Epsom General Hospital

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• 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

At our last assessment we rated this key question good. At this assessment the rating changed to Requires Improvement. The effectiveness of care was reduced by delays in assessment, referral and transfer, particularly for patients requiring surgical or orthopaedic input and for children. The absence of clear pathways and on-site surgical cover contributed to fragmented care and prolonged waits. High demand and poor patient flow led to sustained breaches of the 4 hour national standard and long waits for people experiencing mental health crisis. However, staff followed national guidance and recognised clinical pathways, with up-to-date policies and procedures easily accessible and used in practice. We saw care was planned and delivered with consideration of people’s physical, psychological and emotional needs, and patients were given clear information to support informed decision-making. Consent and Mental Capacity Act processes were well understood, and recent improvements to Mental Health Act systems ensured people were informed of their rights and had access to advocacy. Staff were supported through appraisal and development processes, which helped maintain effective clinical practice.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The trust 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 followed evidence-based care pathways in line with national guidance to provide appropriate care and treatment to patients. Staff told us they knew how to access clinical pathways and clinical guidance when required. Senior managers told us they participated in local and national clinical audits, and audit findings were reviewed, monitored and shared to support service improvement.

Staff had access to up-to-date policies, procedures and treatment guidelines, which were stored electronically and easily accessible. The trust's intranet contained a comprehensive range of up-to-date policies and standard operating procedures (SOPs) which reflected current practice. These were based on best practice guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Emergency Medicine (RCEM) and were regularly reviewed and updated. Staff protected the rights of patients subject to the Mental Health Act and worked in line with the Code of Practice. During handover meetings, staff routinely discussed the psychological and emotional needs of patients, as well as those of their relatives and carers. Staff gave people clear information about their care and treatment needed to support their physical and mental health.

Managers supported staff development by identifying learning needs and providing opportunities to develop skills and knowledge. Staff received annual appraisals with their managers, which were used to review performance, identify development needs and align individual objectives with organisational priorities. We reviewed appraisal data and saw that 87% of urgent and emergency care staff had received an appraisal.

Members of the psychiatric liaison team completed comprehensive bio-psychosocial assessments. We reviewed the records of 2 patients and saw clear evidence that full bio-psychosocial assessments had been completed to support appropriate care and treatment.

The trust had taken action to strengthen processes around the application of the Mental Health Act. A new system had recently been introduced including the use of a tracker which ensured patients were informed of their rights and had access to advocacy services. The patient we spoke with demonstrated a clear understanding of their rights and told us they knew they could leave the department if they wished.

The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Patients requiring onward referral or transfer often experienced prolonged waits and disruption to their care, particularly those needing surgical assessment. Adult patients were frequently transferred between emergency departments. Children experienced significant delays to imaging, escalation and surgery, indicating that referral planning did not consistently prioritise timely outcomes. However, staff worked to progress investigations as quickly as possible and followed agreed age-related referral criteria to ensure patients were directed to the most appropriate service.

Children and adults moving between services did not always receive seamless care, as not all relevant teams were involved early in assessing and planning treatment. This was particularly evident for paediatric patients, where the lack of a defined surgical review pathway led to fragmented assessments and delayed escalation. However, efforts had been made to clarify referral expectations, and staff demonstrated awareness of the risks and escalated concerns when delays occurred.

Patients were affected by gaps in communication between teams, which contributed to uncertainty around responsibility for care and delayed decision-making. Changes to paediatric nursing governance had reduced the effectiveness of information sharing and escalation processes between emergency, paediatric and surgical services. However, teams continued to communicate through established clinical channels, and senior clinicians were available to support escalation when concerns were identified.

Patients experienced delays and inconsistency in assessment and treatment, which increased the risk of harm and led to a poor experience of care. The absence of clear written pathways for surgical and orthopaedic review meant that decisions were often reliant on informal processes, and the lack of on-site acute surgical cover further limited timely senior input, particularly overnight.

