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We are carrying out a review of quality at Epsom General Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 1st May to 3rd May 2019

During a routine inspection

Our rating of services improved. We rated them as good because:

  • The hospital had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risks well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients and key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Staff planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.


  • There were not proper governance arrangements for the management of medicines.
  • Although services offered mandatory training in key skills to all staff, staff attendance at some mandatory training courses did not meet the trust’s own target.
  • Some members of staff did not always have their performance reviewed or had the opportunity to discuss development needs. Nurse staffing was a challenge on medical care wards and shifts were not always covered by the planned number of staff.

Inspection carried out on 29th and 30th October 2018

During an inspection looking at part of the service

This is a report on a focused inspection we undertook at Epsom General Hospital on 29 and 30 October 2018. The purpose of this inspection was two-fold. Firstly, to follow up on concerns raised by Her Majesty's Coroner, in relation to patients being treated for hyponatraemia (low sodium blood levels), and the internal communication of abnormal pathology results. We also followed up on received concerns about the safety of mental health patients in the emergency department, nurse staffing levels in medical care wards and the safeguarding of patients being discharged from hospital. The concerns raised related to both Epsom General Hospital and St Helier Hospital.

Secondly, we followed up on the outstanding requirements from critical care and services for children and young people at Epsom General Hospital. As we had not inspected these services for more than two years, we inspected and rated them in their entirety.

Our key findings were as follows:

  • Staff in the emergency department (ED) provided care and treatment based on national guidance and evidenced of its effectiveness. We saw recently adapted guidance on quality standards for the treatment of patients with hyponatraemia and these were embedded in practice.

  • Medical staff across the ED, acute medical unit (AMU) and medical wards, received training in the management of patients with hyponatraemia.

  • There was a trust wide standardised approach to the detection of deteriorating patients using the National Early Warning Score (NEWS) scoring system and staff knew what action to take when the score was above 4.

  • Pathology results needed to deliver safe care and treatment were available to staff in a timely and accessible way. There was a trust wide standard operating procedure for communicating abnormal blood results to appropriate staff.

  • Staff received effective training in safety systems, processes and practices. The trust trained staff in the Mental Health Act (MHA) and Safeguarding Adults.

  • The design, maintenance and use of facilities and premises were satisfactory. There was a designated room for interviewing patients with mental health needs in the ED at Epsom General Hospital. The room had an emergency panic alarm strip and two exit points and there were no ligature points.

  • ED staff identified adults at risk of causing harm to themselves. Patients assessed as being at risk of suicide or self-harm, received early referrals to the mental health liaison team. Policies and procedures were in place for extra observation or supervision of patients with acute mental health needs.

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

  • The trust 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.

  • Staff we spoke with described service leaders as visible and approachable. In critical care, the leadership worked to improve links between the two sites, including joint working and staff rotation.

  • Managers of the critical care 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 in critical care and learning and development between sites had improved since our last inspection

  • Safeguarding processes had improved since our last inspection across children and young people services. 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 children and young people, including deteriorating health and wellbeing and medical emergencies. Staff were able to seek support from senior staff in these situations.

However, there were also areas of poor practice where the trust needs to make improvements.

  • The critical care 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 in critical care 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 risk register.

  • The critical care service did not always maintain an 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.

  • In the ED at Epsom General Hospital, people’s individual care records were not always written and managed in line with best practice. This meant timely and available information was not available to the multi-disciplinary (MDT) team.

  • Some medical wards did not use a checklist when discharging patients and this could result in parts of the process being missed.

  • 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.

  • There was not a clear vision or strategy for critical care. While the service had defined plans to improve consistency of working between the two sites and had achieved some of these goals, it lacked a defined longer-term strategy.

  • The critical care 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.

  • In the children and young people service, 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.

  • In the children and young people service, staff did not consistently record the temperature of the fridge in the clinical room in the neonatal unit, which was used to store breast milk. This meant that there was a risk that breast milk could be exposed to abnormal temperatures, which could cause the milk to deteriorate.

