King's Mill 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

Leaders had created a positive and proactive culture of openness and honesty about safety. Concerns about safety were fully investigated. The managers’ ensured lessons were learnt to identify and embed good practices. There was a positive learning culture with staff managing incidents and safeguarding patients well. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe.

This key question has been rated good. This meant patients were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. Staff knew how to raise incidents and concerns, which were reported on an electronic system and managers were alerted immediately. Incidents and complaints were reviewed daily at staff meetings and fully investigated. Lessons were learnt to continually identify and embed good practice.

Patients experienced care based on the latest updates and learning which followed national updates and safety incidents. Patients and staff were encouraged and supported to raise concerns. They felt confident they would be treated with compassion and understanding and would not be blamed or treated negatively if they did so.

Leaders put the NHS Patient Safety Incident Framework (PSIRF) in place so the team could respond to patient safety incidents, learn from them, and make improvements. Incidents were fully investigated, and leaders clearly analysed the data and trends, comparing them with previous reporting periods. Leaders discussed incidents at the divisional clinical governance meetings, to review trends and lessons learnt. The team quickly reviewed any incidents that needed immediate investigation.

The PSIRF Oversight Group provided opportunity for shared learning and for the division to present their improvement plans. There was regular cross divisional learning. Themes and actions were routinely triangulated, enabling showing how learning was embedded and how improvements were progressing.

Staff had access to a newsletter which shared learning from incidents. Local leaders made sure important topics were discussed at daily huddles.

There had been 435 incidents reported in December 2025, 467 in January 2026 and 474 in February 2026. Most of these incidents resulted in no harm. Themes included falls, staffing issues, treatment and care and medication issues. All incidents were investigated and actions taken, including additional training, increase communication and support from pharmacy teams.

Staff understood the duty of candour and applied this wherever necessary.

The evidence showed some shortfalls. The service did not always manage or monitor people’s safety, for example patients did not have call bells in the Same Day Emergency Care (SDEC) seated waiting room. However, they worked well with people and healthcare partners to establish and maintain safe systems of care. They did make sure there was continuity of care, including when people moved between different services.

Staff told us the SDEC had been moved to share a space with the medical day case unit, they felt isolated from the emergency department which had resulted in a reduction of patients using the department.

As a result of the move in SDEC, new patients and returning outpatients used the same area with no separation. Although patients had initially been assessed in the emergency department, there was no regular or planned oversight of patients in the seated waiting area. We saw 10 patients waiting in the carpeted reception area, 1 patient had a vomit bowl in this area which did not meet infection prevention and control standards. We saw 1 patient with chest pain waiting for a medical review for 5 hours in this area, it was unclear if they had regular reviews during this time. Patients would have initial observations taken in the reception area which did not maintain privacy, dignity or confidentiality. There were no call bells to alert staff if patient needed help, they relied upon the reception staff to alert clinical staff if any patients required attention. We raised these concerns with senior leaders during our inspection. The trust took immediate action and the following day call bells were placed in the reception area and provided for patients. Dedicated healthcare assistants were responsible for overseeing the reception area and carrying out observations. A dedicated room was identified to carry out any observations. The standard operating procedure for flow of patients was reviewed to ensure that only outpatient or suitable patients waiting for results would wait in the waiting area.

Some wards had more than one extra patient in a bay. Bays that were designed for 4 or 5 beds had an additional bed to help with support the high number of patients admitted. We saw that ward 43 had 3 additional beds, 1 in each bay. Additional beds in bays on wards helped prevent patients having care in corridors, especially in the emergency department. We saw extra curtain rails had been installed to ensure privacy and dignity. There was a policy to ensure patients placed in additional beds were clinically appropriate and did not require high dependency of care.

There were processes and pathways for patients transferred between wards, and collaborative arrangements with other local services to ensure safety and continuity of care. Leaders and staff worked closely with healthcare partners to ensure people were cared for at home.

There were some medical patients placed on surgical and gynaecology wards (medical outliers) due to bed capacity. At the time of our inspection there were 33 medical outliers. We reviewed 4 medical outliers and 2 of the patients had up to 4 ward moves during their admission. Staff told us it was unclear which medical team had overall responsibility for the patients care and nursing staff struggled to contact relevant teams. The 4 notes reviewed showed that patients had been seen by medical staff but did not have a clear discharge plan.

The medical day case unit had reduced capacity due to SDEC recently moving and sharing facilities. We saw mixed sex breaches during our inspection. A mixed sex breach is when patients of the opposite sex are placed in the same area. We saw 2 female patients in gowns opposite a male patient also in a gown in the same bay. We raised this with staff who were unaware that this was a mixed sex breach. The toilets were also unisex and used by SDEC patients. We raised these concerns with senior leaders during our inspection. The trust took immediate action and the following day the matron had completed a walkaround of the unit and carried out a risk assessment. This included a daily review of admission and separating male and female where possible. Physical dividers and placements of patients were implemented to prevent further mixed sex breaches and single sex bathrooms were identified. This had been added to the Trust's risk register.

