Source · CQC inspection

Epsom General Hospital

Provider Epsom and St Helier University Hospitals NHS Trust Type NHS Healthcare Organisation Region South East Last inspected 11 Jun 2026

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 11 June 2026

The service is performing well and meeting our expectations.

Epsom General Hospital provides an extensive range of inpatient, day and outpatient services,and has a busy accident and emergency (A&E;) department. The vast majority of elective (pre-booked) operations at the trust take place at Epsom Hospital. The trust has an extensive range of diagnostic and supporting services at Epsom Hospital, including pathology, radiology (including CT, MRI and ultrasound) and vascular diagnostic services, and a busy modern purpose-built day care and day surgery unit.The Elective Orthopaedic Centre (the EOC) is based at the hospital, providing orthopaedic services to patients from St …

Ratings by service

Maternity

Good

Jul 2025

Medical care (Including older people's care)

Good

Jul 2025

Surgery

Good

Jul 2025

Urgent and emergency services

Requires Improvement

Jul 2025

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (2)

Breach Safe

However, the service was in breach of the regulation for safe care and treatment, in relation to all staff receiving appropriate triage training.

Regulation: Regulation 12 (Safe care and treatment) · 11 Jun 2026

Breach Caring

At this assessment we identified breaches of regulations in relation to Regulation 10, Dignity and Respect, Regulation 12, Safe Care and Treatment, and Regulation 15, Premises and equipment, Health, and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regulation: Regulation 10 (Dignity and respect) · 11 Jun 2026

Earlier inspection findings

pre-2024 framework · 9 must-do 3 should-do

Must-do actions (9)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 9

Must do

Safe

The service must ensure all staff are uptodate with maternity mandatory and safeguarding training modules.

Regulation: Regulation 12(1)(2)(c)

⚠ Not all staff had completed all mandatory training in key skills, and not all staff had training on how to recognise and report abuse.

Must-do action 2 of 9

Must do

Safe

The service must ensure premises and equipment are suitable and fit for purpose.

Regulation: Regulation 15(1)(b)(c)(e)

⚠ The design of the environment was not fit for purpose in all areas. The use of facilities and equipment did not always keep people safe.

Must-do action 3 of 9

Must do

Safe

The service must ensure it assesses and mitigates risks to women, birthing people and babies.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not consistently complete nor update risk assessments and did not always take action to remove or minimise risks. Staff did not always identify and quickly act upon women and birthing people at risk of deterioration.

Must-do action 4 of 9

Must do

Safe

The service must ensure medical staffing for maternity triage is reviewed so there are sufficient numbers of staff to review women and birthing people in a timely manner.

⚠ There could be delays in doctors attending triage unit to review women and birthing people.

Must-do action 5 of 9

Must do

Safe

The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk of deterioration.

⚠ Staff did not consistently fully complete Modified Early Obstetric Warning Scores (MEOWS). We reviewed 7 MEOWS records and found 2 were incomplete.

Must-do action 6 of 9

Must do

Effective

The service must ensure that staff caring for transitional care babies have the appropriate level of qualifications and additional training.

Regulation: Regulation 18(1)(2)(a)

⚠ Staff caring for transitional care babies did not have the qualification and competence for the role they were undertaking.

Must-do action 7 of 9

Must do

Effective

The service must ensure the role of recovery practitioner is carried out by staff with the right level of qualification and additional training.

Regulation: Regulation 18(1)(2)(a)

⚠ Staff supporting women or birthing people following a caesarean section had not been trained to the same standard as for all recovery practitioners working in other areas of general surgical work.

Must-do action 8 of 9

Must do

Effective

The service must ensure records of the care and treatment provided are accurate, complete and contemporaneous.

Regulation: Regulation 17(1)(2)(c)

⚠ Staff did not always maintain detailed records of women and birthing people’s care and treatment. We found inconsistencies in the completion of care records including records where risk assessments and tests were not recorded, and inaccurate records of actual care provided.

Must-do action 9 of 9

Must do

Well-led

The service must ensure it operates effective systems and processes to maintain clear oversight of maternity services and enable it to assess, monitor and improve the quality and safety of services and mitigate risks to women, birthing people and babies.

Regulation: Regulation 17(1)(2)(a)(b)

⚠ Leaders did not always operate effective governance processes, throughout the service and with partner organisations. Local governance systems did not effectively identify risks and issues.

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3

Should do

Safe

The service should ensure ‘fresheyes’ check of cardiotocography (fetal heart rate) monitoring are carried out hourly.

Should-do action 2 of 3

Should do

Safe

The service should ensure staff use the ‘situation, background, assessment, recommendation’ handover format when handing over care of women, birthing people and babies.

Should-do action 3 of 3

Should do

Well-led

The service should ensure midwifery staff complete an annual appraisal.