Cobham Day Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation and promoted an open, fair culture. At our last assessment, we rated this key question as requires improvement because the provider did not have effective processes in place and was not aware of the requirement to ensure all directors met fit and proper person regulations. Fit and proper persons are leaders who are honest, competent and suitable to run a service safely.

At this assessment the rating has remained requires improvement as governance arrangements were not consistently effective and systems to identify, assess and manage risks were not always robust, limiting oversight and assurance. As a result, the provider remains in breach of regulations relating to good governance and improvements are required to ensure safe, high‑quality care. However, leaders promote high‑quality, person‑centred care and a positive, open culture, and staff feel supported.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a vision and strategy for what it wanted to achieve. The service had set out priorities for 2025/26 which included a focus on making improvements that would maximise the impact of care provided, minimise waiting times, and develop services that meet the needs of the local population. The service set out ambitions to achieve this, including working closely with other care providers and being responsive to meet the needs of the community and commissioners. The service also set out ambitions to provide evidence-based care and treatment, provide equitably accessible services and to engage with patients and staff to obtain feedback and act on this appropriately.

Leaders worked with the Integrated Care Board, who commissioned NHS treatment to be carried out at the service and to develop treatment pathways. Minutes from a meeting about eye glaucoma care demonstrated how the service worked with system partners to respond to a redesigned glaucoma pathway ‘bringing eye care closer to home’ as part of the NHS 10 Year Plan (2025).

Staff felt respected and valued. Staff told us they enjoyed working at the service and that they felt well supported. The provider had an equality and diversity policy that promoted fairness, respect, and inclusion. It supported staff at different stages of life. For example, the organisation had signed the ‘Menopause Workplace Pledge’ to better support women experiencing menopause at work. The policy made clear that the service did not tolerate discrimination, bullying, or harassment. We heard examples from staff about raising concerns about inappropriate behaviour from medical staff. Managers appropriately challenged these and supported a resolution. Managers expected staff to follow the policy and raise concerns through their line manager or the formal grievance process. The policy recognised cultural, religious, and gender identity needs and supported these through reasonable adjustments where required. Staff completed mandatory training in equality, diversity, inclusion, and human rights.

There was a comprehensive induction program, and staff were supported to complete training. The service also supported student nurses and gave examples of when support had been extended to ensure equality, diversity, and inclusion.

The service demonstrated a positive and collaborative culture with staff working effectively together to deliver safe and high-quality care and treatment. The service had a shared focus on meeting patients’ individual needs and mutual respect where all staff felt they had a voice to ensure care was coordinated and centered on the best interest of patients and their needs.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness, and honesty.

The service had a clearly defined management and leadership structure. A management board comprising the managing director, medical director, clinical director, compliance director, and a director for IT services led the services. Medical service leads and lead nurses such as the lead nurse for theatres supported the management board.

Leaders had the appropriate skills, knowledge, and experience to manage the service. They understood key priorities and challenges and demonstrated oversight of performance, safety, and quality.

Leaders described a ‘flat hierarchy’ within the service, and staff confirmed they could access leaders and they listened to staff’s concerns. Staff told us they knew how to raise concerns if needed. This supported an open and approachable leadership culture.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service recognised the importance of fostering a positive speaking-up culture in which staff could raise concerns without fear of blame or detriment. Leaders encourage staff to raise concerns with their line managers. In addition, staff had access to a freedom to speak up guardian (FTSUG) and 2 freedom to speak up champions.

The FTSUG received training in line with the National Guardian’s Office and attended speaking up training and national conferences to maintain their knowledge and skills. The freedom to speak up champions promoted awareness and acted as a point of contact for staff. These roles were voluntary and undertaken alongside their substantive duties. The FTSUG and the champions met quarterly to discuss any concerns raised and progress on actions. The FTSUG reported directly to the Management Board and submitted an annual report to the service’s Quality Account. Concerns that had been raised were reviewed by the leadership team and resolution and actions were implemented.

Staff knew the FTSUG function and stated they felt confident they would be listened to. For example, we saw evidence the FTSU Guardian and Champion raised concerns about support requirements in a department. The service responded by providing guidance, arranging ongoing follow-up meetings, arranging day-to-day support, and introducing monthly meetings to help with priorities. Staffing levels were also reviewed and increased. These actions showed that the service took concerns seriously and used them to improve leadership and support for staff.

