A REPORT into the Heddfan Psychiatric Unit at the Maelor Hospital in Wrexham found that 'key improvements' were required. 

Healthcare Inspectorate Wales (HIW) has issued a report today (February 9) into the findings from its inspection of Heddfan Psychiatric Unit, situated at Wrexham Maelor Hospital.

HIW completed an unannounced independent inspection of the hospital on three consecutive days in November last year.

During this period, a number of assessment areas were inspected on the Gwanwyn and Hydref Wards. Both wards accommodate up to 14 patients each and provide a comprehensive range of acute health services, including older persons and psychiatric intensive care.


The report states that staff within the unit were found to be committed to providing safe and effective care, and suitable protocols were generally in place to manage risk, health and safety and infection control.

However, it added that key improvements were required in relation to staff restraint training, medication management and conducting regular audits.

Inspectors say they observed a committed team of staff who had a good understanding of the needs of the patients and were dedicated to providing a high standard of care.

The staff were also passionate about their roles and treated patients with dignity and respect.

The onsite inspection identified that improvements were needed to ensure the activity rooms on both wards were tidied and maintained by staff, temperature control measures were in place, and broken facilities were repaired or replaced.

It was also noted that the facilities for maintaining patient privacy and dignity are to be improved in bedrooms and in shower rooms.

Inspectors were generally assured that processes were in place to manage and review risks to help maintain the health and safety of patients, staff and visitors. 

Some improvements were required in respect of governance, record keeping and medications management. 

HiW say that during the inspection it was concerning to note that the monthly ligature audit workbook had not been completed since February 2022, which could threaten patient safety.

They advised that regular audits must be undertaken to monitor medicine management, security risks and the maintenance of clinic rooms on the wards.

Inspectors said they saw evidence of good collaborative working across the health board to support improvements and learning.

Although they also found that some staff did not have adequate levels of restraint training yet had participated in such incidents. Therefore, they were not assured that staff and patients were being fully protected and safeguarded against injury.

HiW's concerns regarding this were dealt with under their immediate assurance process which requires urgent action be taken in order to keep patients safe.

Inspectors noted that there were a high number of vacancies on both wards at the time of our inspection, with staff telling the inspectors they felt there were not enough staff to enable them to do their job properly.

Senior management confirmed that maintaining adequate staffing levels was challenging, and they relied on agency staff to reduce staffing pressures.

Chief Executive of HIW, Alun Jones said: "It is positive to see the dedication of staff in delivering high standards of care at the Heddfan Unit.

"Our inspection identified improvements which required immediate resolution.

"The health board has produced a comprehensive plan which sets out improvement actions against the other recommendations we made as a result of our inspection.

"HIW will work with the health board to continue to closely monitor progress against this plan."

Becky Baker, Head of Operations and Service Delivery for Mental Health services in the East of BCUHB, said: “We’re pleased that the inspection team noted the commitment of all staff to provide a high standard of care, with patients treated with the dignity and respect they deserve, supported by a leadership team who have a good understanding of patient needs.

“We have taken decisive action to address the improvement areas identified in the inspection report, as part of a comprehensive action plan which we have developed with HIW. This includes a commitment for all patient facing staff to be fully compliant with restraint training by May 2023. It was necessary to stand down this training during the COVID-19 pandemic. However, during this period, we put in place measures to mitigate the risk to both patients and staff. These measures have been strengthened further following this inspection.”