Mental health spot-checks - ward-by-ward

Some of the comments in the reports

Mental health ward-by-ward spot checks for elderly patients across Wales have been revealed.

Reports on how 21 hospitals performed were published on Thursday.

The inspections were ordered by Health Minister Mark Drakeford following the critical Trusted to Care report on elderly patient care last autumn.

The findings have revealed a "considerable variation" in standards.

Here are the summaries for each unit:

Aneurin Bevan University Health Board

Ysbyty Ystrad Fawr in Ystrad Mynach

Annwylfan Ward, Ysbyty Ystrad Fawr - Ystrad Mynach, Caerphilly county

Positives:

• The wards were "clean, calm, quiet"

• The bedrooms are all en-suite, accessible and personalised with patients' own belongings

• All patients were wearing their own clothes and appeared "well cared for"

• Patients have ready access to snacks and drinks and a choice of main meals is provided where possible

• Relatives and carers involved in "a wide range of aspects" of their loved ones' care

• "Excellent understanding" of person-centred care and vision from the ward manager

Negatives:

• Poor service provided by speech and language department

• Two systems of recording patients' information, paper and electronic, which resulted in "inconsistencies in information"

The health board was asked to make immediate improvements in the following area:

• A review of prescribing practices

Cedar Park Ward, Ysbyty'r Tri Chwm - Ebbw Vale, Blaenau Gwent

Positives:

• Clean

• Patients appeared well cared for

• Meals "looked really good and well presented"

• Good arrangements for shift handovers and training

Negatives:

• At night there was "low levels of staff, shared across two wards"

• Only one toilet was dementia friendly

• Specialist beds were not available

• "Inflexibility" in relation to when patients could wake up in the mornings; all needed to be up by 08:30 BST

• Some issues in relation to staff understanding of what constitutes safe holding and how this is dealt with in patients notes"

• Some issues with delays in the mental capacity assessment process

Areas where the health board was asked to make improvements:

• More flexible patient-centred approach

• Raise issues around restraint

• Improve availability of emergency medication

• Review nursing establishments, "especially at night"

Tredegar Ward, St Woolas Hospital - Newport

Positives:

• A "very clean, calm, friendly and safe" environment and a "strong multidisciplinary team"

• All patients were dressed in their own clothes and appeared well cared for

• Good evidence of medication being reviewed and tailored, and of relatives and carers involvement in the care

• Information pack for relatives and carers and risk management arrangements were worthy of note

Negatives:

• Some issues with ensuring that all staff were up to date with their training in safe holding techniques

The health board was asked to make immediate improvements in the following areas:

• The removal-of-out of date medication

Clywedog Ward, Llandrindod Wells Hospital - Llandrindod Wells, Powys

Positives:

• A "light, airy, calm, friendly and well laid out" ward with good visibility everywhere

• Patient areas including the outside space were "personalised, dementia friendly, clean and non-cluttered"

• The staff were observed to be "happy and well motivated"

• Patients were dressed in their own clothes and appeared well cared for

• Well developed and person-centred care and treatment plans

• There was "excellent" evidence of activities undertaken with the patients by all staff, and there was "obvious excellent team working with patients"

Negatives:

• Some minor issues in relation to the storage of medication

• Some difficulties noted with accessing training due to the rural location of the hospital

Areas where the health board was asked to make improvements:

• Asked to improve the provision of bilingual signage and the storage and date checking of medication

• Asked to review fridge policy and remove out of date books for prescribing

Abertawe Bro Morgannwg University Health Board

Cefn Coed Hospital in Swansea

Dyffryn Ward, Cefn Coed Hospital - Swansea

Positives:

• The ward was "well organised" and "welcoming"

• Staff were "happy and well motivated"

• A genuine, positive culture of care "permeated" through the ward

• Excellent team working

• Evidence of decisions about resuscitation being discussed in family meetings with lots of 'thank you' cards on display

Negatives:

• The ward environment is not fit for purpose

• Patients are regularly sent to sleep on another ward

• The lack of suitable outside space for the patients to use noted as "a gap"

Areas where the health board was asked to make improvements:

• Urgent authorisations were not being requested

• Care and treatment planning training was needed

Ward G, Neath Port Talbot General Hospital - Port Talbot

Negatives:

