St Helier Hospital and Queen Mary's Hospital for Children

Updated 11 June 2026

Date of assessment: 02 and 03 December 2025. St Helier Hospital and Queen Mary's Hospital for Children is part of Epsom and St Helier University Hospitals NHS Trust and provides a range of NHS hospital services to people living in Southwest London and neighbouring areas.

This assessment looked at maternity services, medical care, surgery and urgent and emergency care to assess the quality of the care received by patients using those services. The rating of maternity service, medical care, surgery and urgent and emergency care have been combined with the ratings of the other services from the previous assessments.

See our previous reports to get a full picture of all the other services at St Helier Hospital and Queen Mary's Hospital for Children.

The rating of St Helier Hospital and Queen Mary's Hospital for Children changed to requires improvement.

Updated 31 July 2025

Epsom and St Helier University Hospitals NHS Trust provide maternity services at both the St Helier Hospital and Queen Mary's Hospital for Children and Epsom General Hospital. From November 2024 to October 2025 there were 1845 babies born at St Helier Hospital and Queen Mary's Hospital for Children.

We last inspected maternity services at St Helier Hospital and Queen Mary's Hospital for Children on 29 and 30 August 2023. This was a focused inspection of safe and well-led as part of our national maternity inspection programme. We rated the maternity service as requires improvement overall. We rated safe as Inadequate and well-led as Requires Improvement in maternity services.

We conducted this unannounced focused assessment on 2 and 3 December 2025 to follow-up on the 2023 inspection findings. As this was a focused assessment, we only looked at the safe and well led domains. There were no breaches of regulation. However, there were still ongoing areas of improvement around staffing, triage documentation and environment.

We visited the following areas as part of the assessment: labour ward, triage, maternity assessment unit, antenatal clinic, theatres, recovery and the maternity wards. We also looked at bereavement facilities. We spoke with the leadership team, matrons and members of the maternity team including midwives, specialist midwives, governance midwives, obstetric consultants, registrars, resident doctors, maternity assistants and anaesthetists.

We rated the service as good. The service has made improvements and is no longer in breach of the regulation for safe care and treatment and good governance. The improvements made since the last inspection in August 2023, were particularly around the triage process, medicines, care records, mandatory training, staffing, transitional care, bereavement, governance, privacy, dignity and respect for women.

We refer to women in this report, but we recognise that some transgender men, non-binary women and women with variations in sex characteristics (VSC) or who are intersex may also use services and experience some of the same issues.

Updated 31 July 2025

Medical care at St Helier Hospital and Queen Mary’s Hospital for Children provided care that was mostly safe, compassionate and based on national guidance. Staff were kind and respectful, and patients frequently described them as supportive and attentive. Teams worked well together to assess needs, monitor risks and involve patients and families in decisions about treatment, particularly where people had communication needs or complex vulnerabilities. Safeguarding arrangements were well established, and staff understood how to act to protect people from harm. Medicines were managed safely, and pharmacy teams supported both prescribing and discharge planning effectively. Staff used evidence based tools, participated in quality improvement work and learning from incidents and audit was routinely shared. Leaders were visible, approachable and promoted a culture of openness, with governance structures that gave oversight of risks, workforce pressures and performance. Strong relationships with community partners supported discharge planning and continuity of care, including the use of virtual wards‑based tools, participated in quality improvement work

However, the service continued to experience significant pressures linked to patient flow, which affected the consistency of people’s experience. Patients described long waits in areas that were not designed for extended stays, including the same day emergency care unit and the acute medical unit. Some older people experienced limited access to therapeutic activities or regular mobilisation, increasing the risk of deconditioning during prolonged admissions.

Updated 31 July 2025

Date of assessment: 2 to 3 December and 11 December 2025

We carried out an announced comprehensive inspection of surgery services at St Helier Hospital and Queen Mary’s Hospital for Children. We inspected all quality statements across the five key questions: safe, effective, caring, responsive and well-led. The inspection was part of our planned programme of assessments.

During our inspection we visited A3, B3, the Surgical Ambulatory Care Unit (SACU), Mary Moore Ward, the Eye Day Case Unit, surgical theatres, recovery and the interventional radiology suite. We spoke with over 30 members of staff including nursing and medical staff of all grades, pharmacists, healthcare assistants, domestic staff, and managers. We spoke with over 15 patients and their relatives.

Overall, we rated the service as requires improvement. At this assessment we found a breach of regulation in relation to good governance.

There were risks within the environment, including fire risks. Additionally, space constraints and the use of escalation areas compromised patients’ privacy and dignity and cluttered theatres with limited storage contributed to fire safety concerns. We found gaps in risk management processes, such as incomplete or delayed Venous Thromboembolism (VTE) assessments and limited monitoring of National Early Warning Score (NEWS2) compliance. Governance systems and audits were not always effective in identifying or addressing areas for improvement. Staff raised concerns about bullying and discrimination, and some felt hesitant to speak up.

