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

Good: We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them. We reviewed 9 sets of patient records and saw that a comprehensive health assessment of the patient had been completed in a timely manner. Patients were involved in the completion of the care record. Care plans reflected the individual needs of patients on the ward. Where patients had complex needs these had been identified and planned for prior to admission. This included patients who were having life altering surgery and those with learning disabilities or living with dementia.

The trust had implemented the Oliver McGowan mandatory training on learning disability and autism and compliance within the division was above target across all staff groups. Staff we spoke with demonstrated a good understanding of how to assess the needs of autistic people, people with a learning disability and dementia. Staff told us they were made aware of patient's individual and holistic needs during shift handovers.

Patients received a preoperative assessment at which their fitness for surgery was assessed. At this appointment further investigations could be ordered if required. The service monitored the effectiveness of this and had a workstream in place to reduce the number of patients cancelled on the day of surgery because they were deemed unfit for surgery.

Patients were offered a variety of menu options to ensure their individual needs were met. Snacks were available on the ward and the hospital canteen menu was accessible for patients who needed this. Where patients were nil by mouth this was in line with national guidance. However, sometimes patients were admitted in the early morning and did not go to theatre until later in the day. Whilst staff in the surgical care suite tried to ensure that they received appropriate fluids this was not always achieved due to variations in theatre time slots.

Staff on Swift ward spoke a variety of languages and did not often use the services of a telephone interpreter service. Other areas of the service used the translation service to ensure that patients understood what was happening to them. The day surgery unit had several patients who attended regularly who used sign language. Staff used the same person to sign which offered continuity of care and a good understanding on the part of the signer of the procedure undertaken. Staff made sure that patients care was effective by ensuring that they had the right information to maintain their wellbeing.

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. Staff gave people clear information about their care and treatment needed to support their physical and mental health. Staff met people’s nutrition and hydration needs. They used effective tools for screening malnutrition and dehydration and acted on any indicators of concern. Staff serving meals ensured that patients had a meal that they could and would eat. They also ensured that drinks were provided to those patients wanting them.

Staff used the trust’s systems to follow the latest guidance and evidence-based practice. The trust kept its database of guidance up to date. Staff used information given regularly in safety huddles and newsletters to implement new guidance or changes to existing procedures. Safety huddles were recorded so that staff who had not been on duty could see any new practices or issues they needed to be aware of.

The trust’s intranet contained a comprehensive range of up-to-date policies and standard operating procedures which reflected best practice. 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. Care records highlighted patient’s individual needs and assessments were undertaken in line with these. We reviewed 9 patient records and found that each one was assessed for risk of falls, use of bed rails, repositioning of the patient, moving and handling, pain, patient safety and orientation. All records reviewed included risk assessments for venous thrombolisation, nutrition and hydration. Patients who were in hospital more than 7 days had their weight recorded every week to ensure that they were maintaining their ideal weight. Where patients were found to lose weight staff said that they would ask the dietician to review the care provided. Clinical records we saw demonstrated care was provided in line with current guidance and individualised to patient’s needs. The theatre department staff had access to the appropriate equipment to ensure that the risk identified on the ward were managed in the operating theatre. This included devices that encouraged blood flow in the patients’ legs and warming blankets to ensure that the patient’s body temperature was maintained.

The planned care team included or had access to the full range of specialists required to meet the needs of patients in the service. As well as doctors and nurses, teams had access to specialist nursing staff particularly stoma care nursing staff, the enhanced recovery specialist nurses, physiotherapists, occupational therapists and dieticians. Together the team ensured that the patient’s recovery was optimised. Staff were encouraged to learn and develop. In the theatre department a group learning session had occurred following an incident to review the facts from different perspectives and seek people’s ideas on how things may have gone better. Similarly ward meetings were used to reflect on practice. Staff had one to one meetings where senior staff gave them an opportunity to reflect on their own practice and plan for development.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The matron on Swift ward had a plan of when audits would occur. The matron on Swift ward ensured that performance information was sent to the triumvirate on a monthly basis. This information was available for staff in the office. The matron on Swift ward had led a quality improvement project entitled “Go home Swiftly”. This project had been driven by patient feedback. They reviewed the timely discharge of patients from the ward and ensured patient flow through the ward area. Staff appraisal rates were good. In the last 12 months 97% of staff had been appraised. This allowed staff to identify developmental needs. Staff were able to identify where training discussed at appraisal had been attended.

