Archived: King Edward VII's Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a shared priority and that leaders promoted a culture of openness, learning, and collaboration. We checked whether staff felt empowered to raise concerns and whether systems were in place to support continuous learning from incidents. We looked at training compliance and how staff worked with healthcare partners to ensure safe care pathways. We checked whether risks were identified and managed effectively, and whether care was person-centred. We also reviewed patient records and discharge communications, to ensure continuity and safety throughout the care journey.

At our last assessment we rated this key question good. At this assessment the rating has remained good. We found people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders ensured a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were empowered to escalate concerns. Risks were regularly recorded, for example in risk registers and not overlooked.

Staff focussed on learning and improvement. Incident reporting and After-Action Reviews (AARs) were encouraged to foster a culture of learning and improvement. Leaders conducted AARs in line with the Patient Safety Incident Response Framework (PSIRF) to understand and learn from incidents, empowering staff.

Staff demonstrated a commitment to learning from complaints by encouraging feedback. Staff involved people in timely investigations, acknowledged each complaint within three working days and fully responded to within 20 working days. This was in line with Independent Sector Complaints Adjudication Service (UK), a service that handled complaints about independent healthcare providers. Staff learned lessons and shared complaints to make improvements to the service.

The new leadership team encouraged a cultural shift from blame to learning in incident reporting. Staff were encouraged to report incidents using online reporting systems, with follow-up processes such as After-Action Reviews (AARs) and the Patient Safety Incident Response Framework (PSIRF) in place. This approach helped identify systemic issues and supported continuous improvement.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care were prioritised through a collaborative, person-centred approach. Staff, partners, and people using services worked together across referrals, admissions, discharges, and service transitions.

Risks were identified and managed, with systems in place to monitor and improve safety. For example, duty managers used a daily log sheet where they reviewed high risk patients and who they would prioritise as first on the theatres list. Leaders encouraged staff to report all risks to enable action and improvements.

Care planning was co-produced with individuals and healthcare partners to ensure seamless support. Feedback from people, staff, and partners informed ongoing improvements. Shared policies and shared learning across organisations strengthened safety and continuity throughout the care journey.

Theatre staff produced a new theatre care plan to combine all paper documentation in one place. This was an improvement based on staff feedback.

Leaders promoted a person-centred approach to safety by encouraging staff to go beyond checklists and engage with people holistically. Staff were supported to use their senses, professional judgement, and knowledge of the individual to notice subtle changes and respond proactively. This emphasis on seeing the whole person, rather than just tasks or observations helped ensure care was responsive, compassionate, and safe.

Patient records were handwritten in paper files and were detailed. Each record contained risk assessments, allergy alerts and intolerances. Staff noted any mental health conditions and capacity concerns and followed guidance for working with people with cognitive disabilities, for example, people with dementia.

Staff completed well written discharge letters to GPs in the community. Handover information was shared at each stage of the patient's journey, for example, theatre to ward. Patients were given clear guidance on expectations and opportunities to ask questions for clarity.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff escalated concerns quickly and appropriately to leaders.

Staff understood safeguarding and were trained at levels in line with national guidance. For example, all clinical staff received safeguarding training at level 3 adults, and level 2 children. They accessed the safeguarding policy on the intranet. Staff could quickly access a safeguarding flow chart on the board in the staff room. The chief nurse was the safeguarding lead. The deputy chief nurse was lead in the chief nurse's absence; both were level 4 trained. Staff were able to escalate a matter, if they saw something concerning. Leaders had a service level agreement with an external level 5 trained nurse consultant to support them with more complex safeguarding concerns.

Line managers asked employees during rounding (walk rounds to talk to patients on the wards) if they needed to share any safeguarding concerns. There was a confidential helpline available. Staff understood domestic violence, which was clearly connected to safeguarding protocols, with related policies in development.

Staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs which was safe, supportive and enabled people to do the things that mattered to them.

Leaders established clear protocols for escalating clinical risk, including emergency bells, calling a designated quick dial phone number, and following the local critical care outreach pathway. Staff felt comfortable to raise concerns through the incidents process when escalations were not appropriately responded to.

All patients were reviewed daily by clinical nurse specialists (CNS), ensuring consistent oversight throughout their stay. Morning patient rounding included checks on surgical wounds, catheters, and overall wellbeing. Catheters were typically removed the day after surgery to reduce infection risk.

All patients were measured for compression stockings to improve blood flow. This continued post-operatively, with clear explanations provided to patients about the importance of Venous Thromboembolism (VTE) prevention.

