Inspection finds the need for significant improvement at specialist mental health hospital Heatherwood Court

Despite positive findings in relation to leadership and staff knowledge of patients, key improvements were required regarding the management and reporting of incidents. As a consequence of the concerns identified, and the lack of assurance over the processes in place to report, log and learn from incidents, Heatherwood Court was identified as a Service of Concern. We continue to monitor the service to ensure all improvements required are addressed without delay.

HIW completed an unannounced two-day inspection in November last year, specifically focusing on leadership and governance, and the reporting and management of incidents. The low-security, locked rehabilitation hospital accommodates 47 people within single gender units, offering treatment for men and women on a forensic mental health care pathway.

Inspectors observed a passionate and supportive leadership team and multidisciplinary staff, who had a good understanding of patient needs.  We saw information grab sheets were available, which made it easier for all staff to understand the needs of patients. This had a positive impact on the more challenging and vulnerable patients, as it allowed staff to quickly find out how to best help during times of crisis.

During the onsite inspection we saw patient risks being discussed, but we could not be assured that there were sufficient arrangements in place around the management and reporting of incidents. Inspectors reviewed 47 pieces of documentation, which consisted of patient incident forms and safeguarding referrals over a nine-month period. We saw evidence of several incidents that the hospital had not reported to HIW despite this being required by the Independent Healthcare (Wales) Regulations 2011. Providers and managers of independent healthcare services must comply with these regulations. Some of the patient incidents that were not reported to HIW were incidents of self-harm, where hospital attendance was required. Such incidents fall within the serious injury category of the regulations. We also found that there were a number of patient incident forms that had not been appropriately reviewed by a senior manager within the service. This was considered a regulatory breach and subsequently we have issued a non-compliance notice.

The hospital has a regulatory requirement to ensure a registered manager is employed. However, due to staffing issues and delays in recruitment procedures there has been no appropriate person in the role for over 12 months. This has also been considered as a regulatory breach and a further non-compliance notice has been issued.

Chief Executive of HIW, Alun Jones said:

As a consequence of the concerns identified during our inspection, Heatherwood Court was identified as a Service of Concern.

Whilst it is positive to see passionate leadership with a good understanding of patient needs at Heatherwood Court, our inspection identified a number of immediate improvements which require the service to take action.

We will work closely with the provider to ensure that progress is made against these concerns and improvements are made.

• Independent Mental Health Service Inspection Report - Heatherwood Court Hospital, Pontypridd
• Inspection Summary Report - Heatherwood Court, Pontypridd