The service worked well across teams and services to support people. Staff worked effectively across different disciplines to ensure all staff involved in assessing patients' needs to maintain the continuity of care. We observed effective discussions where staff from multidisciplinary teams reviewed and discussed patients to ensure they received the correct treatment and care. The enhanced recovery nurse linked many specialities, such as physiotherapists specialist nurses and community nurses as well as medical staff and GP staff, together to ensure the effective and timely discharge of gastroenterology patients.

Staff effectively handed over people’s assessment of needs when people moved between different services within the hospital or for transfer or discharge. The ward, day surgery unit and the theatre department worked well together to ensure that patients were placed in the most appropriate place to receive care. This included when patients booked for day surgery were found to have no one to stay with them post operatively. These patients were transferred to Swift ward from theatre as this was highlighted in the Surgical Care Suite on admission and appropriate discussions held at that point.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Relevant staff had access to electronic patient records which they could access using secure log-ins. Care plans were then able to be seen by all staff providing care. The system flagged when action needed to be taken in respect of care needs, such as risk assessments requiring updates.

The service worked with other services to ensure reviews of care were undertaken, including where medical patients were admitted to Swift ward. For example, ward staff had enhanced their knowledge of the care of medical patients through additional training sessions with the outreach team, due to this they felt more able to care for patients with a medical need. Medical staff from the medicines directorate came to the ward to ensure that these patients were seen daily. Staff ensured patients had the prescribed medicines to take home and discharge summaries before they left the ward, the ward pharmacist assisted with this process.

The Surgical Care Suite admitted patients who had come into the hospital for a procedure. Patients were seen by the surgeon and the anaesthetist at this point and care was discussed with the patient and any changes to the plan of care made. Patients waited there until it was time to go for their procedure and then they were sent from the theatre department to the area most suited to meet their needs. The Surgical Care Suite could get very busy at the start of an operating list as many patients were told to arrive at the same time. While this meant that the surgeon and anaesthetist could see all patients prior to the list commencing, patients had then to wait until their operation in the Suite. Communication was not always good between the medical teams and the nursing teams in this area. Some patients were brought in ahead of their scheduled arrival time without the nursing team being informed. This led to some anxiety for the patient and their relatives and disorganisation from the nursing staff. This was done to try to use the theatre time available as effectively as possible. However, some staff did not appear to have considered the effect on the patient.

Epsom General Hospital did not undertake emergency surgery. Patients arriving in the Emergency Department were seen by the emergency medicine doctors who referred them to the speciality doctors at St Hellier Hospital. Patients were then sent to St Hellier Emergency Department to be seen by the surgical specialist there. Any patients in Swift ward who required emergency surgery would be transferred to St Hellier Hospital.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. Patients admitted for surgery had a preoperative assessment which included the provision of information about living a healthier life. This included stopping smoking and specialty information such as healthy eating for bowel conditions. The service supported people to live healthier lives and where possible, reduced their future needs for care and support. There were several leaflets available on the ward which promoted healthy living. Staff spoke with patients when they were ordering their meals to advise which meals may be more appropriate for them.

The division had a programme of improvement to ensure that patients were optimised for surgery. This meant that they tried to ensure that patients were not only fit for surgery but had taken steps where necessary to improve their general health, so they recovered as quickly as possible. This programme looked at issues such as high blood pressure, how well the patient moved, if they had an existing condition such as anaemia or diabetes, if they had any breathing difficulties or memory loss and took an assessment of their nutritional status. This programme began with a pilot phase and was about to be rolled out to all units after our inspection. In the pilot phase it was found to decrease the number of patient’s cancelled on the day of admission. The next step was to make the form digital for patients to complete.

There were effective approaches to monitor people’s care, treatment and their outcomes. The service monitored performance through local and national audits and a structured ward accreditation programme. Ward accreditation used a tiered system (Platinum, Gold, Silver, Bronze, and Requires Improvement) to assess care standards and trigger timely re-inspections and improvement plans. Services rated as requiring improvement were supported with robust action plans and quality summits. These processes helped identify areas for improvement and maintain high standards. Swift ward had recently been rated Bronze in the ward accreditation programme. The leadership team were in the process of developing an action plan to address the issues identified. Most national audits had data submitted to by the trust. However, due to the nature of surgery undertaken at Epsom General Hospital they did not contribute to many national audits.

