A M Care Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to medicines management and how these are monitored and how distressed behaviours are managed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Staff did not always investigate and report safety events effectively. Lessons were not always learnt to continually identify and embed good practice.

Safety incidents were being reported and recorded but did not demonstrate a full review of the incident to identify root causes, inform future actions to mitigate risk and improve outcomes for people. For example, 3 behavioural charts for a person using the service were completed by staff in December 2025, these however did not capture the relevant details as stipulated in their care plans. There was no evidence that management had reviewed these charts either. As a result, lessons were not learnt or, strategies put in place to support this individual in an effective, safe, and proactive way.

A local authority inspection of the service was conducted in July 2025, where several issues were highlighted to the current registered manager who had recently started at the service, some of these issues included capturing consent to care and treatment, gaps in recruitment checks and ineffective and inconsistent quality assurance systems. Despite having these issues identified in July of 2025 we found similar issues and breaches of regulations during our assessment on the 27 January 2026. However, there were noted improvements made to the service by the new registered manager and some recommendations had been actioned.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked well with other professionals in assisting transitions, for example one person that they supported required support in a hospital setting, this required an assessment and planning to minimise distress and support the individual directly. They worked directly with the hospital and allocated social worker to make this a success. The social worker involved in the process told us “Service understood that the transition into a hospital setting for my service user would be incredibly distressing, so they initiated 1:1 hours for the service user’s mental health and stability. This was a call that I backed as social worker.”
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. In addition to what has been outlined in other areas of this report we found that people were not always supported and cared for within fundamental legal frameworks.

There were 3 people at the service who were subject to restrictions that had not been properly assessed by the relevant statutory bodies, this failure to adhere to safeguards put people under restrictions that were not appropriately scrutinised and therefore we could not be assured peoples liberty was safeguarded in all cases.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. Risk assessments were not always developed with people using the service or with input from relevant professionals.

Risks assessments relating to people’s health and potential risks were not always as detailed as they needed to be. For example, one risk assessment detailed the support a person needed to access the community but lacked detail for staff to effectively support this person in line with their needs and risks. It was also, unsigned and undated by any individual, and failed to capture the persons views and wishes.

We identified two individuals who were having restrictions placed on them without the appropriate legal frameworks in place, for example mental capacity assessments (MCA) had not always been completed, we also found that where people were subject to some restrictions for their safety, deprivation of liberty safeguards (DoLS) orders had not been sought consistently.
 

The provider did not always control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Whilst the provider had systems in place to assess the environment, for example in weekly environmental audits staff did identify issues to be addressed, however these audits were not consistently reviewed by management and remedial action was not always taken.

The registered manager showed us a system in place with a maintenance book that outstanding works could be added to, however this also was inconsistent and did not match with the audits the service had in place.
 

The provider did not have robust systems in place to ensure that necessary checks and records were in place, though there were enough qualified, skilled, and experienced staff.
We found issues relating to recruitment checks, references were not verified consistently, there were unexplained gaps in employment found for one staff member.

We also found that the provider did not always follow their own recruitment policies and procedures, the registered manager informed us that a DBS check is done routinely every 3 years, however when we observed the matrix that had been prepared, we found that at the time of the assessment that 5 staff member had DBS that were over that time frame, one by over 4 years.
When we spoke to the registered manager about this, they confirmed that there were no current staff file audits in place, they assured the inspection team they would be implementing this.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

We found that the environment was clean and well presented, staff received training for the prevention of infection and control. The home had a dedicated laundry area and people were encouraged to do their laundry with staff support. Family members comments included, “Yes, the room and home seem to be well cleaned,” “The home is beautiful; I love going into the home as I love the smell of the washing” and “Yes, the home is well cleaned and maintained”

We observed staff assisting people to access and use hand washing facilities effectively and prompting where necessary.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff did not always involve people in planning.

We found that there were audits and systems in place to manage and store medicines safely. However, we found PRN medications were not always administered safely or effectively, we found concerns with how the service managed one person’s PRN medicine. There were inconsistencies between the PRN protocol and the (Medicine Administration Record) MAR. The PRN protocol stated that only one tablet could be given in 24 hours, while the MAR stated that one to two tablets could be given in the same period. This inconsistency created a risk of the medicine being used unsafely. When the PRN medicine was administered, staff did not always record the dose given. Records did not show whether the medicine had been effective meaning medicines were not carefully monitored.