King's College Hospital NHS Foundation Trust

On this page

• 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
• Environmental sustainability – sustainable development

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.

We scored the trust as 2. The evidence showed some shortfalls. The trust had more to do to embed its values, so they were experienced consistently across all sites and staff groups. Many staff described a culture of fear, and poor communication. These issues demonstrated a disconnect between the trust’s stated values and the lived experiences of staff and the culture they worked within. However, the trust had a clearly articulated vision and strategy, supported by well‑defined values and broad engagement with stakeholders. Its strategic refresh strengthened focus on financial recovery, inclusive leadership, digital transformation, and addressing inequalities.

Despite a clear strategy and values, the trust could not demonstrate that these were consistently understood, owned or experienced by staff across all sites and services. Persistent cultural concerns, low psychological safety and limited staff engagement indicated that shared direction and culture were not yet embedded or effective trust-wide.

The trust’s five-year ‘Strong Roots, Global Reach’ (BOLD) strategy (2021–2026) set out a vision centred on Brilliant People, Outstanding Care, Leadership in Research, Innovation and Education, and Diversity, Equality and Inclusion. This was underpinned by the values of Kindness, Respect and Teamwork. It was developed through extensive engagement with over 4,500 staff, patients, partners and the public to ensure it reflected the trust’s workforce and communities.

In April 2025, the trust refreshed its strategy, maintaining the BOLD vision while setting focused priorities for 2025–2026 and developing a new strategy for 2026–2031. Priorities included financial recovery, embedding the King’s Improvement Method, reducing waiting times, expanding digital solutions, strengthening workforce development, addressing inequalities, and increasing diversity in research participation. This refresh reflected significant financial challenges in 2023–2024 and the trust’s position within the NHSE Recovery Support Programme, resulting in a tighter focus on financial sustainability, delivery discipline, and inclusive leadership.

The strategy aligned with the South East London ICS, with partners reporting clear strategic direction and involvement in its development. However, partners acknowledged that significant progress was still required to deliver the strategy effectively.

Supporting this were several sub-strategies, including clinical, financial, people and culture, pharmacy, and EDI strategies. The pharmacy strategy (2025–2029) focused on patient safety, digital innovation, and workforce development. The people and culture plan (2024–2026) prioritised wellbeing, inclusive leadership, diversity, and career development. The clinical strategy, under development, aimed to improve outcomes, embed continuous improvement, and integrate research, innovation and digital care. The financial strategy prioritised long-term sustainability through cost improvement, productivity gains and strengthened governance following financial challenges.

Leaders stated that Equality, Diversity, and Inclusion (EDI) were central to the trust’s vision and strategic direction Priorities included expanding staff networks, improving representation, and reducing health inequalities. New action plans for racial equity and disability inclusion were being developed for 2026. The estates strategy, also in development, aimed to support service transformation, align with clinical and financial priorities, and ensure infrastructure was fit for purpose.

Priorities set out in the Annual Quality Account aligned with the trust’s strategic objectives. For 2024–2025, progress was made on workforce safety, deteriorating patient pathways and digital tools, though several actions were incomplete and carried forward. For 2025–2026, priorities included the implementation of National Safety Standards for Invasive Procedures (NatSSIPs2) across all areas delivering invasive procedures, continuation of work relating to acutely unwell patients, and improving the experience of patients with learning disabilities and autism, reflecting risks and inequalities.

Accountability for delivering these priorities was set out in the trust’s operating framework. The board maintained responsibility for strategic oversight, with assurance routed through the quality committee and other board sub committees. The King’s executive was responsible for ensuring the trust effectively discharged its responsibilities as a public body. This included overseeing the implementation of the trust strategy and associated delivery plans, establishing the policy and governance framework through delegated authority from the board, and approving trust-wide policies (except those reserved for the board). The King’s executive also held divisions and corporate services to account for performance and delivery, provided professional leadership across the organisation, and led system-wide engagement, maintaining key relationships with regulators and commissioners. Divisions and Care Groups were responsible for embedding priorities locally through integrated performance reviews and quality governance processes. While these structures provide a framework for oversight, leaders confirmed that several of the systems and data flows underpinning this framework remained in development. This included reliance on newly introduced digital tools, variation in reporting maturity between divisions, and ongoing work to achieve consistent use of dashboards. While strategic priorities were clearly articulated, the trust was still working to ensure consistent operational delivery and full integration of improvement activity across all sites and services.

The trust’s strategy considered population needs and health inequalities across South East London. Through the ‘Vital 5’ focus (blood pressure, mental health, obesity, smoking and alcohol), the trust worked with partners to improve prevention and outcomes, including targeted work with underserved communities. Initiatives such as the partnership with Centric Community Research demonstrated approaches to engage seldom-heard groups and improve culturally competent care.

Evidence from the location inspections at King’s College Hospital (KCH) and Princess Royal University Hospital (PRUH) demonstrated that the trust’s vision was understood at the service level and aligned to the trust’s BOLD strategy. Staff across maternity, medical care and children’s services were generally able to describe the trust’s values and how these informed their approach to patient care, with kindness, compassion and teamwork consistently observed in frontline practice. Patients and families we spoke with during the assessment service group inspections reported being treated with dignity and respect, and staff were observed to be approachable, visible, and empathetic. Local team leadership was generally described as inclusive, visible, and responsive. Team and service leaders were approachable and supported staff development, with regular governance meetings, newsletters, and daily huddles used to share information and promote transparency. However, this positive frontline experience did not translate into a consistently shared trust‑wide culture. Staff feedback indicated variable leadership visibility, engagement and decision‑making, and many staff did not feel that senior leaders consistently demonstrated or lived the trust’s stated vision and values. As a result, the trust could not demonstrate that its vision and values were understood, modelled and embedded consistently across the organisation.

Inspection findings across both sites highlighted a disconnect between strategic intent and lived staff experience, particularly within maternity services. At both KCH and PRUH, staff reported feeling insufficiently involved in decision‑making, with changes to service models, staffing arrangements and operational processes perceived as being implemented without adequate engagement or consideration of staff wellbeing and workload. This was highlighted in maternity services, where staff described low morale, variable leadership visibility and a culture that did not consistently foster trust or psychological safety. Inspection findings from services for children and young people also highlighted concerns about communication and confidence in speaking up.

Staff focus groups during this assessment highlighted a lack of staff engagement with developing the strategy direction. Most staff reported having no engagement in developing the strategy refresh and limited engagement regarding the 2026-2031 strategy design. Some staff groups felt that meaningful engagement was not always facilitated, with requests to participate not always followed up on or acted upon. However, trust documents showed that the development of the 2026–2031 organisational strategy was being undertaken through a phased programme of engagement, including planned engagement with staff, patients, governors, partners, local communities and staff networks throughout 2025 and early 2026. Governors reported positive engagement with the trust in this area, however, they stated staff involvement was not consistent. Senior leaders acknowledged that further work was required to strengthen staff engagement and align behaviours at all organisational levels. Culture within the trust was described as a significant challenge for the trust by both senior leaders and staff. Staff described a perception of a relentless focus on finance that overshadowed staff wellbeing, which negatively affected morale. Staff said they did not hear outcomes from quality impact assessments, particularly in relation to staffing and resource requests. Staff also reported that while compassion and kindness were seen at frontline levels, this was not always demonstrated at senior levels of the trust. Staff felt that the work on cultural development remained static and progress to improve the culture had been slow. At the last well led inspection, staff reported limited opportunities for them to share their views and see action taken. As a result, the trust introduced a range of engagement mechanisms aimed at strengthening staff voice and responsiveness. These included regular “Ask the CEO” sessions, care group‑level listening sessions, and access to the Freedom to Speak Up Guardians. The trust also introduced regular pulse surveys. While these arrangements aimed to increase the number of engagement routes available to staff, staff felt that feedback was not acted on. Staff confidence in the organisation’s responsiveness and psychological safety remained low, and improvements were not yet embedded.

There was a perception among some staff that leaders were not always visible, approachable, or compassionate, and that changes were often made without adequate consultation or assessment of the impact on staff wellbeing and workload.

Staff in focus groups also highlighted issues with bullying and harassment, with some reporting they had experienced or witnessed such behaviour and did not feel confident that it would be addressed appropriately. Where staff have raised continual issues about local culture, for example, within the Liver and Haematology services, the trust had undertaken repeated investigative and developmental work. Concerns were investigated, but the recommendations from the first round of actions did not fully embed in practice, and cultural issues continued. In response, the trust initiated a second cycle of investigations and support, this time with increased involvement from the organisational development team and senior clinical leaders to provide a more structured follow‑through. Leaders acknowledged that earlier actions had not achieved the desired change and needed enhanced monitoring, stronger governance and oversight to embed sustainable changes.

The trust’s September 2024 Medical Engagement Scale survey showed low medical engagement across all domains. Consultants in particular reported disengagement, citing poor involvement in decision-making, limited influence over change, and lack of recognition. Findings highlighted low trust, perceived top-down decision-making, and widespread dissatisfaction with workload, job planning and leadership visibility, with only small areas of positive engagement. The findings pointed to a significant cultural challenge.

The trust’s NHS Staff Survey result over the last five years mirrored this, revealing challenges in staff engagement, morale, and confidence in leadership. Between 2021 and 2024, the trust’s results show prolonged stagnation, with minimal year‑on‑year movement across most of the staff survey People Promise elements and themes, and consistently positioned the trust below the national averages. For the trust’s 2025 result, there was a statistically significant improvement across most People Promise elements and themes, marking a positive shift after several years of flat performance, although scores remain modest and continue to trail national averages and the best‑performing trusts. The results show slight year-on-year improvement, but performance remains below national averages across key indicators. For example, overall engagement increased to 6.68 (vs 6.74 nationally) and morale to 5.72 (vs 5.84), alongside improvements in learning and development, with appraisal rates reaching 92% (above the 86% national average). However, other indicators remain lower, including staff recommending the trust as a place to work (56%) and confidence in speaking up and that concerns would be addressed (50%).

Although action plans for staff survey findings were strengthened with clear delivery dates, staff reported limited improvement in experience. Leaders acknowledged slow progress in culture and engagement and linked this in part to financial pressures and organisational change. In response, leadership capacity within the people function was strengthened, including restructuring the team within the people function to drive a more coordinated approach.

Compared to similar trusts, the trust performed just below average on staff engagement and attitudes toward trust leaders, with persistent issues of low morale, high rates of bullying, harassment, and discrimination, and a lack of psychological safety. Staff reported a lack of involvement in decision-making, limited confidence in senior leaders, and a disconnect between the trust’s stated values and their lived experience. These issues highlighted the need for sustained cultural development and meaningful collaboration with staff to enhance trust and engagement.

While the trust had a clear strategic intent and pockets of positive culture, these were not consistently experienced across the organisation. The lack of sustained improvement in staff experience, psychological safety and engagement demonstrated that shared direction and culture were not yet operating effectively.

