Mental Health Service

Inspection
(Unannounced)
Ty Llidiard
Enfys Ward & Seren Ward
Cwm Taf University
Health Board
Inspection Date: 26 - 28 March 2017
Publication Date: 29 June 2017
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contacting us:

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Communications Manager
Healthcare Inspectorate Wales
Welsh Government
Rhydycar Business Park
Merthyr Tydfil
CF48 1UZ

O r via

Phone: 0300 062 8163

Email: [email protected]
Fax: 0300 062 8387
Website: www.hiw.org.uk

Digital ISBN 978-1-4734-9738-2

© Crown copyright 2017
 Contents

1. Introduction ......................................................................................................... 2

2. Context ................................................................................................................ 3

3. Summary ............................................................................................................. 4

4. Findings .............................................................................................................. 5

Quality of patient experience ............................................................................. 5

Delivery of safe and effective care .................................................................. 11

Quality of management and leadership ........................................................... 21

5. Next steps ......................................................................................................... 24

6. Methodology...................................................................................................... 25

Appendix A ...................................................................................................... 27

1
1. Introduction

Healthcare Inspectorate Wales (HIW) is the independent inspectorate and

regulator of all health care in Wales.

HIW’s primary focus is on:

 Making a contribution to improving the safety and quality of

healthcare services in Wales

 Improving citizens’ experience of healthcare in Wales whether as a

patient, service user, carer, relative or employee

 Strengthening the voice of patients and the public in the way health
services are reviewed

 Ensuring that timely, useful, accessible and relevant information

about the safety and quality of healthcare in Wales is made
available to all.

HIW completed an unannounced inspection of Ty Llidiard Child and

Adolescent Mental Health Service (CAMHS) within Cwm Taf University
Health Board on the evening of Sunday 26 March and the day of 27 and 28
March 2017. The following hospital sites and wards were visited during this
inspection:

 Enfys Ward

 Seren Ward

Our inspection team was made up of one HIW inspection managers and two
clinical peer reviewers (one of whom was the nominated Mental Health Act
reviewer).

During this inspection, we reviewed documentation for patients detained

under the Mental Health Act 1983 in order to assess compliance with the Act.

Further details about our approach to inspection of NHS services can be

found in Section 6.

2
2. Context

Ty Llidiard currently provides child and adolescent mental health in-patient

service in the Bridgend area for South Wales. Ty Llidiard sits under Child and
Adolescent Mental Health Service (CAMHS) Directorate within Cwm Taf
University Health Board.

The setting is a mixed gender hospital with 19 beds. There were 18 patients
there at the time of the inspection.

Although located within the grounds of Princess of Wales Hospital, part of

Abertawe Bro Morgannwg University Health Board, Ty Llidiard is operated by
Cwm Taf University Health Board for patients from across South Wales.

3
3. Summary

Overall, we found evidence that Ty Llidiard provided dignified and

compassionate care for patients. However, there were significant and
numerous shortfalls that meant we are not assured that the service provides
safe and effective care.

This is what we found the service did well:

 Staff provided care to patients at Ty Llidiard in a respectful manner.

 Care and Treatment Plans were completed to a good standard.

 Staff were positive about the openness of the multi-disciplinary

team.

 Staff were positive about the support they received from each other
and the ward management.

This is what we recommend the practice could improve:

 The quality of recordkeeping.

 The quality and completion of clinical audits.

 The robustness of safety procedures.

 The compliance of staff mandatory training.

 With relevant partners, review CAMHS provision for South Wales.

4
4. Findings

Quality of patient experience

Ty Llidiard is a purpose built hospital to provide Child and Adolescent

Mental Health Service (CAMHS) in-patient care. It was evident that great
effort has been made in providing a suitable environment for the patient
group to receive dignified care. However, there were areas of
maintenance required.

Throughout our inspection we observed staff treating patients with

respect and kindness. Staff made every effort to maintain patient dignity.

There had been occasions during 2016 where patients had been placed
‘out-of-area’ due to the acuity and complex needs of the patient group at
Ty Llidiard. The health board must engage with relevant partners to
review the CAMHS provision of South Wales to ensure there is sufficient
capacity to provide timely access to care within their local service

Dignified care

Standard 4.1 Dignified care

People’s experience of healthcare is one where everyone is treated with

dignity, respect, compassion and kindness and which recognises and
addresses individual physical, psychological, social, cultural, language and
spiritual needs.

We found that patients at the hospital were treated with dignity and respect by
the staff.

Ty Llidiard is a purpose built hospital that was opened in 2011 to provide care
for 12 to 18 year olds. It was evident that great effort has been made in
providing a suitable environment for the patient group to receive dignified
care.

Throughout Ty Llidiard the environment was, on the whole, clean and well
maintained. However, the glass canopy at the entrance was very dirty and in
need of cleaning. We also noted that windows, particularly those behind the
mesh screens that prevent items being passed through open windows,
required cleaning.

5
Improvements needed

The health board must clean the glass entrance canopy at Ty Llidiard.

The health board must ensure windows at Ty Llidiard are regularly

cleaned including behind mesh screens.

There was also some superficial damage to interior walls, including holes and
cracks in paintwork and writing scrawled on the wall, in particular the small
lounge on Seren Ward. This could impact upon a patient’s emotional
wellbeing.

Improvement needed

The health board must undertake regular environmental maintenance

audits to identify and rectify damage to the environment at Ty Llidiard.

There was damage to a small section of corridor flooring outside the patient
dining room on Enfys Ward. The area had been taped to prevent any further
damage or injury to patients, staff or visitors; however this required permanent
repair.

Improvement needed

The health board must repair the damage to the corridor floor on Enfys
Ward.

Each ward office had a “patient status at a glance board”1 displaying

confidential information regarding each patient being cared for on the ward.
However, there were no facilities to hide the confidential information when the
boards were not in use. This meant that this confidential information may be
viewed by patients, or visitors, when they entered the office.

Improvement needed

The health board must ensure that staff can cover status at a glance
boards when not in use.

1
A board that provides staff with a quick reference to essential information about the
individual patients being cared for on the ward.

