Heatherwood Court Mental Health Services in Pontypridd De-escalated as a ‘Service of Concern’ Following Improvements

The inspections took place over six days in June and September 2024, and focused on Caernarfon, Cardigan and Chepstow wards. The rehabilitation hospital currently accommodates 35 people within single gender units, offering specialist mental health care.

In May 2024, Heatherwood Court Hospital was designated a Service of Concern after reports of incidents where patients under enhanced observations came to harm or were at risk. Patients are placed under enhanced observations if staff assess they are at risk of self-harm or harming others. This may involve the patient being accompanied by staff at all times and removing harmful items.

The Service of Concern process is used when there are significant service failures, or when there is an accumulation of concerns about a service or setting. Following these concerns, we undertook two unannounced inspections to seek assurance on how the service was operating and to observe the care being provided. During the June inspection, we identified significant shortcomings in risk management and governance procedures. However, by September, through enhanced engagement with the facility’s management, noticeable improvements had been made, with stronger processes implemented to manage risks and prioritise patient safety.

During the inspection in June 2024, we were not assured the processes and procedures in place at the hospital were sufficiently managing the risk of some patients coming to harm whilst being under enhanced observations. The system for decisions on which staff members were assigned to closely monitor patients was not well-organised, or thorough enough, to ensure the best decisions were being made to protect patient safety. The inspection found that handover meetings were poorly organised, with some staff arriving late and missing important details about patient risks. Key documents, such as grab sheets and staff schedules, were inconsistent with each other, and staff were often assigned to patients they were unfamiliar with, which hindered the development of effective therapeutic relationships. Inspectors found instances where staff did not follow required observation levels, engaged minimally with patients, and worked long observation shifts without proper breaks. Patient care plans were often generic, outdated, and lacked personalised interventions, with some failing to reflect the patients' current enhanced observation needs. These concerns were addressed through our non-compliance process, requiring immediate assurances and evidence of improvements. While the hospital provided written assurances and evidence of changes, it remained a Service of Concern as we reviewed the actions taken and allowed time for improvements to embed.

During the inspection in September 2024, it was positive to see significant progress since the first inspection. The actions taken by the service had resulted in a more organised approach to managing risks and making better-informed decisions for the benefit of patients. The inspection found several improvements in the hospital's practices including staff handover meetings being better organised, starting on time and providing clear information about current patient risks. Shift schedules included staff members’ gender and tenure at the hospital, ensuring that experienced staff were assigned to enhanced observations. Staff engaged more meaningfully with patients during these observations, creating a calmer and more relaxed atmosphere. There were no instances of staff working excessive hours on enhanced observations. Additionally, care plans and risk assessments were more personalised, with a more cohesive approach to documenting and addressing patient risks through tools like grab sheets and safety and support plans.

Following the inspections, we continued to engage with the service as part of HIW’s escalation and enforcement process. We received adequate assurance regarding the actions taken to improve patient safety, and the hospital was de-escalated from a Service of Concern in November 2024.

Alun Jones, Chief Executive of Healthcare Inspectorate Wales said:

At Healthcare Inspectorate Wales, our foremost priority is ensuring that services provide safe, quality care that truly supports people’s health and wellbeing. We are encouraged by the progress made at Heatherwood Court, where significant improvements in patient safety and care have been made. While it’s reassuring to see the facility de-escalated from a Service of Concern, our commitment to driving lasting change remains. We will continue working closely with the provider to ensure that these improvements are sustained and that care standards continue to rise, both now and in the future.

September 2024 - Mental Health Service Inspection - Heatherwood Court Hospital, Pontypridd