Cobham Day Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence demonstrated a good standard. The service had a proactive and positive culture of safety based on openness and honesty. Staff were encouraged to raise concerns, report incidents and near misses, and focus on learning rather than blame.

The service used an electronic incident reporting system, which staff knew how to use and understood what to report. Staff also reported incidents directly to the duty manager and reported incidents were tracked electronically through to investigation and action.

Between January and December 2025, the service reported 66 incidents across a broad range of categories, including equipment or IT failures (20%), clinical governance issues (14%), staff injuries (14%), cancellations, drug errors, near misses and patient injury. The range of reporting demonstrated an open reporting culture and enabled the service to identify themes and implement improvements.

The service reviewed incidents using the Patient Safety Incident Response Framework (PSIRF), which is a national approach that helps services learn from incidents and improve safety rather than focusing on blame. In the last 12 months, the service completed one patient safety incident investigation, which the lead investigator had received appropriate training for. The incident was a never event that occurred in July 2025. Never events are serious, largely preventable patient safety incidents that should not occur. The service investigated it thoroughly and identified and embedded learning.

The service had an incident review group and shared learning from incidents through team meetings, safety huddles, newsletters, and emails. For example, following the use of expired fluid during surgery, the service completed a review and risk assessment, delivered additional training, and added another member of staff during more complex surgery for improved safety.

Staff understood their responsibilities under the Duty of Candour, which is a legal requirement to be open and honest with patients when something goes wrong, including offering an apology and a clear explanation. This formed part of staff training, and staff told us they received feedback from complaint investigations and were expected to act on any learning identified. Leaders supported a learning culture by reviewing complaint data and national patient safety alerts to drive improvement. The organisation had an incident reporting policy that incorporated the Duty of Candour. We saw examples of Duty of Candour letters sent to patients, which clearly outlined investigation findings and outcomes, demonstrating openness and transparency.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service received referrals from external providers. A senior nurse reviewed and triaged all referrals to ensure patients met the safety criteria for treatment in a standalone surgical unit. If there were any concerns, they escalated the referral to the medical director and if applicable to the lead consultant anaesthetist. The lead anaesthetist reviewed the patient’s medical history and, where needed, arranged a pre-operative assessment. This process helped ensure patients were clinically suitable for treatment in this setting, reducing the risk of avoidable complications, and supported safe decision-making before surgery.

We observed effective communication between staff when patients moved from the ward to theatre and into recovery. Staff handed over key information about the patient’s care and clinical needs to ensure continuity and safety. Staff completed care records and safety checks using both electronic and paper systems. This supported clear documentation and safe care delivery.

We saw examples of communication with external providers. For example, the service attended meetings with the local Integrated Care Board to discuss plans for health services at the location. We also saw clear communication with GPs and other healthcare professionals about individual patients. This showed the service had clear referral and communication pathways. This supported safe care, continuity of treatment and appropriate follow-up during and after discharge.

We scored the service as 3. The evidence demonstrated a good standard. The service worked with people and partners to promote safety and protect patients from abuse, discrimination, avoidable harm and neglect. Concerns were shared appropriately and without delay.

The service had a well-defined, up-to-date and accessible safeguarding policy, which included clear guidance and contact details for local safeguarding agencies. The policy supported staff to recognise and respond to concerns appropriately. There was a named safeguarding lead, trained to level 3, and all staff knew how to contact them for advice.

Safeguarding formed part of staff induction and mandatory training. Compliance with safeguarding training was high, with records showing 97.5% of staff had completed level 2 adult safeguarding training and 100% had completed children’s level 2 safeguarding training, exceeding the provider’s 85% target. Staff also received training in the Mental Health Act, with 92% compliance.

Staff we spoke with demonstrated a clear understanding of their safeguarding responsibilities. They were able to describe how to recognise adults and children at risk of harm and how to raise a concern, including completing safeguarding alerts where appropriate. We reviewed safeguarding referral records, which clearly documented the concern, actions taken and outcomes, demonstrating effective oversight and follow-up.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A pre-assessment lead nurse oversaw a team that reviewed all pre-assessment information. This process ensured patients were medically, socially and psychologically suitable for day surgery. Staff used medical questionnaires, admission criteria, test results and anaesthetic guidance from a consultant to assess individual risks. Where there was any uncertainty, staff referred patients to the medical director for further review.

Staff discussed specific risks about the surgery with patients before consent was obtained to ensure patients had all the information needed to give consent to surgery. Where appropriate, staff provided lifestyle advice, including support with smoking cessation and reducing alcohol intake, to help lower risks before surgery.

During our visit, we observed staff confirming their roles and responsibilities at morning safety huddles. The World Health Organisation (WHO) Surgical Safety Checklist was completed electronically and in paper format. The WHO Surgical Safety Checklist is a checklist used by surgical teams to make sure important safety checks are done before, during and after an operation to help keep patients safe. Audits of the WHO checklist showed 99% compliance, enhancing patient safety. Emergency equipment was easily accessible, and staff followed clear protocols. For example, staff told us they managed a haemorrhage appropriately, following guidance, which kept the patient safe.

Staff monitored patients for signs of deterioration using recognised tools, understood when to escalate concerns, had a transfer policy and followed agreed transfer arrangements with the local acute trust when required. Emergency equipment and trolleys had a checklist attached and records showed staff checked these regularly.

