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

We looked for evidence that people were protected from abuse and avoidable harm. We found that staff learnt from incidents that occurred and systems were adapted to avoid a repeat. We saw that there were systems and processes that the staff followed to ensure that patients were provided with safe care and treatment. Areas appeared clean and equipment was tested and labelled as being cleaned. Medicines were held securely, and emergency equipment was available when required. Staff were aware of the actions to take if they were concerned for the patient’s safety.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has improved to Good. This meant people were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. Staff were encouraged and confident about raising concerns. These were taken seriously, investigated and people received feedback. There were several ways in which staff could raise concerns including, submitting an electronic incident form, at the safety huddle, and directly to their line manager. Most staff we spoke with felt that they could speak with their line manager and action would be taken. Staff could tell us about action taken by leaders following the 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 for all nursing staff and a new way of working to identify when packs were left in patients to stop bleeding. This was in line with the National Patient Safety Incident Response Framework (PSIRF).

The service had a proactive and positive culture of safety, based on openness and honesty. Managers listened to concerns about safety and investigated and reported safety events. The lessons learnt were shared with others across the division to continually identify and embed good practice. An example of this was the reminding of staff that when giving patients medication such as Co-codamol they did not also give the patient Paracetamol. To do this would have potentially overdosed the patient on paracetamol. Feedback from learning was provided in daily safety briefings. Staff could identify additional learning that had been implemented because of an identified need. This included sessions from the outreach team and mental health teams.

The trust had transitioned to the NHS England’s Patient Safety Incident Response Framework (PSIRF). This meant the trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred. Duty of candour was undertaken initially verbally, where the most appropriate clinician apologised for what had occurred. This was then formalised in a letter asking if the patient had any questions to be answered by the investigation. There had not been any never events since the introduction of the electronic record in May 2025 at Epsom General Hospital. Prior to this there had been one never event in March 2025. Staff were aware of this incident and the actions taken following investigation of the incident and the learning put into place. A “Never Event” is a serious, preventable patient safety incident that should not occur if proper safety systems and precautions are in place.

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. We saw good handovers of care from the theatre department team to staff on Swift ward and when patients moved between day surgery unit and Swift ward. There was a good understanding of patients’ needs and staff in all surgical areas liaised with each other to ensure that the patient was in the best place to meet their individual needs safely. There was a policy in place for when a patient was transferred to a sister hospital site to provide a safe handover of care. This included a clinician to clinician verbal handover and a nursing escort for the patient.

Handovers in the ward areas were comprehensive and personalised to individuals. We saw evidence of this in the handover book where records of handovers were kept for members of staff who could not be present. Safety huddles took place twice a day to share up to date information. Other teams provided individualised patient support on the ward including the mental health team and specialist nursing teams. The enhanced recovery nurse spent time with patients prior to, during and post-surgery to ensure that their recovery went as smoothly as possible. Patients were seen preoperatively and their individual needs assessed by the pre-operative team including nursing staff and clinicians. This information was used to determine post-surgery care. For instance, if a person lived alone, they may not be suitable for day surgery and may require an overnight stay which could be facilitated on Swift ward. Patients with complex needs were identified and suitable plans were put in place to meet their needs whilst ensuring that the emotional support was available to them. Where additional needs were identified on the day of surgery there was effective liaison between the day surgical unit and the ward to ensure that the patient remained safe throughout their stay in hospital and was cared for in the most appropriate ward. Staff ensured that patients were clear about the discharge arrangements and that appropriate support was available in the community.

The theatre department followed the National Safety Standards for Invasive Procedures 2 (NatSSIPS 2). These are designed to reduce misunderstandings or errors and to improve team cohesion. NatSSIPs 2 help achieve the triple goals of improved patient safety, better team-working and enhanced efficiency. The team also undertook the World Health Organisations checklist before and after each operation. This was now an electronic step on the patients' care record and improved the safety of the patients care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Patients and carers were involved in the care planning for care. We heard that when patients with complex needs were admitted the regular care team were involved as equal partners in care of the individual. Staff took time to understand the individual’s needs and how best to care for the person. This included those patients living with dementia.

