Gemcare South West Plymouth

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to safe care and treatment, consent and governance.

This service scored 54 (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 always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The provider did not always assess people’s needs in a reliable or consistent way. Some care plans lacked essential information about people’s assessed needs, including diabetes, catheter care, mobility equipment, and risks such as vulnerable skin. We found contradictions within some records, and updates were not always completed in a timely manner, for example where people’s environments posed risks to staff.

We saw some people’s records were not accurate or contemporaneous, for example some care plans contradicted themselves in relation to equipment to support with mobility.

People told us they were now more involved in their care plan reviews, but this was not consistent across the service.

This contributed to a continued breach in relation to safe care and treatment and governance.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The provider did not always deliver care and treatment in line with evidence‑based guidance. People’s care plans did not consistently include the level of detail required for staff to follow national guidance, particularly for diabetes, catheter care, modified diets and pressure‑area management. In several cases, important clinical requirements—such as weekly catheter changes and swallowing risk guidance were contradictory. For some people at risk of choking, SALT recommendations were either unclear or not reflected in daily records.

Staff told us care plans had recently improved, but we continued to see gaps in accuracy and clinical oversight. Some of these issues were highlighted at the prior inspection and remain not fully addressed.

People who had catheters, were at risk of pressure damage or were at risk of choking did not always experience care that matched what was set out in their plans. Daily care notes did not always show that repositioning, catheter care and food and fluid guidance were followed, which created uncertainty for people and their families about whether important tasks had been completed.

This contributed to a continued breach in relation to safe care and treatment and governance.

The provider worked well across teams and services to deliver people’s care, although some improvements were still needed. People and staff described better communication in recent weeks following the arrival of the new manager, and staff said they now received clearer guidance and support.

Staff told us information sharing had improved through updated care‑planning systems, although some care plans still contained inconsistent or outdated information.

Professionals told us the service had begun to improve responsiveness. We observed concerns being escalated in a timely manner to relevant professionals.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control.

However, for some individuals with high‑risk needs, such as pressure care or choking risks, the service did not always identify or act on opportunities to prevent deterioration. This included unclear food texture instructions and limited evidence of structured monitoring.

Some people experienced inappropriate visit times, which affected medication spacing and wellbeing. Despite this, people said staff were kind and supportive.

Staff understood people’s day‑to‑day routines and provided support with meals, fluids, medication and personal care. People told us staff encouraged independence where possible.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Care plans and daily notes lacked structured monitoring. The provider’s audits did not identify shortfalls, for example we saw one person’s care plan refer to repositioning and for staff to complete this on each visit, daily notes did not always evidence their assessed needs were being met putting people at risk.

This contributed to a continued breach in relation to governance.

People reported variable visit timing and inconsistent support, which affected their outcomes. Although the new manager had taken steps to improve documentation and oversight, these changes were not yet embedded.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The provider did not always follow the principles of the Mental Capacity Act when assessing people’s consent for care and treatment. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Records for several people showed inconsistencies in mental capacity information, including cases where people were recorded as lacking capacity but no decision‑specific assessments or best‑interest decisions had been completed.

Staff understood the importance of gaining consent during day‑to‑day support, and some people confirmed staff asked before providing care.

This contributed to breach of legal regulation in relation to consent.