‘Patients at risk and wards unfit for purpose’ – report
PATIENT safety was put at risk and wards were found to be unfit for purpose during an unannounced inspection of a mental health unit.
Urgent improvements are now being put into place at the Ablett Unit at Ysbyty Glan Clwyd after the Healthcare Inspectorate Wales visit followed concerns from a “number of sources”.
The inspection focused on the Cynnydd and Dinas wards – two of the four wards within the unit.
On Cynnydd ward, an eight-bed locked rehabilitation ward with a section suite attached:
There were issues regarding the location of the Section 136 suite, which when occupied did not allow safe access to the treatment room, which also acted as the pharmacy for the ward. Often when staff needed to access the treatment room they had to in effect leave Cynnydd ward, this impacting on patient safety;
on the night of November 20 there were only male members of staff on shift despite there being two female patients accommodated on Cynnydd ward; this was deemed “inappropriate and should not happen”;
following scrutiny of a number of care plans, there was a lack of patient engagement with the care-planning process, with some of the language being overly technical. On the 20-bed Dinas ward: The location of the main office did not allow for the effective observation of the patient group;
the layout of the corridors and associated blind spots made effective patient observation very difficult;
there was no nurse call system in patient bedrooms. “This issue potentially increases the risk to patient safety were an incident to occur”;
there were no vision panels on doors of patient rooms, meaning that if a patient was on regular observations they would be disturbed through the night;
the bathrooms were in need of refurbishment, including adjusting the position of the nurse call alarm, which was not in an appropriate position;
staff on Dinas ward did not have a clear understanding of intermittent observations, and some timings were not specifically stated on the observation sheets; and
a chair being used on one-to-one observations was blocking the fire exit. “This was not acceptable.”
HIW also found issues that were identified in its previous inspection in 2014 were still apparent, despite the health board developing a clear action plan to resolve them.
Betsi Cadwaladr University Health Board has since produced an improvement plan to address recommendations made in HIW’s report, which is published today.
The report says despite the numerous issues regarding the environment, staff at ward management level were keen to develop the service provided.
It also ruled the new patient care documentation being trialled on Cynnydd ward was working well, reducing the volume of paperwork for staff.
The acute care meeting process used on Dinas ward was also deemed to be a good example of effective communication and of planning a patient’s pathway.
Some areas of noteworthy practice were observed, such as the “motivated, enthusiastic, caring approach” of staff on wards, and a “good rapport between staff and patients”.
Andy Roach, BCUHB’s director of mental health and learning disabilities, said: “We are pleased the team noted the good standards of care provided.”