  • 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's systems. This meant locum staff could not easily access important information such as handover lists, transfer letters and up to date guidelines.

Importantly, the trust must:

  • Improve the environment and facilities on the critical care unit to reduce the infection control risks to patients.

  • Improve systems and processes in critical care so that patients are not delayed from being discharged.

In addition, the trust should:

  • Consider an outreach service to support patients whilst they are waiting to be admitted to the critical care unit.

  • Consider ways to increase engagement and feedback from patients in critical care and those close to them to improve the quality of the service.

  • Develop an agreed vision and strategy for the critical care service and that staff are involved in the process.

  • Ensure that guidelines and processes have adequate version control and are regularly reviewed, so staff have access to the most up to date guidance.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 9 Jan to 6 Feb 2018

During a routine inspection

Our rating of services stayed the same. We rated them as requires improvement because:

  • Mandatory training and appraisal completion figures were low. Staff did not always have their performance reviewed or have the opportunity to discuss development needs.
  • Staffing levels on wards were lower than the recommended safe staffing guidelines at times. Some staff told us they were tired and felt overstretched due to staff shortages and this was starting to affect their morale.
  • Governance and risk management processes were not as strong or effective across all areas we inspected. Incidents were not always reported, which limited the opportunities to review and learn from them. Staff did not always receive feedback on low level incidents.
  • In the emergency department, some key safety targets were not being met and patient outcome measures were not always subject to scrutiny and action. Safety checking procedures were not always carried out routinely.
  • There remained problems with old equipment and the replacement programme was running at a slow pace.
  • In surgery, the service provided to operating theatres for provision and processing of surgical instruments was less than satisfactory. Little had been done to resolve this matter.
  • In maternity, the trust continued to focus more on trust wide outcomes rather than outcomes by unit, which obscured differences between the two units. The overall vision for the unit was not well defined. There was a lack of clarity on whether the maternity service was one service at two locations or two separate units.


  • Clinical staff ensured that patient treatment and care was delivered with kindness and compassion. Patients felt well cared for and were treated with dignity and respect by staff.
  • Staff used professional guidance and best practices, including risk assessment tools and consent procedures to support the provision of safe and responsive care.
  • There was a positive culture of team work, multidisciplinary working, and a strong sense of commitment to doing what was right for patients.
  • Seven day on site cover was provided by consultants, the pharmacy and physiotherapy teams and was well established.
  • The trust planned and provided services in a way that met the needs of local people.

Inspection carried out on Announced visit 10 and 13 November 2015. We also undertook unannounced visits to the hospital on 21, 23 and 27 November 2015.

During a routine inspection

Epsom General Hospital is part of Epsom and St Helier University Hospitals NHS Trust. The trust provides local acute services for people living in the southwest London and northeast Surrey. Epsom General Hospital provides acute hospital services to population of around 180,000.

Epsom General Hospital is home to the South West Elective Orthopaedic Centre (SWLEOC), which is one of the largest hip and knee joint replacement centers in the UK. Most of the trust’s elective surgery is undertaken at Epsom General Hospital and the majority of emergency surgery is carried at the trust’s other location, St Helier Hospital and Queen Mary's Hospital for Children.

Epsom and St Helier University Hospitals NHS Trust employs around 5024.8 whole time equivalent (WTE) members of staff with approximately 705 staff working at Epsom General Hospital. We carried out an announced inspection of Epsom General Hospital between 10 and 13 November 2015.

We also undertook unannounced visits to the hospital on 21, 23, 25 and 27 November 2015. Overall, this hospital is rated as requires improvement. We found urgent and emergency care, surgery, critical care, maternity and gynaecology, services for children and young people required improvement. We found medical care, outpatients and diagnostic services and end of life care were good. We have rated the South a West London Elective Orthopaedic Centre as outstanding.

We found the care of patients was good, but the safety, effectiveness, responsiveness and leadership and management required improvement.

