Tamar House

The assessment was prompted by concerns raised in relation to medication, staffing, environment and governance; we looked at all quality statements.

We identified the provider was in breach of 3 legal regulations relating to safe care and treatment, staffing and good governance.

People experienced kind interactions from staff in day‑to‑day care. However, the quality of care was inconsistent, and systems to keep people safe, deliver person‑centred care and provide effective oversight were not reliably embedded.

We identified shortfalls in risk management and environmental safety. Fire safety actions identified in risk assessments had not been completed or adequately mitigated.

Care planning and monitoring did not consistently reflect people’s assessed needs. Some care plans lacked clear guidance for staff. Records did not always show people received the right support.

We observed positive interactions and a calm atmosphere during our visit. Many people appeared comfortable and supported by staff who knew them well. However, feedback from relatives and staff showed experiences were mixed, and concerns were raised about dignity, consistency of care and the impact of staffing pressures. Activities were available, but people were not always supported to take part in ways that reflected their preferences.

People’s rooms were personalised and staff supported access to healthcare professionals when required.

Governance and provider oversight were ineffective. The service had been without a registered manager for over a year, and frequent changes in leadership had contributed to instability. Quality assurance systems were either absent or not embedded, including audits of care planning, health and safety, infection prevention and call bell response times. Action plans were not clearly owned, dated or monitored. Staff told us they did not receive regular supervision or appraisals, although this had begun to improve recently. While professionals described the manager as open and responsive, there was no evidence of consistent provider oversight to ensure improvements were sustained.

At the time of the assessment, some improvements had started, particularly around leadership presence, staff support and training. However, these changes were too recent to demonstrate sustained improvement, and significant risks remained.

We asked the provider for an action plan in response to the concerns found at this assessment.

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.