King's College 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 priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always kept safe and protected from avoidable harm.

The service was in breach of legal regulation in relation to safeguarding and staffing of the service.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Lessons were not always learnt to continually identify and embed good practice. They did not always investigate and report safety events appropriately. However, staff listened to concerns about safety and the service had a proactive and positive culture of safety based on openness and honesty.

The service reviewed patient safety incidents and lessons were learnt to improve practice. Staff recognised and reported incidents appropriately and knew how to raise concerns using the hospital’s electronic incident reporting system. Managers were responsible for investigating incidents and sharing the learning. Most staff we spoke with told us they received feedback from incidents they reported, and learning was shared in team meetings and by email. The top themes identified from incidents between March 2024 and March 2025 were in the areas of patient identification and discharge safety.

The service delivered a multidisciplinary simulation programme, King’s Interprofessional Clinical Communication and Simulation, (KICCS). The programme examples of incidents which had taken place to develop clinical scenarios that supported reflective learning and promoted continuous improvement in patient safety. This approach simulated the journey of a child from initial presentation through to critical care. Additionally, regular simulations were conducted, ensuring that learning from real cases was continually reinforced across clinical teams. The service hosted a monthly care group wide grand round open to all staff to attend, which shared work on outcomes, service development and unusual cases, with presentations from expert speakers.

People and staff were encouraged and supported to raise concerns. Staff told us there was a no blame culture and they were encouraged to raise incidents. There was evidence that changes to practice and procedures had been made because of learning identified and this was disseminated to teams. For example, we saw part of the learning identified from an incident resulted in a change to how test results are displayed in patient electronic records. Ward meeting minutes showed themes from incidents were routinely discussed. We also saw learning from incidents was shared in newsletters to teams.

Most staff we spoke with were able to explain the duty of candour. When things went wrong, staff apologised and gave children, young people and their families honest information and suitable support. We saw examples of thorough investigations of incidents being performed and where duty of candour had been applied.
Managers debriefed and supported staff after serious incidents. Most staff told us the teaching environment was positive and supportive, and they were encouraged to participate in training opportunities.

Although the service generally managed incidents well we had concerns about learning from safeguarding incidents, which is reported on more fully under the safeguarding quality statement.

The service 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.

We received positive feedback from staff regarding communication and multidisciplinary team working. We saw the service worked collaboratively and in a joined-up approach regarding safety that involved patients and families along with staff and external partners. Staff made sure there was continuity of care, including when people moved between different services. The trust also had processes in place to support young people through the transition from children to adult services.

Leaders told us they had introduced a flow meeting to address patient flow within the service. This sought to ensure effective management of beds and elective procedures.

The service had an electronic system for maintaining patient records. Staff kept detailed records of children and young people's care and treatment. Records we reviewed were comprehensive, clear, up to date, stored securely and easily available to all staff providing care.

Staff knew what action to take in the event a child or young person deteriorated. There was a paediatric critical care outreach team (iMobile) led by both the paediatric and medical critical care team available to provide rapid response and stabilisation to patients in need of immediate attention or transfer. Staff told us the iMobile team was notified if a child or young person’s paediatric early warning system (PEWS) had increased in patient electronic records. Staff we spoke with told us they felt comfortable and were confident to escalate concerns to the iMobile team.

Shift changes and handovers included all necessary key information to keep children and young people safe. During morning handovers staff were made aware of patients who were high risk such as those who were unstable or had a high PEWS score. In addition, children and young people with known safety risks were highlighted so staff allocations for the day were safe and appropriate.

