Epsom and St Helier University Hospitals NHS Trust

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
• Environmental sustainability – sustainable development

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 evidence showed some shortfalls. Leaders had established a clear strategic direction and governance arrangements; however, the vision, values and strategy were not consistently understood or embedded across the organisation. There was limited assurance that strategic priorities were consistently translated into practice, with variation in local ownership, culture and outcomes indicating inconsistent delivery of strategic objectives.

The trust had a clear vision and set of values, with quality and sustainability as key priorities. Its five-year strategy, Outstanding Care, Together: Our Strategy 2023–2028, was developed with patients, staff and partners and aligned with wider system plans. The strategy was supported by four enabling strategies covering quality and safety, people, digital and sustainability. Two further supporting strategies were in development at the time of the inspection; a research and innovation strategy, and an estates strategy.

Governance arrangements were in place to support delivery of the strategy, including Board oversight, the Board Assurance Framework, performance reporting, risk management processes, and executive, site and divisional governance structures.

The trust also had a clear strategic direction through its CARE framework, however this was not always understood by staff. The trust has set four key priorities for 2028, its CARE objectives; Collaborating and working in partnership; providing Affordable services that are fit for the future; delivering the Right care, in the right place, at the right time; and supporting and Empowered and engaged workforce (CARE). The Board and senior leaders had a shared understanding of the organisation’s priorities, supported by the 2025 Board Strategy Review, the Medium-Term Plan, a long-term vision to 2031, and developing plans to merge with St George’s University Hospitals NHS Foundation Trust. 

However, not all staff understood the trust’s vision, values and strategy, or how they contributed to delivering them. While there was corporate-level oversight, there was less assurance about how well the strategy was understood and implemented across divisions and teams. Numerous staff we spoke with when we undertook the assessments of care services on both sites were unclear or did not know the strategy for the trust or, importantly, how it would impact on the areas they worked and how they might contribute to the realisation and development of the strategy. The trust had not routinely engaged to ensure staff understanding of its strategy and values, limiting assurance that these were fully embedded throughout the organisation.

Although the strategy aligned with local health and social care priorities, there had been a lack of pace in progressing some strategic objectives, particularly those relating to the group model and organisational culture. Senior leaders acknowledged that embedding the strategy had taken longer than anticipated, with challenges linked to integrating the two trusts into a cohesive group with a shared purpose and vision. Many conversations across the organisation described a split culture, which contributed to silo working and missed opportunities for collaboration and shared learning. There was a risk that this delay in an effective shared strategy could hamper trust objectives and if not fully controlled could impact on the formal merging of the organisations of the GESH group. We were assured that the trust executives were clearly sighted on this as an immediate priority for the organisation and plans were already in place and others in development to ensure that these risks were mitigated or eliminated. For example, senior leaders had taken steps to understand and formulate plans for health equity in a diverse population, including the appointment of two consultants to lead on this work, alongside an Inclusion Board to ensure consistency and equity for staff and service users.

While the trust was increasingly using CARE Boards (these are divisional boards aligned to the CARE framework objectives) to link local objectives with Group priorities, implementation was not yet consistent across all services and teams. There was also variation in local ownership of strategic priorities and leadership capability, which affected how effectively the strategy was embedded into day-to-day practice. Although patients, staff and partners had been involved in the development of the strategy, staff described co-production as not being consistently embedded within divisional planning and improvement cycles.

Although the trust launched a new set of values 7 years ago, there was variable knowledge and awareness of these values across the organisation. Our observations and interviews confirmed inconsistencies in how well the values were understood and applied. The trust had introduced leadership development programmes, staff engagement initiatives and recognition schemes, including CARE Awards, to reinforce organisational values and behaviours. However, senior leaders recognised that further work was required to strengthen awareness and embed the values consistently. More broadly, there was variation in how organisational culture and leadership were experienced across teams, and inconsistent alignment of local priorities with the overarching strategy. Many staff described differing experiences of culture across the organisation, and some continued to identify distinctions between the hospitals.

The Group Accountability Framework and Inclusion Board provided additional oversight of organisational performance and culture. Board assurance was increasingly supported through triangulation of quantitative and qualitative information to understand staff experience across the organisation. However, we found during our assessments of clinical services in December 2025 that leadership visibility, local ownership of the strategy was not consistent across all areas. In addition, the use of workforce data, including equality, diversity and inclusion metrics, to inform improvement was variable across divisions. While strategic risks were reflected within the Board Assurance Framework, alignment between strategic objectives, risks and improvement activity was not always explicit at divisional level.

The trust was actively engaged in a process of self-improvement and culture change, largely in response to external reviews and staff feedback. While there was evidence of commitment to embedding positive practices, many initiatives remained at an early stage, and delivery against some actions was still in progress. ESTH demonstrated a commitment to cultural improvement, particularly in promoting equal opportunities for career progression and promotion. However, staff survey results from 2024 reflected mixed progress: while more staff felt safe to speak up, there had been a decline in reported opportunities for career development, skills development, and the frequency of appraisals. There was also variation in how workforce equality data was used to support improvement and accountability at divisional level. We had received contacts from staff describing poor cultural practices in parts of the organisation, where managers were slow to take actions to address their concerns.

