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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. The department and staff were well-led by strong leaders who embodied the cultures and values of their workforce. There was improved governance and risk management, and a positive culture. The service worked well with others in the Integrated Care Board to meet the needs of people. They empowered staff to lead change and improve the quality of service to patients.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 service did not have a shared vision and strategy. The trusts strategy was based on the care objectives: Collaboration and partnership, Affordable services, fit for the future, Right care, right place, right time, Empowered, engaged staff. Leaders had undertaken listening events to involve staff in the direction and culture of the organisation. While leaders had identified emerging priorities through the Surgery Clinical Standards and Strategy Group (CSSG) aligning priorities with the group’s transformation programmes and had identified opportunities to improve efficiency, there was no formalised service strategy in place. These priorities included relocating services to create capacity across the group. The values of the organisation were redefined on the official group modelling of the two trusts, St Georges and Epsom and St Helier. Staff demonstrated the value held by the trust that they value respect. Staff lived the behaviours in that they were very kind, positive, professional and worked well together as a team.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff and leaders demonstrated a positive and compassionate culture with a focus on learning and improvement. There was a shared culture of teamworking and improving to enhance the patient experience through respect of each other and the patient’s needs. This culture ran from the top to the bottom of the areas we inspected. We heard from every person we spoke to about how they valued and respected each other leading to enhanced patient care.

Staff felt supported by all levels of their leadership team. Staff spoke positively about the immediate managers and matrons and the way they supported them. Matrons and senior leaders spoke with emotion about how proud they were of their teams, their dedication and compassion to deliver good care. Staff knew who the executive leaders were and told us they sometimes visited the ward.

The local leaders were available when they were needed and led by example. They were knowledgeable about the issues and priorities in the planned care service. They understood the challenges within the services and sought to address these through improvements. They focused on staff wellbeing and ensured a culture promoting good practice, good quality, and safe care and treatment.

Staff told us leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the trust. Staff were aware of the senior leadership team but saw more of the directorate team than the executives. They found the directorate team approachable and would share their thoughts with the team if needed. We spoke to several staff who had been assisted through learning opportunities at the trust to develop into management roles. One described arriving at the trust as a healthcare assistant and when they obtained their nursing registration had been supported to progress to a senior nurse on the ward. Staff in general felt well supported through training and development to progress their career.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff at all levels of the organisation were available to support people who had a concern. Ward staff said that their managers were available if they had any concerns. They felt listened to and that action would be taken to address the issue raised. Staff who had raised concerns in this manner were able to tell us about the concern and the action taken. This included being able to address issues between nursing shifts on the ward. Martha’s rule was currently being piloted on wards at the St Hellier site. However, there were leaflets available to patients about raising concerns which directed them in the first instance to the ward staff to resolve their issues. Patients we spoke with felt able to raise issues with the ward staff and that they would be listened to.

The service had established Freedom to Speak up arrangements. Information about the guardians and how to contact them was available on both the internet and the intranet. Telephone numbers and email addresses were included in the information along with a national helpline for whistleblowing. Guardians aimed to respond to staff within 48 hours. There were advocates across the site so staff could access them more easily. However, staff in the surgical service did not know who these were. Staff were aware of how to raise concerns but stated that they would more likely raise issues with their line manager as action would be taken by them in a supportive manner. However, there was no data supplied which indicated how the surgical service used this pathway to raise concerns. Therefore, it was unclear if there were themes and trends relating to the surgical service staff concerns.

Senior leaders felt that they could do more to utilise the feedback from patients. They had ambitions to start patient feedback panels and to get patients feedback on planned initiatives in the service. This occurred in parts of the hospital but not currently in the surgical service managed by the planned care directorate.

Staff told us that they were able to work flexibly to consider personal circumstances such as caring responsibilities. Managers would put reasonable adjustments in place for staff members.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The trust had several networks which included those for LGBTQI+, Disability, Black, Asian and minority ethnic, carers and armed forces, which were open to all staff. According to the Workforce race equality report for 2025, 47.8% of staff fell into the BAME categorisation. However, the trust had seen a drop in the numbers of BAME staff working in band 8d+ (from 35% to 7.7%) and in the medical category (from 55% to 32%). The trust saw improvement in 3 of the national indicators including BME staff experiencing abuse or bullying and harassment form patients and relatives and from other staff. Two elements had remained static whilst 5 had declined. There was an action plan in place which was monitored by the senior leadership team.

Leaders within the service had identified that they had issues with under representation of ethnically diverse and disabled staff in senior roles, had inconsistent local disciplinary actions and workplace adjustments. Staff, however, felt able to report concerns in relation to inclusion. They had plans in place to address these issues including through inclusive recruitment and standardisation of recruitment and flexible working practices. We reviewed a request from a member of staff and noted how leaders had looked at all options for how they could continue to provide a service and agree to the request. They could not approve the request, so offered the member of staff a compromised solution.