We found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. The service had access to seven days a week diagnostic and support services. Surgical staff we spoke with said that there was good access to services to support patient treatment and care.

Staff had access to and followed a wide range of policies and treatment guidelines which were stored electronically. Policies and procedures were based on best practice from National Institute Clinical Excellence (NICE). Outcomes for patients were monitored and action plans developed to improve the services. This included the delays patients experienced with discharges. “Go home Swiftly” was designed to look at why there had been a delay and how the ward could improve timely discharge. The theatre department followed the National Safety Standards for Invasive Procedures and Local Safety Standards for Invasive Procedures guidance from NHS England. These safety standards ensure that the department has implemented national best practice guidance in order to ensure the safety of patients. We saw that this was measured and displayed on quality boards in the department.

The theatre department used the World Health Organization (WHO) checklist in theatre to ensure the safety of the patient. The WHO checklist places its nineteen items into three "phases" of a surgical procedure: sign-in (before induction of anaesthesia, while the patient is still conscious); time-out (with the surgeon present, before incision); and sign-out, based on the joint commissions universal protocol. At each of these phases, the surgical team members present stop and make sure that the corresponding safety items have been performed (or that there is a valid reason to waive that requirement for the procedure). The trust monitored its completion through audits. The audit for March 2025 demonstrated that at Epsom Hospital there was some noncompliance in the area of signing out and debriefing which is at the end of the process. The hospital had a new electronic patient record system on which the WHO checklist was recorded but this had not been audited at the time of our inspection and therefore assurance that the checklist was fully completed could not be provided. At our inspection we saw good compliance with the WHO checklist apart from one instance where the surgeon was not present at the start but later joined the huddle.

Staff monitored the effectiveness of the theatre suite through audits on utilisation, on the day cancellations. The hospital had transitioned to an electronic patient record in May 2025 and were in the process of developing the system of provide accurate data for monitoring. As such the on the day cancellation rate was collected manually and therefore not as reliable as an electronic data collection. However, data demonstrated that there were a number of factors through which operations could be cancelled on the day. However, these reasons were grouped into clinical, non-clinical, patient initiated and other. Cancellations due to clinical reasons were based predominantly on the patient not being fit for surgery and accounted for 36% of cancellations. Non-Clinical reasons included equipment breakdown or lack of theatre time. This accounted for 33% of cancellations. Patient initiated cancellations accounted for 25% of cancellations with other making up the remaining 7% in September 2025. We saw a tracker for actions taken in respect of the work programme to improve theatre efficiency and this included actions to reduce on the day cancellations. However, this was in its infancy at the time of inspection and had yet to be audited.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Where consent could not be gained, staff understood their role in delivering care in the best interest of the patient. We observed staff obtained verbal consent from patients before interactions.

Staff understood and applied legislation relating to consent. A local audit of consent in the service showed that consent was generally well documented and highlighted that improvements were needed in the legibility of forms. Capacity and consent were clearly recorded. We did not see any Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) or ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) forms, but these options were available should they be needed.

Staff could describe the processes to assess and identify patients at risk and how they assessed and documented mental capacity. A checklist was completed on the electronic patient system which then produced alerts on the electronic patient record which enabled staff to be aware of specific risks. For example, if a patient was assessed as having a high risk of fluctuating capacity or were living with dementia. Staff had a person-centred approach and involved patients, where possible when completing risk assessments. However, the service and trust did not consistently monitor the use of the Mental Capacity Act and Deprivation of Liberty Safeguards to ensure compliance, an audit was last completed in 2023. The audit showed that the MCA and DoLS training is proving effective in enabling clinicians to document the appropriate information required in depriving a patient of their liberty. It also showed an improvement in the quality and standard of DoLS authorisations compared with the previous year Data collection began in April 2025 but was suspended due to other clinical priorities, staff vacancies, and leave. Meanwhile, the safeguarding committee approved a group-wide Mental Capacity Act and Deprivation of Liberty Safeguards audit.

We reviewed the consent forms for 9 patients and found these to be legible and completed correctly. Staff were able to discuss what actions they may take if a patient was not fit to consent for themselves. Staff were clear on capacity assessments for patients who may be living with dementia or having another physical ailment which impacted their ability to consent. Staff did not regularly meet patients who were subjected to or required a deprivation of liberty safeguard but regularly had patients who were at the local prison who may have restrictions on what they could and couldn’t do. Staff worked with the prison officers accompanying the patient to ensure that all patients had appropriate care.