During and throughout the assessment, the CQC received communications form staff describing concerns around alleged discrimination in leadership and recruitment, poor wellbeing and morale, bullying and harassment (particularly in pharmacy and surgery), and a lack of action and fear of reprisal when speaking up. These concerns reflected variation in staff experience across the organisation and were consistent with feedback received through some engagement channels and workforce indicators.

A significant development since the 2019 well-led assessment was the establishment of The GESH Group in February 2022, bringing two trusts together under a group model with shared leadership. Senior leadership changes, including the appointment of a new Group Chair, Chief Executive and Chief Nurse, were intended to support this transformation. The trust had developed a clear strategic direction and was taking steps to strengthen alignment between organisational priorities and local delivery through initiatives such as CARE Boards, the Medium Term Plan and the development of a Quality Management System.

However, embedding a consistent culture, strengthening staff understanding of the strategy and values, improving co-production within planning processes, strengthening leadership visibility and capability, and ensuring alignment between strategy, risk and day-to-day practice remained key areas for improvement. Leaders had identified actions to address these issues, including embedding CARE Boards consistently across services, developing a single set of Group-wide values, strengthening Board-to-Ward alignment, improving communication and measurement of staff understanding of the strategy, enhancing staff engagement mechanisms, and increasing divisional accountability for equality, diversity and inclusion outcomes. While Board assurance regarding strategic delivery was strong at corporate level, improving consistency of understanding, ownership and delivery at divisional and team level remained a key focus for the organisation.

The evidence identified some shortfalls. Leaders understood the context in which care was delivered and demonstrated the skills, knowledge and credibility to lead effectively. However, leadership visibility and effectiveness were not consistent across the organisation, and governance arrangements and culture were not fully embedded, including in promoting a positive and inclusive environment. There had been and remained gaps in key permanent leadership positions prior to and during our well led assessment.

There was a clear board structure in place (board in common with St George’s) with a chair appointed in April 2025. There had been a period of an interim group chief executive between September 2025 and April 2026. Shortly before our well led assessment, a permanent group chief executive had been appointed and was interviewed as part of this assessment. During our assessment there remained 2 key executive positions that had interim appointments in place. These were the interim group chief nurse and the interim group finance director. There had been more stability in senior leadership at the Epsom and St Helier sites though the managing director and chief operating officer were also in interim roles. This demonstrated that there had been significant movement on the board and a lack of stability over the preceding months. The interim executives we spoke with were clearly aligned to the direction of the organisation and were committed to improving and developing the trust. We were told that permanent appointments to these positions were to be made shortly after our trust level assessment. Given the work required to enable the successful alignment of the trust with St George's, both the chair and chief executive were clear on the importance of these appointments.

Most leaders had the skills, knowledge and experience required to undertake their roles. A clear and structured approach to leadership was in place, underpinned by the CARE strategy and a focus on compassionate and inclusive leadership. Leadership development programmes supported leaders at all levels and were aligned to workforce priorities and the trust’s strategic direction, including initiatives to improve leadership diversity and inclusion.

The executive board were open to reviews, for example a Board Effectiveness Review 2025/2026 was completed that identified areas of improvement including rebalancing the board to strategic leadership, allowing detailed assurance to be completed by the board sub committees and which would require further empowering of site and local leadership. Board dynamics should also be improved by ensuring all board members voices were heard at board and ensuring clarity of roles. Importantly, it was recognised that information flows should be improved with key papers sometimes being late, or containing too much information limiting effective scrutiny.

There was evidence of strong leadership in some areas, with leaders visible and engaging staff through forums, walkarounds and structured engagement processes. The Trust was taking steps to strengthen its listening culture through staff surveys, Freedom to Speak Up arrangements and targeted engagement activity. There was also an increasing focus on defining and reinforcing expected leadership behaviours, with recognition that consistent leadership practice is critical to delivering both strategy and culture.

However, staff experience of leadership was not consistent across the organisation. Staff feedback and survey data highlighted variation in engagement, confidence and overall experience, particularly among some protected groups, including disparities for Black and minority ethnic and disabled staff. Leadership visibility, recognition and support were variable across divisions, and there were gaps in succession planning and leadership pipeline development.

While leadership development programmes were in place and had been strengthened, including through the GESH People Management Programme, access and uptake were sometimes limited due to operational pressures. As a result, leadership capability in key areas such as inclusive leadership, coaching and staff engagement was not yet consistent across all levels.

Leaders generally understood the challenges to quality and sustainability and the actions needed to address them. However, they did not always have the capacity or capability to ensure improvements were consistently implemented and sustained. Although leadership development arrangements were established, leadership behaviours were not applied consistently across the organisation. This was reflected in variation in staff feedback, culture and outcomes between services and divisions as well as the findings of the services assessments we completed in December 2025.

A senior leader told us that some governance and operational roles were not always well defined leading to some overlap of roles and accountabilities. It was also not consistent with other areas of the group model increasing the complexity further. These structures and complexity reduced clarity of accountability and created challenges in decision-making and operational delivery, alongside challenges to risk management and governance.

Senior leaders recognised these challenges and had identified actions to strengthen leadership capability, improve succession planning and talent management, and better align leadership development with organisational priorities. There was also a focus on embedding inclusive and compassionate leadership behaviours and supporting leaders to create psychologically safe working environments. However, these actions were not yet fully embedded and had not consistently improved leadership effectiveness across the Trust.

