King's College Hospital

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• 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 service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was not always consistent. Leaders did not always support the delivery of high-quality, person-centred care, as they had not recognised some issues with the way the service was operating. This resulted in risks to patients not being addressed. However, staff provided positive feedback about the culture within the service and described service leaders as approachable and helpful.

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.

Staff in the Emergency Department (ED) did not always feel valued by the trust for their work. The service had a shared vision, strategy, and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, not all staff were aware of this.

Staff told us that they felt valued by their line managers and their colleagues, but not by the wider trust. This was reflected in the NHS Staff Survey 2025, in which only 31.1% of ED staff (including staff at another ED run by the same trust) said that they were satisfied that the trust valued their work (this was lower than the average of 40.4% for the trust).

The trust had a strategic vision for the years 2021 to 2026. The acronym of this strategy was ‘BOLD’, which stood for ‘Brilliant people, Outstanding care, Leaders in research, innovation and education, and Diversity, equality and inclusion at the heart of everything we do’. The trust has since launched a new strategy for the years 2026 to 2031, which was not yet released at the time of our inspection. ED staff members were aware of the ‘BOLD’ strategy, however not all were able to recall what the letters stood for. Staff members told us that they did not believe the trust actually stood by these values. Staff members told us that they believed that the trust’s primary motivation was cost-cutting. Staff members also told us that they believed that risk to patients wasn’t shared across the trust, but was instead concentrated in the ED.

Leaders within the ED had clear goals for the department. Examples included increasing the proportion of paediatric patients streamed to the on-site Urgent Treatment Centre (UTC) and improving the ED environment through estates upgrades (some of which were underway while we were present).

Service-wide updates, such as current operational pressures, were not discussed on a day-to-day basis with staff, such as in handovers. However, this information was distributed on a longer-term basis through ED staff newsletters. These also included information about current financial pressures facing the service.

The service’s leaders did not always identify issues with the way the service was operating, which led to an increased risk of harm to patients. However, service leaders were inclusive, visible, and well-respected by staff.

The Emergency Department (ED) care group senior leadership team (SLT) consisted of a clinical director (a doctor), a head of nursing, and a general manager. The SLT had the skills and experience to lead the service. However, due to operational pressures on the service, service leaders did not always have the capacity to identify issues within the department that put people at risk of harm. For example, issues that were apparent on this assessment, such as staff not applying patient wristbands, issues with equipment available to staff, and issues with cleanliness, had not been identified prior and therefore continued to present a risk to patient safety. When the SLT had identified issues, such as the lack of a corridor care policy, these were not always present on the service’s risk register, so it was not always clear what action had been taken to mitigate these risks. However, the SLT were responsive when we raised these concerns and took immediate action when required. Senior leaders had also already identified some of the issues identified on this assessment. For example, service leaders recognised that the service’s lack of employment of dedicated ED pharmacists and play specialists presented risks to patients. Service leaders told us they had put forwarded a business case for the latter to the trust, but it had been rejected.

ED staff told us that they felt valued by the SLT and other ED leaders. They described a positive culture in which senior leaders were accessible and approachable. In the NHS Staff Survey 2025 (which included staff at another ED run by the same trust), 68.6% of staff said they felt valued by their team, 69.5% of staff said their manager valued their work, and 82.1% said they enjoyed working with their colleagues.

Matrons were respected and liked by junior nursing staff. Nurses told us that matrons had an ‘open door policy’, in which they could go to their office and ask for help if they needed it. Nurses also told us that matrons supported them in upsetting situations, for example by organising debriefs after the death of a patient.

Resident doctors provided positive feedback about consultant doctors. They told us that consultants were available for advice when they needed it, and that they did not feel pressured to act outside of their scope of competence.

However, some members of staff told us that executive leaders from the trust were not very visible, and that they did not believe that the trust always understood key issues facing the service.

Leadership development opportunities, including external courses, were available to staff.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us that they were able to speak up about their concerns without fear of retribution. They described a positive culture in which they were encouraged to identify and talk about problems. In the NHS Staff Survey 2025 (which included staff at another Emergency Department run by the same trust), 91.2% of staff said that they were encouraged to report errors, near misses, and incidents, and 72.9% said they would feel secure raising concerns about unsafe clinical practice. However, fewer staff (49.2%) said they felt confident that their concern would be addressed.

The service had access to a Freedom to Speak Up Guardian, who could listen to concerns if members of staff did not feel able to raise them with leaders. Staff members were aware of this option but told us they did not feel like they needed to use it. Within the 12 months prior to our inspection, the Freedom to Speak Up Guardian had been contacted 6 times by ED staff. We reviewed these contacts and found no repeated themes which would indicate issues raising a certain topic with senior leaders.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all risks to the service had been recognised or addressed through governance systems. However, the service had clear responsibilities, roles, and systems of accountability.

The service had appropriate governance systems. For example, senior nurses, doctors, and operational staff met weekly to discuss issues specific to their staff group. These meetings fed into a weekly multidisciplinary ‘core group’ meeting of senior staff, in which incident themes, audits, patient outcomes, morbidity and mortality incidents, and performance data were discussed and reviewed. Incidents and complaints were reviewed by senior staff in separate weekly meetings. Medication safety meetings, which reviewed any incidents involving medicines, were held monthly. ‘Mental health steering’ meetings, which reviewed incidents and performance data for mental health patients, were held monthly and included staff employed by the nearby NHS mental health trust which provided the Emergency Department (ED) with its psychiatric liaison and mental health nursing services. Weekly safeguarding meetings were held for both paediatric and adult patients.

