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Tamar Manchester, a small domiciliary care agency supporting five people at the time of inspection, was rated Requires Improvement overall following its first CQC inspection, with breaches identified across Regulations 12, 17, 18 and 19 relating to unsafe medicines management, inadequate staff training and induction, unsafe recruitment practices, and ineffective governance systems. While staff were described as kind, caring and person-centred, and sufficient in number, systemic failures in oversight and training placed people at risk of harm.