Gemcare South West Plymouth

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of legal regulation in relation to safe care and treatment and governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to staffing. Improvements were found at this assessment, and they were no longer in breach of this regulation.

This service scored 59 (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 have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff understood the importance of reporting concerns and most incidents were recorded, but reviews lacked depth. This made it difficult for leaders to identify patterns or take timely action to prevent recurrence.

People and relatives told us staff were supportive, but some were unsure how learning was shared across the team. Staff said communication about incidents “could be clearer,” so everyone knew what had changed and why. Oversight systems needed strengthening to ensure learning led to practical improvements.

This contributed to the breach of regulation in relation to governance.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always ensure people were fully protected from abuse and avoidable harm. While staff understood their safeguarding role, systems to recognise, report and respond to concerns were not consistently robust.

Leaders told us, no one using the service had a court of protection authorised to deprive them of their liberty. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. When people receive care and treatment in their own homes, an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) and how they managed DoLS within the service. The service did not always work in line with the principles of the MCA)

The provider had systems to ensure safeguarding concerns were raised with the local authority safeguarding team. However, the provider’s system to ensure the Care Quality Commission were notified of safeguarding concerns had failed.

This contributed to a continued breach in relation to governance.

Most staff had completed training and were aware of their responsibility in raising concerns, however some staff felt safeguarding concerns were not always taken seriously.

People told us they felt safe with staff.

Leaders reviewed safeguarding incidents but did not always demonstrate how learning was used to improve practice.

The service did not consistently involve people, or those important to them, in discussions about risks and how these should be managed.

Some specific risk assessments existed but not all reflected people’s choices or changing needs. One person had bedrails in place, however there was no risk assessment to minimise the risk of entrapment, or associated risk with bedrails. People with vulnerable skin did not always have a risk assessment in place, putting people at risk of avoidable harm.

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

People told us staff were supportive, but records lacked some detail about known risks and the specific controls needed.

Relatives said communication varied and they were not always included in reviews. This limited assurance that risk management was person‑centred.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Some safe recruitment practices were being followed, Disclosure and Barring service (DBS) checks were obtained as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, some staff did not have professional references placing people at risk of potential harm of receiving care from staff who were not suitable for working in the care sector. The regional operations manager told us, they would take action to address this concern.

People told us staff were kind and available when needed, however raised concerns in relation to new staff having the appropriate experience. One relative told us, “(Person’s name) is safe, but I do query new staff, there is no continuity at present. Massive staffing problems”.

Most staff had completed required training and felt supported in their roles, and several staff told us there was a good induction and shadowing opportunities. The management team told us specific learning disability training was being rolled out to all staff, appropriate to the level of support they provided to people.

Most people told us staff were kind during visits, but many also said calls were regularly early or late and they were not told about changes, which affected when they received personal care and medicines. Analysis of call data for three days showed 14% of 496 visits were late and 2% were more than 45 minutes late, and 17% of visits delivered less than half the planned time, including for people with high support needs. Care records for people at high risk of pressure damage and catheter complications had gaps in repositioning, fluid monitoring and catheter care, so the service could not show staff always responded promptly when people’s needs changed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Most people received their medicines on time, and staff understood people’s needs. However, several people and relatives described worries about the impact of visit patterns on medicines and health needs. They told us some visits were planned too close together to allow for the required four‑hour gap between doses of pain relief, and records confirmed examples where medicines such as paracetamol were not given in line with national guidance.

Audits took place but did not always identify issues or drive improvement. People told us staff explained their medicines and storage arrangements were generally appropriate.

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