the young person’s key worker (QS RN-501) 2 For young people transferring to adult services outside the West Midlands, the joint meeting may be by telephone or video-conference. 3 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B, 6C, 6M Cross Reference NHSLA: 2.8, 4.10

SERVICE ORGANISATION AND LIAISON WITH OTHER SERVICES

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Multi-professional pre-dialysis care

Arrangements should be in place to ensure effective communication and regular multi-disciplinary discussion to review the care of pre-dialysis patients. These arrangements should cover the involvement of, at least, consultant nephrologists, lead nurse for pre-dialysis care, dietician, renal pharmacist, clinical technologist (for home dialysis patients), renal social worker and vascular access surgeon.

Notes: 1 The availability of these staff is covered in QSs RN-202, RN-203, RN-210, RN-301& RN-302. 2 This QS is not applicable to Satellite Units. Cross Reference CQC : 4B Cross Reference NHSLA: 2.1


Ref Standard RN-602

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Dialysis quality monitoring

Multi-disciplinary dialysis quality monitoring meetings should take place at an agreed frequency. These meetings should cover, at least: a. Adequacy of dialysis b. Clinical parameters c. Dialysis access d. Water quality e. Significant events f. Patients on ‘concerns register’ (QS RN-605 ) g. Patients on the transplant list

Notes: 1 Attendance at these meetings is not defined. Attendance should involve, at least, the consultant, lead nurse and dietician. Other professions may also attend. 2 Where Satellite Units care for patients of more than one renal service, separate meetings with each may be held. 3 This QS overlaps with QSs RN-605 & RN-798. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Eligibility for free transport and temporary dialysis away from home

Guidelines should be in use covering: a. Eligibility for free transport b. Expected timescales for transport to dialysis and to home after dialysis c. Eligibility for temporary dialysis away from home

Note: Guidelines on temporary dialysis away from home should be based on NICE guidance (2002). Cross Reference CQC : 4B

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Liaison with diabetes services

Guidelines on the pro-active management of patients with diabetes should be in use, covering at least: a. Indications for involvement of the renal service b. Arrangements for joint review with diabetologist and nephrologist c. Joint management / care of people with diabetes who are receiving renal replacement therapy or who

have a renal transplant d. Monitoring of the number of patients with diabetes:

o starting dialysis o with a renal transplant

Notes: 1 If patients from more than one renal service are cared for at a Satellite Unit then arrangements should be in place covering each of these services. 2 This QS is not applicable to children’s renal services. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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‘Concerns Register’

The renal service should have arrangements for identifying and regularly reviewing patients approaching the end of life and those where there are concerns about their ability to cope with the expected dialysis regime. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RN-606

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Publicity of transplant successes

The unit should have arrangements for taking advantage of local opportunities for publicising ‘transplant successes’. Cross Reference CQC : 1H

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Unit / Transplant Centre liaison 1

Staff from the unit should meet with a representative of the team at the main Transplant Centre/s to which patients are referred at least three times a year in order to review transplant-related patients and issues.

Note: This QS is not applicable to Transplant Centres and Satellite Units. Cross Reference CQC : 4B

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Unit / Transplant Centre liaison 2

A representative of the Transplant Centre team should meet with the renal team from each of its main referring units at least three times a year in order to review transplant-related patients and issues.

Note: This QS is applicable only to Transplant Centres. Cross Reference CQC : 4B, 6C

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Transplant Centre coordination

Representatives of the Transplant Centre should attend the twice yearly network transplantation meeting (QS RY-601) and contribute details of patients for discussion.

Notes: 1 The Transplant Centre representatives should normally be a nephrologist, transplant surgeon and nurse. 2 This QS is applicable only to Transplant Centres. Cross Reference CQC : 4B, 6C

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Transition: Joint clinic

Transplant Centres with lead responsibility for the care of young people aged up to 25 years should hold a regular joint clinic with a paediatric nephrologist from the Renal Service for Children within the network.

Note: 1 This QS applies only to Transplant Centres with lead responsibility for the care of young people aged up to 25 years. 2 The frequency of the joint clinic is for local decision. Cross Reference CQC : 4B, 6C Cross Reference NHSLA: 4.9

GOVERNANCE

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Renal Registry data submission

The service should be submitting data to the Renal Registry and UK Transplant. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1


Ref Standard RN-702

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Audit

The service should have a rolling programme of audit, including: a. Audit of implementation of evidence based guidelines (QS RN-500s) b. Participate in agreed network-wide audits

Note: The rolling programme should ensure that action plans are developed following audits and their implementation is monitored. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Unit audit: dialysis

The unit should have undertaken an annual audit of: a. Travel times for dialysis patients, including waiting times for return journeys b. Relationship between timing of access surgery and start of dialysis

