Epsom General Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver safe, integrated, person-centred, and sustainable care, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. The service was in breach of good governance because it did not always operate effective systems and processes to maintain clear oversight of maternity services and mitigate risks to women and babies. Since then, the service had made improvements and is no longer in breach of this regulation. This was because the service now had improved governance processes, leaders were aware of key risks within the service and took appropriate actions to manage and mitigate them. As a result, the rating for this area improved to good.

We have not awarded this service a score for Well-led.

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

The service had a shared vision and strategy and was continuously working to improve the culture.

Maternity services followed the trust vision and strategy. The trust vision for 2023-2028 was “to provide outstanding care, together”. The strategy to accomplish the vision was set out by the CARE objective:

• Collaboration and partnership
• Affordable services, fit for the future
• Right care, right place, right time
• Empowered, engaged staff

The service was working to produce a St George’s, Epsom and St Helier University Hospitals and Health Group wide maternity and neonatal strategy. The plan was to develop this strategy with staff, women and external stakeholders, with a completion date of November 2026.

Staff we met were welcoming, friendly, and helpful. We observed staff working together as a team to provide high quality care and to positively impact women’s experience. Most of the staff we spoke with were positive about the service. The service had many cultural initiatives such as members of staff being members of anti-racism advisory groups, cultural awareness sessions for staff and staff forums.

The service carried out a trust wide staff survey to understand the culture within the trust. Findings showed that only 38% of staff felt teams dealt with disagreements constructively, 17% of staff never or rarely felt frustrated at work and only 43% of staff felt their working relationships were unstrained. The service developed an action plan in response to the findings and recommendations. This highlighted that there was still room for improvement in the service's culture.

Leaders had the skills, knowledge and experience to lead effectively.

Maternity services provided by Epsom and St Helier University Hospitals were delivered across their Epsom General Hospital and St Helier Hospital sites. Maternity services were part of the women’s and children's division, and the trust had a defined leadership structure cross-site. The cross-site quadrumvirate consisted of the director of midwifery, the divisional medical director and the associate director of neonates and paediatrics, who were also the maternity safety champions for the trust and the division, and the divisional director of operations. The service also had 3 maternity board safety champions, and we observed posters identifying who they were across the unit.

Leaders had the skills, knowledge and experience to perform their roles and demonstrated a good understanding of the services they managed. They had oversight and were aware of the risks within the service and could describe the mitigations and action plans in place. This was an improvement since the last inspection. The quadrumvirate had regular meetings to discuss changes, risks and updates within the service. Leaders reported having enhanced access to the board and described a recent financial investment, that had supported improvements in maternity services since the previous inspection.

Staff told us leaders were visible in the service and approachable. There were clear lines of reporting from the site leadership team through to the quadrumvirate and the board. However, some staff reported that middle management were not always available to support clinically during times of high acuity, which negatively impacted morale.

Leaders understood the needs of the local population, including how health inequalities affected treatment and outcomes for women, babies and families from ethnic minorities and disadvantaged groups. The service had a service improvement and transformation lead midwife, who worked closely with women from the local population and stakeholders such as the local maternity and neonatal voices partnership (MNVP). The information gained through various initiatives was then fed back to leaders to improve the service.

The service conducted monthly board safety champion meetings which were attended by board safety champions, trust level leadership and service level leadership. Meeting minutes we reviewed showed meetings were comprehensive and well attended

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff at all levels reported feeling comfortable speaking up. The trust had freedom to speak up (FTSU) guardians who were clearly displayed on posters in the unit. Staff we spoke to were aware of how to access support. Since April 2025 there had been no concerns raised with the freedom to speak up guardians from staff working within Epsom Hospital maternity services. Staff also had access to professional midwifery advocates (PMA). Staff reported the PMA’s were very approachable and useful when they required support.