The 2025 annual staff survey saw 3435 staff members participate across ESTH, a reduction from 3849 participants in 2024. NHS staff survey results showed compassionate leadership had slightly worsened since 2024, but had improved since 2023, though it remained in line with the national average.

Fit and proper person regulation (FPPR) is the regulation that requires NHS trusts to check all executive and non-executive directors (or equivalent roles) are suitable and fit to do the role. The service had implemented robust systems to ensure compliance with the FPPR. We reviewed the files of 5 executive staff files and found that they demonstrated the necessary suitability and fitness for their respective roles, as defined by the regulation.

The evidence identified some shortfalls. The trust had established systems and processes to support speaking up, including a Freedom to Speak Up service and supporting governance arrangements. However, staff feedback, survey data and FTSU reporting identified inconsistent experiences of speaking up, including variation in confidence, responsiveness and the embedding of learning across divisions.

People did not always feel they could speak up and that their voice would be heard.

The Trust had a developing culture of speaking up. There was a well-established Freedom to Speak Up (FTSU) Guardian service, with a highly visible, accessible and committed Guardian who was actively engaged across the organisation. There were clear governance arrangements, including Board-level leadership and oversight, with regular reporting of themes, trends and learning to the Board and People Committee.

Staff had access to multiple routes to raise concerns. These were supported by a group-wide FTSU policy aligned to national guidance and a standardised triage process to support the consistent handling and escalation of concerns. Leaders increasingly triangulated FTSU information with workforce, quality and patient safety data to strengthen organisational oversight.

A total of 85 concerns were raised through the FTSU service over Q3 and Q4 2025/26. The majority of concerns were raised by nursing, midwifery, and administrative and clerical staff, with the highest number originating from the medical clinical division. The most common themes of concerns were management conduct, bullying and harassment, and HR-related issues. Concerns relating to management conduct included unaddressed inappropriate behaviour, lack of timely intervention and inconsistencies in leadership response. Concerns also highlighted issues with confidentiality, delays in processes and perceived lack of fairness in the application of policies.

There was evidence that concerns raised led to action and service improvement, including immediate mitigating actions, external reviews and targeted improvement programmes in areas such as water safety, interstitial lung disease and acute medicine. However, the concerns relating to interstitial lung disease were raised by staff and the trust was initially slow to respond to these concerns. The Trust promoted a culture of openness through staff engagement mechanisms, leadership visibility and alignment with wider priorities relating to safety and learning. Engagement with the FTSU service had improved in recent years, and there was evidence that some services responded constructively to concerns and used them to inform improvement. Learning from concerns was increasingly captured within governance processes.

However, the experience of speaking up was not consistent across the organisation. Staff survey results indicated that confidence in speaking up remained below national benchmarks, with variation across divisions. While many staff reported feeling able to raise concerns about unsafe clinical practice, fewer felt confident to speak up more broadly or that concerns would be acted upon. Staff described variability in leadership response, including the timeliness and quality of human resources investigations, and there remained concerns about potential detriment. Delays in resolving concerns and inconsistent adherence to policy timescales impacted staff confidence and wellbeing.

It was clear that the freedom to speak up guardian was well sighted on the issues that were of concern, the themes and trends of the contacts they had received alongside clear methods of escalation. At the time of the inspection, there was one Group FTSU Guardian and one Deputy FTSU Guardian. There were vacancies in the team which had implications for the resilience of the service. Executive leaders were sighted on this risk and determining the actions required to support the service. Given the concerns highlighted in staff surveys regarding culture in parts of the organisation, this would remain a key priority area. 

Furthermore, there were ongoing issues with timeliness of responses with some concerns not resolved quickly enough which had been reported by staff. Information received prior to the inspection from staff that concerns they raised in relation to a variety of issues such as clinical or employment were not managed in a timely way. The ongoing concerns in some areas of the workforce and the themes that were identified by freedom to speak up across the trust indicated that the organisation did not have a strong grip on some of the themes and recurring concerns, impacting staff welfare but system-based learning and improvement.

The Trust recognised these issues and had identified actions to strengthen leadership accountability for openness and psychological safety, improve the consistency and timeliness of responses, and enhance feedback and visibility of learning. There was a focus on addressing variation through targeted leadership development and cultural improvement.

The evidence identified some shortfalls. Workforce data, staff feedback and inspection findings demonstrated inequalities in staff experience and outcomes, particularly for Black and minority ethnic staff and disabled staff. Although systems were in place to monitor inequalities through WRES and WDES, these had not consistently led to improvement. There was limited evidence of routine triangulation between workforce inequality and patient safety data, and initiatives to promote inclusion were not consistently embedded or effective across the organisation.

Our interviews with staff at all levels and review of documentation demonstrated that the trust did not always value diversity within its workforce. Senior leaders did not consistently recognise or fully consider the impact of workforce inequality on service delivery and patient safety. However, leaders demonstrated a commitment to working towards a more inclusive culture to promote equality and equity for staff.

The trust’s stated commitment to continuously improving organisational culture was not fully reflected in staff experience. At the previous Well-led assessment in 2019, areas for improvement had included addressing bullying and harassment, embedding equality and diversity networks, and promoting equality in career progression, particularly for Black and minority ethnic staff. Our review found that, while there had been some developments, there remained work to do in these areas and limited evidence of sustained improvement.

