King's College Hospital

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm and safety was a priority for everyone. 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 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulation 12 (safe care and treatment), regulation 15 (premises and equipment) and regulation 18 (staffing). These breaches were in relation to incidents, staffing, records and risk assessments and safe environment 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.

The evidence showed some shortfalls. Leaders did not always investigate incidents or close actions plans. This raised concerns that lessons were not always learnt in a timely manner to embed good practice. However, staff reported incidents and leaders had a positive culture of safety based on openness and honesty.

From 1 May 2025 to 30 April 2026, the service reported 1,373 incidents, which were mainly graded as no or low harm. The top themes from the incidents were medication errors, capacity issues, faulty equipment, delayed diagnosis, nutrition and hydration and patient identification.

At the time of our assessment, the service had 360 open incidents, of which 296 were overdue an investigation, closure or had unresolved recommendations; some dating before 1 May 2025. The reason for the backlog was reduced governance capacity and staffing shortages. This impacted on closing of incidents, embedding learning in a timely way, increased potential for avoidable harm to patients. However, the trust had an action plan in place to review and close the incidents.

Staff knew what incidents to report and how to report them. Staff told us they knew how to use the incident reporting system and were encouraged to report all incidents, including near misses. Most staff said leaders listened to their safety concerns. However not all staff felt leaders listened to their safety concerns particularly in the neonatal intensive care unit. Staff described adverse events that had been reported, including medication errors, clinical incidents in neonatal care and equipment faults.

Staff received feedback from incident investigations through handover, team meetings and internal communications. Staff told us they discussed incidents regularly, in a supportive environment, and reviewed themes and outcomes. Support was given to staff after serious incidents, including opportunities to reflect on practice

There was evidence that the service made changes following incidents and complaints. For example, the service launched quality improvement (QI) projects on preventing pressure ulcers, blood transfusion and total parenteral nutrition following recent incident investigations and learnings. The service had also developed a standard operating procedure for liver speciality patients being cared for on other paediatric wards. This was following an incident investigation that highlighted delays in decision making. The service had also developed an information leaflet on lumbar puncture following a complaint investigation.

Staff understood duty of candour. Staff told us they were open and transparent when things went wrong. They gave patients and families clear explanations and provided support throughout any investigations.

Overall, staff showed a positive approach to reporting and learning from incidents. However, the service had a backlog of overdue incidents and the delays in investigation processes limited the service’s ability to demonstrate timely learning and improvement.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had an up to date safeguarding and baby abduction policies and had improved their governance on management of safeguarding incidents and referrals, this was an improvement from the last assessments.

From April 2025 to March 2026, staff reported 3,020 safeguarding referrals in the service, which demonstrated active identification and escalation of risks. This was an improvement since the last assessment.

Staff could describe how to protect children and adults from harassment and discrimination, had awareness of equality and diversity and described how they supported patients and families with different needs. This included tailoring communication and recognising vulnerabilities in children, young people and families receiving care in specialist care settings.

Safeguarding was supported through regular meetings and multidisciplinary, working with internal and external stakeholders to manage risks and protect patients.

Staff followed procedures to support children and families visiting the service. Staff described how they supported parental involvement and ensured safe visiting arrangements. The service was able to protect patients from all unauthorised access using controlled access via video entry.

Staff demonstrated an understanding of restrictive practices and how to minimise their use. Staff described using de-escalation techniques and maintaining patient safety while reducing the need for restrictive interventions. There was a focus on maintaining dignity and supporting patients in the least limiting way.

However, not all staff had completed safeguarding training relevant to their specific role. Staff knew how to make a safeguarding referral, were aware of the safeguarding processes within the service and knew how to escalate concerns using established safeguarding pathways.

Data provided by the trust showed 88.4% of staff had completed their safeguarding adult and children training and this was a slight improvement from the last assessment. However, we observed significantly poor compliance in some specialities such as neurology (60%), speciality nurses (60%), medical CCC (60%) and hepatology (69.2%). Also, the medical surgery compliance was 72.2% and medical secretaries achieved 78% compliance, which were below the trust target. The trust had an action plan in place to improve compliance to above 95% by 31 July 2026. Following the assessment the trust explained that lower compliance was due to the temporary absence of the named nurse for safeguarding and vacancies within the safeguarding team, which had affected the delivery of training. At the time of the inspection, the vacancies had been filled, and the named nurse had recently returned to post. As at 31 July 2026, compliance for Safeguarding Level 3 was 89.7%.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive.