Note: Recommended standard: All patients travelling by hospital transport should arrive within 30 minutes of their starting time for dialysis and should be picked up within 30 minutes of finishing dialysis. Adult patients should not travel for more than 30 minutes or 25 miles (whichever is less) unless by choice. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Unit audit: transplantation

The unit should have a programme of audit of compliance with its protocols for acceptance, suspension, annual review and removal of patients on the transplant list, including at least annual audit of: a. Relationship between timing of dialysis and listing for transplantation b. Proportion of patients who have had an annual review c. Time from work-up to the transplantation for living related donors

Note: This QS is not applicable to Satellite Units. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Transplant Centre audit 1

Transplant Centres should have undertaken an audit of the timeliness of communication of decisions about acceptance onto the transplant list to the patient and the referring Renal Unit.

Notes: 1 This QS is linked to QS RN-509 . 2 This QS is applicable only to Transplant Centres. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Transplant Centre audit 2

Transplant Centres providing an antibody incompatible transplantation service should participate in the national AiT Registry Audit (when established)

Notes: 1 The audit should include all patients who start on treatment with a regime based on IVIg or plasmapheresis and not just those who receive transplants. 2 This QS is applicable only to Transplant Centres. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1


Ref Standard RN-707

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Transplant surgeon minimum activity

Transplant surgeons should normally undertake a minimum of 15 renal transplants each year.

Notes: 1 Units should specifically consider the experience needed to maintain competence in renal transplantation in children weighing less than 30kgs. 2 This QS is not applicable to Satellite Units and Renal Units. Cross Reference CQC : 13A, 14F Cross Reference NHSLA: 1.9, 2.1

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Antibody incompatible transplantation service minimum activity

Transplant Centres providing an antibody incompatible transplantation service should normally treat at least five patients per year.

Note: This QS is applicable only to Transplant Centres. Cross Reference CQC : 13A, 14F Cross Reference NHSLA: 2.1

RN-798 All

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Review and learning

The service should have appropriate arrangements for multidisciplinary review of positive feedback, complaints, morbidity, mortality, serious incidents and ‘near misses’. Cross Reference CQC : 4B, 4M Cross Reference NHSLA: 2.2, 2.3, 2.5, 2.6

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Document Control

All policies, procedures and guidelines should comply with the Trust (or equivalent host organisation’s) document control procedures. Cross Reference CQC : 6E Cross Reference NHSLA: 1.2

RENAL NETWORK

Ref Standard

GUIDELINES

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Haemodialysis: Control of infection

The network board should have agreed clinical guidelines covering: a. Care of temporary and cuffed dialysis lines and arterio-venous fistulae, including locking solutions

and dressings b. Preparing vascular access for haemodialysis c. Decontamination of equipment after each treatment session d. Decontamination of equipment after use by patients with blood born viruses. e. Dialysis away from ‘base’ Cross Reference CQC :4B, 8 Cross Reference NHSLA: 2.8


Ref Standard RY-502

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Suitability for transplantation

The network board should have agreed clinical guidelines on the suitability of patients for all types of renal transplantation.

Note: These guidelines should form the basis for both referral of patients for consideration for transplantation and acceptance of patients onto the transplant list and should cover all types of transplantation. Cross Reference CQC : 4B Cross Reference NHSLA:2.8

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Suspension and reinstatement on transplant list

The network board should have agreed guidelines on the suspension and reinstatement of patients on the transplant list. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Cardiovascular work-up prior to transplantation

The network board should have agreed guidelines on cardiovascular work-up prior to transplantation. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8

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Referral for combined kidney and pancreas transplantation

The network board should have agreed guidelines on criteria and arrangements for referral of patients with diabetes for combined kidney and pancreas transplantation.

Note: This may involve agreement of referral pathways and guidelines to services outside the West Midlands. Cross Reference CQC :4B Cross Reference NHSLA:2.8

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Pre and peri-operative care: antibody incompatible transplantation

The network board should have agreed guidelines covering pre- and peri- operative care of patients undergoing antibody incompatible transplantation. Cross Reference CQC :4B Cross Reference NHSLA: 2.8

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Post-transplantation referral back to Renal Units

The network board should have agreed guidelines on referral of patients back from Transplant Centres to the care of Renal Units. These guidelines should be explicit about the stage at which patients are referred back to the Renal Unit. These guidelines should cover all aspects of QS RN-535.