Records we reviewed showed PEWS scores were recorded and updated appropriately. However, data shared with us showed between April 2024 and April 2025 only 33.7% were recorded within an appropriate time and untimely documentation of PEWS can lead to deteriorating patients not being picked up or referred promptly. An audit of PEWS data between June 2024 and April 2025 showed observations and paediatric early warning scores were not consistently audited. Audit data between December 2024 and January 2025 was not available and there were a further 9 weeks where audit data was not recorded. The lowest compliance was in July 2024 of 80.8%. As a result, it was unclear whether the service had complete information for the assurance of consistent application of the PEWS system to identify and escalate deteriorating patients. However, the audit data showed improved compliance between September 2024 to November 2024 and February 2025 to April 2025. Although we did not see there was an action plan in place to address the timely documentation of PEWS and inconsistent PEWS compliance auditing, meeting minutes, we reviewed showed the service was working to improve timely PEWS documentation through use of targeted training and use of technology to better facilitate documentation of observations at the bedside.

The service did not share concerns quickly and appropriately. They did not concentrate on improving people’s lives or protect on, avoidable harm and neglect.

We reviewed the service’s safeguarding children and young people policy. This was available on the hospital intranet system. The policy detailed individual responsibilities, processes for reporting and escalation of concerns and who to contact. We found this was considerably out of date, with a review date in May 2023. This meant that staff referring to this policy could not be assured that the information was in accordance with the latest national guidance or best practice.

An incident submitted in August 2024 highlighted that were several missed opportunities to safeguard a child prior to their death. On reviewing the case, it was highlighted that the leads of the area had not attended safeguarding supervision. This incident was also incorrectly recorded as resulting in no patient harm. There had been 70 safeguarding incidents reported by the children and young people’s service in the 2024/2025 financial year. 45 of these were identified as incidents of missed opportunities to safeguard people and staff, however, in most cases action was later taken to address the safeguarding concerns. This provided limited reassurance that the service had appropriate preventative measures in place to protect people from harm and suggested learning from previous incidents was not fully embedded. However, we saw that the service identified themes from safeguarding incidents and these topics were included in future safeguarding training.

The service had a safeguarding lead, and 2 deputy leads trained to a level 4 in safeguarding. Staff had training on how to recognise and report abuse. All staff received mandatory training in safeguarding adults’ levels 1 and 2, and safeguarding children levels 1 to 3. Evidence submitted showed training compliance for safeguarding children level 3 required improvement. This was below the trust target for compliance in medical and nursing staff, at 68.6% and 83.4% respectively and we did not see that there was a plan in place to improve compliance.

Access to wards was by swipe card access locked doors for staff and intercom / buzzer systems were in place for visitors to access the units. However, some of the wards we visited did not have a ward clerk, whose job would be to perform clerical and administrative duties in addition to permitting access to visitors. When permitting access to visitors, staff were expected to confirm the reason for their visit or which patient they were visiting to ensure entry and exit was as secure as reasonably possible. We witnessed several staff throughout the service allow access to individuals without confirming the purpose of their visit, when asked, staff admitted they did not always know who they let in or how many people which posed a safeguarding risk to patients. A risk to safe monitoring of visitors was identified on the risk register only in the Neonatal Intensive Care Unit (NICU) and the paediatric intensive care unit (PICU), however we observed that this was also a risk in other areas of the service. Following inspection, the service amended the risk to include safe monitoring of visitors across all areas.

Staff we spoke to were not aware of the child abduction policy, although most staff could generally describe the correct process of informing a manager and security. We observed the neonatal abduction guideline was out of date, with a review date in December 2024. There was an up-to-date Infant/Child Abduction Guideline and Missing Persons Policy. Following a review by the service, in May 2025 the neonatal guideline was combined into one Baby, Child and Young Person Abduction Management Policy for the service.

Staff we spoke with were able to identify safeguarding leads and knew who to inform if they had concerns. Staff had knowledge of the Gillick competences and Frasier guidelines and knew how to apply them. Gillick competence was used to assess a child's capability to make and understand their decisions in a wider context, particularly around consent to treatment. Fraser guidelines are applied specifically to advice and treatment that focuses on a young person's sexual health and contraception.

The service did not always work well with people to understand and manage risks. Processes and systems were not always in place to ensure care consistently met people’s needs, was safe, supportive and enabled people to do the things that mattered to them.

