Date of Assessment: 15 October and 18 December 2025, the service is a domiciliary care agency providing personal care to 56 adults. There had been a delay in between inspection days due to system issues and the decision made to be proportionate to extend inspection period. The assessment was carried out to review compliance with 2 warning notices served by CQC in April 2025 in response to continued breaches of regulation. We found sufficient improvements had not been made and the provider remained in breach of legal regulations relating to safe care and treatment and governance. Medicines were not always managed safely. Service users did not have care delivered in line with their assessed needs. There was a lack of effective governance and management of the service, leading to missed calls and a failure to identify and address where there were gaps in the delivery of personal care. This left service users at continued risk of poor care. This is the fifth consecutive inspection where concerns have been raised over the governance and management of the service. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
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Date of assessment: 11 March 2025. The Business Centre is a domiciliary care agency which provides personal care to people in their own homes. The service provides support to older people, people living with dementia and younger adults with a range of needs including people with physical disabilities. It also provides support to children from 0-18 years and people with learning disabilities and Autism. Not all people who receive support are in the receipt of the regulated activity personal care. We found 2 breaches of legal regulations in relation to safe care and treatment and good governance. People did not always receive their medicines as prescribed or have accurate recording of medicines. This placed people at risk of harm. The provider had some quality systems and processes in place; however, these were ineffective in identifying the concerns we found during this inspection. There were enough staff, however they had not always had the required training to meet people’s needs. Staff understood their roles and responsibilities. People were involved in assessments of their needs which included people’s communication, personal and health needs. 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.The overall rating for this service is requires improvement based on the findings of this inspection. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website.
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Gaps Healthcare & Training Services Limited improved its Safe rating to Good following the previous breach of Regulation 19, with robust recruitment and safeguarding practices now in place. However, Well-led remains Requires Improvement due to inconsistent governance, unanalysed feedback, incomplete audit trails, and communication failures around late or missed visits.
Concerns (7)
moderateGovernance: “The management team had not used audits to identify gaps in care plans and risk assessments. This meant that some care plans lacked up to date information.”
moderateCare planning: “Risk assessments were not always completed or did not record full information about risk. For example, we found one person did not have a falls risk assessment.”
moderateSupervision / appraisal: “The management team did not always record when spot checks of staff practice had taken place so could not be fully assured all staff were competent in their roles.”
moderateMissed or late visits: “One relative said, 'I wouldn't recommend them due to not turning up.'”
minorMedication management: “Medicines audits required further improvement, to ensure they were completed in a timely manner to ensure mistakes are followed up straight away.”
minorCommunication with families: “People and relatives views about communication with managers was mixed. This related to call times and not always being informed if calls would be late or missed.”
minorIncident learning: “Feedback provided to the service was not used to support quality improvement. People had completed surveys, but these had not been analysed to understand themes.”
Strengths
· Safe recruitment practices fully restored; all pre-employment checks including DBS completed, resolving previous breach of Regulation 19.
· Staff demonstrated in-depth knowledge of the people they supported, mitigating gaps in risk assessments.
· Care plans were completed, reviewed regularly, and signed by people receiving support — an improvement from the previous inspection.
· Medicines were administered safely by trained staff, with regular senior competency checks.
· Staff felt supported by management and described a positive, family-like workplace culture.
Quality-Statement breakdown (8)
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks, and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Engaging and involving people using the serviceRequires improvement
Focused inspection found a breach of Regulation 19 due to gaps in employment references and a missing staff risk assessment, alongside inadequate documentation of health risks and overdue care plan reviews. The overall rating dropped from Good to Requires Improvement, with both Safe and Well-led rated Requires Improvement.
Concerns (5)
criticalStaff competency: “Staff were not always recruited safely in line with the providers policies. During the inspection, we identified gaps in the employment references for five staff members.”
moderateGovernance: “The provider's systems and processes to monitor the service were not always effectively operated or embedded as they had failed to identify the issues we found in relation to recruitment files and risk assessments.”
moderateCare planning: “Risks associated with people's health needs were not always clearly documented. For example, clear guidance was not in place for staff to follow in the event of a person having an epileptic seizure to keep them safe.”
moderateRecord keeping: “Two people's care plans had not been reviewed, in line with the providers policy. We identified one review was overdue by five months, another was overdue by one month.”
minorMissed or late visits: “One person said, "I never know whose coming or what time, I would prefer to know." ... Call logs viewed during the inspection confirmed the timing of calls did vary for some people.”
Strengths
· People felt safe with staff and reported total faith in them
· Medicines administered safely by trained staff with competency assessments
· Staff received safeguarding and infection prevention training; PPE used appropriately
· Contingency plan in place for adverse weather and service continuity
· Registered manager open, honest and took immediate action to address concerns
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering