Epsom General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also ensured that women’s liberty was protected when it was in their best interests and in line with legislation.

At our last assessment, we rated this key question as requires improvement. The service was in breach of safe care and treatment, premises and equipment, good governance and staffing. As a result, the rating for this area improved to good, this is because the service has now improved its record keeping, mandatory training and risk assessment figures. The service was also undergoing improvements to the environment. However, the service remains in breach of safe care and treatment and staffing in relation to all staff receiving appropriate triage training and staffing.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report, how to report them and felt encouraged to do so. Staff understood the duty of candour and could give examples of times they had been open and transparent with women and their families when things went wrong.

Staff reported they received individual feedback following incidents and that learning was shared with the wider team via safety huddles and weekly newsletters. We also observed incidents being discussed at unit staff meetings and during handover on the maternity ward.

The service had a maternity specific governance team that initially reviewed all incidents submitted. This involved confirming the level of harm caused, to determine whether further investigation was required. Incidents that were identified as low harm were assigned to the relevant manager for local review. Incidents graded moderate and above or low harm with potential for significant learning were presented at the weekly maternity review panel. This panel would then determine the appropriate learning response, which included either an after-action review (AAR), multidisciplinary team review (MDT), patient safety incident investigation (PSII) or an immediate action debrief huddle.

We reviewed meeting minutes from the weekly maternity incident review panel and found they were well attended, comprehensive and identified areas of learning and action.

The service did not have set targets for incident closures; however, they aimed to complete all PSII’s within 6 months and monitored all incidents that were over 30 days old. As of 19 December 2025, the service had 1 AAR in progress that was over 30 days old and 1 PSII open over 6 months. However, both incidents were at draft stage and were awaiting final approval.

The service made changes in response to safety alerts, incidents and feedback. We observed the service working closely with the pharmacy team to reduce the impact of the national shortage of epidurals in labour and ensure that the service continued to provide pain relief for women.

The service learned from complaints. In response to complaints regarding delays in discharge due to medication not being processed by the pharmacy, the service was currently trialling the storage of additional medication on the maternity ward to avoid delays in discharge. The service also responded to women’s complaints of delays in the antenatal clinic. They did this by increasing appointment times from 15 minutes to 30 minutes; this change resolved the issue of increased waiting times and delays.

The service also made changes to practice in response to incidents and disseminated learning from incidents to staff, via seasonal maternity patient safety newsletters, which was an improvement from the last inspection. An example of this was the introduction of a new sepsis calculator to reduce the number of babies being screened and treated with intravenous (IV) antibiotics. The introduction of the calculator showed a 42% reduction in screening and treatment of newborns.

There were still improvements required to ensure women had timely access to advice via the telephone triage line. However, the service worked to establish and maintain safe and continuous systems of care.

Women were able to access the unit as needed. The maternity unit had been closed 0 times in the last 12 months. However, management of the telephone triage line was not always in line with national guidance and women were not always able to access the line in a timely manner. The service had a telephone triage line and a face-to-face triage, which most women were initially assessed through before admission. The purpose of the telephone triage line was to reduce the number of unnecessary attendances to the unit and provide immediate advice to women. The telephone triage line service was staffed remotely and covered all NHS trusts within Surrey Heartlands, which included Epsom General Hospital. Calls were triaged by a dedicated core team in a private area away from the clinical area in line with the Royal College of Obstetricians and Gynaecologists (RCOG): Maternity Triage, Good Practice Paper.

At the last inspection, there were concerns that the triage line was often closed due to sickness and absence, resulting in the triage line being diverted locally and abandoned calls. Data showed that between August and October 2025, the telephone line was open on average 90% of the time, which was an improvement from the previous assessment.

However, staff reported that if the triage line was closed then the calls were diverted to a dedicated triage phone line within labour ward. This was not in line with RCOG guidance that says calls should be taken outside of the clinical area. Data showed that only core triage midwives had received additional training about triage and prioritisation of women. This was a concern as staff reported that calls could be triaged by any midwife. This meant we could not be assured that all midwives were equipped to triage calls appropriately. This was also raised as a concern at the previous inspection. Leadership reported that they were assured that the triage line was being managed appropriately. This was because there were low diversion rates to the unit and midwives had a proforma on the electronic patient record (EPR) system that prompted them to ask all appropriate questions. Proforma’s we reviewed on EPR were completed appropriately.

