Inspectors raise serious safety concerns at Welsh mental health clinic

Amelia Jones

Inspectors have raised serious concerns at a Welsh clinic after finding long-standing safety and environmental problems remain unresolved during an unannounced visit.

The inspection was carried out over three days in October 2025 at  Tawe Clinic at Cefn Coed Hospital managed by Swansea University Health Board.

It focused on two wards providing mental health care for people admitted to hospital, Clyne Ward and Fendrod Ward.

Healthcare Inspectorate Wales (HIW) said the inspection identified issues that compromised patient safety and dignity, including inadequate laundry facilities, poor food provision and environmental damage that had been raised in previous inspections but not resolved.

Patients expressed frustration at having to wear unclean clothes, which undermined their hygiene and dignity.

Environmental issues first raised in 2019 and again in 2022 remained unresolved, with damaged flooring, mould, and a lack of outdoor spaces compromising safety and dignity.

Inspectors also raised immediate concern about shortages of essential keys, low compliance with Immediate Life Support training and the lack of a dedicated safe space for managing distressed patients, all of which required urgent assistance from the health board.

Despite these concerns, staff on both wards were praised for their kindness, professionalism and commitment to patient care.

The inspection found nursing and medical care was generally timely and compassionate, safeguarding arrangements were robust and medicine management was mostly safe.

Patients also benefitted from weekly advocacy services, tailored support for sensory impairments and access to private rooms they could personalise.

While overall compliance with the Mental Health Act was satisfactory, staff training was not mandatory and lacked a structured programme.

Immediate assurances were required to address a serious breach of the Mental Health Act after a patient missed a Hospital Managers’ Hearing. This was a breach of safeguards designed to protect patient rights and raised concerns about the lawfulness of their continued detention.

Inspectors noted that care lacked a clear, treatment-focused model, with limited psychological input and inconsistent activity schedules, leaving some patients feeling unstimulated during their admission.

The health board has provided HIW with immediate assurance on key safety issues and has developed a comprehensive improvement plan to address the findings.

Alun Jones, Chief Executive of Healthcare Inspectorate Wales, said: “Staff at Tawe Clinic are clearly committed to providing compassionate care under challenging circumstances, and we recognise the positive practices in safeguarding and teamwork.

“However, it is disappointing to see that some environmental risks and safety concerns first identified several years ago remain unresolved. These issues compromise patient dignity and safety and must be addressed without delay.

“Urgent action is needed to ensure that therapeutic care is strengthened and that the environment supports recovery. We will continue to monitor progress closely and expect the health board to deliver meaningful improvements.”