However, staff treated people with kindness and respect, and people told us they felt informed and involved in decisions about their care. We observed how staff treated people with kindness and compassion. There was a culture of quality improvement and innovation throughout the service.

We have requested an action plan, this will be requested upon publication of the final report.

Updated 31 July 2025

St Helier Hospital is run by Epsom and St Helier Hospitals NHS Trust. The urgent and emergency care service at St Helier Hospital consist of an adult emergency department (ED) and a paediatric ED.

We carried out an announced assessment of urgent and emergency care at St Helier Hospital on 2 and 3 December 2025 in line with our assessment priorities. We returned for an unannounced assessment on 11 December 2025.

Overall, the service was rated as requires improvement.

We assessed 25 quality statements from safe, effective, caring, responsive, and well led key questions. We rated safe, caring, responsive, and well led as requires improvement. The service was in breach of legal regulation in relation to Regulation 10, Dignity and Respect, Regulation 12, Safe Care and Treatment, and Regulation 15, Premises and equipment, Health, and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have requested an action plan for the trust to address this.

We looked at 26 sets of patient clinical records; we spoke with 15 patients, 7 family members or friends, and 39 members of staff. We visited and observed all areas of the ED including the main ED, triage and waiting areas, ambulance handover, urgent treatment centre, resuscitation area, majors, same day emergency care (SDEC), rapid assessment and treatment (RAT) area, and the paediatric ED.

We assessed quality statements within key questions. Each quality statement assessed is awarded a score. Details on how we score can be found on our website: https://www.cqc.org.uk/about-us/how-we-do-our-job/ratings.

You can find further information about how we carried out our assessments at:

https://www.cqc.org.uk/about-us/how-we-do-our-job/what-we-do-inspection.

Updated 14 May 2018

Our rating of this service improved. We rated it as good because:

• There was a good overall safety performance in the service and a culture of learning to ensure safety improvements. Staff were encouraged to report incidents and received timely feedback. There was evidence of learning from incidents, which was shared in a number of ways.
• There were processes in place to ensure safe staffing levels. The service had 24 hour consultant cover.
• There were effective processes in place to assess and escalate deteriorating patients.
• There was good compliance with infection prevention and control processes. Equipment was checked regularly and medicines were stored appropriately.
• Staff had a good understanding of safeguarding and were aware of their responsibilities in relation to safeguarding children. The service had good multi-agency partnerships to share relevant safeguarding information.
• Patient records were completed to a good standard.
• Staff provided care and treatment in line with national guidance and good practice. The service monitored the effectiveness of care and treatment through continuous local and national audits.
• There were effective processes in place to ensure that patients’ nutritional and pain management needs were met.
• Staff were supported to develop and there was a culture of learning and teaching within the service.
• There was effective multidisciplinary team (MDT) working both internally and externally to support patients’ health and wellbeing.
• There was a range of information and support available for patients and their families and carers. Staff helped patients manage their own health.
• Staff understood their responsibilities as set out in the Mental Capacity Act (MCA).
• Staff in children and young people’s services demonstrated a patient-centred approach which encouraged family members to take an active role in their child’s healthcare.
• All staff interacted with patients and their family members and carers in in a caring, polite and friendly manner.
• The service had a broad programme of emotional support services for children and young people and their families and carers. This included a variety of therapeutic support services.
• There was timely access to a broad range of children and young people services including a number of highly specialist paediatric services. The flow of patients through children and young people services from admission, through theatres, wards and discharge was mostly managed effectively.
• There was provision to meet the individual needs of children and young people using services at the hospital, including vulnerable patients and those with specific needs. There were efforts across the hospital to make the environment more child-friendly and welcoming for young people.
• There was an established and stable leadership team in the CYP service. Staff told us senior leaders of the service were visible, approachable and supportive. There was an inclusive and constructive working culture within the services. We found dedicated staff that were knowledgeable about their work.
• The department used appropriate governance, risk management and quality measures to improve patient care, safety and outcomes. Senior staff understood their local challenges and demonstrated a desire to improve CYP services for the benefit of patients.

However:

• There remained some challenges with staffing vacancies, for example, nurse staffing in the neonatal unit (NNU) and on the children’s ward. Managers were aware of these challenges and there were interim measures in place to ensure safety.
• The hospital had one lift to serve all floors. The lift was taken out of service when routine maintenance was required. However, a business plan was in place to build a new external lift.
• There was no formal clinical supervision for nursing staff.

Updated 27 May 2016

We rated the critical care unit as ‘requires improvement’ overall. Although staff were reporting incidents, there was no system in place to ensure that all staff were learning from incidents. We identified gaps in record keeping and found that intravenous (IV) fluids were not being stored securely. The unit was small and cramped and staff told us this made it difficult to have all the equipment required around the patient bedspace.

There was a lack of agreed guidelines specific to the critical care unit and multidisciplinary working was not well embedded. The unit had a larger number of delayed discharges and out of hours discharges compared to similar units and staff in other parts of the hospital reported delays in accessing critical care.