The service could not demonstrate effective auditing of patient assessments to ensure consistent compliance with local and national guidance and improve patient safety. Audits were conducted manually because the hospital’s electronic patient record system did not allow retrieval of the required nursing metrics for children and young people, although this functionality was available for adult services. However, we observed from patient records we reviewed that staff completed and updated risk assessments for each child and young person and removed or minimised risks. Staff identified and acted upon children and young people at risk of deterioration. We saw this was recorded in patient records. We also saw evidence of assessments performed by a disability nurse to account for patient individual needs.

The PEWS system was used for the early detection of any deterioration in a child’s condition based on observations. Data suggested people were not always actively engaged in managing risk. Parental concern should have been recorded within PEWS records, however audit data showed this was only recorded approximately half of the time. Parent feedback data showed although 82.5% of parents agreed they were encouraged to express concerns, only 12.5% reported being aware of PEWS. As a result, the service had identified the need to ensure wards improve documentation of parental concern conversations. There was not an approved policy or guideline in place for managing children with sepsis, we reviewed a draft guideline for Paediatric Sepsis which required consultation with other services for approval. The guideline included a screening tool applicable to all clinical areas for children and young people and there was a sepsis care bundle in use. The trusts electronic health record system did not allow for the necessary metrics to be collected to perform audits of sepsis management. As a result, the service was unable to demonstrate and assure themselves that management of sepsis was in line with best practice. However, staff we spoke to were aware of and understood escalation protocols for deteriorating patients and the use of PEWS. We reviewed patients’ PEWS charts and observed they were regularly updated.

There was a paediatric liaison psychiatry team to provide emergency mental health support to children and young people who required assessment or intervention of severe mental health needs. The iMobile team were available 24 hours a day and could be called to review any child or young person concerns had been raised about or where records indicated deterioration. In 2024, 405 referrals were made to the iMobile team, staff reported this to be an effective and efficient service.

We saw evidence that World Health Organization (WHO) checklists were being used appropriately for children and young people undergoing surgery. Data we reviewed showed there was good compliance with WHO checklist for children and young people.

People we spoke with felt able to give their views and felt staff took their concerns seriously. The trust had implemented Martha’s Rule. Martha’s Rule is a major patient safety initiative providing patients and families with a way to seek an urgent review if they or their loved one’s condition deteriorated, and they were concerned this was not being responded to.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service was not always able to control potential risks in the care environment due to limited space within the estate. Staff did not always ensure equipment, and technology supported the delivery of safe care. We checked various consumables and found many to be out of date. This meant there was a risk staff may have used out of date consumable items for children and young people which were less effective and potentially dangerous to use.

Staff told us portable appliance testing was performed every year and equipment should have been labelled to indicate this was done. However, we found some equipment had not been labelled in the last year to indicate that portable appliance testing had been carried out to ensure devices were fit to use. Data showed electrical safety testing is integrated into the trust planned preventative maintenance (PPM) schedule and PPM jobs were automatically generated based on manufacturer recommendations.

The current lack of physical space for children’s services was presenting challenges for the trust. The cot space in the NICU was found to be cramped and not in line with current guidance. However, the service had a number of areas for parents and family, including a parent sitting room, a dedicated breastfeeding room and a bereavement room all situated on the neonatal unit. The risk register identified there was a risk to NICU patient safety due to cot and space limitations. The environment posed an increased risk of hospital acquired infections. Control measures had been implemented such as the use of screens and personal protective equipment and data we reviewed suggested infections were not spreading. However, the service risk register stated that despite the controls in place cases of infection had continued to occur. We therefore could not be assured that the risk was being controlled. The Trust had plans to reconfigure the NICU, approved in 2020. The NICU expansion plans, including improvements to cot spacing and surrounding areas, were paused at the time of the inspection due to costs exceeding available capital funding. Following the inspection, NHS England approved revised plans in July 2025, reducing the scope but addressing all key priorities. The final design and Building Safety Regulation approvals were underway, with construction due to start in early 2026 and completion forecast for February 2027.