Crowding and limited senior availability during peak hours delayed timely assessment and decision-making, which disrupted coordination of care across teams. This was compounded by inconsistent senior paediatric presence and gaps in specialist support. However, middle-grade staffing had improved which provided greater consistency, and additional senior cover had been introduced at key times to better support children and improve overall quality of care.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The trust did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Over the period from 30 November 2024 to 30 November 2025, the average patient reattendance rate was 12.4%, based on the data reviewed. Reattendance rates were generally consistent throughout the period, remaining between 9% and 11% for most months. However, there were notable increases in May 2025 (25.2%) and June 2025 (27.5%).

From the end of July to mid-September 2025 the percentage of type 1 patients at Epsom spending less than 4 hours in A&E at Epsom Hospital was consistently above 70%, during the same period the national average was between 60-65%. However, Epsom did not manage to meet the national target of 78% between June and September 2025. Prolonged waits increased the risk of delayed assessment, treatment and escalation of care, particularly for patients with time-critical conditions. This indicated sustained pressure on patient flow and capacity within the emergency department.

Effective arrangements were in place to support timely ambulance handovers, which helped to protect patient safety and maintain ambulance crew availability. Between December 2024 and November 2025, the trust achieved an average ambulance handover time of 22.3 minutes, with monthly averages remaining relatively stable and largely between 20 and 23 minutes, with a temporary increase to 26 minutes in May 2025 during a period of known system pressure. When compared with the national average ambulance handover time for the same period, which was approximately 35 minutes across England, the trust consistently performed better than the national position.

Shorter handover times reduced the length of time patients waited in ambulances before clinical assessment and treatment, supporting safer and more responsive care. In addition, timely handovers improved system resilience and helped maintain capacity to respond to emergency calls across the local area.

Sustained demand from people presenting in mental health crisis continued to place pressure on emergency care services and had the potential to compromise patient experience and timely care. Between December 2024 and November 2025, the emergency department recorded an average of 127 mental health patient presentations per month, with monthly figures ranging from a high of 172 in January 2025 to a low of 91 in May 2025. Over the same period, the average proportion of these patients waited longer than 12 hours in the department with a mental health condition was approximately 46.5%. Monthly percentages fluctuated, from a low of 32% in June 2025 to a high of 62% in October 2025.

The emergency department participated in national clinical audit activity relevant to emergency medicine, including audits coordinated through the Royal College of Emergency Medicine (RCEM). This activity was intended to support quality improvement, patient safety, and assurance against national standards.

The trust experienced a delay in receiving RCEM audit reports for the 2023/24 period because authorisation of the required payment had not been completed. This resulted in a temporary gap in access to benchmarking information and limited the department’s ability to review performance against national indicators during that period. To mitigate this a meeting was held with the emergency department clinical lead, and arrangements were made to identify individual audit leads within the department. These actions supported improved ownership and oversight of audit activity. Following implementation of the electronic system, plans were put in place to recommence continuous RCEM audits to ensure ongoing monitoring of performance.

The Trust recognised that timely engagement with national audit programmes was essential to effective governance within the emergency department. Actions taken demonstrated a commitment to restoring compliance with national audit requirements and strengthening assurance processes within the trust.

The trust told people about their rights around consent and respected these when delivering person-centred care and treatment.

People were supported to receive effective care and treatment through clear and appropriate consent processes. The trust ensured people were informed about their rights in relation to consent, and these were respected when delivering person-centred care. In the emergency department, consent was usually obtained verbally, which was appropriate to the clinical context and supported timely and effective care delivery.

The trust had robust policies and procedures in place that reflected current legislation, national guidance, and recognised best practice. These included effective arrangements for situations where patients were unconscious or otherwise unable to provide consent. We reviewed the consent policy and saw that appropriate consent documentation was available and used to support safe and effective care and treatment.

Staff supported patients to make informed decisions about their care and treatment and consistently followed national guidance when gaining consent. They demonstrated a strong understanding of mental capacity and were able to assess capacity appropriately. Staff knew how to support patients who lacked capacity or were experiencing mental ill health, ensuring decisions were made in people’s best interests and contributed to effective outcomes.