Note: The stage at which patients are referred back may vary between Renal Units but should be explicitly agreed. Cross Reference CQC : 4B, 6C Cross Reference NHSLA: 2.8

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Post-transplantation follow-up

The network board should have agreed guidelines for the follow up of patients following transplantation. Cross Reference CQC : 4B Cross Reference NHSLA: 2.8


Ref Standard RY-509

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Payment of live donor expenses

The network board should have agreed a protocol on the payment of expenses for living donors. This protocol should be explicit about the timescale within which payment will be made and the contact point for queries about expenses. Cross Reference CQC : 4B

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Transfer to adult care

The network board should have agreed guidelines on transfer to adult care. These guidelines should cover all aspects of QS RN-538.

Cross Reference CQC :4B, 6C, 6M Cross Reference NHSLA: 2.8, 4.10


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Cooperation between services

The network team should ensure that a twice-yearly meeting of Transplant Centres and Renal Units within the network is organised in order to: a. Share information on transplant patients’ progress and complications and b. Consider opportunities for collaboration and improving the pathway for transplant patients Cross Reference CQC : 4B, 6C Cross Reference NHSLA: 2.1, 2.6

GOVERNANCE

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Annual audit: BTS outcome standards

The network board should agree an annual programme of audit against BTS outcome standards. Cross Reference CQC: 16A Cross Reference NHSLA: 2.1

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Annual report: Potential Donor Audit

The network board should receive an annual report of the Potential Donor Audit. Cross Reference CQC: 16A Cross Reference NHSLA: 2.1

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Annual report: Dialysis access

The network board should receive an annual report covering the availability, usage and expected future need for: a. Hospital, satellite and home haemodialysis b. CAPD c. APD

The report should cover all renal services within the network and should take into account the need for choice of dialysis modality and for temporary dialysis away from home. Following consideration of this report, the Network Board should make recommendations to commissioners on the commissioning of renal services (QS RZ-601). Cross Reference CQC: 16A Cross Reference NHSLA: 2.1


Ref Standard RY-704

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Annual report: Dialysis quality

The network board should receive an annual report of key indicators of the quality of dialysis services. Cross Reference CQC: 16A Cross Reference NHSLA: 2.1

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Dialysis action plan

If the dialysis access and quality annual reports (QSs RY-703 & RY-704) identify any issues of concern, the network board should agree an action plan including, if appropriate, proposals to commissioners. Cross Reference CQC: 16A Cross Reference NHSLA: 2.1

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Transplant annual report

The network should receive an annual report covering at least: a. Activity at Transplant Centres within the network for each type of transplantation b. Activity for each transplant surgeon (QS RN-707) c. Transplant rates for each PCT within the network and for the network as a whole for each type of

transplantation d. Transplant rates for different ethnic groups. e. One, five and ten year patient and treatment outcomes at each Transplant Centre f. Number of pre-emptive transplants at each Transplant Centre g. Compliance with BTS outcomes standards (see QS RY-701)

Note: For some analyses it will be necessary to group PCTs. Cross Reference CQC : 16A Cross Reference NHSLA:2.1

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Transplant action plan

If the annual report (QS RY-706) identifies any issues of concern. The network board should agree an action plan including, if appropriate, proposals to commissioners

Note: An action plan is required if: a. Activity rates are too low to maintain competence or so high that available capacity may be exceeded. b. There are unexplainable variations in outcomes. c. There are unexplainable variations in access to transplantation. d. There is concern about access to transplantation across the network. Cross Reference CQC : 16A Cross Reference NHSLA: 2.1

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Service development plan

The network board should have agreed a prioritised service development plan which brings together: a. Action plans, including commissioning proposals, on improving:

o Dialysis access and quality (QS RY-705) o Transplant services access and quality (QS RY-707)

b. Areas where network-wide service improvement work is being pursued.

Note: Commissioning proposals should cover the next three years. Cross Reference CQC : 4B, 4M Cross Reference NHSLA:2.1


COMMISSIONERS OF RENAL SERVICES

Ref Standard Commissioning Quality Standards are the responsibility of the National Commissioning Board or successor bodies responsible for the commissioning of renal services.


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Commissioning of services

Commissioners of renal services should have agreed the configuration and providers of: a. Renal Services for Children b. Renal Services for Adults:

o Satellite Units o Renal Units o Transplant Centres, including the types of transplantation available at each Centre o Transplant Centre/s with lead responsibility for the care of young people aged up to 25 years This should ensure that, except in remote rural areas, patients do not have to travel for more than 30 minutes or 25 miles (whichever is less) for haemodialysis

c. The expected number of patients at each service receiving haemodialysis, CAPD, APD. assisted APD and home haemodialysis

d. The number of haemodialysis stations needed at each service for the expected number of patients e. The expected number of self-care patients f. Providers from which vascular access surgery is commissioned and the hospital sites where surgery

should be offered

Notes: 1 The expected need for dialysis services should take into account: o Patient choice of out of hours haemodialysis schedules o Provision of temporary haemodialysis away from home