6
Patients had their own bedrooms with en-suite facilities including toilet, sink
and shower. Patient bedrooms were suitably furnished and had sufficient
space for the patient and their belongings. Patients were able to access their
bedrooms freely and lock them from within; staff were able to over-ride the
locks if required.

On each ward patients had access to enclosed garden areas. These had
been designed to be suitable for the young patient group. However, at the
time of our inspection the garden areas were in need of maintenance such as;
the removal of weeds and over-grown plants along with cleaning the surfaces
and facilities within in the gardens.

Improvement needed

The health board must ensure that regular garden maintenance is

undertaken.
Ty Llidiard provides patients of school age with education input. Outside of
school hours patients have individual activity and therapy plans and were able
to choose what activities and therapies they wish to do each day. Patients had
access to therapy and activities rooms such as a games room and a music
room. There was also an occupational therapy kitchen that patients could
access for individual and group sessions.
A development since our previous inspection in 2015 was the introduction of
an arts and crafts room on Enfys Ward. The arts and crafts activity room
appears to be appreciated and used extensively by the patients and would
benefit from a wash basin and appropriate storage for arts and craft items so
they can be tidily and securely stored.
Disappointingly we were informed that the cinema room was no longer in use.
Staff were unclear as to why the cinema room was not being used for its
intended purpose. There was also a pool table at Ty Llidiard, however the
cloth was badly damaged which meant that use of this valuable facility could
not be used. Staff informed us that these two facilities were previously well
used and a benefit to the patient experience.

Improvement needed
The health board must review the cinema room to ensure that it is
operational and safe for patient use.
The health board must repair the pool table cloth.
There were also damaged items awaiting collection, such as; damaged
furniture in the unused Rumpus room on Seren Ward, damaged drawers in

7
Seren Clinic room and a broken water cooler in the dining room of Enfys
Ward. These need to be removed for safety reasons.

Improvement needed
The health board must ensure that damaged items are removed from the
hospital.
There was also a damaged soap dispenser and a paper towel dispenser in
one bathroom on Seren Ward. This area was not being used by patients at
the time of the inspection, however the items require replacing.

Improvement needed
The health board must ensure that the damaged soap dispenser and
paper towel dispenser are repaired.
Ty Llidiard had a sports hall for patient use. During our previous inspection
there was a water leak that had caused significant damage. We saw that
although the leak had been rectified the sports hall floor remained heavily
marked. Although this doesn’t prevent the use of the hall it would however
benefit from the marked areas being replaced. There was also an external
sports area for tennis, netball and hockey.
The hospital also had a designated vehicle so that staff could facilitate taking
patients to the local shops and on community trips further afield. Where
appropriate (after risk assessments) patients were also able to leave the
hospital with their family or unescorted.
There were designated rooms for patients to see visitors. It was commendable
that Ty Llidiard also has a Family Flat which allows for family members to stay
overnight; where appropriate the patient can also stay within the flat. This was
of great benefit to family members, particularly those families that are located
some distance away from the setting as it provides in-patient care for all of
South Wales.
Throughout the inspection we saw visitors coming to see patients and noted
that the Family Flat was also being used.
Patients had access to a ward telephone to make personal phone calls.
Patients also had set times when they could use their mobile phones.

Standard 4.2 Patient information

People must receive full information about their care which is accessible,
understandable and in a language and manner sensitive to their needs to

8
enable and support them make an informed decision about the care as an
equal partner.

Standard 3.2 Communicating effectively

In communicating with people health services proactively meet individual

language and communication needs.

Throughout the ward there were areas where up-to-date patient information
was clearly displayed and we noted appropriate signage throughout the ward.

Through our observations of staff-patient interactions it was evident that staff

ensured that they communicated with patients effectively. Staff took time to
undertake discussions using words and language suitable to the individual
patient. Where patients remained unclear or misunderstood, staff would
patiently clarify what was said.

Timely care

Standard 5.1 Timely access

All aspects of care are provided in a timely way ensuring that people are
treated and cared for in the right way, at the right time, in the right place and
with the right staff.

Ty Llidiard provides in-patient care to 12 to 18 year old people requiring

hospital mental health assessments. The hospital provides care for patients
from six health boards across South Wales2. The community CAMHS teams
within the six health boards refer to Ty Llidiard.

At the time of our inspection Ty Llidiard was commissioned as a 15 bed

hospital. The hospital had a total of 19 bedrooms, 14 bedrooms on Enfys
Ward and five bedrooms on Seren Ward. During the inspection there were 18
patients being cared for at the hospital.

2
Aneurin Bevan University Health Board, Abertawe Bro Morgannwg University Health Board,
Cardiff & Vale University Health Board, Cwm Taf University Health Board, Hywel Dda
University Health Board and southern area of Powys Teaching Health Board

9
We were informed that due to the current levels of demand on the in-patient
service, Ty Llidiard was regularly providing care for more patients than the 15
bedded service which it was commissioned and staffed to provide. Therefore,
additional staff via the bank system or agency was required (see Standard 7.1
Workforce).

We were also informed that at times during 2016 where patients’ had been
placed ‘out-of-area’ due to lack of patient beds in Ty Llidiard. This meant that
some patients within the South Wales catchment area were not able to
receive timely access to care within their local service.

Improvement needed

The health board must engage with relevant partners to review the
CAMHS provision in South Wales to ensure there is sufficient capacity
to provide timely access to care within their local service.

10
Delivery of safe and effective care

Care and Treatment Plans developed as part of the Mental Health

(Wales) Measure 2010 were completed to a good standard; however they
failed to identify patients’ unmet needs.

There was poor recordkeeping at Ty Llidiard; this included the

completion of records and filing. There were errors and omissions in a
number of areas including, Mental Health Act documentation,
observation charts and Medication Administration Records.

We also found weaknesses in maintaining the safety of patients, this

included emergency clinical items and medication that was out-of-date,
a delay in locating ligature cutters and a delay in being able to contact
the on-call manager.

Application of the Mental Health Act

We reviewed the statutory detention documents of four patients who had been
detained under the Mental Health Act (the Act) at Ty Llidiard.

