Epsom General Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service planned and delivered care in line with legislation and evidence‑based practice, and people consistently reported that their needs were met and staff were supportive and attentive.

Staff accurately assessed patients’ needs using appropriate risk tools, monitored skin integrity, participated in ward rounds, and had access to tools such as medical histories to support safe and personalised care.

Teams worked well together across services, with daily consultant‑led ward rounds and well‑attended multidisciplinary team meetings that supported smooth transitions, discharge planning, and continuity of care.

The service monitored outcomes effectively through an audit programme, although staff were still adjusting to the new electronic patient record system introduced in July 2025.

Staff encouraged patients to participate in decision‑making about their care, explained rights around consent clearly, and demonstrated strong understanding of legislation such as the MCA and DoLS.

Records reviewed showed up‑to‑date documentation, clear plans for discharge, good MDT working, and evidence that people’s cultural, nutritional, rehabilitation, and specialist needs were met by accessible therapy and support services.

We have not awarded this service a score for Effective.

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

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service undertook reviews of sepsis risk and national early warning scores (NEWS) using national institute for care and excellence (NICE) guidance . The Sepsis review was based on NICE Sepsis Quality Standard QS161 and presented performance data up to March 2025. Which showed the number of patients with suspected sepsis who were being assessed using a structured set of observations to stratify risk of severe illness or death. The results from March 2024 to March 2025 showed a steady improvement in completion of observations but the service was still not meeting the national target of 90%.

Patients we spoke with told us their care and treatment needs were met, and they spoke at times very highly of the staff. They knew their care plans, saw appropriate medical teams daily and were involved in conversations about their care.

Staff knew and understood how to assess patient needs and used appropriate risk assessments to ensure safe care, including nutrition, hydration and falls risk assessments were regularly assessed in line with guidance. Staff were aware of how to monitor skin for pressure ulcers and use body maps when repositioning recording skin integrity. Staff told us they could access medical staff and that they participated in daily ward rounds, as well as morning handovers.

Staff had access to various tools and information to assess patients’ needs. This included current and past medical history, health, and care passports (such as ‘This is me’ booklets for dementia patients), communication booklets, and communication aids.

The trust used an electronic patient records system which flagged patients with additional needs. This included patients with complex or communication needs. Staff routinely assessed patients’ psychological and social needs and reviewed this in preparation for discharge.

Specialist support from allied health professionals such as dieticians, occupational therapy and therapies were available for patients who needed it.

Staff adjusted patients’ meals to allow for religious, cultural, and personal preferences. Staff on the wards made sure patients had enough to eat and drink, including those with specialist nutrition and hydration needs.

We saw that care episodes were documented and kept up to date. Records reflected individual care needs and end goals of care were documented highlighting progress towards discharge to an appropriate environment. We saw a good standard of multidisciplinary team (MDT) working which was also documented in patients’ records.

Patients had the equipment they needed to mobilise readily available and to hand.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Patients gave positive feedback about all staff working together, with one patient’s relative telling us they were happy that their family member had been cared for so well.

Staff described good working relationships with colleagues in the division with medical staff being accessible but at times there was a delay in responding, which sometimes resulted in patients waiting a long time for further medical input. Patients were assessed on admission to the ward and reviewed regularly.

Consultant-led ward rounds took place daily and all staff were a part of this. Multidisciplinary meetings were well attended and were thorough with a review of each patient with input from social care and the local authority on a regular basis which aided discharge planning. Staff were positive about these meetings.

Plans for transition, referral and discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. When people were due to move between services, all necessary staff, teams and services were involved in assessing their needs to maintain continuity of care. The service could access virtual wards, physiotherapy, Speech and Language Therapy (SaLT) teams, and specialist care teams to support patients.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The trust had implemented a new electronic patient record system in May 2025, that enabled all staff members to contribute to care planning, treatment and diagnostics. However, the ward staff told us they were still getting used to the system and at times found it hard to find the documentation. Senior management acknowledged the implementation of the system to become business as usual had taken longer to embed than they had hoped.

Staff used risk assessments to identify the needs of patients in relation to risk of falls and their nutritional needs. They identified patients preferred options and these were recorded for all staff to access as required. Staff supported people to take part in activities to promote wellbeing and maintain independence, we saw this during our assessment in the activities room in the frailty unit. Processes ran smoothly on a day-to-day basis to ensure daily assessment of patients by doctors and multidisciplinary teams on ward rounds and in daily meetings.

Individual needs were considered when discharges were being planned, and patients were able to remain for rehabilitation in the frailty unit, even when medically fit for home, improving their overall standard of living. Physical therapy staff were accessible on the wards.

The trust had an audit programme which was extensive. Audits undertaken demonstrated compliance in areas including dementia and VTE assessment of patients and hand hygiene and PPE compliance audits. Where areas of improvement were identified actions were developed and monitored and learning shared.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

All patients we spoke with told us they had the opportunity to talk to staff and ask questions about their care and treatment, and staff made sure they understood what was being said to them. They felt listened to by staff. One patient told us staff always asked permission prior to starting any treatment.

Staff took time to build rapport with patients to help build their confidence in their decision making. Patients we spoke with told us that they really appreciated staff taking time to talk to them.

Patients understood their rights around consent to the care and treatment they were offered. Patients told us staff explained care and treatment options and gained verbal consent for physical assessments.

Staff understood and were able to tell us about the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989 and 2004 and they knew who to contact for advice. The records we reviewed all had evidence of consent being sought from the patient documented. Staff could describe and were able to show us how they accessed the policy and where to get advice on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs).