Care praised but further improvements require attention at a specialist mental health unit in Cardiff
Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of Hafan y Coed Mental Health Unit at University Hospital Llandough, run by Cardiff and Vale University Health Board over three consecutive days in April 2025.
The inspection focused on Maple Ward, which provides secure mental health services for adult men who have committed a serious crime or are at risk of harm to others and have a serious and enduring mental illness.
Inspectors observed several positive aspects of patient care and experience. Staff consistently treated patients with kindness and respect, providing personalised care. The ward was calm and supportive, with each patient having access to an ensuite bedroom and benefiting from a wide range of therapeutic activities. Staff actively promoted patient rights, and compliance with training in equality, diversity, and human rights was high. Clear, accessible information helped patients and families better understand the care provided. It was also positive to note the presence of Welsh-speaking staff and multi-faith facilities, which supported an inclusive and respectful environment.
However, some areas require improvement, including infection control and health and safety concerns. Issues raised in HIW’s 2020 inspection remain unresolved, such as bedrooms without emergency call points and a shortage of personal alarms. Additionally, mirrors to remove blind spots in communal corridors have still not been installed, leaving ongoing safety risks. Maintenance and cleanliness problems, such as water damage, broken fixtures, clutter, and hygiene risks were identified. Cleaning responsibilities between ward and housekeeping staff were unclear, and audit documentation did not accurately reflect the ward’s condition.
Inspectors found there were clear systems and checks in place supporting safe and effective care, with risk management procedures and audits. However, certain issues, including delays in fire risk mitigation and the overdue review of health board policies, highlighted gaps in implementation and oversight. Staff understood restrictive practices and used them appropriately. However, Positive Behaviour Support plans had not been implemented consistently, and several specialist risk assessments were overdue due to staffing pressures and training gaps.
Care planning met national standards and was well recorded, but there was limited involvement from advocacy services. While overall compliance was good, more consistent advocacy and patient involvement in decisions are needed.
The ward had a stable, skilled workforce with high staff retention and strong leadership, and staff supervision, appraisals, and feedback systems supported ongoing improvements. However, compliance with some key training, such as Fire Safety, Information Governance, Consent, and Duty of Candour was overdue or incomplete. Staff also raised concerns about limited senior management visibility and communication challenges with them, affecting morale.
Alun Jones, Chief Executive of Healthcare Inspectorate Wales, said:
We observed many examples of dedicated care at Hafan y Coed Mental Health Unit, where staff showed clear commitment to supporting patients with empathy and professionalism. However, it is concerning that some safety and environmental issues identified in previous inspections remain unresolved. These must now be addressed as a priority. We will continue to work closely with the health board to ensure sustained progress as part of their ongoing improvement efforts.