Health First Surrey

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This is the first assessment for this service. This key question has been rated requires improvement. This meant there were shortfalls in service leadership and governance.

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.

The service had a clear vision of a phlebotomy service that supported early diagnosis and empowering people to understand more about their health through ensuring available blood testing services.

The strategy for the service was based on collaboration with private blood testing services and laboratories to support early testing and diagnosis as well as giving people the information to better manage their health. In addition, the service supported health screening through collaboration with a private GP who rented a room within the service.

The registered manager understood the context in which the service delivered care and support. They did embody the culture and values of their organisation. However, the registered manager did not effectively manage the service.

The registered manager was the phlebotomist for the service. They worked alone, with remote administrative support provided by a contracted service. They provided a service that received positive feedback from people who used the service. However, we found concerns in some areas, including health and safety, waste management, training, policy management and expired clinical consumables within the service. This meant there were concerns in relation to the lack of skills within the service to identify issues, concerns and risks and to manage these appropriately.

Health First Surrey is an independent health service. They provide a phlebotomy service where they carry out blood tests to support the diagnosis of a wide range of health symptoms and characteristics. The service is operated by the registered manager who is the only person working within the service. Therefore, this quality statement is not relevant to this service.

The service valued diversity; however, staff had not completed relevant training in equality, diversity and inclusion. The workforce consisted of the registered manager who was also the lone phlebotomist and a remote administrative worker.

There was a diversity and inclusion policy in place, however, the registered manager could not evidence that they had completed equality, diversity and inclusion training.

The registered manager was responsible for the systems of accountability and good governance. However, there was a lack of understanding of these responsibilities. Information about risk and performance was not always acted on.

Risk management processes were not embedded within the service. An annual check list relating to health and safety was not sufficient in supporting the identification of risks within the service. Premises monitoring activities such as regular checks of the sample fridge temperature were not consistently carried out.

There was an audit policy, however the registered manager was unable to demonstrate that audits had been completed. There was no record of infection prevention and control or clinical waste audits. The service had a governance and quality policy. This policy made reference to regular audits conducted relating to infection control, medicines management and health and safety, none of which were provided. It also made reference to a continuous improvement plan; however, this was not provided when we asked.

Mandatory training requirements were not clearly identified or monitored or monitored by the service. Training in relation to the Mental Capacity Act (2005), equality and diversity and learning disabilities and autism could not be evidenced.

The service had a range of operational policies in place. During our visit we reviewed policies and saw some of these such as safeguarding and infection control, were overdue review. Other policies including an emergency policy did not reflect what was happening in practice. Policies had been adopted from templates from an external consultancy; however, they had not been fully adapted to the needs of the service. We did see there were back up arrangements for the patient record system, however there was no business continuity plan that identified potential unplanned interruptions to aspects of the service or a plan to address these. The service’s statement of purpose was out of date and had not been reviewed.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The registered manager shared information with partners. However, arrangements with a GP service within the building were unclear around collaboration and shared use of equipment.

The service worked within agreed protocols with the services they undertook a phlebotomy service on behalf of. This included ensuring that blood results were shared appropriately, including with the consent of the individual who had received the blood test.

The service collaborated with a GP within the same location which included referring some patients to them following blood test results. However, there was a lack of clarity around areas such as the use of and responsibility for emergency medicines and equipment.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. Staff did not actively contribute to safe, effective practice.

The service had governance and quality policies in place, where these included the identification of quality assurance and improvement activities such as audits. However, the audits prescribed in the policies had not been conducted. This included infection control and medicines management. There was a health and safety check list conducted annually; however, this was a list of policies and procedures in place rather than an audit focused on providing assurance or a basis for quality improvement.