We scored the trust as 2. The evidence showed some shortfalls. Leadership was not yet consistently effective. Ongoing restructuring resulted in staff feeling leaders were not always accessible or responsive. Staff felt operational demands contributed to a lack of compassionate and inclusive behaviours. Despite actions to improve representation, significant disparities remained between the ethnic diversity of the board and the workforce and population the trust served. Staff did not always feel supported, valued or listened to. While leaders showed ambition and integrity, their behaviours and cultural leadership were not yet embedded across the organisation. However, the board comprised of experienced and skilled leaders. Leaders acted with respect and a clear commitment to improving services. Board development, externally facilitated leadership programmes and the King’s Improvement Method demonstrated a commitment to learning, reflection and strengthening cultural leadership.

Despite experienced leadership and clear intent, the trust could not demonstrate that compassionate and inclusive leadership behaviours were consistently modelled or felt by staff. As a result, leadership capability had not yet translated into a consistently positive staff experience.

The trust’s board comprised an experienced executive team including the chief executive, deputy chief executive, chief nurse and executive director of midwifery (held by a single post‑holder), chief financial officer, chief delivery officer, chief people officer and chief medical officer, alongside the trust’s chair. Since the last assessment, there had been several changes at executive level, including the appointment of a new chair in June 2024, a new chief financial officer in November 2024 (following a secondment from March 2024), a new chief medical officer in January 2025, a new chief people officer in 2025. As a result of an operational restructure in July 2025, a Chief Delivery Officer role was established. It was filled by an existing board member whose role had been disestablished as a result of the restructure. Non‑executive directors brought a broad range of experience, including senior clinical and nursing leadership, social care and community‑based services, public sector strategy, voluntary sector leadership, academic and research expertise, and organisational development. The board also included non‑executive members with specialist backgrounds in finance and digital transformation, providing independent scrutiny of financial sustainability, digital modernisation and data‑driven improvement.

Executive leaders held defined portfolios. The chief nurse and executive director of midwifery oversaw safeguarding, infection prevention and control, governance, legal services, complaints and PALS, and acted as the trust’s maternity safety champion, reflecting a wide remit across key quality and safety functions. The chief finance officer held traditional financial responsibilities alongside direct oversight of the trust’s commercial subsidiaries and group‑level commercial governance. The chief people officer led the full workforce and organisational development agenda and maintained executive accountability for equality, diversity and inclusion, supported by a director of EDI. The chief medical officer provided executive leadership for clinical governance, patient outcomes and regulatory performance. The deputy chief executive held a cross‑cutting portfolio across transformation and digital governance. The chief delivery officer provided executive oversight of operational performance and divisional delivery, ensuring alignment between operational plans, improvement priorities and day‑to‑day performance management.

We observed the trust’s board and committee meetings and reviewed minutes. In all meetings, we saw leaders acting with professionalism, respect and a commitment to meeting population needs. In addition to its public and private board meetings, the board held regular board development sessions. Leadership development for board members has included a series of externally facilitated seminars focusing on culture, leadership, operating in complex systems, and board priorities during major strategic change. Leaders felt this programme supported the board to reflect on leadership behaviours, teamwork, and its role in shaping culture. These processes demonstrate a commitment to learning, team cohesion, and strengthening the board’s oversight and cultural leadership capabilities. Leadership behaviours were embedded within the trust’s improvement and governance systems, including the King’s Improvement Method, which supported leaders to create the conditions for learning, innovation and improved performance.

Leaders reported walk‑arounds between board meetings at frontline services to gather insights. They described these as opportunities for hearing staff views directly and triangulating information from governance systems. However, staff reported variable visibility and inconsistent impact of these approaches. Some staff described limited access to senior leaders and raised concerns that frontline issues, including staffing and equipment, did not receive timely attention. Staff were aware of engagement mechanisms such as “Ask the CEO” sessions but found these inaccessible or limited in impact. System partners said leaders were present within the local system and engaged with integrated care system‑level work. Partners felt the trust board had the experience, capability and values needed to lead the organisation and were positive about individual senior leaders.

The trust had implemented a divisional operating model with triumvirate leadership (clinical divisional chief, director of nursing, and director of operations), going live in July 2025. Divisional chiefs attended the King’s executive, enhancing the clinical voice in senior decision-making. This structure was designed to support integrated decision-making and accountability by distributing decision‑making closer to operational services while still ensuring board and committee oversight. However, leader and staff feedback reported that the associated accountability structures and leadership behaviours were still being embedded. Leaders acknowledged that the pace of change and the scale of operational pressures have contributed to leader fatigue, and persistent tensions between performance imperatives and inclusive, compassionate decision-making. Leaders spoke of the need to balance financial and operational performance with compassionate challenge and inclusive decision-making. Staff fed back that this balance was not yet achieved in practice, with teams experiencing a culture of top-down directives and limited opportunities for collaborative problem-solving. Staff felt this was undermining morale and some felt that immediate performance targets were prioritised over long-term capability building.

As a result, the trust could not yet demonstrate that recent leadership and structural changes had improved staff confidence, inclusion or engagement, limiting assurance that leadership arrangements were effective at this stage.

At the last inspections, concerns were raised that HR policies and procedures were not always enacted promptly, particularly in relation to recruitment and employee relations processes. The trust has taken steps to strengthen oversight of workforce processes. Recruitment services were brought back in‑house in April 2024, resulting in improved time‑to‑hire and increased contract compliance, which had risen to 92% at the time of this inspection. The employee relations team had also strengthened its approach to case management, working more closely with managers to expedite decisions and hearings. Cases were now monitored against a 12‑week key performance indicator, with the aim to improve oversight and accountability. Leaders said these actions were improving the process. However, consistent with wider workforce and culture findings, leaders acknowledged that sustained performance and consistent application were still required to ensure these improvements were fully embedded and translated into improved staff confidence and experience across all services. Leaders told us the trust valued and recruited diversity at senior levels. The trust’s 2025 Workforce Race Equality Standard (WRES) shows overall workforce ethnic diversity at 58% for Black and ethnic minority staff. Black and ethnic minority representation among very senior managers and senior medical managers remained at 31%, the same as the previous year. There remained a 39% difference between the ethnic diversity of the board and that of the workforce, although this was an increase of 3% compared with the previous year. This indicated the board was not yet representative of the communities it served. The trust had taken active steps such as executive coaching, strengthened staff network sponsorship, and comprehensive cultural intelligence training for leaders, but these have not yet closed disparities in leadership ethnic diversity.

Leaders could describe some succession planning as part of a broader approach to talent. The trust used structured career conversations, NHS England’s Scope for Growth and nine‑box talent mapping to identify stretch, depth and breadth talent across leadership cohorts, with the intention of building a sustainable and more inclusive leadership pipeline. The trust’s people and culture strategic plan set out an ambition to embed a leadership framework and pathways for inclusive talent management and succession planning, with standardised leadership roles and responsibilities to support equity and inclusion. However, the trust did not have a fully developed trust‑wide executive succession plan setting out designated successors, with leaders suggesting further work was needed on this. This limited assurance that succession risks at the highest levels were fully considered.

The trust had a fit and proper person policy, and board members had completed checks in line with the requirements.

Leaders understood the importance of building a just and positive culture. Leaders spoke of a commitment to staff health and wellbeing, but leaders acknowledged that this was not consistently realised in practice. Staff expressed a perception that unacceptable behaviours sometimes went unchallenged, and that not all staff and managers were held to account. This undermined efforts to foster psychological safety and trust across the organisation. Leaders described the trust’s performance management framework and appraisal structure, but recognised these processes were not yet fully embedded or applied consistently across teams. While the ambition for a positive culture was clear, it had not yet translated into consistent behaviours or experiences for staff. Staff feedback emphasised that while local teams showed commitment and compassion, senior leadership often lacked compassion and inclusivity, with some staff reporting a lack of kindness and support at higher management levels. Staff felt a relentless focus on financial pressures has negatively impacted staff morale and the overall culture. Leaders were aware of and acknowledged these challenges.

The location inspections at King’s College Hospital (KCH) and Princess Royal University Hospital (PRUH) found that generally leaders at services possessed the skills, experience and professional credibility required to lead complex services. At the maternity services across both sites, staff reported variable accessibility of senior leaders, particularly at PRUH, and described feeling insufficiently consulted on service changes. At KCH, staff raised concerns about senior vacancies, leadership responsiveness, fairness in rota management and the impact of staffing and pay decisions on morale and retention. Although the trust has taken steps to stabilise leadership structures and strengthen senior presence, and initiated mitigating actions, including increased walk‑rounds, leadership training and renewed focus on wellbeing and inclusion, the inspections indicate that these actions had not yet translated into consistent staff experience of supportive, inclusive leadership.

While leaders showed clear individual strengths and a strong ambition to improve, there remained notable inconsistencies in leadership behaviours and staff experience. Some leaders demonstrated professionalism and compassion, but further development was needed to ensure these qualities were cascaded and felt consistently across the organisation. Staff did not feel consistently supported, valued, or listened to by leaders. Overall, leadership intent and capability were evident, but inconsistent leadership behaviours and lack of sustained impact meant the trust did not yet meet the characteristics of capable, compassionate and inclusive leadership trust-wide.

We scored the trust as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard. The trust did not demonstrate a consistently open culture in which staff felt able to raise concerns without fear. While the trust has established Freedom to Speak Up arrangements and the speaking‑up service was accessible, staff reported low psychological safety and variable confidence that concerns would be acted upon. Many staff described reluctance to raise issues due to previous experiences of limited feedback, delays, or an absence of visible change, and uncertainty about how concerns would be managed remained as significant barriers. Although senior leaders expressed commitment to improving the speaking up culture, staff did not consistently experience leaders role modelling the behaviours required to build trust. As a result, speaking up was not yet embedded as a valued part of everyday practice across the organisation.

The trust could not demonstrate that staff felt consistently safe to raise concerns or confident that speaking up would lead to action. This represented a significant improvement area in organisational culture and assurance.

The trust has Freedom to Speak Up (FTSU) arrangements in place. This included two full‑time FTSU Guardians, supported by the Chief Nurse as executive lead and a designated non‑executive director who met regularly with the Guardians, and reporting through People and Quality Committees. The trust had a FTSU policy in place. The trust board received an annual report on the trust’s FTSU function. The trust had 65 King’s Ambassadors, covering FTSU, EDI, values, and wellbeing functions. Staff reported accessibility of the FTSU service had improved, with increased reach across sites and a growing number of staff engaging with the FTSU function. However, despite these developments, staff confidence in psychological safety and in the organisation’s response to concerns remained low and inconsistent.

For the 2024-2025 reporting period, the trust recorded 321 FTSU cases. This was significantly above the national average and placed the trust among the highest reporting trusts nationally. While this reflected high visibility and ease of access to FTSU functions, it also suggested persistent cultural concerns across the organisation. Compared with national averages, the trust reported higher proportions of bullying and harassment concerns and patient‑safety‑related issues. Rates of anonymous raising and detriment concerns aligned with national averages. This indicated that although staff were willing to use FTSU functions, they remained uncertain about the safety and impact of doing so.