Processes to remove bias from recruitment, promotion and workforce practices were not always effective or fully embedded. Some staff described experiences consistent with structural discrimination. Monitoring arrangements were in place through the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES); however, these had not consistently translated into improved outcomes.

Workforce data demonstrated ongoing inequalities. Black and minority ethnic (BME) staff were over‑represented in lower pay bands and under‑represented at senior levels, including non‑clinical management roles above band 8b and at Board level. For example, only 7.1% of non‑clinical very senior manager posts were held by BME staff, and Board composition did not reflect the diversity of the wider workforce or local population. Recruitment disparities had also worsened, with White applicants 1.56 times more likely to be appointed from shortlisting compared to BME applicants, and BME staff more likely to enter formal disciplinary processes.

There had been some positive progress in building capability of EDI through champions networks and divisional engagement and there were some positive examples of improvement and embedding practice such as in maternity and some other targeted interventions. However, there remained some inconsistent embedding across the organisation with ongoing challenges in awareness, capacity and engagement. Leaders were aware of these challenges and that they had been ongoing for some time with out being adequately addressed.

Staff from BME groups reported worse experiences than white staff across a range of indicators, including discrimination, career progression and workplace treatment. Although there had been some improvement in reported harassment, bullying and abuse, 13.4% of BME staff continued to report discrimination from managers or colleagues. These findings were consistent with feedback from staff during the inspection.

Similarly, staff with a disability or long‑term condition reported worse experiences than those without. They were more likely to experience harassment, bullying or abuse, including from managers (19.6% compared to 9.6% of staff without a disability), and less likely to feel valued by the organisation. Staff with a disability also reported poorer perceptions of equal opportunities for career progression and were more likely to feel pressure to attend work when unwell. Although there had been some improvement, including 68.8% of staff reporting that reasonable adjustments had been made, this remained below national benchmarks (73.5%) and indicated further work was required.

Staff feedback about culture and the working environment was mixed. Some staff described the trust as a supportive place to work where diversity was embraced in parts of the organisation. However, staff also raised concerns relating to bullying and harassment, racism, and perceived unfair treatment. These concerns reflected themes identified in WRES, WDES and Freedom to Speak Up data and indicated variation in staff experience across the trust.

We were concerned that the trust was not consistently triangulating workforce inequality data with patient safety information to understand and respond to the potential impact on care delivery.

Leaders had taken action to address bullying and harassment, including implementing policies, initiatives and support mechanisms. However, some staff felt these were not always effective in preventing or addressing concerns.

Staff equality networks had been established to promote inclusion. The trust had four staff networks, but these were not consistently effective. Not all networks had an executive sponsor, and some had lacked leadership for extended periods. Staff told us they were not always given protected time to attend network activities, which limited engagement. Where networks were active, events were described as positive, and there were plans to strengthen their impact.

At the time of inspection, the trust had introduced a new group diversity and inclusion action plan for 2025–2027, aligned to the People Strategy and NHS England’s EDI Improvement Plan. This included six priority workstreams: leadership commitment, health and wellbeing, inclusive recruitment and talent management, eliminating pay gaps, supporting internationally recruited staff, and safeguarding the workforce. Senior leaders demonstrated awareness of the challenges in embedding a group-wide approach and were committed to improving measurable outcomes.

The trust had also implemented an Inclusion Board as part of its inclusion and leadership development approach. At the time of our assessment, members of the Inclusion Board had been appointed and had attended their first private and public Board meetings, which leaders reported as a positive step towards improving representation and inclusivity in decision making.

Executive leaders acknowledged that aspects of the organisation required further development. They identified that elements of the people function, including employee relations, required strengthening and described this area as fragile. Leaders had implemented a range of initiatives aimed at addressing workforce inequalities and improving staff experience across the organisation, although these had not yet consistently translated into improved outcomes.

The evidence identified some shortfalls. The trust had established governance, management and assurance frameworks, supported by a group model with defined accountability and oversight through the Board, committees and Board Assurance Framework. However, inspection findings, documentation and staff feedback demonstrated that these arrangements were not consistently effective in practice. Although systems for risk management, performance oversight and assurance were in place, several strategic risks remained subject to limited assurance, with gaps in controls identified in areas including safety culture, workforce and leadership. Variation in the application of governance processes, including risk identification, escalation and use of data, limited assurance that risks were consistently managed and governance systems were operating effectively across the organisation.

The trust had entered into a group model of governance and accountability in February 2022 (after agreeing to a formal group model in June 2021). This meant there was a group executive team with overall responsibility for achieving the shared strategic objectives for each of the trusts within the group model. A group governance and accountability framework was in place which identified roles, responsibilities and areas of accountability at group level. For each trust, site‑level leadership teams were responsible for ensuring that governance, performance and operational issues were escalated appropriately through group structures. Though the group model had been in place for some 4 years, the trust was not as far along the integration path that would be expected, for example structures were different between the constituent parts of the group. We found the different structures across organisations meant that there was some overlap in accountabilities and responsibilities and therefore a lack of clarity around this in some areas of the organisation. A number of senior leaders we spoke with recognised this as a key issue for the trust and its place as part of the group model. Clear structures and accountabilities were required to ensure progression to a formally combined group was achieved.