• Patients had access to high risk areas such as bathrooms

• TVs with hanging wires

• No evidence in patients' notes in the use of restraint management

• Little evidence of activities with patients; not always possible due to staffing levels

• High number of patients given anti-psychotic medication compared to other wards; one chart not signed by a doctor

• Door to the treatment room unlocked

• "Some tensions" noted between management and staff; no clear lines of accountability

• No written handover in some patient documentation

Areas where the health board was asked to make improvements:

• Carry out audit of ligature points within 48 hours of spot check

• Make ward more dementia friendly and need to have clear systems and processes

• Review prescribing practices for anti-psychotic medication, heating, TV wires, care and treatment plans, nurse staffing and skill mix

Ward 2, Angelton Clinic, Glanrhyd Hospital - Bridgend

Positives:

• Light and welcoming with entry to it via a "fantastic" atrium which is clearly used for activities with the patients

• Lots of photos of activities and events which the staff had undertaken with the patients

• The patients looked well cared for and were wearing their own clothes

• Managers observed to be strong leaders

Negatives and action:

• Asked to make improvements over the short to medium term by reviewing care and treatment planning

• Training needed for staff to use resuscitation trolley

Tawe Ward, Ystradgynlais Community Hospital - Ystradgynlais, Powys

Positives:

• The ward was "light, airy and calm" with wide corridors and large communal areas

• Environment was felt to be dementia friendly

• Some evidence of activities on the ward for the patients

• High proportion of Welsh speaking staff and staff working hard to deliver person-centred care with limited resources

Negatives:

• Provision of services on this ward

• "Significant issues" with staffing levels; short and long term sickness and staff performance reporting arrangements

Areas where the health board was asked to make improvements:

• Staffing levels

• An assessment of the function and purpose of the ward

• Staff performance reporting

Suite 2, Tonna Hospital - Tonna, Neath Port Talbot

Positives:

• Warm and homely feel

• All patients were wearing their own clothes and looked well cared for

• Good understanding of safe holding

• Medication not overused or underused

• Flexible visiting times and "excellent" information on notice board and in information packs

Negatives:

• Flooring and decoration

• Lack of ready access to dietician for 10 patients who require special diets

• No Mental Health Act assessments were found in patient notes

• Staff activities with patients hampered due to lack of resources

Areas where the health board was asked to make improvements:

• Carry out an audit of ligature points within 48 hours of the spot check

• Review the availability of resuscitation equipment

Cwm Taf University Health Board

Ysbyty Cwm Cynon in Mountain Ash

Ward 7, Ysbyty Cwm Cynon - Mountain Ash, Rhondda Cynon Taff

Positives:

• Ward was observed to be clean, quiet and calm

• Staff were warm, friendly, helpful and responsive

• Care was observed to be delivered in a "timely and appropriate way"

Negatives:

• Bathrooms cannot be unlocked from the outside so a risk that patients could lock themselves in

• Some wheelchairs in use on the ward are not safe

• Issues in relation to the storage of medication, date checking of medication and dealing with unused medication

• Relatives and carers are not actively encouraged to assist protected mealtimes

• Communal rooms were "cold"

• Issues securing general medical staff to "attend the ward"

• Lack of "therapeutic activities"

• Decoration was "bland" and not particularly dementia friendly

Areas where the health board was asked to make improvements:

• The replacement of the wheelchairs with a more appropriate model

• The fitting of locks to the outside of bathroom doors

• The administration of covert medication

• Activities for patients and improving the surroundings to be more dementia friendly

Cambrian Ward, Ysbyty George Thomas - Treorchy, Rhondda Cynon Taff

Positives:

• High quality person-centred care

• Strong ward leadership

• A dedicated and motivated staff team

Negatives:

• Access to social work, speech and language therapy services was by referral and described as "poor"

No recommendations made, however it was requested ill fitting curtains/lockers were replaced.

