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

At our last assessment we rated this key question good. At this assessment the rating changed to Requires Improvement. The trust’s vision and strategy were not well understood by frontline staff, and there was limited evidence of meaningful engagement in shaping improvement. Staff survey results showed declining morale, enthusiasm and confidence in fairness of career progression. Although governance structures were comprehensive, they were complex and did not always translate into timely improvement.

However, staff felt supported by their immediate managers and remained committed to delivering high-quality care despite sustained pressure throughout the department. Governance arrangements were established, with regular safety huddles, incident reviews, clinical governance meetings and effective use of risk registers. Leaders understood the key risks facing the department, including patient flow, corridor care and staffing pressures, and these were appropriately escalated. The trust worked collaboratively with system partners, including ambulance services, mental health providers and the integrated care board, and staff generally felt able to speak up and raise concerns.

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 trust did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The trust had a strategy for 2023 to 2028 of ‘Outstanding care, together’ with 5 key aims. However, staff we spoke with did not know about the vision or strategy. This meant there was limited evidence of frontline staff contributing to strategic discussions.

Staff we spoke with felt supported and valued by their immediate line managers. However, staff told us the senior leadership team were not visible or supportive. Staff described senior leaders not understanding the clinical needs of the department. However senior leaders we spoke with told us about the long and medium-term direction was focused on the ambition to replace the existing emergency department with new facilities. These would address the issue that demand on the department far exceeded capacity.

Staff could explain how they were working to deliver high quality care. We spoke with staff who told us how they worked to support patients in the department to ensure they were safe and cared for. Throughout our inspection we saw staff working hard to deliver care and provide the best possible outcome achievable.

We reviewed data obtained from the staff survey. The survey was completed in 2024. The 2024 staff survey had a 28.2% response rate. Survey findings indicated that staff remained engaged in their clinical work, with a majority reporting that time often or always passed quickly while working. This suggested that staff felt able to remain focused and involved in patient care. However, fewer staff reported looking forward to coming to work, and enthusiasm levels declined slightly compared to the previous year. This indicated emerging pressures on morale, suggesting that the department’s culture was increasingly affected by workload and operational demands.

Although staff generally reported remaining absorbed in their work, the downward trend in motivation and enthusiasm suggested that existing wellbeing and engagement systems may not have fully mitigated the impact of sustained pressure within the emergency department. This indicated a need for strengthened wellbeing support and proactive engagement with staff to understand and address factors affecting morale. However, staff continued to report high levels of engagement during their shifts, suggesting that they were able to deliver effective care.

The trust had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However following our inspection, we were informed the trust did not undertake any audit monitoring of the adult acuity tools to measure effectiveness and compliance. This meant leaders could not identify whether these tools were used well or if there were areas for improvement. The trust did not demonstrate effective oversight of patient acuity and deterioration. This posed a risk to patient safety.

During the inspection, we found that the senior leadership team (SLT) was not consistently visible or accessible to staff. Many staff members told us they did not feel supported by the SLT and felt that communication from senior leaders was limited. However, the latest staff survey showed some positive indicators of compassionate leadership. A higher proportion of staff reported that their immediate manager worked with them to understand problems, and more staff felt that their manager cared about their concerns compared to the previous year. These improvements suggested that elements of empathy and relational leadership had begun to strengthen and that some managers were making efforts to engage more closely with staff.

We observed breaches in relation to privacy and dignity, particularly in the delivery of care within corridor areas where patients were being assessed or treated without sufficient privacy. This practice did not comply with regulatory standards and placed individuals at risk of embarrassment and emotional distress. Staff expressed concern about the impact these practices had on maintaining dignity and confidentiality.

We identified issues with the completion and accuracy of patients’ records. Documentation such as National Early Warning Scores (NEWS), falls risk assessments, and pressure sore assessments were not consistently completed or updated. Incomplete or missing information posed a risk to patient safety and reduced the effective monitoring of clinical risk.

Staff reported a mixed experience of equality and inclusion. The majority of respondents stated that they had not experienced discrimination from patients, service users, relatives or members of the public, and this improved compared to the previous year. In addition, more staff reported that they had not experienced discrimination from managers, team leaders or colleagues. This indicated progress in creating a more respectful and inclusive working environment at team level. However, areas of concern were identified. Fewer staff felt that the organisation acted fairly in relation to career progression, which represented a notable decline from the previous year. This suggested that opportunities for development and advancement were not consistently perceived as equitable. Similarly, fewer staff reported that the organisation respected individual differences, indicating that staff did not always feel their diversity and personal circumstances were fully recognised or valued.

The trust fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with said they were able to speak up and knew how to raise concerns. Staff knew how to access policies online through the trust intranet.

Staff we spoke to reported there was a culture of openness and staff said their voice was heard. Staff told us their ideas were listened to but things did not always change.

We can see from the latest staff survey showed some improvement in staff confidence to raise concerns and speak up. More staff reported that they would feel secure raising concerns about unsafe clinical practice, and a higher proportion stated that they felt safe to speak up about anything that concerned them within the organisation. These improvements indicated growing awareness of speaking-up processes and suggested that staff were increasingly willing to raise issues when they arose.