Our key findings were as follows:


  • Systems and processes were in place for reporting and investigating incidents but learning from incidents and complaints was inconsistent.
  • Low nurse staffing levels on some surgical and children wards meant there was a risk to the quality of patient care. There was also a large number of vacant medical staff posts and high use of locum doctors in paediatrics. However, the hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies.
  • Cardiac monitors used in the majors area in ED were not fit for use and this had been an ongoing risk for over a year, without an adequate solution. Major incident equipment we observed was out of date and not ready for use in the event of a major incident.
  • Mandatory training completion rates were low.

  • The hospital was visibly clean. However data supplied by the trust indicated that wards repeatedly fell short of the infection prevention control compliance threshold. Staff reviewing patients on the unit did not always comply with infection control practices such as being bare below the elbow and hand washing.

  • Appropriate procedures and staffing were in place to prevent harm.

  • We identified gaps in record keeping and safe storage of medicines management in some areas.


  • Patient outcomes were good across most specialties and the trust performed well in national surgical audits. In the SWLEOC, patient outcomes and patient satisfaction consistently exceeded national averages.
  • We found staff appraisal completion rates were low.
  • There was a lack of clarity amongst some staff with regard to how the Deprivation of Liberty Safeguards should be used
  • There was a lack of agreed guidelines specific to the critical care unit and no system to ensure consistency of care, even though three different consultants cared for patients in one day. The unit had a larger number of delayed discharges compared to similar units.
  • There was good multidisciplinary teamwork and collaborative care.


  • Patients and their relatives commented positively about the care they received and the attitude of the staff. Staff provided care in a compassionate and kind way that preserved patients’ dignity. Patients felt supported and involved in their care and treatment.
  • Whilst Family and Friend Test feedback was positive, the response rate was notably low.
  • Patients were kept informed of their treatment, given detailed information about their diagnosis, and given time to ask further questions.


  • At Epsom ED for the 12 months between November 2014 and October 2015, 94% of patients were seen, admitted, transferred or discharged within four hours.
  • In all but neurology and dermatology, the medical directorate achieved the 18 week referral to treatment standard. The average length of stay at Epsom was slightly longer for non-elective care than the England average.
  • The medical directorate was slow to respond to complaints, achieving an 8% response rate within designated timescales.
  • Not all women received one to one care in labour.
  • 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.


  • Vision and strategy within departments were not well developed or known by all staff.
  • There were good local governance structures and reporting mechanisms in place, however we found a lack of responsiveness to some known challenges and concerns.
  • In critical care, the strategy for the unit had not been agreed due to difficulties in reaching an agreement among the critical care workforce across the two sites and staff were not aware of the vision for the unit. Not all risk had been identified on the risk register and some risk had been on the register for some time and senior staff were still unclear on the timescale to address these risks.
  • The trust monitored maternity services based on merged data from both maternity units. This was misleading because the units were very different, with different staff and serving different populations.
  • The hospital had a number of innovative projects underway, including some related to patients living with dementia. We saw several areas of outstanding practice including:
  • The leadership of the outpatients and diagnostic imaging teams was outstanding with staff inspired to provide an excellent service, with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences. However, there were also areas of poor practice where the trust needs to make improvements.

We saw several areas of outstanding practice, including:

  • The leadership of the outpatients and diagnostic imaging teams was outstanding with staff inspired to provide an excellent service, with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.
  • The safety and leadership of the SWLEOC, where outcomes for patients were consistently excellent and based on national guidelines.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure there are adequate numbers of nurses and midwives to deliver safe and quality care.
  • Implement agreed guidelines specific to the critical care units.
  • Ensure the management, governance and culture in the critical care units, supports the delivery of high quality care.
  • Obtain feedback from patients/relatives in the critical care units, so as to improve the quality of the service.
  • Identify, analyse and manage all risks of harm to women in maternity services
  • Ensure identified risks in maternity services are always reflected on the risk register and timely action is taken to manage these risks.

  • Improve the quality and accuracy of performance data and increase its use in identifying poor performance and areas for improvement.