2 QSs RN-205, RN-311 & RN-610 apply to the Transplant Centres with lead responsibility for the care of young people aged up to 25 years. Cross Reference CQC : 1D, 4A, 16A, 16B, 16C, 16E Cross Reference NHSLA: 2.8


Ref Standard

GOVERNANCE

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Clinical quality review meetings

Commissioners should regularly review with each service: a. Number of patients on each dialysis modality b. Number of patients on home therapy c. Number of patients on the transplant list d. Number of patients on haemodialysis having less than four hours dialysis three times a week, and

reasons for sub-optimal dialysis e. Results of audits (QS RN-703 & RN-704) of:

o Waiting times for patient transport o Relationship between timing of access surgery and start of dialysis o Relationship between timing of dialysis and listing for transplantation (N/A to Satellite Units) o Proportion of patients who have had an annual review (N/A to Satellite Units) o Time from work-up to transplantation for living related donors (N/A to Satellite Units)

Note: The recommended standard is: All patients travelling by hospital transport should arrive within 30 minutes of their starting time for dialysis and should be picked up within 30 minutes of finishing dialysis. Patients should not travel for more than 30 minutes or 25 miles (whichever is less) unless by choice. Cross Reference CQC : 4M 16A Cross Reference NHSLA: 2.2, 2.3, 2.5, 2.6


APPENDIX 1 REFERENCES

Listed below are key guidance documents used in the development of these Quality Standards. The table below shows

the links between the Quality Standards and key guidance documents. Quality Standards without a reference are based

on the consensus of the group of patients and carers, clinicians and commissioners which developed the Quality

Standards.

Guidance Documents

1 British Transplantation Society. UK Guidelines for Living Donor Kidney Transplantation (2011)

2 British Transplantation Society. Guidelines for Incompatible Antibody Transplantation (2011)

3 Department of Health. High Quality Care for All Our NHS Our Future; NHS next stage review final report (2008)

4 Department of Health. Addendum: Guidelines for dialysis away from base (2010)

5 Department of Health. Eligibility Criteria for Patient Transport Services (2008)

6 Department of Health. End of Life Strategy (2008)

7 Department of Health. Good Practice Guidelines for Renal Dialysis/Transplantation Units: Prevention and control of blood-borne virus infection (2002)

8 Department of Health. Income Generation Car Parking Charges Best Practice for Implementation (2006)

9 Department of Health. Reimbursement of Living Donor Expenses by the NHS (2009)

10 Department of Health. Saving Lives: High Impact Intervention: Renal haemodialysis catheter care bundle (2005)

11 Department of Health. The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance

12 Department of Health. The National Service Framework for Renal Services – Part One: Dialysis and transplantation (2004)

13 Department of Health. The National Service Framework for Renal Services – Part Two: Chronic kidney disease, acute renal failure and end of life care (2005)

14 Gold Standards Framework (2006)

15 International Society of Peritoneal Dialysis: Clinical Practice Guidelines for Peritoneal dialysis- related infections recommendations (2010)

16 International Society for Peritoneal Dialysis: Clinical Practice Guidelines for Peritoneal Access (2010)

17 NICE Clinical Guideline 114 Anaemia Management in People with Chronic Kidney Disease (2011)

18 NICE Clinical Guideline 73: Chronic kidney disease – early identification and management of chronic kidney disease in adults in primary and secondary care (2011)

19 NICE Technology Appraisal Guidance No. 48 – Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (2002)

20 NICE Technology Appraisal Guidance No. 85 – Renal transplantation immuno-suppressive regimens (adults) (2004)


21 NHS Estates. Facilities for Renal Services, Health Building Note 53: Volume 1, Satellite Dialysis Unit & Volume 2, Main Renal Unit

22 NHS Kidney Care/National End of Life Care Programme. End of Life Care in Advanced Kidney Disease: A framework for implementation (Undated)

23 NHS Kidney Care. Improving Choice for Kidney Patients: Five STEPS toolkit to home haemodialysis (2010)

24 NHS Kidney Care. Specification for the Commissioning of Peritoneal Dialysis Pathway (2010)

25 Recommendations of the National Renal Workforce Planning Group (2002)

26 Renal Association Clinical Guidelines for Assessment of the Potential Kidney Transplant Recipient (2011)

27 Renal Association Clinical Guidelines for Blood Borne Virus Infection (2009)

28 Renal Association Clinical Guidelines for Detection, Monitoring and Care of Patients with CKD (2011)

29 Renal Association Clinical Practice Guideline for Peritoneal Access (2010)

30 Renal Association Clinical Practice Guideline for Peritoneal Dialysis (2007)

31 Renal Association Clinical Practice Guideline for Post-operative Care of the Kidney Transplant Recipient (2011)

32 Renal Association Clinical Practice Guideline for Planning, Initiating and Withdrawal of Renal Replacement Therapy (2009)

