Inspection finds dedicated staff at Swansea mental health wards amid ongoing safety and dignity issues
Healthcare Inspectorate Wales (HIW) has published its inspection report following an unannounced visit to Tawe Clinic at Cefn Coed Hospital, managed by Swansea Bay University Health Board. The inspection was carried out over three days in October 2025 and focused on two wards providing mental health care for people admitted to hospital, Clyne Ward and Fendrod Ward.
Staff were praised for their kindness, professionalism, and commitment to patient care, and patients consistently reported feeling treated with dignity and respect. The inspection team observed positive practices including robust safeguarding arrangements, strong teamwork, and medicines management was generally safe. Nursing and medical care were generally timely and compassionate, and patients benefited from weekly advocacy services, tailored support for sensory impairments, and access to private rooms they could personalise.
Care plans and risk assessments were comprehensive and person-centred, ensuring patients’ individual needs were clearly documented and addressed. Inspectors found that patient records were well-organised and covered all key areas of a person’s life such as health, housing, education, work, social needs, and recovery goals, in line with the Mental Health Measure domains.
However, the inspection team highlighted that care provision lacked a clear, treatment-focused model, with limited psychological input and inconsistent activity schedules, leaving patients feeling unstimulated. Patients also raised concerns about poor food provision, describing meals as repetitive with limited healthy options, and reliance on personal funds for alternatives. Immediate assurance was required regarding laundry services, which inspectors found to be inadequate, with broken facilities on one ward and unreliable off-site arrangements on the other. 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 highlighted poor accessibility, including unsuitable bathrooms and outdoor areas for patients with mobility needs. The inspection team raised concerns about the lack of a dedicated safe space for managing distressed patients and workforce pressures affecting morale and skill mix. Inspectors were also informed of delays in arranging patient aftercare meetings due to local authority staffing shortages. Further immediate assurances were required regarding the shortage of essential keys which compromised timely access in emergencies, and low compliance with Immediate Life Support training posing risks to patient safety.
Despite the health board’s ongoing Mental Health Transformation Programme, which aims to improve mental health services, governance challenges were evident. Inspectors raised concerns about a backlog of incident reviews, outdated policies and staff reported a lack of clear guidance about the placement and support of transgender patients. Inspectors highlighted concerns about staff awareness of whistleblowing processes, as well as poor visibility of complaints and feedback mechanisms. Patients also had no way to raise concerns anonymously. 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.
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.