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

Staff reported that they used an electronic incident system, received feedback, and took part in debriefs, and clinical areas displayed recent incidents and learning; senior leaders also monitored incident themes.

Incidents we reviewed were investigated or learned from with duty of candour being applied as required.

Safeguarding arrangements were in place and staff received the required training. Staff described knowing how to raise safeguarding concerns, understood mental capacity act (MCA) and deprivation of liberty safeguards (DoLS), and found the safeguarding lead supportive.

However, risk assessments were not always completed for patients waiting long periods in the emergency department before being admitted to a medical ward. Staff generally understood and manage risks, using tools such as national early warning scores (NEWS) and communicating effectively, but medical cover at night was limited. There were ongoing pressures from delayed transfers of care.

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 evidence showed a good standard. 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.

As part of our post assessment data request, we asked the trust for incident investigation reports and action and learning plans. The trust provided data which showed learning from incidents. We reviewed 3 responses to incidents which showed duty of candour had been completed, review undertaken, learning was identified and actions plans to implement learning had been developed.

Staff told us and we reviewed documentation which demonstrated the trust had an established process for reporting and learning from incidents. Staff recorded incidents using the trust’s electronic system and confirmed they received feedback from leaders during meetings, handovers, and via emails. The service complied with the duty of candour policy by informing patients of incidents and sharing investigation outcomes when appropriate.

Clinical notice boards highlighted the top 3 incidents for the month, which helped with raising staff awareness. The clinical boards also identified learning from incidents. The service highlighted incidents in handover meetings.

Leaders encouraged and supported staff to raise concerns about risks to safety. Most staff we spoke with were able to tell us what incidents to report using the trust’s electronic incident management system. “Staff could tell us about action taken by leaders following an incident which was classed as being significant had occurred. These actions included a review of all steps that led to the incident, formalisation of an educational package required for all staff and introduction of any new ways of working that might be required. This was in line with the National Patient Safety Incident Response Framework (PSIRF) and staff felt this was important for their wellbeing.

Senior leaders had oversight of themes from incidents and complaints

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had staff in place to support discharge planning and transition of patients. The service worked closely with social workers and the local authority to facilitate patient discharge where necessary.

The service held daily bed meetings to identify patients who were ready for discharge and discuss arrangements for their discharge. However, the discharge of patients was slow during the day and much reduced at weekends.

At the time of the assessment, the discharge lounge was being used with longer opening hours than usual, but it wasn’t being used to its capacity. When inspectors visited in the morning on the second day of the assessment, we found the area had capacity for many more patients than were present, even though the rest of the hospital was under pressure. Because of this, the lounge wasn’t reliably helping to move patients out of the wards, which made it harder for staff to free up inpatient beds quickly. Leaders were holding regular meetings to manage patient flow, but these weren’t as effective as they could have been because there wasn’t a clear, consistently followed discharge process.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe.

During our assessment we saw the medical wards were boarding patients daily. A boarding patient is one who had been admitted onto a ward and was temporarily placed in a non-dedicated bed space, often a hallway or waiting area, due to bed capacity issues. Staff told us they only boarded patients that were safe to be boarded and reviewed them regularly to ensure that had not changed. We reviewed the patients being boarded during our assessment and found that they were all suitable to be boarded and we spoke with some of them and they fed back they felt cared for and safe.

The trust worked with other trusts, local authorities, social services, and community teams to co-ordinate and facilitate patient discharges. However, we observed the service had significant capacity issues with significant levels of delayed discharges on the wards. This was often due to patients awaiting suitable care home placements, new equipment required at home, or new or changes to care packages.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The data requested post assessment demonstrated good compliance with safeguarding training for all staff levels. All staff we spoke with told us they had completed their safeguarding training. We were assured people were safeguarded from harm.

Staff were able to describe how to make a safeguarding referral and knew who to discuss safeguarding concerns with. Safeguarding concerns were discussed during huddles to inform staff of referrals made.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The hospital had a safeguarding lead and staff found them approachable and supportive.

Resident doctors, registered nurses and healthcare assistants were able to explain their understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and how to act in accordance with the MCA when providing care and treatment. All records we reviewed that required MCA documentation, had it and it was completed as required.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff used the National Early Warning Score (NEWS) tool to identify patients at risk of deterioration. NEWS observations were recorded in the majority of the patient records we reviewed (8 out of 10 sets of patient notes); staff’s completion of these assessments was carried out regularly. We saw sepsis pathways were being effectively used. The service could access outreach and resuscitation teams when required.

Staff communicated with patients so that they understood their care and treatment including those with communication difficulties. For example, staff accessed language line for patients for whom English was not their first language. This meant that patients were able to understand the care and treatment being offered.

Staff enabled patients to make advance decisions when appropriate. We saw examples in the medical records we reviewed where patients and their families had discussed refusing life-sustaining treatment, such as resuscitation or antibiotics, even if it meant a shorter life. These decisions were documented in people’s records.

Staff could access out-of-hour medical support via a bleep system. However, staff told us doctor reviews were not timely and often they had to escalate this to the site team. Medical staff said there was insufficient cover for the medical wards at night. Although there had been no incidents relating to harm to patients at night due to staffing, they often felt stressed and overwhelmed. They had reported this to senior leaders but felt there was a lack of action to address concerns raised. The data provided by the trust did not show reduced staffing levels at night, so we could not confirm the extent of this issue.