Patient files were disorganised and copies of statutory documentation was

poorly filed and therefore difficult to review. We were able to verify that all
detentions reviewed were compliant with the Act; however there were a
number of areas of improvement in line with the 2016 Mental Health Act Code
of Practice for Wales.

There was Section 5(2)3 detention documentation where the completing

person did not delete the relevant option to identify that they were either “the
registered medical practitioner” or “the approved clinician” (who is not a
registered medical practitioner).

In one case there was also no record of the responsible clinician’s

consultation with the patient and their decision making on the patient’s file.
Therefore there was no evidence that this had occurred.

3
Section (2) - Doctor’s holding power entitles the authorities to hold the patient for up to 72hrs
in order for a Mental Health Act assessment to be undertaken.

11
We saw evidence of poor record keeping and filing in patient records. There
were a number of copies of statutory documentation missing from the files we
reviewed or only one side of the form copied.

When reviewing the process for one Section 24 detention, the patient’s notes
recorded that the Approved Mental Health Professional 5 (AMHP) would inform
the ward when the assessment date and time had been agreed between the
AMHP and the two doctors (one GP and one Section 12 doctor6). However,
there was no evidence that the views of the patients’ relatives and that all
other considerations had been sought prior to the application being made for
Section 2 detention, as guided by paragraphs 14.58 & 14.59.

Staff we spoke to at Ty Llidiard stated that they required training in the

administration of the Act. They also felt that the poor staffing capacity did not
allow for all statutory documentation to be reviewed and correctly filed in a
timely manner.

The health board must ensure their staff are competent to undertake their
roles. Well trained administrative support on wards contributes significantly to
ensuring that all statutory documentation is reviewed and correctly filed and
that, in conjunction with Mental Health Act Managers, statutory timescales
under the Act are met.

Improvement Needed

The health board must provide staff with training in the administration of
the Mental Health Act.

4
Section 2 - Provides for someone to be detained in hospital for an assessment and
treatment of their mental disorder.

5
Approved mental health professionals (AMHPs) are trained to implement elements of the
Act in conjunction with medical practitioners. They perform the pivotal role in assessing and
deciding whether there are grounds to detain mentally disordered people who meet the
statutory criteria.

6
A doctor trained and qualified in the use of the Mental Health Act 1983, usually a
psychiatrist.

12
The health board must ensure that Ty Llidiard has sufficient
administrative support to ensure that statutory documentation is
appropriately filed.

Staff had access to the 2016 Mental Health Code of Practice for Wales (the
Code); however this was only available in English and not Welsh.

Improvement Needed

The health board must ensure there is sufficient copies of the Code in
English and Welsh so that staff, patients and relatives can review a copy
as and when required.

Care planning and provision - Monitoring the Mental Health (Wales)

Measure 2010

We reviewed three sets of Care and Treatment Plan (CTP) documentation.

The following positive observations were identified:

 CTPs were complete and appeared to be kept up-to-date

 Physical health assessments were undertaken on admission

 Risk assessments set out the identified risks and how to mitigate and
manage them

 The care and treatment plans identified patients’ care co-ordinators.

However, there was not a record of individual patient’s unmet needs in

patients CTPs. This would allow the care coordinator and Ty Llidiard to review
the provision of care to reflect any required changes.

Improvement needed

The health board must ensure that patient’s unmet needs are recorded
in their Care and Treatment Plan.

On admission a new CTP would be devised as opposed to updating the

patient’s community CTP. Staff stated this was often due to not receiving the
community CTP in a timely manner. This may result in the lack of continuity of
care planning when devising plans without relevant information. The health
board should liaise with the community teams across the respective health
boards to address the difficulties in receiving timely community CTPs.

13
Safe care

Standard 2.1 Managing risk and promoting health and safety

People’s health, safety and welfare are actively promoted and protected. Risks
are identified, monitored and where possible, reduced and prevented.

Ty Llidiard is a purpose built CAMHS hospital. The design and layout provides
a safe environment with appropriate fixtures, fittings and furniture to help
maintain patient safety.

However, we were concerned about a number of areas in regards to

maintaining a safe environment for the care of patients. During our first night
we toured the environment and found a pen that had been left in the sports
hall. We were concerned that if this item was found by a patient it could have
potentially been used for self-harm or a weapon. We gave the pen to the
nurse accompanying us.

Improvement needed

The health board must ensure that objects that can be used to harm are
not left in patient areas.

As previously stated, the hospital is commissioned for 15 patients and during

our inspection there were 18 patients being cared for at Ty Llidiard. On the
first night of our inspection there was an additional patient awaiting transfer to
another hospital, therefore there were 19 patients present on the first night.

There were additional staff at Ty Llidiard to reflect the additional patient

numbers. However, through our observations it appeared that an agency staff
member had limited knowledge about the ward and its layout. When directed
by the staff nurse to take something to another area of the ward they required
detailed instructions to know where to go. This could have caused a critical
delay during an emergency situation.

Improvement needed

The health board must induct all bank and agency staff working at Ty
Llidiard to ensure that they are familiar with the environment and day to
day running of the ward.

Due to the level of activity on the first night of our inspection, we informed the
nurse in charge to use their on-call arrangements to inform senior

14
management that we were in attendance along with the current situation on
the ward. However, despite reassurance from staff that they had been in
regular contact with their on-call manager throughout the day, it took
approximately 30 minutes to contact the on-call manager that evening. This is
a significant delay for on-call arrangements. A senior member of Ty Llidiard
staff attended the hospital that night which provided staff with further support
and advice.

Improvement needed

The health board must ensure that on-call staff are available to ward
staff when required.

We were concerned that during our inspection there was discrepancy in the
location of the ligature cutters; some members of staff stated they were in the
clinic in Enfys and others stated Enfys ward office. It took staff approximately
10 minutes to locate the ligature cutters; this could have been a critical delay
during an emergency situation. During the inspection the ward manager
arranged for ligature cutters to be sorted on each of the wards. Maintenance
workers fixed a location for ligature cutters on each of the wards which
provided us with assurance that they would be available to staff when
required.

Improvement needed

The health board must ensure that all staff know where ligature cutters
are located at Ty Llidiard.