A small increase was also seen in the proportion of staff who felt the organisation would address concerns they raised, indicating some progress in staff confidence that issues would be acknowledged.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The trust had established governance and management arrangements intended to oversee performance and support the sustainability of the service. However, these arrangements had not adequately improved performance. Leaders had not effectively identified, monitored, or addressed ongoing concerns in a timely manner. In particular, governance processes had not ensured that patient records were consistently complete or accurate. This had resulted in weaknesses in record-keeping systems and oversight. In addition, the trust had not consistently ensured that people’s privacy and dignity were protected in practice. As a result, the governance framework had not been sufficiently effective in driving improvement or ensuring that care was delivered in a safe, respectful, and well-managed way.

The trust had a governance framework in place which was supported by a structured programme of meetings that provided oversight of safety, quality, and operational performance. This was positive and demonstrated a clear commitment to monitoring risk, escalating concerns, and supporting safe service delivery across the organisation. However, leaders told us they understood but did not always have resources and space to manage the priorities and issues the trust faced. Capacity constraints within the trust and across other parts of the hospital impacted on patient flow in the emergency department.

Within the emergency department, daily ED and AMU safety huddles were held and attended by senior leaders. This was positive as it allowed immediate risks, staffing concerns, and patient flow issues to be identified and addressed promptly. Staff we spoke with understood the arrangements for working with other teams, both within the trust and external, to meet the needs of the patients.

Clinical governance within the emergency department was overseen through a monthly emergency department clinical governance meeting. This provided a formal forum for reviewing incidents, audits, and quality improvement activity. Fortnightly emergency department and blood transfusion meetings also supported focused review of transfusion-related incidents and Datix reports which strengthening patient safety oversight.

Incident review processes were robust, with medicine incident review meetings being held 3 times per week. This was positive as it ensured incidents involving the emergency department were reviewed regularly, learning was identified, and actions were tracked.

Specialty and role specific governance meetings further supported safe care. Monthly cross-site emergency nurse practitioner meetings enabled incident review and shared learning across sites, which was positive. Monthly mental health liaison meetings supported discussion of challenges in caring for patients with mental health needs, although the frequency of these meetings highlighted ongoing complexity and pressure within mental health pathways. Weekly paediatric safeguarding meetings were attended by the Band 7 safeguarding lead, which was positive and demonstrated strong oversight of safeguarding responsibilities.

Leadership and workforce governance were supported through regular staff meetings for Band 7, Band 6, Band 5, and healthcare assistant staff. This was positive as it promoted communication, staff engagement, and dissemination of learning. However, the number of separate meetings across different forums created a complex governance structure, which may have made it difficult to ensure consistent oversight and assurance without clear coordination.

Operational quality and safety were overseen through the clinical quality and assurance committee and its subcommittees, including health, safety and risk and information governance. These arrangements supported monitoring of both clinical and non-clinical risks and ensured information governance and cyber security risks were appropriately managed.

Leaders were aware of the concerns in the department and could explain the root causes, what mitigation was being used, and what long-term solutions might be implemented. However, these solutions were often reliant on significant funding and recruitment of staff, neither of which were immediately available which has impacted on capacity issues within the department. Risks were captured on a local and trust level risk register and were rated in terms of likelihood, consequence and actions required. The risk register included information on the controls in place and the adequacy of these controls for each risk. The trust had risk management processes which meant that risks were escalated appropriately from the emergency department up to board level when required.

We reviewed the risk register for the emergency department. It correlated well with the risks we had seen and been told of during our inspection visit as did the plan to reduce and mitigate the risks. The leaders we spoke with were aware of the top 3 risks in the department. There were patient flow challenges in the department leading to longer waiting times, corridor care and staffing levels.

The trust understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated to promote improvement.

Many of the processes, audits and governance arrangements were part of hospital, trust, or health economy-wide mechanisms and the department worked with other departments, providers and agencies. For example, monthly ambulance handover meetings were chaired by the emergency department general manager and attended by ambulance services. These were a positive feature and supported collaborative working with system partners to address handover delays.

The department and the trust as a whole worked with mental health providers, the integrated care board, general practitioners and other providers and agencies.

The patients voice and feedback was obtained electronically and that information was held by the trust. Staff told us if they obtained individual feedback from patients this was given to senior leaders in meetings. We saw the results of the NHS adults inpatient survey 2024 for the trust. The survey was completed by 544 patients and we saw a 46% response rate.

The trust focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The trust provided data following our inspection which highlighted they used real-time data, multi-agency meetings, and patient feedback to reduce avoidable admissions, improve care coordination, and streamline patient flow. Innovations included embedding therapy staff in neighbourhood teams, virtual wards, and integrated urgent care pathways, enabling rapid specialist support in the community and reducing waiting times. However, when we spoke with staff, they were not able to describe any improvement or innovation work the department were doing in the department.

The department fed learning from audits, incidents and complaints into its management and clinical governance structures and these generated discussions about root causes and possible solutions and mitigations.

Mortality review group meetings were held monthly. Minutes showed appropriate discussion of identified cases and identified learning to feedback to teams. This included patient case studies and organisational learning.