Access to the FTSU function has broadened geographically. For the 2024-2025 reporting period, case numbers rose significantly at PRUH, from 27 to 100 cases, and at Queen Mary’s Hospital from 2 to 14, while KCH remained the busiest site with 191 cases. Most concerns continue to be raised by staff rather than managers, although manager initiated concerns had increased.

Many staff felt unable to speak up within the trust. Trust data showed that bullying, intimidation and mistreatment account for over half of the top‑rated themes that were raised. These concerns correlate with lower staff survey scores on psychological safety and voice. The 2025 NHS Staff Survey showed that 54% of staff agreed with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was lower than the national average of 59%. Most staff felt leaders would not act to address concerns. The 2025 NHS Staff Survey showed 43% of staff agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was lower than the national average of 46%.

Staff described a persistent reluctance to raise concerns, with many reporting that they felt ”what is the point,” or believe that ”nothing changes.” Staff described instances where raising concerns through the FTSU process had “completely backfired”, creating fear of negative consequences, including potential impact on their employment. Staff described a lack of psychological safety. Staff reported reluctance and fear to speak up or share their views openly, expressing concerns that doing so could result in negative consequences. As a result, some individuals requested that their comments not be attributed to them. Despite the Guardians being highly visible, accessible, and trusted, staff felt that the organisation’s response to concerns was inconsistent and often lacked transparency. Staff described raising issues such as unsafe staffing, bullying, poor behaviour, and equipment concerns, without visible follow‑up or resolution. Staff felt that the trust had not yet developed the capability to fully ensure that learning from FTSU cases was acted upon systematically. Staff trusted the FTSU Guardians and the King’s ambassadors, but did not trust the system. The most significant issue highlighted was the lack of a functioning feedback loop. Staff reported frequently receiving no update after raising a concern, which contributed to a sense of disengagement. Staff described situations where concerns were escalated appropriately but no assurance or outcome was provided by divisions or HR, leaving staff disappointed and reluctant to speak up again.

This lack of feedback and visible action undermined staff confidence and meant the trust could not provide assurance that learning from speaking up was consistently embedded or acted upon.

Findings from location inspections of the maternity services at both KCH and PRUH indicated that psychological safety remained fragile, with staff lacking confidence that speaking up would lead to timely or effective action. At both sites, staff reported feeling discouraged from raising concerns, citing fear of negative consequences, limited feedback and lack of visible change following escalation. These themes were reflected in the staff survey results. While leaders acknowledged the volume of FTSU cases and described actions taken in response, including staff engagement sessions and process reviews, the inspection findings highlighted that staff confidence in the wider organisational response remained low. This represents a risk to safety culture and learning, particularly within maternity services, where staff concerns related to staffing, governance and risk management.

Leaders acknowledged that the culture of speaking up was not yet where it should be. They described efforts to improve awareness, such as strengthening divisional oversight, embedding cultural intelligence training, and enhancing data triangulation through the Integrated Quality Report and the Red Flags Tracker (a developing organisational early warning system designed to identify cultural and patient safety risks). Leaders said improvements in complaint handling, including clearer grading, early contact, and structured investigation plans, were beginning to support more consistent learning. However, these processes were not fully embedded and had not yet been translated into a consistently psychologically safe environment for staff. In July 2025, the board undertook the NHSE/National Guardian’s Office board Self‑Reflection Tool to compare governance insight with staff experience. The review, alongside an 89% response rate from FTSU service users, demonstrated a consistent gap between board and staff perceptions. Board self-rated scores were significantly higher than staff scores across all principles, including speaking‑up culture, leadership visibility, learning and improvement, and addressing barriers. For example, under ‘culture of speaking up”, the board scored 3.80 compared with staff at 2.30. Under ‘leaders actively role model’, the board scored 3.85 compared with staff at 2.56. The board subsequently agreed on five FTSU strategic priorities to focus on going forward: leadership and accountability, data‑driven insight, oversight of detriment, communication and transparency, and embedding speaking up across divisions. These priorities were accompanied by milestones for delivery (November 2025; March 2026; July 2026; November 2026), with quarterly board reporting. To make sustained progress, the trust set out four key improvement requirements, each supported by specific actions. The trust focused on strengthening psychological safety through visible, compassionate leadership and clear follow‑through on concerns. This was supported by improved oversight, including systematic detriment risk assessment and sustained executive/NED involvement. It also enhanced its data‑driven early warning approach through dedicated analytics, alongside stronger accountability and feedback loops at divisional level.

Senior leaders recognised that significant work was still required to build trust, strengthen accountability, ensure timely action, and embed psychological safety at every level of the organisation. While the trust’s ambition for the organisation’s culture to have a strong ‘speak-up’ component, this aspiration was not reflected in staff experience or current organisational behaviours. The trust has not yet embedded a culture of openness or ensured visible and timely action on concerns. Staff confidence in the FTSU process remained low, and significant development was required for the trust to demonstrate an effective, psychologically safe speaking‑up culture. Although formal FTSU structures were in place, persistent low staff confidence showed that the trust had not embedded a psychologically safe culture of openness.

We scored the trust as 2. The evidence showed some shortfalls. While leaders had articulated a commitment to Equality, Diversity and Inclusion (EDI), this had not translated into consistent, equitable experiences for staff across the organisation. Staff feedback, survey data and workforce indicators demonstrated persistent inequalities, particularly for ethnic minorities and disabled staff, and limited evidence that existing arrangements were resulting in meaningful or sustained improvement.

The trust could not demonstrate that its stated commitment to EDI had resulted in consistently fair or inclusive experiences. Although policies, structures and programmes were in place, these were not yet embedded or effective in addressing disparities in outcomes or experience.

At the last well-led inspection, progress against Workforce Race Equality Standard and Workforce Disability Equality Standard targets was identified as an area for improvement. At this assessment, leaders expressed a commitment to Equality, Diversity and Inclusion (EDI), with the trust embedding this as a core element of its strategic direction and organisational culture. The roadmap to inclusion (2022–2024) provided a foundation for this work, and the trust strengthened its EDI infrastructure as these commitments transitioned into the refreshed people and culture strategy plan (2024–2026) and the strategic planning for 2026–2031. Leaders said this area was an organisational priority, supported by governance structures, comprehensive programmes of staff development, and a commitment to reducing inequalities for both staff and patients.

The trust had taken steps to strengthen elements of its EDI infrastructure, including governance arrangements, policy frameworks and staff development programmes. Equality risk assessment processes were applied to new and updated policies, and initiatives such as cultural intelligence training and leadership development programmes had been introduced. However, these remained inconsistently embedded and it was not always clear how they were driving measurable improvement or reducing inequalities in practice. For example, while some senior clinicians had EDI objectives within appraisal processes, uptake was variable and there was limited evidence this had led to consistent changes in leadership behaviour.

Leaders stated that improving leadership diversity was a priority for the trust. Through the trust’s people and culture strategy plan, the trust committed to achieving a senior leadership profile that better reflected the diversity of its wider workforce. Planned actions included analysing recruitment pathways, revising career development processes, and establishing a comprehensive approach to talent management that specifically aimed to improve representation at Bands 8a and above. However programmes such as reciprocal mentoring, and targeted leadership development for ethnically minoritised staff had not yet resulted in demonstrable improvements in representation or progression outcomes.

While the leaders demonstrated an aspiration to improve the culture of the organisation in the context of equality, diversity and inclusion, feedback from staff showed a mixed picture. Staff reported variable experiences of leadership behaviours relating to equality, diversity and inclusion. Some staff told us leaders actively reviewed and improved the culture locally, providing examples such as supporting flexible working arrangements, encouraging participation in staff networks, adjusting work patterns for carers, and modelling respectful behaviours. However, others reported that leaders did not always act promptly or consistently when concerns about behaviour or fairness were raised, and some said discriminatory conduct or unfair treatment was not always challenged. Staff with protected characteristics, including ethnic minority and Black staff, disabled colleagues and LGBTQ+ staff, reported mixed experiences of development and acting‑up opportunities and progression, with some feeling supported while others described barriers compared to their peers.

In 2025, the trust restructured the EDI leadership portfolio. While the director of EDI post was not formally downgraded in terms of pay band, and it retained senior manager status, the reporting line was changed so that the post now directly reported to the chief people officer rather than reporting directly to the chief executive officer. The post holder no longer routinely attended board meetings, only attending when requested. This structural change was perceived by many staff, particularly Black and ethnic minority staff, as a significant downgrading of the EDI agenda. The vast majority of staff described a sense that EDI had been ‘pushed aside’ and that there was now ‘nobody there championing’ the EDI agenda at the highest level. The chief people officer was now the board level advocate for workforce EDI, however the staff we spoke to perceived this as a retrograde step, reducing the visibility and influence of EDI within the trust’s most senior decision-making forum. Staff from the staff networks expressed extreme concern that the change signalled a de-prioritisation of EDI, and that the trust’s leadership was not fully committed to tackling structural inequalities. Staff said this had a profound psychological impact on staff across the organisation. Many felt this change reduced board‑level visibility and assurance for EDI and contributed to staff perceptions that equality and inclusion were not being prioritised at the highest level.

Staff also highlighted the lack of visible ethnic diversity at the board and executive level, noting that apart from the chief medical officer, there were very few Black or ethnic minority leaders in the most senior roles. This lack of representation, combined with the change to the EDI director role, contributed to a perception that the trust was not doing enough to promote inclusion or address the barriers faced by minority staff. Staff described feeling that their voices were less likely to be heard, and that opportunities for progression and influence were limited.

The trust had five staff networks: King’s Able (staff disability network), the Race Ethnicity and Cultural Heritage (REACH) network, the Women’s network, the Inter Faith and Belief network, and King’s and Queers (LGBTQ+ network), each with an identified executive sponsor. While these structures were established, they were not consistently embedded in a way that enabled staff voice to influence leadership behaviour or organisational decision-making. Feedback from network members demonstrated variability in how inclusion and leadership behaviours were experienced across the organisation. Staff consistently described a perception that equality, diversity and inclusion were not prioritised within senior decision-making. Strategic discussions were described as being dominated by financial and operational pressures, with limited focus on people, inclusion or lived experience. As a result, staff did not feel that EDI considerations were systematically incorporated into organisational priorities.

Opportunities for staff networks to influence decision-making were inconsistent. Some networks reported more regular access to senior forums, while others described limited engagement. Staff reported that involvement in key workstreams was not routine and often occurred late or required networks to actively seek inclusion. Engagement with networks was not proactive or systematic, which reduced the extent to which diverse perspectives informed organisational planning and leadership decisions.

Although formal executive sponsorship arrangements were in place, the visibility and direct involvement of senior leaders varied. This inconsistency contributed to staff perceptions that EDI was not prioritised equally across the organisation. Members of networks also described challenges in securing protected time to carry out network roles, with workload pressures limiting their capacity to contribute consistently. This further constrained the influence of staff voice within organisational learning and strategy.

Staff networks delivered a range of activities that supported equality, diversity and inclusion, including training, leadership development, awareness campaigns and cultural events. These initiatives provided localised benefits and strengthened staff engagement. However, staff felt they did not consistently influence wider organisational culture or leadership practice.

