Tamar House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safe care and treatment and staffing.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Although incidents and accidents were recorded, some had not been reviewed or signed off by the management team. There was no consistent system to analyse themes and trends or to evidence learning over time.

Staff told us the manager was open and responsive and was beginning to introduce improvements, including new training and oversight arrangements. However, these systems were not yet embedded.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Assessments and care plans were in place, but some lacked clear guidance for staff, including escalation pathways for changes in people’s health.

Relatives gave mixed feedback. Some felt communication and planning had improved, while others described poor coordination and lack of involvement during significant transitions, including discharge and placement endings. These issues increased the risk of people experiencing unsafe or distressing transitions.

Pre-admission checks were completed and the manager told us they would visit the person to ensure they were suitable for the service. A staff member told us some people deciding to move into the setting, visit for lunch and an afternoon first, as they recognise this was a big decision to make.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Relatives gave mixed feedback about how concerns were handled, with some saying they did not feel listened to or taken seriously by the provider.

Systems to manage people’s money were unclear, with a lack of consent records, audits and defined responsibilities. We discussed an issue with a person not having access to their money. On the third day of our site visit, the manager and staff told us the person still did not have access to their money through the provider’s systems. However, they had supported the person to purchase what they wanted.

Staff and professionals described a period of management instability which affected morale and confidence in raising concerns. One staff member told us they had previously escalated issues directly to the local authority safeguarding, due to not seeing any action being taken within the service.

We saw records of safeguarding concerns being raised when identified.

People could only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The manager had applied for DoLS appropriately to the local authority and in line with the Mental Capacity Act 2005.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Most people had risk assessments, but some were missing or lacked detail, including clear control measures. For example, we identified a person with a risk of choking did not have an associated risk assessment. We also identified a person’s daily records did not always evidence people were having a modified diet. We discussed this with the manager who told us, people do receive their modified diet, however it was not always recorded correctly within daily records.

A relative told us, they had identified risks within a person’s care and discussed this with staff, however appropriate action wasn’t taken, and the person remained at risk. Some relatives told us they were not involved with peoples care plans and risk assessment.

This contributed to a breach of regulation in relation to safe care and treatment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Fire risk assessments identified actions that had not been completed or adequately risk‑managed, including long‑standing recommendations to upgrades to the fire systems. Some fire doors were not managed as required, and fire drills were not consistently evidenced for all staff, including night staff. We saw records of concerns with the fire system being escalated to the provider, but no evidence of action being taken since it was identified in 2021. A staff member told us, “I take the worry home with me, regarding the fire system”. Following our site visit, we shared our concerns about fire safety arrangements with Devon and Somerset Fire and Rescue Service.

This contributed to a breach of the legal regulations in relation to safe care and treatment.

Staff and relatives raised concerns about delayed repairs, equipment safety, and environmental risks. Comments included, ‘We would raise concerns and nothing was being done. There was a seat that wasn’t going down in the bath, it was only responded to when there were lots of the same complaints and no option but to do something”, and “The bleep system was not working. I kept reporting this, but nothing was done. It was faulty for a few months”.

Routine checks such as weekly fire testing, equipment checks and legionella testing were being completed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People and relatives told us reliance on agency staff had affected continuity of care. A staff member told us, “They do get agency workers in when staff are low and I see that this impacts residents. Not all the residents want to be supported by a stranger. They prefer to be supported by familiar faces and people they know”.

Recruitment processes were not always robust, with gaps in employment checks. We saw one staff member did not have 2 references in line with the provider’s policy.

Some relatives told us they had no confidence with the provider’s recruitment process in relation to the management team and senior staff within the service. They explained a situation where they had questioned the integrity and knowledge of staff. Comments included, “It was a lack of training and lack of awareness of dignified care”, and “The staff member was so unhelpful and didn’t know (Person’s name)”.

Staff told us they had not consistently received supervisions or appraisals. Records confirmed this. We discussed this with the manager, who told us they were planning to implement regular supervisions.

Training had increased under the current manager, however the service support people who were living with dementia, not all staff had training relevant to support these people. There were support topics relating to people’s needs where staff had out of date or no training. For example, mental capacity, fire safety and infection control.

This contributed to a legal breach of regulation in relation to staffing.

We saw records of Disclosure and Barring service (DBS) checks, as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

We observed staff visible in the home and supporting people in a timely manner.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Cleaning schedules and checks were mostly in place, and we did not observe offensive odours. However, records did not always demonstrate communal areas were consistently monitored. Systems to monitor compliance and learning from IPC audits were still developing and not yet fully embedded.

Staff had access to PPE and understood basic IPC principles. Staff had COSHH (Control of Substances Hazardous to Health) records available.

Relatives told us the home was tidy and clean.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were stored securely, and staff had completed medicines training. However, there were missing PRN (When required medicines) protocols and incomplete MAR records. While leaders were aware of these issues and had begun to act, systems were not yet fully effective in reducing risk.

We observed a person saying they were in pain; however, their PRN (When required) medication was not available. Staff told us they would contact the GP.

This contributed to the legal breach of regulation in relation to safe care and treatment.

One relative told us, “When you go into the care home, they have all the medication in a room that looks out into the car park. The blind is always up and you can look through the window and see the resident’s pictures, names and room numbers”.

We received mixed feedback from relatives in relation to medicines management. Comments included, “I had to ask them to contact the GP (In relation to a person refusing medication and deterioration of health)” and “I think medicines are well managed”.