We also found the general layout of the Paediatric Short Stay Unit (PSSU) to be cramped and cluttered. The PSSU was a significant distance away from the main Child Health area, Variety Children’s Hospital. There were limited amenities for staff, parents and children, for example only one bathroom for patients and carers, staff told us if they needed to use the toilet, they had to leave the unit to use toilets in the emergency department (ED) and a play area which was also a throughfare. The location of the unit required children and young people to travel through the adult ED. Staff told us this was not ideal as when the ED was busy there may be aggressive patients or patients with police escorts. We saw the risk of children and young people being exposed to violent and aggressive situations due to the location of the PSSU had been recently added to the risk register. There had been two recorded incidents relating to the environment in the PSSU in the last 12 months. One in relation to the PSSU lobby/play area being accessible to the public and an incident in which the only available lift was out of order providing no route of exit and access to non-ambulatory patients. Leaders told us of plans to relocate the unit, however there was not a timescale for this work to be completed due to financial constraints. However, there were no recorded incidents of PSSU patients being exposed to violence and aggression in ED.

We observed there was a dedicated recovery area for children and young people in a clean and child friendly environment. Age-appropriate equipment was available throughout the service. The service also had play areas designed for young children and a designated area for adolescents.

In case of an emergency, there were emergency trolleys in each area. These contained a standardised set of equipment appropriate for the area. Routine checks were completed by the ward staff and data showed compliance was above 90% in regular audits.

Staff and leaders considered how environments can keep people safe from harm. We saw that a risk assessment of ligature points in the Critical Care Centre had been completed. We observed a safe room on the Toni and Guy Ward, which was ligature free. We were informed there was a ‘safer room’ in all clinical wards for patients with psychiatric needs.

We observed that chemicals and substances used for cleaning purposes such as chlorine tablets that are hazardous to health were not always stored in areas that were locked and therefore accessible to patients and visitors to the wards. A member of facilities staff told us that the need for this area to be locked had been escalated to management but not actioned.

People we spoke with were generally happy with the environment in which their children were cared for. However, some staff told us they could not always control the temperature adequately in Lion Ward due to poor air conditioning and felt bedspaces on Princess Elizabeth Ward required redecoration. Since the inspection the trust has repaired the air conditioning on Lion Ward. The trust informed us that Princess Elizabeth Ward is scheduled for refurbishment in May 2026, which includes a comprehensive renovation of the environment to include 3 additional ensuite cubicles and the installation of a new ventilation system.

Children, young people and their families we spoke with were positive about the equipment available and environment.

The service did not always make sure there were enough qualified, skilled and experienced staff. Leaders did not always make sure staff received effective support, supervision and development. However, staff worked together well to provide care that met people’s individual needs as much as possible.

The service tried to ensure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Not all staff had received updated training. However, we observed good multidisciplinary team working.

Most of the nursing staff in child health we spoke with reported generally sufficient levels of staffing. However, nursing staff in the NICU told us they often had low staffing levels, which they described could be overwhelming. Leaders told us of ongoing recruitment work and work to improve staff retention in the face of national shortages in NICU nursing staff. The nursing staff shortage in the NICU was on the department’s risk register and was recognised as leading to an inability to provide safe one-to-one nursing care for all NICU babies. Neonatal nurse staff shortages were recognised as being negatively impacted by the trust not currently recruiting nurses internationally. Staff told us there were occasions they felt overwhelmed and exhausted due to low staffing. Nursing staffing in the NICU was not compliant with British Association of Perinatal Medicine standards (BAPM). Data we reviewed showed the service was consistently unable to achieve BAPM minimum nursing staffing for neonatal intensive care and neonatal high dependency care. There were some mitigations in place to address this such as delivering a Neonatal Specialty Module for nurses at the trust in collaboration with a local university to address gaps in nurses qualified in the specialty. However, this had been on the service’s risk register since 2017 and actions taken had not resulted in sustained improvement.