33 Renal Association Clinical Practice Guideline for Vascular Access for Haemodialysis (2011)

34 Renal Association Clinical Practice Guideline for Haemodialysis (2009)

35 The Health and Social Care Information Centre, National Kidney Care Audit Transport Survey Report 2008 (2010)

36 The Organisation and Delivery of the Vascular Access Service for Maintenance Haemodialysis Patients: Report of a Joint Working Party (2006)

37 UK Encapsulating Peritoneal Sclerosis Clinical Practice Guidelines (2009)

38 West Midlands Renal Network. Reimbursement of Living Donor Expenses Policy (2006)

39 West Midlands Renal Network. Exception Reporting Guidelines for People Receiving Less than Three Times Four Hour Haemodialysis

40 NHS Kidney Care. Supporting Young Adults with Kidney Disease: Literature Review (2010)

41 Department of Health. The National Service Framework for Renal Services. Working with Children and Young People (2006)

42 West Midlands Renal Network Service Quality Metrics (2010)

43 Department of Health. The National Service Framework for Diabetes (2001)

44 Department of Health. Modernising Services for Renal Patients. Redesigning the workforce and re-engineering elective dialysis surgery (2005)

45 NHS Blood and Transplant/ British Transplantation Society: Guidelines for Consent for Solid Organ Transplantation in Adults (2011)

46 West Midlands Renal Network. Renal Transplantation Standards (2005)

47 Department of Health. Saving Lives, Valuing Donors – A Transplant Framework for England: One year on (2004)


48 National Protocol for Assessment of Kidney and Pancreas Transplant Patients (2003)

49 West Midlands Renal Network. Best Practice Guidelines for the Ongoing Care of a Patient Undergoing Haemodialysis Via a Central Catheter (2009)

50 NICE Clinical Guideline No 125 Peritoneal Dialysis: Peritoneal dialysis in the treatment of stage 5 chronic kidney disease (July 2011)

51 Department of Health. Transition: Getting it right for young people (2006)

52 Improving the standard of care of children with kidney disease through paediatric nephrology networks, Royal College of Paediatrics and Child Health, August 2011

Guidance Documents Links to Quality Standards (by number)

