
Inspectors say they're concerned over safety and environmental issues on a mental health ward at Llandough Hospital.
Although care was praised, Healthcare Inspectorate Wales (HIW) called for health and safety issues, including infection control, to be "addressed as a priority".
The Cardiff and Vale University Health Board (CAVUHB) said it welcomed the findings.
Last October, health chiefs were told to make "immediate improvements" on two other wards at the mental health unit, after inspectors raised concern over patient restraint.
An unannounced three-day inspection took place in mid-April on the Maple ward, which treats adult males who have committed a serious crime or are at risk of harm others and have a serious and enduring mental illness.
In their summary, HIW noted that the ward was "calm and supportive" with staff consistently treating patients with "kindness and respect, providing personalised care."
Patient rights were "actively promoted" and "clear, accessible information" was provided to patients and families on the care provided. It also highlighted an "inclusive and respectful environment" which included Welsh-speaking staff and multi-faith facilities.
But the report goes onto highlight areas requiring improvement - including bedrooms without emergency call points and a lack of personal alarms, which were both raised during the last inspection five years ago.
They add: "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 also noted there were "delays in fire risk mitigation and the overdue review of health board policies", highlighting gaps in implemenation and oversight.
Although there were clear systems and checks in place - and staff understood restrictive practices - plans for positive behaviour support "had not been implemented consistently, and several specialist risk assessments were overdue due to staffing pressures and training gaps."
Care planning was "well recorded" and met "national standards" but the report highlights "limited involvement from advocacy services" and called for patients to be more involved in decisions.
Staff had also raised their concerns about the limited visibility of senior management, with communication issues said to be affecting morale.
Although the workforce was described as "stable and skilled" with strong leadership, some compliance in key training areas such as consent, fire safety and duty of candour was either "overdue or incomplete".
Alun Jones, HIW chief executive, 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."
A CAVUHB spokesperson told Bro Radio News: "The inspectorate identified many examples of kind and compassionate care, with patients being treated with respect and dignity, demonstrating the health board's commitment to delivering high-quality care."
"The ward team have worked tirelessly to improve the clinical experience of service users in their care and this report is a testament of that."
"While HIW were clear that there were no issues requiring immediate assurance, any concerns identified by the Healthcare Inspectorate were either rectified immediately or a comprehensive action plan has been developed to address these issues going forward."
"Work is ongoing between colleagues on the ward, service users and their families to continually enhance the environment for service users and improve the experience."
"There were some issues that proceeded the report from a previous HIW inspection, and these are being addressed through the improvement plan."
"Many of the maintenance issues that were subsequently highlighted are more recent estate issues, which are currently being worked through with estates colleagues."
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