The service welcomed feedback from women and their families and displayed information about how to raise concerns across the unit. Women and their families could complete the friends and family test (FFT) on the unit. FFT data from September to November 2025 showed 71% of women had a very good experience, 24% experienced good care and 5% reported experiencing neither good nor poor care. The most common themes in the 5% of women who experienced neither good or poor care were; delays in care, lack of communication and limitations in the food menu. However, the service did not highlight any work being done to improve these specific areas.

The service worked collaboratively with the maternity and neonatal voices partnership (MNVP) chair to better understand the needs of the local population and ensure the voices of women were heard. As part of this, the MNVP chairs hosted regular listening groups in the community and used social media platforms to connect with women, understand their needs and involve them in decision making. The feedback collated was then shared with the service to support improvement efforts. The service introduced breastfeeding support workers on the unit and organised breastfeeding cafes in the community. This was in response to women’s feedback about lack of breastfeeding support to the MNVP.

The service also conducted focus groups for women from ethnic minority groups to hear about their experiences of maternity. This focus group was facilitated by the service improvement and transformation lead midwife and the MNVP chair.

The service also monitored themes from negative feedback and complaints. The service received 3 complaints and had 2 reopened cases between September and December 2025, all of which were currently under investigation. There were no clear themes identified.

The service valued diversity in their workforce and were working towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service enrolled in an anti-racism framework programme in December 2024 and established an anti-racism implementation advisory group in March 2025. The group held meetings; however, it was unclear how often these were. The meeting covered multiple agenda items such as staff engagement, staffing issues and information from various global majority forums. Staff and leaders, we observed were broadly representative of the population of people using the service.

The NHS staff survey 2024 included trust specific data on Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES). The data was representative of the trust as a whole and not specific to maternity services. The finding showed 24% of white staff and 22% of staff from other ethnic groups had experienced harassment, bullying or abuse from staff in the last 12 months. Findings also showed that 55% of white staff believed the organisation provided equal opportunities for career progression or promotion, while only 51% of staff from other ethnic groups felt the same.

Findings from the trust workforce disability equality standards question showed, 16% of staff without long-term conditions or illnesses had experienced harassment, bullying or abuse from other colleagues in the last 12 months. Whilst 25% of staff with long-term conditions or illnesses had. Findings also showed that 54% of staff without long-term conditions or illnesses believed the organisation provided equal opportunities for career progression or promotion. Whilst only 48% of staff with long-term conditions or illnesses felt the same. These findings showed a slight improvement from the trusts 2023 NHS staff survey data however, still identified room for improvement.

Staff we spoke with did not report experiencing any harassment, bullying or abuse and leadership development opportunities were available for staff. This included a rolling 6-month labour ward coordinator secondment, that all band 6 midwives could apply for as a development opportunity.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality care, treatment, and support.

Leaders operated effective governance processes, throughout the service and with partner organisations. The trust governance team was made up of a lead midwife for governance, 2 patient safety midwives for each hospital site, an audit and compliance midwife and a patient safety support midwife.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. The trust held monthly perinatal governance meetings, chaired by the divisional medical director and attended by multidisciplinary staff. We reviewed the meeting minutes from October to December 2025 and found the meetings were well attended and comprehensive. Standing agenda items included incidents and learning, quality reports, workforce updates and external audits. Policies and guidelines were discussed at the women’s and children's health quality meetings and monitored by the audit and compliance midwife.

Staff we spoke with were aware of the risks within the service. The service had a risk register that had 18 open risks recorded at the time of the assessment. The register included the risk ID, the date the risk was added, a description, the current risk rating, the allocated owner, the review date and the controls in place. The risk register included the risks we identified during the onsite assessment, which provided assurance that leaders and staff were aware of the risks and had mitigations in place.

Data and notifications were submitted to external organisations. The service submitted all qualifying cases to the maternity and newborn safety investigations (MNSI) programme. All NHS trusts are required to tell the MNSI about specific safety incidents that happen in maternity, which are then investigated and where relevant safety recommendations are made. The trust had referred 1 qualifying case to the MNSI in the last 6 months which was still being investigated.

