Epsom General Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics. People could access care and treatment when they needed it in a variety of ways. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service was aware of system pressures and sought to develop services that met the changing needs of patients.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

We have not awarded this service a score for Responsive.

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

The service made sure patients were at the centre of their care and treatment choices wherever possible. We saw that staff took care to include the views of all relevant people when planning care. Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act.

People with specific care needs were supported as individuals and those needs met. Staff undertook risk assessments to identify specific needs such as nutrition, hydration, mobility, and falls risks. Staff made reasonable adjustments to help those with complex needs remain independent. We saw positive interactions between all staff, patients and families or carers. Staff made sure patients living with mental health problems, learning disabilities and dementia, received the necessary care to meet all their needs. Staff in all areas discussed the care planning arrangements for those patients who may find coming into hospital very distressing and could give examples of how these individual needs were addressed. For example, undertaking preadmission visits and putting these patients first on the operating list. Staff also took time to work with the regular carers of these patients in order that they addressed the individual needs of the patient as well as they could.

Patients received care and treatment from services that understood the diverse health and social care needs of their local communities. Due to the nature of surgery undertaken at Epsom General Hospital, staff had time to plan the delivery of care that met the individual’s needs. All surgical staff worked closely with the care team in the community, specialist nursing staff and hospital staff to ensure that the individual patient was supported emotionally and physically for their operation. This included meetings preoperatively to understand any individual needs. Supported visits by the individual to familiarise themselves with the ward area were undertaken. Regular carers in the community were encouraged to participate in care within the hospital setting where appropriate.

In the Day Surgery Unit, we heard that several deaf patients regularly came to the unit for treatment. People who could provide signing services were regularly contacted to ensure that these patients understood their care and treatment. These translators were in the Day Surgery Unit for 2-3 hours at a time and were familiar to the staff and regular patients. Staff in this area stated that they also had regular contact with some patients who were living with a learning disability who came for blood tests and scans under general anaesthetic. Staff used the patients’ health and care passport to plan care. However, the staff became familiar to many of these patients who came regularly and were aware of their individual needs.

The service had two local prisons who used surgical services at Epsom General Hospital. Staff were sensitive to the emotional wellbeing of these patients. Day surgical staff discussed with Swift ward if they had a side room available for these patients despite them usually only being in hospital for less than 24 hours. Using a side room protected their privacy as much as possible in the hospital. Staff could describe how they would care for patients who were homeless or from the travelling community but rarely saw this type of patient.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. We saw information in racks on the walls of patient areas that patients or their families could access about their care and treatment. Leaflets complied with the Accessible Information standard. Staff told us that these could be provided in other languages if required.

Staff made notifications to the relevant external bodies where applicable. Records of implants used in treatments were kept in the theatre department. Patient records were kept confidentially on secure IT platforms. We observed staff accessing care records and ensuring that they signed out each time their record keeping was completed. Leaflets about raising concerns were available to patients and their families. However, all the patients we spoke with told us that they felt comfortable in raising any concerns with the care team. We observed care staff ensuring that family members and those close to patients were informed of care in line with the patient’s wishes.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. There were posters throughout the surgical department telling patients and family members about what to do if they were concerned about their loved one or the care they were receiving. There was a QR code located on the posters to make it easier for people to share feedback about their care. However, Swift ward reported that their response rate had dropped following a change in the system, so they had printed questionnaires and encouraged patients to complete these whilst on the ward. This information was then entered into the system. The average response rate was between 125 and 140 patients’ responses a month, scoring an average of 97%. The hospital kept a log of compliments to each area. We saw that the surgical department had three positive comments on this log in 2025.

We were sent information on the numbers of complaints at a divisional level, this was not broken down by hospital site. This demonstrated that the planned care division made up over 20% of PALS contacts in quarter three of 2025. This report acknowledged that communication with patients and their relatives remained a key focus for the surgical staff. However, there had been some complaints regarding relatives not always being fully updated on medical plans, treatment progress, discharge arrangements, and delays in transfers. We heard in patient areas how the staff asked patients if they were okay and where they had a concern this was dealt with immediately. Teams reflected on patient feedback through daily huddles and regular discussions of Friends and Family Test (FFT) results. Learning from complaints and compliments was shared in weekly divisional meetings. The ward manager, matron, and senior leaders were involved in reviewing complaint responses. The matron on Swift ward told us how they contacted patients who had made a complaint to ensure that they fully understood the complaint and could address their concerns effectively. However, most informal complaints were dealt with on the ward and day patient areas by staff without the complaint becoming a formal complaint.

Ward staff told us that informal complaint themes of feedback centred around waiting times for surgery. Patients felt that they were admitted too early as they spent a long time in the Surgical Care Suite waiting for their surgery. The theatre working group were aware of this and seeking ways to address this issue. On Swift ward we were told of a complaint where a patient felt that they had not had access to timely pain relief. The matron investigated the incident and spoke with nursing staff on duty at the time. Staff were reminded of the need to provide timely medications but also received further training on how to deliver messages about the amount of pain control available to patients.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it. Not all care was provided on the Epsom General Hospital Site and patients with postoperative issues sometimes had to go elsewhere for specialised services. People did not experience discrimination or inequality. People with additional needs had reasonable adjustments made for them such as for people with disabilities, those with communication difficulties or cognitive impairment. People were listened to when they wanted to share their experience. Staff worked hard to remove any barriers to access for patients. There was a strong culture to prevent discrimination and inequalities supported by training, guidance and specialist nursing and care staff.