Patients were not always given the opportunity to be involved in their care. There was a poor response to patient feedback surveys and the unit did not offer a follow up clinic for patients post discharge.

The leadership team had struggled to achieve good team dynamics because of behavioural issues from certain staff members and had not been successful in their attempts to manage this. The service had been unable to agree a strategy and an external advisor had been appointed by the trust to assist the critical care workforce in achieving this. The culture on the unit was very hierarchical and challenges were not always welcome.

The unit had good outcomes for patient when compared to similar units and staffing was in line with national guidelines, although agency nurses were used frequently. Staff, including agency, received a good induction and competency based assessment prior to caring for patients independently. Doctors in training received good teaching and support from consultants and patients we spoke with spoke highly of the staff and the care they received on the unit.

Updated 27 May 2016

The Specialist Palliative Care (SPCT) team provided end of life care and support six days a week, with on call rota covering out-of-hours. There was visible clinical leadership resulting in a well-developed, motivated team.

Patients told us the ward based staff and the palliative care clinical nurse specialists were caring and compassionate and we saw the service was responsive to patients’ needs. The SPCT responded promptly to referrals. There was fast track discharge for patients at the end of life wishing to be at home or their preferred place of death.

Staff throughout the hospital knew how to make referrals to the SPCT and referred people appropriately. The team assessed patients promptly, to meet patient needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Most hospital staff were complimentary about the support they received from the SPCT. Junior doctors particularly appreciated their support and advice, and said they could access the SPCT at any time during the day. They recognised that the SPCT worked hard to ensure that end of life care was well embedded in the trust.

The director of nursing had taken the executive lead role for end of life care, along with a non-executive director (NED), to ensure issues and concerns were raised and highlighted at board level. The trust's board received EOLC reports, outlining progress against key priorities within the EOLC strategy, including audit findings, themes from complaints and incidents, evidence of learning and compliance with end of life training requirements.

The SPCT provided a rapid response to referrals, assessed most patients within one working day. Their services included symptom control and support for patients and families, advise on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

The National Care of the Dying Audit 2013/2014 (NCDAH) demonstrated that the trust had not achieved three out of seven organisational key performance indicators. At the time of the inspection, the trust had not fully rolled out the replacement of the LCP, and this delay meant that staff were not fully supported to deliver best practice care to patients who were dying. The leadership failed to apply enough urgency to have an individual plan of care in place.

Updated 27 May 2016

Overall, we found that outpatients and diagnostic imaging were good. The service was rated as good for safety, caring, responsive and well-led. The effective domain was inspected but not rated. Some aspects of the delivery of safe patient care in relation to radiation safety were excellent.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. The pathology department had a comprehensive quality management system in place with compliance targets set at higher than the national average to improve safety and quality. There was evidence of excellent practice for the monitoring and administering of patient radiation doses to be as low as possible.

The environments we inspected were visibly clean and staff followed infection control procedures. Records were almost always available for clinics and if not, a temporary file was made using available electronic records of the patient. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Nurse staffing levels were appropriate and there were few vacancies. The diagnostic imaging vacancies were higher, particularly ultra sonographers. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the emergency eye service offered Monday to Friday 8.30am to 4.30pm for patients with sight threatening eye conditions, requiring urgent specialist ophthalmic treatment. National waiting times were met for outpatient appointments and access to diagnostic imaging. A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics, but patients received good communication and support during their time in the outpatients and diagnostics departments. Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients with a learning disability or living with dementia.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.

The outpatients and diagnostic imaging departments had a local strategy plan in place to improve services and the estates facilities. From December 2015, the current outpatient services that are in Clinical Services Directorate will move to a new Outpatients and Medical Records Division. Staff expressed some concern over these changes.

Governance processes were embedded across outpatients and diagnostics. The directorate was commended on its risk register in a recent review of risk registers in the trust. Senior managers told us the newly appointed quality manager had made significant improvements in making sure priorities, challenges and risks were well understood. Good progress was evident for improving services for patients.

We found good evidence of strong, local leadership and a positive culture of support, teamwork and innovation.

Updated 27 May 2016

Overall, we found renal services were good. Reviews of care through incident investigation and morbidity and mortality were completed throughout the service and opportunities for learning were shared with staff. Infection control practices were robust in all areas. Staffing levels and skill mix were appropriate in all areas across the service with low agency staff usage.

Patient outcomes were in line or exceeded with national standards and effectiveness was regularly assessed and benchmarked. There was effective multidisciplinary working, with specialist nurses and allied health professionals and joint clinics were held with relevant specialties including diabetes. However we noted that standards for vascular access for haemodialysis were not met.

Most patients’ spoke positively of the care they received within the hospital, and individual patient needs were met. Delays in transport were noted as a particular concern by patients’ and their carers.

The environments in the dialysis units were cramped and in some areas, including at St Helier, facilities for patients were limited.

The service was well led with a clear vision and strategy and effective governance and risk management processes. Managers in the service were aware of shortfalls and took steps to address them. Staff spoke positively of the leaders and culture within the service .