The trust had established governance, management and assurance frameworks to support the delivery of its strategic objectives. These were underpinned by defined organisational structures from Board to ward and formal accountability arrangements through the Group Accountability Framework. Board and Committee structures were in place, with oversight of quality, safety, finance, performance, infrastructure and workforce provided through Board Committees, the Group Executive Committee, Site Leadership Group, divisional governance meetings and the Integrated Quality and Performance Report.

The Group Board met in public bi-monthly, with private board meetings and board development sessions at other times. The Trust’s financial governance was overseen by the Group Audit and Risk Committee; and the Group Finance, Performance Committee (FPC). The audit committee was chaired by a senior accountant of seniority focus on assurance on operational risk management; the chair of FPC also had significant senior leadership experience in finance and performance management. Patient stories were utilised to give examples of where improvements could be made and also where good care and treatment was given. On occasion, the patients and their family were invited to board.

Our observations, review of documentation and interviews with staff at various levels demonstrated that the interaction between group and site leadership was not always effective. This impacted on the effectiveness of governance arrangements in some areas. For example, issues in maternity, surgery and urgent and emergency care had been identified through previous inspections and incident data. However, there was limited evidence that actions had been taken in a timely way to mitigate these risks and reduce the potential for avoidable harm. This indicated a lack of consistent governance oversight and accountability in some areas and affected the level of assurance provided to the Board regarding known risks to quality of care and delivery of strategic objectives. Board members we spoke with had a clear understanding of the need to develop more probing conversations at board and sub committees.

Through the trusts Board Assurance Framework (BAF) the Group recognised that its principal strategic risks related to its infrastructure and its financial sustainability. St Helier hospital had been part of the NHS new hospitals programme; but the Trust told us that rebuild plans had been deferred beyond the current planning period, meaning that risks to critical infrastructure had increased. The Trust had been successful in accessing capital funds to support the implementation of its electronic acute patient record system in 2025-26; Furthermore, the trust has been successful in gaining capital for the improvement of the emergency departments.

The BAF was aligned to the trusts strategic objectives, identifying 14 principal risks to delivery of the Group strategy. Oversight of these risks was undertaken by Board Committees, with escalation and assurance ratings reviewed at Board level. Eleven risks were overseen through committees, with three reserved to the Board. The BAF was supported by corporate and divisional risk registers and a Group Risk Management Policy. A Risk and Assurance Group had been established to support oversight of risk management processes, including identification, escalation and monitoring of risks across the organisation.

The BAF identified strategic risk areas. Core controls included Board‑level oversight, structured reporting through committees, and established governance processes for key risks including patient safety, workforce, estates and digital. However, assurance ratings for a number of risks remained limited. At Q3 2025/26, risks relating to patient safety, staff experience and wellbeing, inclusive culture and workforce development were all rated as having “limited” assurance, with risk scores remaining above the trust’s defined risk appetite.

The BAF also identified gaps in controls across several areas. These included safety culture, learning from incidents, workforce experience, leadership capacity and consistency of governance processes. A number of mitigating actions were in place; however, several actions were not yet fully embedded or were reported as off track.

In response to key strategic risks, the trust had formed an Infrastructure Committee to oversee the assessment and management of infrastructure risks. This committee reported to the Group Board. Business cases were signed off by the Finance and Performance Committee which also undertook in-depth risk reviews; post-implementation reviews and assurances of benefits realisation.

NHS England had assessed the Trust as being in segment 3 of its National Oversight Framework, meaning that it received a greater level of oversight and scrutiny from regulators. It was expected that the implementation of the Trust’s new acute electronic patient record, together with greater consistency and accuracy of data submissions, would improve the trusts position in the oversight framework.

There were systems in place to provide assurance on performance and risk. The IQPR brought together data on quality, safety, workforce and performance and was regularly reviewed through governance structures. The papers for the board contained information about quality and risk to give board members sufficiently detailed information to enable them to focus on areas of concern and ensure plans were in place to address them. The Group Executive Committee reviewed key performance issues, and escalation arrangements were in place to Board and committees where required. There were processes to manage current and future performance, and the trust demonstrated an approach to performance oversight that sought to provide a holistic view of quality, patient experience, operational and financial performance from ward to Board.

Internal and external audit reports indicated that the trust had a generally effective control environment. Head of Internal Audit opinions over the previous five years provided reasonable assurance, and financial governance arrangements had been subject to external review, which identified a broadly sound control framework.

Governance arrangements had developed as the group model had evolved. The introduction of the Group Accountability Framework provided greater clarity of roles, responsibilities and escalation processes. The trust had also developed a Quality Governance Improvement Plan, which set out structured actions to strengthen escalation, assurance and consistency. In addition, the Board had agreed that the BAF would be refreshed to align with the Medium Term Plan and transformation programme.

Although governance systems were well defined at corporate level, there was variation in how these were implemented across divisions and services. This included differences in the quality of risk identification and articulation, the effectiveness of escalation processes, and the use of data to inform decision‑making and improvement. Evidence from documentation and inspection findings demonstrated that governance processes were not consistently applied in practice at divisional and team level.

Furthermore, there were different organisational structures in place at Epsom and St Helier when compared to the other hospital in the group model. This meant that for Epsom and St Helier, governance arrangements were not fully aligned with the rest of the group even though the group model had been in existence for some 4 years prior to the commencement of this well led assessment. The trust was committed to formalising the group model through a merger with St George’s University Hospitals. We were concerned that the inconsistency in governance arrangements meant executives and other senior leaders may not always effectively manage risks and importantly, developing opportunities as part of the group model.