Observation records were poorly completed. There were records with missing
information and therefore we could not be assured that the required
observations had been completed by staff. We also observed that an
observation record had been completed for one patient and then crossed
through. We were informed that this patient had been out on leave with family
members and the entries on the observation record were for another patient
with the same first name. This is a significant error by the staff members
completing the observation record.

The observation records only record the first name of the staff member
responsible for completing the observation. The full name of the staff member
must be included.

Improvement needed

The health board must ensure that staff complete patient observation
records as and when required.

15
The health board must ensure there full name of the staff member
responsible for completing patient observation records is recorded on
the associated form.

There was also poor record keeping in regards to; the Mental Health Act, risk
assessments, medication administration and clinical equipment that impacted
upon the safety of patients. These are covered in more detail later in the
report.

Standard 2.5 Nutrition and hydration

People are supported to meet their nutritional and hydration needs, to

maximise recovery from illness or injury.

Patients at Ty Llidiard are provided with their meals at the hospital. The
hospital has a three week rotation menu and there were five options for lunch
and evening meals. Patients also had access to snacks and refreshments.

Housekeeping staff stated that they try and be flexible to meet the needs and
preferences of the patients. We saw a record of patients likes and dislikes and
there was additional stock available within the kitchen stores to provide
alternatives to the menu choices.

There were appropriate dining room facilities on both wards with a larger
dining room on Enfys Ward and a small bright room in Seren.

There were working water dispensers within each of the dining rooms,
however as previously stated there was additionally a broken water dispenser
awaiting collection on Enfys Ward.

We were informed that for the majority of time all patients had their food in
Enfys dining room so that they all ate together. However, if a patient was
unwell they could eat their food in the Seren dining room for privacy and not to
disturb other patients.

We observed one meal time and saw that staff and patients ate together
which provided a conducive and therapeutic experience.

At times some patients would require feeding with nasogastric (NG) tube. We
reviewed the equipment stock and supplies for NG feeding and there was
sufficient equipment for providing the required NG feeds at the time of the
inspection. Staff stated that stocks were regularly monitored and ordered.

16
There were eight staff trained in NG feeding, we were informed that this was
sufficient to meet the current needs, however staff felt it would be beneficial if
more staff were trained. Staff also raised their concerns regarding maintaining
their competency in NG feeding as there would be periods when no patients
would requiring this type of assisted feeding and therefore staff would not be
continuingly providing this specialist procedure. To remedy this we were
informed that the hospital had ordered a specialist dummy for practicing the
NG feeding procedure to maintain the skill. At the time of the inspection no
date could be provided for when the dummy would be provided.

We were informed that NG feeding would occur in the clinic room of the ward
there the patient was admitted. However, when we discussed with staff where
a patient would be NG fed if they were non-compliant, we had differing views.
Some staff advised that they may be NG fed within their bedrooms. However,
one of the ward managers stated that any NG feed that may require restraint
should be undertaken in the high care area on Seren Ward where suitable
safe facilities are available.

Improvements needed

The health board must ensure that there are sufficiently trained staff
experienced in providing nasogastric (NG) feeding at Ty Llidiard.

The health board must ensure that there are suitable arrangements in
place for staff at Ty Llidiard to maintain their NG feeding skills.

The health board must ensure that all staff know the correct procedures
regarding administering NG feeding to non-compliant patients.

Standard 2.6 Medicines management

People receive medication for the correct reason, the right medication at the
right dose and at the right time.

Medication was stored securely within the clinic rooms. Medication cupboards,
fridges and trolleys were locked when not in use.

The completion of Medication Administration Records (MAR Charts) in both

clinics of Ty Llidiard were of a poor standard. There were gaps in recording of
whether prescribed medication had been administered or not. This was not
isolated to a singular patient’s record or a time period, but occurred regularly.
When medication is not given, registered nurses must record on the MAR

17
Chart why the medication had not been administered using the standardised
coding. Additionally, MAR Charts did not always include the patients legal
status in reference to the Mental Health Act.

Improvement needed

The health board must ensure staff complete Medication Admission

Records (MAR Charts).

The health board must ensure the patients legal statuses are written
clearly on Medicine Administration Record Charts

We reviewed a sample of medication within the clinic rooms on both wards;

there was out-of-date medication within the stock on Enfys Ward. The nurse
accompanying us immediately disposed of the medication appropriately.

Improvement needed

The health board must ensure that there is a regular audit of medication
to prevent clinic rooms holding out-of-date stock.

The drug administration policy was not available to staff in either clinic rooms.
This was addressed during the inspection. We also discovered an out-of-date
Cardiff & Vale drugs policy from 2002 within one of the clinics, which staff
removed immediately.

Improvement needed

The health board must ensure that all relevant (medication) policies are
up to date and available to staff in each clinic room.

Standard 2.7 Safeguarding children and adults at risk

Health services promote and protect the welfare and safety of children and
adults who become vulnerable or at risk at any time.

We reviewed staff training completion rates on Child Protection and saw that
41 out of 52 had completed relevant training. During discussions with staff
members it was evident that they were knowledgeable and competent in child
safeguarding procedures.

18
Improvement needed

The health board must ensure that all staff complete relevant Child
Protection training.

Standard 2.9 Medical devices, equipment and diagnostic systems

Health services ensure the safe and effective procurement, use and disposal
of medical equipment, devices and diagnostic systems.

We reviewed the emergency equipment in each of the clinics at Ty Llidiard.

The secure tag was missing from the Emergency Grab Bag on Enfys Ward,
despite this being identified in the regular audit on 2 March 2017.

There was out-of-date equipment on the resuscitation trolley on Enfys Ward.

Improvement needed
The health board must ensure there are appropriate audit systems in
place and completed to identify and replace any missing or out-of-date
clinical equipment.

Standard 3.5: Record keeping

Good record keeping is essential to ensure that people receive effective and
safe care. Health services must ensure that all records are maintained in
accordance with legislation and clinical standards guidance.

There was evidence of poor recordkeeping in a number of areas at Ty Llidiard

across different disciplines, this included:

 Poorly organised patient records

 Incomplete copies of Mental Health Act documentation

 Poor completion of Medication Administration Records

 Incomplete and incorrect patient observation records

Improvement needed

19
The health board must establish appropriate systems to ensure that
staff complete and maintain records to a high professional standard.

