- Care home
A M Care Home Limited
We served 2 warning notices on A M Care Home on 18 February 2026 for failing to meet the regulation related to good governance (Regulation 17) and need for consent (Regulation 11).
Assessment report published 18 March 2026
Contents
Ratings
Our view of the service
Date of Assessment 27 January and 30 January 2026. A M Care Home is a residential care home, providing accommodation and personal care to adults under 65 with a range of support needs, including those living with mental health needs, autism and learning disabilities. The service can accommodate up to 8 people, at the time of our assessment 6 people were living at the service. People were supported across a large house that had in the past been two separate residences. We inspected this service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
At this inspection, the quality-of-care people received was mixed. While people were supported by a staff team described as kind and caring, and improvements had begun under new leadership, there remained significant shortfalls in safety, effectiveness and governance that impacted the overall quality of care.
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.
People's experience of this service
During the inspection, we gathered people’s experiences through telephone interviews with five relatives and through a Short Observational Framework for Inspection (SOFI) undertaken during the evening meal period by our inspection team. Overall, feedback indicated that people were content living at the service and felt safe and well supported by staff. Relatives consistently described improvements since the new manager took up post around eight months ago, noting increased stability within the staff team and a more positive atmosphere in the home.
People and their relatives said staff cared for people and kept them safe. Comments included that staff were “very good” with people, and several relatives described long-standing staff members who had built trusting relationships with people. One relative explained that their family member, "Is well looked after without a shadow of doubt" and said they felt staff genuinely cared. Another relative described the home as “a regular home from home.”
However, experience of communication varied. Some relatives said they only heard from the service when there were health concerns or emergencies, while others described regular updates and proactive contact. Several relatives stated they had not seen newsletters, questionnaires, or general updates about the home for some time. Some said feedback was not always provided when they had completed satisfaction surveys previously. One family member noted that communication about their relative’s health, medication or daily wellbeing was limited, though this had improved following the appointment of the new manager.
People were supported to maintain their health and access professionals when needed. Relatives told us staff sought medical support appropriately, and people received routine healthcare appointments such as GP visits, optician reviews, and hospital care. In some cases, relatives felt confident that they were informed when health changes occurred, while others were unsure of what medication their relative received or whether external professionals were involved, indicating some inconsistency in communication. People experienced positive, warm interactions with staff. SOFI observations showed that staff engagement was positive, respectful and conducted at a relaxed pace.
People were observed being offered choices and supported sensitively during mealtime. When one person became upset after not liking their meal, staff responded with kindness, offering alternatives and helping the person to eat safely. Their mood improved as a result. Overall, the mood of people during the observation was mostly neutral with periods of positive engagement and only occasional low‑mood episodes.
People were supported to take part in activities they enjoyed. Relatives shared that their family members continued to access the community, including shopping trips, meals out, craft clubs and day trips. The SOFI observation also showed people choosing how to spend their time, including eating together, watching television, and listening to music. People appeared comfortable in each other’s company and spent time engaging socially.
People and relatives expressed strong confidence in the new manager. Many relatives described concerns about the home before the new manager’s arrival, referencing staffing instability and organisational issues. They felt the manager had brought improvements, increased staff stability and was working to rebuild trust. One relative said the manager was "putting foundations in place to steady the home." Relatives felt able to speak with the manager and said they responded appropriately to concerns.
Some relatives said they had not been informed about events, updates or changes within the service and had not received questionnaires or feedback. Others said they were engaged in annual reviews but did not always receive follow‑up information from social workers when reviews were held without them.
Despite this, most relatives described the home as a “happy place to visit” and said they would recommend it to others.