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.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not always demonstrate a shared direction and culture.
Staff described the previous culture as disorganised and unresponsive, however over the past two weeks some recent improvements were evident. People and staff reported communication had “got better over the last two weeks”. Team meetings had begun to resume, and staff told us minutes would now be shared with those who could not attend.
However, improvements were at an early stage and not yet embedded. The provider’s previous assurance systems had not detected significant issues with medications and care planning.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

There had been changes in management which meant there had not been consistent leadership at the service for some time. The absence of a registered manager for a prolonged period contributed to disorganisation and a lack of accountability.

One relative told us, “We have confidence in the carers not the service. It is not professional at times and not sure if its well managed”.
However, staff said the new manager was supportive, proactive and improving communication and oversight. Leaders had restarted routine governance meetings and coaching, and oversight from the regional manager had increased.

People felt able to speak up; however, they did not always feel their views were heard.

A person using the service and a relative told us they had raised concerns. Action was taken in the short term, but the same issues reoccurred over time, particularly around visiting times and the impact on them. They described feeling frustrated and were reluctant to raise concerns again because actions were not sustained.

One staff member told us, “Gem Care has not been a positive company to work for, especially in terms of management”. They told us they had raised multiple concerns but felt appropriate action had not been taken.

Some recent improvements were identified. Staff told us they felt more supported by the new manager and more able to raise concerns.

The provider did not always promote equality, diversity and inclusion.

We received mixed feedback from staff in relation to them feeling they are treated fairly. Comments included, “I am not always treated fairly and appreciated,” and “Mostly”.

Some people did not consistently receive visits at planned times, which affected their ability to plan their day and maintain independence.
There was some emerging good practice: flexible working arrangements had begun to be discussed at regional manager meetings and buddy systems were in place to support staff.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Provider audits had not identified key concerns we found at this assessment, including medication errors, inaccurate care plans and missing risk assessments. Governance arrangements needed strengthening to ensure concerns were properly monitored.
Significant issues remained which had been identified at the last assessment including inaccurate and incomplete care plans relating to catheter care and mobility. This meant the providers systems had failed to ensure the risks to service users were assessed and managed in a safe way that mitigated all reasonably practicable risks.
The new manager had begun to take action to improve documentation, communication and visit scheduling, but these systems were still new and not yet effective or embedded.
This contributed to breach of the legal regulation in relation to governance.

The provider understand their duty to collaborate and work in partnership, so services worked seamlessly for people.
Professionals told us they had engaged with a process involving safeguarding. However in relation to engaging for sharing learning and improving outcomes a professional told us, ‘Not been involved for the last year, but will be encouraged to join forums this year’.

Staff shared information with external professionals, escalated concerns to medical teams where required.

One relative told us, “They (Staff) are supportive. In the past they have liaised with the GP/ DN”.

Relatives told us communication was sometimes inconsistent, and people were not always updated about visit changes or delays.

The provider did not always 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.

Action the provider told us they would take following our last assessment had not been completed, including inaccuracies within care plans, ineffective audits, and poor medication practice.
Improvements made by the new manager were recent, small‑scale and not yet embedded. The provider’s systems had not led to sustained learning or meaningful quality improvement.

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