A M Care Home Limited

“People and their relatives told us they felt safe, and staff demonstrated a clear understanding of safeguarding processes. However, systems designed to keep people safe were not consistently effective. We found concerns in key areas of practice including medicines management, recruitment checks, environmental safety, and the monitoring of risk. Some people were subject to restrictions on their liberty without the appropriate legal safeguards in place, demonstrating a failure to apply the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) requirements consistently. Incidents and behavioural records were not always reviewed or analysed to identify learning or to improve people’s care. These issues meant people were not consistently protected from avoidable harm.”

“Although some staff worked well with external professionals and supported people to access healthcare, care plans and reviews were not always developed with people themselves or their representatives. Inconsistencies in the use of evidence‑based practice were found, particularly for people experiencing distress. Records did not always show that alternative de-escalation strategies had been attempted before administering as needed (PRN) medicines. Opportunities to learn from feedback sought through the providers quality assurance processes were missed, and outcomes for people were not always monitored or reviewed to drive improvement. These concerns reduced the overall effectiveness of the care being provided. Despite these issues, we observed caring and respectful interactions between staff and people. Feedback from relatives and professionals reflected that staff treated people with kindness, dignity, and compassion. The atmosphere in the home was relaxed, and people were supported to take part in activities they enjoyed. Staff knowledge of people’s preferences and interests contributed positively to people’s daily experiences.”

“The leadership of the service had undergone recent change, and many relatives and professionals reported visible improvements since the new manager took up post. Staff described leaders as approachable and supportive. However, governance systems remained ineffective, and key areas identified by the local authority in 2025 had not been resolved. Audits lacked oversight, actions were not followed through, and monitoring systems did not provide adequate assurance of safe and consistent care.”

“While caring practice remained a strength and some progress had been made, the service must improve safety, effectiveness and governance to ensure people consistently receive safe, person‑centred care.”