Staff were trained in safeguarding with safeguarding training compliance for levels 1 and 2 being above the trusts target. However, the planned care nursing staff compliance was at 69% and the doctors were at 47% compliance for safeguarding level 3. The leaders told us that a new safeguarding package was being introduced. For children’s level 2 and 3 safeguarding training the doctors were 80% and 57% compliant and the nursing staff 95% and 84.6% compliant. Staff knew how to make a safeguarding alert and said that they did so when appropriate. Staff focused 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 with the local authority. Staff could give examples of when this had happened and how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Ward staff used the least restrictive practice for patients with mental health issues and those living with dementia. Swift ward had a bay that was used for medical patients when the numbers requiring admission were more than the designated medical service beds. Extra staff were provided to care for these patients. Staff had received extra support to meet the needs of these patients and saw them as a part of their ward. Staff recognised the potential additional care needs these patients required and felt competent to meet these. Additional training had been provided to staff to maintain their competence in caring for medical patients that were accepted as part of the admission criteria.

The service always worked with people to understand and manage risk by thinking holistically. Staff spent time with patients to understand their individual needs and during observation it was evident that patients were at the centre of their care. For example, a patient who was having a stoma wanted it placed higher than usual due to their trouser waistband. The stoma specialist nurse took this into account when marking the patient with the surgeon. The site of the stoma was agreed by all involved in care and the patient.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Observations were recorded on the electronic patient record where the clinical team could see trends. Staff flagged when patients were at risk of deteriorating and the critical care outreach team reviewed those patients who were identified by an increasing NEWS (National Early Warning Score) assessment. There was a doctor available 24 hours a day on Swift ward to review patients who may be at risk of deterioration. Senior medical and nursing support was available from the team on call at the St Hellier Hospital site. Medical patients on the ward had access to medical speciality doctors 24 hrs a day. We saw the medical team on the ward and staff told us they were responsive to calls. There had been two patients transferred out of Swift ward since April 2025. These required further surgery at the St Hellier site as they developed complications which needed emergency surgery. There was a policy in place for this to ensure that the handover of patients was safe.

The service monitored that risk assessments were effective through a dashboard containing incidents of falls, pressure ulcer development, infections and transfers during the night. For November 2025 this demonstrated that Swift ward had no incidents in any category and scored 100% in handwashing and crash trolley audits. Staff were aware of Martha’s rule and that this was being trialled at St Hellier Hospital. Martha’s rule is a patient safety initiative that empowers patients, families and staff to request an independent medical review if they feel their concerns about a patients care are not being adequately addressed. However, concerns raised by patients or their family with the team were treated seriously and investigated to manage any risks. A leaflet was available for patients and their family who wanted to raise a concern telling them to speak to staff or to contact the Patient Advice and Liaison Service (PALS). We heard a relative raising a concern about a patient and this was dealt with appropriately.

The service used an electronic patient record system which enabled staff to be aware of specific risks for patients. For example, if patients were at the end of their lives, living with dementia or at risks of falls. Staff had a person-centred approach and involved patients, where possible when completing risk assessments. Patients we spoke with said that they had been involved in planning their care and knew where they were in their recovery journey. We heard staff explaining and checking that patients understood the post operative discharge information. A discharge letter was given to patients to inform any further care giver of the procedure undertaken and care given.

The surgical service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The areas we visited were visibly clean, and we saw cleaning staff in most wards and departments. Swift ward and the day surgical unit were visibly clean and free from dust including in hard-to-reach places. We noted that walls and most floors were intact. This allowed good cleaning of the areas. The housekeeper kept a daily cleaning diary on Swift Ward. There was a cleaning book for staff to sign when daily cleaning of identified areas was undertaken. This highlighted any individual needs of patients or specific areas to focus the day’s activity on. Equipment such as desks and keyboards were wipe clean. The equipment in the ward areas we saw was visibly clean. We saw staff cleaning equipment following use and stickers applied which told users that it had been cleaned.

