East Surrey Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At the last assessment we rated this key question as good. 

At this assessment the rating has changed to requires improvement.

We assessed 6 quality statements

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent. 

We have not awarded this service a score for Effective.

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

The service did not always make sure people's care and treatment were effective because they did not consistently assess, review and respond to people's health, care, wellbeing and communication needs in a timely way. Delays in clinical review increased the risk of patient deterioration.

The trust used digital patient records to record and manage patient information.

Self-presenting patients had their needs assessed either by a GP or Emergency Nurse Practitioner (ENP) when streamed to the Minors area, or by a triage nurse when streamed to Majors. Flags were added to patient records to highlight significant risks, needs or safeguarding concerns. This enabled staff to quickly identify and respond appropriately to protect patient safety and support effective care. Examples included safeguarding concerns, risks of violence or aggression, and allergies or other critical medical alerts.

Staff were able to explain the process used to identify and manage time-critical medication at triage. Patients requiring time-critical medication were identified with a yellow wristband, and this was recorded in their patient notes. Nursing staff would liaise with a doctor to ensure timely prescribing and administration.

Pain scores were recorded at triage. We reviewed 10 patient records and found that in 8 cases appropriate action had been taken by the triage nurse in response to recorded pain levels.

However, triage was not consistently completed within 15 minutes. At times during the day, patients waited up to and over an hour for triage. This resulted in delays in assessing patients’ needs and in receiving appropriate care and treatment.

Patients arriving by ambulance did not always have their needs assessed in a timely way. Triage processes were not consistently effective, and patients were often managed in order of arrival rather than clinical urgency, which increased the risk of deterioration going unrecognised.

There were also significant delays to initial assessment by a clinician. These delays compromised patient safety, as urgent conditions could go unrecognised or untreated, potentially leading to deterioration, increased risk of harm, and poorer outcomes. During the inspection, we observed delays to care and treatment across multiple areas of the emergency department, including the corridor, children and young people’s ED and waiting room.

Patients were not always placed in appropriate clinical areas for their needs. The service cohorted patients or asked them to wait in spaces that were not always suitable, and we saw examples of patients being inappropriately placed in temporary escalation areas.

In addition, emergency department clinicians did not always complete electronic patient records at the time of assessment. As a result, documentation timestamps sometimes showed assessments recorded after specialty team reviews, which did not reflect the actual sequence of clinical decision-making. The records we reviewed showed delays in assessment, medication administration, and access to diagnostic tests.

The service did not always plan and deliver people's care and treatment in line with current evidence-based guidance. While policies and clinical guidance were available, these were not always up to date or consistently followed. In addition, gaps in audit activity and clinical oversight limited the service's ability to demonstrate compliance with current standards.

The service demonstrated inconsistent delivery of evidence‑based care and treatment. While some care aligned with national guidance, this was not consistently achieved due to system pressures, including high demand, workforce gaps, and capacity constraints.

A range of clinical guidelines and pathways were available, and several were up to date, including rapid tranquillisation, atrial fibrillation (irregular heart beat), and antibiotic quick-reference pathways, which staff found accessible and helpful. However, not all policies were current; the major trauma pathway had not been ratified and the acute administration policy was outdated, creating a risk of variation in practice.

The service completed mental health assessments in line with national guidance. However, patients experienced prolonged stays in non-therapeutic environments, including the Clinical Decision Unit. The service had identified gaps in Mental Health Act processes, and a policy on Section 17 leave policy, which sets out the arrangements for patients detained under the Mental Health Act being able to leave the hospital in a planned and authorised way, was in development.

Despite the availability of guidance, it was not always applied in practice. For example, a local policy to prioritise moving patients who should not be managed in corridors into appropriate clinical areas was not consistently implemented due to operational pressures. This demonstrated the service’s inability to apply its own safety guidance consistently. In children and young people services national standards were not met, including the absence of paediatric emergency medicine consultants and a lack of high dependency unit (HDU) capacity, which affected the delivery of appropriate care for high-acuity children.

The service used clinical audit to support the delivery of evidence-based care. However, there was limited consultant engagement, and the service had opted out of participation in one of the national Royal College of Emergency Medicine (RCEM) audits. This reduced the effectiveness of the audit programme in providing clinical assurance and benchmarking against national standards. Combined with ongoing overcrowding and operational pressures, the department was not consistently able to prioritise audit activity or embed learning into practice, reducing its overall effectiveness.

The service did not always work effectively across teams and services to support people, particularly in supporting timely access to appropriate care. 

The service demonstrated variable effectiveness in how staff, teams and services worked together. Despite significant operational pressures, hospital flow challenges and wider health system pressures, the emergency department (ED) team demonstrated a strong commitment to working together, supporting one another to maintain patient care in difficult circumstances.  

