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

At our last assessment we rated this key question good. At this assessment the rating has remained the same.

This meant people 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. Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and leaders encouraged and supported to raise concerns, and felt confident that they would not be blamed, or treated negatively if they did so. Staff were aware of NHS England best practice guidance: Learn from Patient Safety Events (LFPSE). Some staff reported receiving feedback following an incident they had reported. Staff were supported by leaders following a distressing incident.

All staff described the ways in which information from incidents was shared within the department. This included the use of a private encrypted messaging group chat, emails, through a monthly newsletter and at handover. Most staff used emails or the messaging group to make themselves aware of changes to practice following incidents. Staff described that “hot” debriefs were in place, which happened as soon as practicable following an incident. This discussion of those involved and the investigation team allowed learning and actions to be undertaken soon after the incident. Leaders checked on the wellbeing of staff following these incidents.

Staff were aware of the duty of candour and enacted this at a patient level when aware of a complaint or incident. The service used the learning from complaints and concerns as an opportunity for improvement. Senior members of staff and leaders were involved in reviewing complaints and incidents at a daily review. For example, we heard about an issue of extending expiry dates on liquid medications which was not in line with best practice. In response to discussion around this issue several ideas were discussed for potential highlighting and resolving the issue. Following agreement on an action the leaders fed back to their own teams.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The department worked collaboratively with internal colleagues and external partners to maintain patients’ safety. Continuity of care was maintained by effective handover of patients and communicating their individual needs. All patients entering the department on foot were required to check in at the reception desk. This would initiate streaming by the 24 hour receptionist and a nurse who was present between 10am and 10pm. The patient would then be sent to the most appropriate pathway. These pathways included: majors’ area, resuscitation, minors’ area, fit to sit area or to the primary care provider. The major’s area saw patients who require more intensive care. Resuscitation is an area where the most seriously ill patients go for treatment. Minors and fit to sit areas are for patients that have less serious conditions.

Receptionists at the front desk explained the process of streaming and triage to patients. The department had different coloured chairs for triage and streaming. However, patients were unaware of this and sat wherever and waited for their name to be called. Triage patients we followed were seen within 15 minutes in 1 of the 3 triage rooms in operation. Initial observations were recorded, and tests were performed and then appropriate patients were returned to the waiting room to await being seen by a clinician. Some patients would be sent directly to other areas in the department. Children were sent through to the paediatric waiting area from reception. The waiting room was monitored by the nurse in reception who undertook observations on patients as necessary. We saw that when a patient fainted, staff saw this and gave treatment quickly.

Patients were called by clinicians from the waiting room to the appropriate area for assessment and treatment. We saw a mixture of paper and electronic records in place for patients. On paper records we noted that risk assessments were completed but sepsis screening was undertaken on the electronic patient record. Staff used a dual system of recording patient information. However, they were looking forward to having one electronic patient record system which was about to be implemented following our inspection. Having one electronic patient record ensures that all patient information is in one place and this increases the safety of that patient.

Staff knew about the pathways of care for specific patients. For example, staff knew that trauma patients requiring secondary transfer, patients who required neurosurgery, patients with burns and severely ill children would all be transferred to different hospitals. There were good communications systems in place to ensure a robust handover was given and patients received timely care on arrival. Staff reported good working relationships with the hospitals that they regularly transferred patients too.

The department had a clear pathway for patients with mental health needs. When people with mental health needs arrived in the department, triage nurses or the reception nurse completed an initial assessment. They referred the patient to a third-party mental health trust who could stream patients with mental health needs directly to other services.

Mental health trained security staff supported clinical staff when a there was a risk of violence and aggression. We saw that they responded quickly but did not provide support and restraint unless advised by care staff. Staff completed an emergency department adult mental health triage safety and observational tool designed to assist staff to the recognise the needs of the patient. This form was designed following a member of staff identifying a need to support patients with a mental health condition and nursing staff. It also assisted with referral to the mental health team as appropriate.

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 worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Patients we spoke with told us they felt safe and that if they had any concerns or issues, they would feel comfortable to tell someone.