Following the inspection the trust submitted evidence which showed the service had reduced nursing staff vacancies from 19.51% in September 2024 to 13.1% in June 2025. The trust informed us that vacancies in the NICU had decreased, with a trajectory to be fully established by March 2026. This was following a successful recruitment campaign and in-house, university-accredited Qualification in Speciality (QIS) training programme.

NHS Staff Survey results showed only 17.5% of staff across the service agreed that there was enough staff for them to do their jobs properly. This is notably lower than the 28.3% of staff across the organisation. However, staff generally reported good levels of staffing with use of bank staffing when short staffed and occasional use of agency staffing in the NICU. During our inspection we saw there was generally appropriate staffing levels and skill mix. The actual staffing levels largely met the planned levels. Overall, in the 6 months prior to our inspection the percentage of vacancies across child health nursing staff had declined, and there were no vacancies in medical or allied health professional staffing in this period.

Medical staff told us staffing was generally good. In line with best practice standards there was consultant paediatrician cover available in the hospital during times of peak activity Monday to Friday, and on weekends, till 5pm with on call from home. However, resident doctors told us at night there are sometimes gaps in medical staff rotas, which we were told did not always go out to locum staff. This led to delays in responding to requests for review. Staff also told us there was medical support available on the PSSU until 16:30, however after this time nursing staff experienced delays in response from medical staff, most especially overnight.

The service had a small team of play specialists available to support patients and families. They provided preparation and support for potentially stressful experiences such as medical or surgical procedures. However, vacancies in psychology services for children and young people had resulted in waiting lists for outpatient mental health input.

Staff received training appropriate to their role. New staff to the trust received a comprehensive induction. This included mandatory training. Mandatory training had variable compliance with the trust’s target of 90%. Data provided showed particularly poor compliance with Sepsis in Paediatrics training with average compliance of 57%. However, the trust informed us low compliance rates were impacted by sepsis training being recommissioned to a different provider at the of the inspection. Training figures provided by the service showed completion rates varied across staff groups. For example, a variable range of compliance amongst different staff groups in Oliver McGowan training of between 26% to 100%. It was not clear that the service had appropriate oversight of competencies for anaesthetists, staff told us this was monitored by a different care group within the trust. Evidence we reviewed for anaesthetists who may care for children and young people showed their training did not include training for sepsis in paediatrics or paediatric immediate life support. This can increase the risk of staff not being able to respond effectively in emergency situations. Low mandatory training compliance had not been identified on the service risk register, and it was unclear what action was being taken to improve compliance.

Appraisals took place annually. Data we reviewed showed 85% of medical staff and 83% of non-medical staff had completed an appraisal. The trust target for appraisal completion was 95%, however at the time of our inspection the trust appraisal window had recently opened.

The service did not always minimise the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Most of the areas within the service we inspected were clean and had suitable furnishings, which were well-maintained. Although we observed the presence of a used wash bowl, gloves and hairbrush in a bathroom on Lion ward which suggested it had not been cleaned. We also observed that cleaning records were not consistently completed and up to date and one in the PSSU was entirely empty, which suggested areas were not always cleaned regularly. We saw that the Child Health Infection Prevention and Control Committee discussed how to improve infection prevention control in all areas; however, meeting minutes we reviewed had not addressed the cleaning checklists that had not been updated.

Items were labelled as ready for use once they had been cleaned, although we observed some that had not been updated for a few days, this suggested they had not been cleaned since. We observed some staff were not always adhering to ‘bare below the elbow’ practice and at times when the units were busy some staff were not performing appropriate hand hygiene. However, there were hand wash sinks available on entering wards, to wash your hands before entering or leaving a patient area. Alcohol hand gel was available in patient areas. Personal protective equipment, such as aprons and gloves, were readily available and staff were observed using these to protect themselves and others and reduce the risk of cross infection.