The trust used an electronic patient record (EPR) throughout the hospital. Therefore, hospital teams completed the same record for each patient. This meant patient information was accessible for all, easy to find and helped facilitate better communication between healthcare professionals. However, emergency department clinicians did not always complete records contemporaneously, which reduced the reliability of some documentation timestamps and the recorded sequence of clinical decision-making.

The emergency department (ED) had a 24-hour diagnostic imaging service to support timely access to some investigations, this was not consistent across all teams. Key services, including the rapid testing facility, were not available overnight, and this was not aligned with admission policies for the children and young person’s (CYP) ward. As a result, delays in testing and admission were identified, with some children remaining in the ED overnight. This lack of coordination between teams reduced effective joint working, delayed patient flow, and increased the risk of prolonged stays in inappropriate environments and infection transmission.

The frailty and medical same day emergency care (SDEC) teams were well integrated within the emergency department and supported the early assessment and treatment of appropriate patients. This included frail and older patients, as well as patients with ambulatory conditions who could be assessed, treated and discharged on the same day without the need for admission. Examples included patients requiring intravenous antibiotics, those experiencing exacerbations of chronic illness, and patients requiring further investigation or specialist review. The frailty team included nursing, medical and therapy staff and supported admission, discharge to community settings, or return home, with established links to local community services.

Both frailty and medical same day emergency care (SDEC) teams proactively identified and transferred suitable patients from the emergency department to more appropriate care pathways, which supported patient flow and demonstrated effective joint working between teams. However, wider capacity pressures limited the effectiveness of these services. Although the trust's intention was that SDEC should not be used to accommodate patients overnight, data showed that patients routinely remained in SDEC for 1 or more nights due to delays accessing inpatient beds. This reduced the capacity available for same day emergency care activity and limited the ability of these services to fully support patient flow from the emergency department. Staff nevertheless spoke positively about these services and the contribution they made to patient care and flow.

In contrast, the surgical same day emergency care (assessment unit) was more limited in its ability to support patient flow from the emergency department. Following a previous incident, stricter acceptance criteria had been introduced, which meant that patients with a perceived higher level of risk were not routinely transferred from ED. This reduced the unit’s flexibility to support demand and limited its effectiveness in working collaboratively with the emergency department, with some patients remaining in ED waiting areas without timely clinical oversight.

Some patients depending on their clinical severity would need to be transferred to other acute hospitals for more specialist care. Patient pathways and standard procedures were used to ensure continuity of care for the patient and effective collaborative working between the hospitals.

Staff across the children and young people emergency department, children’s ward, and supporting specialties (including anaesthetics) worked well together at a clinical level. There was effective day-to-day collaboration in assessing and managing unwell children, with joint working evident during resuscitation and escalation. Teams supported each other to manage deteriorating patients, and joint simulation training and shared clinical input helped to maintain coordination and consistency in care delivery. However, working between services was less effective across the wider pathway, particularly between ED, the children’s ward, and the retrieval service. The children’s ward was not commissioned to provide higher levels of care, and there was a gap for children who were too unwell for the ward but not retrieved, meaning they often remained in ED. Referrals to the retrieval service did not always result in transfer, and advice was not always aligned with local capability, with recommendations sometimes based on high dependency unit (HDU) or paediatric intensive care unit (PICU) level care that was not available within the trust. This resulted in fragmented pathways, prolonged stays in ED, and a lack of clarity about which team was responsible for the ongoing care of higher-acuity children.

The ED worked closely with the psychiatric liaison team from the local mental health trust, with arrangements for joint working which included 24/7 cover, contribution to daily ED meetings, and supported information sharing through access to the electronic patient record. Staff reported that liaison working was effective and supported care planning for patients presenting with mental health needs. However, access to services was not consistent across age groups. While the adult psychiatric liaison service was available 24/7, access to Child and Adolescent Mental Health Services (CAMHS) for children and young people was more limited and variable, with out-of-hours provision relying on the adult team. In addition, high demand and challenges in accessing onward mental health placements meant patients often remained in the emergency department for extended periods. This limited the ability of services to work together effectively to maintain patient flow, despite positive collaboration between teams.

The ED team had access to specialist teams within the trust, such as the dementia team, learning disability team and alcohol liaison nurses. Staff we spoke with described these teams as responsive and supportive.

Most referrals from the emergency department were to acute medical or surgical specialty teams. Medical staff in ED told us they felt supported by colleagues across the hospital. However, high demand and limited ward capacity resulted in delays transferring patients from the ED to inpatient areas. While patients were referred to and under the care of specialty teams, they often remained in the ED, where emergency staff continued to provide clinical oversight and monitor for deterioration. This delayed specialist care. The ED carried the risk for these patients and absorbed patient‑flow pressures for the whole hospital.

