Healthcare Improvement Scotland (HIS) carried out an inspection of acute inpatient services in August and have now published their report.
The evaluation covered five wards and involved interviews with staff and patients, as well as a review of relevant policies and procedures.
“Significant concerns” were raised about inadequate adult support and protection measures, particularly around sexual safety, as well as issues with governance, patient safety and staff training.
Donna Maclean, chief inspector at HIS, said: “During our inspection, we saw staff treating patients with care and compassion.
“Mealtimes were well organised and patients were offered a choice of meals.
“However, areas for improvement include ligature assessments were inconsistently completed and did not align with NHS Forth Valley’s own ligature risk assessment policy.
“The healthcare environment was variable with some areas in a poor state of repair.
“Improvements are required in the oversight of patient and staff safety incidents, including delays in reviews of adverse events.
“We also observed the impact of low staffing levels on staff training and supervision with low rates of basic life support training and child protection training.”
The inspection identified eight areas of good practice, one recommendation, and 19 requirements for improvement.
Eddie Docherty, director of quality assurance and regulation at HIS, added: “Our previous mental health inspection programme was focused on infection prevention and control.
“It was agreed with Scottish Government to widen the inspection focus from infection prevention and control to a broader assurance function, creating a new and revised ‘safe delivery of care’ assurance model in NHS adult mental health units.
“We believe it is important to provide public assurance that adult mental health units in Scotland are safe for patients and staff, provide quality person-centred care, with clear leadership and a focus on improvement.”
NHS Forth Valley has developed an action plan to address the findings.
Prof Karen Goudie, executive nurse director at the health board, said: “The inspectors observed local staff treating patients with care and compassion and ward areas which were calm and well organised. They also observed good practice in the care of people with dementia, activity programmes, patient involvement and learning from incidents.
“However, we fully accept that further improvements are required and a number of immediate actions were taken to respond to issues raised at the time of the inspection visit in August 2025. This included changes to improve patient safety and reduce potential risks, both within the Unit and its surrounding external areas.
“Training compliance has improved in the acute mental health unit over the last six months since the inspection took place and we have also successfully recruited more than 30 mental health nursing graduates to support mental health services across the organisation.
“Work is underway to address all of the recommendations and requirements outlined in the report and we will closely monitor progress to ensure improvements are delivered and maintained.”