Immediate improvement needed at Ebbw Vale's mental health hospital

Health Inspectorate Wales (HIW) made an unannounced visit to Cedar Parc, Ysbyty Tri’r Chwm - a specialist mental health hospital - in August 2023 and has now released a report on their findings.

The hospital, run by Aneurin Bevan University Health Board provides mental health services for people over 65. HIW’s inspection focused on the Cedar Park Ward, which has 14 beds and provides specialist assessment and treatment to dementia patients.

Inspectors could not be assured that the "health, safety and welfare of patients, staff and visitors was being actively promoted and protected". In addition, potential risks of harm were not being identified, monitored and where possible, reduced or prevented.

In response the health board said it is "building a programme of improvement to further enhance the quality of their mental health services".

During the inspection several issues required "immediate action by the health board, for example, inspectors observed missing handrails in the ward corridors with exposed sharp edges which posed a risk of injury".

Inspectors also found the "call bells within patient bedrooms were located across the room from patient beds and others were positioned where they could not be reached by patients whilst lying down".

HIW was provided with restraint data which indicated that "within the past three months, four patient restraints had been conducted by staff who were non-compliant or had not completed the relevant training". Also, the health board’s Use of Restrictive Physical Intervention policy was out of date since 2019.

A general lack of communication between senior staff and ward staff was also identified and HIW "were not assured that the hospital’s governance systems and arrangements supported continuous improvements and shared learning from serious incidents".

Outside Ysbyty Tri’r Chwm Hospital (Image: Google Maps)

Positively, inspectors found patient records evidenced detailed and appropriate physical assessments and monitoring. Care and Treatment Plans (CTPs) were also individualised, person-centred and "reflected the needs and risks of the patients in the hospital".

However, several issues were identified that "compromised the privacy and dignity of patients". Issues included the ward having insufficient washing facilities and no designated gender toilets.

Inspectors also witnessed patients receiving personal care in their bedrooms with doors left open.

During HIW’s previous inspection of the ward in 2018, several areas "compromising the privacy and dignity of patients" were found, and HIW said "it was disappointing to find similar issues".

The ward was "generally clean and provided a relaxed environment of care for patients". However, HIW noted that the "ward must be tidied and de-cluttered to ensure staff and patient safety".

Inspectors praised that staff treated "patients with respect and kindness throughout the inspection. Patients appeared confident in approaching staff to engage in discussions".

Statement from Aneurin Bevan University Health Board:

A spokeswoman for Aneurin Bevan University Health Board said: “We support the publication of the HIW’s report into the unannounced inspection of Cedar Parc, Ysbyty Tri’r Chwm in August 2023.

“It is reassuring that the inspectors witnessed care received by patients that was person-centred and tailored to their individual needs. They also observed polite, committed and respectful interactions between staff and patients, and that good professional relationships had been developed to support patients’ health and wellbeing.

“During the inspection, HIW did identify some areas for concern that required urgent action. While the majority of these concerns have already been addressed, we have also developed a comprehensive plan to focus on the other recommended areas for development. 

“We are committed to continuously improving our services to provide the very best standards of care and experience to our patients and are building a programme of improvement to further enhance the quality of our Mental Health services.”

HIW has set out an improvement and asks the health board to confirm action has been taken in line with management responses documented in the improvement plan.

HIW has also asked the health board to provide documented evidence of action taken and/or progress made.