Health First Surrey

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last inspection we rated this key question requires improvement. At this assessment the rating has changed to good. However, the service was still in breach of Regulation 12 (Safe Care and Treatment).

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.

The service did not always have a proactive and positive culture of safety. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. This was consistent with our findings at the previous inspection.

The service did not have an effective system for identifying, recording and learning from safety incidents. Although the manager stated no incidents had occurred since the service opened, this was not consistent with our findings. For example, lost blood samples had previously caused delays and required repeat tests for patients, but these events had not been recorded or reported as incidents. Staff were also unable to accurately recall incidents that had occurred, indicating a lack of oversight and learning.

Following the inspection, we reviewed the incident log and found 2 incidents recorded in 2025 (a failed venepuncture and a specimen identification error). This demonstrated missed opportunities to identify themes, improve practice and share learning. While the service is very small with limited staff, there remained opportunities to record incidents and share learning more broadly with relevant external parties to support improvement.

However, there was a duty of candour policy and staff described a no-blame culture. The staff we spoke with understood their responsibilities under duty of candour, which is a legal and professional obligation for health and care services to be open and honest when something goes wrong.

The service had a raising concerns policy that clearly set out who staff could contact if they had a concern, both within the service and externally. Staff told us they felt confident to raise concerns with the manager and believed these would be listened to and taken seriously.

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 manager was the tenant for the floor within the building and rented clinical rooms to other services. This included services such as a private GP practice, an acupuncturist, and an aesthetics service. Patients could be referred internally between services where appropriate, for example to the on‑site GP, which supported continuity of care.

The service had clear processes for the safe handling and transportation of blood samples. The day before clinic sessions, the manager contacted a courier service to arrange timely collection of blood samples for transport to a laboratory in London.

Some patients attended with blood testing kits issued by their GP or a private screening provider. In these cases, patients were responsible for returning their blood sample kits in line with the issuing organisation’s instructions. The service explained these responsibilities clearly to patients.

Patients received blood test results via a secure online portal. Staff shared results directly with the patients’ GP with the patient’s consent. If a patient did not have a GP, they could be referred to the on‑site GP service for follow‑up. The manager told us they did not interpret test results, which they clearly communicated to patients.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

At the last inspection, the manager had not completed level 3 safeguarding children training. This had since been completed, demonstrating improvement in safeguarding knowledge and practice. The manager had also completed level 3 safeguarding training for adults and was the designated safeguarding lead for the service. They were in the process of completing level 4 training. The administrative staff completed level 3 safeguarding training this ensured staff had the knowledge and skills required to recognise and respond to safeguarding concerns.

The service had an up-to-date safeguarding policy which included clear guidance for contacting the local authority safeguarding teams.

The manager clearly described the action to take if they identified a safeguarding concern and demonstrated a clear understanding of their responsibilities. The service had not reported any safeguarding concerns.

The service carried out 6 monthly safeguarding audits to monitor compliance with best practice. It also published a modern slavery statement and its safeguarding policy on its website.

However, the service did not display any signage or notices to make it clear that parents or carers remained responsible for supervising their children while on the premises. This meant the service did not clearly communicate expectations and could increase the risk of children not being appropriately supervised.

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.

Since the last inspection, the service had updated its risk assessment and emergency policy. This clearly stated that the service did not have access to emergency medication held by the GP practice.

The manager had up-to-date basic life support training, and in the event of patient deterioration, the service contacted emergency services.

Administrative staff collected pre‑assessment information from patients prior to their appointment; this included a history of fainting, needle phobia, medications affecting coagulation, infections and mobility issues. This process helped identify potential risks in advance. Where staff identified risks, they escalated these to the phlebotomist for further review.

The manager completed appropriate safety checks before proceeding with clinical interventions. This included confirming whether the patient had applied moisturiser or substances to their arms that could affect blood sample quality, checking for known allergies and verifying that the patient had followed nil-by-mouth instructions where required.

The organisation had a consent policy and clear processes to support informed decision-making.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service had a clinical fridge and used it to store blood samples. Staff monitored fridge temperatures and we saw evidence of completed daily checks. However, the temperature recording chart did not include clear instructions on what action staff should take if the temperature fell outside the acceptable range. Staff kept the fridge locked at all times. The manager carried the key during operating hours and stored it securely in a lock box outside of service hours, reducing the risk of unauthorised access.

The service stored clinical waste in a locked clinical waste bin; however, this was located within a communal residential and business car park and was not secured to a fixed structure or enclosed within a fenced area. Although the bin itself was locked, the lack of additional security measures meant the arrangements were not in line with Environment Agency guidance and did not adequately mitigate the risk of unauthorised access.

