East Surrey Hospital

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• 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At the last assessment we rated this key question good. 

At this assessment the rating has changed to requires improvement.   

We assessed 7 quality statements.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Following the inspection, CQC issued a Section 29A Warning Notice in relation to concerns requiring urgent action to reduce the risk of harm to patients. The Warning Notice included concerns regarding governance arrangements supporting the delivery of safe care. The trust responded with an improvement action plan which included actions to strengthen leadership oversight, governance processes and operational management within the Emergency Department.

The breaches identified were based on evidence gathered during the assessment and considered against the legal standards that services must meet. While some of the same evidence was used, the breaches and the Warning Notice served different purposes. The Warning Notice addressed concerns that required immediate action, whereas the breaches related to areas where the service was not consistently meeting the standards expected for safe and quality care.

At this assessment we found the service was in breach of legal regulation in relation to good governance.

The service did not operate effective systems and processes to assess, monitor and improve the quality and safety of the service. Whilst risks were identified, monitored and escalated through governance arrangements, learning and actions were not consistently effective in the reduction of risks, sustained improvement or timely resolution of longstanding concerns. As a result, the service could not consistently demonstrate that governance systems were operating effectively to improve the quality and safety of care.

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.

Leaders had developed ambitions and priorities for urgent and emergency care services, and staff described a positive and supportive culture within the department. However, there was less evidence of a clearly shared and current direction for the emergency department, and staff and leaders did not always feel involved in decisions affecting the future development of the service.

Staff consistently spoke positively about the culture within the Emergency Department (ED). Staff described supportive working relationships and frequently referred to the department as being "like a family". Staff told us they felt supported by colleagues and immediate managers and remained proud of the care they provided despite sustained pressures relating to patient flow, overcrowding and workforce challenges. During the inspection, we observed positive interactions between staff and examples of collaborative working across professional groups.

Leaders within the division described a clear ambition to improve urgent and emergency care pathways, strengthen same day emergency care services and reduce unnecessary admissions. However, there was less evidence of a clearly defined and current strategic direction for ED. The strategy provided did not demonstrate it was current or reflected some of the key challenges affecting the service, including increasing children and young people (CYP) acuity and mental health demand.

Some senior ED leaders told us they were not routinely involved in planning and transformation work affecting the department and did not always feel their expertise informed decisions relating to service development and risk management. For example, ED leaders reported they had not been involved in work to review and determine future arrangements for the assessment and care of patients presenting with mental health needs, despite mental health demand representing a significant and longstanding operational challenge for the department. Senior leaders also described frustration regarding the pace of progress in addressing longstanding issues relating to patient flow, corridor care and capacity pressures.

The 2025 ED staff survey results reflected some of these concerns. Staff were less positive than trust averages when asked whether they were able to contribute towards improvements at work and whether teams worked together to improve the way care was delivered. This suggested staff did not always feel fully involved in decisions and improvements affecting the service.

Overall, staff demonstrated a strong commitment to the service and maintained a supportive local culture. However, there was less evidence of a clearly shared and current strategic direction for the emergency department, and some staff and leaders did not feel fully involved in decisions about how longstanding challenges relating to patient flow, capacity, mental health demand and increasing CYP acuity would be addressed.

Leaders at departmental and divisional level understood the challenges affecting the service and demonstrated commitment to supporting staff and improving patient care. However, some senior Emergency Department leaders did not always feel involved in decisions affecting the service and lacked confidence that concerns and priorities affecting the department were consistently reflected in wider organisational decision-making.

The Emergency Department (ED) was led by a Clinical Director, Associate Divisional Chief Nurse and Associate Director of Emergency Flow. At the time of inspection, the Associate Divisional Chief Nurse post was vacant. The leadership team was supported by matrons, service managers, clinical leads and senior nursing staff who provided day-to-day operational, professional and clinical leadership across the adult and paediatric emergency departments.

