- SERVICE PROVIDER
Gloucestershire Health & Care NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 15 January 2026
Contents
Ratings - Wards for people with learning disabilities or autism
Our view of the service
We assessed Berkely House between 15 to 17 July 2025
We completed this assessment to review the conditions imposed at the October 2023 assessment. We carried out a comprehensive assessment.
Berkeley House is a stand-alone learning disability unit located in a residential housing estate on the edge of the town of Stroud. It does not share its location with any other NHS or Social Care services. It comprises of 7 flats. At the assessment 3 were occupied.
The Trust was registered for the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983, Diagnostic and screening procedures and Treatment of disease, disorder, or injury
We assessed the service to review the progress made against the conditions that were imposed on the providers registration following the last assessment in October 2023.We found that the service had made some improvements. However there had not been sufficient improvement to remove the conditions. The conditions will therefore remain in place.
During this comprehensive assessment we assessed all quality statements from the 5 key questions and found areas of practice that required improvement. We rated the service as requires improvement.
At this assessment we found 3 breaches of the regulations. The service was in breach of the legal requirement in relation to Safe Care and Treatment in relation to the safe management of incidents, the safe management of risks to patients and the management of medicines.The service was in breach of the legal requirements in relation to Premises and Equipment due to the poor condition of some of the flats.The service was in breach of the legal requirements about Good Governance because their governance processes did not always operate effectively.
We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
We rated the service as requires improvement:
Staff did not consistently protect people from abuse and improper treatment. Staff did not always assess risks to people's health and safety or mitigate them where identified.
Governance systems were not always effective in identifying or addressing areas for improvement. People were not always supported by staff members to do things that mattered to them. Staff mostly took practical steps to enable patients to make their own decisions.
However:
There had been some improvement in activities with people going out to collect takeaways and going to the beach. Staff were working closely with new social care providers to support people to get to know the new service prior to being discharged from the service.
Leaders made sure there were enough qualified, skilled and experienced staff and worked well across teams.
Mental Health Act
Over 90% of staff had received training in the Mental Health Act.
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice.
There was easy access to information about independent mental health advocacy. Patient information leaflets included contacts for the independent complaints’ advocacy.
Mental Capacity Act
Over 90% of staff had had training in the Mental Capacity Act.
Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.
Staff knew where to get advice from within the provider regarding the Mental Capacity Act.
Staff took all practical steps to enable patients to make their own decisions.
People's experience of this service
We spoke with six relatives and observed care and treatment on the wards. Feedback was mixed, with most relatives expressing concerns about the quality of care. While some were satisfied, others reported dissatisfaction, regarding the length of hospital stays and limited opportunities for patients to engage in exercise or activities that mattered to them.
Concerns were also raised about staff communication skills, with some relatives feeling staff were not adequately trained to communicate effectively with patients. Views on involvement in care planning were mixed; while some relatives felt listened to, others were less confident their concerns would be addressed.
Relatives were concerned about inconsistencies in how staff reported incidents.