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

The previous overall rating of safe at King’s Mill Hospital was good. At this inspection, our rating remains good. 

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them, and kept safe care records. Staff managed medicines well. The service managed safety incidents well and learned lessons from them. 

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

The service demonstrated a positive approach to learning and continuous improvement. Leaders and staff understood the importance of learning from daily practice, incidents, feedback, and complaints to improve the quality and safety of care. 

Staff told us they felt encouraged to reflect on their practice and to speak openly about what was working well and what could be improved. They said managers were approachable and supportive, and that learning was viewed as an opportunity to improve rather than to blame. This helped to create an open and honest learning culture. Managers debriefed and supported staff after any serious incident. 

The service had systems to learn from incidents, accidents and near misses. Records showed these were reviewed, with clear actions identified to reduce the risk of recurrence. Where appropriate, learning points were shared with the wider staff team through team meetings, handovers, and written communications to support shared learning. 

We saw learning following incidents at other trusts was used and embedded at King’s Mill Hospital (KMH).  

Incidents were analysed to identify trends or themes and potential links to individual practitioners. There had been themes of pressure damage, falls, and medicine errors. 

Managers monitored quality and performance through audits and checks. Findings from audits were used to inform learning and service improvement. Action plans were developed where shortfalls were identified, and progress was reviewed to ensure improvements were sustained.

The evidence showed a good standard of care. The service worked with patients 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 service had established effective systems to support safe admission, care transitions, and discharge. Referral pathways were clearly defined and well understood by staff. Clinicians reviewed referrals to the end of life care team from hospital staff, GPs and community services. This helped support safe and timely decision-making.  

Both the palliative care team, who were from a local hospice, and the palliative and end-of-life team based at the trust, used electronic and telephone referral methods. They met regularly throughout the day to triage patients and determine the best team to provide care. This meant patients were seen and received the care and supportive treatment more quickly. The trust used additional tools, including the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) and the Electronic Palliative Care Co-ordination System (EPaCCS), to record patients’ preferences and support coordinated care. All staff had access to these tools to support patient transitions between departments and teams. 

There were safe and effective handover processes at each stage of the patient pathway, including admission, ongoing care, and discharge. Relevant clinical, psychosocial, and social information was shared appropriately to support continuity of care and effective risk management. 

Staff worked closely with external professionals, including other acute hospitals, GPs, community teams, and social care services, to ensure timely information sharing. This supported coordinated care and safe transitions between services. 

Staff also supported people to make informed decisions about their future care, including their preferred place of care. These preferences were clearly recorded, regularly reviewed, and shared with the multidisciplinary team. Staff demonstrated awareness of patients’ wishes and used these to guide care and decision-making. 

Staff working within the discharge teams at KMH were empowered to follow processes which supported the safe and timely discharge of patients at the end of their life. Staff within other areas contributed to the discharge process, such as the end of life care team, critical care staff and chaplaincy. Staff worked with patient transport services to make sure patients at the end of their life were transferred easily and safely.  

Arrangements for post-death care were respectful, well organised and maintained patients’ dignity. Families were given time and support following bereavement to say goodbye to their loved ones and make practical arrangements.

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 effective safeguarding systems to protect patients and others from abuse and neglect. A clear safeguarding policy was in place, aligned with current national guidance, and staff understood how to access and apply it in practice. 

Staff were knowledgeable about how to raise safeguarding concerns and were confident in identifying and reporting abuse, neglect, and exploitation. Safeguarding concerns were appropriately shared within the team, and learning was discussed and used to improve practice. There were clear arrangements for liaising with local authority social work teams and other safeguarding partners. The service actively engaged with local safeguarding systems and shared relevant information when required. 

There were clear arrangements for liaising with local authority social work teams and other safeguarding partners. The service actively engaged with local safeguarding systems and shared relevant information when required.

At the time of our inspection, data showed that the end of life care team had 100% compliance with safeguarding training, against the trust target of 90%. The end of life care team (EOLC) team were trained to level three safeguarding children and adults which was in line with the trust's mandatory training schedule, and national best practice. 

Staff understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They know how to support patients experiencing mental ill health and those who lacked capacity to make decisions about their care. 

Nursing and medical staff completed mental capacity assessments to identify if patients had the capacity to consent to routine care and treatment. We saw that these assessment records were completed in line with legislation. Whilst minor other improvements could have been made with documentation, overall, it was clear that patients had been assessed within the legal framework. 

A mental capacity assessment is a legal test used to determine if a person over the age of 16 can make a specific decision at a particular time. Based on the Mental Capacity Act 2005, it evaluates if an individual can understand, retain, weigh, and communicate information regarding their health, finances, or welfare.

The evidence showed a good standard. 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. 

The service protected patients from avoidable harm. Patients were risk assessed to ensure they were suitable for care and treatment at the service and staff monitored them appropriately. 

Staff completed a comprehensive risk assessment when admitting patients to the hospital, regardless of the clinical area the patient arrived to. Staff followed processes to identify when patients were in the last days of their life and started a last days of life individualised care plan. The care plan prompted a clinical review and care plan which recorded personalised needs and preferences. 

Staff supported patients to make informed decisions about their care and activities, including where there were potential risks. For example, when patients wanted to eat or drink something specific that meant a medical device may need to be temporarily removed. Staff worked with patients to understand their wishes and balanced risk appropriately, respecting individual choice where patients had capacity. This included supporting people to fulfil preferences at the end of life while taking reasonable steps to reduce harm. 