We scored the service as 2. The evidence showed some shortfalls. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them. However, the service valued diversity in their workforce.

Staff spoke of the arrangement for sick pay which caused them some concern. If staff went off sick, they only received 50% of their pay for a maximum of 120 days. Staff could use time off in lieu or annual leave to ensure full pay whilst they recovered. Leaders were aware of the concerns raised about sick leave and told us they planned to review the company’s sick pay policy.

Although independent healthcare providers are not required to collect or report Workforce Race Equality Standard (WRES) data, the service voluntarily monitors workforce race equality information to support equality, diversity and inclusion. The most recent report showed that the representation of staff from ethnic minority backgrounds was reflective of the local population. Leaders were committed to promoting equality, valuing diversity, and fostering an inclusive workplace.

The service had an Equality and Diversity policy (2026) embedded in practice. The policy outlined ways staff should support people from diverse backgrounds in line with the Equality Act 2010. Anyone experiencing less favourable treatment was encouraged to use the organisation’s grievance procedure as the first step. The service also supported staff through flexible working arrangements and reasonable adjustments for those with disabilities.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not have an effective system to oversee risk or ensure risks were assessed, monitored and mitigated. For example, clinical waste was stored in a shared external area that was accessible to the public. At the time of our assessment, scaffolding was in place, requiring contractor access; however, the service had not completed a risk assessment to manage this. Leaders also did not recognise risks created by the department layout, which compromised the separation and flow of clean and used instruments.

While some risks were identified and recorded, these were managed in isolation without a structured framework to assess their significance, prioritise actions or evidence risk reduction, including residual risk. Risk information was fragmented and not maintained within a central risk register. This limited leaders’ ability to monitor progress, review risks collectively or identify patterns and recurring issues.

Overall, governance arrangements were weak and did not support the effective identification, grading or management of risks to people using the service, staff or the public. Leaders did not have effective systems to identify, assess, manage or review risks, which reduced oversight of environmental and external hazards and increased the risk of harm.

The service did not display the ratings from the last inspection which is not in line with requirements as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a clinical governance framework to ensure accountability for continuous improvement and assuring patient safety. The director of clinical governance ensured compliance with the clinical governance processes. The service had an extensive internal audit program. The service was in the process of transitioning to an electronic platform which would ensure audits were allocated and completed by named staff.

Clinical governance, including patient outcomes, audits and learning from incidents was discussed in departmental meetings, in service leads meetings, at the Medical Advisory Committee (MAC) and at the Management Board meeting. We reviewed the minutes of the MAC meeting from August 2025. The MAC has consistently met every 6-8 months since our last inspection, in accordance with the clinical governance policy. We reviewed the management board meeting from January 2026 and saw that staff effectively reported issues and the board discussed them.

The service discussed incidents in the incident review group, which met monthly. We reviewed the minutes of the meeting held in November 2025 which followed a standard agenda including actions from the previous meeting, new incidents and a discussion of ‘After Action Reviews’.

Leaders described the processes to follow in the event of incidents that could disrupt services. The service had an incident response policy and a business continuity plan to manage unexpected events. These documents provided guidance for staff on how to respond.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service had positive and collaborative working relationships with external partners, which supported effective care provision and service development. Service leaders met regularly with commissioners to discuss delivery and quality of care. For example, we saw evidence of a multi-agency network meeting involving the local Integrated Care Board, GPs, independent providers and ambulance services. The meeting focused on how providers and commissioners could work collaboratively to improve patient access, with the overall aim of reducing waiting times.

The service was planning to introduce a patient representative into the incident review group to ensure patient involvement in identifying opportunities for improvement.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice, and research.

Staff demonstrated a commitment to continual learning and improvement. The service openly discussed feedback and opportunities for improvement, supporting a culture where people felt involved in finding solutions and improving services.

We saw evidence that the service completed ‘After Action Reviews’. These reports included learning from incidents, identified improvement actions, and recognised what had worked well. Actions were monitored to ensure improvements were effective and sustained over time.

The service completed an annual review of quality performance, which set priorities for improvement. For example, leaders identified the need to update patient information leaflets to reflect current guidance. They set up a team to review and update the information, which they planned to publish on the service’s website so patients could access it at any time.

Leaders used data, audit results and feedback to review safety and quality performance and gave examples of when improvements were made. For example, the fasting time before surgery under general anaesthesia had been extended for patients using slimming injections. This followed an incident and the actions ensured the safety of patients.