CQC rating for learning disability and autism ward at Berkeley House drops from good to inadequate following CQC inspection

Published: 1 March 2024 Page last updated: 1 March 2024

The Care Quality Commission (CQC) has dropped the rating for wards for people with a learning disability or autism at Berkeley House run by Gloucestershire Health & Care NHS Foundation Trust from good to inadequate following an inspection October.

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 six of the flats were in use. One person was under 18 and five were aged over 18.

As a result of concerns that were self-reported to CQC by the trust, CQC suspended Berkeley House’s ratings in October following the inspection. CQC can suspend ratings whilst investigating information of concern. This ensures that people looking for information about an organisation, can be confident that ratings are an up-to-date accurate reflection of the care being provided.

This inspection was carried out in response to those concerns around the care and safety provided to people at Berkeley House.

Following this inspection, the ratings for Berkeley House have now been unsuspended and updated. The overall rating for Berkeley House has dropped from good to inadequate as have the ratings for safe and well-led. Effective has dropped from outstanding to requires improvement and caring has dropped from good to requires improvement. This inspection didn’t rate how responsive the service was, so it remains as good from a previous inspection.

Catherine Campbell, CQC’s director of operations in the south, said:

“Berkeley House needs to be doing more to redesign their service to help people avoid long stays in hospital. Autistic people and people with a learning disability, should be supported to live as independently as possible, and follow their interests and goals to support them to move adapt back into the community and to independent living.  

“Staff didn’t always encourage people to engage in hobbies or interests due to perceived risks and we found no detail in care plans about what people liked to do or what their personal goals were. For example, one person had not undertaken any activity for 14 days while another had only had six activities in 31 days. There was no evidence within their records to provide any rationale for this.

“Helping or encouraging people to live in their own home in the community helps to bring independence for the person living there. However, we found that people didn’t always have clear plans, risk or psychological assessments in place to support and prepare them for this potential move. There was also no evidence that any information about these plans had been shared with family members.

“When we inspected the service, we also were very disappointed to find people being cared for in flats which were neither safe, clean, or well looked after. In fact, some flats needed major repairs with boarded up windows and doors. The areas did not always meet people’s sensory and physical needs, and some had very few personal effects around to make people feel more comfortable. This is unacceptable.  

“Staff were unnecessarily restricting people’s freedoms. They weren’t supported to leave the service and engage with the local community. This meant that people in the service were not supported to be independent and have control over their own lives. The service seemed unaware how significant restrictions like this on people’s human rights and freedom could impact their wellbeing. Autistic people and people with a learning disability should have access to the same rights that most people are able to take for granted.

“The service was still not dignified for people which we highlighted as far back as 2022. Staff did not always follow the trust’s guidance when they observed people using CCTV cameras and the usage was excessive. Anyone could access the footage and we saw one person had five cameras in their flat with no real reason in their care plan about why this was needed.

“Immediately after the inspection we told the trust the areas where significant and rapid improvements are needed, and have been told the work has commenced on this. We will return to check this has been done and will continue to monitor the service while this happens.”

Inspectors also found:

  • There was not a psychologist in place at the service for over two years. The community learning disability team supported with psychology input on a regular basis by referral
  • The service failed to analyse incidents to consider triggers, themes, and trends and how incidences of distressed behaviour, and restrictive practices could be reduced
  • The service failed to review and monitor significant restrictive practices and consider how they could be reduced. However, staff had commenced the harness, opportunities, protective enhance system training to support their knowledge in restrictive practices
  • Staff members did not always safely follow the trusts medicines policy. Health care assistants were administering medicines which were not in line with the trust’s guidance
  • Staff did not always work well together to provide the planned care required for each person
  • While family members said they were happy with the care provided, but two said they did not wish to make a complaint and rock the boat.


  • People’s communication needs were met, and information was shared in a way that could be understood
  • People’s risks were assessed regularly, and their care and support plans reflected their needs
  • Staff ensured that people had regular contact with their families
  • People had access to advocates when required.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.