Staff completed regular skills and drills training to practise clinical, teamwork and communication skills in simulated scenarios, which supported safe care and effective risk management.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We saw the environment was clean, clutter-free and well-maintained. Staff followed infection prevention protocols. The organisation had a decontamination policy and outsourced the sterilisation of instruments.

All equipment was maintained and regularly checked to ensure it was safe to use. Records included a list of medical devices, service dates, maintenance certificates and audits of equipment checks, all showing a high completion rate.

The building had clear fire safety signage and accessible fire exits, with extinguishers in place. A fire risk assessment and fire safety report were available, and the service had completed recommended actions. The premises were secure, with controlled access where needed to protect patients, staff and visitors. We saw a locked cupboard containing substances that are hazardous to health. Control of Substances Hazardous to Health (COSHH) is the law that requires employers to control and safely manage substances that could harm people’s health. The service stored these securely and restricted access to trained staff. This reduced the risk of accidental exposure, misuse, or injury to patients, visitors and staff.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, only 80% of staff had received an annual appraisal.

The service planned and managed staffing effectively by using rostered templates for each specialty. They considered procedure and anaesthetic type and templates for the staff roster could be adjusted when needed. Data showed agreed staffing levels for operating lists were met 100% of the time, with extra staff added when required.

Staff could view shifts up to a month in advance. The service managed leave and non-working day requests through the rostering system, which helped to maintain safe cover and effective list management.

The workforce was made up of 74% clinical staff and 26% non-clinical staff. To ensure shifts could be covered staff worked bank shifts to cover as and when needed.

There were two vacancies at the time of the inspection. Agency use was very low at 0.1%. Bank and agency staff received an induction relevant to their role. Managers ensured agency staff were fully familiar with the service before working independently. The service carried out pre-employment checks to ensure staff were appropriately recruited, skilled and had the required experience in line with legislation.

Thirty-three staff members registered a period of sickness during the last quarter, which was a total of 26% of the absence hours claimed for all reasons, including annual leave. Despite this, staffing levels were maintained and staff turnover was low. Eighty percent of staff had completed their annual appraisals, which were comprehensive, included personal development goals, and conducted on a yearly basis. However, no target had been set for achieving 100% appraisal completion each year.

Staff were up to date with mandatory training, with compliance of 92% for clinical staff and 99% for administrative staff. Mandatory training included safeguarding, immediate life support and data security awareness. The provider also included Oliver McGowan training as a mandatory programme, which is designed to raise awareness and understanding of learning disabilities and autism, focusing on improving care, support, and safeguarding for people with these conditions.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified several infection prevention and control (IPC) concerns. We saw staff had left a box containing dirty surgical instruments in a clean clinical room. Used instruments entered and exited the department via the same route, which was not in line with best practice. Although this was due to the building layout, no risk assessment had been completed to mitigate the associated risks. This could increase the risk of infection spreading.

Staff told us they sometimes placed boxes containing dirty instruments in clean areas, including clinical rooms and the recovery area, and on occasions on the floor, to await collection by the sterilisation service.

The service did not have a clear or effective process for managing dirty instruments leaving the location for collection by the sterilisation service. This was not reflective of the services infection prevention and control policy which clearly stated there should be clean and dirty segregation. There was no evidence the risk had been considered as part of the annual cycle of infection prevention and control risk review, as described in the services policy.

We found poor systems in place for the safe management of clinical waste. During the inspection, we observed clinical waste bins and sharps boxes stored in open bins, in an unsecured external area. This meant clinical waste was accessible to staff, patients, visitors, and members of the public.

Clinical waste and sharps should be stored securely and kept closed and locked to reduce the risk of injury, contamination, and the spread of infection. Leaving bins open increased the risk of accidental exposure to blood or body fluids, needle-stick injuries, and unsafe handling or interference with waste. These risks were avoidable and showed that effective control measures were not in place to protect people from harm and that risks related to clinical waste storage were not identified, assessed, or mitigated. This raised concerns about oversight and governance arrangements for infection prevention and control.

We found some empty and non-working hand gel dispensers. Although the provider said they had ordered replacements, they had no interim measures in place. These issues increased the risk of cross-contamination and did not fully support safe IPC practices.

The service had an IPC policy and produced an annual IPC report. Cleaning schedules were in place, and we saw staff had completed and checked daily cleaning records. Clinical areas and equipment were visibly clean and well maintained. An external cleaning company cleaned the premises each evening after hours.

The service monitored hand hygiene through regular audits and spot checks, which showed 100% compliance. We observed staff washing their hands and using alcohol gel appropriately, and they demonstrated correct donning on and off of sterile protective clothing.

Surgical site infection rates were in line with national averages. Data showed there had been 4 reported surgical site infections between April and June 2025. All infections were mild and treated with antibiotics. Patients were informed of this risk prior to surgery. The service continued to monitor infection data and provided patients with post-operative guidance to reduce the risk of infection.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

The service had a comprehensive medicines management policy that provided clear guidance on the safe handling, storage, and administration of medicines. Current audits showed 93% compliance with safety standards and appropriate storage of all medicines. Staff maintained clear records, which aligned with national guidance.

However, there was an incident in which staff issued an out-of-date medication to a patient. The organisation responded promptly, reviewed the event and reinforced procedures to prevent recurrence. Staff received additional training to ensure they had the knowledge and skills to manage and administer medicines safely, and an extra member of staff has been added to complex operating lists to prevent future errors. These measures supported safer practice, reduced the risk of medication errors, and improved patient outcomes.