Staff did not always complete risk assessments for each child and young person. There had been improvements in the undertaking of audit of patients’ risk assessment to ensure compliance with local and national guidance to improve patient safety. However, compliance in the audits was poor.

Staff did not consistently complete nutrition screening tools. From November 2025 to 30 April 2026, staff achieved 23% compliance in the paediatric skin assessment audit and 32% in the nutrition screening audit. Poor compliances in the nutrition screening were mostly related to Toni & Guy, Princess Elizabeth, Ray Of Sunshine, Paediatric Short Stay Unit (PSSU) and Lion wards. This meant people at risk of malnutrition or dehydration may not have been identified promptly, and appropriate support, monitoring or referrals may not have been put in place in a timely way. This did not provide assurance that people’s nutrition and hydration needs were always assessed, monitored and managed safely.

Staff did not consistently complete paediatric falls risk assessments. In the same period, the paediatric falls assessment audit showed an overall compliance of 42.4%. Rays Of Sunshine ward had significantly poor compliance in this audit and compliance ranged from 2.82 to 5.1%. No action in place to address areas of poor compliance. This meant children and young people at risk of falls may not have been identified promptly, and appropriate actions to reduce the risk of avoidable harm may not have been put in place. This did not provide assurance that falls risks were consistently assessed, monitored and managed safely.

Staff did not consistently complete paediatric pain assessments. In the same period, staff achieved between 60% to 70% compliance in the paediatric pain assessment audit and 58% to 66% in the scanning compliance audit. This meant children and young people’s pain may not have been identified, monitored or treated in a timely way. This did not provide assurance that staff consistently assessed children’s pain, acted on their needs, or reviewed whether interventions were effective.

Staff used a nationally recognised tool to monitor and respond to clinical deterioration. The Paediatric Early Warning Score (PEWS) was used to identify children and young people at risk, with appropriate escalation procedures in place. From November 2025 to April 2026, staff achieved between 83 to 97% compliance. However, there were significant gaps in the timeliness (25% to 45%) and completeness (65% to 84%) of PEWS. However, action plans were in place and to be completed by end of July 2026 to address low compliance and improve performance.

Staff did not consistently complete sepsis, MRSA and other required risk assessments. The compliance with sepsis and risk assessment tools ranged between 20% and 70%. Similarly, MRSA screening ranged between 35% to 100%, indicating inconsistency in admission, risk assessment and infection control processes. Overall, core safety risk assessments were not yet embedded to keep people safe. This meant risks to children and young people’s health and safety may not have been identified, escalated or managed in a timely way. This included risks linked to clinical deterioration, infection prevention and individual care needs. This did not provide assurance that staff consistently assessed, monitored and acted on risks to keep children and young people safe from avoidable harm.

The vital observations audit compliance showed improvement and compliance was between 88 % and 96%. Between January and April 2026, staff achieved 96% compliance in the World Health Organisation (WHO) surgical safety checklist audit.

Staff communicated with children, young people and families, so they understood their care and treatment. This included involving parents in discussions about care and ensuring they understood treatment plans. Staff supported families to remain involved in care, which helped them to understand risks and contribute to decision-making. This included discussing treatment options and respecting patient choices where appropriate. Staff were aware of the need to support advance decisions, including decisions to refuse treatment, and used available information within patient records to guide care.

The service provided facilities to support families and carers, including overnight rooms, food preparation areas and quiet working pods. These helped carers stay with patients while managing other commitments. These arrangements enabled carers to remain present during care and treatment.

Families were encouraged to give feedback through conversations and meetings, and staff supported access to additional services, including advocacy where needed.

The service worked collaboratively with children, young people and their families to manage risks. For example, the service had invited school children from a neighbouring school to visit the service and take part in an educational session to help develop their first aid and cardiopulmonary resuscitation (CPR) skills. This enabled the school children learn basic skills of first aid and CPR techniques, to help them step in to support someone else in need.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

The environment did not consistently support safe care. We identified several environmental risks that could affect safety and dignity. In the Neonatal Intensive Care Unit (NICU), the environment did not fully meet relevant health building standards and national guidance on space between beds. We observed cramped conditions and lack of adequate storage space of equipment, which limited space for staff to deliver care safely and posed an evacuation risk. The service had plans to redevelop these areas and senior leaders told us that expansion and refurbishment plans of NICU will commence in mid-2026.