Staff were acutely aware of unseen disabilities including patients who were neurodiverse or living with any form of dementia. We observed staff explaining patiently and repetitively the care and treatment required to a patient on the ward living with dementia. Ward staff and others coordinated discharges to ensure packages of care or support were available to those who required ongoing support at home. The safeguarding quarterly report dated July 2025 demonstrated that Swift ward facilitated a complex stay with a service dog. This allowed the patient to retain more of their independence whilst in hospital. All staff spoken with on Swift ward were able to speak about how care had been adapted to meet an individual’s needs.

There was adequate medical cover throughout the 24-hour period seven days a week. The medical staff at Epsom General Hospital could access specialist consultant surgeons at either St Georges Hospital or St Hellier Hospital. There was access to a critical care outreach team should a patient show signs of deterioration. This team provided in reach training sessions to Swift ward staff to assist them to identify early signs of deterioration. Discharge was planned with the patient in mind. Support services were made aware of discharge plans and transport where required was booked when the patient was ready to go home. This sometimes meant a wait for patient transport. The matron was implementing an action plan called “Go home Swiftly” which aimed to get patients home in a timely manner.

The trust had previously performed well in theatre utilisation locally. After introducing the electronic patient record system, utilisation had declined as clinical activity was reduced as staff became familiar with the new system. The service had a recovery trajectory to return to an improved utilisation of the theatre department. In November 2025, capped theatre utilisation across the trust was 74.9%, which was below the Getting It Right First Time (GIRFT) recommended level of greater than 85%. This shortfall meant fewer procedures could be scheduled, increasing waiting times for surgery and negatively impacting the ability to access timely care. Data we reviewed showed that in October 2025 within the division 322 patients had been on waiting lists for over 52 weeks. Leaders described ongoing work to improve referral to treatment times. This included initiatives aimed at improving waiting lists throughout the service, including collaboration with the outpatient transformation team to optimise ophthalmology clinics and the implementation of telephone triage clinics in foot and ankle surgery, which had led to reduced patient wait times. The numbers of patients waiting over 65 weeks had reduced from the peak in October 2025 at 37 patients to 28 patients in November 2025. The plans in place to improve this were regularly monitored at the operational meetings.

The theatre department monitored the utilisation of the theatre lists. The trust compared the data from August 2025 and November 2025. This showed that in August 2025 43% of lists started late. Most of these late starts were less than 15 minutes however 2 were over 30 minutes due to a meeting attended by the surgeons. In November 2025 there was some improvement in that 38% of lists started late but nearly half of these started over an hour late. In August 2025 60% of lists finished early, 30% on time and 10% finished late. Most late finishes were under 30 minutes. Of the 60% of lists that finished early 83% finished early by more than 60 minutes. These were due to cancellations or patients not turning up. In November 2025 34% of lists finished early, 34% on time and 32% finished late. Most late finishes were under 30 minutes. Whilst the 3 early finishes finished early by 45 minutes and 4 were between 90 and 120 minutes. This demonstrated that whilst the number of late starts improved the impact on utilisation of theatre time got worse. The service was aware of the issues of theatre utilisation and had a plan to address this.

Staff and leaders listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. The staff highlighted issues and challenges that affected those patients most likely to experience inequality. Leaders and staff were alert to discrimination and inequality that could disadvantage different groups of patients using their services, whether from wider society, organisational processes and culture or from individuals. The staff proactively sought out ways to address these barriers to improve people’s experience, act on information about patient’s experiences and outcomes and allocate resources and opportunities to achieve equity. Staff were trained in equality, diversity, inclusion and human rights where there was a 97% compliance.

The trust had been awarded the Veterans Aware award. The Veteran Aware program is an NHS accreditation initiative aimed at supporting health care providers in understanding and meeting the needs of the Armed Forces Community. It has 8 criteria to which the trust must subscribe. These included ensuring that veterans are identified and provided with appropriate support whilst in hospital and on discharge. There was an update on Veterans in the Patient Experience Newsletter produced regularly. The trust’s strategy contained an objective around culture, inclusivity and diversity. The objective stated that by being a more inclusive employer staff would be supported to give great care. The group of hospitals are implementing a cultural development programme which will include action on equality, diversity and inclusion.

Staff created personalised care plans to account for the patient’s needs, wishes and feelings. The enhanced recovery nurse worked with patients having major bowel surgery to ensure that they fully understood the impact of their surgery and the steps that they could take to enhance their recovery such as a different diet and stopping smoking. Staff supported patients to make decisions about their care and treatment and their future. As above an example of this is the siting of a stoma for patients. We spoke to a patient who had undergone major bowel surgery and they told us how they had been involved in important decisions and had felt part of the decision about options on surgery. However, whilst most patients we spoke with were not at the stage of making decisions about their care at the end of their lives staff were sensitive to all patient needs. Staff could explain how these conversations were completed and by whom. Care for people who were nearing the end of their life or who were being given life changing news was managed and communicated in a sensitive and dignified way. We saw evidence and staff told us that they ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.