What the CQC found at Tamar House Nursing Home

Medicines were stored and managed safely. Staff recorded when people declined medicines and told relevant staff.

“People's medicines were managed and stored safely.” from the report

The home had records about people's health and care risks. Emergency evacuation plans and fire safety checks were in place.

“Each person had a personal emergency evacuation plan (PEEP), in place, which described their support needs should the home need to be evacuated in an emergency.” from the report

People were offered choices about food and drink. Mental capacity assessments, best-interest decisions and applications for safeguards were in place where needed.

“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report

People's records included their health needs and oral health support. Staff raised changes in health with the nurse and contacted outside professionals when needed.

“Appropriate records of people's health were in place. This helped staff identify if someone's health was changing.” from the report

Some staff started work without references or satisfactory evidence about their conduct in similar roles. The home had not completed risk assessments to manage these gaps.

“One staff member had been recruited and started work, even though no references had been sought.” from the report

Care staff were also covering cleaning and laundry, including when the housekeeper was away. This reduced the time available for care, and at times there were only two care staff to support nine people who needed two staff to move.

“The provider had not ensured staff were deployed effectively.” from the report

Some areas were unclean and cleaning records were incomplete. Towels, bedding and a damp pillow were left in ways that increased the risk of cross infection. Some staff had not completed recent infection-control training.

“Staff had left some people's clean towels on the floor outside their door, some bedding had been left on a side table in a corridor and a damp pillow left to dry on a bath chair.” from the report

Some people were not positioned safely or comfortably to eat. Staff gave limited encouragement and checks to people who could eat independently but still needed support.

“One of the people, whose food was on an overbed table had resorted to eating a stew with their hands because the table was to the side of them and they were too low down in the bed to use their knife and fork.” from the report

Many staff had not completed or updated training relevant to their roles, including nutrition, hydration, fire safety, food hygiene, infection control and safeguarding. Agency nurses' training and skills were not confirmed in writing.

“Not all staff had up to date infection control or safeguarding training.” from the report

Carpets were worn and corridors and bathrooms needed redecoration. The provider's checks had not identified or fixed important problems, and there was no regular system for gathering and reviewing people's views.

“The provider had failed to assess, monitor and improve the quality of the service.” from the report