There was a widespread perception among staff that the trust’s EDI agenda was not embedded across the organisation. While individual leaders within EDI roles were recognised for their commitment and drive, this work was not consistently supported or owned at executive level. As a result, progress was perceived as fragmented and confined to specific initiatives, rather than being delivered through a coordinated, organisation-wide approach.

Several staff, managers and leaders questioned whether there was a clear and shared vision for equality, diversity and inclusion. Although some senior leaders acknowledged its importance, there was limited clarity regarding strategic leadership, accountability and board-level ownership for delivering improvement. Staff survey results relating to culture and inclusion were described as static, with little evidence of sustained progress over time. Leaders recognised that improvement in staff experience had been limited.

The trust’s performance across staff surveys also showed a mixed picture. The Workforce Race and Disability Equality surveys showed that minority ethnic and disabled staff were less likely to believe the trust provided equal opportunities for career progression and were more likely to experience discrimination or enter formal capability processes. Results in the 2025 NHS Staff Survey remained just below national averages across several People Promise elements, particularly in areas linked to equality, safety and staff experience. While there were incremental improvements compared to previous years, such as increases in ‘We are always learning’, ‘We work flexibly’ and ‘Morale’, progress was modest; scores for ‘We are safe and healthy’ and ‘We are recognised and rewarded’ continued to highlight cultural pressures.

The trust continued to monitor and report on workforce race equality. Its Workforce Race Equality Standard (WRES) 2023-2024 and 2024-2025 data showed some positive movement. Representation at senior levels (Band 8a and above) rose modestly from 30% to 31%, however representation at Very Senior Manager/Senior Medical Manager level remained at 31%. These increases indicated gradual progress in leadership diversity, although the profile did not yet reflect overall workforce diversity. The relative likelihood of white applicants being appointed from shortlisting compared with Black and Ethnic applicants declined from 1.65 to 1.82. The proportion of Black and Ethnic staff entering formal disciplinary processes declined from 1.85 to 2.17. The trust scored worse than the national average for all 4 of the NHS WRES of the 9 indicators measured through the 2024-2025 NHS Staff Survey for staff from all other ethnic groups combined, indicating worse experiences for these staff members when compared nationally. White staff at the trust scored better for all 4 of the metrics, indicating worse experiences for staff from all other ethnic groups when compared to white staff. The trust’s results still showed worse experiences for staff members when compared nationally.

Workforce Disability Equality Standard (WDES) indicators also showed mixed results. Disabled representation increased slightly from 3.3% to 3.5%, though the figure remained significantly below the proportion self‑reported in the staff survey. The relative likelihood of disabled applicants being appointed from shortlisting improved marginally from 1.1 to 1.2, however, disabled staff remained 3.8 times more likely to enter the capability process, and the gap between disabled and non‑disabled staff remained significant across most indicators. Compared with national averages, the trust performed worse in the majority of WDES metrics, particularly in experiences of bullying, harassment and discrimination. Although disabled staff experienced some improvements around harassment from patients and managers, disparities persisted in workplace treatment, career opportunities, wellbeing and the extent to which staff felt valued.

The trust also monitored experiences of discrimination relating to sexual orientation and disability. Results for discrimination on the grounds of sexual orientation were broadly in line with other trusts, although staff reporting such discrimination had increased over the past four years. Similarly, discrimination on the grounds of disability had worsened since 2021.

The trust monitored fairness in recruitment and career progression and had action plans to address indicators identified in the WRES and WDES reports. Progress was monitored through the people and culture committee.

The trust monitored the gender pay gap, with data showing women earned 6% less than men, an improvement compared with wider NHS averages. The trust had taken steps to address disparities, including increased access to flexible working and targeted leadership opportunities for women.

Leaders described actions to promote equality, diversity and inclusion, including inclusive recruitment approaches, policy updates, workplace adjustment processes and leadership development programmes. External partners also reported that the trust demonstrated a commitment to EDI within the wider system. However, the impact of these actions was limited and not consistently experienced by staff across the organisation.

Overall, while the trust had taken steps to develop its approach to workforce equality, diversity and inclusion, these actions were not yet embedded or delivering consistent improvement. Persistent inequalities in staff experience, limited progress in leadership diversity and inconsistent inclusive leadership behaviours meant that EDI was not effectively implemented at trust level. Staff confidence in the organisation’s commitment to equality and inclusion remained variable.

We scored the trust as 2. The evidence showed some shortfalls. Governance arrangements were in place but not yet working consistently across the whole organisation. Leaders and staff described uncertainty in reporting lines, duplication across committees, and variable information flow from ward to board.

Governance, management and sustainability arrangements at the trust were variably implemented. Although structural frameworks are in place, they lack the consistency and clarity to fully ensure reliable oversight or sustained improvement. Leaders across the organisation acknowledged that while governance systems were in place, they were not yet fully effective. Feedback from leaders and staff showed some structural ambiguity and inconsistencies in assurance mechanisms. This positioned the trust with further work to do to ensure governance processes function optimally to deliver safe, effective and sustainable services. At the time of this assessment, the trust was under Segment 5 of the NHSE National Oversight Framework, reflecting the highest level of regulatory intervention and support.

The trust implemented a major organisational restructure in July 2025. They moved from a site‑based arrangement to a three-division clinical model, each led by a divisional chief (a clinician), a director of nursing, and a director of operations, with care groups aligned beneath them. The operating framework introduced at this point set out the new divisional configuration, Divisions A, B and C, which brought together related specialities. In Division A: cancer, child health and women’s health, in Division B: acute and integrated medicine, in Division C: cardiovascular, critical care, trauma and surgical services. Leaders reported that the restructure was designed to address long‑standing operational fragmentation between KCH and the PRUH, improving cross‑site collaboration, and creating clearer lines of clinical and managerial accountability. Leaders described early benefits, including improved collaboration and new governance forums. However, the model remained in its early stages, with staff reporting uncertainty about reporting lines, roles and responsibilities, and how information should flow through governance structures. Data needed for oversight was available but not yet consistently synthesised or escalated effectively.

The trust had in place a governance framework incorporating divisional governance. In addition to the board, the subcommittees included the Quality Committee, Audit and Risk Committee, People, Education, Inclusion, and Research Committee, Finance and Commercial Committee, Improvement Committee, as well as an Academic Committee in Common in partnership with a neighbouring NHS trust and a London University. The trust also operated a range of divisional governance committees, including the Divisional Quality and Governance boards, Care Group Quality and Governance Meetings, the Divisional Senior Leaders Group, Care Group Finance Meetings and Care Group Performance Reviews, as well as cross‑cutting forums such as Patient Safety Incident Response Framework panels, and wider patient‑safety structures including Safeguarding and Patient Safety Committees and the Sexual Safety Steering Committee, which support oversight, risk management and operational assurance across divisions and care groups. These provided structured assurance to the board to escalate key risks and issues following each meeting. There were terms of reference and descriptions of the work of each committee and subcommittee, and each had a programme of work to ensure areas were reviewed.

However, leaders described significant uncertainty about how these structures were intended to work in practice. Staff at all levels reported some confusion about the flow of information from ward to board, with variable understanding of committee remits, and unclear relationships between divisional and corporate governance. Leaders and managers reported that the volume of meetings often created duplication rather than clarity, and there was a risk of some overlap in committee functions. Leaders described uncertainty about how operational data should be routed through the governance structure. This reflects a broader lack of clarity in the flow of information from ward to board. Committee papers supported these findings. Audit and Risk Committee papers highlighted development areas in internal reporting and control operating effectiveness, which posed a risk to regular monitoring and assurance (February 2025). In addition, the Finance and Commercial Committee papers (September 2025) identified ongoing development needs in estates governance arrangements and actions arising from the Strategic Estates Review. These findings highlighted that while the trust was aware of a need to refine some of the reporting structures, this remained an ongoing challenge. As a result, the trust could not consistently demonstrate a clear and reliable flow of information from ward to board, weakening organisational oversight.

This lack of consistent information flow and assurance reflected broader weaknesses in the trust’s governance and oversight of partnership working, particularly in relation to safeguarding. For example, while the trust demonstrated partnership work to safeguard people through appropriate information sharing in safeguarding and statutory contexts, including multi-agency safeguarding arrangements and compliance with information sharing requirements, issues found at the assessment service group inspections and a review of 10 randomly selected adult and child safeguarding records identified gaps in documentation, follow-up actions and outcomes and assurance processes. These findings indicated that governance processes did not consistently ensure that safeguarding actions were completed, risks were mitigated, or outcomes were clearly recorded where responsibilities sat with partner organisations. Although actions were at times appropriately progressed by external agencies, including police and local authorities, oversight arrangements did not reliably provide assurance that these actions had been followed through or that risks had been effectively managed. This limited the trust’s ability to demonstrate clear accountability for safeguarding outcomes across organisational boundaries. Governance arrangements for information sharing and follow‑up were also inconsistent. Safeguarding decisions and outcomes were often recorded across multiple systems, with limited use of central tracking mechanisms to provide oversight. While staff could articulate appropriate professional decision‑making, this was not consistently documented, reducing the trust’s ability to assure itself and system partners that safeguarding processes were applied consistently and in line with expected standards. Variation in governance frameworks across services further weakened assurance. In maternity services, safeguarding guidance was not always up to date and there was no maternity‑specific safeguarding policy at the time of inspection, meaning partnership arrangements for managing perinatal risks were not consistently underpinned by clear governance structures. In children’s services, although partnership working was well established, governance weaknesses were evident in missed safeguarding opportunities, inconsistent escalation and limited evidence of learning being embedded from safeguarding incidents.

At trust level, safeguarding information was reported through established governance forums; however, there was limited triangulation of data, partner intelligence and outcomes to provide comprehensive assurance. Leaders acknowledged that information from incidents, training, partner feedback and service‑level risks was not routinely brought together to demonstrate whether partnership arrangements were effective in managing risk or improving outcomes. As a result, board‑level oversight did not consistently provide robust assurance regarding the effectiveness of safeguarding partnerships or the trust’s management of safeguarding risks.

Risk management systems were established, including a corporate risk register and Board Assurance Framework (BAF), with risks owned and reviewed through divisional and committee structures. The BAF was aligned to strategic priorities and monitored through board committees, Leaders described the BAF as improving but still requiring greater clarity and transparency in how risks are articulated and scored. Leaders noted that earlier BAF iterations “didn’t really reflect the concerns of the board” and lacked explanation of what was driving the risk score or any movement in it, resulting in risks appearing static even when internal pressures changed. Similarly, they highlighted that quality oversight often relied on large volumes of raw data without synthesis, limiting the board’s ability to triangulate BAF risks with incident trends, clinical outcomes, or patient experience findings. Leaders also referenced the need for clearer articulation of how strategic risks (such as workforce, digital and estates dependencies) evolved.

