Tamar House

Updated 7 May 2026

Date of Assessment: 8 to 20 May 2026. The service is a residential care home, providing personal care to adults over 65 years old, living with dementia and/ or physical disabilities. The service is registered to provide accommodation to a maximum of 29 people. At the time of our assessment, 28 people were using the service.

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.

Updated 7 May 2026

We spoke with 3 people living at the service, 3 professionals and 8 relatives to help assess and understand how people’s care needs were being met.

People’s experiences of care at Tamar House were mixed. Some people and relatives told us they were generally satisfied with the care provided and described staff as kind, caring and supportive. Others raised significant concerns about dignity, communication, continuity of care and how concerns were listened to and acted on.

Several relatives spoke positively about the approach of care staff, describing them as compassionate and attentive, particularly when people’s health declined. Some relatives said people felt settled and enjoyed activities, meals and social opportunities, including group activities and visits from external providers.

However, other relatives described distressing experiences. These included concerns about people being left in soiled clothing, poor personal care, limited engagement, and people spending long periods alone in their rooms. Some relatives described occasions where people appeared upset and confused and felt their individual preferences and routines were not always respected.

Several relatives and staff raised concerns about how changes in management and staffing affected people’s sense of stability and emotional wellbeing.

Relatives provided mixed feedback about communication and involvement. Some felt informed and involved, while others said they did not feel listened to or confident that concerns would be acted on.

We observed a generally calm and friendly atmosphere during the inspection, and most people appeared comfortable in communal areas. We saw staff responding to call bells promptly and offering reassurance when people needed support.

We used a Short Observational Framework for inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who can not talk with us. We also used records and feedback from relatives and staff to better understand their experiences.

While some people and relatives expressed satisfaction with aspects of care, our assessment found people’s experiences were not always positive and did not consistently reflect the expected standards of care.