Staff we spoke with knew how to identify adults and children at risk of, or suffering, significant harm. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies such as police and local authority safeguarding teams, to protect them. We saw that children who left the department without being seen by a doctor were flagged for follow up by the social worker liaison team.

Staff had training on how to recognise and report abuse, and they knew how to apply it. Data provided to us by the trust showed that compliance with all safeguarding training were over the trusts target of 90% within both the nursing staff and medical staff. Safeguarding children level 1, 2 and 3 training were all above 95% compliance for staff. Adults safeguarding training at all levels were above 96% compliance.

Staff had access to safeguarding policies, which referenced appropriate legislation and best practice guidance. Safeguarding information was displayed throughout the department. Staff told us they were confident in raising safeguarding concerns and the process for referrals on electronic patient record system and was easy to complete. Staff were able to tell us when they recently completed referrals. Staff told us there were safeguarding nurses who provided support and advice when needed. We heard that feedback from investigations was shared with the department.

The service shared concerns quickly and appropriately. Where applicable doctors completed Mental Capacity Assessments (MCA) for best interest’s restrictions. The trust had delivered training courses on the Mental Capacity Act. Staff told us that they found the training helpful. Staff considered patient’s capacity when assessing them. Staff recorded an assessment of capacity in one of the records we reviewed.

The department had effective processes and tools for assessing patients when they first presented to the department and monitored patients for signs of deterioration when they were taken into the department. Patients we spoke with told us their wait for triage had been timely. Patients were triaged by trained triage nurses. If they were fit to sit to wait for treatment, they were observed by the nurse at reception when they were on duty.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Staff in the department consistently assess patients using standardised risk assessment tools. For example, they consistently assessed the risk of venous thromboembolism (VTE), falls, skin integrity, or clinical frailty. NHS guidance states the Clinical Frailty Score (CFS) should be completed within 30 minutes for all adults over the age of 65 who present in ED. Whilst this was not always complied with due to the pressure on the department, we found that risks assessments were undertaken and reviewed during a patients stay.

Sepsis risk assessments were undertaken where appropriate. However, staff told us that winter pressures led to patients being moved through the department due to space constraints before sepsis treatment had begun, which increased clinical risk. We did not see any evidence of harm to patients because of this. Patients’ observations were recorded and scored as per the National Early Warning Score (NEWS). In children this was scored in line with the Paediatric Early Warning Score (PEWS). This allowed staff to assess any improvement or deterioration in patients and commence treatment at the earliest opportunity.

Security staff were trained in least restrictive restraint. Restrictive restraint was only used as a last resort. We noted one episode where the security team were called. They arrived promptly and awaited further instruction from the care team. They were not required as the care team were able to manage the situation.

Patients told us they felt safe and supported whilst they were in the ED. They could approach staff if they felt their health was deteriorating and they were confident staff would respond to their concerns.

We saw posters about Martha’s rule, a programme which enabled friends, relatives and patients themselves to make a direct referral to the outreach team if they felt the clinical condition of an adult or child patient was actively deteriorating. However, staff felt that this route was rarely used as family and friends would approach staff within the department first. The hospital had been one of the first to introduce Martha’s rule in the UK in September 2024.

Staff we spoke with described the processes to assess and identify patients at risk and how they assessed and documented mental capacity. Staff had a person-centred approach and involved patients, where possible when completing risk assessments.

The service mostly detected and controlled potential risks in the care environment. They made sure equipment and technology supported the delivery of safe care.

The equipment and facilities, in the main, supported the delivery of safe care. Although patients experienced long waits, waiting rooms and designated areas, such as cubicles built originally for I patient, were often used to admit 2 people, patients told us they were well looked after by staff. There was a separate area for children and their families which was easily accessed from the main waiting room and rest of the department. However, this area was not secure as per Facing the Future Standards for children and young people in emergency care guidance, October 2025. This guidance recommends that “Paediatric areas in the ED should be zoned off, with secure access points to control entry and exit”. However, doors at either end of the department were not secured, and patients, visitors and staff could walk through the department unimpeded. Patients were seen quickly and checked on regularly.