In outpatient areas, we found that safety controls were not always effective. Safety gates designed to restrict access were not consistently locked, which increased the risk of falls. We highlighted this to senior leaders and staff were reminded to ensure the safety gates were locked however, on day 2 of our assessment we observed a safety gate still being unlocked despite the new extra safety signage.

There were additional risks relating to storage and layout. Equipment, including children’s bikes, were stored in corridor areas. This created potential trip hazards and could obstruct evacuation routes in an emergency. Staff we spoke to were not sure if a risk assessment had been carried out where children’s equipment were been stored. In the Paediatric Short Stay Unit (PSSU), treatment areas were cramped and we identified potential ligature risks. The PSSU still had limited play facilities, toilet and bathroom facilities. The risk identified at the last assessment of children and young people attending PSSU being exposed to violent and aggression situations in the emergency department (ED), was still present at this assessment. Staff told us they were exploring charity funding to refurbish the PSSU and improve its environment.

In the paediatric intensive care unit (PICU), we observed a broken blind which was reported on 3 May 2026 and a faulty door reported on 12 May 2026. Although staff had identified these issues, they had not been resolved promptly. This meant the faulty blind and door were not being actioned in a timely manner.

Overcrowding and layout issues reduced staff’s ability to maintain clean and safe environments to minimise infection risk particularly NICU and Princess Elizabeth Ward. In some areas including rehabilitation bays, limited space and overcrowding, which increased risks related to infection prevention and control and reduced privacy and dignity for patients. Although the risk had been recognised in NICU, with an expansion plan in place, the Trust had also recognised the environmental risks on Princess Elizabeth Ward and plans for refurbishment works were underway at the time of the inspection, with completion planned for November 2026.

Despite these concerns, there were examples of good practice. Access to paediatric areas was controlled through video entry systems, which supported the security of children and young people.

The service provided a range of clinical environments, including cubicles and open bay areas, which supported the monitoring of children and young people. The layout of wards enabled staff to observe patients effectively and respond to their needs. Dedicated treatment spaces were available in some areas, which supported the safe delivery of minor procedures.

Staff had enough suitable equipment to safely care for children and young people. Staff carried out daily safety checks of fridge, specialist and emergency equipment, in line with safety requirements. Data showed that staff achieved between 83% and 100% in the emergency equipment audit.

Equipment was visibly clean, appropriately PAT (portable appliance testing) tested, maintained and within servicing dates. There were systems in place to maintain and service critical equipment such as ventilators. This provided assurance that risks associated with equipment failures were recognised and managed.

Overall, while some areas of the environment supported safe care, risks relating to space, maintenance and layout meant the service did not consistently provide a safe environment for children and young people.

The evidence showed some shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. Not all staff were up to date with their mandatory and role specific training modules. However, staff received effective support and supervision.

The service did not consistently maintain one-to-one nursing care for babies and children who required intensive or advanced critical care. Improvements required in staffing had not been fully achieved since the last assessment and continued to impact the safety and sustainability of the service. Staffing levels within the NICU and PICU had remained below recognised British Association of Perinatal Medicine standards (BAPM) and Paediatric Critical Care Society (PCCS) standards. Both PICU and NICU were not meeting the PICCs nor BAPM standards and not complying particularly with the 1:1 care for intensive care.

Although this was a longstanding issue, the service had an action plan in place to address this such as recruitment, use of temporary staff and safer staffing tool. The service was not consistently able to provide1 to 1 care for high-dependency neonatal patients. During the assessment staff told us there were gaps in medical cover overnight. Following the assessment the trust provided evidence the medical rota was covered overnight. However, the gaps in 1 to 1 care meant staff may not have been able to provide the level of continuous observation, monitoring and timely intervention required to meet patients’ acuity and dependency needs. This increased the risk that deterioration, equipment alarms, treatment complications or urgent care needs would not be identified and acted on promptly. This did not provide assurance that staffing levels and skill mix were always sufficient to keep babies, children and young people safe from avoidable harm. However, staff told us there have been recruitment of nurses since the last assessment, which have resulted in a slight improvement in staffing.

From February to April 2026, the unfilled shifts rate in the service was 23% for nursing staff. Whilst the other staff achieved an overall 8% unfilled shift rate. However, the figure was high in the month of April 2026 and was 25%. Recent data from April 2025 to March 2026, showed that PICU reported 52% unfilled shifts and whilst NICU reported 26% unfilled shifts.

Leaders calculated the number and skill mix of staff required to meet patient needs. However, staffing levels did not always meet planned levels.