The risk register provided a structured system for capturing and escalating risks, but leaders identified ongoing weaknesses in the quality of controls, clarity of ownership and evidence of mitigation. Long standing risks remained without meaningful change, particularly in estates and infrastructure. These themes were directly reflected in the risk register itself. For example, issues at the Princess Royal University Hospital site, fire risk, ventilation risk, and water systems risk have all remained at maximum rating since mid‑2024, with broadly worded controls such as ‘ongoing monitoring’. Leaders also highlighted risks where controls were non‑specific, such as electrical sub-stations and stand-by generators being overloaded, a high estates risk that had shown no score reduction since November 2024, and listed controls as ‘not occurred’. While risk oversight can be seen through committees, the speed and impact of risk reduction for some risks provided only partial assurance.

Overall, while both the BAF and risk register were in place and actively used, weaknesses in scoring, ownership and risk mitigation limited their effectiveness, meaning governance arrangements did not yet provide consistent or reliable assurance of safe, sustainable service delivery. Inspection findings further demonstrated variation in governance effectiveness across services. While medical care and children’s services showed more mature governance arrangements, maternity services continued to demonstrate recurrent weaknesses, including risks remaining on registers without sufficient mitigation, gaps in assurance processes and inconsistencies in risk scoring. This reduced assurance that governance systems were consistently effective across the organisation. Staff felt that service pressures and staffing were significant organisational risks. These were reflected in the trust’s risk management systems. The trust continued to face significant pressures across emergency care, elective recovery, imaging, theatre capacity and speciality fragility. Data systems such as EPIC supported real-time monitoring of harm-free care, safety indicators and staffing breaches, and dashboards providing visibility of performance trends to committees. Workforce sustainability was also confirmed within the trust’s risk systems, highlighting consultant shortages in breast surgery, ear, nose and throat, trauma and paediatric services, nursing shortages and rota challenges across multiple wards in emergency and acute services, and delays within radiology and specialist pathways. While the People Committee regularly reviewed vacancy rates, turnover, sickness and safer staffing indicators, staff told us they had not seen meaningful or sustained improvement in some workforce pressures. Trust documents provided subsequently demonstrated improvements in several workforce metrics, including vacancy and turnover rates and safer staffing indicators. However, some specialist workforce challenges remained, particularly within neonatal and paediatric services where staffing levels and specialist nurse availability continued to be subject to ongoing recruitment and improvement plans. System partners felt the trust’s risk management arrangements were broadly improving, with clearer lines of accountability and more consistent cross‑system working. Partners in Lambeth and Southwark highlighted strengthened multidisciplinary oversight at KCH, such as flow hubs, a seven‑day adult social care presence, and twice‑weekly discharge meetings. They said this helped manage operational pressures and support safer transitions of care. System partners described the trust as a proactive and visible contributor to system governance, noting that the trust’s senior representation at the Integrated Care Board and its participation in system planning groups provided stronger sight of risks and collective priorities. Stakeholders also reported that the trust engaged constructively on service‑specific risks, and that learning from emergency care challenges, such as prolonged emergency department waits was now more routinely shared through review processes.

System partners felt the trust’s risk management arrangements were broadly improving, with clearer lines of accountability and more consistent cross‑system working. Partners in Lambeth and Southwark highlighted strengthened multidisciplinary oversight at KCH, such as flow hubs, a seven‑day adult social care presence, and twice‑weekly discharge meetings. They said this helped manage operational pressures and support safer transitions of care. System partners described the trust as a proactive and visible contributor to system governance, noting that the trust’s senior representation at the Integrated Care Board and its participation in system planning groups provided stronger sight of risks and collective priorities. Stakeholders also reported that the trust engaged constructively on service‑specific risks, and that learning from emergency care challenges, such as prolonged emergency department waits was now more routinely shared through review processes.

System partners consistently identified financial sustainability as the trust’s most significant organisational risk. They highlighted the underlying deficit and reliance on £75m of national deficit support funding as ongoing pressures on long‑term stability, with delivery of the cost improvement programme viewed as high risk despite reported progress. Partners also raised workforce and culture risks, including higher than expected levels of bullying and harassment and low reporting of wellbeing concerns. The previous inspection identified inaccurate rota data and inconsistent compliance with safer working standards, limiting assurance over the safe deployment of resident doctors. The trust strengthened oversight through the appointment of Chief Registrars, resident doctor forums and governance arrangements including the Guardian of Safe Working Hours. However, workforce complexity, increasing less than full time working and 62.7 WTE vacancies continued to affect sustainability, alongside data reliability challenges. Exception reporting reflected ongoing workload pressures, and although oversight had improved, supervisor response times were not consistently compliant. While actions such as rota redesign, recruitment planning and improved facilities demonstrated progress, arrangements were still being embedded and did not yet provide consistent assurance of safe and sustainable practice across sites and specialties. Leaders acknowledged that arrangements were still being embedded, and that continued monitoring was required to ensure consistent safer working practice across sites and specialities.

Governance arrangements within the pharmacy service were clear and embedded, with effective committee structures supporting oversight and risk escalation. Risks to quality and sustainability were well understood, particularly staffing pressures and the complexity of medicines management, with mitigations in place. Operational risks, including temperature control, storage capacity and medicines shortages, were appropriately managed. Clinical pharmacy coverage was strong, and reporting lines functioned effectively, enabling timely action on safety information. Although digital system fragmentation continued to present challenges, the trust was working with partners to improve interoperability. Overall, governance was effective, but leaders noted that full embedding of strengthened processes would take time.

At trust level, governance arrangements for legal frameworks including the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were not consistently effective. While policies and structures were in place, reviews and inspection findings identified inconsistent recording, variation in staff understanding and gaps in oversight. Key information was held across multiple systems, and decisions, including capacity assessments, best interests and escalation rationale, were not always clearly documented. Leaders acknowledged gaps in MCA and DoLS practice, including inconsistent application and reliance on local authority processes, and that policies required updating. Although improvement actions were underway, including policy review, increased training compliance and strengthened oversight arrangements, governance processes did not yet provide sufficient assurance that legal requirements were consistently applied or that staff were supported to make, record and escalate decisions in line with statutory frameworks.

The trust is a large acute provider with an annual income of approximately £1.9 billion (2024–2025). In 2023–2024, the trust reported a deficit of £78.7 million and was subject to enhanced oversight within NHS England’s National Oversight Framework (NOF) Segment 4. During 2024–2025, the trust reported a reduced deficit of £33.7 million, representing an improvement compared with previous years, although the trust remained in deficit. During this period, the trust delivered £50.8 million in savings through its Cost Improvement Programme, achieved through service redesign, procurement efficiencies and strategic workforce planning. In parallel, the trust invested £91.1 million in infrastructure and technology, including the rollout of the EPIC electronic patient record, refurbishment of the Liver Intensive Care Unit and expansion of emergency and respiratory care facilities. Governance is led through a unitary board structure.

At the time of the trust‑level well‑led assessment in September 2025, the trust remained within enhanced NHSE oversight arrangements. Published NHSE performance data placed the trust in NOF Segment 4, with subsequent transition into Segment 5 during late 2025 as national oversight arrangements evolved, reflecting the trust’s level of challenge and the application of enhanced regulatory support. As part of this, the trust received targeted improvement support and increased scrutiny across performance, finance and governance.

Leaders described financial sustainability as one of the trust’s main organisational priorities. At the time of inspection, the trust was managing a £2bn revenue budget and a £54.8m capital programme while delivering an £82.4m cost improvement plan. Despite the challenges leaders were confidence in achieving the overall financial control target. Financial sustainability had been an area of ongoing regulatory concern, and the trust entered NHS England’s Recovery Support Programme (RSP) in April 2024. Leaders demonstrated clear ownership of the associated regulatory undertakings, with strengthened grip over financial recovery, planning and assurance. Progress against the Recovery Support Programme was formally endorsed by NHS England, and in March 2026 the trust exited the programme and moved to Segment 3 of the NHS Oversight Framework, reflecting an improved regulatory position. Following the inspection, the trust reported delivery of its 2025–2026 financial plan. This was the second consecutive year that the trust closed the financial year on, or ahead of, plan. While this reflected an improving financial position, leaders and external partners recognised that significant challenges remain, particularly in reducing the underlying deficit, delivering future efficiencies and sustaining progress over the medium term. There was clear evidence of strengthened financial governance following external review. The chief finance officer, in post since March 2024, had led improvements in financial planning, reporting and assurance. Committee chairs with significant senior financial experience provided visible challenge and oversight. External and internal audit provided positive assurance, with external auditors providing substantial assurance on internal controls, including financial governance arrangements.

Financial decisions were subject to appropriate governance and risk testing. All proposed cost improvement and financial change schemes were required to undergo quality impact assessments with clinical input alongside equality impact assessments. These assessments supported decision‑making by identifying potential adverse effects on service quality, patient experience or staff groups. Where risks were identified, schemes were adapted, mitigations were put in place or issues were escalated through clinical governance routes. NHSE representatives reported increased confidence in the trust’s approach to financial planning and risk management, supported by regular regional engagement.

The trust continued to work to strengthen committee functions and escalation pathways. Terms of reference for boards and committees were being refreshed under the Director of Corporate Affairs, although this work remained ongoing at the time of inspection. Leaders acknowledged that further triangulation and review were required to ensure that assurance and escalation processes functioned consistently and reliably.

The trust had a strengthened, centralised complaints process with clear triage, early engagement and proportional handling, supported by divisional oversight and clinical input. Complaints were managed centrally through a dedicated complaints team, working closely with clinical divisions and Patient Advice and Liaison Services. From the 10 complaints reviewed, there were clear examples of learning and local action, including improvements to communication and handovers, staff reminders and training on medication safety and pain management, reinforcement of dignity, compassion and respectful behaviour, and changes to ward routines, huddles and documentation practices. The trust received approximately 1,200 complaints per year. Analysis of complaint data identified consistent themes, including communication with patients and families, values, attitudes and behaviours of staff and delays in care, investigations or discharge processes. These themes were aligned with wider patient experience intelligence, and in some areas, mirrored issues raised through Freedom to Speak Up and staff feedback. Review of complaints showed appropriate investigation, use of Duty of Candour and evidence of local resolution and learning, with themes analysed and reported through governance structures. Improvements to backlog management and accountability had reduced delays and increased engagement with complainants. However, timeliness, particularly for complex complaints, remained an area for oversight. Leaders demonstrated improved visibility of themes, including communication, staff behaviour and delays in care, which were triangulated with wider quality intelligence. Overall, while processes and learning were clearer and more consistent, complaints governance still required continued focus to ensure timely and effective resolution.

Complainants were routinely signposted to the Parliamentary and Health Service Ombudsman. The trust benchmarked ombudsman referrals and outcomes against peer organisations to identify learning. While ombudsman escalation did occur, leaders did not report disproportionate adverse findings, and complaints were generally resolved prior to external escalation.

At the time of the trust-level assessment, in the NHSE acute trust league table, published 9 September 2025 and updated 27 October 2025, King’s College Hospital NHS Foundation Trust was placed in Segment 4 with an aggregated metric score of 2.45, ranking 79 out of 106 acute trusts. By June 2026, the trust’s aggregated performance had improved. The trust was now ranked 81 out of 134 acute trusts with an aggregated score of 2.39 and had moved into Segment 3 of the NHSE oversight framework. Their performance domains were now ranked as Access to Service – 3 (below average), Finance and Productivity – 1 (high performing), Effectiveness and Experience – 3 (below average), Patient Safety – 4 (low performing), and People and Workforce – 2 (below average).This position reflects comparative performance across urgent and emergency care, elective recovery, diagnostics, cancer, and related measures, alongside oversight framework considerations such as financial deficit rules.