There were systems in place for the outcomes of these meetings to be provided to senior trust leadership. The emergency department sat within division B of the trust’s 3 divisions. Divisional meetings were held regularly and included a monthly ED performance meeting and a monthly divisional quality and governance board meeting, in which high-level risks could be escalated.

Senior leaders operated a risk register that was specific to the ED. This was reviewed fortnightly in a dedicated meeting. Risks were rated for their perceived severity and mitigations for each risk were recorded. At the time of our inspection, the highest-rated risks were, ‘Risk of patients spending a prolonged period in the ED waiting for assessment by specialties or beds for admission’ and ‘There is a risk that patients with Acute Behavioural Disturbance or Acute Mental Health crisis will have a negative experience in the ED, and that there may be an impact on other patients and staff’. The risks on this risk register were reflective of issues faced by ED staff and patients.

However, the above systems had not identified all risks to patients using the service. This resulted in gaps in the governance of the service. For example, service leaders were aware that the service had no corridor care policy in place, but this had not been added to the risk register. This had prevented leaders from taking action to mitigate the risks this presented and resulted in patients receiving corridor care when this was not appropriate (see ‘Involving People to Manage Risks’). The risk register also did not include the service’s lack of a dedicated pharmacy service, despite this being contrary to Royal College of Emergency Medicine (RCEM) guidelines (see ‘Medicines Optimisation’). This again meant that mitigation plans for this risk were not in place.

There were multiple ‘clinical leads’ for the management of different aspects of care (such as a governance lead, safeguarding leads for adults and children, and a patient outcomes lead). However, some leads told us that they were not allocated enough time to complete these aspects of their job.

The trust had clear emergency preparedness and major incident policies. These contained specific guidance and responsibilities for ED staff. There was also a clear protocol for ambulance handover delays, with clear criteria for escalation to the clinical site manager.

The service understood and carried out their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement.

Service leaders within the local ambulance NHS trust provided positive feedback about working with Emergency Department (ED) staff. They told us that service leaders were easy to contact, that they have regular meetings, and that senior staff engage well when there are incidents that involve both providers. We observed ED staff and ambulance staff working well together, including ambulance staff helping to take observations for nurses when handing over patients. However, we saw some ambulance staff waiting in the ED for up to 45 minutes even after they had handed over their patient. This was because they were waiting for their trolley to be returned, even though the patient was still using it and was unlikely to be moved off it.

The service worked well with staff from the nearby mental health NHS trust which provided its psychiatric liaison and mental health nursing services. Staff from this trust were able to access the notes and incident reporting systems of both trusts. Staff described a good working relationship with each other. ED nurses received training in mental health from this adjoining NHS trust. Staff from both trusts attended a monthly ‘mental health steering’ meeting, which reviewed incidents and operational data for mental health patients. Service leaders within the ED were involved in work with this trust to decrease the number of mental health patients presenting to King’s ED.

The service worked well with the police to manage violence and aggression. Staff told us that new police recruits in local boroughs received tours of the department to familiarise them with it, and that senior ED staff had provided education sessions for police officers.

The service worked with charities to improve the outcomes of some population groups. For example, staff could refer patients under 25 who had been victims of violence (particularly gang-related violence) to a charity which provided psychological support. Volunteers from the King’s College Hospital Charity were also present on our visits, helping to guide patients around the department. We saw evidence of independent domestic violence advocates (IVDAs) attending service safeguarding meetings.

Senior staff also attended the clinical governance meetings of the Urgent Treatment Centre (UTC), which was operated by a different provider but present on the same site.

The service used the same Electronic Patient Record (EPR) as another nearby hospital run by a different NHS trust. This allowed staff to review the notes and investigation results of patients who had previously attended that ED.

The service focused on continuous learning, innovation and improvement. The service encouraged staff to think about how to deliver equality of experience, outcome, and quality of life for patients.

The service offered regular teaching and education to staff. All band 5 nurses were offered a course linked to Royal College of Nursing (RCN) level 2 competencies. Successful completion of this course was required to progress to band 6. The service had a team of practice development nurses (PDNs) who developed and delivered a teaching programme. This included ‘bitesize’ teaching offered every weekday morning, which was often tailored to staff requests or areas noted as requiring improvement in recent complaints or incidents, and weekly simulation training with a hypothetical clinical scenario. We saw evidence that these training sessions were being delivered and were well attended. Nursing staff provided positive feedback about these sessions. However, some PDNs told us that it was difficult to maintain this quantity of teaching because they were often asked to cover shifts in the Emergency Department (ED) due to vacancies.

Resident doctors, including those not on training pathways, told us they received a weekly 2-hour teaching session, as well as other paediatric teaching sessions. We were told these were rarely or never cancelled and that senior doctors ensured they had the time to attend.

Staff were encouraged to take part in audits and quality improvement projects (QIPs), and there was evidence that these resulted in changes to care delivery. For example, a ‘management of hypertension in the ED’ QIP resulted in an updated guideline being uploaded to the trust intranet for staff to review, and a Royal College of Emergency Medicine (RCEM) audit (‘Care of Older People in the Emergency Department’) showed an improvement in the rates of delirium screening for at-risk patients from a mean of 19% in the first year to 39% in the second year. There were systems for audit and QIP results to feed into governance meetings.

The service had recently implemented a ‘digital front door’ (electronic tablets on which walk-in patients could book themselves into the ED without speaking to a receptionist). This resulted in significant improvements in the median time to triage for adult patients (from 22 minutes in May 2025 to 3 minutes in April 2026). As part of the introduction of this system, the service ran a survey of 279 patients who had used it, which showed 67% of patients used it without needing any additional support and that 58% of patients rated it as ‘good’ or ‘very good’.