The leaders from SDEC and the emergency department met fortnightly to review patient pathways.

The virtual ward team offered support and treatment to patients in their own homes, this was assessed and planned in advance of discharge. The Same Day Emergency Care (SDEC) service and virtual ward aimed to prevent hospital admissions. The aim was to care and monitor patients in their own homes and enable early discharges. Such as patients requiring infusions, medication, oxygen and monitoring.

Staff saw patients from the emergency department, GP’s and community referrals to assess and treat patients to allow them to return home. Patients could return for ongoing treatment to prevent admissions. The service was open from 7am to midnight 7 days a week. Staff had good working relationships with the emergency department. This meant staff in SDEC were able to take appropriate patients from ED.

The discharge lounge accepted patients from all wards once they had a planned discharge. The electronic system showed how many bed spaces and sit up chairs were available to allow staff to transfer patients waiting for discharges. The discharge lounge staff arranged medicines to take home and transport for patients. Staff also liaised with families and discharge location such as a care home. The discharge lounge had overnight beds for those patients whose discharge was the following day or delayed. There was access to bathroom facilities and meals to cater for patients’ needs whilst on the discharge lounge.

The trust reported delayed discharges monthly. For October and November 2025 there were 86 delayed discharges. Each delayed discharge was reviewed and actions taken. Common themes for delayed discharges were awaiting transfer to another hospital, packages of care and placements. Delayed discharges were discussed at the trust flow meetings, staff handovers and board meetings.

Patient assessment processes included the use of recognised tools such as ReSPECT forms. This is a personalised document for individuals with complex health needs. Staff completed falls assessments. There was an Amber care bundle used for patients’ to improve the quality of care for people whose recovery and prognosis was uncertain.

Staff had handovers at the beginning of each shift. These included details of patient ongoing care and treatment, any interventions required, risk assessment and medication. Staff were engaged in the process and shared information to ensure patient safety. Medical, nursing and allied health professionals attended board rounds on the wards and emergency assessment unit (EAU). Staff attending discussed the ongoing care and treatment of patients, interventions required and plans for discharges or moves to other wards. All staff had the opportunity to engage and shared information and ask questions. However, medical staff on EAU told us that locum medical staff did not always receive adequate handovers and skill sets were not always checked.

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

Staff understood their safeguarding responsibilities and knew how to take appropriate action when necessary. The trust had a clear safeguarding policy which was available for staff to access.

All staff were trained to level 2 safeguarding adults and level 2 children, with some senior staff trained to level 3 and 4. The trust had safeguarding leads that staff could contact for advice. In March 2026, 97% of staff in the medical division were up to date with safeguarding training.

Patients were supported to understand their rights, including their human rights, rights under acute services, the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of patients with protected characteristics.

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

Safety was a priority that involved everyone, including staff as well as people using the service. Staff made sure that people understood the care and treatment that was being provided.

We saw risk assessments such as venous thromboembolism (clots in the leg or lungs), falls assessments and skin integrity were completed and documented in line with national guidelines. These were completed by staff caring for patients. Staff closely monitored patients so they could respond quickly if their health deteriorated. They used a National Early Warning Score (NEWS 2) to record patient vital observation and identify deteriorating patients. Observations were entered onto an electronic system and all staff had access to review patients' observations. Any patient with high scores would be alerted to senior staff to review. Critical care outreach team would visit patients with a NEWS score of 7, ward staff were able to refer patient direct for support and advice.

Allied health professionals, such as physiotherapists and dietitians who visited the patients were provided with written and verbal information to ensure that all staff involved in patient care were fully informed of patients’ condition and care needs.

The service detected and controlled potential risks in the care environment. Staff on the wards, EAU and discharge lounge made sure equipment, facilities and technology supported the delivery of safe care.

We visited the EAU, the SDEC, medical day case unit, the discharge lounge, virtual ward and 7 medical wards. All wards and areas visited had suitable facilities to safely meet the needs of patients.

All areas visited were visibly clean and tidy with appropriate equipment available to maintain safe levels of care. Competent staff tested medical equipment within required timeframes. Staff stored sterile equipment off the floor on appropriate shelving, we looked at 10 pieces of equipment, and all were in date. Staff had access to sharps bins and labelled these correctly when opening a new one.

Fire extinguishers had within date service checks and there were signs pointing out fire exits throughout the hospital.