Quality Standard Guidance Documents Quality Standard Guidance Documents

RA-501 12, 13, 17, 18, 28, 32, 43 RN-515 19, 30, 32, 34

RN-101 12, 41,50 RN-516 7, 34, 43

RN-102 12, 18, 26, 30, 32, 41, 42, 50 RN-517

RN-103 12, 13, 18, 19, 30, 32, 41, 50 RN-518

RN-104 12, 29, 33, 41 RN-519 41

RN-105 1, 12, 26, 41 RN-520 4, 7

RN-106 1, 9, 12, 26, 38 RN-521 6, 13, 22, 32

RN-107 12, 31, 41 RN-522 34, 39

RN-108 40, 41 RN-523 7, 10, 33

RN-109 12, 17, 18, 19, 24, 32, 41 RN-524 33

RN-110 12, 13, 17, 18, 24,31, 41, 43 RN-525 30, 50

RN-111 12 RN-526 15, 16, 29, 30

RN-112 8, 35 RN-527 15, 30, 37

RN-113 34 RN-528 20, 31

RN-199 12 RN-529 31

RN-201 RN-530 1

RN-202 24, 25 RN-531 1, 20, 26

RN-203 RN-532 1, 2

RN-204 25 RN-533 1, 20, 31

RN-205 41 RN-534 31

RN-206 41 RN-535

RN-207 12, 25 RN-536 1, 20

RN-208 12, 25, 30, 44 RN-537 1, 9, 12, 38

RN-209 12, 44 RN-538 51

RN-210 25 RN-601 12, 13

RN-211 23 RN-602 34


Quality Standard Guidance Documents Quality Standard Guidance Documents

RN-213 25 RN-603 5, 34, 35

RN-301 12, 18, 25, 31 RN-604 13, 43

RN-302 25, 33 RN-605 6, 13, 14, 22

RN-303 31 RN-606 47

RN-304 1, 46 RN-607

RN-305 25, 46 RN-608

RN-306 1, 2, 25, 26, 46 RN-609

RN-307 46 RN-610

RN-308 2, 25 RN-701

RN-309 46 RN702 2

RN-310 46 RN-703 34

RN-311 41 RN-704 26, 31

RN-401 12, 21, 34 RN-705 26

RN-402 34 RN-706

RN-403 34 RN-707

RN-404 34 RN-708 2

RN-405 34 RN-798

RN-406 RN-799

RN-407 RY-501 49

RN-408 4, 7 RY-502

RN-409 RY-503

RN-410 23 RY-504

RN-501 12, 13, 18, 19, 23, 28, 30, 32 RY-505

RN-502 12, 4, 18, 31 RY-506

RN-503 12, 13, 17, 18, 43 RY-507

RN-504 18 RY-508

RN-598 13, 22, 41 RY-509

RN-599 3, 6, 13, 14, 22, 32, 41 RY-510 51

RN-505 12, 13, 18,19, 23, 24, 30, 32, 34, 50 RY-601

RN-506 7, 11, 12, 33 RY-701 35, 39

RN-507 12, 24, 29, 33 RY-702

RN-508 26, 32 RY-703

RN-509 1, 12, 26, 32 RY-704

RN-510 26, 48 RY-705

RN-511 26 RY-706

RN-512 26, 45 RY-707

RN-513 26 RY-708

RN-514 26


APPENDIX 2 CROSS-REFERENCES TO CARE QUALITY COMMISSION AND NHS

LITIGATION AUTHORITY STANDARDS

Shaded boxes show where a WMQRS Quality Standard addresses one of the Care Quality Commission’s Essential

Standards of Quality and Safety. More detail can be found against each individual Quality Standard. The table also shows

links between the WMQRS Quality Standards and the NHSLA Risk Management Standards 2012/13.

