The Care Quality Commission (CQC) has upgraded the rating for wards for people with a learning disability or autism at Berkeley House run by Gloucestershire Health & Care NHS Foundation Trust from inadequate to requires improvement following an inspection in July 2025.
Berkeley House is a stand-alone unit for autistic people or people with a learning disability, who have been detained under the Mental Health Act 1983. Accommodation is arranged into seven individual flats. At the time of the inspection three of the flats were in use.
Inspectors found the service had improved in some areas. However, the trust remains in breach of regulations relating to safe care and treatment, premises and equipment, and good management.
Following significant concerns identified at a previous inspection, CQC imposed conditions on the service’s registration to safeguard people and ensure safe care and treatment. At this inspection, CQC found there had not been enough improvement to remove these conditions.
CQC has upgraded the ratings for safe and well-led from inadequate to requires improvement. Caring has been rerated as requires improvement. Effective has improved from requires improvement to good and responsive is rated as good.
Serena Coleman, CQC deputy director for mental health in the South West, said:
“When we inspected Berkeley House, we found some systems intended to protect people weren’t always working effectively. This meant that risks to people’s safety were not consistently identified or recorded, and safeguarding concerns weren’t always managed as robustly as they should’ve been.
“As a result, people didn’t always receive consistent, person-centred care. Relatives raised concerns about how well staff communicated with them and how incidents affecting their loved ones were explained. We also found some people spent extended periods in restrictive environments, with missed opportunities to support them through meaningful activities that reflected their individual interests and needs. For example, care records contained inconsistencies in how restrictive interventions were reported, and while staff told us one person had unrestricted access to the garden, the garden door was locked on the day of our inspection.
“However, we also saw areas of improvement since our previous inspection that had a positive impact on people’s care. Staff had significantly reduced the use of physical restraint by adopting de-escalation techniques, helping people to feel safer and more supported. The service had also worked closely with commissioners to support people to move on to more suitable accommodation, including thoughtful, personalised features such as a cycle track for someone who enjoyed cycling.
“We have been clear with the trust about where further improvements are still required. The conditions will remain in place, and we will continue to monitor the service closely to ensure people receive safe, compassionate and high-quality care.”
Inspectors found:
- Leaders didn’t ensure people lived in bungalows and flats that were maintained properly. CQC found exposed radiator heating elements and damage caused by previous occupants putting their safety at risk.
- Staff didn’t always record checks of people’s physical health when they harmed themselves or sustained head injuries.
- Staff did not consistently record people’s activity choices in care plans, which meant they could not always offer meaningful alternatives when someone refused a planned outing.
However, inspector also found:
- Staff worked closely with adult social care service that transitioned off the ward into, in order to plan smooth transitions, getting to know people's routines to ensure continuity of care.
- The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.
- Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes.
We will publish the Gloucestershire Health & Care NHS Foundation Trust report on our website in the coming days.