For patients receiving care at the end of their life, routine clinical observations such as blood pressure, temperature and heart rate were not undertaken. Instead, patients received comfort observations to assess pain, distress and symptom management, ensuring care remained focused on comfort and dignity.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. 

The design, maintenance and use of facilities, premises and equipment kept people safe. The service environment followed national guidance. Staff had access to enough equipment to meet the needs of patients.  

Equipment used to deliver care was suitable for the intended purpose. Staff stored equipment securely and completed safety checks. For example, daily checks took place on resuscitation trolleys. Sterile equipment was stored off the floor on appropriate shelving. Staff stored consumable items such as bandages and syringes safely. All consumable items we checked were within date of their expiry. 

Some patients required continuous medicine administration through a syringe driver to control their symptoms. A syringe driver (or syringe pump) is a small, portable, battery-operated device that delivers continuous medicine just under the skin (subcutaneously). It is used at the end of life to keep patients comfortable and manage symptoms when they can no longer swallow pills or keep medicine down. We looked at 4 syringe drivers during our inspection; they were all in date and ready to be used. There were enough syringe drivers for the size, setting and design of the ward aligned with best practice. End of life care team provided training for staff to use syringe drivers safely. We saw the most recent training opportunity was in April 2026 for new starters to the trust and staff more widely who had not previously used a syringe driver.  

Patients, including those deceased, were kept safe by physical security measures. Access to the mortuary was restricted and confirmed to standards expected by the Human Tissue Authority. Access to all wards and clinical areas, except for ED, was through a swipe card system. This meant these areas were secure and minimised the risk of unauthorised access. 

Staff and leaders reported and reviewed incidents related to the environment or equipment, and actions were taken to reduce future risk. 

All clinical areas we inspected had an emergency resuscitation trolley and could access the emergency resuscitation team by way of an emergency bleep system.

The evidence showed a good standard. The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met patients' individual needs. 

Managers made sure there were enough qualified, skilled, and experienced staff, who received thorough support, and supervision. 

There was dedicated end of life care (EOLC) team based at the trust. The team consisted of 2 consultants, 2 clinical nurse specialists a lead nurse and an administrator. The EOLC team were supported by the Specialist Palliative Care Team (SPCT) who were based at the local hospice and external to the trust. Staff could access advice and guidance from this team 24 hours a day.  

The ward teams had dedicated allied health professionals (AHPs) such as physiotherapists and occupational therapists working on the wards. Other specialist staff such as psychologists, specialist nurses and dietitians would visit patients upon request.  

We saw staff on wards who had an additional role of end of life care champions. The end of life care champions attended specialist meetings, training, and provided updates to other staff working with patients. 

Staff within the end of life care team were up to date with trust mandatory training modules. The end of life care staff were 100% compliant. All end of life care staff had received an appraisal in the last year. We also saw that nurses who worked with patients at the end of their life had completed revalidation with the Nursing and Midwifery Council (NMC) which meant they were legally allowed to practice nursing. 

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. 

Staff kept the environment clean to reduce the risk of infection transmission. All areas we inspected, were visibly clean and free from clutter. Furniture complied with national standards required for infection prevention and control. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. “I am clean” stickers were placed on equipment to indicate pieces of equipment that had been cleaned. 

Specialist cleaning staff undertook routine environmental cleaning. They had enough equipment and a daily checklist. Staff on the wards also carried out daily cleaning of the equipment and environment.  

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our assessment. For example, staff regularly washed their hands and used hand sanitisers when entering and exiting patient areas. Staff wore PPE when caring for patients. 

Staff had access to enough supplies to minimise the risk of infections. Soap and disposable hand towels were available next to sinks along with instructions on how to effectively decontaminate hands were displayed above the sinks. Patients, families and loved ones could also use these facilities.  

Staff managed clinical waste safely by following national best practice and trust policies. 

Signs for infection prevention and control (IPC) were displayed on doors to alert people about entering certain areas or side rooms.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happen. 

Staff followed best practice and local policy when prescribing, dispensing, administering and monitoring medicines for patients receiving end-of-life care, including anticipatory medicines. Staff used the Electronic Prescribing and Medicines Administration (EPMA) system effectively to prescribe and administer medicines. The system highlighted important patient information, such as time-critical medicines.  

The service used anticipatory prescribing, also known as "just in case" medicine. This is the pre-emptive prescribing of medicine for palliative or end-of-life patients to treat potential, predictable symptoms before they become severe. 

Staff stored medicines securely on all wards we inspected. They kept medicines in locked rooms and cupboards, and all medicines we reviewed were within their expiry dates. Staff ensured oxygen was readily available and accessible across the wards. 

Staff managed controlled drugs safely and in line with legal requirements. We observed two nurses completing controlled drug checks appropriately and signing the required documentation. Staff completed and recorded twice-daily stock checks, and the controlled drugs registers we reviewed showed that two authorised staff members had signed and dated all entries. Staff stored controlled drugs securely and maintained accurate records to support their safe custody and use. 

Staff checked emergency resuscitation trolleys daily and completed comprehensive weekly checks to ensure equipment was available and ready for use in an emergency.