East Surrey Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

We have not awarded this service a score for Responsive.

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

The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Staff did not always refer to patients by name when discussing their care with colleagues, instead using terms such as “day 2 patient” or bed space numbers. This approach was not person-centred and increased the risk of patient identification errors.

Wards had protected mealtimes. However, we observed these were not always adhered to. Staff were expected to focus on supporting patients with eating, but we saw instances where this did not consistently happen. For example, a patient living with dementia sat for over 20 minutes with the cover still on their meal, as there was no staff available to provide support. We saw meals were available in a variety of textures to support patients with swallowing difficulties. However, we saw another patient requiring a pureed diet who was struggling to feed themselves without assistance. This indicated mealtime support was not always effectively delivered to meet patients’ individual needs. 

Care plans reflected patient’s needs. Staff on Godstone Ward told us when a patient with an identified risk of suicide was admitted to the ward, they completed daily ligature risk assessments to monitor and manage risks within the environment. Environmental audits had also been undertaken to identify potential ligature points. As a result of these assessments, staff informed us coat hooks had been removed from bathrooms to reduce the risk of harm. This demonstrated the service had taken action to mitigate risks and improve patient safety.

Staff told us they worked with advocates and other professionals to ensure the patient’s needs were appropriately considered. A young patient who required support after discharge, had alternative accommodation identified in a care home suitable for younger people, rather than the initial proposal of discharge to an elderly care home. This ensured the patient was discharged to an appropriate care setting. 

The service understood the diverse health and care needs of people and their local communities. However, care was not always joined-up, flexible or supportive of care provision and continuity.

Processes to support integrated discharge planning and continuity of care were not consistently effective. Medical staff did not routinely establish or monitor estimated discharge dates, resulting in delays to patient discharge and extended stays. Predicted discharge dates were often absent from patient records, and communication regarding discharge readiness and completion of discharge documentation was inconsistent. Key discharge information was also not routinely shared across teams, impacting the timely coordination and continuity of patient care.

In response the service developed a ‘Let’s Get You Home’ initiative and policy to support timely discharges. This initiative supported a 0.5-day reduction in the average patients’ length of stay, for the second consecutive year. However, staff reported the model was heavily promoted when it was launched but was still not embedded as routine practice, which resulted in a lack of early discharge planning. 

Staff also reported difficulties in sourcing packages of care. This led to delays and a reduction in the availability of beds, increasing capacity pressures on the service. Clinical leaders escalated concerns but reported they did not progress further. 

Staff were positive about the Transfer of Care Hub (TOCH) referral service, which supported discharges and continued care outside of hospital where appropriate. Staff reported this service helped to get people home quicker. 

Staff understood the local geography and demographics of the service. They shared an understanding of the ageing population they served and how this affected service delivery, including delays in accessing social services. This impacted patients by causing them to remain in hospital for longer than required. 

There were some effective arrangements across the hospital to support patient flow through collaborative working, such as by the Frailty Same Day Emergency Care (FSDEC) team. They demonstrated strong multidisciplinary team working and played a key role in reducing unnecessary admissions. The team proactively identified and accepted appropriate patients from the Emergency Department. The team brought together decision-makers who were able to undertake comprehensive assessments, treatments, care planning and discharge coordination within a single service, enabling people to receive timely care without the need for admission wherever possible.

Staff understood people’s needs and received appropriate training to support them. One nurse shared how they liaised with external services to support continuity of care. They shared how they communicated with people’s carers and district nurses to ensure people were appropriately supported once they had been discharged. 

During our observations, a consultant reviewed a patient who was being cared for as an outlier on a different ward. It was evident a strong rapport had been established, with open and involved discussions with the patient about their care, treatment plans and preferences. This demonstrated continuity of care and effective coordination across ward areas, ensuring clinical teams had oversight of patient’s located away from their specialty ward. This supported and promoted integrated care delivery.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff provided information in ways for people to understand, avoiding the use of complex medical terminology where possible. People told us they had been kept updated about their care and treatment. Staff tried to involve family members in communications where appropriate. Some families we spoke with reported they were not always regularly updated but knew who they could contact for information.

Corridor care spaces were clearly identified. Signs identified the bed number, explained the purpose of the space, and advised anyone with concerns to speak with a nurse, clinician, or the nurse in charge. 

Information leaflets were available on the wards for people to access. Leaflets contained further information about local services and how to complain. Staff had access to translation services to aid communication with patients where English was not their first language. Staff recognised many colleagues spoke different languages and were happy to support with translations if required. Staff reported they tried not to use people’s family members to translate. 

Medical notes trollies were kept in appropriate spaces, such as staff-only rooms. These trollies were locked to support patient confidentiality. Staff appropriately disposed of handover sheets in confidential waste bins. 

The trust website included features to support accessibility, allowing users to change font type, size and background colour. These features could assist people with dyslexia and visual impairments to enable clearer reading. The website could also be translated into over 200 languages to support a diverse population. This support extended to the online patient portal, where people could access appointment and referral details. There was accessibility portal support available online for frequently asked questions. 

