Healthcare Inspectorate Wales said some patient-safety concerns at the Royal Glamorgan Hospital had previously been raised in 2023 but had not been properly resolved
SERIOUS and longstanding safety concerns, including unresolved ligature risks, mould, damaged facilities and extremely low staff training levels, have been uncovered on mental health wards at a Welsh hospital.
Healthcare Inspectorate Wales carried out an unannounced inspection of Ward 21, Ward 22 and the Psychiatric Intensive Care Unit at the Royal Glamorgan Hospital, Llantrisant, between April 13 and 15.
Inspectors used their immediate assurance process after identifying significant concerns involving the ward environment, infection control, staff training and the management of patient-safety risks.
The report identified damaged furniture, fixtures and fittings, broken doors and locks, non-functioning lighting, water damage, mould and bathrooms which were unsuitable or out of use.
On Ward 21, inspectors found missing and water-damaged ceiling tiles, damaged walls and flooring, faulty equipment and a smashed nursing office window.
Lighting was not working in parts of the ward, including a kitchen and patient bedroom, with staff reporting that mobile phone torches had been used while providing care.
A communal male bathroom had also been out of use for a prolonged period, resulting in male patients having to use female facilities.
On Ward 22, mould and damp which had reportedly been logged as a serious health and infection-control risk in September 2025 remained an issue at the time of the inspection.
Inspectors also found an unlocked ward area which could allow patients to access potentially dangerous items. Records showed the matter had been logged in September and escalated repeatedly during October, November and December.
Within the Psychiatric Intensive Care Unit, inspectors identified longstanding ligature risks, mouldy shower-tray sealant in every en-suite bedroom, structural damage and a missing cupboard door in a sluice room.
HIW said the mental health inpatient environment had remained on the health board’s risk register since 2018, indicating a “long-standing and unresolved risk”.
Estates records examined by inspectors contained multiple urgent and high-risk maintenance issues dating back to December 2024. Staff said the estates service was severely understaffed and that, from autumn 2025, work had largely been limited to urgent or mandatory repairs.
Training compliance as low as 10%
The inspection also uncovered very low compliance with training considered essential for responding to medical emergencies, violence, restraint and rapid tranquillisation.
Only 10% of staff in the Psychiatric Intensive Care Unit were compliant with Immediate Life Support training. Basic Life Support compliance was 50%, while fire-safety training compliance stood at 44%.
On Ward 21, Immediate Life Support compliance was 24% and rapid-tranquillisation training stood at 50%.
Ward 22 recorded 35% compliance for Basic Life Support, 39% for violence and aggression training and 57% for rapid tranquillisation.
Inspectors were told that 38 patient restraints had taken place in the mental health unit during the previous 12 months. However, staff could not confirm whether any of those restraints had involved employees who were untrained or whose training had expired.
No staff had completed competency-based training in the safe use of portable oxygen cylinders.
HIW said similar concerns about low training compliance had been raised as an immediate patient-safety issue following its November 2023 inspection.
The latest report said this demonstrated a failure to implement the previous improvement plan and carry out actions agreed by health board management.
Frontline staff praised
Despite its concerns, HIW praised the compassion and professionalism of frontline workers.
Inspectors observed staff treating patients with kindness, dignity and respect, while six of the seven patients who completed questionnaires rated their care as good or very good.
Care and Treatment Plans were comprehensive and regularly reviewed, safeguarding arrangements were clear and patients were generally involved in decisions about their care.
However, patients described limited access to outdoor space and therapeutic activities, problems with washing facilities and shortages of basic equipment.
There was no structured programme of therapeutic activities across the three wards, the activities coordinator position was vacant and there was no dedicated occupational therapist for patients in the intensive care unit.
Patients on Wards 21 and 22 also relied on an external laundry service which could cost £25 for each bag. Inspectors were told ward pressures sometimes delayed collections by another week, increasing costs and leaving patients waiting for clean clothes.
Wards 21 and 22 continued to provide mixed-sex accommodation and shared bedrooms without separate communal areas, which inspectors said affected privacy, safety and dignity.
On Ward 22, confidential patient information was visible from outside the nursing office.
Health board identifies 167 maintenance issues
The health board’s immediate improvement plan, published alongside the report, said 167 maintenance issues had been identified across the three wards following a comprehensive review.
It said remedial work began on April 17 and that male and female bathrooms had been returned to use by April 23. Curtains were replaced where required, hand-soap dispensers were ordered and new monitoring arrangements were introduced.
The health board also said training had been arranged with the aim of reaching 85% compliance in key areas. Some actions were marked as completed, while others, including a review of estates resources and capacity, were due to continue until the end of July.
HIW chief executive Alun Jones said direct care was being delivered compassionately but the health board had failed to sustain earlier improvements.
HIW said it would continue monitoring the health board to ensure the required improvements were completed and maintained.
Natasha Asghar MS, the Welsh Conservatives’ Shadow Minister for Health and Social Care, said: “It is deeply concerning that Healthcare Inspectorate Wales has identified such serious shortcomings in mental health services, particularly when many of these issues were raised during a previous inspection three years ago.
“While the report rightly praises the compassion and professionalism of frontline staff, it is unacceptable that they are having to provide care in these circumstances.
“Ministers must ensure that the resources, leadership and oversight are in place as a matter of urgency to deliver necessary improvements at the Royal Glamorgan Hospital and in mental health services across Wales.”