In addition the trust should:

  • Ensure cardiac monitors used in the majors area in ED and major incident equipment are fit and ready for use in the event of a major incident.
  • Ensure the target for 85% compliance for mandatory training is met.
  • Ensure staff always comply with infection control practices.
  • Ensure child protection notifications from the trust are up to date.
  • Ensure staff appraisals are completed as required.
  • Ensure all relevant staff are clear about how the Deprivation of Liberty Safeguards should be used.
  • Ensure there are agreed guidelines specific to the critical care unit and that there are systems to ensure consistency of care.
  • Improve the response times to complaints in the medical directorate.
  • Ensure all women receive one to one care in labour.
  • Improve the 31 day cancer waiting times for people waiting from diagnosis to first definitive treatment and the 62 day waiting time for people waiting from urgent GP referral to first definitive treatment.
  • In critical care, ensure there is an agreed strategy for the unit that includes the critical care workforce across the two sites and that all risks are identified and on the risk register.
  • In maternity, ensure monitoring data is separated by location.
  • Improve and strengthen governance within the ED.
  • Develop the leadership skills of labour ward coordinators to prepare them for this role and hold them accountable for their performance.
  • Monitor action plans to ensure timely response to risk actions.
  • Ensure the consultant hours in the emergency department meet the RCEM recommendation of 16 hours a day, seven days a week of clinical consultant working.
  • Ensure that the paediatric emergency department complies with Royal College of Paediatric and Child Health staffing guidelines.
  • Ensure all staff working with children are adequately trained to an agreed and measureable standard.
  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • Increase the number of sonographers in radiology.
  • Improve compliance with all stages of the World Health Organization (WHO) Surgical Safety Checklist across all surgery services.
  • Ensure local anaesthesia drugs are stored separately from general anaesthesia drugs in all operating theatres.
  • Take further steps to update and improve operating theatre infrastructure and equipment.
  • Improve scheduling of surgical procedures to improve theatre utilisation and efficiency.
  • Ensure all reported risks in surgery services are addressed in a timely way.
  • There is access to seven day week working for radiology services.
  • Staffing is improved in radiology for sonographers.
  • Improve the response rate of patient feedback.
  • Ask patients and relatives for feedback on critical care.

  • There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • There are appropriate processes and monitoring arrangements in place to improve the 32 and 61 day cancer targets in line with national targets.
  • There is improved access for beds to clinical areas in diagnostic imaging.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 6, 7, 20 February 2014

During a themed inspection looking at Dementia Services

We visited the Accident and Emergency department, Alexandra ward and Chuter Ede (Acute Medical Unit) as part of this unannounced inspection of Epsom General Hospital. We spoke with twelve people using the service, eight relatives or friends of people using the service, sixteen staff members and four senior managers during our three visits. Comment cards were received from seven people using the service or their relatives or friends and three staff members following the inspection.

People using the service told us that staff were caring and treated them with dignity and respect saying "The care is very good, no complaints", "I can�t fault anything as staff are good and the food is good" and �The care is wonderful�. One person told us that they hoped the care people got at care homes �Was as good as here�.

Relatives or friends told us �I have watched with amazement the patience and dedication shown by staff on the ward� and "They do get good care here�, �The treatment for people with dementia is probably as good as resources allow� and �Staff are nice�some are better than others yet overall they are caring�.

Both people using the service and their relatives or friends said that staff on the medical wards were always very busy and said they sometimes had trouble finding the right staff member to talk to on the ward about the care and treatment being provided. Some people told us that the days could be �boring� and there was nothing provided to positively engage people living with dementia apart from the bedside televisions provided. We saw that there were opportunities to make the A&E and wards more dementia friendly.

Staff spoken to said that their experience was that people living with dementia were treated with dignity and respect at the hospital. Staff working on Alexandra ward in particular reported on the improvements made within the last year saying �I�ve seen a dramatic improvement�, �The ward has come a long way� and �There is a good team now�. Feedback from staff on both medical wards however was that they would welcome more time to spend with people living with dementia. Comments included �Staff on the ward endeavour to provide high quality care but there is just not enough of them� and �Not enough staff to cope with complex needs�.

