GPS Care Services improved significantly from its previous Inadequate rating, with four of five key questions now rated Good following remediation of breaches in regulations 9, 12, 18 and 19. However, a continuing breach of Regulation 17 (Good Governance) due to absent audit systems for medicines records and daily logs, and poor care review documentation, resulted in an overall rating of Requires Improvement.
Concerns (5)
critical
Governance
: “the provider continued to have no system for checking people's medicines administration records and daily logs for quality and safety issues.”
moderateRecord keeping: “Records of people's care reviews remained poor and lacked sufficient detail to provide a clear audit trail of when changes were made to people's care and why.”
moderateGovernance: “the provider's safeguarding policy did not reference the local authority's safeguarding process.”
minorMedication management: “staff did not always have access to clear information on where to apply people's creams.”
minorSupervision / appraisal: “the management team carried out spot checks on staff, but this practice was not well-embedded as this process was newly established.”
Strengths
· Significant improvements made since last inspection; provider no longer in breach of regulations 9, 12, 18 and 19.
· Recruitment practices much improved with appropriate background checks completed for all staff.
· People received support from the same core group of staff, promoting good continuity of care.
· Staff arrived on time and call schedules were well managed.
· Medicines were now managed safely with accurate and up-to-date administration records.
Quality-Statement breakdown (18)
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrong; safeguarding people from the risk of abuseGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions; respecting privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control; end of life care and supportGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles; understanding quality performance, risks and regulatory requirements; continuous learning; promoting a positive cultureRequires improvement
well-led: How the provider understands and acts on the duty of candour; engaging and involving people and staffGood
Date of Assessment: 5 June to 17 June 2025. GPS Care Services is a domiciliary care agency providing personal care to people living in their own homes. At the time of the assessment 9 people were receiving personal care. The service provides support to younger adults and older people, some of whom were living with dementia. This assessment took place due to the length of time since the last inspection, and to follow up on previous inspection findings. We rated this service under our previous methodology in July 2022 where it was inspected and rated as requires improvement overall. At this assessment we reviewed all 5 key questions and rated the provider good overall. The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation. People were supported by caring staff who knew them well and followed their wishes. Managers at the service undertook regular monitoring of the care provided to ensure ongoing quality, this included spot checks and monitoring their online systems. Staff received training to enable them to deliver care that was safe and in line with current best practice. Staff told us they felt supported by the management team at the service. Managers at the service worked well with health and social care services in the local area.
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GPS Care Services was rated Inadequate overall and placed in special measures, with breaches identified in medicines, risk management, needs assessment/care planning, recruitment, staff training and support, and governance. Despite positive feedback from people about the kindness of staff and the registered manager's hands-on approach, systemic failings in records, oversight and person-centred planning placed people at increased risk of harm.
Concerns (12)
criticalMedication management: “the provider had failed to ensure the proper and safe management of medicines. This placed people at an increased risk of medicine-related harm.”
criticalCare planning: “Care plans were not always in place... Information held in people's homes resembled a 'task list' and provided bullet points with brief details about the care they required.”
criticalStaff training: “Staff had not received appropriate induction and training to prepare them for their role... trainers did not have the skills or qualifications to train staff in these areas.”
criticalSupervision / appraisal: “Staff had not received regular supervisions in line with the provider's policies and procedures... had not received an annual appraisal.”
criticalGovernance: “systems were either not in place or robust enough to demonstrate the quality and safety of services was effectively managed.”
criticalRecord keeping: “Records relating to staff and people were disorganised and not easily accessible to authorised personnel.”
criticalSafeguarding: “the provider had failed to operate effective recruitment procedures to ensure all persons employed were suitable for the purposes of carrying on a regulated activity.”
criticalPerson-centred care: “the provider had failed to ensure all people had received a robust of assessment of their needs and preferences.”
moderateConsent / capacity: “pre-assessment documentation did not address people's mental capacity to consent to their care and support arrangements.”
moderateIncident learning: “the provider's engagement practices did not robustly promote an improvement culture at the service.”
moderateCommunication with families: “we were not confident the service was consistently identifying people who fell within the scope of AIS”
minorMissed or late visits: “A relative told us how this negatively impacted a person's evening routine as staff would put them to bed early if they arrived early.”
Strengths
· People and relatives reported they were happy with the care and felt safe with staff.
· Continuity of care was promoted through support from the same core group of staff.
· Staff were described as kind and treated people with dignity and respect.
· Registered manager praised for a 'hands on' approach to concerns and queries.
· Infection control systems and PPE provision were in place.
Quality-Statement breakdown (19)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrong; Systems and processes to safeguard people from the risk of abuseNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced diet
Not rated
effective: Staff working with other agencies; supporting people to live healthier livesNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
responsive: Planning personalised care to ensure people have choice and controlNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsNot rated
well-led: Duty of candour; engaging and involving people, public and staffNot rated
well-led: Working in partnership with othersNot rated