Staff, mostly, had access to all the equipment they needed and guidance or instructions for using it. We were told that when the department was busy, staff did run short of thermometers and cardiac monitors. Maintenance staff undertook planned preventive maintenance and completed electrical appliance tests were completed. All electrical equipment we checked had undergone electrical safety checks within the last 12 months. The department’s fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately. Fire exits were not blocked; evacuation routes were signposted.

The department was split into defined areas to treat different types of patients. These included streaming, minors, majors, resus, fit to sit and paediatrics. Ambulance arrivals had four bays where streaming took place for patients arriving by ambulance. Minors was an area where patients with minor injuries were treated. Majors were where those patients with illnesses or chest pain were treated. Resus was an area where the most seriously ill patients were treated. Those patients who did not need urgent treatment were asked to wait in the fit to sit area.

The department had a resuscitation area which had capacity for 15 patients, including an area to treat children. At times of peak demand, the area flexed to 2 trolleys in it to allow for an extended number of patients in the resuscitation area. Whilst the original bay was large enough to easily allow for a multi-professional team to care for and treat the patient this was restricted when 2 patients used the same bay. Screens were used to separate patients and to maintain a sense of privacy and dignity. In the event of an emergency in one half of the cubicle the other patient was moved to ensure staff had space to deal with the emergency.

In the major’s area there was an open area which had 8 designated bays. However, at peak activity these bays designed for 1 patient would also be used to admit 2 patients. The central area was also used at times to have patients on trolleys. This made the area very difficult to navigate and to easily observe patients, especially when patients were accompanied. This area was designed for 8 patients but could be used for up 24. Whilst there had been no safety events reported due this this congestion there could be a risk in identifying and treating an emergency within the area. This process was described in their escalation policy for when the department was busy.

Equipment, facilities, and technology supported the delivery of safe care. Each treatment area had a standardised equipment. Standardisation of equipment aims to reduce the risk of harm to patients because staff who work between these areas will have greater familiarity with a smaller number of devices, thereby reducing the risk of error.

The department regularly used a room for supporting people with mental health needs. This room was at the end of a corridor and in a quieter area of the major’s department. The room had minimal furniture in it and did not contain any obvious ligature anchor points. This room was bare apart from 3 heavy chairs. We saw a patient using 2 chairs together to form a bed on which to rest. This room did not conform to the Psychiatric Liaison Accreditation Network January 2026 guidance on caring for patients with mental health needs. The previous guidance was to have 1 door which opened both ways and the new guidance states the room should have 2 doors to improve safety. The trust has a redevelopment plan which is currently in the planning phase. This will include dual entry rooms for high-risk mental health patients. At present the trust utilise a dual entry cubicle in the major’s area for this purpose. Patients are risk assessed throughout their stay and placed in the appropriate location to meet their needs.

The service had enough nursing staff to keep patients safe, and the nursing staff matched the planned numbers on the day. Skill mix was reviewed regularly and adjusted throughout the day. The department had 27 whole time equivalent emergency consultants, who were supported by doctors at different levels of their training. There was consultant cover in the department from 7am to 2am seven days per week. The children's department was staffed with doctors and nurses with the appropriate paediatric competencies. There were 2 consultants with Paediatric Emergency Medicine certification. However, the department was covered by all consultants in the emergency department. The paediatric emergency department had recently opened 24 hours a day, November 2025. However, at the time of the inspection, medical staffing was allocated 10am to 2am as this was seen to be the busiest times for the department. Very sick children were transferred to a nearby unit once stabilised.

Staffing was flexed to meet the needs of the patients attending the different areas of the department. Huddles occurred regularly throughout the 24-hour period to review the needs of patients in the department. Staff were reallocated if necessary.

There were safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their role. All new starters received a comprehensive induction. Nurses who had newly qualified followed a standard preceptorship programme. This was extended if required. The department had a cohort of Advanced Clinical Practitioners in training as well as others who already worked in the department. These staff had received additional training to undertake some procedures which would have been undertaken by doctors. Staff told us that the trust were supportive of their personal needs in respect of training.