The service had completed a risk assessment in relation to the absence of a sink within the clinical room. However, this assessment did not fully consider that the available sink was not a dedicated clinical hand‑washing sink and was located within a public toilet. In addition, the sink tap was loose and affected by limescale, which may limit effective hand hygiene. The service therefore did not fully identify or mitigate risks associated with these environmental limitations.

After the inspection the manager provided evidence that a plumber had been organised to fix the loose tap.

The clinic was located on the second floor of a building accessed via steep, angular stairs. The service had also not considered the risk of a patient becoming unwell when leaving the premises and falling on the stairs.

The service had made some improvements to the environment since the previous inspection. The kitchen area was now appropriately organised, and the kettle was stored safely. Window restrictors had also been fitted in the reception area, reducing risks to patients using the service.

Staff completed daily room checks to ensure the environment was safe and suitable for patients and staff.

We saw the clinic environment was now clean, clutter-free and well-maintained. Staff followed infection prevention protocols.

The emergency call cord in the communal toilet was now positioned so it was reachable from floor level, in line with accessibility and safety requirements. This ensured the manager could be alerted if someone needed assistance. The manager had completed a risk assessment, which included daily checks to ensure the cord remained correctly positioned and fit for use.

The building had accessible fire exits, with extinguishers. Fire extinguishers were all in date and regularly checked. The service had a fire risk assessment and fire safety policy. The premises were secure, with controlled access to protect patients, staff and visitors.

Clinical equipment, including the centrifuge, had undergone electrical safety checks and calibrated in line with manufacturer and regulatory requirements. A centrifuge is a laboratory device that is used for the separation of fluids, gas or liquid.

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.

The service had now identified and completed additional mandatory training. This included training in information governance, the Mental Capacity Act, safeguarding children, manual handling, learning disabilities, autism awareness, and equality, diversity and inclusion. The service carried out pre-employment checks on administrative staff to ensure they were safe, had the right to work, and had the appropriate skills in line with legislation.

The manager was the sole phlebotomist working within the service. They had completed appropriate competency-based training for their role in the form of phlebotomy training and updates. The manager received monthly supervision to support them in their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had an infection prevention and control (IPC) policy. Improvements had been made with the introduction of an audit schedule, and we saw evidence that regular audits of cleaning and hand hygiene were now being carried out. Staff maintained clinical areas to a good standard; these were visibly clean, clutter‑free and well maintained, and clinical waste was appropriately segregated. The sharps bin was used only for sharps waste, in line with best practice, and was now appropriately labelled.

We observed staff follow effective cleaning procedures. All clinical areas and equipment were cleaned before and after use. Patients rested their arms on wipeable pillows, which were cleaned between each patient. Tourniquets were disinfected with antibacterial spray after every use, and clinical chairs were cleaned with antibacterial solution following each patient interaction.

The manager demonstrated good hand hygiene practices and adhered to national guidance by being bare below the elbows, helping to reduce the risk of cross‑infection. Appropriate personal protective equipment (PPE) was used when taking blood samples, including the use of alcohol-based hand gel between glove changes and between patients.

There was evidence of strengthened oversight of environmental risks, with an external provider now carrying out six‑monthly legionella testing; no concerns had been identified.

The manager was up to date with vaccinations in line with Chapter 12 of the UK Health Security Agency Green Book (Immunisation of healthcare and laboratory staff).

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service maintained appropriate stock control arrangements. They completed a weekly stock inventory and had a contract with a laboratory provider which ensured a reliable supply of blood sample tubes. Patients attending with their own test kits used the sample bottles supplied. For tests carried out following GP referral, the service used its own equipment. The service also maintained a small stock of in-house test kits.

We checked all clinical stock and found it to be in date, and the service had a policy in place for the safe disposal of expired stock to support safe care and treatment.

The only medicine owned by the service was an adrenaline auto-injector (EpiPen), an emergency injection used to treat severe allergic reactions, for use in the event of an emergency. The manager had up-to-date training in administering the medication and undertook checks to ensure it was in date and had not expired.

The medication was stored in a locked cupboard within a consulting room rented by the GP, rather than in a communal area. A verbal agreement was in place that the GP consultation could be interrupted in the event of an emergency to allow access to the equipment. Although the service had a risk assessment, this was not sufficiently comprehensive, as it did not consider the risk of unexpected access to the room, which could impact patient dignity and confidentiality.