The trust had identified this variation and had plans in place to strengthen consistency. These included embedding the Group Accountability Framework across all levels, implementing the Quality Governance Improvement Plan, improving triangulation of risk, quality and performance data, and strengthening risk management capability across divisions.

The Group Quality and Safety Strategy 2024 to 2028 was developed with staff and aligned to address some of the strategic risks and opportunities outlined in other documents referenced here. The strategic objectives were grouped into three areas; strong governance, better flow/ shorter waits and a learning organisation. There were clear actions in place for each strategic objective (aligned to the national patient safety strategy), with in year milestones. Some of the objectives could be difficult to measure, certainly in terms of lasting impact, over a longer period of time. The strategy also referenced co production with staff and patients, identified as essential to effectively deliver the strategy.

The trust estates were a significant risk to the organisation, given the age and condition of some areas. There was an estates strategy in place (2021 to 2026) which required review, given the nature of the risk and that large capital spending was planned to manage some of the most challenging areas of the estate. During our assessments of urgent and emergency care particularly, we found that estates challenges were negatively impacting on the safety, privacy and dignity and care of people using the departments. Whilst the trust took immediate action to address our most serious concerns, estates remain a significant (identified) risk. The strategy clearly showed where improvements had been made, along with strategic priorities for managing the estate in the longer term and work done to reduce the backlog of critical infrastructure work. Whilst capital grants should improve the experience of patients, operational management and safety, the estates will require significant ongoing investment and management.

The trust had made significant investment into digital and IT systems in the preceding year before our well led assessment. In May 2025 a new electronic patient record (EPR) system was implemented across the trust. There had been some initial challenges including data management and some slow down in patient flow through parts of the hospital as staff became used to the new system. During our assessments in December 2025, staff told us that there were still some issues with how the EPR was being used. Further work was required to ensure that staff were fully trained and that the information that staff and the organisation needed to effectively care for people through sometimes complex pathways were available. As noted elsewhere in this report, and by the Infrastructure Committee in February 2026, there remained significant challenges for staff working in community settings with barriers that could impact safety, quality and risked creating inefficiencies across the wider health system with impacts on the trust. NHS England (London region) had highlighted a number of actions required by providers and we were told these were in progress.

The trust had in place a full major incident plan, business continuity plan and Emergency Preparedness, Resilience and Response (EPRR) in place. These had been regularly reviewed and updated. The directors and heads of function that we spoke with about these plans, from operational to communications teams, were aware of their role and responsibilities under the plans, methods of control and communication plans which would be used in the event of the plans being used.

The trust had engaged on significant work in relation to health inequalities and health equity. A health equity dashboard had been recently launched in recognition of poor data capture of patient’s ethnicity and recognition of issues either that could be either due to a lack of data or one that was impacting negatively on peoples and population health. Data captured included referral to treatment times, outpatient did not attend rates and others that were then plotted against known demographics and characteristics to identify any areas of concern or hotspots that could be addressed. The Health Inequalities Steering Group (which reports to the patient safety and quality group) met monthly with topics of focus discussed and best practice shared with how to improve health equity and reduce inequalities. The trust had appointed two health equity leads who were senior medical staff at the trust. The role was to enable embedding of the strategy and to engage staff and empower them. The leads were looking to implement an “Engaged champions” programme and had held workshops with over 60 people attending. Furthermore, the health equity leads had set up a south west London health equity clinical network to share best practice. At the time of the assessment, a focus on key health inequalities hadn’t been identified. The health equity leads met weekly, though were constrained by the amount of time they had to complete the role which would be a challenge against these ambitious plans.

There had been a general improvement in complaints management and handling at the trust with 99% of complaints acknowledged within 3 days standard. 423 complaints were received by the trust which was a 5% decrease on the previous year. The trust acknowledged that timeframes for completion of complaints was not met at the trust due to challenges within the complaints and divisional teams from operational pressures resulting in divisional teams having to manage competing clinical priorities alongside their responsibilities within complaints investigation amongst others. There were some quality metrics in place such as the number of reopened complaints, it was not clear if the trust undertook a quality or feedback survey following the closure of an individual complaint.

The evidence showed a good standard. Collaboration was well established and embedded within the trust’s strategy, contributing to improvements in clinical pathways and system outcomes. The service understood and fulfilled its duty to work in partnership, with effective sharing of information and learning to support improvement. However, variation in integration and delivery meant the benefits of the group model and wider partnerships were not consistently realised across the organisation.

The trust and senior leaders understood their duty to collaborate and work in partnership so that services worked more seamlessly for patients. Collaboration was a core element of the trust’s strategy and was reflected in board papers, the trust vision and the CARE strategy. The trust had entered into a group model with another NHS trust to make more efficient use of resources and improve quality of care.

Our observations, review of documentation and interviews with senior leaders demonstrated that partnership working was well established and there was evidence of a mature approach to collaboration across the trust and wider system. The trust worked closely with partners across acute, community, primary care and local authority services, supported by established governance arrangements, shared accountability and information‑sharing processes.

However, senior leaders recognised that, whilst the group model and wider partnerships were progressing, the full benefits had not yet been realised. There was evidence of early improvements, including better utilisation of theatres across the group and efficiencies in some corporate and administrative functions. Collaboration across the group had also supported improvement in some clinical pathways, although this was variable across services.