QS

CQC Essential Standards of Quality and Safety

NHSLA Risk Management

Standards 2012/2013

Resp

ectin

g an

d in

volv

ing

peop

le

who

use

serv

ices

Care

and

wel

fare

of p

eopl

e w

ho

use

serv

ices

Mee

ting

nutr

ition

al n

eeds

Co-o

pera

ting

with

oth

er p

rovi

ders

Clea

nlin

ess a

nd in

fect

ion

cont

rol

Man

agem

ent o

f med

icin

es

Safe

ty a

nd su

itabi

lity

of p

rem

ises

Safe

ty, a

vaila

bilit

y an

d su

itabi

lity

of e

quip

men

t

Requ

irem

ents

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g w

orke

rs

Asse

ssin

g an

d m

onito

ring

the

qual

ity o

f ser

vice

pro

visio

n

1 4 5 6 8 9 10 11 12 13 14 16 RA-501 2.8

RN-101 2.3,2.10 RN-102 5.2 RN-103 5.2 RN-104 5.2

RN-105 5.2 RN-106 5.2 RN-107 5.2 RN-108 2.8, 4.9, 4.10

RN-109 2.8 RN-110 1.8, 2.8 RN-111 - RN-112 -

RN-113 - RN-199 2.3, 2.10 RN-201 1.9 RN-202 1.9

RN-203 1.9 RN-204 1.9 RN-205 1.9


QS



Standards 2012/2013

Resp

ectin

g an

d in

volv

ing

peop

le

who

use

serv

ices

Care

and

wel

fare

of p

eopl

e w

ho

use

serv

ices

Mee

ting

nutr

ition

al n

eeds

Co-o

pera

ting

with

oth

er p

rovi

ders

Clea

nlin

ess a

nd in

fect

ion

cont

rol

Man

agem

ent o

f med

icin

es

Safe

ty a

nd su

itabi

lity

of p

rem

ises

Safe

ty, a

vaila

bilit

y an

d su

itabi

lity

of e

quip

men

t

Requ

irem

ents

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g w

orke

rs

Asse

ssin

g an

d m

onito

ring

the

qual

ity o

f ser

vice

pro

visio

n

1 4 5 6 8 9 10 11 12 13 14 16

RN-206 1.9 RN-207 1.9, 3.1, 3.2 RN-208 1.9, 3.1, 3.2 RN-209 1.9, 3.1, 3.2

RN-210 1 3.1, 3.2 RN-211 3.1, 3.2, 5.4 RN-213 - RN-301 2.8

RN-302 4.8 RN-303 2.8 RN-304 3.1, 3.2 RN-305 3.1, 3.2

RN-306 3.1, 3.2 RN-307 1.9, 5.7 RN-308 5.7 RN-309 2.8

RN-310 2.8 RN-311 2.8, 4.10 RN-401 2.8 RN-402 5.4

RN-403 5.4 RN-404 5.10 RN-405 5.4 RN-406 5.4

RN-407 5.4 RN-408 2.8 RN-409 5.4 RN-410 -

RN-501 2.8, 4.9 RN-502 2.8


QS



Standards 2012/2013

Resp

ectin

g an

d in

volv

ing

peop

le

who

use

serv

ices

Care

and

wel

fare

of p

eopl

e w

ho

use

serv

ices

Mee

ting

nutr

ition

al n

eeds

Co-o

pera

ting

with

oth

er p

rovi

ders

Clea

nlin

ess a

nd in

fect

ion

cont

rol

Man

agem

ent o

f med

icin

es

Safe

ty a

nd su

itabi

lity

of p

rem

ises

Safe

ty, a

vaila

bilit

y an

d su

itabi

lity

of e

quip

men

t

Requ

irem

ents

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g w

orke

rs

Asse

ssin

g an

d m

onito

ring

the

qual

ity o

f ser

vice

pro

visio

n

1 4 5 6 8 9 10 11 12 13 14 16

RN-503 2.8 RN-504 2.8 RN-598 2.8 RN-599 2.8

RN-505 5.2 RN-506 2.8 RN-507 2.8 RN-508 2.8, 5.2

RN-509 2.8, 5.2 RN-510 5.2 RN-511 2.8, 5.2 RN-512 2.8, 5.2

RN-513 2.8, 5.2 RN-514 2.8 RN-515 3.5, 5.2 RN-516 2.8, 5.7

RN-517 2.8, 5.7 RN-518 2.8 RN-519 2.8 RN-520 2.8

RN-521 5.2 RN-522 2.8 RN-523 2.8 RN-524 2.8

RN-525 2.8 RN-526 2.8 RN-527 4.8 RN-528 2.8

RN-529 2.8 RN-530 -


QS



Standards 2012/2013

Resp

ectin

g an

d in

volv

ing

peop

le

who

use

serv

ices

Care

and

wel

fare

of p

eopl

e w

ho

use

serv

ices

Mee

ting

nutr

ition

al n

eeds

Co-o

pera

ting

with

oth

er p

rovi

ders

Clea

nlin

ess a

nd in

fect

ion

cont

rol

Man

agem

ent o

f med

icin

es

Safe

ty a

nd su

itabi

lity

of p

rem

ises

Safe

ty, a

vaila

bilit

y an

d su

itabi

lity

of e

quip

men

t

Requ

irem

ents

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g w

orke

rs

Asse

ssin

g an

d m

onito

ring

the

qual

ity o

f ser

vice

pro

visio

n

1 4 5 6 8 9 10 11 12 13 14 16

RN-531 2.8 RN-532 2.8 RN-533 2.8 RN-534 4.9, 4.10

RN-535 4.9, 4.10 RN-536 4.9 RN-537 - RN-538 2.8, 4.10

RN-601 2.1 RN-602 2.1 RN-603 - RN-604 2.8

RN-605 2.8 RN-606 - RN-607 - RN-608 -

RN-609 - RN-610 4.9 RN-701 2.1 RN-702 2.1

RN-703 2.1 RN-704 2.1 RN-705 2.1 RN-706 2.1

RN-707 1.9, 2.1 RN-708 2.1 RN-798 2.2, 2.3, 2.5,

2.6 RN-799 1.2 RY-501 2.8 RY-502 2.8


QS



Standards 2012/2013

Resp

ectin

g an

d in

volv

ing

peop

le

who

use

serv

ices

Care

and

wel

fare

of p

eopl

e w

ho

use

serv

ices

Mee

ting

nutr

ition

al n

eeds

Co-o

pera

ting

with

oth

er p

rovi

ders

Clea

nlin

ess a

nd in

fect

ion

cont

rol

Man

agem

ent o

f med

icin

es

Safe

ty a

nd su

itabi

lity

of p

rem

ises

Safe

ty, a

vaila

bilit

y an

d su

itabi

lity

of e

quip

men

t

Requ

irem

ents

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g w

orke

rs

Asse

ssin

g an

d m

onito

ring

the

qual

ity o

f ser

vice

pro

visio

n

1 4 5 6 8 9 10 11 12 13 14 16

RY-503 2.8 RY-504 2.8 RY-505 2.8 RY-506 2.8

RY-507 2.8 RY-508 2.8 RY-509 - RY-510 2.8, 4.10

RY-601 2.1, 2.6 RY-701 RY-702 2.1 RY-703 2.1

RY-704 2.1 RY-705 2.1 RY-706 2.1 RY-707 2.1

RY-708 2.1 RZ-601 2.8 RZ-701 2.1, 2.2, 2.3,

2.5, 2.6


APPENDIX 3 EVIDENCE PREPARATION

Each Quality Standard reference column includes a box which illustrates how compliance will be reviewed.

Background information: This means that the information should be included in your background report.

Visiting facilities: Reviewers will look for the information while they are walking around the service.

Meeting patients, carers and staff: These Standards will be discussed with patient, carers and /or staff as appropriate.

