- Homecare service
Gemcare South West - Extra Care Scheme
We served a warning notice on Gemcare South West Limited on 11 and 14 July 2025 for failing to meet the regulations related to safe care and treatment and good governance at Gemcare South West - Extra Care Scheme.
Assessment report published 23 October 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
We received mixed feedback from people who used the service.People who used the service did not always feel safe. One person said, “I have raised safeguarding concerns about myself on more than one occasion. I never received a response”. Another person told us, “I have never felt as scared as I do now. I am afraid someone will physically abuse me next time or be hurt again.”
People did not always receive their care and support as agreed. People told us that staff frequently did not stay for the full length of the visit, staff did not complete their care and rushed them. One person said, “Some staff are rough as anything with me, rush, rush, rush.”
People did not feel their views and wishes were considered when their care was planned. Comments included, “It’s funny, you’ve got your own place, but you’ve got to do what they want” and “I don’t want to go to bed at that time, but they get you up and you are in bed, and they shut the door. I want to watch the TV, but I don’t get a choice.”
People told us they were not always treated with kindness and compassion. Comments included, “Some staff won’t make conversation and ignore me” and “I'm just a job to do. Staff treat me like a piece of meat.” We spoke with 3 people who showed clear signs of emotional distress, including tearfulness.
Some people told us they had not raised concerns with the service as they were not confident their views would be respected, taken seriously, and treated compassionately, without negative repercussions. Comments included, “If I try to speak to someone it’s as though I am being fobbed off, they say it will get better, but it doesn’t. I am not sure what the answer is?” and “We have had several issues particularly over recent times. I also find them very poor at communication.” However, several people who lived in one unit, said the on-site manager was approachable and resolved issues for them.
People told us new staff and agency staff didn’t know how to meet their needs. One person said, “I try to get a shower on a Friday because most weekends they are agency, and they don’t know what they are doing.” However, where people had regular staff who knew them well, people had a better experience. Comments included, “The carers are all very good, kind very caring but they don’t have enough time for everyone they look after” and “They look after me. [Staff member’s name] comes to see me – [they are] brilliant and other people come in and they are all very kind."