The trust had established processes to prevent and control infections, supported by a clear Infection Prevention Control (IPC) governance structure led by an executive director of IPC and an active IPC Committee. The board received annual IPC and antimicrobial stewardship reports and regular updates through the Quality Committee. This provided appropriate oversight. Governance was largely compliant with the National Infection Prevention and Control Manual (NIPCM), though some areas, such as cleaning standards, water safety, ventilation, and IPC training, remained partially compliant. Year‑to‑date performance showed improvement, with a 39% reduction in MRSA bacteraemia and a 7.7% reduction in C. difficile cases, although C. difficile infections remained slightly above trajectory. Gram‑negative bloodstream infection targets were narrowly missed by under 3%. Outbreak management was generally effective, though significant challenges arose during a major Enterobacterales outbreak on the Liver Intensive Therapy Unit and a C. auris outbreak on one of the medical wards requiring enhanced precautions. Surgical site surveillance demonstrated good performance with no total hip replacement infections and low total knee replacement infection rates.

PLACE (Patient-Led Assessments of the Care Environment) 2024 results showed the trust performed strongly in several aspects of the care environment, particularly cleanliness. All three sites achieved scores above 97%, placing the trust above the national average. Food provision was also consistently rated highly across the organisation, with combined food scores between 94% and 95%, and organisational food at KCH was rated at 100%. However, the trust performs below the national average in key patient‑experience domains relating to privacy, dignity and wellbeing, as well as dementia‑friendly and disability‑accessible environments. These deficits were most pronounced at the PRUH and KCH sites, where dementia and disability scores fell into the 82% to 86% range.

Performance data for 2024-2025 showed the trust experienced significant operational pressures across urgent and emergency care, with Accident and Emergency (A&E) performance remaining a key area of concern. By July 2025, the trust ranked as the fifth‑worst performing major emergency department in London (out of 23) and 83rd nationally, reporting 6,575 four‑hour breaches that month (where a patient spends more than four hours in A&E from the time they arrive to the time they leave the department). These figures reflected sustained congestion within emergency departments, with performance consistently below London and England averages. These pressures also contributed to continued challenges in ambulance handover efficiency, with the trust’s overall urgent care performance indicating ongoing delays in transferring patients safely from ambulance crews (delays of over 30 and 60 minutes).

In contrast, the trust demonstrated comparatively stronger performance in elective waiting times. Referral to Treatment data for June 2025 showed the trust performing better than both the London and England averages, supported by favourable trends in reducing the size of the waiting list and improved performance across long‑wait cohorts, including 52-week, 78-week, and 104-week waits. This demonstrated effective oversight and day-to-day control of planned care recovery.

However, the trust did not meet the 31-day or 62-day cancer treatment targets and performed worse than most trusts nationally on two of the three main cancer measures. It also ranked 107 out of 118 acute trusts for the 62-day cancer treatment standard, placing it among the lowest performers.

Mortality and safety indicators were positive. The Summary Hospital‑level Mortality Indicator for April 2024–March 2025 was categorised as ‘as expected’, with no concerning trends identified across diagnosis groups or deprivation quintiles. Safety reporting systems appeared well embedded, with high levels of incident reporting via Learning From Patient Safety Events and 2 Never Events recorded for 2024–2025. However, the trust reported 15 StEIS notifiable incidents between August 2023 and August 2025, with a concentration in surgical and ‘other’ specialities.

Overall, while the trust demonstrated strengths in elective care recovery, mortality outcomes and safety reporting, persistent underperformance in A&E flow, ambulance handovers and cancer treatment pathways indicated ongoing pressures on operational sustainability and highlighted the need for sustained executive oversight and system‑wide coordination to improve timely access to care.

In June 2024 the trust faced significant data security concerns following a major ransomware cyber‑attack on an external pathology provider. This led to the shutdown of pathology IT systems across South‑East London, reducing processing capacity to around 10% and causing widespread disruption to diagnostic testing, delays to clinical decision‑making and cancellation of procedures. Critical incidents were declared, and full service recovery was not achieved until October 2024. The Information Commissioner’s Office (ICO) was notified and supported the trust. Governance records confirmed ongoing scrutiny of the third‑party provider, with strengthened oversight of subsidiary cybersecurity responsibilities. Information governance risks remained high, including concerns about third‑party system access and lack of multi‑factor authentication (MFA) on some externally hosted platforms. The trust responded by strengthening controls, including improved firewall protection and patching processes to meet NHS England MFA requirements, and participating in the national incident response. External audit identified the incident as a key risk and reviewed the trust’s response and assurance processes.

While statutory duties were met and actions taken strengthened cyber controls and oversight, the incident exposed weaknesses in third‑party assurance and system resilience. Improvements were reflected in the Board Assurance Framework, demonstrating learning, but also highlighting the need for continued strengthening of digital and information governance assurance.

We scored the trust as 3. The evidence showed a good standard. The trust demonstrated a commitment to partnership working, community engagement and addressing health inequalities, with positive relationships across the local system and strong operational collaboration at service level. Leaders were present and engaged within system forums, and partners described the trust as open, constructive and willing to work collaboratively to support patient care, flow and system priorities. The trust had established programmes and initiatives to support population health and reduce inequalities, alongside meaningful engagement with local communities and seldom‑heard groups.

The board recognised the importance of its partnership working. The trust was represented on the SEL ICS board by its chief executive as a partner member and participates in system-level groups, such as the System Sustainability Group and the System Financial Sustainability Group. Leaders at the trust invested time in building relationships, understanding perspectives, and constructively engaging with partners within the ICB, place-based partnerships and provider collaboratives and other relevant forums, including primary and social care partners. Feedback from system partners noted that the current trust leadership was open and willing to work with other stakeholders and other providers. There was recognition that steps had been made to support and build relationships with the local system partners and stakeholders to effectively support patient care and flow through the health and social care system.

The trust also made some progress in addressing health inequalities. Through the King’s Health Inequalities Programme, the trust collaborated with community partners to publish research reports exploring barriers to engagement, experiences of clinical research, and the needs of diverse local communities. The recommendations from this work informed improvement initiatives, including improved demographic data capture and targeted engagement with communities at risk of poorer health outcomes. These efforts aligned with the trust’s broader ambition to act as an anchor institution and to contribute to reducing health disparities across Southeast London.

Leaders described active involvement in system‑level forums, including Integrated Care System (ICS) arrangements, place‑based partnerships and provider collaboratives. Trust strategies, including their Strong Roots, Global Reach and the BOLD visions, articulated an ambition to work collaboratively with partners and communities to improve population health, address health inequalities and increase participation in research. These ambitions were reflected in the structured health inequalities programme, which comprised several defined workstreams aimed at reducing unfair and avoidable differences in access, experience and outcomes for patients and staff. The Health Inequalities Programme was supported by programme‑level governance arrangements, including a steering group and workstreams focused on improving data and insight through a health inequalities dashboard, increasing participation of under‑represented groups in research and clinical trials, and engaging communities through co‑production and partnership working. This work aligned with national and system priorities, including Core20PLUS5 and Southeast London population health priorities set by the ICB.

The trust had invested significant effort and innovation in community engagement and population health activity. Documentary evidence demonstrated partnership working with local research organisations to co-design engagement approaches with local communities across Lambeth, Southwark and Bromley. This included the development of Community Research Networks, Patient and Community Advisory Groups and targeted initiatives to address institutional mistrust in research and clinical trials. These approaches supported meaningful engagement with local communities, including seldom heard groups, and enabled active involvement in community-based initiatives such as health and wellbeing outreach, education events and collaboration with the voluntary and community sector. The EDI Annual Report evidenced increased community engagement, co-design approaches and efforts to improve inclusion in research and service development. This work was well developed and reflected a clear organisational commitment to improving inclusion, participation and reducing health inequalities. However, staff and leaders reported that the embedding of this activity within core governance, assurance and operational delivery was still developing and was not yet consistently applied across all services. While partnership working was referenced within strategic documentation, evidence of regular and structured board oversight of the effectiveness, risks and outcomes of partnership activity, particularly in relation to population health and reducing health inequalities, varied and was not yet fully established across the organisation.

Leaders described awareness of population-level pressures, including the impact of cross-borough patient flows on demand, capacity and service experience. However, this insight was not yet consistently translated into coordinated or sustained partnership action at system level, indicating that this aspect of partnership working remained at a developing stage.

Overall, the trust demonstrated a strong commitment to working with partners and communities, with well-developed examples of engagement and collaboration. However, governance, strategic coordination and consistent embedding of partnership and population health activity across the organisation were still developing. Leaders gave examples of how the trust worked in partnership with other organisations within the local system. Leaders and staff described a range of effective operational partnerships, particularly at service level. Examples included joint surgical working with another local NHS trust, which staff reported had reduced duplication and improved service delivery, and collaborative arrangements within the Emergency Department with a local mental health NHS trust, including access to mental health beds to reduce pressures in the system. Maternity services also demonstrated partnership working through the Local Maternity and Neonatal System, including shared learning following serious incidents and participation in regional safety initiatives. There was also established partnership working within safeguarding, including regular engagement with local authority safeguarding boards, Independent Domestic Violence Advocates, and other voluntary sector partners. While these examples demonstrated commitment at service level, leaders and staff consistently described this activity as operationally driven rather than strategically commissioned or overseen. It was unclear what the mechanisms were for evaluating these partnerships or assuring their impact at trust level.

The trust’s governors said they felt supported to undertake their roles and represent local communities. Governors received induction and training for their roles. Governors could access specific workshops and were supported to undertake visits to services. Governors described a generally positive and open relationship with the trust, highlighting that senior leaders, including the Chair, were approachable and responsive to issues raised. Governors felt listened to and reported a shared commitment to the trust’s values and to serving local communities.

However, governors identified inconsistencies in how partnership working was led and assured at the trust level. While there were examples of effective collaboration with system partners, this activity was seen as largely operationally driven, with limited evidence of clear strategic prioritisation, board‑level ownership or systematic assurance of impact. Governors were unclear about how partnership activity informed decision‑making or contributed to addressing population health and health inequalities. Governors also noted variable non‑executive director engagement with the Council of Governors, which limited opportunities for strategic challenge and shared oversight of partnership working. Overall, governors considered the trust to be at an early stage of maturity in this area and described relationships as positive, intent as clear, and felt the foundations for stronger strategic oversight of partnerships were in place.

The trust played an active role within the Southeast London ICS and is a core member of the SEL Acute Provider Collaborative. The trust worked collaboratively with neighbouring acute trusts to address shared system challenges, including elective recovery, diagnostics, and access standards, and to manage capacity and demand across organisational boundaries. This includes joint work to reduce diagnostic waiting times and coordinate recovery activity across the system. Leaders demonstrated a clear commitment to system working as a strategic priority. They recognised that improved outcomes for local populations required collective action. System collaboration was referenced as a key delivery mechanism within the trust’s strategies, and engagement with provider collaboratives was positioned as part of the trust’s future sustainability.

