Epsom General Hospital

Updated 11 June 2026

Epsom General Hospital provides an extensive range of inpatient, day and outpatient services,
and has a busy accident and emergency (A&E) department. The vast majority of elective (pre-booked) operations at the trust take place at Epsom Hospital. The trust has an extensive range of diagnostic and supporting services at Epsom Hospital, including pathology, radiology (including CT, MRI and ultrasound) and vascular diagnostic services, and a busy modern purpose-built day care and day surgery unit.

The Elective Orthopaedic Centre (the EOC) is based at the hospital, providing orthopaedic services to patients from St George's, Croydon Health Services and Kingston hospitals in addition to patients from Epsom and St Helier hospitals.

Updated 31 July 2025

Epsom and St Helier University Hospitals NHS Trust provide maternity services at both the Epsom General Hospital and St Helier Hospital sites. From November 2024 to October 2025 there were 1639 babies born at Epsom General Hospital.

We last inspected maternity services at Epsom General Hospital on 29-30 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 at this inspection as requires improvement overall.

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.

We visited the following areas as part of the assessment: maternity assessment unit, antenatal clinic, triage, labour ward, theatres, recovery and the maternity ward. We also looked at bereavement facilities. We spoke with members of the maternity team including maternity assistants, junior doctors, registrars, consultant obstetricians and anaesthetists, band 6 and 7 midwives, specialist midwives, safeguarding midwives, matrons and the quadrumvirate.

We rated the service as good. The service has made improvements and is no longer in breach of the regulation for good governance. The service now had enough appropriately trained midwifery and medical staff to keep women and babies safe, involved women to understand and manage risks, managed records effectively and had effective governance processes and leaders who were aware of the risks within the service. However, the service was in breach of the regulation for safe care and treatment, in relation to all staff receiving appropriate triage training. We have asked the provider for an action plan in response to the concerns found at this assessment.

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

Epsom and St Helier University Hospitals NHS Trust provide medical care including older people services at both the Epsom General Hospital and St Helier Hospital sites.

We last inspected medical care services at Epsom General Hospital on 19 September 2019. This was a comprehensive inspection. We rated the medical care service at this inspection as good overall.

We conducted this unannounced assessment on 2 and 3 December 2025.

We visited the following areas as part of the assessment: same day emergency care unit, wards and the discharge lounge. We spoke with members of the medical care team including junior doctors, registrars, consultants, band 5 and 6 nurses, healthcare assistants, matrons and the quadrumvirate.

We rated the service as good.

Updated 31 July 2025

On Tuesday 2 and Wednesday 3 December 2025 we carried out an inspection at Epsom General Hospital of the surgery service. This report relates to Swift ward, the day surgery unit and the main theatres at the hospital. The planned care directorate spans across all sites at the Epsom and St Helier University Hospitals NHS Trust. We went to Swift Ward, Day Surgical Unit, Surgical Care Suite and theatres, which cared for surgical patients at the hospital. We spoke with 8 patients and reviewed 9 sets of patient records. We spoke with more than 22 staff which included: consultants, resident doctors, nurses, senior leaders, healthcare assistants, administration staff and housekeeping staff.

We assessed 34 quality statements across the safe, effective, caring, responsive and well-led key questions and we have combined the scores for these areas with scores from the last inspection to give the rating.  

Updated 31 July 2025

Epsom Hospital is run by Epsom and St Helier Hospitals University Hospitals NHS Trust. The urgent and emergency care service at Epsom Hospital consists of an adult emergency department (ED), a paediatric ED and a Same Day Emergency Care (SDEC).

We carried out an announced inspection of urgent and emergency services at Epsom Hospital on 2 and 3 December 2025. We returned for an unannounced inspection on 11 December 2025. Epsom Hospital provides a range of NHS hospital services. This assessment looked at urgent and emergency services due to risks highlighted, which we rated as requires improvement.

In our assessment of urgent and emergency services, we assessed 25 quality statements from safe, effective, caring, responsive and well led key questions. We rated safe, effective, caring, responsive and well led as requires improvement.

We looked at 45 sets of patient clinical records; we spoke with 20 patients, 20 family members or friends, and 49 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), and the paediatric ED.

At this assessment we identified breaches of regulations 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.

Updated 29 January 2019

• Safeguarding processes had improved since our last inspection. Staff had instant access to information, which was held electronically. This meant staff were immediately aware if a child was known to social services, was a looked after child, or subject to a child protection plan.

• Staff identified and responded appropriately to changing risks to people who use services, including deteriorating health and wellbeing and medical emergencies. Staff were able to seek support from senior staff in these situations.

• People received safe care and treatment. Vacancy rates for nursing staff had improved significantly since our last inspection.

• Staff understood their responsibilities to raise and record safety incidents, concerns and near misses. Learning from incidents was routinely shared with staff across the service in several ways, such as regular ward meetings.

• The service used a range of evidence-based guidance, legislation, policies and procedures to deliver care, treatment and support to patients.

• From June 2017 to May 2018, the trust performed better than the England average for the percentage of patients aged 1-17 years old who had multiple readmissions for asthma.

• Staff treated patients and their families with kindness, dignity, respect and compassion. We saw that staff took the time to interact with people who use the service and those close to them in a respectful and considerate way.

