Gemcare South West Plymouth

Date of assessment: 9 to 29 June 2026.

Gemcare South West Plymouth is a homecare agency, providing personal care to people under and over 65 years old, people living with dementia, learning disabilities, mental health conditions, physical disabilities and/ or sensory impairment. At the time of our assessment, 61 people receiving the regulated activity were using the service. 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 needs were being met in relation to respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

Gemcare South West Plymouth was rated requires improvement at its previous assessment in January 2026. Since our last assessment, the provider had made improvements. The service isno longer in breach of regulations. However, the overall rating remains requires improvement as systems were still new and needed to be embedded to ensure improvements were made and sustained.

The manager was aware of the further improvements needed and was working on areas such as staff conduct and consistency, visit duration, communication, and engagement with people and staff.

Care plans now contained detailed person-centred information. Risks had been assessed and staff had guidance on how to keep people safe. Staff recruitment was safe and staff received regular supervision. Visit timings had improved. The manager had continued to work on building relationships and making improvements. The provider had improved oversight and governance.

We carried out an assessment of Gemcare South West Plymouth between 14 and 30 January 2026 as part of a warning notice return following previous regulatory concerns. Gemcare South West Plymouth is a homecare agency, providing personal care to people under and over 65 years old, people living with dementia, learning disabilities, mental health conditions, physical disabilities and/ or sensory impairment. At the time of our assessment, 57 people receiving the regulated activity were using the service. 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 needs were being met in relation to respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

We looked at whether the provider had made the improvements required and whether the service was delivering safe, effective and well-led care. Gemcare South West Plymouth was previously rated requires improvement at its last inspection in 2025. Since our last assessment, the provider has made some improvements, however the overall rating remains requires improvement.

People and relatives told us they generally felt safe, and staff understood their safeguarding responsibilities. Records showed some improvements in care planning, induction, and training, and we saw examples of the new manager beginning to strengthen communication, the organisation and rota processes. Staff described the new manager as proactive, supportive and improving stability within the team.

However, these improvements were not consistent or embedded. We identified continuing concerns in several areas. Governance systems had not identified or addressed important shortfalls, including issues with medicines safety, care records, and risk management. Several people’s care plans were inaccurate, incomplete or contradictory, including those relating to skin integrity, mobility equipment, catheter care and ‘when required’ medicines. We also found examples where national guidance for catheter care was not followed, and daily care notes did not always evidence repositioning or other required support.

We found 3 breaches of regulations. We found continued breaches of the legal regulations in relation to safe care and treatment and governance. We also identified a new breach of the legal regulations in relation to consent.

The provider was previously in breach of the legal regulation in relation to staffing and person-centred care. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

This service has been in Special Measures since 12 June 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate in well-led. Therefore, this service is no longer in Special Measures.

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. We will request an action plan from the provider to understand how they will improve the quality and safety of the service.

Date of assessment 10 March to 2 May 2025

Cera Plymouth is a domiciliary care agency. It provides personal care to people living in their own homes. 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, 91 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. At this assessment the overall rating was requires improvement. This is the first assessment for this service at its new office location.

People did not always have risk assessments to guide safe practice. Staff had not updated care plans to reflect people’s current care needs. The service did not always have enough staff to deliver safe care. Staff did not always have sufficient travel time to get to their visits on time. People’s visit times were variable; some were early and others very late. Staff did not stay the full visit time at a high number of visits. We found instances where care staff were undertaking care tasks when they were not trained or assessed as competent. There was a lack of provider oversight. People and staff were not always listened to when they raised concerns and actions were not taken to resolve issues. Governance systems and audits were not effective in identifying or addressing areas for improvement.

However, some people were happy with the care they received. Some staff told us they were happy working at the service and felt supported.

An assessment has been undertaken of a service that is used by autistic people or people with a learning disability but is not registered as a specialist service. 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 that most people take for granted. People had some regular staff who knew them well. However, they also had visits from new staff who did not know them. They were not in control of their lives as systems did not support this in practice. They did not feel listened to and issues that were reported were not always acted upon.

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.