Leaders told us that there was good team culture within the department, that across the professions there were good training opportunities and multiprofessional relationships. We were told there was a culture of supporting staff to develop and progress. The department had a vacancy rate of 7.8% for nursing staff and 10.4% for medical staff. This is within the expected vacancy rate. Staff undertook additional shifts or an agency was use to cover when necessary. The vacancy rate for medics reflected a gap in registrar staff. The turnover rate for nursing staff over the 12-month period was 3.64% and 7.23% for medical staff. Turnover rates were below the national average. Whilst overall sickness rates were 6.5% the majority of this fell in the non-clinical staffing band. This meant that staff were picking up additional duties below their skill set, which may impact on the care given.

During the inspection, the department was busy with more patients being cared for than the department was built for. The service had seen a rise of 36% in attenders since pre-covid levels. They were now seeing between 450 and 500 patients a day. This put pressure on staff. However, staff said they felt able to respond to increasing demand as staff supported one another well. We observed staff who were busy but remained positive. They could highlight the issues they faced but were resilient to these because of the support they received from leaders and other staff. Nursing staff spoke about doubling the number of patients on their workload as the day became busier. Staffing was assessed at the huddles to ensure that available staff were being utilised appropriately and to maintain the safety of patients. There was a good degree of support and mutual respect among staff working in the department. We observed effective and cohesive teamwork. There was a culture of just “one team” and shared responsibility.

Staff received mandatory training appropriate and relevant to their role. Overall compliance for all staff was 90.15%, which was above the trusts target for compliance at 90%. Where training compliance was lower than the trust target, managers had actions in place to address this. Leaders monitored training and provided extended training as required to staff.

The service had a process for carrying out appraisals, 92% of nursing staff had received an appraisal and 91% of medical staff had received an appraisal. Both were better than the trust target of 90%.

Medical staff were supported by named supervisors. Resident doctors had protected time for teaching. Feedback from resident doctors was positive, they felt supported and invested in to develop and gain new skills.

Staff told us specialised mental health training was available. Staff had access to a mental health resource file within the department. This file contained information on services and how to access them as well as other useful information. It was maintained by the nurse who linked with the mental health team. This was kept up to date by the mental health link nurse. Whilst mandatory training for staff in issues relating to mental health training ranged between 82% and 92%. ED members of staff could attend day training course on mental health. This training included sessions on mental health awareness, the mental health liaison team, conflict resolution, management of agitated patient, substance misuse and the application of the Mental Health Act in ED.

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.

The service had an infection and prevention of infection policy, which staff were aware of, and which set out key information for staff to support maintaining infection, prevention and control standards. 92.3% of staff were up to date with their 3 yearly training and 88% of staff were up to date with their annual training in infection prevention and control. However, mandatory training was paused due to winter pressures. This meant that most training was planned over a 9-month period. Staff had access to essential training if required during this pause.

Hand hygiene, local cleaning and infection prevention and control audits were undertaken by the service. The hand hygiene audit across the last 6 months (September 2025 – February 2026) demonstrated that compliance was consistently rated above 95%. The environmental audit across the last 6 months demonstrated that compliance was consistently rated above 90%.

During the assessment we observed staff comply with the ‘bare arms below the elbows’ policy, in accordance with National Institute for Health and Care Excellence (NICE) guidance. Personal protective equipment (PPE) and handwashing facilities were readily available. We observed staff washing their hands between patients and good use of PPE when required.

Cleaning staff were visible within the department. We observed both clinical staff and the cleaning staff cleaning equipment and the environment. We saw ‘I am clean’ stickers placed on surfaces that had been cleaned. The floors were visibly clean despite heavy foot traffic and the constant movement of people and equipment. The cleaning schedule set out by the service was followed. Staff labelled disposable curtains with the date they were last changed. Cleaning records we saw were up to date and demonstrated all areas and equipment were cleaned regularly. Clinical waste was disposed of safely.

