Gloucestershire Health & Care NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has improved from inadequate to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed.

At this assessment the service was in breach of legal regulation in relation to safe care and treatment and premises and equipment at the service.

The conditions placed on the services registration will remain in place.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always investigate or report safety events effectively. Lessons were not always learnt to continually identify and embed good practice.

We reviewed 20 incident forms from June to July 2025. These forms did not contain sufficient information to fully understand the context leading up to the incidents. There was limited or no information about antecedents prior to the escalation. Staff analysis of incidents were not individualised and did not always identify strategies to prevent incidents occurring again. This resulted in missed opportunities to understand why people were becoming distressed and how future incidents could be prevented.

Members of the multidisciplinary team (MDT) reviewed incidents and logs to identify themes and trends, which were then discussed in the newly established weekly meetings, where staff could discuss individual formulations and goal setting. While some outcomes and actions were noted, the overall analysis lacked consistency and formal documentation. It was often unclear how conclusions had been reached, and there was limited evidence to show that all contributing factors had been fully explored and learned from.

Some patterns were recognised but the records frequently conflicted and failed to capture key factors that could help staff better understand and manage people’s distress. For example, one person’s Positive Behaviour Support (PBS) plan identified a lack of activity and restrictive environments as known triggers for distress. However, incident reports did not reflect any consideration of these factors. MDT records noted that the person had not left their flat for 10 days, but there was no follow-up analysis of how this might affect their mood, anxiety, or sense of self-worth. We recognised that some new activities had been introduced by the staff team, some people continued to spend prolonged periods in a restrictive environment.

Themes identified during MDT meetings were not always consistent with the information in the patient’s incident records. For example, there was a plan to assess whether hunger on waking was a contributing factor to a patient’s distress. The pattern described in the MDT minutes and the incident forms were different. This meant staff were not all using the same information to inform their practice.

Some people regularly engaged in self-injurious behaviours like banging their heads. There was limited evidence in the incident recording that the potential physical or psychological consequences of this were being explored as possible causes of further distress.

learning was not consistently identified across the service.

However, staff told us they were debriefed and received support after a serious incident.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met within the service. Since the last assessment, the service had not admitted any new individuals. In July 2025, one person was discharged and was living in the community under Section 17 leave, with no plans for their return. Section 17 leave refers to permission for a patient detained under the Mental Health Act (MHA) 1983 to leave the hospital for a specified period. It is a legal mechanism that allows detained patients to spend time outside the hospital, either for therapeutic purposes, family visits, or social activities, while remaining under the care of the hospital.

Records showed staff were involved in referring patients to other services. The staff worked closely with the Integrated Care Board (ICB) to identify accommodation. This involved bespoke housing designed to meet peoples specific care and treatment needs. Staff from the new provider worked alongside staff at Berkeley House to ensure a smooth transition and consistency in care.

The team at Berkeley House had been heavily involved in the design of the new accommodations to ensure they met the specific needs of each person. For example, one property included a cycle track for a person who enjoyed cycling, and activity pods were included to reflect current preferences and routines.

We received mostly positive feedback from carers and individuals about the planned discharges. However, relatives gave mixed feedback about their involvement in the discharge process. While some felt consulted and informed, others felt there was room for improvement.

Between May and July 2025 we identified possible safeguarding incidents that had occurred between May and July 2025 that had not been reported to the local authority. These included the use of non-standard physical interventions and that staff had not ensured that physical health monitoring was completed following incidents of self-harm involving head injuries. We also identified a ligature incident that occurred in June 2025, but there was no recorded analysis of the contributing factors or any review of the effectiveness of existing risk management strategies.

We raised these concerns with the trust who told us that all non-standard physical interventions were reviewed by the behaviour support team. Any incidents that they rated as meeting the safeguarding threshold would trigger an alert to the local safeguarding team. We saw that all recorded incidents were reviewed by the staff team. We also saw that staff had identified tying ligatures as part of a sensory profile and had appropriate care plans for the staff to follow. However, we did not find evidence that the staff team always recorded physical health checks completed on patients following incidents of self-harm involving head injuries.

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The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not ensure risks were managed safely. Improvements were needed to ensure people were safe and enabled to engage in activities that mattered to them.

Care records between June to July 2025 showed that staff did not always recognise risks associated with restrictive practices or the impact this had on people’s wellbeing.

Staff did not always ensure there was sufficient information in incidents to ensure restraints were always used as a last resort.Some restraints were used despite being documented as posing risks in individuals’ and some risks, including epilepsy, were not included Positive Behaviour Support (PBS) plans.

In the three care files reviewed there where inconsistencies in how restrictive interventions were reported in care files and staff practice. We were told a person had unrestricted access to their garden but on the day of assessment the garden door was locked.