Staff undertook governance, risk and performance meetings. However, action plans submitted to us did not have dates attached to actions and data was not always broken down to site or departmental level. We reviewed minutes from the governance meeting. There was a range of accurate and timely data and information available to understand performance and quality and improvements were made as needed. Governance was used to learn, improve and innovate at a local level. Information held about patients was kept secure and protected. Senior leaders met with ward leaders to discuss the issues in their areas in a supportive way to drive improvements.

There were monthly meetings of the divisional board where governance issues from all areas within the surgical service at Epsom were discussed. These had standing agenda items. We reviewed the minutes from the previous six months and found that this addressed salient points of good governance. These demonstrated that risks were discussed, actions and rating agreed by all present. Complaints and the speed at which these were addressed was reported at the meeting. A weekly meeting occurred for those complaints whose response was delayed. It was not possible given the data sent to us to see how many complaints the surgical team at Epsom General Hospital received as complaints information was across the division. Information was disseminated to all staff through a newsletter as well as during the safety huddles occurring three times a day. There was a site meeting which occurred daily across the hospital however, within Swift ward the staff only attended when they had medical outliers on the ward as this was when they predominantly utilised additional staff.

Ward huddles occurred several times a day and included patient safety events and learning. Information shared was recorded in a huddle book. This allowed staff to read what had happened when they had had some time off. It also assisted with complaint management in that issues for individual patients were recorded. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. All staff we spoke with were aware the relevant clinical nurse specialist and who to contact for continuing care at home for patients. Relationships at this micro level were well established and good.

The risk register was reviewed as part of the governance meeting and risks were mitigated and rated appropriately. However, it was not always possible to identify where the risk was an issue as the site was not always listed. This made it difficult to know which risks were across the service and which pertained to the Epsom General Hospital site.

Due to the implementation of the patient electronic record system the service and the trust had had some difficulty in obtaining reliable data to audit some aspects of care effectively. Some work arounds were in place to address this such as manual recording of the decision to cancel an operation on the day of surgery. Research initiatives had also been difficult during this time. However, the trust had been successful in recommencing this programme shortly before we inspected.

There were multiple policies for what to do in the event of an issue which would impact on the service. Overarching business continuity plans were in place alongside impact assessments for the ward and department areas. These were not always complete in that they had not been signed off by the senior responsible officer. Staff ensured that patient records were kept confidential and computer screens were locked when not in use. Ward and area managers had access to information about their area and department and could identify the challenges, issues and where their area of responsibility excelled. The matrons and the leaders at ward level were able to describe challenges that they had faced in terms of staffing. In the day surgery unit this related to the influx of newly registered staff and in theatres the utilisation of staff undertaking additional shifts to ensure cover.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The service worked together with others regularly to host Multi Agency Discharge Events (MADE). During the identified time multiagency staff from health and social care were on site at the hospital to review patients who were to be discharged. These events ensured that patients who may have complex discharges were discharged to safe environments. Senior leaders stated that during the time these events ran they had no problems discharging patients but progress towards a timely discharge for patients with complex needs were not sustained after the event. The latest event was held on 11 November 2025.

Whilst length of stay was not usually a problem at Epsom General Hospital, as around 91% of patients went home within 24 hours, complex discharges sometimes had to go to rehabilitation settings prior to being supported to return home. The enhanced recovery nurse liaised with social services about packages of care. However, waiting for assessment and placement took some time. Directorate leaders engaged with external stakeholders during the MADE events, but it was unclear of any future plans to ensure joint working to enhance the discharge process.

Staff and leaders had a good understanding of how to make improvement happen. Staff felt empowered to make simple and quick improvements to the service. However, there was a formalised approach for the bigger projects such as the transformation project in the theatre department and the project on Swift ward to promote a timely discharge. This was called “Go home swiftly.” The theatre transformation project included actions to improve theatre start and finish times, reduce patient waiting times in the department pre surgery, reduce the number of list changes currently occurring and effect cultural change within the department. The tracker we were sent had actions identified alongside their owners but did not have completion or target dates for completion. It was therefore unclear how far the service had progressed with this despite being able to tell us about the changes made. A further initiative to reduce cancellation on the day of surgery was being implemented. The Pre-Operative Admission (POA) had been piloted but a rollout had been paused and planned for December 2025. The tracker we were sent had actions identified alongside their owners but did not have completion or target dates for completion. It was unclear how far the service had progressed with this. Despite the documentation we were sent, the staff we spoke with were aware of several improvement projects underway. On the ward they had participated in a ward accreditation scheme and whilst they were disappointed with the outcome, they had begun to plan actions to be taken to achieve a better score on reauditing.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. These were shared across sites at safety huddles which occurred at the beginning of each shift and in the early afternoon. Swift ward staff could describe the actions taken since the never event in March 2025. They had also received extra training on several areas where they had identified they needed support. The theatre department had a QI board which contained information on how the length of stay for joint replacement patients had been reduced. The average length of stay for a patient having a total knee replacement had reduced from 2.07 days to 1.76 days and for a hip replacement from 1.76 to 1.5 days. Other metrics of savings were the amount of bed days freed up by this initiative (15) and the reduction of waiting times to 5 weeks.