Tamar House

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 good. At this assessment the rating has changed to 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.

The provider was in breach of legal regulation in relation to good governance.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We discussed with the nominated individual and manager that the service was currently not registered correctly in line with people’s primary diagnosis. They told us, they would discuss this with the provider.

Prolonged instability in leadership and a lack of effective provider oversight meant staff did not have a clear sense of vision, priorities or accountability. Staff and relatives described uncertainty about leadership and decision-making. One relative told us, “I worry about the culture of the service”.

Staff told us frequent changes in the management team and limited visibility of senior leaders had led to uncertainty and a reactive culture, rather than one driven by shared values. Some staff described relying on their own commitment to people rather than guidance from the organisation. Relatives also told us they lacked confidence in the service’s direction.

Although a new manager had recently begun to stabilise the service and improve communication, this was too early to demonstrate a positive culture was embedded or shared across the staff team. Improvements relied on individual effort and had not yet translated into a consistent, organisation‑wide direction.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The home had been without a registered manager for over a year, and staff and relatives described the impact of repeated leadership changes on care delivery, communication and staff confidence. There was a lack of evidence of provider oversight.

A staff member told us, “I’ve had residents crying to me constantly because managers have changed. Since (Manager’s name) has been started i can see that there is light at the end of the tunnel. Residents trust me and ask if (Manager’s name) is staying. I am trying to give reassurance. We get no support higher up from the committee (Provider)”.

A relative said, “The general consensus is that the committee (Provider) are not responsive”.

The current manager was visible, approachable and described positively by staff and professionals, who told us they listened to concerns and was acting to improve training, staffing and care planning.

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

Relatives also told us they did not always feel listened to or reassured when raising concerns, particularly during periods of management change.

Staff told us concerns raised with senior management or the provider were not always addressed, which led some to escalate issues directly to external agencies. Since the current manager’s appointment, staff said they now felt more able to raise concerns within the service and felt listened to locally.

We saw records of resident and relative meetings as well as recent surveys.

The manager valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The manager actively promoted equality, diversity and inclusion for both staff and people using the service. The manager demonstrated respect for different cultures, religions, backgrounds and pronouns.

Most staff had completed equality and diversity training. Staff did not raise any concerns in relation to equality and diversity.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes to monitor and check the quality of care to ensure the service complied with the regulations were either missing, incomplete, lacked clear actions, timescales and accountability. For example, the service improvement plan was not dated; some actions had completion dates from 2025, however we identified concerns remained.

The provider failed to implement their policies in relation to falls prevention and management and quality assurance.

Governance processes, such as resident of day checks, failed to translate in to action. For example care plans were not always accurate, complete and contemporaneous.

There was limited evidence of effective provider oversight, which meant the provider was slow to respond to risks relating to staffing, the environment and quality of care.

The service had been without a registered manager for an extended period, which contributed to a lack of continuity and effective quality assurance. Although the current manager had started to introduce improvements and new monitoring processes, these were recent and not yet embedded. As a result, the provider could not demonstrate governance systems were effective or improvements were sustainable.

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

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

Due to some concerns identified at this assessment, in relation to ‘when required’ medication and catheter care. We found the provider was not always working collaboratively and in line with national guidance.

Professionals told us the manager was responsive and sought advice when needed. They also told us about multi-agency working, including liaising with health and commissioning partners, and the manager attending care home meetings, training and workshops.

The manager told us how they were working with local occupational therapists (OT) to support training of trainee occupation therapists, they explained the benefits for the local OT team and people using the service, as they were able to obtain advice and support promptly.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although some audits and improvement actions had been started, these were not routinely reviewed, tracked or used to drive sustained improvement.

Staff described recent improvements in training and support since the manager’s appointment, including new processes such as ‘resident of the day’. However, these approaches were not yet consistently applied or evaluated. As a result, the service could not demonstrate that learning and improvement were fully embedded or that changes were leading to sustained improvements in people’s care and experience.

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