The service had plans for patients to see their diagnostic imaging appointments on the portal from November. Digital advancements would further support inclusion and access to healthcare information. 

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service provided feedback cards to patients and/or relatives on discharge. The feedback cards were put into a box however, staff were not sure who collected the completed feedback cards, but reported they received feedback from their manager in huddles and handovers. 

Staff told us they tried to manage complaints at the time of receiving them, to resolve them quickly. They would try to communicate with the complainant to resolve any matters, if concerns remained, they would escalate to their manager. 

Complaints were logged by a central corporate complaints team, then sent to the appropriate divisional team, with a lead person identified to manage the complaint. The key performance indicator (KPI) for closing complaints was 60 working days. Although the complaint tracking graph showed an improving trajectory, staff stated the KPI was challenging to meet, due to the complexity and back log of complaints. 

The service reported annual complaint trends and themes were usually reviewed through an annual report. However, the last report was produced for 2023-2024, and a full thematic review had not yet been created for the current period. 

Complaints were monitored through patient experience reports and raised to the divisional group. Complaints data from February 2026, showed volumes received remained relatively stable, with the overall caseload and backlog reducing. Learning outcomes and actions were identified from complaints. For example, feedback highlighted the need to further embed consistent communications to ensure families were kept up to date. Actions from this were shared with staff. People we spoke with were generally satisfied with the care and treatment they received. They said staff kept them informed and involved them in discussions about their care and treatment.

We observed a ‘Meet the Matron’ notice was displayed, informing patients and their families that clinical leaders offered a weekly opportunity to discuss any concerns. The notice explained patient consent would be sought where appropriate, before discussions took place. This enabled people to raise concerns directly to a leader to ensure their views were listened to and addressed.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

There were delays throughout the service which affected patient flow through to discharge. There were pathways to support flow, such as the same day emergency care services. However, these services were also affected by the wider pressures, adding to delays. Therefore, the provider had not achieved a sustained improvement in patient flow.

Care was not always prioritised appropriately. We observed a doctor’s handover where there was no process to discuss the most unwell patient. Key features relevant to the person were discussed instead of critical information. This could create a risk of uneven access to timely and appropriate care.

The trust monitored demand, length of stay (LOS) and discharges to identify trends and areas for improvement. The trust recognised concerns regarding flow and developed action plans to support improvement. However, these actions had not yet delivered consistent reductions in delayed discharge days. Other initiatives included establishing processes to discuss discharge from the point of admission, with the aim of supporting more efficient care, bed management and timely discharge.

Data from June 2025 to February 2026 showed that total discharge-ready LOS days fluctuated, with increased pressure during winter periods. The overall trend remained broadly stable rather than consistently decreasing. This indicated that the provider continued to experience challenges in reducing the number of days patients remained in hospital after becoming medically fit for discharge. This limited sustained improvements in patient flow and bed capacity. This could negatively impact patients’ health and wellbeing, as prolonged admission could lead to infection, physical deconditioning, and a loss of personal independence.

The hospital experienced increased occupancy, requiring the use of the critical care escalation beds. The increased occupancy was contributed to by the closure of one of the hospital zones, due to building defects. The trust worked closely with the local Fire and Rescue Service to ensure appropriate oversight and risk management throughout the closure. The closure was a known risk, that had been regularly risk assessed, with mitigating actions implemented to minimise impact and prioritise patient safety. The trust was transparent with the public, with a public board paper introduced to share information and updates. Staff were kept informed through communications on the intranet. There were plans for staff listening groups to gather feedback and to ensure staff views were considered. 

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. 

Staff were aware how to access services and support for patients, for example translators and hospital specialists. However, some ward staff told us they sometimes relied on patients’ family members or friends to translate. This was not in line with best practice guidance, due to the risk of safeguarding concerns being missed and patient confidentiality being compromised.

The most recent completion rates for learning disability and autism training were particularly low across the division, with only 45% of staff completing the second tier of training. This meant staff may not have the appropriate level of understanding to care for people with a learning disability and autism.

We spoke with some patients and relatives, who told us they were treated in a non-discriminatory way. Staff were trained in equality, diversity and inclusion and human rights. The majority of staff were up to date with the training, with an average total compliance of 91%.

Staff explained they took time to assess and treat people, which could prevent avoidable admissions, particularly for older people. They understood unnecessary hospital stays could adversely affect mobility, independence and physical wellbeing. 

The service did not provide additional data to demonstrate how equality and diversity had been implemented in the service for medical care.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff personalised care plans to each individual and updated them regularly. Staff demonstrated a clear understanding of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms, for which they received training. Patient preferences were recorded within care plans, which helped prevent repeated discussions. We reviewed medical records with completed ReSPECT forms which contained clear documentation of preferences and family involvement in discussions. 

Multidisciplinary team meetings considered both patients’ medical needs and what was important to them, ensuring care was person-centred and tailored to individual preferences. Staff arranged for meetings with family members, to discuss forward planning and ensure everyone was informed and involved in decision making.