Senior leaders from the trust held significant external-facing leadership roles within the local, regional and national health system, supporting integration and influencing system-wide decision-making. The chief executive officer had been an acute partner member of the ICB since 2022, contributing directly to system-level planning, prioritisation and governance across Southeast London. The chief executive also served as Chair of the Shelford Group, a national collaboration of leading NHS teaching hospitals, enabling the trust to influence national policy discussions and share best practice across the wider NHS. The trust also hosts the integrator function for the London Borough of Bromley, demonstrating a leadership role in place-based system coordination and integration across health, local authority and wider partners.

Leaders demonstrated an understanding of the trust’s role as an anchor institution and how this extends beyond the delivery of acute services. Leaders and staff acknowledged the trust’s position as a major employer and partner to support local communities, promote inclusion, and work collaboratively with system and voluntary sector partners to improve outcomes. The trust worked closely with local authorities, voluntary sector organisations and community partners across the boroughs of Lambeth, Southwark and Bromley, recognising its responsibilities as a large acute provider and anchor institution. Place-based partnership working included the delivery and development of services in partnership with local authorities and other sectors, such as Sexual Assault Referral Centres. The trust also contributed to local regeneration initiatives, such as work linked to Loughborough Junction, supporting wider social and economic determinants of health. In addition, the trust collaborated with third sector organisations, creating employment and development opportunities for young people with learning disabilities and/or autism.

The trust operated a well-established volunteering programme, which formed part of its anchor organisation approach and community engagement model. Volunteers support patients, visitors and staff across hospital sites, helping to improve experience, accessibility and connection with local communities. Leaders saw the trust’s volunteering as key to strengthening relationships with local people and providing opportunities for community involvement. In addition to volunteering, the trust supported work experience, apprenticeships and local employment opportunities.

We scored the trust as 2. The evidence showed some shortfalls. Shortfalls remained in the consistency, timeliness and assurance of learning, particularly in relation to incident backlogs, staff feedback, and the systematic embedding and evaluation of learning across all services. As a result, learning systems were not yet operating consistently and reliably across the organisation. However, the trust had established systems to learn from incidents, deaths, patient safety events and external reviews, with clear alignment to PSIRF principles and a demonstrated commitment to compassionate, system focused learning. There was evidence of meaningful learning and improvement arising from serious incidents and mortality reviews. People using services were involved in improvement and innovation, but this was variable and not yet embedded at trust level. The strongest examples of co-production were evident within maternity services, with emerging practice in a small number of other areas. While the trust had established systems for audit, quality improvement, research and innovation, trust level oversight, consistency and spread of learning were variable. The trust could not demonstrate that learning was consistently timely, evaluated or embedded across all services.

People using services were involved in improvement and innovation, although this remained variable across the trust and was not yet consistently embedded. Examples of co‑production and engagement were evident at the service level, particularly within maternity services, with emerging practice in paediatrics, cancer services and selected safety‑critical programmes. In maternity services, women and families were actively involved in improvement through established and well‑functioning Maternity and Neonatal Voices Partnerships (MNVPs). These forums were used to co‑design service changes, review patient information, and influence environmental and operational improvements. Leaders described how structured feedback from MNVP walk‑arounds, listening events and engagement sessions directly informed changes to communication approaches, wayfinding, patient information materials and the use of clinical space. This engagement informed improvements in patient experience and safety and supported measurable service-level changes. This work contributed to improved outcomes and supported the trust’s successful exit from the Maternity Safety Support Programme in December 2024.

In addition, there were other emerging examples where the patient and family voice was increasingly embedded within safety‑critical improvement work. The Worry and Concern Project, incorporating the application of Martha’s Rule, represented a significant trust‑wide improvement initiative arising from serious incident learning. The programme strengthened escalation pathways for deteriorating patients and embedded patient and family voice into safety processes, with learning informing implementation and communication. Learning from this work was shared internally and externally, demonstrating growing organisational maturity in using patient insight to inform safety improvement.

However, at the trust level, there was less consistent evidence of systematic service user involvement in improvement and innovation through board or sub‑committee structures. Governors described mechanisms for service users to raise concerns, challenge decisions and share ideas, but felt patient insights were not consistently integrated into trust-wide improvement priorities or used systematically to inform decision-making at scale. While opportunities for engagement existed, these were not yet consistently applied across the organisation to support coordinated co-production.

Senior leaders acknowledged that patient voice was not yet fully embedded within trust‑wide quality improvement and transformation work. While there were pockets of strong engagement and positive service‑level examples, this was not underpinned by a consistent approach demonstrating how patient insights were systematically gathered, prioritised, acted upon, evaluated for impact and fed back. As a result, learning from people using services was often localised rather than driving organisation‑wide improvement and innovation. This provided limited assurance that learning from people using services was driving organisation‑wide improvement.

The trust demonstrated an increasing focus on learning culture, although staff experience remained mixed. In the 2025 NHS Staff Survey, the trust scored 5.73 for the People Promise element “we are always learning”, which was slightly above the national average (5.57) but slightly below the highest performing trusts. This represented a modest improvement from previous years, indicating some progress but highlighting ongoing challenges in embedding a consistently positive learning culture. Staff feedback indicated relatively stronger performance in access to development opportunities, particularly in specialist and research‑active services, but weaker results for appraisal quality, feedback and consistency of learning support. Staff described variability in access to protected learning time and development opportunities, particularly during a period of sustained financial constraint, workforce pressure and organisational change. Staff indicated that learning was not always experienced as equitable, consistent or clearly linked to improvement priorities.

Leaders recognised these challenges and described actions taken to strengthen learning culture, including refreshed appraisal processes, targeted leadership development programmes and additional support for middle managers. These initiatives reflected an understanding of the critical role of line managers in embedding learning and improvement at the team level. However, the impact of these actions was not yet consistently evident across the divisions, and there was variation in staff experience.

The previous inspections identified the absence of a named clinical lead for sepsis, limiting strategic oversight of this high‑risk area. In response, the trust appointed a Trust‑wide Sepsis Clinical Lead in September 2023. The trust introduced mandatory sepsis training for adult and paediatric staff, developed in collaboration with the UK Sepsis Trust, and updated sepsis protocols across adult, paediatric, maternity and neutropenic pathways. The trust had also developed an Adult Sepsis Navigator within the EPIC electronic patient record in partnership with another local acute NHS trust, with a paediatric version in development. A Deteriorating Patient Improvement Group was established under the Patient Safety Incident Response Framework, including a patient representative from the UK Sepsis Trust.

The trust had established systems for clinical audit and participated in a wide range of national audit and benchmarking programmes. Leaders described an annual audit cycle and ongoing audit programmes across care groups, covering areas such as medicines management, safeguarding, restrictive practice and adherence to national guidance, including National Institute for Health and Care Excellence standards. Participation in national audits included maternity‑specific programmes such as MBRRACE UK and the Saving Babies’ Lives Care Bundle, alongside speciality‑specific national audits relevant to acute and specialist services. At the service level, there were clear examples where audit findings were used effectively to drive improvement. This was particularly evident in maternity, neonates and specialist services, where audit outcomes informed changes to fetal monitoring practice, multidisciplinary learning, incident review processes and mortality and morbidity governance. In these areas, leaders were able to demonstrate measurable improvements, including strengthened compliance with national standards and improved outcomes. However, at trust level, the use of audit findings to support learning and improvement was variable. Leaders and staff described inconsistent follow-through of audit outcomes, with limited evidence of re-audit in some areas and a lack of clarity about how learning was shared or applied beyond local teams. As a result, national and local audit findings were not consistently used to drive organisation-wide improvement and innovation. Leaders acknowledged these gaps and described work underway to strengthen how audit findings are used to inform learning, improve data quality and support more consistent benchmarking and improvement activity across services. The trust had taken steps to establish a more coherent and structured approach to quality improvement through the introduction of the King’s Improvement Method (KIM). This framework was designed to provide a consistent approach to improvement aligned with the trust’s strategic objectives and operating model, supporting clearer strategy deployment from board to frontline. The KIM aimed to support clear alignment between strategic priorities and frontline improvement activity through agreed objectives, metrics and routine Strategy Deployment Reviews. Leaders described how the method was being used to respond to off‑track performance, support local problem‑solving through improvement huddles and align improvement activity with priorities such as patient safety, flow, access and financial sustainability. However, KIM was still at an early stage of embedding. Understanding and application varied across divisional staff, and staff were yet to fully understand how their improvement work contributed to the trust-wide priorities. While leaders articulated a clear ambition for KIM to underpin all continuous improvement, the impact on the consistency, pace and sustainability of improvement was still developing.

The trust had a strong and well‑established research profile, supported by close partnerships with universities, academic networks and clinical research organisations. King’s was a high‑performing trust for recruitment to National Institute for Health and Care Research portfolio trials, with large numbers of patients participating in research annually. Leaders described robust research governance arrangements, including dedicated oversight committees and reporting through board‑level structures. Research and innovation activity across the trust was extensive and included major clinical and digital transformation programmes, research‑led innovation in specialist services such as transplantation, fetal medicine, neuroscience and oncology, and the development of digital tools, AI‑supported diagnostics, virtual care models and patient applications. Leaders highlighted that the trust had received national and international recognition for aspects of clinical care, research, digital innovation and workforce practice. At organisational and service level, the trust and its teams had received multiple national awards and short‑listings, including recognition through HSJ Awards, Nursing Times Awards and Health Tech News Awards. These awards reflected innovation in patient care, digital pathways, and workforce inclusion. The trust was also shortlisted and recognised for its large‑scale digital transformation programmes, including the implementation and optimisation of the EPIC electronic patient record, delivered in partnership with system partners. In addition, several clinical services achieved international recognition, with Obstetrics & Gynaecology and Gastroenterology services ranked high globally. The trust was designated as a Tessa Jowell Centre of Excellence for neuro‑oncology for a second consecutive term, recognising excellence in clinical care, research and patient experience following peer review. The trust’s role within King’s Health Partners, an Academic Health Science Centre, further supported translational research, innovation and collaboration across organisational boundaries.

Leaders also described a strong portfolio of external clinical accreditations, which assured nationally and internationally recognised standards. These included Joint Advisory Group accreditation for endoscopy services, Imaging Services Accreditation Scheme, ISO 15189 accreditation for medical laboratories, Improving Quality in Physiological Services, Anaesthesia Clinical Services Accreditation, Gold Standards Framework accreditation for end‑of‑life care, and Diabetes Care Accreditation Programme accreditation for inpatient diabetes services at Princess Royal University Hospital. These accreditations reflected robust, clinical quality within specific services, although leaders acknowledged that accreditation coverage was not yet consistent across all clinical areas.