Planned preventive maintenance and electrical appliance tests were completed annually and equipment had stickers so that staff knew it had been tested. We checked equipment and it had undergone electrical safety checks within the last 12 months. There were effective systems to ensure emergency equipment in the surgical wards were checked daily. Medical gases were stored securely. In the theatre department fire action boards were seen. These contained the fire safety action plan, high and low signage, fire alarm pads and the route for escape. Fire equipment was present and located in clearly marked areas. We checked the air sockets in all areas and noted that as per guidance these were sealed so that patients were not given air instead of oxygen by mistake.

Annual ventilation and inspection reports for the theatre department at Epsom General Hospital described aged air handling units which were or were coming to the end of their useful life. This affected the air exchange rates in some theatres and the differential pressures in others. Whilst this could potentially affect the efficacy of the clean air in the theatre environment leading to increased infections for patients. The infection data demonstrated that the number of infections post-surgery were within expected limits. We saw actions had been taken to address this issue by the service including regular auditing of infection control processes by the infection prevention and control team. The service sent us a business continuity plan for the surgical assessment care unit which was undated. This plan described how the service should react if they lost some or all of the essential services. This document was supported by further information about what to do in the event of loss of services to the areas.

The day surgery unit environment was an older part of the building and lacked space for storage and good observation of patients awaiting transport home. Staff ensured that patients who they may be concerned about were kept within the ward area so that they could be observed. The waiting area in the day surgery unit was small and often full in a morning when patients were arriving. Patients were mainly signposted to check into this area prior to going to the Surgical Care Suite for admission to the service. Staff ensured that patients were transferred to the Surgical Care Suite in a timely manner so that this area was not overcrowded. There was limited space for the storage of equipment and consumables in the day surgery theatre area, making the area cluttered. Bay 4 in the recovery area had been used to store equipment in. Most of this equipment was kept clean but some that was awaiting disposal had not. These two pieces of equipment were very dusty. However, when we showed this to the senior team the equipment was immediately removed from the recovery area.

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. Staffing on the ward and theatre area was planned and managed according to national guidance. Leaders used recognised staffing tools to ensure that there was enough staff to deliver care and treatment. This had last been reviewed in September 2025.

Staffing was discussed in regular trust level site management meetings twice a day so that staff could be deployed if needed. Staff from Swift ward attended bed meetings when they had medical outliers on the ward to escalate these patients. Bed meetings review the flow of patients through the hospital and does not manage the elective care pathway. Staffing was monitored daily by the matron for the area and monthly through governance meetings and by the divisional team to ensure that there were sufficient staff to provide care. Where necessary, temporary staff were utilised, but this consisted of bank staff or those already part of the ward team undertaking extra shifts. Leaders monitored staff activity and made sure that staff had adequate rest periods away from the ward. Staff had extended competencies to safely care for patients in specific areas of the service such as the theatre department and in caring for medical patients on Swift ward.

In the operating theatre department staffing was in line with national guidance. We noted that there were very few vacancies across the planned surgical care pathway at Epsom General Hospital. On Swift ward the establishment for nursing staff was over budget at just over 1 whole-time nursing vacancy. However, the actual worked nursing hours were 2.8 whole time equivalent over budget. The band five nursing whole time equivalent budget had been reduced in September from 12.5 to 9.2 and may account for the numbers of actual staff above budget and the overbudget number of hours worked. In theatres there were 7 vacancies across all the theatre department. These vacancies were covered by staff undertaking extra shifts. In the day surgical unit, the ward manager informed us that they had had a significant turnover recently for personal reasons but had managed to recruit junior nurses into these posts. Overall turnover within planned care was 6.7% better than the trusts target of 12%.

There was minimal agency nurse usage in Swift ward across the year. In the year December 2024 to November 2025 the ward requested 4,422 hours of which 94% was filled mainly with bank staff and only 3% of the total filled was agency staff. Bank staff are employed by the trust and could be permanent members of staff undertaking extra shifts. Therefore, they usually know the ward area and the hospitals policies better than infrequently employed agency staff.