Staff consistently spoke positively about local leaders within the department. Staff told us matrons, senior nurses, service managers and consultants were visible, approachable and supportive. During the inspection, we observed positive interactions between staff and leaders and found staff were able to access support and advice when required. Staff described local leaders as having a good understanding of the operational pressures affecting the department and acting as advocates for staff and patients. Several staff highlighted the support provided by matrons and senior nursing staff during periods of sustained overcrowding, workforce pressures and challenging incidents. Staff told us local leaders were accessible and responsive when support, advice or escalation was required.

The Emergency Department sat within the Medicine Division, which was led by a Divisional Chief Nurse, Divisional Director for Clinical Services and Urgent and Emergency Care, and Chief of Medicine. Divisional leaders demonstrated a good understanding of the challenges affecting urgent and emergency care and described actions they had taken to strengthen workforce establishments, improve governance processes and support staff wellbeing. Leaders also described work to strengthen same day emergency care (SDEC) services and pathways, expand front-door frailty services and redesign patient pathways to improve flow and reduce unnecessary admissions. They had also secured additional investment in the emergency department nursing establishment and practice development resource to support workforce development and service sustainability.

However, many of the challenges affecting the department required wider organisational and system solutions. Some senior ED leaders told us they were not routinely involved in planning, transformation work and service development programmes affecting the department. They described difficulties progressing concerns relating to patient flow, mental health provision, workforce pressures and operational risks through wider organisational processes. For example, ED leaders described frustration that work relating to mental health pathways and patient flow did not always include ED representation, despite these being significant operational challenges for the department. Senior ED leaders also highlighted difficulties influencing decisions relating to discharge processes, capacity constraints and wider system flow, which they felt affected the department but sat outside their direct control. Several leaders told us they did not always receive timely feedback following escalation of concerns and did not always see longstanding issues addressed in a timely way.

Executive and divisional leaders were aware of the challenges affecting the department through a range of governance and reporting processes. However, many frontline staff told us executive leaders were not routinely visible within the Emergency Department. Some frontline staff and senior Emergency Department leaders felt executive leaders did not fully understand the impact that overcrowding, corridor care and capacity pressures were having on staff and patients.

The service encouraged staff to raise concerns and most staff felt able to speak up within the department. However, some senior Emergency Department leaders described concerns regarding psychological safety and did not always feel confident that concerns raised would be heard, acted upon or lead to meaningful improvement.

The trust had established Freedom to Speak Up (FTSU) arrangements, including a Freedom to Speak Up Guardian (FTSUG). Information about the service, including how to raise concerns and contact the guardian, was displayed within staff areas and available through the staff intranet. Staff told us they knew where to access information about the FTSU service if required.

Frontline staff told us they would feel comfortable raising concerns with line managers, matrons, consultants, senior nurses or service managers. Staff consistently described local leaders as approachable and supportive. Staff told us concerns raised within the department were listened to and discussed. Staff generally described a culture where concerns relating to patient safety, quality of care and staff wellbeing could be raised without fear of detriment.

However, some senior Emergency Department (ED) leaders described a different experience. These leaders told us they had concerns regarding psychological safety when escalating issues through wider organisational structures. Some leaders told us they did not always feel listened to, involved or supported when raising concerns or challenging decisions affecting the department and the delivery of patient care.

Some senior ED leaders told us concerns affecting the department had been escalated repeatedly over prolonged periods without sufficient progress. As a result, some leaders lacked confidence that speaking up through organisational and governance processes would consistently result in meaningful change.

The 2025 staff survey results also indicated lower confidence than trust averages that concerns raised would be addressed. This supported feedback that some staff and leaders did not always feel concerns raised through wider organisational processes resulted in meaningful action or improvement.

The trust demonstrated a commitment to equality, diversity and inclusion and had arrangements to monitor workforce experience and address inequalities.  However, detailed plans outlining how these objectives would be delivered and monitored at a local level were not clearly described. 