Waste management was handled in line with national standards, with different colour coding for general waste and clinical waste. All clinical bins were seen to be operated with pedal lids and were not overfilled. Staff disposed of clinical waste safely. Sharps boxes were dated, closed for safety, and placed out of reach. We reviewed the trust Safer Sharps Policy which was in date.

We reviewed the infection control policy which was comprehensive and in date. Staff could easily access this on the hospital intranet. Infection control audits undertaken between November 2024 and February 2025 showed variable levels of compliance across the service. However, areas with poor compliance were identified and work to improve infection prevention and control and hand hygiene in these areas were discussed at the Child Health Infection Prevention and Control Committee.

Routine infection control and hand hygiene audits were carried out to check compliance against infection prevention and control policies and guidelines. Hand hygiene audits showed overall compliance of approximately 85%. The Child Health Infection Prevention and Control Committee had identified that improvements were needed to improve compliance with hand hygiene. Actions to address poor compliance included regular auditing, email reminders and hand hygiene reminder notices on the ward.

The estate did not always allow for infection risk to be minimised. The service had identified that there was a risk that babies in the NICU may be placed at a higher risk of infection since the unit decontamination area was not fit for purpose. In addition, there was a higher risk of hospital acquired infections in the NICU due to the number of cots in the limited space.

The service 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.

Medicines, including Controlled Drugs (CDs) were generally managed well. Access to areas where medicines were stored was restricted to authorised staff.

The service used an automated medicines dispensing cupboard (AMDC) in some areas which supported staff in selecting the correct medicine and replenishing stock. The temperature of areas where medicines were stored was monitored. There was a clear process for managing Total Parenteral Nutrition (TPN). The service was able to use standard TPN or order bespoke TPN bags.

Staff had access to emergency medicines. These were checked regularly to ensure they were in date and accessible.

We saw that children and young people’s allergies and weight were up to date in records we reviewed which support with safe prescribing of medicines.

Staff were supported by pharmacists and pharmacy technicians on the wards. They supported with clinical queries, obtaining medicine histories and reviewing prescriptions. Pharmacists on specialised wards supported children based at other hospitals and at home. This included managing an enquiry inbox available to children and their families, internal staff and external health care professionals. They demonstrated how this service supports GPs in the community to safely care for children and young people. This included resolving issues around shared care and access to medicines. Staff spoke highly of this service. Staff had access to medicines information. This was through pharmacy support to the areas and online resources including the services policies. We asked to review medicines policies to ensure that they were up to date and reflected national guidance, but these were not provided. Staff told us pharmacy support was always available.

Staff received medicine related training to support them in their role. This included regular and ad-hoc training.

The service supported children and young people to take their medicine. They offered a “pill school” which supported children and young people moving from liquid formulations to solid tablet formulations. This helped with compliance and reduced the impact on the environment.

The service completed regular controlled drug audits. We saw wards generally performed well. Themes of areas for improvement were reviewed and discussed at medicines governance meetings. We were told the service completed regular medicines audits covering security, storage and ordering of medicines and prescribing of antibiotics. Staff described some of the learning and actions taken of the most recent audit. We asked the service to provide further details of these including learning and actions, but these were not provided.

The service had oversight of medicine related risks in the department. We saw an up to date register detailing risks with mitigating actions put in place. However, we found liquid medicines that had expired. We also saw some intravenous (IV) fluids were not stored in line with guidance. We saw excess mixed IV fluids stored in unlabelled boxes. Some medicines cupboards areas where excess medicines were stored were not tidy. This was raised to staff on the ward to address. We asked for assurance following the inspection that this had been remedied but this was not provided.

Additionally, there was limited workspace to prepare, reconstitute and administer medicines in the NICU. The medications room for Toni & Guy Ward was located on the ward. However, the medications room for the Phillip Isaac Ward was located opposite the ward within the footprint of the department. This meant nurses had to leave the ward to retrieve and prepare medication, which could leave the ward poorly staffed. We received mixed responses from staff in this area about the process for checking medication. It was therefore unclear whether medications were brought back to the ward by staff to check without the necessary packaging to avoid poor staffing.