Staff achieved safety improvements by introducing the use of Local Safety Standards for Invasive Procedures (LOCSSIPS) and National Safety Standards for Invasive Procedures (NATSIPPS). These are safety measures in the form of checklist to keep people free from harm.

Nurses were trained to be critical thinkers, using clinical judgement to assess risks dynamically. For example, they evaluated catheter use and post-operative symptoms in real time, rather than relying solely on routine tasks.

While handovers were generally effective, variability in quality was acknowledged. Staff used these opportunities to discuss patients in depth when needed. One incident led to improved clarity from consultants regarding post-operative instructions, demonstrating a commitment to learning and adaptation.

Staff detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care. Staff raised concerns in relation to the environment and all issues were on the risk register to monitor and manage.

People were cared for in safe environments that were designed to meet their needs. Facilities were well-maintained.

However, staff were concerned about the weight of the theatre doors and had raised concerns through the incident reporting system. Leaders noted concerns on the risk register. Leaders had plans on managing risks on the risk registers. Staff were given guidance on how to mitigate risks. Long terms plans were in place to replace the doors.

Equipment used to deliver care and treatment was not always suitable and readily available. Some equipment was aged and due to be replaced. Staff incidents reported showed that while equipment was generally safe, isolated issues caused some disruption. For example, in February 2025, staff cancelled and rescheduled 4 surgical cases due to problems in theatre. In May 2024, 2 procedures were cancelled and rescheduled when a fan failed in day surgery. In September 2024, a consultant cancelled an orthopaedic case because the required kit was unavailable. These cancellation actions showed staff took risks to patient safety seriously.

Leaders made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs.

Staff were compliant with a wide range of mandatory training. All training was above the 95% target.

Senior nurses held monthly supervision. Ward appraisals were above target. Theatre appraisals were at 59%. All outstanding appraisals were booked with full compliance expected by 31 May 2025 which was the appraisal cycle deadline. Revalidation of nursing staff was 100%.

Staff received regular training, including Infection Prevention and Control (IPC) and safeguarding. Staff received mandatory training in Safeguarding Children and Young People (CYP) and Adults at level 3 for senior nurses. Staff also received mandatory Oliver McGowan training to improve their understanding of learning disabilities and autism.

Staff sickness was higher in theatres (8.7%) than wards (6.4%). Theatres had 3 vacancies under review. Bank and agency use was 18% in theatres. The wards only use bank staff and the bank rate was 7%. Wards had no vacancies and full appraisal compliance.

Leaders ensured compliance with National Institute for Health and Care Excellence (NICE) guidelines and other policies ensuring safe staffing. Staffing on the ward met safe standards, maintaining a minimum 1:5 nurse-to-patient ratio, supported by a supernumerary ward manager and duty manager. From January to April 2025, patient feedback was positive, with 98% feeling respected, 95% involved in their care, and 99% rating their experience as good or very good. While these outcomes reflected good performance, some staff expressed a desire for more time to engage meaningfully with patients.

Staff assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The infection prevention and control lead (IPC) nurse managed policies, infection rates, audits, reporting, and monitoring. There were two IPC leads who attended all staff meetings and provided training.

Staff monitored surgical site infections, with audits and investigations conducted to identify and mitigate risks. Staff used an evidence-based toolkit for audits, ensuring they followed NICE guidelines.

Leaders held regular reviews and discussions with microbiology to manage surgical infections. There had been no reported hospital acquired infections over the past 12 months. Staff provided regular mandatory training, webinars, and Continuing Professional Development (CPD) opportunities, including IPC training and mini teaching sessions.

Staff made sure that medicines and treatments were safe and met people's needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Leaders had an established medicines audit programme, with 85% compliance. Identified actions and outcomes were recorded to meet a target of 95%. These included quarterly audits on controlled drugs (CD), medicines reconciliation during admission and discharge, drug administration, and prescribing practices.

Pharmacy and the clinical staff developed a guide for using medication charts to reduce prescribing errors. As a result, incidents had significantly decreased. A pharmacist and ward staff reviewed medication incidents and identified learning points at a weekly meeting.

Leaders spotlighted medicine incidents monthly with pharmacy reports on themes, shared learning, and updates. Senior nurses carried out supervision directly with staff once a month to highlight areas for improvements.

People's medicines were prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence.

Staff recorded accurate, up-to-date information about people's medicines in patient records, in line with current national guidance.

There were effective arrangements for the safe management, use and oversight of controlled drugs (CD). However, we highlighted some minor records gaps, for example, missing dates and signatures in the CD books.