During an assessment under our new approach
Date of assessment: 20 May to 8 July 2025
Gemcare South West – Extra Care Scheme consists of 7 extra care housing units in the Plymouth area. It provides personal care to people living in specialist housing. Not everyone using the service received a regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
We carried out this assessment as we had received some information of concern.At the time of this assessment, 156 people were receiving personal care from the service. We carried out onsite and offsite assessments. We assessed all quality statements under the 5 key questions; Safe, Effective, Caring, Responsive and Well-led. We found 5 breaches of the legal regulations in relation to safe care and treatment, person centred care, staffing, notifications, and governance.
Safety concerns were not listened to or responded to effectively. Safeguarding incidents had not been reported to CQC as legally required. Risk assessments were not completed and placed people at risk of harm. Records for monitoring risks were missing or contained gaps. This meant information could not be shared effectively with other health and social care professionals to ensure the best outcomes for people. There were not enough staff to meet people’s needs which meant people’s care was not delivered as agreed. Some staff did not know how to meet people’s needs. Medicines were not safely managed.
People were not always treated with kindness and compassion and staff lacked information to understand their individual needs and preferences.
Experienced staff were passionate about delivering good care for people, but they were frustrated they could not achieve this under their current working conditions. Most staff told us there was poor communication, they did not feel supported or listened to. They said when they had escalated concerns they were not responded to. They described a bullying culture and were afraid to speak up for fear of repercussions.
The provider’s audit system had not identified and addressed the shortfalls we found during this assessment. We did not receive information we requested in a timely way. Records were not well organised, complete, accurate, or easily accessible. The provider had not notified the CQC of all incidents, as legally required.
However, some people were happy with the care they received from regular staff who knew them well. Some staff told us they were happy working at the service and felt supported.
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.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.