Restrictions recorded in MDT minutes were not always reflected in care plans or incident reports. MDT records showed that staff had needed to lock doors in peoples flat, and turn off water and electricity for safety reasons but this was not recorded in the incident forms. Staff were unclear on the reasons for these restrictions, their duration, and whether they complied with legal frameworks.

People were not always able to do the things that mattered to them, as activity records lacked clarity on preferences and follow-up planning. Many spent prolonged periods confined to the unit without leaving. MDT minutes noted that one person preferred to remain in the garden, but records did not record how this had been identified.

Staff did not differentiate between planned activities, such as outings, and the persons walking in their flats. Records we reviewed between 4 July and 14 July 2025 identified pacing as an activity, but the person’s care plan did not explain why this was considered a meaningful activity.

Staff told us that a room inside one person’s flat, used for staff interaction and engagement, was always available to the person but staff confirmed that this space was often locked.

However, records showed that the use of restraint had decreased for people since our last inspection. There were also positive developments in increasing people’s activities outside the unit, including drives to takeaways, days out, cycling, and walks.

Staff completed assessments of the environment in relation to electrical installation condition, the cleanliness of the flats, fire risk assessment, gas safety and Legionella.

People did not always have access to a safe environment. For example, the bungalow and the remaining flats were in a poor state of disrepair and required substantial refurbishment. Evidence of damage from previous occupants included radiators with torn covers, exposing the heating elements, and writing covering one wall in another person’s room. The accommodation not in use was not suitable for readmission of patients.

However, we observed that staff had introduced a new ‘ante lounge’ ( a designated area for staff and the person living in one of the flats). Staff spoke positively about this space.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff used the Safe Staffing tool to ensure there were always sufficient staff on duty. In addition to the regular staff at the service, there were extra staff from the new provider working alongside to get to know the people and support a smooth transition to their new homes. We observed many staff on duty actively assisting people.

Since the last assessment, a psychologist had joined the team. There were currently vacancies for healthcare assistants and a clinical manager, with interviews underway to recruit for these positions.

The use of bank staff was low, and the service used bank staff who were new the service and people.

Staff sickness levels were low, averaging 5%, with two staff members on long-term sick leave.

Staff had received and were up to date with appropriate mandatory training, with a current attendance rate of over 97%. Clinical supervision attendance was at 95.1%. The training provided was relevant to the needs of the people using the service, including trauma-informed care, information governance, and breakaway training.

Relatives did not raise any concerns regarding staffing levels.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection effectively. Staff identified and controlled risks of infection spreading and promptly shared concerns with appropriate agencies.

Aside from the previously noted environmental issues, the service was clean. They had an infection prevention and control policy in place that followed national guidance.

Staff followed this policy alongside specific protocols covering areas such as hand hygiene. They were aware of their roles and responsibilities and had received appropriate training.

The service conducted regular audits to ensure compliance with policies and to measure their effectiveness. These audits included hand hygiene checks and a monthly infection prevention audit carried out by the infection control lead for the trust.

There was an adequate stock of the prescribed medicines. Medicines, including controlled drugs, were stored securely. Temperatures of medicine storage areas, including the medicine refrigerator, were monitored daily, and these were within the required range. Emergency medicines were available and regularly checked. However, an appropriate warning label was not installed for the oxygen held in stock for emergency use.

Staff used electronic patient record systems to prescribe and administer medicines. People prescribed psychotropic medicines were monitored appropriately in line with national guidance. Psychotropic medicines are used to treat mental illness. Physical health checks, such as weight, blood pressure, and electrocardiogram (ECG), were carried out periodically.

People's medicines were regularly reviewed by a multi-disciplinary team. A clinical pharmacist attended these meetings to provide expertise for the optimal use of medicines.

People were prescribed anxiolytics to be administered on a when-required basis. The administration of these medicines was regularly reviewed by a multi-disciplinary team, including a clinical pharmacist. There were positive behaviour support (PBS) care plans in place. A PBS is a person-centred framework used to understand, prevent, and manage challenging behaviours by focusing on an individual's needs. The care plans referenced protocols for the prescribed when required anxiolytics. However, these protocols were not always in place to help guide staff to administer these medicines. One person who experienced seizures was prescribed a rescue medicine, however, there was no information in their care plan about when staff should use this medicine, putting them at risk of harm.

There was a medicine management policy in place. Medicine management audits were completed regularly. There was a process in place to report incidents and errors. There was a process in place to receive and act on medicine alerts.

The staff received training to handle medicines safely. However, we could not seek assurance that all staff members had been competency assessed for medicines management. The service informed us that the staff members’ competency would be assessed following the inspection.