On both days of our assessment during the day shift; NICU were short of nurses and staff were redeployed from PICU to maintain safe staffing. However, PICU had low acuity and was not understaffed on day 1 of our assessment. Staff were also redeployed from NICU to the surgical ward during the assessment to ensure safe staffing. On day 2, we observed 2 babies requiring 1:1, did not have dedicated staff during staff break or preparation of medicines. This left their colleagues to look after the babies and also raised concerns that the nurses in charge, may not always be supernumerary. On the first night of our assessment NICU was short of 4 nurses and could not maintain 1:1 care in intensive care to safely care for babies. Staff told us 1:1 was achieved in NICU around 90% of the time due to staffing. We observed PICU was short of 4 nurses on day 1 during the day shift but achieved safe staffing due to low acuity. However, this would not be achieved if they admitted more patients and had high acuity.

Managers deployed staff and used bank and agency staff to maintain safe staffing levels on shifts. While this supported the delivery of care, the continued reliance on temporary staff affected team continuity and stability.

The service did not always have enough medical staff to keep babies, children and young people safe. From 20 November 2025 to 20 May 2026, the service reported 10 unfilled shifts for registrars and 9.6 unfilled shifts for senior house officer (junior doctors) for medical staff due to sickness and vacancies. Recent data for medical staff between February and April 2026 showed 18% unfilled shift rates for medical staff. Leaders advised they had mitigation in place such as use of consultant, senior doctors and advanced clinical practitioners to fill the gaps for medical staff. However, on day 2 of our assessment we observed the special care baby unit (SCBU) was short of 2 registrars and 1 registrar on postnatal ward. Consultants and other registrars covering other areas in high dependency unit (HDU) and NICU were expected to offer support in SCBU.

Medical staffing arrangements covering the 24-hour service provision did not consistently support safe care. The service relied on consultants and locum medical staff to maintain clinical cover however there were gaps in rota. Consultants in the NICU worked beyond their planned job roles, which impacted on their wellbeing and family work life balance. This had the potential to affect staff wellbeing and clinical oversight. Staff raised concerns about the sustainability of the medical staffing model, and whether it met recognised national safety standards. However, senior leaders advised the trust was proposing a model that would make them in line with national recommendations.

At the time of the assessment the service had 63% Qualification in Speciality (QIS) trained staff in PICU and 49.5% in NICU. However, this did not meet the national requirement of 70% of staff requiring QIS qualifications in SCBU, HDU and Neonatal Intensive Care Unit (NITU). Senior staff told us 4 nurses were currently on the QIS training in PICU and will qualify in August 2026. The QIS training is 12 months, and senior staff told us it will take 2-3 years to meet the QIS target for NICU with their current workforce and course availability.

At the time of our assessment, NICU was not compliant with the BAPM recommendation that all NICU staff appointed after 2010 should have a certificate of completion of training (CCT) in neonatal medicine. Leaders advised that they had 2 consultants who are non-neonatal CCT trained and had been recruited to the non resident rota. Leaders told us they had received some complaints around this which was being addressed as part of a transformation piece. Since the assessment, the trust had completed a programme of work to transform the NICU workforce model. The implementation of the revised model was planned from September 2026. The Trust has undertaking a local review of the 2 consultants who hold a CCT in Paediatrics to review their relevant competencies and experience. Leaders have also confirmed that all future recruitment to relevant NICU consultant posts will be undertaken in accordance with BAPM recommendations.

Workforce data provided by the trust showed an overall vacancy rate of 4.7% during the period reviewed. As of March 2026, the overall vacancy rate was 4.1%, which was below the trust target of 10%. As of March 2026, the medical workforce vacancy rate was 0% and the nursing workforce vacancy rate was 5.5%. This indicated that overall, medical and nursing vacancy rates were below the Trust's target at the time of the assessment. The additional clinical services had a high vacancy rate of 21%. In PICU and other wards in this service, there were vacancies at Band 6 level, with 5 posts unfilled at the time of inspection. In the NICU, staffing levels data showed a shortfall of 28 whole-time equivalent staff. The unit was not meeting the recognised national staffing standards, which increased pressure on staff and affected the viability of safe staffing arrangements. These pressures have led to a high reliance on bank staffing, particularly in nursing, with relatively low agency use, but persistent unfilled shifts remain, most notably in NICU and PICU. This combination of vacancies, turnover, sickness and unfilled shifts presents a safety risk to children and young people. However, since the last assessment the vacancies of nursing staff had reduced by 8%. The service had ongoing recruitment and development initiatives to address the vacancy rates. Leaders had recruited additional staff to strengthen workforce capacity, including 27 whole-time equivalent posts within PICU and other wards in this service. However, due to the shortage of paediatric nurses, senior leaders highlighted that it may take 3 years for the service to comply with the BAPM standards. Staff in the multidisciplinary teams (MDT) told us they did not always feel confident that senior support was available when needed.

