Gemcare South West Plymouth

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.

This is the first assessment for this service at its new office location. This key question has been rated 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. There was a lack of provider oversight. Governance systems and audits were not effective in identifying or addressing areas for improvement.

This service scored 29 (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 notunderstand the challenges and the needs of people and their communities.

Some staff and people felt there was a closed culture and told us concerns had not been addressed. Staff commented, “I don’t know what is going on, don’t get told anything. I like to know what’s going on. There is a lack of communication” and “They started to do a monthly meeting and we do get some communication but it is not as good as it used to be as they are so short of staff.”

Staff meeting minutes from October 2024 showed the registered manager had identified issues concerns around visit timings and staffing. They said this would be monitored but issues had not been resolved. Due to the lack of availability of management and office staff, at times, staff were unable to seek advice and guidance for concerns they had.

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.

The registered manager and regional operations manager ended their employment at the service during our inspection. The regional operations director was overseeing the running of the service and had brought in 2 other operations managers from other regions.

Staff told us they found the deputy manager approachable. However, several staff said the deputy manager had been busy because they had covered a lot of care visits and the office staff had left.

At the time of our site visit, the deputy manager was on leave and there were no office staff. The regional operations director told us they were recruiting for the vacant posts.

People did not feel they could speak up and that their voice would be heard.

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, but 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. Some staff told us about relationships between other staff members. Comments included, “We are told we can raise concerns, I would struggle to do so through fear of being found out that it was me” and “You can't say anything to them because it all gets fed back, and nothing will be done.”

However, some staff told us they felt able to speak up. However, due to the lack of management cover and office staff opportunities to speak up were limited.

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

Some staff felt under pressure to take on more visits. Comments included, “I am guilted into it most of the time” and “I wish there was less pressurised phone calls to work outside of availability.” However, some staff told us they felt treated fairly and equally.

The service had an equality and diversity policy in place and told us they accommodated staff flexible working arrangements where they could. Staff received training in equality and diversity.

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 inspection. We found issues relating to staffing levels, staff training and supervision, risk assessments, care plans, visits to people who use the service, people who use the service, staff not being listened to and governance.

We asked to see the care plan for the newest person using the service. We later found out this person was receiving care at 1 of the provider’s other locations. This shows the provider did not have sufficient oversight to know what was happening at the service.

The provider had carried out an internal audit in December 2024 and rated the service as ‘requires improvement’. The management team told us the provider’s quality team had carried out an audit. We requested this report several times and were then told it had not been completed.

The provider had not notified the CQC of all incidents, as legally required. We asked them to send 1 safeguarding notification retrospectively and received this after the inspection.

The service confirmed they had stopped taking new packages of care until they made improvements.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

People and staff told us they sometimes didn’t feel listened to and didn’t get a response when they made contact with the service.

The local authority had met with the provider. They are currently working with the service and there is a service improvement plan to monitor their progress. Following our inspection, the service was placed into a whole service safeguarding process due to the level of concerns.

However, staff and the provider told us how they contacted health and social care professionals when needed. The provider had links with Age UK.

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

The provider’s action plan had identified some of the shortfalls we have found throughout this inspection 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 learned to drive improvements had not always been possible.

The service has been rated requires improvement at the previous 3 inspections, before moving to this office location. We were not assured systems to drive improvement were effective.