The trust played an active role in the South West London Acute Provider Collaborative. Our review of documentation and discussions with leaders confirmed that the trust was engaged in a range of joint initiatives to improve care and address demand pressures. This had led to the development of services that had a positive impact on providing care in the right place for the patient whilst reducing some demand at the acute hospitals.For example, the trust worked with other providers to deliver an elective orthopaedic centre, which had contributed to improved outcomes for patients. Data showed that patients undergoing procedures such as knee replacements experienced shorter lengths of stay compared to the national average, enabling improved patient flow and increased capacity.

Leaders of community services were positive about the commitment of the trust to developing and enhancing the partnership that had been in place since 2017. Services included primary care networks, community inpatient beds and other services such as admission avoidance and specials services. Community partnerships had enabled the development and support of 200 ‘virtual ward’ beds which had contributed to a reduction in discharge delays of over 2 days. Additional work in anticipatory care including a frailty MDT and neighbourhood teams was showing a reduction in emergency care attendances for care concerns such as frailty. Trust leaders were well sighted on the risk and opportunities of the partnership working and there was a clear focus on providing care where the patient needs it most.

The trust also worked with local boroughs, integrated care partnerships and community providers to develop services for local populations. Integrated care models, such as Surrey Downs Health and Care and Sutton Health and Care, demonstrated improvements in system outcomes, including reductions in emergency department attendances, non‑elective admissions and waiting times for some services. These arrangements supported more coordinated care and improved access for patients. The trust also had strong engagement across clinical and operational networks as well as academic partners, enabling sharing of specialist knowledge, new service pathway development as well as development of staff and the roles at the trust and more widely. The trust were aware of the challenges with strengthening joint transformation plans, particularly in relation to outpatients and non-elective care to improve integration across the trusts acute, community and tertiary referral area.

Our observations and discussions with staff demonstrated that the trust was actively engaged in system‑wide collaboration and shared information openly with partners. This included working with system partners to address challenges that impacted patient experience, such as improving pathways for patients with mental health needs to access care in the most appropriate setting. Staff across the organisation demonstrated a commitment to improving outcomes for the communities they served.

These differences in focus between Community Heath and Care services commissioned for Surrey residents and those commissioned for London. Financial challenges were having an impact and there was a lower perceived management attention to cost improvements and performance. Discussions with board members indicated that some relationships with Surrey and Sussex ICB commissioners were less developed than those with South West London ICB.

There was also evidence of wider collaboration through clinical networks, specialist services and partnerships with academic organisations. These supported shared learning, innovation and the development of consistent standards of care. The trust contributed to system‑wide transformation programmes, including elective recovery, diagnostics and outpatient transformation.

However, there were challenges in achieving consistent integration across all partnerships. Working across multiple systems and integrated care boards created complexity, including duplication of governance processes and increased administrative burden. Limitations in interoperability between digital systems also affected the sharing of information and coordination of care across organisations.

Senior leaders were aware of these challenges and had plans in place to address them. This included strengthening joint transformation programmes, improving outcome measurement across partnerships, and addressing system enablers such as digital integration and financial alignment. The trust also recognised that ongoing changes in NHS commissioning arrangements had impacted the pace of integration and had incorporated actions within the medium term plan to address this, including investment in community services to reduce demand on hospital‑based care.

The evidence showed a good standard. The trust had an established approach to learning, improvement and innovation, supported by the CARE strategy, a Group Quality Management System and systems for learning from incidents and data-driven improvement. Improvement activity was delivered through programmes including continuous improvement pathways, ward-level routines, patient safety processes and research activity. However, there was variation in the consistency of embedding learning and improvement across the organisation, including differences in staff confidence, use of data, visibility of learning and sustained improvement across some services.

The trust demonstrated an established approach to learning, improvement and innovation, supported by the CARE strategy and the development of a Group Quality Management System (QMS). There was evidence of an organisational commitment to continuous improvement, with structured programmes in place to develop capability across the workforce. This included a continuous improvement (CI) pathway with defined stages and plans to expand training to a larger proportion of staff. Initiatives such as High Performing Wards, CARE boards and daily improvement routines supported the embedding of improvement practices into operational delivery and strengthened the link between strategy, performance and service delivery.

Our review of documentation and discussions with staff demonstrated that systems and processes were in place to support learning from incidents and good practice. This included the use of Datix reporting, Patient Safety Incident Response Framework (PSIRF) processes and clinical audit activity to inform improvement work. PSIRF learning responses were included in the Patient Safety Incident Response Plan (PSIRP) which outlined the agreed trusts priorities for learning responses. Analysis of the outcomes of the learning responses, alongside themes and trends were used to identify learning priorities for the coming years. There was evidence of increasing use of data and system‑based analysis to support learning, with divisional safety improvement plans being developed from identified risks and patient safety intelligence.

The trust had a system in place for learning from deaths and patient safety incidents. At the time of our assessment, the trust’s Standardised Hospital Mortality Indicator (SHMI) was reported as ‘expected’ and ‘lower than expected’ in some clinical groupings. Divisional incident review groups (DIRGs) had been introduced in February 2024 and DIRG reports were shared monthly via internal governance. These meetings brought together multi‑disciplinary teams to review incidents where there were opportunities for learning. Our observations and review of documentation confirmed that these meetings were conducted in an open and transparent way, with staff working collaboratively to understand issues and identify actions to reduce the risk of avoidable harm.