The health board must review the administrative support arrangements

for Ty Llidiard.

20
Quality of management and leadership

There was a dedicated and committed workforce at Ty Llidiard that

worked cohesively as a multi-disciplinary team. However, staff
vacancies and sickness impacted on the continuity of care.

Staff had difficulty in completing mandatory and additional training. It

was positive to note that staff had group clinical supervision and
individual managerial supervision.

Ty Llidiard needs to develop robust audit and governance systems to

provide high quality, safe and reliable patient-centred care. At the time
of our inspection these were lacking which impacted heavily upon the
delivery of safe and effective care.

Governance, leadership and accountability

Health and Care Standards, Part 2 - Governance, leadership and

accountability

Effective governance, leadership and accountability in keeping with the size

and complexity of the health service are essential for the sustainable delivery
of safe, effective person-centred care.

It was positive that throughout the inspection staff at Ty Llidiard were

receptive to our views, findings and recommendations.

Ward staff spoke positively about the leadership and support of the ward
managers, and stated that occasionally they would provide direct support on
the ward to fill gaps in the shift rota. We saw evidence of this in the staff rotas.
However, this ultimately affected the amount of time that ward managers
received to fulfil their managerial duties.

The staff we spoke to commented positively on multi-disciplinary team (MDT)

working. Staff said the MDT work in a professional and collaborative way and
individual views were sought and valued.

Ty Llidiard had group clinical supervision which allowed for staff members to
reflect upon the care provided. The staff we spoke to were positive about the
process.

21
Staff had regular management supervision. However, there was no over-
arching record in place to monitor its completion and regularity.. Records were
maintained in individual staff member’s files. We suggested that a record of
managerial supervision for staff at Ty Llidiard is maintained so that ward
managers can be quickly assured that managerial supervision is taking place.

It was evident that the service was under significant pressure to provide care
for more patients that the number it was commissioned for. This impacted
upon staff’s ability to consistently provide high quality, safe and reliable
patient-centred care.

The number of areas of improvement identified in the “Delivery of safe and

effective care” section of this report highlights the need for major improvement
in audit and governance at Ty Llidiard. It was positive however to hear that
there were processes in place to ratify and implement policies to support staff
in their work.

Improvement needed

The health board must ensure that there are robust audit and
governance arrangements in place at Ty Llidiard to ensure the delivery
of safe and effective care.

Staff and resources

Standard 7.1 Workforce

Health services should ensure there are enough staff with the right knowledge
and skills available at the right time to meet need.

We were informed that a number of experienced staff had left to take up new
roles to develop their careers. At the time of our inspection there were six
ward staff vacancies, three registered nurses and 2 health care support
workers. There was also an occupational therapist vacancy.

During January 2017 there had been high levels of staff sickness (due to work
related injuries), although this had improved by the time of our inspection.
However, because of the vacancies and sickness levels there was a reliance
on bank and agency staff to fulfil the staffing requirements. Whilst there was
an attempt to source regular bank and agency workers, this was not always
possible. Therefore there was an inconsistent workforce at Ty Llidiard which

22
impacts on the ability of the service to provide continuity of care and the
quality of recordkeeping.

Improvement needed

The health board must address the recruitment to the vacant posts at Ty
Llidiard

Due to the pressures of providing staff for the wards, we were informed that
staff were having difficulty in completing mandatory and additional training.

It was positive to note that during our inspection a selection of staff were at Ty
Llidiard to undertake Restrictive Physical Intervention (RPI) training. We also
saw that there were high compliance rates for child protection, food hygiene,
manual handling and fire training. However, there were significant shortfalls in
infection control, Mental Health Act and Mental Capacity Act.

Improvement needed

The health board must ensure that all staff complete their mandatory
training and associated update training.

We saw that some members of staff had completed additional training to help
support and care for patients. These courses included: Maudsley training for
Eating Disorders, Meal Support, NG feeding, Suicide and Self Harm
Reduction and Internet Addiction training. However, these courses had been
completed prior to 2016 and staff confirmed that recently they have had little
opportunity to complete similar training opportunities.

Improvement needed

The health board must support staff in completing additional training

which would help staff support and care for patients at Ty Llidiard.

23
5. Next steps

This inspection has resulted in the need for the health board to complete an
improvement plan (Appendix A) to address the key findings from the
inspection.

The improvement plan should clearly state when and how the findings
identified at Ty Llidiard will be addressed, including timescales.

The action(s) taken by the service in response to the issues identified within
the improvement plan need to be specific, measureable, achievable, realistic
and timed. Overall, the plan should be detailed enough to provide HIW with
sufficient assurance concerning the matters therein.

Where actions within the service improvement plan remain outstanding and/or
in progress, the service should provide HIW with updates to confirm when
these have been addressed.

The improvement plan, once agreed, will be evaluated and published on

HIW’s website.

24
6. Methodology

The Health and Care Standards (see figure 1) are at the core of HIW’s
approach to inspections in NHS Wales. The seven themes are intended to
work together. Collectively they describe how a service provides high quality,
safe and reliable care centred on the person. The Standards are key to the
judgements that we make about the quality, safety and effectiveness of
services provided to patients.

Where appropriate, HIW inspections of mental health services consider how

services comply with the Mental Health Act 1983, Mental Capacity Act and
Deprivation of Liberty Safeguards.

Figure 1: Health and Care Standards 2015

Mental health service inspections are unannounced and we inspect and report
against three themes:

 Quality of the patient experience: We speak to patients (adults

and children), their relatives, representatives and/or advocates to
ensure that the patients’ perspective is at the centre of our
approach to how we inspect

25
  Delivery of safe and effective care: We consider the extent to
which services provide high quality, safe and reliable care centred
on the person

 Quality of management and leadership: We consider how

services are managed and led and whether the culture is conducive
to providing safe and effective care. We also consider how
services review and monitor their own performance against
relevant standards and guidance.