There were opportunities for development and staff received appraisals. Swift ward team were split across the managers in the ward team to ensure that appraisals happened. The senior team held meetings to ensure that appropriate information was understood by all managers. The appraisal rate on Swift ward was 97%. The remaining 3 % related to a nurse who had just returned from maternity leave. The appraisal rate for doctors across planned care was above 90% with 3 out of 5 departments achieving 100% of doctors appraised. We spoke with several staff who had been supported to develop their career. This included staff at all levels such as matron, nurse and associate nurse. Specialist teams provided on site education in a variety of areas so that staff felt competent to care for the variety of patients cared for on Swift ward.

Staff had completed mandatory training including training to manage risk and incidents. The planned care directorate completion rate for doctors mandatory training was 80.9% this was below the trusts target of 85%. The team were aware of the two areas that were below target and was addressing this. Similarly, the data presented for the whole division of planned care in relation to nursing staff demonstrated compliance with the trust target in most areas of training. Where there were deficiencies the leadership team had a plan to address these.

The trust had a system by which patients needing a greater level of observation were assessed and the appropriate staff allocated. Risks were communicated at handover and at board rounds.

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. Staff followed infection prevention and control (IPC) guidance, washed hands between patient contact and wore appropriate Personal Protective Equipment (PPE). Patients who required to be cared for in isolation were able to have single rooms and staff managed effective barrier nursing. The department had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. We saw checklists which followed national guidance. The ward had the same cleaners assigned to it and these staff were treated as members of the team. The recent audit which had resulted in a bronze award being assigned to the ward noted that the flooring in the kitchen area was dirty. However, when we inspected we saw this had been addressed and the flooring was visibly clean.

The trust monitored the number and type of infections seen in the hospital. Regular audits were undertaken by the teams in the clinical areas and by the infection prevention and control team. Hand hygiene and environmental audits including equipment audits were carried out. The results of these audits were discussed with the relevant departments and an action plan to identify areas of deficit agreed. Random sampling of hand hygiene audits in the planned care service demonstrated that planned care met the 90% trust target in all months between June to November 2025 with an average of 96%. The theatre department audit contained an action plan for improvement which had actions assigned to teams and achieved by dates, but we did not see evidence that these actions had been completed. Swift ward had 1 E. coli infection and 1 C. difficile infection in the year April 2024 to March 2025. This was below the trusts target.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in managing their medications, including when changes happened. The pharmacist gave advice to patients on their individual medication and ensured that they were aware of possible side effects when their medication changed. We spoke with the pharmacist on Swift ward who was on a 6 monthly rotation of ward areas. The pharmacist reviewed medication charts to ensure that patients receive the right medication at the right time. They ordered any medication for patients being discharged and provided guidance and support to medical colleagues. We saw that areas where medicines were stored were temperature controlled. The ambient temperature of rooms was monitored, and staff knew what to do if this exceeded the limits in place. The fridge temperature was also recorded and reported if out of range. The staff kept a fan in the medication room in case the temperature rose above the maximum temperature.

Pharmacy supplied medications based on usage and need. This prevented a buildup of medication that was seldom used. Controlled drugs were stored in the appropriate locked cupboard that met national guidance. Controlled drugs were checked daily and signed to state that there were none missing. Keys to the cupboard were held by the nurse in charge of the shift. We observed a medicine round and saw that the safety of medicines was maintained during this time. Controlled drug audits were undertaken quarterly.

Within the theatre department we found cupboards locked when the area was not in use. The intravenous fluid cupboard was also locked, and fluids were stored in their original box, off the floor. This made identification of the correct fluid easier and reduced the risk of incorrect fluids being administered. The Control of Substances Hazardous to Health (COSHH) cupboard was locked and when inspected this was kept tidy. The medicines cupboards in the anesthetic rooms were tidy and organised so that staff could find medicines easily. Prepared drugs were in labelled syringes identifying what drugs were in them. Resuscitation trolleys were sealed to ensure that necessary items were available in an emergency. We opened and checked 2 of these. We found that all items were present despite some of the daily checks being not signed for. We also saw that the theatre department had a difficult intubation grab bag and an emergency drug box. The department also kept a malignant hypothermia trolley fully stocked with the appropriate medicines and guidance for these emergency situations. Malignant Hypothermia is a rare but life-threatening condition that can occur in people, who are susceptible when using anesthetic medications.