• The trust provided timely and accessible services for children and young people which reflected the needs of the population served. Trust leaders had worked collaboratively with trust staff, external bodies and children and young people, and their relatives to do so.

• The trust listened and responded to people’s concerns and complaints about services for children and young people, and used these to improve the quality of care. The service received a very low number of complaints.

• Leaders had the required skills, knowledge, experience and integrity to carry out their roles effectively.

• There were clear and effective systems of governance and management across services for children and young people at Epsom General Hospital, in close liaison with St Helier Hospital, the other trust's site.

However:

• Medical staff did not meet the completion rate target of 85% for nine out of the 11 mandatory training modules for medical staff. This meant that not all medical staff had received training essential to providing safe patient care.

• Staff did not consistently monitor the temperature of the fridge in the clinical room in the neonatal unit which was used to store breast milk. This meant there was a risk that breast milk could be exposed to abnormal temperatures, which could cause the milk to deteriorate.

• The trust paediatric policies we looked at were not all up to date. For example, one of the policies we looked at, had expired in September 2017.

• Locum medical staff did not have access to the full information technology systems and could only use a generic log on to access the trust systems. This meant locum staff could not easily access important information such as handover lists, transfer letters and up to date guidelines.

• Some staff told us they would use other staff members to translate for parents or relatives. This was outside of best practice and trust policy.

Updated 29 January 2019

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately and learning was shared across the two sites. Staff could give us clear examples of when learning from incidents had resulted in changes to practice. This had improved since our last inspection.

• The service had sufficient nurses to ensure patients received safe care and treatment. The unit followed the Guidelines for Provision of Intensive Care Services (GPICS) for registered nurse to patient ratios in level two units.

• The service monitored the effectiveness of care and treatment and used the findings to improve them. The trust regularly participated in national clinical audits and managers demonstrated a good awareness and understanding of the patient outcomes of the unit.

• Mortality rates in the unit were within the expected range and unplanned readmission rates to the unit within 48 hours of discharge to a ward were better than the national average.

• Staff took the time to interact with people in a respectful and considerate way and were supportive to patients. During ward rounds and other interactions, staff answered patient concerns, explained symptoms and reassured patients.

• The service took account of the individual needs and choices of patients. Staff discussed patient needs and made reasonable adjustments to support patient requests where possible.

• Staff described service leaders as visible and approachable. Since the last inspection, the leadership had worked to improve links between the two sites, including joint working and staff rotation.

• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• There was a clear drive from the clinical leadership to improve consistency and collaboration across the two sites; and learning and development between sites had improved since our last inspection.

However:

• The service did not have suitable premises and the design of facilities did not meet the needs of patients. At the last inspection, there were several concerns about the facilities not being suitable for the patients including the unit not having any isolation rooms for patients and excessive temperatures during summer months. During our inspection, we saw these concerns remained, although they were identified on the service's risk register.

• Some printed guidelines and policies we saw had passed their review date, or did not have a review date, which meant staff were at risk of not following the most up to date guidance.

• The service did not always maintain effective patient flow through the department. Delayed discharges remained consistently worse than the national average in the Intensive Care National Audit Research Centre (ICNARC) audit and this was graded as an extreme risk on the service’s risk register.

• The trust did not have a clear vision or strategy for the unit. While the service had defined plans to improve consistency of working between the two sites and had achieved some of these goals, the service lacked a defined longer-term strategy.

• The service had limited engagement with patients, staff, the public and local organisations to plan and manage appropriate services. Responses to the Friends and Family Test (FFT) were limited and there was limited active engagement of patients and relatives to provide feedback.

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.

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. Trust board received EOLC report 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, end of life care (EOLC), and support for patients and families, advised them on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

Most of the nursing 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.

Nursing staff knew how to make referrals to the SPCT and referred people appropriately. The SPCT assessed patients promptly to meet their care needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Referrals for patients who required support during end of life care were made electronically to the specialist palliative care team from clinicians throughout the trust. The specialist palliative care team had daily morning briefings to update on changes in patients’ condition, assess new referrals and allocate work for the day.

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

We rated this service outstanding as there was an open and transparent safety culture in practice and patient outcomes were amongst the best in the country. When things went wrong, there was thorough analysis and investigation owned by staff and changes weremade in a timely way. The approach to staffing and skill mix across all staff groups meant that highly skilled staff always cared for patients.

Patient outcomes and patient satisfaction consistently exceeded national averages. Innovative practice in recording outcomes was the basis for national guidelines. The lead surgeon used patient outcomes to validate and proactively change each consultant’s performance. The service was proactively met the needs of the population it served, coordinating with referring hospitals, external and community providers to ensure the surgical pathway was appropriate.

Staff understood the ethos of the service values, and unequivocal in praising the support received from leadership team and there were measurably high levels of staff satisfaction. Patients who used the service were actively involved in the way the service operated.

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.

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 quality improvement in place following the restructure of pathology services. The focus on low radiation doses in radiology was excellent.

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 contract for MRI services. National waiting times were met for outpatient appointments and access to diagnostic imaging although the wait for MRI services had increased. 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. The outpatients department at Epsom hospital had good information display boards available for staff and patients to access.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally. The service had no open complaints at the time of the inspection.

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.