Working at Tamar House Nursing Home

No registered manager in post yet, so leadership oversight has gaps like missed medication errors.

At the time of our inspection there was not a manager registered in post. However, the manager was in the process of applying to CQC to become the registered manager. The provider had failed to identify the concerns found... regarding medicines management and the monitoring of pressure relieving mattresses.

Daytime nurse role covered by agency staff, so less continuity in medication practices.

The service did not have a permanent nurse who worked during the day. This post was being covered by agency staff. Whilst the agency staff were mostly consistent there was little continuity of practice regarding medicines management.

Medication errors and missing checks on pressure mattresses make safety processes unreliable.

Systems and processes for medicines that required additional security were not followed. Records showed poor documentation... The failure of the provider to effectively assess, monitor and mitigate risks relating to the safe management and administration of medicines is a breach of Regulation 17... Air filled pressure relieving mattresses were not always set correctly... no process in place.