The service held monthly multidisciplinary perinatal mortality review tool (PMRT) meetings and used the perinatal mortality review tool to review care and deaths that occurred within the service. Collated data was submitted to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) as required. The trust also produced a quarterly board report of PMRT data. The MBRRACE- UK 2023 perinatal mortality report showed that the trust’s perinatal mortality rates were average when compared with similar trusts.

The service collected and analysed reliable data. The trust submitted data to the maternity services data set (MSDS). The MSDS is a national dataset that captures patient-level information from the booking appointment until discharge.

The service had a local maternity performance dashboard, which was developed to monitor performance and strengthen oversight. The performance metrics included but was not limited to the number of bookings, number of births, types of birth, stillbirths and postpartum haemorrhages (PPH). The service generally performed well in offering carbon monoxide testing, still births and breastfeeding initiation rates. Through the dashboard the trust identified that they were currently a national outlier with PPH. In response the trust had implemented new changes in September 2025 to combat this. This included mandatory PPH management training and the introduction of new medication for active management of bleeding during the third stage of labour. Data from the local dashboard showed a decrease from 4% of PPH’s in August 2025, to 2% in September and October 2025.

The service also submitted data to the local maternity and neonatal system (LMNS) dashboard. This dashboard contained performance data from all trusts within the LMNS and was used by managers for internal and external benchmarking and comparison. It included but was not limited to the number of bookings, still birth rates and neonatal deaths. Trust was not an outlier for neonatal death between June and October 2025. The service reported 1 neonatal death in October 2025, which was being evaluated through standard processes.

The trust was compliant with the clinical negligence scheme for trust (CNST): maternity incentive scheme (MIS) year 6, which was an improvement from the last inspection. The MIS is a financial incentive programme designed to enhance maternity safety within NHS trusts. It rewards trusts that can demonstrate they have implemented a set of core safety actions. At the time of the assessment the service had submitted their evidence for year 7 and were awaiting confirmation of compliance.

Managers and staff carried out a programme of repeated local audits to check improvement over time. Local audits included but were not limited to diabetes, induction of labour, carbon monoxide monitoring and antenatal and new born screening pathway health equity. Each audit had an auditor and an audit lead. The audits were sufficient to provide assurance and staff acted on the results when needed, to improve the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The service engaged and collaborated with external stakeholders, such as commissioners, the local maternity and neonatal system (LMNS) and the maternity and neonatal voices partnership (MNVP).

The MNVP chair reported being actively involved in the service and having good working relationships with leaders. The MNVP held bi-monthly meetings with the service, which were attended by members of the midwifery team, service users and the maternity board safety champions. Meeting minutes were comprehensive, and actions were identified in response to the discussions. These meetings were also attended by charities, specialist health care professionals and representatives from health visiting teams.

The service worked with a charity to facilitate free professional hand/foot casting for women who experienced baby loss. The service also worked closely with religious leaders to facilitate the religious and cultural wishes of women and their families.

The service encouraged learning, innovation and participation in research and staff encouraged creative ways of delivering training.

Leaders encouraged learning, innovation and participation in research. The women’s and children's health division held quality meetings to share learning from incidents and inquests, discuss outcomes from audits and guideline updates. These meetings were held every 2 months and were well attended by multidisciplinary staff.

The trust was actively involved in the legacies and futures research study, which aimed to gain a better understanding of resilience and vulnerability in pregnancy.

The practice development team were also dedicated to finding new and innovative ways to provide training and information. This included the creation of training videos and plans for a maternity safety month initiative in January 2026.

The service had also been accredited as a baby friendly initiative (BFI) gold standard trust by UNICEF in September 2018. This initiative supports breastfeeding and parent infant relationships by working with public services to improve standards of care. The service had been revalidated as a gold baby friendly service in 2022 and was revalidated in October 2025. The outcome of this revalidation was unknown at the time of the assessment.

In addition, the trust made efforts to recognise and celebrate staff contributions. The trust held a continuous improvement virtual celebration event in June 2025 to recognise the improvement work being done by staff across the trust.