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

The service had a shared vision and culture based on transparency, equality, human rights, and inclusion. Staff understood how their roles supported the long‑term strategy introduced in 2023.

Leaders communicated the strategy effectively, and staff demonstrated strong awareness of strategic goals, despite pressures such as consistently high bed occupancy that sometimes-limited wider improvement work.

Leadership within the medical division was described as credible, supportive and inclusive, with senior staff maintaining visibility on wards and fostering safe, open communication where staff felt confident raising concerns.

A positive “freedom to speak up” culture existed, supported by an active guardian team who promoted psychological safety and ensured concerns were investigated confidentially and constructively.

Governance structures were clear, with regular reviews of risks, performance and incidents, though some requested incident data was not provided; risks were monitored through a risk register but without named owners for each risk.

The service worked collaboratively with partners and focused on continuous improvement and innovation, including national recognition of frailty services and the introduction of emotional‑intelligence training for nursing staff.

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 evidence showed a good standard. The service had a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust’s vision, values and strategy have been developed, through a structured planning process in collaboration with people who use the service, staff and external partners. This 5-year strategy commenced in 2023, aimed at recognising that demand for the services was increasing, but resources were stretched.

Leaders ensured the vision and strategy was shared with staff, and we found the staff we spoke with knew, understood and supported the vision, values and strategic goals and how their role helped in achieving them. The strategy focused on improving patient outcomes and patients’ overall experience. Its aims also were working toward improving work culture and increasing equality and diversity amongst the divisional workforce.

The divisional leaders were aware that the hospital was under pressure, experiencing continued bed occupancy above the 92% threshold. This was deemed a significant challenge and sometimes consumed the attention and energy of leaders to the detriment of other continuous improvement objectives they had.

The medical division followed the trust’s “CARE” strategy, based on the key principles of collaboration and partnership, affordable, right care, right place, right time and empowered, engaged staff to work towards improving bed usage and patient flow, assess equity in professional development, promote opportunities for black, Asian, and other ethnic staff amongst others.

The evidence showed a good standard. The service had inclusive leaders at local and divisional levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The triumvirate leadership team for medical care demonstrated the trust’s values and were described by staff as being credible, supportive, and promoting a positive culture. The leadership and management supported development of new leaders through training, to plan for succession.

Senior managers told us they visited clinical areas, supported on wards when required and met with matrons weekly. Matrons were ward based to increase visibility and met with their senior nurses to identify challenges and potential solutions.

Most staff we spoke with reported satisfaction working for the trust despite demanding conditions. They felt leaders were approachable and they could raise any concerns with them. Staff told us they had good lines of communication and working relationships with their managers who were accessible and visible. Staff understood reporting mechanisms and the purpose for them. They presented themselves as feeling confident and safe to use such reporting structures, free from fear of reprisal and they were knowledgeable about the risks facing their services.

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

Staff felt confident to raise concerns to management and they received support and were not afraid of recrimination for raising concerns.

When concerns were raised, staff told us they felt assured that managers investigated sensitively and confidentially, and lessons were always shared with them and acted on.

The trust had a freedom to speak up guardian team with whom staff could raise concerns about any issues. Staff we spoke with knew who the freedom to speak up guardians were and how to contact them.

The freedom to speak up team celebrated a freedom to speak up month during November 2025 and held events across all hospital sites. The central theme of the freedom to speak up month was psychological safety.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had a clear governance structure with defined roles and responsibilities. Staff understood what their roles and responsibilities were, and they were able to access the information they needed about patients’ care and treatment. This clearly defined governance structure also supported the flow of information from frontline staff to senior managers and the trust board.

Regular governance meetings were held to review information about the service, including performance, risks, incidents, and complaints.

There were robust arrangements for the availability and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. Patient records were stored securely on all the wards we assessed.

At trust level, daily site conference calls were held to monitor capacity and patient flow. This enabled staff to have an up‑to‑date understanding of the pressures within the service and they supported timely decisions and escalation.

Information was shared with staff through daily handover meetings and emails. This kept staff up to date with what was happening in the trust, social events and updates on training and policies.

The medicine incident review meetings were held 3 times per week. We reviewed the meeting minutes from the last 3 patient safety and quality group meetings held in June, August and November of 2025. At each meeting they discussed incidents which had occurred since the last meeting, they reviewed which audits had happened and risks the service was experiencing.

Senior leaders used a risk register to manage risks. At the time of our assessment, there were 16 risks on the risk register. These related to various issues regarding staffing, including both recruitment and retention of staff specifically in relation to cardiology and respiratory consultant levels, facilities and equipment amongst others. Controls that were in place to mitigate the risks were listed and the risks were regularly reviewed by senior staff. However, there was no specific named member of staff responsible for each risk, this did not provide us with assurance they risk had a designated person who was working to mitigate or eradicate the risk.

Various policies and procedures were in place to cope with unexpected events. Business continuity plans were in place for the division which detailed strategic arrangements and activities undertaken within the trust to support emergency preparedness.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The service at all levels including leaders engaged with external partners and external stakeholders to support patient care, transfer and discharge. They worked with commissioners, GP practices, other local acute hospitals and community teams to care for patients. The service had access to 106 beds in virtual ward in the community to support keeping patients at home receiving the care they required,

We saw collaborative working at the MDT meetings we attended between the local authority’s social care teams and the service.

Staff told us they could provide feedback to their immediate leaders as well as more senior leaders.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff spoke positively about the opportunities for learning and development which enabled them to assist in improving the services.

The frailty team working on the Mary Seacole Unit, which was part of a partnership between local NHS organisations to provide adult community health services in Surrey Down. The team were invited to present their service model and outcomes at the national British geriatric society conference November 2025. They presented to the NHS Providers event in July 2025. They were invited to be part of the national collaborative frailty network and a poster presentation of part of the service at the European society of geriatric medicine.

The trust developed emotional intelligence training was presented to band 5 nurses. The purpose of this training was to explore and understand how emotional intelligence is relevant to nursing practice and emotional intelligence supports professionalism, teamwork, and patient safety.