Seren Ward, Royal Glamorgan Hospital - Llantrisant, Rhondda Cynon Taff

• Ward manager described as providing "excellent leadership"

• Regular reviews by the occupational therapist

• Vibrant decoration of the wards and communal areas

Negatives:

• Access to ward via locked doors where there is "considerable traffic" which is disruptive to the patients

• The ward environment was not dementia friendly

• Medicines fridge was locked however the key to open it was lost

• Issues for staff over access to training

• Doctors making decisions without informing other staff, such as DNR or breaking bad news

Areas where the health board was asked to make improvements:

• Involve relatives and carers in decisions

• Replace the medication fridge

• Develop a policy relating to covert medication

• Staffing skill mix

Cardiff and Vale University Health Board

Llandough hospital in Penarth

Ward East 10, Llandough - Penarth

Positives

• Carers group which is well supported

• Bedroom door sensors which enable patients to be monitored

• Friendly, helpful and knowledgeable staff on duty

Negatives

• Not very clean and the ward treatment room and office were observed to be untidy and cluttered

• "High number of instances" of delays to patients being discharged home or into the community

• Patients' bathrooms and toilets were in need of cleaning

• Clothing looked tired

• Much more could be done to encourage patients to carry out productive tasks

• Some patients were seen to wander along the corridors which appeared to be a result of them being "under-stimulated and disengaged"

• Day room not conducive to encourage social interactions

• Families voiced concern regarding their lack of involvement in decision making and rigid approach to visiting hours

• High staff sickness and vacancy rates

Areas where the health board was asked to make improvements:

• The cleanliness of the ward environment

• Repair both of out of order lifts preventing ready access to the outside space

• Staffing levels and management of sickness absence

Coed y Felin Ward, Iorwerth Jones unit - Llanishen, Cardiff

Positives:

• Multidisciplinary team

• Photographs on patients' notes

• Personalised placements to assist with mealtimes

• Information on wardrobes setting out assistance patients may need with personal care

Negatives:

• Physical environment of ward, especially in the common areas, "inappropriate" for the needs of patients and "looked uncared for"

• In places the floor was "sticky" and there was a "musty smell" in some areas

• Lack of understanding of safe holding or information in care and treatment plans about its use

• Some "unusual" prescribing of medication

• Issues with storing medication and administration/recording of its use

• High amount of long term sickness and concerns about management's ability to recruit staff

Areas where the health board was asked to make immediate improvements:

• Replacement of the floor throughout the ward

• Overall ward cleanliness

• Removal of rubbish and broken furniture from the internal and external communal areas

St Barruc's Unit, Barry Hospital - Barry, South Glamorgan

Positives:

• Person-centred care

• Nurses shadowing physiotherapist and occupational therapist to develop their skills

• Continuity of care

• Sensory stimulation throughout the ward

Negatives:

• Unsure as to the level of staff understanding of mental health legislation, mental capacity legislation and DoLS

• Mix of hard copy and electronic records for each patient which was felt to be unhelpful

• No dedicated occupational therapy provision for the ward

• Fridge thermometer broken and medication storage inadequate

• Some evidence medications not being administered correctly in one case and some inappropriate practice

• Medical/consultant input into the ward was felt by some of the staff to be irregular

Areas where the health board was asked to make improvements:

• Staff training in mental capacity legislation

• The administration of medication including "covert medication"

Betsi Cadwaladr University Health Board

Wrexham Maelor Hospital in Wrexham

Gwanwyn Ward, Wrexham Maelor Hospital - Wrexham

Positives:

• Carers group

• Open and flexible visiting times

• Daily multidisciplinary team meetings

• All staff have some level of dementia training

Negatives:

• The ward was "chaotic and disorganised"

• The ward environment, whilst clean, was generally unkempt

• Rising damp was seen as was peeling paint and plaster

• The bedrooms were sparse without any personal touches and in places there were unpleasant odours

• Most of the walls were bare

• Activities for the patients were very limited

• Some "significant issues" with staffing on the ward; there were nine vacancies and recruiting has proved slow and difficult as the posts are considered to be unpopular

Areas where the health board was asked to make improvements:

• Doctor/consultant and occupational therapy support issues being reviewed

• Staffing levels over the Christmas period being addressed

• Staffing across all disciplines

• Communal area needs to be dementia-friendly

• Review medication management

Fan Gorau Ward, Montgomery County Infirmary - Newtown, Powys

Positives:

• The ward was observed to be calm, quiet, clean and tidy

• Bathrooms and toilets were very clean

• Inspectors found evidence of good practice, with a consultant psychiatrist being based on the ward

• Involvement of relatives and carers in multidisciplinary team discussions about their loved ones care