The service also monitored call abandonment rates; the number of calls abandoned was 17% in August, 19% in September and 18% in October 2025. This meant that not all women were able to access advice in a timely manner. The service did not specify whether abandoned calls would be returned by a midwife or if there was an action plan to address this.

During the assessment, the face-to-face triage area was fully staffed and staff had access to the on- call labour ward doctors for reviews and a dedicated consultant since September 2025. The service used a formalised triage tool to assess women on arrival. The triage tool was used to assess how quickly women presenting with pregnancy-related concerns should be seen, based on their clinical need. Staff used a red, amber, green (RAG) rating system to prioritise care. According to the local policy, women should be seen by a midwife within 15 minutes of arrival, and a RAG rating should be allocated based on their presentation. Each colour identified how soon women should be reviewed by a doctor or midwife as required. A red rating required immediate transfer to the labour ward, amber required a review within 15 minutes, yellow within 1 hour and green within 4 hours. The service had 100% compliance for the 15-minute initial review between August and October 2025. The service monitored overall doctor waiting times for women RAG rated yellow or amber, which meant we are unable to identify individual compliance of each rating. However, data showed compliance of women being reviewed within 60 minutes of the initial review was 81% in August, 79% in September and 92% in October 2025. This was an improvement from the last inspection.

The service had a clear referral process to access maternity care at the beginning of pregnancy. Women could self-refer to the service when they became pregnant or be referred by a clinician. The service aimed to book pregnant women in by 9 weeks and 6 days gestation, in line with national institute for health and care excellence (NICE) guidelines which was monitored by the service. Most women were booked by 9 weeks and 6 days, data showed compliance was 84% in August, 86% in September and 85% in October 2025. The service did not identify a target for compliance.

Women’s notes were available via the service’s EPR system. During the assessment we found that notes were secure and detailed. However, we noted that staff did not always document the triage RAG rating on EPR, which could affect audit data. We raised this with leadership within the service, and they reported triage admission data and RAG ratings were also collated by midwives on an electronic logbook, which we observed. This provided an extra level of documentation to gather audit data.

Handovers and safety huddles across the unit involved all relevant members of the multidisciplinary team. Shift changes and handovers included all necessary key information to keep women and babies safe.

Staff did not always complete safeguarding training however; the service worked well with women and healthcare partners to ensure women and babies were safe.

The service provided adult and children safeguarding training that was comprehensive and included topics such as female genital mutilation (FGM), perinatal mental health, substance abuse and domestic violence. However, not all staff had completed it. The overall compliance rate for trust wide midwifery and medical staff was 82% which was an improvement from the last inspection but did not meet the trust target of 90%. We discussed this with the lead safeguarding midwife who reported that an action plan was being developed to improve compliance.

The trust had a named safeguarding midwife, and 5 specialist safeguarding midwives' cross site that covered perinatal mental health, substance abuse and teenage pregnancy. Staff we spoke with were aware of the safeguarding team and how to contact them. The safeguarding team identified domestic violence, substance misuse and perinatal mental health as the top safeguarding risks. The service worked in collaboration with partners such as independent domestic violence advisors (IDVA) and a nearby NHS mental health trust to protect women and babies.

The service had a maternity safeguarding and child protection guideline that was comprehensive and in date. Staff knew how to make safeguarding referrals and liaised with other agencies to protect vulnerable adults and children.

The service had an infant and child abduction policy and a guideline for newborn security. The last baby abduction drill took place in January 2025 whereby the abduction attempt from the maternity ward was successful. Positive points and learning were identified and disseminated to staff and an action plan was developed in response.

Safeguarding concerns were appropriately discussed during handovers, ensuring staff were aware of any potential risks and the actions required to mitigate them. Safeguarding information was accessible to all appropriate staff via an electronic patient record (EPR) system to aid confidentiality. However, during the assessment we observed that the labour ward handover was completed at the midwife station. This raised concerns around confidentiality as this was a public area that patients had access to . This was escalated to the service, and they explained that this was due to estate limitations. The mitigations to support confidentiality was to ensure all labour ward and clinical rooms were closed and pausing the handover if a birthing partner leaves the room, which we observed whilst onsite. There were also concerns about patient identifiable information being visible on a whiteboard near the midwives’ station, this was also escalated, and the service immediately removed all identifiable information with further plans to increase confidentiality of this board.

