Spotlight Case Study of Good Practice - Heatherwood Court
We want to ensure healthcare services reflect on our inspection and assurance work and measure their own services against these findings to drive forward service improvement. We hope the findings of good practice illustrated within this case study below can be transferred between organisations, and across the wider health service to support system improvements.
Last year we undertook two inspections at Heatherwood Court in Pontypridd in response to incidents that had occurred at the hospital. The inspections took place over six days in June and September 2024 and focussed on the care being provided to patients under enhanced observations. The improvements we observed between the two inspections highlight the positive outcome of our approach to responding to emerging risks to patient safety and working collaboratively with a service receptive to our findings.
During our first inspection, we found that the processes and procedures in place at the hospital were not effectively managing the risk of preventing 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, to ensure the best decisions were being made to protect patient safety. 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. We found instances where staff did not follow required observation levels, engaged minimally with patients, and worked long observation shifts without proper breaks. The care plans we saw were often generic, outdated, and lacked personalised interventions, with some failing to reflect the patients' current enhanced observation needs.
HIW worked closely with the service following our first inspection to seek assurance that appropriate actions would be taken in response to our concerns. During our second inspection it was positive to see the progress that had been made since our first inspection. It was clear that staff had worked intently to review and implement processes that led to a more organised approach towards managing risk and making more informed decisions in the best interests of the patients.
We saw that staff handover meetings were much improved since our previous visit. Each meeting was more structured, with a clear description provided of current risks for each patient, including discussions on Dynamic Appraisal of Situational Awareness and Deliberate Self Harm scores. The information provided to staff during the handover meetings was now accurately reflected in the information recorded on individual patient grab sheets and staff schedules.
Throughout our second inspection we felt staff were more engaged with patients when undertaking enhanced observations, which meant there appeared to be an improved and more relaxed atmosphere on the units. We observed staff members always adhering to the required levels of enhanced observations for their patient.
Following our first inspection, the hospital had started to upload paper documentation to a new electronic system. Despite its infancy, it was clear during our return visit that work had been undertaken to improve the wide range of patient documentation. We saw evidence of more personalised care plans and risk assessments. There was an improved joined up approach visible in terms of capturing current patient risks through the risk assessments and other documentation such as grab sheets and safety and support plans that were detailed and comprehensive.
We also noticed considerable improvement in the arrangements for allocating staff members to patients to undertake enhanced observations. The staff members leading the staff handovers and planning the shift schedules showed an improved level of oversight and leadership. We saw that each shift schedule included pertinent information about each staff member, such as their gender and length of time worked at the hospital. This helped ensure only staff members with experience of the patients at the hospital were being allocated to undertake enhanced observations.
This case study provides a positive example of how settings are striving to improve following our inspection and assurance work and demonstrates how valuable sharing learning and insight can be in driving forward improvement within healthcare services across Wales.