The trust monitored workforce equality through the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) and produced annual reports and action plans to address identified areas of concern. Workforce equality issues were reviewed through established governance arrangements. The trust had also established a range of staff networks and forums to support inclusion and staff engagement, including the Administration Professionals Forum, Cultural Inclusion Champions Network, LGBTQ+ Network, Men's Health Network, SASH Ability Network and Women's Network.

The 2025 WRES findings demonstrated some improvement across a number of indicators. However, staff from black and minority ethnic backgrounds remained more likely to experience harassment, bullying or abuse from patients, relatives and members of the public than white staff. Staff from black and minority ethnic backgrounds were also less likely to report equal opportunities for career progression and promotion.

The 2025 WDES findings demonstrated disabled staff reported poorer workplace experiences than non-disabled staff across a range of indicators, including bullying and harassment, career progression, staff engagement, wellbeing and feeling pressured to attend work when unwell.

Emergency Department 2025 staff survey results provided some insight into workforce experience within the service. Most staff reported they had not experienced discrimination on the grounds of age, disability, gender reassignment, pregnancy and maternity, or sex. However, responses relating to race and religion or belief were less favourable. Staff were also less positive than the trust average when asked whether colleagues treated each other with respect.

Whilst trust leaders had identified workforce equality issues through the 2025 WRES and WDES reports and developed action plans to address them, we found limited evidence demonstrating the impact of these initiatives specifically within the Emergency Department.

The service had systems and processes to oversee quality, safety, performance and risk. However, governance arrangements did not consistently ensure that identified risks were managed effectively, that actions were implemented in a timely way, or that governance activity resulted in sustained improvement for patients.

The Emergency Department (ED) operated within an established governance framework supported by departmental, divisional and trust-level governance structures. Governance arrangements included clinical governance meetings, risk management processes, audit programmes, mortality and morbidity reviews, performance monitoring and quality improvement activities. Information relating to safety, quality, performance and risk was routinely reviewed and escalated through organisational governance structures.

The service had identified governance leads and leaders were clear about their responsibilities for quality, safety and risk management. Risks were discussed through departmental and divisional governance meetings and recorded on risk registers where appropriate. We reviewed governance records and found evidence that issues affecting the service were routinely discussed, monitored and escalated through governance structures.  Staff told us they could raise concerns through line management structures, governance meetings, incident reporting systems and Freedom to Speak Up arrangements. Learning and governance information was shared through team meetings, safety briefings and departmental communications. However, we found examples where risks identified by the department remained awaiting approval through divisional governance processes before being added to the divisional risk register. This indicated governance processes did not consistently support timely escalation and oversight of identified risks. 

The service monitored a range of quality and performance measures and participated in national audits, quality improvement programmes and benchmarking activity. Governance processes supported the review of incidents, complaints, risks and patient outcomes, and learning was shared through meetings, safety communications and education forums.

However, despite the governance arrangements, many of the issues identified through governance processes remained evident at the time of inspection. We found examples where concerns relating to patient flow, corridor care, workforce pressures, children and young people services, mental health pathways and environmental risks had been recognised and discussed over prolonged periods. Whilst actions had been identified and risks escalated, governance processes did not consistently demonstrate that risks had been mitigated, resolved or reduced.

Many of these issues were known at departmental, divisional and organisational level and were reflected within governance discussions, risk registers and action plans. However, the service could not consistently demonstrate that this oversight resulted in timely resolution of risks or sustainable improvement for patients. We also found examples of policies, standard operating procedures and guidance documents that remained in draft and had not yet been formally ratified, despite being used within the service. This indicated governance processes did not consistently support the timely approval, implementation and oversight of proposed changes.

Some senior ED leaders described difficulties progressing concerns through wider organisational processes and did not always receive timely feedback or support following escalation of risks. Whilst governance arrangements provided assurance that risks were recognised, monitored and discussed, there was less evidence that governance processes consistently translated into timely organisational action or sustainable improvement.