We reviewed documentation and information from a number of sources

including:

 Information held by HIW

 Conversations with patients and interviews with staff

 General observation of the environment of care and care practice

 Discussions with senior management within the directorate

 Examination of a sample of patient medical records

 Scrutiny of particular policies and procedures which underpin

patient care

 Consideration of quality improvement processes, activities and

programmes.

HIW inspections capture a snapshot of the standards of care patients receive.

They may also point to wider issues associated with the quality, safety and
effectiveness of healthcare provided and the way which service delivery
upholds essential care and dignity.

We provide an overview of our main findings to representatives of the service

at the feedback meeting held at the end of each of our inspections.

Any urgent concerns emerging from these inspections are brought to the
attention of the service via an immediate action letter. These findings (where
they apply) are detailed within Appendix A of the inspection report.

26
 Appendix A

Mental Health Service: Improvement Plan

Service: Ty Llidiard Child & Adolescent Mental Health Service (CAMHS)

Date of Inspection: 26 – 28 March 2017

Page Improvement Needed Standard Service Action Responsible Timescale

Number Officer

Quality of the patient experience

6 The health board must clean the 4.1 Job logged with Estates Department Sam Stroud 31 July 17
glass entrance canopy at Ty Llidiard. 5/4/17 and House Keeping & Nigel
Manager. Awaiting date of work. Llewellyn
Reminders sent on a regular basis. (ABMU
House
Keeping)
6 The health board must ensure 4.1 Job logged with Estates 5/4/17 and Sam Stroud 31 July 17
windows at Ty Llidiard are regularly established way of cleaning & Nigel
cleaned including behind mesh specialised windows. Information Llewellyn
screens. shared with House Keeping (ABMU
Manager responsible for window House
cleaning contract. Awaiting date of Keeping)
work. Reminders sent. Bi-monthly
meetings arranged with House
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Keeping Manager.

6 The health board must undertake 4.1 Daily check lists introduced to be Nursing Staff, Feedback
regular environmental maintenance undertaken by ward staff. Many Ward given to
audits to identify and rectify damage issues reported to Estates and Managers staff and
to the environment at Ty Llidiard. House Keeping. Reviewing and Locality refreshed
progress on a daily basis. All staff Manager approach
reminded to report issues when now
identified. Locality Manager and ongoing and
Ward Manger have undertaken monitored
environmental checks and will regularly
continue to on a monthly basis.
6 The health board must repair the 4.1 The damage has been reported to Locality 31 July 17
damage to the corridor floor on Enfys Estates where they have made the Manager and
Ward. temporary repair. We have asked Estates
Estates to provide a quote for repair. Manager
Awaiting costings.
6 The health board must ensure that 4.1 Request made to administrator Locality 31 July 17
staff can cover status at a glance responsible for ordering stock. Manager &
boards when not in use. Surveyor invited to give quote on admin
11/5/17, awaiting up-date, reminder
sent 9/6/17. Once quote received
and administrator to enter to
procurement system for
authorisation.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
7 The health board must ensure that 4.1 Request made to Estates for the Sam Stroud Locality
regular garden maintenance is gardens to be tidied up, which was & Estates Manager
undertaken. completed on 21/4/17. Request given
made to Estates Manager for feedback
confirmation on regularity of garden and
contract. Awaiting response. Bi- refreshed
monthly meetings arranged with approach
Estates Managers. now
ongoing and
monitored
regularly
7 The health board must review the 4.1 Room made safe by altering lock Sam Stroud Completed
cinema room to ensure that it is and vision window. Room usable. May 2017
operational and safe for patient use.
7 The health board must repair the pool 4.1 Requested quote for repair to Sam Stroud 31 July 17
table cloth. administrator responsible for & Darren
procurement. Once quote received Rees
to be submitted to Senior
Management Team for approval.
8 The health board must ensure that 4.1 Included in daily environmental audit Ward Completed
damaged items are removed from the checks and staff reminded of Managers May 2017
hospital. procedure.
8 The health board must ensure that 4.1 Logged with Estates on 5/4/17 Sam Stroud Partly
the damaged soap dispenser and & Estates completed
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
paper towel dispenser are repaired. on check
undertaken
13 June 17
additional
call logged
13 June 17
10 The health board must engage with 5.1 This can be measured by the Chrystelle Clinical
relevant partners to review the number of patients referred out of Walters & Dr Lead and
CAMHS provision in South Wales to area due to no bed availability. This Darwish Senior
ensure there is sufficient capacity to is a very rare occurrence and has Nurse given
provide timely access to care within happened once in the last three feedback
their local service. years due to bed blocking by a and
patient who did not fall into Ty refreshed
Llidiards criteria. approach
ongoing
with
partners