Staff described positive working relationships with ambulance crews and generally effective communication between services. However, ambulance handover delays affected the timely transfer of patient care. Ambulance crews told us they often waited up to 45 minutes to hand over patients to emergency department staff. In March 2026, there were 16 handover delays exceeding 45 minutes and 9 exceeding 60 minutes, which reduced the effectiveness of joint working between services and contributed to delays in patient care.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. 

The service’s primary role was the assessment and management of acute illness and injury. However, staff also recognised opportunities to support people to live healthier lives by identifying wider health and wellbeing needs during attendance.

Where appropriate, staff were able to draw on and refer to a range of wider hospital teams and services, such as safeguarding teams, mental health liaison, specialist nurses, and discharge or care coordination teams. This ensured that patients received holistic care and were connected to ongoing support beyond their immediate episode of care.

While the focus remained acute treatment, there was evidence that staff consider the person’s broader needs and made appropriate referrals or signposting to support longer-term health outcomes if required.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. 

The service used a range of systems and data sources to monitor, audit and benchmark the quality of care and outcomes for patients. This included review of national performance data, Getting it Right First Time (GIRFT) indicators and internal reporting processes, which enabled benchmarking and identification of areas for improvement.

Data was collected, analysed and reviewed over time to understand how the department was performing and to identify areas for improvement. This demonstrated that the service was experiencing sustained operational pressure. GIRFT data and local performance information showed higher than expected demand, including a high number of attendances per consultant and consistently high levels of emergency ambulance arrivals.

The service reviewed trends in activity and demand. Attendances remained consistently high, typically between 9,000 and 11,000 per month, with a peak of 12,321 attendances in December 2025, representing an increase compared to the previous year. The department also managed a higher proportion of major emergency cases compared to the national average, indicating increased acuity and complexity of patients.

Performance against national standards was consistently below expected levels. The percentage of patients admitted, transferred or discharged within 4 hours remained below the 95% standard and had shown a declining trend over time. Performance was broadly in line with national averages, where around 60–75% of patients were seen within 4 hours in major emergency departments. In addition, waiting times following the decision to admit had increased, with a growing proportion of patients experiencing delays of over 4 and 12 hours. The proportion of patients waiting over 12 hours was notably higher than the England average, with local data indicating around a quarter of patients affected compared to approximately 1 in 10 nationally.

The service monitored patient outcomes and safety indicators, and performed comparatively well in some areas, including lower rates of patients leaving without being seen and readmission rates. The service also participated in national audit activity, including the Royal College of Emergency Medicine Quality Improvement Programme (RCEM QIP) Mental Health (Self-Harm) audit, which reviewed 64 patient records. Patient experience was also monitored through the 2024 Urgent and Emergency Care Survey. Results showed positive feedback about staff attitudes, compassion and professionalism. However, feedback also highlighted concerns about long waiting times, communication, coordination of care and the use of corridor environments, which impacted patient experience and dignity.

The service had a clear understanding of demand, performance and patient experience. However, despite monitoring these metrics, sustained pressures and limitations in data quality limited the effectiveness of actions taken to improve outcomes, particularly in relation to waiting times, patient flow and timely access to care.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The service did not always support patients to fully participate in decisions about their care in line with legislation and best practice. While there were examples of appropriate holistic assessment, particularly within mental health services where patients were involved through comprehensive care that considered patients’ physical, mental and social needs approaches, this was not consistently supported across the department. Significant operational pressures, including overcrowding and long waits, meant that patients were not always assessed or reviewed in a timely manner, limiting opportunities to involve them fully in decisions about their care.

Patients were frequently cared for in inappropriate environments, such as corridors and waiting areas, which did not support privacy or dignity and reduced the ability to have meaningful conversations about care and treatment. There were also examples where communication needs were not promptly met, including delays in accessing appropriate support for patients with hearing impairment. These factors increased the risk that patients were not always able to give fully informed consent. Staff demonstrated an awareness of the principles of consent and patient involvement. However, the overall environment and system pressures reduced the service’s ability to consistently apply these principles in practice.

Staff understood the processes to follow when managing patients who required restrictive interventions. Emergency department staff were not routinely trained in restraint. However, where restraint was required, staff contacted the trust’s security team or the police. Security staff were trained in restraint and, alongside clinical staff, completed risk assessments prior to intervention. Following any restraint, body maps were completed and incidents were reviewed, including use of body worn camera footage. 

The trust's Mental Capacity Act (2005) and Deprivation of Liberty Safeguards policies were in date and reflected current legislation and guidance. The service had policies and procedures for rapid tranquillisation and sedation. Between March 2025 and February 2026, there were 10 recorded sedations and 9 restraint incidents. These were investigated, with outcomes and learning identified.