Gemcare South West - Extra Care Scheme

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Most staff felt there was a closed culture and told us concerns had not been addressed. They told us, “The worst company I have ever worked for” and “They really, really do not care.”

People told us the service did not meet their expectations. One person commented, “The carers are wonderful as people but that’s where it ends, it should be no care.” Some people told us they had not been notified the service had recently changed its name.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The manager who registered with the CQC in March 2025, had left the service and applied to cancel their registration in April 2025. The regional operations director was overseeing the running of the service and 2 operations managers from other regions were supporting.

People and staff told us they did not always know who the managers were. A staff member commented, “No support for us staff and we have had so many managers who have been pushed to the limit.” Staff said they did not always know if there was going to be a manager in their unit.

Some people and staff told us, if they had any issues relating to care, they spoke with the housing managers, as they did not feel comfortable speaking with the provider's management. Housing managers were not employed by the provider and did not have responsibility for care.

A new manager had recently been appointed in one of the units. Staff told us they hoped they could make improvements. A staff member told us they were told a new manager was being employed by a person who lived at the service and commented, “We are not told anything.”

People did not feel they could speak up and that their voice would be heard. One relative told us they had not always raised issues with the service because they were fearful of potential repercussions.

The culture at the service had led to staff feeling afraid to speak up about unsafe practice resulting in a lack of transparency.

The service had a whistleblowing policy. However, some staff told us they did not feel able to speak up. We found there was a closed culture at the service with a lack of external scrutiny and oversight.

Staff told us when they had raised concerns, they were not listened to, and action wasn’t taken.

The provider told us the process of changing culture through leadership takes time and they were committed to taking steps to ensure every person and staff member felt able to raise concerns without fear of reprisal.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they did not feel they were treated fairly. Staff talked about a bullying culture within the service where they felt pressured to take on more work.

Staff members told us they had raised concerns about being racially abused by people, they told us action had not been taken, and they had not felt supported.

The provider assured us they knew changes needed to be made and identified embedding such a change might take some time, but they were committed to rebuilding trust in their staff team

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s audit system had not identified and addressed the shortfalls we found during this assessment. We found issues relating to safeguarding, staffing levels, staff training and supervision, medicines, risk assessments, care plans, visits to people who use the service, people and staff not being listened to, and governance.

We did not receive information we requested in a timely way. Records were not well organised, complete, accurate, or easily accessible. Records did not clearly show who was working and when which meant the provider did not have good oversight of staffing.

The provider had not notified the CQC of all incidents, as legally required.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

People and staff told us they did not feel listened to and did not receive a response when they made contact with the service.

Professionals told us they had raised concerns, but issues had not been resolved.

The local authority had met with and were working with the provider. Prior to our assessment, the service was placed into a whole service safeguarding process due to the level of concerns.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider’s improvement plan had identified some of the shortfalls we found throughout this assessment, but they had not taken sufficient action to resolve issues. Shortfalls we have identified have led to breaches of regulations. This meant quality performance had not always been assessed, potential risks to people were not always identified and lessons were not learned to drive improvement.

Systems to drive improvement were not effective. The service was rated requires improvement at the previous assessment. There are continuing breaches of regulations at this assessment.