Risk assessments for VTE, pressure ulcers and falls were regularly completed once patients had been admitted to a ward.

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

Overall, the service followed national guidance and had suitable facilities and equipment for patient care.

Relevant staff had swipe or keypad access to clinical areas. Staff conducted daily safety checks on specialist equipment. All equipment we reviewed conformed to the relevant safety standards and had been serviced annually. Fire extinguishers were serviced yearly and were in date for servicing. Staff told us they had received training to use this equipment.

We saw sharps bins were set up correctly and were dated and signed, we reviewed two resus trolleys, one on AMU and one in Mary Seacole Unit which had items in each drawer which were not on the stock sheet, causing overcrowding of the drawers. This might cause delays in an emergency situation making it hard to find the required emergency lifesaving equipment required. All resus trolley stock sheets were signed and dated each day as being correct.

Pressure relieving mattresses were available as needed. On our visits to wards we found that call bells were always in reach of patients.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff informed us that there were sufficient numbers of nursing staff on duty during the majority of shifts. At times the numbers of nursing staff were in excess of the planned number due to the increased acuity of patients. We reviewed the staffing rotas and found this to be the case. The service used the Safer Nursing Care Tool (SNCT) to manage staffing. Staff said they escalated any staffing issues to senior staff who worked to ensure they had sufficient safe nursing staff levels. Bank and agency staff were used to fill gaps in rotas when required. The data provided by the trust covering the period November 2024 to November 2025 showed that nursing fill rates ranged from 95.6% in March 2025 to the lowest fill rate of 87.6% in October 2025. Nursing staff vacancy rate was 6.24% (averaged last 12 months). There was 7.03% of nursing staff turnover, and 5.81% sickness. This was on the whole good and supported the level of nursing staff required on the wards.

We found that new and agency staff completed an induction when joining the service. The skill mix on the wards at the time of the assessment was suitable for the acuity of the patients in the service.

Medical staff told us there was generally safe staffing numbers for medical staff, however, they raised some concerns around medical staffing numbers at night time. There was only one medical registrar covering the stroke service overnight. The medical registrars and consultants reported a very high workload. Data provided by the trust covering the period November 2024 to November 2025 showed medical staffing fill rates ranged from 100% in November and December 2024 to 94.4% in November 2025. Medical staff vacancy rates were 1.17% (average last 12 months). There was 3.51% turnover, and 2.72% sickness. This was good and demonstrated there was sufficient levels of medical staffing for the wards. Junior doctors told us they felt well supported. They had sufficient time to attend training sessions and were given appropriate supervision.

Staff we spoke with confirmed they had completed an appraisal in the last year. The service had an annual appraisal rate of 81.5% for nursing staff but no data was provided for the appraisal rates for medical staff. However, feedback from resident doctors was that they felt very well supported by consultants. There was a “flat hierarchy”, and they felt supported to call consultants about any concerns they had. They had protected time to attend teaching.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas of the service that we observed were visibly clean and free from clutter. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. “I am clean” stickers were placed on equipment to indicate pieces of equipment that had been cleaned.

Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our assessment, such as hand washing and using hand sanitisers when entering and exiting patient areas and wearing personal protective equipment (PPE) when caring for patients.

There were enough hand-washing sinks available, in line with the Health Building Note (HBN) 00-09: Infection control in the built environment. Soap and disposable hand towels were available next to sinks and instructions on how to effectively decontaminate hands were displayed above the sinks.

Signs for infection prevention and control (IPC) were displayed on doors to alert people about entering certain areas or side rooms. The trust provided us with IPC audits. The audit for Alexandra Ward dated 9 October 2025 showed a 54.8% compliance with 14 out of 31 question having a negative response. Including was patient equipment clean – No, Were the storerooms visibly clean – No, were staff wearing gloves appropriately – No

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Medicines, including controlled drugs (CDs), were stored securely, and access was restricted to authorised staff. Staff described clinical pharmacy input as accessible and helpful, and staff had access to medication guidance, including for medicines requiring therapeutic drug monitoring. We saw adherence to antimicrobial stewardship principles (safe and effective use of antibiotics), such as prompt intravenous-to-oral switches and compliance with local antimicrobial guidelines. Staff knew how to report incidents, and learning was shared. These practices support safe prescribing and reduce the risk of antimicrobial resistance.

Temperature logs for fridges were often recorded as above 8 degrees Celsius, and while records indicated that this was ‘to be reported’, we could not be assured that appropriate action had taken place. Failure to maintain correct storage temperatures may compromise medicine stability and effectiveness.

CD audits were routinely undertaken with pharmacy teams, which provides assurance that medicines are managed safely and effectively. However, CD registers contained entries that had been crossed out which was not in line with policy.

We also found pill crushers with residue, creating a risk of cross-contamination and poor infection control during medicines administration.

Hypoglycaemia boxes were found on wards where medication had been used but not replenished in line with policy, and stock was missing without clear accountability. For example, one box recorded the use of three tubes of Glucogel in April 2025, but the box should contain six tubes. This meant three tubes were unaccounted for, and stock had not been replenished since April. Another hypoglycaemia box was found to have five tubes missing. While staff knew where to source Glucogel if needed, failure to maintain these boxes could delay treatment for patients experiencing low blood sugar. There was also variation in how such boxes were monitored, for example one ward did a daily check of them, whilst the other did no such oversight.