Tamar House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

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

This meant people’s needs were not always met.

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 always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People’s rooms were personalised and we observed familiar belongings in shared areas, which helped people feel at home. However, care plans were often task‑focused and did not always reflect what mattered to people, including their preferences, wishes, routines and up to date information.

Relatives gave mixed feedback. Some told us staff knew their family member well and treated them kindly. Others described serious concerns, including people being left in wet pads, undignified care, and personal preferences such as appearance not being met. One relative said they had found their family member “crying, confused, wet and naked”.

Staff told us person‑centred care had started to improve under the current manager. A staff member told us, “Person centred care means that I make sure that the person I support is being supported in the way they want. I uphold privacy and dignity by making sure doors and windows are closed, ask for consent, give them choice and knowing them personally”.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People and relatives told us agency staff were used within the service, they expressed this could influence the continuity of care. Comments included, “Staffing levels appear to be quite poor because agency is used. Eg can be 3 agency workers on duty at one time, nobody knows what’s going on, no consistency”, and “It went through a period of using agency staff a lot. They didn’t know mum’s needs and were slightly aloof compared to permanent staff”. However, most relatives recognised agency use has recently reduced.

A professional told us, “Tamar House makes referrals in a timely fashion. I have requested on a visit before that they liaise with district nursing team regarding a patient, and this was done on the same day in an appropriately timed fashion”.

People could access GPs, dentists, chiropodists, district nurses, SALT (Speech and Language Therapist) and other professionals when referrals were made.

The provider was able to supply appropriate information in formats that were tailored to individual needs.

The manager discussed being able to provide information in different formats when needed. Since 2016 all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard. The Accessible Information Standard tells organisations what they have to do to help ensure people with a disability or sensory loss, and in some circumstances, their carers, get information in a way they could understand.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

Some people and relatives told us staff and managers listened and acted when concerns were raised, and that meetings and feedback opportunities were available. However, other relatives said they lacked confidence in raising concerns, felt ignored, or believed issues were dismissed. Comments included, “The staff and management listen and take complaints seriously”, and “I feel comfortable raising concerns with the current manager, but I have no confidence in the committee (Provider)”.

Several relatives described feeling excluded from care planning and decision‑making, particularly during complaints or safeguarding concerns.

Staff told us they feel more listened to by the current manager and said this has begun to improve relationships with people and families.

The provider did not always make sure people could access the care, support and treatment they needed when they needed it.

We received mixed feedback from relatives in relation to people getting support and treatment when they needed it. Some relatives reported people having to wait and being left in soiled clothes. In relation to staff responding to people’s call bell, a relative told us, “Mum has said no, she is often left waiting for some time, particularly when on the toilet. I have also witnessed during weekend visits that call bells are sometimes left for extended periods”. However, a person living in the service told us, “Staff come when I need them”.

Some relatives told us they were excluded from involvement because they did not hold formal legal authority, despite being the main advocate or next of kin.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

While some people received kind, responsive care and enjoyed meaningful activities, others experienced poor outcomes, including undignified care, unmet personal needs and distress. Relatives described wide variation in quality depending on staffing levels, agency use and management presence.

Staff and relatives both linked poorer experiences to previous instability and lack of oversight. We found that monitoring of care quality was not robust enough to identify and address inequality in people’s experiences.

People were able to move freely around the home and access outdoor areas. We observed a person being supported to attend a family wedding and a relative told us, “The home has been very accommodating in supporting mum to attend concerts outside the home, which she greatly enjoys”.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Some end of life care plans were lacking detailed information, including what was important to people at that stage of their life, specific wishes relating to funeral arrangements, people’s decisions on who they would want present and what mattered to them personally.

The manager told us they were working on improving the care plans and the detail within them.

Relatives described distress where moves or placement endings were poorly planned and communicated.