King's College Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance of the service.

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

Leaders told us the vision for the service was to provide outstanding care for the local population alongside the specialist care services they deliver nationally. Data we reviewed showed the service had developed strategy and priorities in November 2023. This included developing health inequality projects, helping staff to become mentors and leaders and building on their engagement work by introducing a parent/carers group. There was a strategy for achieving the priorities and delivering good quality sustainable care, with areas outlined for development. This supported the trust’s overall ‘BOLD’ vision and strategy, which stood for Brilliant people, Outstanding care, Leaders in research, innovation and education and Diversity, equality and inclusion.

Staff throughout the service were focused on providing high quality care for their patients. It was clear from speaking to staff their work was important to them, and they felt passionate about their contribution to care and were committed to improving the health of children and young people.

There was a varied view from some staff on the culture within the service. Leaders told us there were initiatives to celebrate staff regularly. Most staff felt they were able to provide feedback and suggest ways to improve the service or staff experience, however not all staff felt action would be taken based on their feedback. In the 2024 NHS Staff Survey, 51.7% of child health staff who responded to the survey agreed they feel safe to speak up about anything that concerns them in the organisation. This compared less favourably with the 53.5% of staff who agreed in the organisation. Actions identified to address staff survey results included hosting monthly inclusivity sessions. However, there was an absence of specific, time-bound actions to effectively address this. Following the inspection the trust provided an action plan in response to staff survey results in child health and had made progress on completing the actions.

Some staff also told us they had experienced bullying and harassment, which did not align with the trust values of kind, respectful, and working as one team. Only one member of staff who told us they had experienced bullying and harassment said they were able to raise this with their manager and felt the manager took appropriate action. Data from the 2024 NHS staff survey showed 26.4% of staff in child health experienced bullying and harassment. Less than half (44.2%) of staff said the last time they experienced harassment, bullying or abuse at work, they or a colleague reported it. We saw that the service wanted staff to demonstrate allyship when seeing or facing biases in the service. The medical team had published work on allyship and delivered inclusivity sessions encouraging teamwork and speaking up for others. In collaboration with the Organisational Development team, initiatives such as team away days, 360 team surveys, and the Compassionate Teams Programme had strengthened collaboration across NICU, PICU, and Hepatology. The psychology team provided ongoing support through debriefs, reflective sessions, and compassionate engagement events. However, due to reports of bullying and harassment and the levels indicated in the staff survey, it was not clear the extent to which these measures have had an effect.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. However, leaders did not always demonstrate they had the appropriate oversight of risk to keep people safe.

There was a clear management structure with defined lines of responsibility and accountability. Local leadership was provided by matrons and ward managers. They were supported by lead nurses who fed into a clinical director, general manager, and head of nursing for the care group. Leaders had the skills, knowledge, and experience to lead effectively. Although the service had inclusive leaders who understood the context in which they delivered care, treatment and support, there was more to do around culture and values.

Evidence we reviewed showed that leaders did not always have appropriate oversight of risks. The department held a risk register which did not entirely reflect the concerns we found on inspection for example the numerous expired guidelines in the service, topics with poor mandatory training compliance and the electronic patient record system not allowing for audits to be completed effectively.

Leaders were generally visible and available to their staff and teams. However, some staff we spoke with told us they were not always supported by the leadership team and did not feel confident they would take fair action to address their concerns. Leaders told of us of initiatives to improve culture and staff wellbeing such as launching 360 feedback and work to improve inter team working. Additionally, they were working to build an allyship culture and had developed a patient and parent charter to show staff they are supported by leadership.

We saw evidence of succession planning and development pathways for clinical and administrative staff of all levels. Staff told us how they were supported to access courses and in their development. Staff also had access to a trust leadership programme named ‘Kaleidoscope’.

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

The leadership team endeavoured to foster a positive culture where people felt they could speak up and their voice would be heard. Most staff we met said they would not be anxious to speak up if they needed to. However, this was not the case for all staff, and some admitted they were not confident to speak up. The NHS Staff Survey showed 51.7% of staff from child health who responded agreed they felt safe to speak up about anything that concerns them in the organisation. However, 72.7% of staff in child health felt secure raising concerns about unsafe clinical practice.

The trust had a Freedom to Speak Up Guardian with whom staff could raise concerns about any issues. The trust had an appropriate and up to date Freedom to Speak Up Policy (incorporating Whistleblowing).

Recent concerns raised to the guardian highlighted that some Allied Health Professionals (AHPs) for example physiotherapists and speech and language therapists working in the child health service had expressed a desire to report directly into the child health care group rather than therapies rehabilitation and allied clinical services. We saw this had been considered but due to vacancies the current structure remains, and an action plan had been developed to address the concerns raised.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

NHS staff survey data showed that 31.5% of staff in child health reported that they had not experienced racial discrimination. Although this was better than the organisation overall, this indicated more work was needed to reduce experiences of discrimination. The service identified from staff survey responses that one of the areas to improve was issues around bias and inclusivity. Actions were identified to address this. This included a staff suggestion box, monthly inclusivity sessions and local recognition awards. However, we did not see there was a timeframe to put the actions in place.

The service made efforts to promote equality and diversity in daily work and provided opportunities for career development. We saw supporting black and ethnic minority staff to apply for leadership roles formed part of the service strategy. Leaders took steps to ensure staff and leaders were representative of the population of people using the service.