Staff carried out daily safety checks of specialist equipment, such as the resuscitation trolley. Resuscitation equipment was easily accessible and located in each area. Resuscitation equipment had been checked daily and an up-to-date checklist confirmed all equipment was ready for use.

There was a process to manage the safety, maintenance and repair of facilities, premises and equipment.

Managers made sure there were enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. Staff worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe. All staff had a period of induction and had supervision before commencing work. Where shifts had gaps, managers booked bank and agency staff. Bank staff told us they have an induction into the area they would work in and support from staff on the ward.

Every morning, staff could raise concerns about staffing levels and any support they required. Staff from other wards would move to work on areas that where short staffed required additional support. Staffing levels and staffing requirements were discussed at the trusts daily flow meetings, this included any gaps in staffing levels and patients 1 to 1 care needs.

Ward Manager's told us there were additional beds in bays, but staffing levels had not increased to meet this demand. They sometimes felt there was not adequate staffing levels. Ward manager would work supervisory, this allowed them to be included in the numbers if there were any short-notice staffing gaps to maintain safer staffing levels. Sisters and ward manager's would often be required to be allocated a group of patients to look after due to staff shortages. Staff told us this sometimes meant that management duties and coordination of patients care may be delayed.

There were link champions such as tissue viability, infection prevention and control and dementia on the wards, who attended meetings and training. They provide peer support and updates to staff on the wards. They can impact on patient outcomes by ensuring safety protocols and implemented and improve overall compliance with care such as hand hygiene and wound care.

Nursing staff had completed their Nursing and Midwifery Council re-validation checks and updates to develop their competencies.

Staff received training appropriate and relevant to their role. Staff had additional competencies for their roles such as cannulation and catheterisation. All staff had an induction, and staff were provided with supervision as needed. Training compliance data showed 92% of all staff had completed their mandatory training.

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

All areas visited and wards were visibly clean, tidy and well-maintained.

Dedicated cleaning staff were responsible for keeping the environment clean. They had enough equipment and followed a daily checklist to ensure they had completed all tasks. Staff on the wards also carried out daily cleaning of the equipment and environment. We saw cleaning and alcohol wipes were available throughout the hospital.

Staff followed infection control principles including the use personal protective equipment (PPE). Hand-washing and sanitising facilities were available for staff and visitors. We observed staff using PPE and hand sanitising gel appropriately during the inspection.

Infection prevention and control audits were carried weekly out as part of the matrons’ checks. Environmental audits for the medical wards in March 2026 were generally over 96% compliant. Any concerns would be raised directly with the staff at the time.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.

Staff mainly followed systems and processes to prescribe and administer medicines safely. We reviewed 10 medication charts and found patients’ medicines were appropriately prescribed, supplied and mainly administered in line with the relevant legislation, current national guidance or best available evidence. Patients received the right choice of medicine, at the right time, to achieve the best possible health outcomes.

However, we saw patients that were administered medication for anxiety or as a sedative were not always closely monitored post administration, which did not follow national guidelines. Guidelines state that monitoring required close observation of respiratory function, blood pressure, and heart rate. We found patients on ward 43 that had been administered the medication, had not had the required monitoring. We raised this during our inspection. Following our inspection the trust informed us of 4 similar incidents that they were reviewing and completing an internal Patient Safety Incident Investigation (PSII). The PSII resulted in actions taken including additional training, a review of prescribing and safeguards when prescribing, with support from pharmacy and the dementia team.

Staff did not always document information consistently on drug charts. We saw on ward 44 and 43 that height and weight was not always recorded, some medication did not have an indication for its use and antibiotics did not always have a review date.

Processes were in place for managing medicines and safe storage. Staff on the ward completed regular checks of medications and controlled drugs (CDs) in line with the policy. Medications were stored in locked cupboards in locked rooms. Controlled drugs are drugs that are subject to high levels of regulation because of government decisions about those drugs that are especially addictive and harmful. We saw staff checked CD cupboards and drugs at each shift change over and were correct. However, we did see liquid drugs open on ward 44 and 43 that did not have a date they had been opened. We raised this with the nurse in charge during our inspection.

Staff monitored fridge temperatures and checked to ensure these were within the required range. These were monitored and recorded daily. However, on the EAU and the virtual ward area, we saw medication fridges were not locked. Staff told us the keys for the fridges on EAU were missing and they were waiting for new fridges. Staff on the virtual ward area were unsure of the location of the keys. We raised this with senior staff during our inspection and the EAU fridge keys were located.

Staff wore red tabards to identify that they were carrying out drugs round and should not be disturbed. Drug trolleys were locked, clean and tidy and kept outside the bays with specific medication for the bays in the bays. However, we did see drug trolleys were left open and unattended during drug rounds on ward 44 and EAU. We did raise this at the time of the inspection and immediate action was taken to close the trolley and remind the staff.