- Homecare service
Gemcare South West Plymouth
Assessment report published 7 April 2026
Contents
Ratings
Our view of the service
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.
People's experience of this service
People’s experience of the service was mixed. Many people and relatives told us their regular carers were kind, caring and treated them with dignity and respect, and most said they felt safe when staff were with them. Several people described strong relationships with a small number of consistent carers who “know what I need and help me straight away”. However, their confidence in the service as a whole was undermined by frequent changes to staff, unreliable visit times and poor communication with the office.
People and relatives consistently raised concerns about visit punctuality and reliability. They told us staff were often early or late for planned visits and did not always let them know when times changed. In one example, a family described a scheduled evening visit that did not take place until after midnight, without any warning. This meant people could not always plan their day, and some did not always receive care for the full time they were expecting.
Some people and relatives told us visits requiring two members of staff were usually delivered as expected, however electronic call monitoring showed some visits where there was little or no overlap between staff, which created a risk that people’s assessed needs were not always met.
Feedback about communication and responsiveness from the office was also mixed. Some people and relatives told us that communication with the new manager had recently improved and that concerns were now being followed up more promptly. Others said it was very difficult to get through by phone, particularly out of hours, and that when they did raise issues, they did not always see action or receive a clear response.
Relatives told us, they felt frontline carers were generally compassionate and respectful, but not all would recommend the service because of high staff turnover, inconsistent visit times and problems contacting or getting a response from office staff.
Most people told us staff treated them with dignity and respect during personal care and understood how they liked things to be done. People valued staff who took time to talk with them and involve them in day‑to‑day choices. However, the quality of people’s experience depended heavily on which staff attended.