The service worked with people to understand and manage risks.

Staff maintained detailed records of women and birthing people’s care and treatment via the service’s electronic patient record system. Records were stored securely and available to all staff providing care. This was an improvement from the previous inspection.

Staff assessed whether each woman and birthing person was high or low risk at booking, in the notes we reviewed onsite. This was done to ensure women received the appropriate care. Audit data showed 100% compliance between the months of July and September 2025. The management plan was also updated at each appointment in the notes we reviewed onsite. Audit data showed 83% compliance between the months of July and September 2025. A target was not identified for these assessments.

Staff used a nationally recognised tool to identify women at risk of deterioration; the service used a modified early warning score (MEOWS) chart to document women’s observations. MEOWS charts we reviewed during the assessment were completed, scored and escalated appropriately if required. Audit data provided by the trust showed over 90% compliance between the months of May and October 2025. This was an improvement from the last inspection.

When babies were born, staff completed newborn risk assessments using recognised tools which they reviewed regularly. Staff then completed newborn observations and documented them on EPR. Newborn observation charts we reviewed were completed, scored, and escalated appropriately when required. The service did not provide audit data for newborn observations, which meant we were unsure how the service monitors compliance of this risk assessment or if this audit was being completed.

Staff in maternity theatres used the World Health Organisation (WHO) surgical safety checklist. Audit data showed an average of 99% compliance between June and November 2025. Staff also completed venous thromboembolism (VTE) risk assessments in the notes we reviewed onsite. Audit data showed 100% compliance between the months of July and September 2025.

During labour, high-risk women were monitored using a cardiotocograph (CTG), a device used to monitor fetal heart rate and uterine contractions. According to NICE guidelines, CTG traces during a woman’s labour, should be reviewed hourly by two clinicians (a process known as a ‘fresh eyes’ review), this is to ensure the baby is safe to continue with labour. Staff completed hourly fresh eyes in the notes we reviewed onsite. The service carried out 6 monthly audits of fetal monitoring and data showed an average of 82% compliance with fresh eye reviews between January and March 2025. This exceeded the local maternity and neonatal system (LMNS) target of 80%.

The service made the decision to temporarily turn off the CTG central monitoring, due to the system being intermittently faulty in some labour rooms. This had been identified on the risk register since November 2025. CTG central monitoring is a system that allows all CTG traces to be viewed remotely, which increases oversight. The service believed the mitigations of enhanced oversight by labour ward coordinators, hourly fresh eyes and support from the fetal monitoring midwife was sufficient. At the time of the assessment the fault had been reported both to the manufacturer and the service’s IT team.

At the previous inspection there were concerns that the situation, background, assessment, recommendation (SBAR) handover format was not always used, with audit data showing only 50% compliance. Recent audit data showed SBAR compliance was 86% in August, 70% in September and 90% in October 2025, which was an improvement.

Staff communicated with women in a way that helped them understand their care and treatment. We observed a multilingual poster around the unit encouraging women to contact the patient advice and liaison service (PALS) if they required information in their own language. We also observed posters around the unit encouraging women and their families to give feedback on their care.

Staff gave women and those close to them help, emotional support and advice when they needed it. Staff also made sure women living with mental health conditions and learning disabilities received the care needed to meet all their needs. The service had 24-hour access to mental health liaison and specialist mental health support.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The maternity services at the hospital consisted of an antenatal clinic, maternity assessment unit (MATAU), triage, birth centre, labour ward and maternity ward. The unit was open 24-hours a day, 7 days a week and was fully secure with an entry and exit system monitored by ward clerks and maternity staff.

The maternity unit was undergoing estate works to address issues that had been identified at the previous inspection, after receiving investment from the trust. The service now had a second obstetric theatre and recovery room within the labour ward, which was an improvement from the last inspection.