We saw examples where structured approaches to learning contributed to changes in practice. For example, the use of simulation and human factors approaches had been used to identify risks in clinical pathways and inform changes to equipment and processes to improve patient safety. There was also evidence that improvement activity had contributed to pathway redesign and adjustments to workforce models, demonstrating the application of learning to service improvement.

The trust had also launched a group quality and safety strategy in December 2024, which focused on strengthening quality governance and learning from areas of concern identified in services such as maternity and surgery. Senior leaders described a commitment to embedding continuous improvement and had implemented the ‘High Performing Wards’ initiative to support staff in improving services. The trust had also increased capacity within continuous improvement and project management teams to support delivery.

There was evidence that improvement capability was being developed and applied in practice. Programmes such as the CI capability pathway and events designed to build improvement skills supported this. Ward‑level initiatives such as huddles enabled teams to review performance and undertake daily problem‑solving. The trust also demonstrated activity in research and innovation, including participation in national research programmes and partnerships with academic organisations, which supported evidence‑based practice and wider system learning.

However, our review of documentation and discussions with staff identified variation in how consistently learning and improvement approaches were embedded across the organisation. Whilst some teams were able to describe clearly how learning from incidents had led to changes in practice, others reported less visibility of learning outcomes and feedback. This was consistent with findings from other areas of the inspection, including maternity, surgery and urgent and emergency care, where concerns indicated that learning was not always effectively translated into sustained improvement.

There was also variation in the maturity of continuous improvement capability across divisions and in the use of data to support improvement. Although systems were in place, staff did not consistently demonstrate confidence in using data for measurement of improvement. Operational pressures and workforce constraints also limited some staff’s ability to engage fully in improvement activity.

In addition, the involvement of patients and communities in co‑production of improvement activity was not consistently evident, and the alignment between improvement, research and innovation activity was not always clear at frontline level.

Whilst there was a focus on research, there were key gaps in workforce capacity including a research nursing shortfall and limited inclusion in job planning for medical staff. This meant that there was an uneven capability and engagement in some areas including community services. The trust was aware that there were opportunities for fellowship programmes and other investment in staff development that were being explored.

The trust had recognised these areas for development and had plans in place to address them. This included further embedding the Quality Management System, expanding continuous improvement capability, improving data literacy and the use of real‑time information, strengthening feedback mechanisms, and aligning improvement, research and innovation activity more closely.

The evidence showed a good standard. The trust demonstrated a clear and structured approach to environmental sustainability, supported by Board‑level leadership, a refreshed Green Plan and established governance arrangements. There was evidence of delivery across clinical and operational areas, supported by dedicated infrastructure and integration into quality improvement activity.

However, variation in engagement, embedding and impact measurement was identified across divisions. Sustainability was not consistently integrated into all service planning and decision‑making, and the use of data to demonstrate impact was variable at divisional and service level.

Senior leaders understood any negative impact of the organisation’s activities on the environment. The trust worked hard to make a positive contribution in reducing any negative impact and supporting people to do the same.

The trust demonstrated a clear and developing commitment to environmental sustainability, supported by Board‑level leadership and a Group Green Plan. A refreshed Green Plan had been approved in 2025, setting out the trust’s strategic approach to sustainability and its links to population health and organisational performance. Governance arrangements were in place, including oversight through the Infrastructure Committee and reporting through established governance structures. A Green Plan scorecard was used to monitor progress across key areas.

Our review of documentation and discussions with staff demonstrated that there was an established infrastructure to support delivery of sustainability objectives. This included a dedicated Green Plan team, a structured approach to communications and training, and the development of a network of Green Champions. Sustainability initiatives were increasingly being incorporated into quality improvement and clinical transformation programmes, including the use of sustainable quality improvement approaches and clinical workshops to support lower‑carbon care.

There was evidence of delivery across a range of clinical and operational areas. For example, initiatives included the removal of high‑carbon anaesthetic gases, changes to clinical pathways to reduce carbon impact, and actions to improve energy use, procurement and waste management. These demonstrated that the trust was implementing elements of its sustainability strategy and taking steps to reduce its environmental impact.

The trust had also begun to integrate sustainability within wider organisational planning. This included alignment of the Green Plan with the medium‑term plan and transformation programmes, and the development of a Climate Change Risk Assessment to support consideration of environmental risks within operational and clinical decision‑making.

However, our review identified variation in how consistently sustainability was embedded across the organisation. Engagement with clinical sustainability initiatives and workshops was not consistent across all divisions, and sustainability considerations were not routinely integrated into all areas of service planning and decision‑making. Staff engagement was affected by capacity and operational pressures, which limited participation in some activities.

There were also limitations in the consistency of impact measurement. Whilst governance structures and reporting mechanisms were in place, there was limited evidence that impact, including carbon, cost and clinical outcomes, was consistently measured and used at divisional or service level. The integration of sustainability into preventative healthcare and clinical strategy was also at an early stage.

Leaders were aware of these challenges and had plans in place to address them. This included further embedding sustainability within governance and planning processes, strengthening measurement and reporting of impact, expanding staff engagement and training, and supporting clinical teams with practical tools and guidance to incorporate sustainability into routine practice.