While leaders were clear that these awards, accreditations and research designations demonstrated considerable strength and ambition, they also acknowledged limitations. Award‑winning practice and research‑led innovation were not yet consistently translated into trust‑wide improvement. While innovation activity was substantial, innovation was not consistently evaluated or spread beyond specialist areas. Evaluation and sustainability of innovations remained variable, and leaders were still developing a systematic approach to ensuring that learning from recognised excellence informed routine practice across all services. Leaders recognised that further work was required to embed learning, scale innovation and ensure consistent impact across the whole organisation.

The trust had systems in place to learn from patient safety incidents, deaths, inquests and national safety alerts, aligned with the Patient Safety Incident Response Framework (PSIRF). PSIRF priorities had been agreed through governance processes informed by risk profiles, incident trends and national guidance. Leaders described mechanisms for sharing immediate learning through safety huddles, governance meetings and trust‑wide communications. The trust was open and transparent with patients and their families when incidents occurred. We reviewed records of three recent notifiable safety incidents and saw that people were informed promptly, both verbally and in writing, in line with the duty of candour regulation. Patients and their families were involved in the investigation of incidents and were provided with copies of incident reports. The provider was compassionate in its responses; apologies were offered, explanations were clear, and details of actions taken to prevent recurrence were documented.

Processes focused on a holistic review of patients who died whilst in the care of the trust, including structured mortality reviews and escalation of cases where deaths were considered more likely than not to be related to problems in care. Mortality learning was reported through care group governance, trust level quality and safety forums. Evidence from death reviews demonstrated that learning was identified and translated into improvement actions, including changes to clinical pathways, escalation processes, training, and assurance mechanisms. Examples included learning related to recognition and escalation of deterioration, staffing models, access to specialist services, and system resilience. Mortality learning was also triangulated with other sources of intelligence, such as incident reports, complaints, and audit data, to inform broader quality improvement priorities. While the trust could demonstrate structured processes for learning from deaths, the extent to which learning was consistently embedded and evaluated varied between services. For example, learning from Patient Safety Incident Investigations (PSIIs) relating to deteriorating patients and medication safety was clearly aligned to trust‑wide improvement programmes, whereas in some services, including parts of maternity and acute inpatient care, learning resulted in local actions without consistently clear evidence of ongoing monitoring to assure sustained impact.

While the trust had clear processes for reporting and reviewing incidents, there were backlogs in the completion of incident reviews in some services, with several incidents remaining open beyond trust timescales. These backlogs were more evident in high‑pressure clinical areas with high incident volumes, which limited the trust’s ability to provide timely learning. Leaders acknowledged that delays in completing reviews reduced the effectiveness of learning, particularly where immediate safety actions had been taken, but formal investigation findings and thematic learning were not finalised promptly. As a result, opportunities to identify trends, share learning consistently and confirm the effectiveness of actions were sometimes delayed. Staff feedback reflected this. Staff said they generally understood how to report incidents and felt confident that serious incidents were taken seriously by leaders. However, feedback to staff following incident reporting was inconsistent, with some staff describing limited visibility of investigation outcomes, learning points or resulting changes to practice. In some cases, staff reported that learning was shared informally through safety huddles or team discussions but was not always reinforced or revisited, making it difficult to see how learning had been embedded or sustained over time. Where incident backlogs persisted, staff felt that confidence that reporting led to meaningful change was reduced, particularly for lower‑level or recurrent incidents. Leaders described actions underway to address these issues, including strengthened divisional oversight of incident backlogs, clearer prioritisation of reviews, additional patient safety capacity, and renewed emphasis on closing the feedback loop with staff. However, at the time of inspection, these actions were not yet consistently embedded across all services, and the impact on timeliness, staff feedback and assurance was still developing.

The trust had systems to respond to coronial inquests and external reviews, including the identification and dissemination of learning and oversight through governance committees. Leaders described mechanisms for ensuring that learning from inquests informed policy, practice and training where relevant. The trust engaged with local Child Death Overview Panels (CDOP) and safeguarding review processes. Relevant professionals attended panels, and that learning was considered through safeguarding and quality governance routes. However, the trust was not consistently able to demonstrate how learning from CDOPs and Child Safeguarding Practice Reviews was systematically tracked, disseminated and embedded across all relevant services. This limited the consistency of learning across services.

The trust reported 2 Never Events for 2024–2025. Leaders were able to describe learning and risk reduction actions taken following previous serious incidents and historic Never Events, including strengthened policies, revised clinical processes, enhanced training, and improved assurance mechanisms. Where relevant, Never Events and high‑risk incidents were reviewed through PSII processes, with learning shared across sites and services. Examples of actions included improvements to surgical safety processes, swab and instrument counts, procurement and device governance, and reinforcement of national safety standards such as National Safety Standards for Invasive Procedures.

However, the trust did not yet consistently demonstrate systematic evaluation of the effectiveness of learning and risk reduction actions over time, particularly where learning depended on behavioural change or sustained compliance. Leaders acknowledged this and described work underway to better evaluate the impact of learning over time.

While there were clear strengths and examples of excellence, inconsistent spread, delayed learning and limited evaluation meant improvement systems were not yet reliable or embedded trust-wide

We scored the trust as 4. The evidence showed an exceptional standard. The trust fully understood any negative impact of its activities on the environment and strived to make a positive contribution in reducing it and support people to do the same. The trust demonstrated an awareness of the organisation’s environmental impact and showed a organisation‑wide and strategically embedded commitment to improving environmental sustainability. They spoke confidently and consistently about the risks climate change poses to population health, service resilience and operational continuity, and they were able to describe in detail the work undertaken to reduce the trust’s carbon footprint. They provided clear and demonstrable examples of measurable improvements and tangible outcomes made across estates, clinical practice, transport, procurement and waste management, reflecting an integrated approach to environmental stewardship.

The Deputy Chief Executive held the executive portfolio for sustainability as the board‑level lead for the Green Plan. This ensured robust, board‑driven strategic oversight at the highest level and positioned sustainability as a core organisational priority rather than an isolated set of initiatives. The governance structures supporting this work were well‑established, robust and increasingly effective. Leaders had strengthened oversight arrangements through the establishment of the Green Plan Delivery Board, chaired by a senior director and attended by executive and divisional leaders. The board provided systematic and focused scrutiny of progress across the ten Green Plan workstreams, including energy and the built environment, travel and transport, waste, medicines, procurement, food, adaptation and ways of working. It oversaw a clear and well‑embedded accountability framework, with senior responsible officers leading each area and reporting through structured performance and governance processes.

The trust had an established Green Plan covering 2022–2025 that aligned with national Greener NHS requirements. Leaders were in the process of finalising the 2025–2028 Green Plan, which incorporated significant staff and patient engagement and aligned with wider integrated care system sustainability priorities. Leaders described the trust’s responsibilities as an anchor institution and demonstrated an understanding that environmental sustainability, population health and health inequalities are closely interlinked. They showed clear, data‑informed insight into the trust’s historical carbon performance and the scale of transformation required to meet national targets. They described clear mechanisms to track progress, including annual and biannual sustainability reporting to the board, alignment with national data collections such as Estates Returns Information Collection returns and Greener NHS datasets, and plans to further align sustainability reporting with the Task Force on Climate‑related Financial Disclosures framework. Although leaders expressed frustration at the lack of feedback from national submissions, they consistently met reporting requirements and demonstrated a commitment to transparent accountability.

The trust delivered several large‑scale and innovative initiatives that represented outstanding practice and exceeded national expectations. This included publication of a joint Clean Air Plan with another local acute NHS trust, the first cross‑trust plan of its kind in the NHS. The plan addressed air quality through commitments relating to transport, construction, procurement, estates and clinical practice, and leaders demonstrated ambition to go beyond national requirements by incorporating air quality as a dedicated focus area in the refreshed Green Plan. Leaders also delivered nationally recognised work to reduce emissions from nitrous oxide through decommissioning manifold systems and switching to portable cylinders, resulting in reduced waste, lower emissions and significant cost savings. Decarbonisation of the estate was supported by successful bids for external funding, enabling LED upgrades, solar photovoltaic installations and work to explore low‑carbon heating solutions. The trust maintained ISO14001 certification for environmental management, demonstrating a robust and well‑embedded oversight of environmental compliance and continuous improvement.

Further examples of innovation included significant progress in electrifying the trust’s fleet and enabling active and low‑carbon travel. Leaders oversaw the expansion of electric vehicle charging infrastructure, including the NHS’s only dedicated A&E rapid charger supporting London Ambulance Service fleets, which had delivered hundreds of charging sessions since commissioning. Staff uptake of low‑carbon vehicles through the salary sacrifice scheme had increased, supported by trust‑wide engagement and improved infrastructure. The trust also developed multiple behaviour‑change initiatives, including a successful Gloves Off campaign that reduced unnecessary glove use and associated carbon emissions, walking‑aid reuse schemes and the implementation of offensive waste pathways expected to achieve substantial carbon and financial savings. Leaders also described tangible progress in low‑carbon clinical care, with reductions in emissions from inhaler use and trust participation in the national inhaler recycling pilot.

Leaders demonstrated a mature and proactive understanding of the need to adapt to climate change as well as mitigate it. The trust had a detailed Climate Change Adaptation Plan covering 2023–2026, which identified clear risks relating to heat, flooding, air quality, infrastructure vulnerability and operational resilience. Leaders had established a Climate Adaptation Working Group responsible for translating the plan into structured and iterative annual action cycles, including assessing thermal risks in clinical areas, undertaking flood risk assessments and integrating climate risks more clearly into the corporate risk register. Leaders recognised the potential for climate change to disrupt supply chains, energy and water security, and transport systems, and described collaborative partnerships with local authorities and integrated care system partners to help build system‑wide resilience.

Staff engagement and training in sustainability were developing areas. Leaders acknowledged challenges around carbon literacy and workforce capacity but had taken proactive steps to address this. They had appointed a full‑time communications and engagement lead for sustainability, strengthened the Green Champions network by introducing protected time for staff, created accessible training resources and integrated sustainability into quality improvement methods. Staff described increased opportunities to participate in sustainability initiatives and noted improvements in internal communication about environmental priorities. Leaders recognised that participation remained variable and that sustainability was not yet embedded consistently across all staff groups, but they could describe credible plans to strengthen training, expand the champions network and embed sustainability into appraisal and mandatory learning pathways.

System partners were aware of the trust’s sustainability commitments and spoke positively about its contribution to integrated care system priorities. The trust worked closely with partners on air quality, inhaler recycling, fleet electrification, and shared learning between organisations. Leaders described their involvement in system‑level forums and collaborative networks, and partners confirmed the trust’s active engagement and commitment.

Overall, leaders demonstrated strong awareness, ambition and innovation in environmental sustainability. They understood the relationship between sustainability, population health and organisational resilience, and they had established robust and well‑embedded structures to oversee delivery of the trust’s commitments. While some areas, such as staff carbon literacy and the consistency of sustainability embeddedness across services, required further development, the trust’s achievements represented an exceptional standard. The scale of progress, the strength of governance structures, the trust’s success in securing external funding, and the breadth of innovative and high‑impact initiatives indicated a clear and embedded organisation-wide commitment to environmental sustainability.