At the previous inspection, it was also identified that the bereavement room in the labour ward was not in line with national guidance. This was due to the location of the room, the absence of a separate entrance and the room not being soundproof. The room was now soundproof, and the service had commenced work to create a new bereavement space that was private, soundproof and had a separate entrance. This work was due to be completed in January 2026.

It was identified at the previous inspection that the environment of triage did not promote women’s privacy and dignity. In response to this the location of triage was also due to be moved to another area within the labour ward. The planned changes would accommodate a waiting area and increase triage space. This work was due to be completed in March 2026, however, staff reported that the current triage footprint was sufficient and they had access to labour ward rooms if confidential or sensitive discussions were required.

The service also planned to move the MATAU into the maternity block, closer to labour ward and expand antenatal clinic in response to estates issues they had identified. This work was due to be completed by March 2026.

The service carried out ligature risk assessments of the environment in line with NHS England National Patient Safety Alert/2020/001/NHSPS. We did not observe any ligature risks onsite and staff were aware of the location of ligature cutters.

The service had enough suitable equipment to safely care for women and babies. This included cardiotocographs (CTG), sonicaids, and observation machines. Equipment had been serviced when it should have been, this was an improvement from the last inspection.

Staff had access to adequate emergency and safety equipment and carried out daily checks on them. Emergency equipment included neonatal resuscitaires, neonatal emergency trolleys, adult resuscitation trolleys, post-partum haemorrhage and sepsis boxes. The majority of the equipment checks were completed daily by staff. These findings were corroborated with the services audit findings between August and October 2025 which all exceeded 96% compliance.

Women could reach call bells, and we observed staff responding quickly when they were called. Staff disposed of clinical waste safely; we observed sharps bins being filled within a safe limit and clinical and domestic waste being segregated and labelled correctly.

The service did not always ensure there were enough qualified, skilled and experienced midwifery staff, who worked together well to provide safe care that met people’s individual needs.

The service had high numbers of maternity ‘red flag’ staffing incidents, with no immediate actions in response to this. A midwifery ‘red flag’ event is a warning sign that there may be a concern with midwifery staffing levels. The service reported 91 red flag events between 1 June and 2 December 2025 which was an increase from the previous inspection. There were 28 delays between admission for induction of labour (IOL) and beginning the process. IOL audit data between September and November 2025 showed that 34% of women from the audit sample experienced delays starting the IOL process, and 13% experienced delays moving to the labour ward to continue the IOL. In response to these findings the service planned to commence an IOL quality improvement project in January 2026.

There were also 48 red flags where the labour ward coordinator was unable to maintain supernumerary status. This meant that the coordinator could not always maintain oversight of the activity within the unit. The service had an escalation policy in place that encouraged the labour ward coordinator to contact the manager on call to support them remaining supernumerary. However, the red flag data showed that this was not being followed. Staff we spoke with reported that there had been an increase in acuity which negatively impacted on staffing capacity and sickness.

The service did not report any immediate actions in response to the red flag data. However, they reported that the most recent midwifery workforce exercise took place in July 2022, which did not consider the current acuity and growing complexity of the local population. In response the service had commissioned an updated midwifery workforce exercise in September 2025 which would potentially resolve staffing issues.

However, during the assessment the numbers of midwives, maternity support workers, and medical staff matched the planned staffing levels in all areas. The service had a good skill mix of medical staff on each shift and reviewed this regularly. The service reported that an obstetric and anaesthetic consultant were on call during evenings and weekends.

The overall shift fill rate for midwifery staff was 98% in June 2025, 99% in July and 99% in August 2025. The overall shift fill rate for medical staff was 100% between June and August 2025. These figures exceeded the trust target of 94%. The vacancy rate for all staff was consistently below the trust target of 10% between June and October 2025. However, the overall sickness rate for all staff was consistently above the trust target of 3.8% between June and October 2025. The service reported that they used regular bank and agency midwives who were familiar with the service and made sure all bank, agency, and locum staff received a full induction to the service.

The service used the operational pressures escalation level (OPEL) framework to measure operational pressures. They also used the Birthrate Plus acuity tool to calculate the number of midwives needed on the maternity unit. The Midwife in charge carried out the calculation every 4 hours and redeployed staff locally or escalated staffing concerns as per the escalation policy where necessary.

