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 leadership, management and governance ensured high‑quality, person‑centred care, supported learning and improvement, and promoted an open and fair culture.

At our last inspection, this key question was rated as requires improvement, and the service was in breach of the regulation relating to good governance.

At this assessment, the rating has improved to good. This indicates that the service was generally well managed and well-led, with evidence of improvement since the last inspection. However, we identified some ongoing shortfalls in the management of risk and governance systems.

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 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 clear vision, with a focus on preventative health and wellbeing. This vision was understood by the manager and informed the direction of the service and future planning. The service’s business strategy was to maintain existing services while developing new areas of practice.

Staff working for the service felt respected and valued. The service had 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. There was mutual respect where staff felt they had a voice to ensure care was coordinated and centred on the best interest of patients and their needs.

The service had an inclusive leader who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce. Leaders had the skills, knowledge, experience and credibility to lead effectively.

The 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.

Since our last inspection we saw evidence that the manager had strengthened oversight of their own practice and the service. They had arranged external professional support from a clinician to provide additional oversight. The clinician had regularly observed the manager’s clinical practice, including hand hygiene and procedural techniques.

The manager attended external training to keep their phlebotomy skills up to date and in line with best practice. The company formally assessed and signed off the manager’s clinical competencies and training each year, providing independent assurance of their competence. The manager also completed reflective supervision sessions with a therapist every six weeks to support their professional development.

Health First Surrey is an independent health service. They provide 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 with remote administrative support. Therefore, this quality statement is not relevant to this service.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service recognised the importance of equality, diversity and inclusion and aimed to promote a fair and inclusive culture for staff. There was an equality and diversity policy to support this. The workforce was small and consisted of the manager, who was the sole phlebotomist, and a remote administrative worker. Since the last inspection the manager had completed their equality, diversity and human rights training.

Staff had not experienced any disrespectful, discriminatory or abusive behaviour from patients. They said they felt confident they could report poor behaviours to their manager and that appropriate action would be taken.

The service did not always have effective systems of accountability or good governance.

Since the last inspection, the service had completed some risk assessments; however, we found gaps in several areas, which were not sufficient to assess and mitigate all risks effectively. These included the storage of clinical waste awaiting collection, and environmental risks such as the use of a non-clinical handwashing basin. The service did not maintain a risk log or have a process to review risks, which meant it could not track progress against actions or identify recurring issues over time.

The service had an audit policy and audit calendar and carried out regular audits. However, a review of audits identified some issues with their quality and reliability.For example, the clinical waste audit recorded that the storage area was secure and not accessible to unauthorised persons. However, this did not reflect what we observed during the assessment. In addition, the clinic room cleaning audit stated that the service had met the standard for sinks and taps in the clinical area, despite there being no sink.

Although the manager discussed some audits at monthly governance meetings and identified actions, these inconsistencies raised concerns about the effectiveness of the audit process and whether it provided an accurate assessment of risks.

We reviewed the service’s policies and found that most included a review date in line with best practice. However, some did not. While all policies were in date at the time of inspection, the lack of future review dates meant the service could not clearly demonstrate consistent oversight or a structured review process.

However, the service held monthly governance meetings with an external advisor. The service kept minutes of these meetings, which demonstrated access to relevant expertise and a commitment to improving governance and oversight.

The manager held weekly informal catch-ups with the remote administrative staff to discuss referrals and day-to-day operational matters; the service did not formally record these discussions.

The service had a business continuity plan to manage unexpected events. The document provided guidance for staff on how to respond, including situations such as a failure of the booking system or a loss of utilities.

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 followed agreed protocols with the organisations it was contracted to provide phlebotomy services to. This included ensuring blood test results were shared appropriately with the consent of the individual who had undergone the test.

The service also referred patients seeking a medical consultation to the private GP based at the service following their blood test.

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 and effective practice.

The manager demonstrated a commitment to improving the service by seeking external support to provide additional guidance and expertise in delivering safe and effective care. They had also attended training to develop their knowledge and skills. In addition, the manager was introducing new treatments to expand the business, although these were outside the scope of CQC-regulated activities.