Delivery of safe and effective care

12 The health board must provide staff Application of Mental Health Act Administrator has Mental Health 31 July 17
with training in the administration of the Mental been requested to provide the Act
the Mental Health Act. Health Act relevant training. Meeting arranged Administrator
for 24th May 2016.
During the meeting it was agreed
that the Mental Health Act
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Administrator will deliver some
training, dates are to be confirmed
by the administrator.
13 The health board must ensure that Ty Application of Localities Manager to identify if Sam Stroud 31 July 17
Llidiard has sufficient administrative the Mental there is sufficient admin time to & Mental
support to ensure that statutory Health Act provide this support. Capacity Health Act
documentation is appropriately filed. available within current Administrator
administration team. Discussed
with Mental Health Act Administrator
24/5/16 where she will deliver
training to administration staff. Also
discussed use of separate files for
statutory documentation, awaiting
sample file from Mental Health Act
Administrator reminder sent 9/6/17
13 The health board must ensure there Application of The Unit now holds 5 hardback Rebecca Completed
is sufficient copies of the Code in the Mental copies, 2 of which are in Welsh. James April 2017
English and Welsh so that staff, Health Act There is a copy of the English and
patients and relatives can review a Welsh version on both wards and
copy as and when required. one kept in the Ward Managers
Office. The document is also
available in the Mental Health Act
folder stored on the Q drive.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
13 The health board must ensure that Monitoring Patients unmet needs are discussed Rebecca
patient’s unmet needs are recorded in the Mental on admission and in Ward Round. James /
their Care and Treatment Plan. Health Unmet needs are documented in Sharon
(Wales) CTP. Howatson
Measure Unmet needs need to be clear in the
2010 CTP on admission.
There are a large amount of patients
being admitted without a CTP in
place. In-patient staff then take on
the responsibility of completing the
CTP but it is difficult to capture the
unmet need evident in the
community.
Senior Nurse to speak with SMT 30 June 17
Chrystelle
regarding a procedure around this Walters
14 The health board must ensure that 2.1 Daily system put in place to ensure Senior Staff Completed
objects that can be used to harm are that Senior Staff Nurses are doing a Nurses May 2017
not left in patient areas. regular check of the environment.
This will be communicated on
induction.
Ward Manager to do a monthly walk Rebecca Completed
around. This will aim to address James and on-
any areas of risk. This will be going
Sharon
discussed in Nurses Meeting. Howatson
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Removing objects will need to be Staff have
balanced with patients needs and been given
requirements to lead a normal life. feedback
There is a clear procedure indicating and this will
what can and cannot be brought be
onto the unit. monitored
regularly
against
agreed
procedures
14 The health board must induct all bank 2.1 Bank and Agency Induction is in Rebecca Completed
and agency staff working at Ty situ. Ward Manager is presently James/ May 2017
Llidiard to ensure that they are revising the Induction packs for all Sharon
familiar with the environment and day staff, including bank and agency Howatson
to day running of the ward. and kept on the ward.
B6 nurses understand their role to Completed
Rebecca
ensure that bank and agency May 2017
James/
inductions take place. This is part of
induction and on-going changes will Sharon
be communicated via Nurses Howatson
Meeting and line management.
Ward Managers do weekly checks Ward Ward
of induction paperwork which will be managers Managers
cross referenced with the off duty. given
Any induction concerns will be feedback
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
addressed accordingly. and
refreshed
approach
now
ongoing and
monitored
regularly
15 The health board must ensure that 2.1 On-call staff are expected to be SMT Completed
on-call staff are available to ward staff available to ward staff when carrying May 2017
when required. out this duty. There will be times
whereby a call cannot be taken and
a message will need to be left
requesting a call back e.g on call
member of staff could be driving.
15 The health board must ensure that all 2.1 The ligature cutters are affixed to Rebecca Completed
staff know where ligature cutters are the wall in both nursing offices. James/ May 2017
located at Ty Llidiard. Sharon
Both are out of sight of young
Howatson
people. All nursing staff are
informed of this on induction. This
has also been conveyed to staff in
nurses meeting.
15 The health board must ensure that 2.1 Shift co-ordinators are responsible Shift Co- Completed
staff complete patient observation for carrying out/delegating ordinators April 2017
records as and when required. appropriate nursing observations and on-
and completing paperwork (Always going
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
a qualified Band 5 or 6 Nurse).
This procedure is included on
induction.
Rebecca
Non-compliance should be James/
managed by the Ward Manager.
Sharon
On-going non compliance to be Howatson
escalated to the Senior Nurse.
Ward Managers are required to
undertake weekly spot checks of
observation records and address
any staff concerns accordingly.
16 The health board must ensure the full 2.1 Ward Managers to inform all staff of Rebecca Completed
name of the staff member responsible this requirement. Staff to be James/ April 2017
for completing patient observation informed via line management and Sharon
records is recorded on the associated nurses meeting. Howatson
form.
All staff to be given and sign that
they have read the All Wales Prior
Observation Policy which is 31 July 17
currently under review and awaiting
Governance approval.
Completed
Ward Managers are required to April 2017
undertake weekly spot checks of and on-
observation records and address going
any staff concerns accordingly.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
17 The health board must ensure that 2.5 Ty-Llidiard do not have a high Rebecca Senior
there are sufficiently trained staff number of YP requiring NG feeding James/ Nurse and
experienced in providing nasogastric and as such maintaining Ward
Sharon
(NG) feeding at Ty Llidiard. competence proves to be very Managers
Howatson
difficult. given
feedback
Benchmarking with other like for like
and this will
general CAMHS providers have
be
communicated the same difficulties
monitored
and many units do not accept young
regularly
people with NG tubes.
Previously the Health Board did not
routinely provide training in this
area. We are now aware that this is
included in the graduate nurse
programme 2017. General Nurses
are trained via their nurse training.
The competency requirements
indicate that each staff member
needs to observe sighting and then
practice sighting under supervision
on 3 occasions to receive
competence.
Staff have in the past received
training in this way. However, staff
trained on induction are often not
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
required to carry out this procedure
regularly and report that even
though they have had the training
they do not feel competent, given
the time lapse between training and
practice.
A dummy to train staff on NG
feeding has been ordered (now
delivered) to promote regular
practice. Receipt of this will also
support maintaining staff
competence.
Please see below for further details
on delivery of training.
If a patient should require NG Tube
Chrystelle
and there is nobody trained to do
Walters
this on duty, the patient should be
risk assessed and accompanied to
the paediatric ward for sighting if
safe to do so. Ward managers will
monitor compliance with care-plans.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
17 The health board must ensure that 2.5 Awaiting delivery of a dummy to Sam Stroud Completed
there are suitable arrangements in ensure that staff remain competent May 2017
place for staff at Ty Llidiard to to pass NG Tube.
maintain their NG feeding skills. Chrystelle
Meet with SMT to discuss training Walters 30 June 17
arrangements in place and
reassurance that this will be Dr Darwish
adequate to ensure staffs
competency.
Newly qualified nurses are given
Ward 30 June 17
opportunity to attend a graduate
Managers
programme which includes NG
siting. We are exploring whether
the UHB can support us with further
training.
17 The health board must ensure that all 2.5 All staff in Ty-Llidiard understand Ahmed April 2017
staff know the correct procedures that a young person’s care plan Darwish/
regarding administering NG feeding should be followed as indicated by Peter Halford/
to non-compliant patients. the MDT. All care plans are Chrystelle
individual. Walters
All concerns regarding non-
compliance are discussed daily
(Monday-Friday) at MDT level and
decisions are made regarding
detention for treatment if indicated
as necessary.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Young people who are non- Ward 22 Aug 17
compliant with NG feeding are likely Managers
to be physically resistive to feeding.
All staff in Ty-Llidiard are trained in
de-escalation and RPI.
Where Ty-Llidiard staff are unable to
safely sight an NG tube difficulties
may arise as paediatric staff are
unable to assist in sighting an NG
tube to someone who is under
restraint.
Ty-Llidiard monitor the physical well-
being of patients at all times. In the
event of a young person becoming
physically compromised Ty-Llidiard
would seek immediate medical
advice.
Some young people may exceed
the remits of a General CAMHS
unit. Such cases would prompt
referral for more specialist care.
This can be evidenced in our Eating
Disorder protocol and we are
developing a NG feeding protocol
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
18 The health board must ensure staff 2.6 Ward Managers are required to Rebecca Ward
complete Medication Admission undertake weekly spot checks of James/ Managers
Records (MAR Charts). MAR Charts and address any staff given
Sharon
concerns accordingly. feedback
Howatson
and
Medication policy is part of qualified
refreshed
staff induction.
approach
now
ongoing and
monitored
regularly
18 The health board must ensure the 2.6 Ward Managers are required to Dr A Darwish Clinical
patients legal statuses are written undertake weekly spot checks of Lead given
clearly on MAR Charts. MAR Charts and address any staff feedback
concerns accordingly. and
refreshed
Expectations to be communicated to
approach
all medical staff commencing work
now
at Ty Llidiard.
ongoing and
monitored
regularly
18 The health board must ensure that 2.6 Weekly audit sheet to be compiled Rebecca May 2017
there is a regular audit of medication and completed every Sunday night James/
to prevent clinic rooms holding out-of- by Senior Staff Nurse on duty. Sharon
date stock. Howatson
All out of date stock to be disposed
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
of as per procedure. May 2017
Ward managers to do monthly
checks of compliance.
18 The health board must ensure that all 2.6 Rapid Tranquilisation procedure is Rebecca Completed
relevant (medication) policies are up in situ, up to date and located in James/
to date and available to staff in each both clinics. There is also an Sharon
clinic room. electronic version stored on the Q Howatson
drive. This is communicated to
staff on induction
Chrystelle Completed
Health Board policy on Medication 13 June 17
Walters /
Administration is available to all staff Rebecca
and part of induction. James
19 The health board must ensure that all 2.7 All staff are booked on training on Rebecca 30 June 17
staff complete relevant Child induction and when required James/Sharo for up-date
Protection training. following this. n Howatson/ then
ongoing and
Staff training log in situ, locality Senior Staff
monitored
manager sends regular emails to Nurses.
regularly
managers when updates are due.
Ward pressures do on occasions
prevent staff from attending booked
training but this is always
rescheduled.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Compliance checks to be Ward
undertaken on a monthly basis. Managers &
Locality
Manager
19 The health board must ensure there 2.9 The item that was noted by the Rebecca May 2017
are appropriate audit systems in inspection team was left from ABMU James/
place and completed to identify and who previously supplied Ty-Llidiard Sharon
replace any missing or out-of-date with the crash trolley; the item out of Howatson
clinical equipment. date has been disposed of.
Ty-Llidiard now use the grab bags
supplied by the health board, an
audit is in place for all crash
equipment.
Monthly audit in place to ensure that
equipment is in date.
20 The health board must establish 3.5 Ward Managers to compile checklist Rebecca 30 June 17
appropriate systems to ensure that based on best practice guidelines. James/
staff complete and maintain records Sharon
Medical Sectaries to ensure that all
to a high professional standard. Howatson
new case notes has a copy of the
checklist affixed to the inside of
each patient file. Sam Stroud
Ward managers to do monthly spot
checks of a random selection of
files.
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
Discuss in POG 27/06/17
20 The health board must review the 3.5 Admin support systems to be Chrystelle June 2017
administrative support arrangements reviewed. There is no extra funding Walters
for Ty Llidiard. for this. This will need to be
escalated to SMT.