Case Note Review: A few Standards require reviewer’s to look at case notes or other clinical information.

Documentation: These are mostly policies and guidelines which reviewers need to see. Do provide this in your usual format- although it is helpful if you guide reviewers to the relevant document. This may involve giving reviewers access to your Trust intranet. Do use your self–assessment to guide reviewers to relevant documents.

QS Back

grou

nd re

port

Visit

Mee

ting

Patie

nts &

St

aff

Case

Not

e re

view

Docu

men

tatio

n ne

eded

BI Visit MP&S CNR DOC

RA-501

X RN-101

X X

RN-102

X X RN-103

X X

RN-104

X X RN-105

X X

RN-106

X X RN-107

X X

RN-108

X X RN-109 X

X

RN-110

X X X RN-111

X X

RN-112

X RN-113

X X

RN-199

X

X RN-201 X

RN-202 X RN-203 X

X RN-204 X

X

RN-205 X RN-206 X


QS Back

grou

nd re

port

Visit

Mee

ting

Patie

nts &

St

aff

Case

Not

e re

view

Docu

men

tatio

n ne

eded


RN-207

X

X RN-208

X

X

RN-209

X

X RN-210

X

X

RN-211

X RN-213 X

X

RN-301 X

X RN-302 X

X

RN-303 X

X RN-304 X

RN-305 X

X RN-306

X

RN-307

X RN-308

X

RN-309

X RN-310

X

RN-311 X

X RN-401

X X

RN-402

X X RN-403

X X

RN-404

X X RN-405

X X

RN-406

X

X RN-407

X

X

RN-408

X RN-409

X X

RN-410

X X RN-501

X X

X

RN-502

X

X RN-503

X X X

RN-504

X X X RN-598

X

RN-599

X RN-505

X X

X

RN-506

X

X RN-507

X

X

RN-508

X

X


QS Back

grou

nd re

port

Visit

Mee

ting

Patie

nts &

St

aff

Case

Not

e re

view

Docu

men

tatio

n ne

eded


RN-509

X

X RN-510

X

X

RN-511

X

X RN-512

X X X

RN-513

X

X RN-514

X

X

RN-515

X X

X RN-516

X X X

RN-517

X X X RN-518

X X X

RN-519

X X X RN-520

X

X

RN-521

X X X RN-522

X

X

RN-523

X

X RN-524

X

X

RN-525

X

X RN-526

X

X

RN-527

X

X RN-528

X

X

RN-529

X

X RN-530

X

X

RN-531

X

X RN-532

X

X

RN-533

X

X RN-534

X

X

RN-535

X

X RN-536

X

X

RN-537

X RN-538

X

X

RN-601

X

X RN-602

X

X

RN-603

X RN-604

X

RN-605

X RN-606

X

RN-607

X


QS Back

grou

nd re

port

Visit

Mee

ting

Patie

nts &

St

aff

Case

Not

e re

view

Docu

men

tatio

n ne

eded


RN-608

X RN-609

X

RN-610

X RN-701 X

X

X

RN-702

X

X RN-703

X

X

RN-704

X

X RN-705

X

X

RN-706

X

X RN-707

X

X

RN-708 X

X

X RN-798

X

X

RN-799

X

X RY-501

X

X

RY-502

X

X RY-503

X

X

RY-504

X

X RY-505

X

X

RY-506

X

X RY-507

X

X

RY-508

X

X RY-509

X

X

RY-510

X

X RY-601

X

X

RY-701

X

X RY-702

X

X

RY-703

X

X RY-704

X

X

RY-705

X

X RY-706

X

X

RY-707

X

X RY-708

X

X

RZ-601

X

X RZ-701

X

X


APPENDIX 4 ABBREVIATIONS

ACE Angiotensin converting enzyme

APD Automated Peritoneal Dialysis

AV Arterio-venous

BTS British Transplantation Society

CAPD Continuous Ambulatory Peritoneal Dialysis

CCU Critical Care Unit

CHD Coronary Heart Disease

CKD Chronic Kidney Disease

CMV Cyto-megalo virus

CRSs Children’s Renal Services

DH Department of Health

eGFR Estimated glomerular filtration rate

ESRF End Stage Renal Failure

GFR Glomerular filtration rate

GP A GP is a medical doctor, sometimes called a family doctor. They are usually the

first person patients see for their health care and they help patients to access other

services

HCA Health care assistant

HD Haemodialysis

HLA Human leukocyte antigen

NAWI Non-Automatic Weighing Instrument

NICE National Institute for Health and Clinical Excellence

NSF National Service Framework

PD Peritoneal Dialysis

RU Renal Unit

TC Treatment Centre