Health First Surrey

Date of assessment: 1 May 2026

This assessment was a focused, short notice announced inspection to review the progress made against the warning notice and action plan issued following an inspection in September 2025.

This assessment looked at whether the service was safe, responsive and well-led.

The rating for the service has been combined with key questions inspected from the previous inspection for caring and effective. Please refer to our earlier reports for a full overview of the service.

At this assessment, we found the service had made improvements since the previous inspection However, we found the service was still in breach of Regulation 12 (Safe Care and Treatment). We found clinical waste was not stored securely. This meant there was a risk of unauthorised access, spillage, or contamination, which could compromise the safety of people using the service, staff, and visitors. The provider had not ensured appropriate systems and practices to safely manage and contain clinical waste in line with current guidance.

The service did not consistently demonstrate a strong learning culture. The staff did not always recognise, record or report incidents appropriately, and missed opportunities to learn from events. Staff did not always recall incidents, which raised concerns about oversight and learning.

We found the service did not always identify and manage risks effectively. The manager did not fully assess or mitigate environmental and safety risks. We found governance systems were not always sufficient to ensure the identification, monitoring and addressing of risk.

However, the service provided responsive and person-centred care, and patients reported positive experiences of care and treatment. The service had effective systems relating to infection prevention and control, staffing, and partnership working.

The service demonstrated a commitment to improvement, worked well with partners, and had a positive culture in which staff felt able to speak up and patients were treated with respect.

Health First Surrey was rated requires improvement at our previous inspection in September 2025. At this inspection the overall rating for Health First Surrey has changed to good.

We undertook an unannounced assessment at Health First Surrey on 2 September 2025.

Health First Surrey provides phlebotomy services for people requiring private blood tests. The service operates from a site in Cobham, Surrey. The clinic is open Tuesday to Friday, and people can book in for a blood test in the mornings on those days. The service is run by the registered manager who is also the only phlebotomist. This was a risk-based assessment due to the length of time since registration without an assessment.

In our assessment of diagnostic services, we found the service did not evidence a learning culture. The systems for recognising or identifying incidents, issues and concerns were limited. Staff did not fully understand and manage risks. The management of clinical waste was insufficient and infection control risks were not fully recognised. The national guidelines in relation to the safe disposal of sharps were not followed. Not all mandatory training was recognised or up to date. They did not have clear processes to follow in the event that people did not have mental capacity. There was a risk to privacy where patient information was stored on a desk in the waiting area. There was not a culture of continuous improvement, and learning was not always prioritised. Risks and issues were not always recognised. Governance processes were not comprehensive and there were gaps in policy management, information management, training completion, risk management, health and safety and environmental issues including the governance of infection control and the management of clinical waste.

However;

People could raise concerns. The facilities and equipment met the needs of people, were clean and visibly well-maintained. The registered manager had up-to-date phlebotomy skills, qualifications and experience. They took account of people’s communication, personal and health needs. They made sure people understood their blood taking processes to enable them to give informed consent. People were treated with kindness and compassion. Staff protected people’s dignity during phlebotomy procedures. Staff treated people as individuals and supported their preferences. People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. People received fair and equal care and treatment. There was a vision to provide good quality phlebotomy services.

We found breaches in regulation 12 in relation to safe care and treatment, regulation 17 good governance and regulation 18 staffing.