The average staff turnover rate for the period 20 November 2025 to 20 May 2026 was 13.4% however, the service reported a high turnover rate of 22% in March 2026. This was against the trust target of 13%. The high turnover rate for March 2026 mainly related to health care scientist (71%), additional clinical staff (20%) and nursing staff (10.1%). The service had high sickness rates. Data showed that the sickness rates for additional clinical services for the same period was 13% and 10% for estate staff. This was against the trust target of 3.5%. However, the nursing staff had a 4% sickness rate.

Since the last inspection the mandatory training rate had improved however, not all staff were up to date with their mandatory and role specific training modules. At the time of the assessment 85.3% staff had completed their mandatory training against the trust target of 90%. However, staff in children and young people services only met the trust target on 5 out of the 13 training modules. Staff achieved 66% compliance on the resuscitation level 3 paediatric immediate life support (PILS) and European paediatric immediate life support (EPILS), 71% on manual handling and 79.3% on the resuscitation level 2 mandatory trainings.

Staff were expected to complete additional training specific to their role. Data showed the overall compliance for the role specific training was 77.8%. There was low compliance in Oliver McGowan training with 69.7% and blood transfusion training with 76.6%. In the paediatric life support training medical staff achieved 68% compliance, while nursing staff achieved 88% compliance.

Mandatory training compliance had also previously been below target, this issue, alongside ongoing reliance on temporary staffing and workforce pressures, indicated that previous actions to strengthen staffing and competency had not been fully effective.

Managers supported staff to develop through yearly, constructive appraisals of their work to deliver safe care. At the time of the assessment, 90.1% of staff had completed their appraisal. The nurses met the trust appraisal target however, doctors, admin and additional professionals’ staff were slightly below the trust target. Following the assessment the trust provided updated compliance for appraisals which had increased to 94.6%.

Leaders had systems in place to manage staffing levels and to measure the severity of a patient's illness across the service. Managers reviewed staffing levels, patient dependency and clinical risks through daily bed management meetings. This supported oversight of staffing pressures and enabled escalation where required. Leaders described reallocating staff and escalating concerns through operational meetings. However, ongoing vacancies meant that staffing levels were not always sufficient on all shifts to meet patient needs.

Staff told us that bank and agency staff received a local induction and were supported by permanent staff to work safely within the service.

Most staff spoke positively about initiatives to support wellbeing and retention, including a flexible rostering arrangement. These measures supported staff during periods of operational pressure.

Although leaders had systems to manage staffing and had taken action to improve workforce capacity, ongoing vacancies, the reliance on temporary staff and concerns about medical staffing meant the service could not consistently ensure safe and effective staffing.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Clinical areas were generally clean and well maintained. Wards had appropriate furnishings to support safe care. Staff completed cleaning tasks regularly. Personal protective equipment (PPE) was available throughout the service, and staff followed infection prevention and control guidance. We observed staff being bare below the elbow and washing their hands and using PPE in line with guidance.

Hand hygiene audit data showed an overall 91% compliance. The infection prevention and control (IPC) and cleaning audit showed an overall 90.1% compliance, indicating generally good standards with some variability in performance across audit periods.

Staff managed sharps safely. Sharps (items such as needles or other medical objects that can cut or pierce the skin) were appropriately handled; containers were secured, not overfilled, and disposed of in line with national guidance.

However, staff told us they tried to maintain equipment and the environment despite the environment constraint to support infection prevention and control.

In neonatal and paediatric areas, staff were aware of the needs to manage risk while supporting family-centred care, which was shown by the awareness of reminding visitors, parents and staff of hand hygiene.

The estate and environment did not always allow for infection risk to be minimised. In the NICU and rehabilitation areas, bed spaces were crowded and storage areas were limited. Equipment and items stored in corridors reduced available space. This affected staff ability to consistently maintain effective infection control practice and increased the risk of cross infection.

Overall, while staff followed infection prevention and control procedures and maintained equipment appropriately, environmental constraints meant the service could not consistently minimise infection risks.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.