Negatives:

• The bedrooms were "stark and bland" and lacking in personal touches

• A general lack of environmental stimulus

• No structured or meaningful activities available to the patients, nor any specialised equipment

Areas where the health board was asked to make improvements:

• Upgrade ward environment to better cater for specific needs of patients with cognitive impairment, like colour coding

• Review the nurse management structure

• Staff development for dementia care

• Develop information for patients and relatives

• Training for staff in preparing patient documentation

• Review need to install a shower

Tegid ward, Ablett Unit, Ysbyty Glan Clwyd - Rhyl, Denbighshire

Positives:

• Accessible and dementia' friendly garden

• Personalised bedroom areas

• "Passionate and committed" staff

• Ward manager was a good leader and "empathetic and caring" in her manner

Negatives:

• The physical environment of the ward was "inappropriate" for patients' needs

• The lounge and dining room were "too small" with adequate seating

• No dementia friendly facilities

• Evidence of lack of ward clerk support; office very untidy and there was no evidence of notes or documentation management

• Some concerns about the effectiveness of communication channels between senior management and ward staff

• Some concerns about the attitudes of some of the unqualified staff

Areas where the health board was asked to make immediate improvements:

• Development of care and treatment plans

• Ensure patients were informed of their right to advocacy

• Storage of medication

• Provision of resuscitation equipment

• Repairing the out of order toilet and installing a shower curtain

Cemlyn Ward, Ysbyty Cefni - Llangefni, Anglesey

Positives:

• Good practice and well managed

• Use of colour throughout the ward "dementia friendly"

• Policy of not allowing bank staff to administer medication until they know the patients well

• Strong team relationship

Areas where the health board was asked to make improvements:

• Improving Care and Treatment Planning

• Ensuring patients were informed of their right to mental health and mental capacity advocacy

• The provision of pharmacy support

Hywel Dda University Health Board

Bronglais General Hospital in Aberystwyth

Enlli Ward, Bronglais General Hospital - Aberystwyth, Ceredigion

Positives:

• Excellent support from clinical psychologist

• Patients in own clothes and appeared well cared for

• Generally good awareness and application of mental health legislation

Negatives:

• No evidence of tailored activities being provided for patients and the activities room is used as a storage space

• The garden area cannot be used because of uneven floor and other surfaces

• Many of the chairs for patients are not fit for purpose

• Some patients were observed to be unable to get out of their chairs

• Staff do not feel involved in major decisions

• Strict routines which were not patient centred

• Recruiting difficulties

• Some nutrition issues

Areas where the health board was asked to make immediate improvements:

• The appointment of senior ward management staff

• Difficulties in securing the ready availability of food, drink and snacks

St Non's Ward, Withybush General Hospital - Haverfordwest, Pembrokeshire

Positives:

• Well organised, light, airy, calm, quiet and clean

• Staff were "very welcoming"

• Standards of assessment and care plans appeared to be "very good"

• Patients in own clothes and appeared well cared for

• Nutrition project has helped improve choice; standard of documentation excellent

• Good application and awareness of mental health legislation

• Always a Welsh speaking member of staff

Negatives:

• Some difficulties in moving patients into the community due to closure of local care home

• Long response times for fixtures, fittings and equipment "appeared to be the norm"

• Strict ward routines not felt to be person centred

• Pharmacist only visits once a week

Areas where the health board was asked to make improvements:

• Review ward routines

• Undertake dementia friendly audit of environment

• Review number of hi-low beds

• Review pharmacy support

• Review response times from support facilities

• Remind staff of importance of checking patient identification before administering medication

Bryngolau, Prince Philip Hospital - Llanelli, Carmarthenshire

Positives:

• Well lit, though some areas would benefit from decoration

• TV in lounge which is well used by patients

• Patients wearing their own clothes and looked well cared for

• No food issues observed and a "pleasant" dining room

• Good awareness of mental health legislation

• Activities clearly take account of patients' diagnosis

Negatives:

• Five bedrooms out of sight of nurses

• Minor issues with storage and date entries on medication

Areas where the health board was asked to make improvements:

• Refocus service to be more patient centred

• Address fridge problems with pharmacy and review medicines stock checking

• Review hi-low bed availability

• Address emergency medical cover response when required