The provider should note that shortfalls were identified about how the mental health, emotional and personal history and presentation of people living with dementia was assessed and met. The absence of assessment information was reflected in the quality of the care plans seen for people when these were available. We did not find any specific care plans identifying the person�s emotional and behavioural presentation, their responses to staff interventions or how their care should be delivered.

The enthusiasm and commitment of the lead consultant geriatrician and the lead nurse for care of the elderly was noted during this inspection. Their ongoing work included arranging a dementia open day at the hospital, delivering induction sessions to new staff and developing the dementia pathway for people using the service.

It was noted that the Trust had a dementia action plan for Epsom General Hospital in place and it intended to build on existing good practice to create a more effective service for local people living with dementia. However, we did not find evidence that the action plan was being prioritised at all levels of the Trust.

Inspection carried out on 29, 30 October 2012

During a routine inspection

Patients and visiting relatives told us staff that worked on the wards we visited were kind and caring. One person said �the staff on the ward are brilliant�, and a visiting relative told us �all the staff I have met here are wonderful. I could not fault any of them�. Another person said �Nurses are wonderful, marvellous. They go out of their way to help�. Another person said �The whole staff are really good and really helpful. (They) look after us and really good�. Another person told us �Staff are very pleasant and reassuring and feel I can confide in them�. They also told us about the care they had received and said they were �perfectly happy with it. I have been well looked after�.

Most people told us they felt they had been involved in making decisions about their care and treatment at the hospital. They said doctors explained things clearly to them so that they understood what was happening. Most told us that staff treated them with dignity and respect. One person said �Staff show deference to you when they are going to do something�. Another person said �Staff are really good about maintaining privacy and close bedside curtains when they are giving care�.

Most people told us they would complain to nursing staff and the complaint would be listened to and acted on. However only a few people told us they had seen a complaints procedure or had been advised about how to make a complaint. Most people said they were sure they could find out if they needed to.

During an inspection looking at part of the service

We inspected Epsom Hospital on the 24th of May 2011 and found that improvements were needed. Policies and procedures were in place to help to ensure that children were protected from the risk of abuse. However, there were shortfalls in staff training regarding the protection of adults and therefore the potential for vulnerable adults to be at risk.

We carried out this review, which did not include a site visit or talking to people at Epsom Hospital, to look specifically at all the actions the provider told us they had taken to achieve compliance with the essential standards of quality and safety.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 24 May 2011

During a routine inspection

Generally the people that we spoke with during our visit were very happy with the treatment and care that they received at this hospital. Many of them perceived it as being their local community hospital and told us that they preferred it there rather than other hospitals that they could have gone to. They said it was always very clean and we saw that there were good measures in place with regard to infection control, with hand washing facilities and antibacterial gel available. We noted that it was well signposted and there were several toilets for visitors use.

Most people considered that they were given the opportunity discuss their treatment options with the doctors and that they were kept informed about what was happening, although some highlighted the fact that it was more difficult at the weekends, when there were fewer staff around. They knew what their medication had been prescribed for, they received it on time and they were not ever left in pain.

Feedback that we received about the staff, especially the nurses, was very positive with people telling us how kind they were �even though they are sometimes rushed off their feet� and �they have such a good sense of humour�.

We asked people about the food that was served in the hospital; most of them said it was �good� or �quite good� although there were also some adverse comments. On the wards we visited we saw that the food was hot, looked appetising and portion sizes were appropriate. There were no problems experienced by those people who needed special diets or a vegetarian option.

We have highlighted the need to ensure that those people who are need of assistance, to ensure that their nutritional needs are met, are appropriately supported.

People that we spoke with said that they felt very safe in the hospital and had not witnessed anything of concern. However, we found that some of the staff lacked knowledge around adult protection issues and there appeared to e some shortfalls in training with regard to this. We have asked The Trust to provide us with information about how this will be addressed.

We also raised some concerns about patient confidentiality. Male and female patients were all being nursed in single sex wards or bays and had separate toilet facilities however, in several areas of the hospital; there is limited room available for staff to speak in private with patients and conversations, which may often be difficult, can be overheard.