The service held a daily safety huddle, with the option to organise additional huddles if acuity was high. The safety huddle was multidisciplinary and was coordinated by the labour ward coordinator. The safety huddle covered topics such as staffing, acuity levels and safeguarding concerns where applicable.

The practice development team provided and monitored mandatory training for midwifery and medical staff. Overall compliance for statutory mandatory training was 85% for all staff, which met the trust target of 85%. However, there was low compliance in individual training.

Compliance for adults’ resuscitation level 1-3, which was part of the statutory mandatory training was only 72%. However, the service provided practical obstetric multi-professional training (PROMPT) which involved a session on maternal collapse, escalation and resuscitation.

The overall compliance for the maternity specific training for midwives and maternity support workers was 94% excluding newly introduced training, and 94% for medical staff. Both of which exceeded the service target of 90%.

It was identified at the last inspection that staff supporting women or birthing people following a caesarean section had not been trained to the same standard as for all recovery practitioners working in other areas of general surgical work. The service now had fully trained recovery nurses with high dependency unit experience working within maternity. The service also now had separate scrub nurses to cover caesarean sections which was also an improvement from the last inspection.

At the last inspection it was identified that staff responsible for supporting babies requiring transitional care (TC) had not had additional neonatal training and there was not a designated neonatal nursing lead (Band 7) for neonatal transitional care, as recommended by the British Association of Perinatal Medicine. Leadership reported that they had received investment in the transitional care model and now had a band 7 TC lead nurse in post, with work ongoing to recruit transitional care support workers. In the interim they reported that staff nurses from the special care baby unit would support the midwives on the ward.

Managers supported staff to develop through yearly, constructive appraisals of their work. Appraisal data showed 98% compliance for midwifery staff and 95% compliance for medical staff against a trust target of 90%.

The service assessed and managed the risk of infection.

Clinical areas were visibly clean and had suitable furnishings which were clean and well-maintained. Daily cleaning was performed by domestic staff and maternity support workers. The service performed well for cleanliness; cleaning audit data across the labour and maternity wards showed compliance of 99% in September, 99% in October and 100% in November 2025. Staff cleaned equipment after patient contact and labelled equipment with green ‘I am clean’ stickers to show when it was last cleaned. The service met the control of substances hazardous to health (COSHH) standards.

Staff had clear roles and responsibilities around infection prevention and control. We observed staff following infection control principles, including the use of personal protective equipment (PPE) and hand hygiene. Hand washing stations and alcohol rub was available throughout the service. Hand hygiene audit data showed 100% compliance from September to November 2025.

The service completed a bi-monthly infection prevention and control audit in all inpatient areas. This audit focused on monitoring healthcare associated infections and invasive devices such as methicillin-resistant staphylococcus aureus (MRSA), Clostridioides difficile (C. Diff), peripheral cannulas and urinary catheters. Audit data showed 0 healthcare associated infections and good compliance with the use of invasive devices between July and September 2025.

The service made sure that medicines and treatments were stored securely and managed appropriately.

Staff mostly followed systems and processes for the safe prescribing and administration of medicines. Prescriptions were managed through an electronic prescribing and medicines administration (EPMA) system. We reviewed 10 records, and they showed allergies and weights were always documented to ensure medicines were prescribed safely and, medicine charts were fully completed by staff when administering medicines. However, on 1 EPR, medication had been omitted with no documented explanation.

At the previous inspection the EPMA system had failed, and staff could not clearly describe how to use the alternative prescribing method which was paper prescription charts. At this assessment staff were able to explain the business continuity plan for when the EPMA system failed.

Medication was stored securely in locked clinical rooms. Staff regularly monitored ambient, fridge and freezer temperatures where medicines were stored, and staff we spoke with demonstrated awareness of escalation procedures when temperatures fell outside safe ranges.

Controlled drugs (medicines requiring additional security measures due to their potential for misuse and diversion) were stored securely and checked daily to ensure their balances were correct.

All staff received medicines management training however, only midwives and maternity support workers received this as a standalone training. Overall training compliance among midwives and maternity support workers was 95%, exceeding the trust target of 90%.