Cobham Day Surgery

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the provider met people’s needs. At our last assessment, we rated this key question as good. At this assessment, the rating has remained as good. This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

We saw evidence the service placed people at the centre of their care and treatment and worked in partnership with them when planning and delivering care.

Staff gave patients clear information at each stage of their pathway to help them understand their treatment and make informed choices. Patient information leaflets included detailed information about procedures and post-surgery instructions. The service sent leaflets by post or email or handed them directly to patients during appointments. Patients could access literature on the provider’s website, and the service displayed literature within hospital corridors, making information easily accessible.

Before surgery, the pre-assessment nurse checked patients had received, read and understood the patient information leaflet. They gave patients the opportunity to ask questions. This supported patients to feel informed and empowered to make decisions about their care and treatment.

We saw examples of personalised care planning. Staff specifically adapted care plans for people with a learning disability, ensuring they recorded individual needs and preferences. For example, reasonable adjustments included playing music through headphones during procedures and allowing family members to accompany patients who required additional support.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

People could easily access the hospital. It was located close to two train stations and had ample on-site parking. The car park had disabled parking spaces. The premises were on one level, with wheelchair-accessible entrances and toilets. This supported equitable access for people with reduced mobility and helped remove physical barriers to care.

The service demonstrated joined up working with other healthcare providers. We saw evidence of regular communication via email and online meetings with healthcare partners. Referrals were received through established pathways and clinical staff attended multidisciplinary team meetings with other healthcare organisations. For example, clinical nurse specialists worked with outside professionals to share details about patient care to keep care consistent and help patients move smoothly between services.

The provider had an unplanned transfer policy for when patients needed to be transferred to a general hospital in an emergency. The policy gave staff clear guidance on how to manage the transfer and what information to share, to support continuity of care.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service provided information that was clear, easy to access and suited to people’s individual needs. The service met the Accessible Information Standard. This means people with a disability or sensory loss received information in a way they could understand. Staff completed yearly training on how to ask about and record communication needs. The electronic patient record system flagged these needs so staff could respond appropriately. Training focused on recording what support the person needed, rather than simply noting a diagnosis.

The service also used a ‘hospital passport’ for adults with a learning disability, autistic people and those with specific communication needs. For example, one autistic patient’s hospital passport documented they needed to be first on the theatre list to reduce anxiety. The service allowed them to wear ear defenders during treatment and had family members present for support. The passport made each person’s preferences and reasonable adjustments clear for staff, so they could provide information and care in a way that met individual needs.

Patients could get information by letter, email, phone, or text. The provider could organise access to translation, interpreting, braille, audio, and British Sign Language services through external providers. The service’s website and leaflets detailed treatments, and noticeboards showed local support services.

The service had information governance systems in place to keep patient information safe. The organisation had data protection and information technology (IT) security policies, which formed part of mandatory staff training. The service stored patient records securely and protected these by passwords. They shared information with patients or other providers securely. The provider also tested staff with fake phishing emails, which are scam messages that try to steal personal information. Staff who did not recognise them received extra data security training.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They involved people in decisions about their care and told them what had changed as a result.

The service made it easy for people to share feedback, raise concerns, and be involved in decisions about their care. The service clearly displayed information on how to raise concerns in reception. Patients could contact the provider directly through an online form or escalate concerns to the Independent Sector Complaints Adjudication Service (ISCAS). ISCAS is an independent body that reviews complaints about private healthcare if patients are not satisfied with the provider’s response. One complaint was made to the Parliamentary and Health Service Ombudsman (PHSO), which is an independent organisation in England that investigates unresolved complaints about public services and the NHS, but this was not upheld by Cobham Day Surgery.

Patients were encouraged to provide feedback through the organisation’s website, waiting area screens or by joining a patient feedback group, supporting involvement in their care. Information on how to raise concerns was available on the website and through a poster in reception.

The senior team reviewed complaints. We saw evidence of investigations, meetings to agree on actions, identified learning and sharing amongst teams. The service kept patients informed about their complaint throughout the process and provided feedback and outcomes.

Between January and December 2025, the service received 31 complaints. Of these, 40% related to patient experience, 10% patient safety, 30% clinical governance, and 20% administration. The service upheld 7 complaints, meaning the investigation found the complaint to be justified. They partially upheld 11, meaning some aspects were found to be valid.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service made sure people could access the care, support and treatment they needed in a timely way. The provider reported short waiting times for treatment. However, during 2025/26, Integrated Care Boards placed financial limits on independent provider contracts. This meant activity was capped and any work above the agreed level would not be funded. As a result, the provider advised that waiting times may increase despite having capacity to treat patients sooner. This was outside of the provider’s direct control.

The service identified patients with additional needs at the point of entry to the service. Records had patient passports attached, clearly setting out individual requirements and reasonable adjustments. This helped ensure equitable access and appropriate support throughout their care.

The service had a clear recovery and discharge policy. This outlined criteria for safe transfer from recovery to the ward and required a structured handover between staff. This supported safe, timely movement through the patient pathway.

We scored the service as 3. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff told us managers promoted an open culture where people could share their views. Patients and staff were encouraged to give feedback through surveys, electronic display boards, the providers' website, and through independent complaint routes such as Independent Sector Complaints Adjudication Service (ISCAS).

The service had systems to identify and support people at risk of inequality. The electronic record system flagged communication needs, and staff used patient passports for people with learning disabilities, autistic people, and those needing reasonable adjustments. Patients accessed information in different formats, with interpreting and British Sign Language services provided when required.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.