Although the service undertook local and national audit activity, overall audit participation was limited. The department had opted out of one Royal College of Emergency Medicine (RCEM) national audit and was not participating in all available national audit programmes. Consultant engagement in audit activity was limited, and there was no identified consultant lead for audit. Participation in a limited number of national audits reduced opportunities to benchmark performance against national standards and demonstrate improvement. While audits identified areas requiring action, the service could not consistently demonstrate that learning had been embedded into practice or resulted in sustained improvements in patient care.

The service worked collaboratively with a range of partners to support patient care and system improvement. However, opportunities to strengthen collaboration and shared planning had not always been fully realised, and partnership working had not consistently addressed some longstanding system pressures affecting patient care and access.

The service worked with a range of health and care partners, including ambulance services, mental health providers and community healthcare teams, to support patient care and access to appropriate services. Staff described positive working relationships with these organisations and collaborative approaches to managing patients with complex needs. The service worked with mental health providers to support patients requiring specialist assessment and treatment, and leaders told us that mental health pathways and system pressures were regularly discussed through operational and governance processes.

The service also worked closely with social care and safeguarding partners to support vulnerable adults and children. Safeguarding teams held weekly meetings with local authority partners to discuss cases and worked with social work teams following discharge to help ensure appropriate support arrangements were established. The service also participated in multi-agency domestic abuse arrangements, including Multi-Agency Risk Assessment Conference (MARAC) processes, to support people at risk of harm.

The service had established links with voluntary and community sector organisations. This included participation in the Barnardo's Family Support Pilot, which provided psychosocial support to children and families experiencing wider social, emotional and health challenges. The service helped families access community resources and support services, including those affected by domestic abuse, financial hardship, neurodevelopmental needs and social deprivation.

However, partnership working was not always effective in addressing some longstanding system pressures. Despite ongoing collaboration with mental health providers, patients with mental health needs continued to experience significant delays accessing assessment, treatment and onward care. There was also limited evidence of coordinated strategic engagement between the trust, commissioners and specialist children and young people (CYP) retrieval services to review increasing demand, patient acuity and service configuration. Despite consistently high referral rates to retrieval services over several years, there was limited evidence of system-wide planning to address gaps in provision for CYP requiring enhanced monitoring and treatment.

The service worked collaboratively with a range of partners to support patient care and system improvement. However, opportunities to strengthen collaboration and shared planning had not always been fully realised, and partnership working had not consistently addressed some longstanding system pressures affecting patient care and access.

The service worked with a range of health and care partners, including ambulance services, mental health providers and community healthcare teams, to support patient care and access to appropriate services. Staff described positive working relationships with these organisations and collaborative approaches to managing patients with complex needs. The service worked with mental health providers to support patients requiring specialist assessment and treatment, and leaders told us that mental health pathways and system pressures were regularly discussed through operational and governance processes.

The service also worked closely with social care and safeguarding partners to support vulnerable adults and children. Safeguarding teams held weekly meetings with local authority partners to discuss cases and worked with social work teams following discharge to help ensure appropriate support arrangements were established. The service also participated in multi-agency domestic abuse arrangements, including Multi-Agency Risk Assessment Conference (MARAC) processes, to support people at risk of harm.

The service had established links with voluntary and community sector organisations. This included participation in the Barnardo's Family Support Pilot, which provided psychosocial support to children and families experiencing wider social, emotional and health challenges. The service helped families access community resources and support services, including those affected by domestic abuse, financial hardship, neurodevelopmental needs and social deprivation.

However, partnership working was not always effective in addressing some longstanding system pressures. Despite ongoing collaboration with mental health providers, patients with mental health needs continued to experience significant delays accessing assessment, treatment and onward care. There was also limited evidence of coordinated strategic engagement between the trust, commissioners and specialist children and young people (CYP) retrieval services to review increasing demand, patient acuity and service configuration. Despite consistently high referral rates to retrieval services over several years, there was limited evidence of system-wide planning to address gaps in provision for CYP requiring enhanced monitoring and treatment.