Clinical areas we saw were clean and had suitable furnishings which were clean and well-maintained. Toys in the paediatric department were cleaned regularly and checked for their integrity.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff did not always follow the trust’s policy regarding initial assessments including medicine information. For example, staff did not ask patients or paramedics during handover whether they were taking any critical medicines, despite this being a requirement of the trust’s protocol for initial assessment.

The ED did not have pharmacy support in line with national guidance produced by the Royal College of Emergency Medicines (RCEM).

Not all staff recorded medicine information accurately or administered medicines in line with best practice. Medicine reconciliation (the process of identifying an accurate list of a patient's current medicines) was undertaken by pharmacy staff in the major’s area in the ED. We reviewed 5 medicines charts and found that allergies were recorded. We followed the care of one patient who was prescribed insulin and found concerns relating to the safe management of their diabetes on arrival at ED. The records were not clear on whether the patient had arrived with their own insulin. The patient presented with a high blood glucose reading, yet insulin was administered 1 hour and 39 minutes later, indicating a delay in treatment. In addition, the patient was given a different brand of fast-acting insulin from the one they normally used, despite the electronic record clearly documenting the correct brand from a recent admission. Different brands can act at different speeds in the body, which can affect blood sugar control and increase the risk of low or high blood sugar if switched. Therefore, posing a potential risk to the patient.

Staff did not always record when liquid medicines were opened, which meant they could not be assured the medicine was within date and safe to give. For example, in the paediatric clinic room, opened liquid medicines were not labelled with the date of opening or an amended expiry date, as required for safe medicines management. We observed a medicine being administered with a 28 day in use expiry, but staff were unable to confirm when it had been opened, indicating a risk that time-expired medicine may be used. Following the inspection, this has been raised as an incident, and learning has been shared within the department. The hospital was able to confirm that the medication was in date as it had recently been dispensed from the pharmacy to the paediatric ED.

Staff raised concerns about the overprescribing of lorazepam for people living with dementia and those receiving mental health care. However, we found that the trust was already aware of this risk and had taken steps to stop inappropriate prescribing. The pharmacy team had recently introduced updates to the electronic prescribing system, designed to give clearer prompts and improve clinical decision-making when prescribing. On the day of the inspection, we observed that the trust continued to review this issue in a patient safety committee meeting led by a specialist nurse, who discussed the use of lorazepam in patients with dementia.

Staff did not always store patients’ own medicines safely or manage general medicine stock well. For example, staff stored patients' own insulin inside the resuscitation medicine fridge, a practice inconsistent with national medicines management guidance. NHS guidance states that once insulin pens or cartridges are opened and in active use, they can be stored at room temperature for up to 28 days without refrigeration. When the resus fridge was checked, it was found to have no lock and to be disorganised with its own stock and patients' stock. We noted that room temperatures were not being monitored in the clinic room. Most medications are required to be stored below a certain temperature. Using medication which has not been stored correctly could negate the effect of the medication.

In the ED, medicines were stored in automated cabinets that supported secure access and effective stock control; however, due to winter pressures, an additional trolley was brought into the clinic room. It was thought that this would make dispensing medications quicker for nursing staff. This medicine trolley was observed to contain loose strips and loose tablets, indicating poor medicines-handling practice. Staff were using this trolley instead of accessing the automated cabinets, which compromised the intended safeguards and did not meet expected standards for the safe storage of medicines.

Medical gases were not managed safely. We saw oxygen cylinders not stored safely. A sign stated that the oxygen rack must be used and cylinders should not be on the floor. However, staff were storing used cylinders on the floor of the area. This was reported on inspection to the senior team and we saw that these had been moved when we returned to the department.

Controlled drugs (CDs) were stored securely. Nursing and pharmacy staff undertook checks to ensure that drugs were reconciled and boxes contained the correct amount of medication. However, we observed a box of controlled medicine from a patient who had left the department 2 months ago for a patient. This could pose a safety issue. A patient's own medicine was observed in a bag in the clinic room and had not been destroyed in a timely manner

There was a policy for the management of prescription (FP10) pads. These were stored securely and access was limited to senior staff. However, on the day of inspection, pad logs were observed to be untidy and lacked clear oversight in ED. This was not in line with the FP10 usage policy.