The Trusted To Care review was held after concerns at Neath Port Talbot Hospital and the Princess of Wales Hospital in south Wales.
It followed the neglect of patient Lilian Williams, 82, who died after being treated at both hospitals.
Her family complained and it led to the review, they are now calling for a public inquiry.
Mrs Williams, from Porthcawl, had been admitted to both hospitals a total of four times between August 2010 and November 2012, when she died.
The ombudsman who investigated her family’s complaint was highly critical of her care, and called the case tragic.
Abertawe Bro Morgannwg University (ABMU) Health Board subsequently apologised and admitted the case had been “completely unacceptable”.
Since then, campaigners have called for a public review and the resignation of the board’s chief executive. They claim “hundreds” of examples of poor care have come to light.
A review was ordered by Health Minister Mark Drakeford into levels of care offered by both hospitals.
It catalogued a series of failings at the two hospitals, describing “a sense of hopelessness” in its care for frail and elderly patients. It found “poor professional behaviour” and a “lack of suitably qualified, educated and motivated staff.” One patient told the review team: “I am in Hell.”
Others said elderly patients were instructed to go to the toilet in their beds, medicines had been recorded as given when they were not, and staff tolerated dangerous practice.
The report also found there was:
- Variable or poor professional behaviour and practice in the care of frail older people
- Deficiencies in elements of a culture of care based on proper respect and involvement of patients and relatives
- Unacceptable limitations in essential 24/7 services leading to unnecessary delay to treatment and care
- Lack of suitably qualified, educated and motivated staff particularly at night
- Adversarial and slow complaints management
- Disconnection between front-line staff and managers and confusion over leadership responsibilities and accountabilities
- Problems with organisational strategies on quality and patient safety, capacity development and workforce planning
- The report also says some staff felt ill equipped to meet the needs of patients with dementia
The report said: “There are aspects of the care of frail older people which are simply unacceptable and must be addressed as a matter of urgency.
“ABMU has not at any point been ‘another Stafford’. But no one should be in any doubt that there are aspects of the care of frail older people which are simply unacceptable and must be addressed as a matter of urgency through action by the Board of ABMU and by the Welsh government.”
Health Minister Mark Drakeford apologised to those patients affected.
Too many checks are “planned” – they should all be spot and random – including educational ones