Quality of management and leadership

22 The health board must ensure that Part 2 - There is a lead for audit identified on Dr Peter Leads for
there are robust audit and Governance, the unit. Halford, audit and
governance arrangements in place at leadership governance
There are meetings and a structure
Ty Llidiard to ensure the delivery of and given
in place for staff to communicate
safe and effective care. accountability Chrystelle feedback
effectively and escalate matters.
Walters and
Governance meetings occur bi- arrangemen
monthly. ts will be
monitored
regularly
23 The health board must address the 7.1 All present vacancy requisitions SMT The SMT
recruitment to the vacant posts at Ty have been submitted. All posts are with HR are
Llidiard. signed off by SMT in a timely working on
manner recruitment
strategies
There is a large turnover of staff due
on an
to vast community developments.
ongoing
Some higher banded posts are basis
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
more difficult to fill.
Recruitment process is lengthy
resulting in vacant posts for long
periods.
23 The health board must ensure that all 7.1 Staff training log in situ, locality Rebecca All
staff complete their mandatory manager sends regular emails to James Managers
training and associated update managers when updates are due. given
training. feedback
Ward pressures do on occasions Sharon and
prevent staff from attending booked Howatson refreshed
training but this is always
approach
rescheduled.
now
Some mandatory training is via ESR Sam Stroud, ongoing and
and nurses are given time to Rebecca monitored
complete this. This is audited James & through
monthly to ensure compliance. Also Sharon action plan
monitored by Senior Management Howatson review
Team
23 The health board must support staff 7.1 Staff are encouraged to apply for Rebecca May 2017
in completing additional training training that will help them in their James/
which would help staff support and role on the unit. Sharon
care for patients at Ty Llidiard. Howatson
All training opportunities are sent by
the locality manager to the nursing
team. Line managers make every
effort to support staff in training
Page Improvement Needed Standard Service Action Responsible Timescale
Number Officer
opportunities.
There has recently been investment
to train Ty Llidiard staff in Dialectical
Behaviour Therapy (DBT) and
Triangle of Care. There is further
agreement for investment in Non-
Violent Resistance (NVR) training
due to commence August 2017.

Service representative:

Name (print): ................................................................................................

Title: ................................................................................................

Date: ................................................................................................