Most staff we spoke to were aware of the available staff networks and knew how to access or were a part of them. Staff had access to multiple networks including:

• Inter Faith and Belief Network
• King’s Able – staff disability network
• King’s and Queers – LGBTQ+ Network
• Race Ethnicity and Cultural Heritage (REACH) Network
• Women’s Network

The service did not always have clear responsibilities, roles, systems of accountability or good governance. The service did not always have robust systems and arrangements to manage current and future risks to the quality of the service.

There was evidence of a multi-professional governance framework. The service held monthly clinical governance meetings to discuss quality issues such as incidents, audits, and guideline ratification. Metrics were used to gain assurance around staffing including culture, wellbeing and safety. Meeting minutes showed patient experience data could not always be reviewed due to issues with the platform, though complaints were discussed to ensure oversight, and staff reported following up and monitoring themes and trends. The Trust informed us they have since improved the patient experience platform. The mortality and morbidity meetings across all services occurred monthly. The information was reported through the governance structure to ensure early intervention. The data was monitored by the Child Health Governance and Risk Committee and reported to the Children and Young People Oversight board.

Staff we spoke with had a good awareness of governance processes and knew how and where to escalate their concerns. Wards and teams held regular team meetings to discuss incidents, audit results, and safety alerts. We reviewed a sample of team newsletters and meeting minutes across the service which shared information regarding patient feedback, learning from incidents, and education opportunities for staff. Additionally, meetings included welcoming new staff as well as recognising staff and team achievements. Staff had access to a range of policies, procedures and guidance which was available on the provider’s intranet. However, we found several policies were considerably out of date. The service had an action plan in place to improve compliance with guideline reviews.

We reviewed the service risk register. The service held monthly reviews of their risk register. However, we found there was no documentary evidence, such as meeting minutes, to demonstrate that monthly reviews of the service’s risk register had taken place. Following the inspection, the trust advised that updates were recorded electronically within its Risk Management System (InPhase) and that significant changes were discussed at governance meetings. While this indicated that a process for review existed, the absence of contemporaneous records at the point of inspection meant this could not be verified. The service risk register did not comprehensively reflect the risks within the service, such as out-of-date guidelines, missed opportunities to safeguard people and the lack of comprehensive audits. An inability to provide safe one-to-one nursing care for all NICU babies had been recorded as an open risk on the risk register since November 2017, this was categorised as a medium risk. Although the trust had put measures in place to address this, we could not be assured the actions put in place were able to meaningfully mitigate the risk as data we reviewed between March and May 2025 showed the number of nursing staff providing one-to-one or two-to-one care consistently fell short of established standards. Following the inspection, the trust informed us that a targeted recruitment strategy had been implemented and an action plan linked to the risk indicated that full NICU staffing levels were expected to be achieved by March 2026. However, the service risk register showed key risks and control measures were identified. Risks had a review date and an accountable staff member responsible for managing each risk. The risk register was discussed at some, but not all, governance meetings. Where discussed we saw evidence of feedback and updates on existing risks and discussion of new risks.

There was data and information available to understand performance and quality. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through team meetings and newsletters. However, there was not robust audit data of risk assessments available to monitor compliance and trends in performance against safety standards and organisational objectives. Where there was audit data available for example PEWS audits, there was not an action plan to address gaps in auditing and compliance.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

Staff worked with local and national partners to drive improvement. Key organisations included the London Neonatal Operational Delivery Network, South Thames Paediatric Network and the Integrated Care Board. The service also ran quarterly GP training programmes and consultants ran weekly triage meetings with GPs in two local boroughs.

Staff told us they have good partnership working with the local Child and Adolescent Mental Health Service as well as improving relationships with community health partners.

Staff regularly engaged with local communities, parents and young people who used the service to gain feedback and improve people’s experiences via feedback surveys and patient forums.

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

There were effective systems in place to ensure leaders had oversight of incidents in the child health service, through monthly child health incident meetings. The meeting minutes we reviewed showed evidence of trend analysis and discussion of improvements and learning identified from incident reports. We also saw that updates were provided on ongoing quality improvement projects.

There was a plan for the service to focus on continuous learning, innovation and improvement. The quality improvement projects developed met the needs of the service, for example their Home on Time quality improvement plan to improve flow and patient experience. A parenteral nutrition quality improvement group had also been established to review and minimise reoccurring parenteral nutrition errors, which had introduced actions to address common error themes.

Leaders encouraged innovation and participation in research. Junior medical staff told us they were happy with research opportunities in the hospital. The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work, including research and had an extensive portfolio of clinical trials across multiple specialities for children and young people to take part in. We saw creating a clinical research culture as well as embedding learning from complaints and incidents in staff training formed part of the service strategy.

The service had a committed team of practice educators. Their role was to support with education for staff, including development and advancement, and through this to help with staff retention. Members of staff had access to training programmes which were both mandatory and role-specific depending on their role and experience.

Staff and leaders encouraged creative ways of delivering equality of experience, outcomes and quality of life for people. The service applied for a license to use Nanoknife technology, on the youngest person to be treated with this technique, which uses an electrical current to treat areas of cancer.

Learning from internal and external reviews was effective and included those related to mortality or death of a person using the service.