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 requires improvement. At this assessment the rating has remained 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.

This service scored 57 (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 was working towards a shared vision, strategy and culture. However, there were still improvements to be made.

Since the previous assessment, the manager had improved engagement with people and staff.Team meetings for staff were being held. Feedback from people who used the service was being collected and actions taken, where needed.

However, some people who used the service did not feel their needs or preferences were fully understood or respected. Some staff were not yet aligned with the values of the service.

Staff told us they had seen improvements. Comments included “It had improved a little bit in January but now it is so much better” and “It is better now (manager’s name) has taken over.”

Improvements had been made and this work was ongoing. However, the changes were not yet embedded and there were still improvements to be made in relation to care delivery.

The service has not had a registered manager for over a year, despite this being a requirement for the service. There had not been consistent leadership and proper oversight which resulted in shortfalls within the service.

The manager of the service told us they were applying to register with the CQC. Working alongside the senior management team, they had already made a number of improvements since starting at the service earlier in the year.

Staff praised the new manager and said, “(Manager’s name) is doing much better and they are doing a fantastic job and I hope they are the one that lasts” and “I really like the manager and every time I have spoken to them, they have helped me and if I needed anything it has been very well explained to me.”

Office staff had recently been recruited and were settling into their roles. One staff member said, “Sometimes it feels it is not well organised but we do understand the office staff are new and they are trying to do the best they can.”

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

Some people and relatives told us they contacted the office, but concerns were not always addressed. One relative said, “I feel I am always complaining but nothing ever changes.” Other people felt listened to.

Staff told us they now felt able to raise concerns. One staff member said, “We are encouraged at every staff meeting that if we have any concerns, to contact the office, no matter how small the concern.”

However, some staff said communication still needed to improve. A staff member said, “They say they will call me back and I have to follow up and that happens fairly frequently.”

The provider valued diversity in their workforce. The culture at the service had improved and the manager continued to work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff told us they were treated fairly and equally. The service had an equality and diversity policy and told us they accommodated staff flexible working arrangements where they could. Staff received training in equality and diversity.

Further improvements were needed but the provider had introduced responsibilities, roles, systems of accountability and good governance.

The provider now had systems to monitor and manage service performance. Oversight had improved. There were regular checks and audits. Within the last 6 months, improvements had been made to care plans, risk assessments, staffing, medicines, visit timings, reporting events, mental capacity assessments/best interest decisions, engagement, and the culture at the service.

The provider had notified the CQC of incidents as legally required.

The service was no longer in breach of regulations. The manager was aware of the further improvements needed and was working on these. Systems were still new and needed to be embedded to ensure improvements were made and sustained.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider was working on continuous learning and improvement across the organisation and local system.

The provider had started to take action to resolve issues we identified at previous assessments. Further engagement with people who used the service and staff was needed to ensure everyone’s voices were heard. Further improvements needed to be made, monitored and sustained.