A M Care Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance procedures to ensure effective and safe care delivery. There were risks identified over staff recruitment checks and ineffective quality control systems at the service.

This service scored 62 (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 had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff covered the company's vision and values during their induction; we observed staff working together with kindness and respect as well as showing kindness and respect to people at the service.

When we asked a staff member about the vision and values of the service, they told us “We have the values in the office in a folder. Compassion, love, quality of life are some of the values mentioned.”
 

The provider had inclusive leaders at all levels who embodied the culture and values of their workforce and organisation. They did so with integrity, openness, and honesty. We found that leaders of the service engaged with our inspection team in an open, honest, and transparent way including in our dealings with the registered manager and nominated individual.

The new management at the service was well reported on by professionals and family. 1 family member we spoke to told us, “Would definitely recommend the home with [registered manager] in charge”, another family member told us “I think [registered manager] is putting foundations in place to steady the home.

An advocate who supports a person at the service told us about the registered manager “Since [registered manager] has been in post things have improved and are coming along nicely.”

Leaders were accessible, management was on site and staff said they felt free to approach them, the director and nominated individual were also easily accessible at the service. A staff member told us, “We have the director’s phone number on our work phone, and he comes in every day.”
When referencing the nominated individual, the registered manager told us, “I get support from [nominated individual] to improve the home environment and he is responsive and does it straight away.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had a good knowledge of whistleblowing procedures and were able to tell us how they would keep people safe by speaking up.

One staff member told us, “I feel like I am able to raise concerns I don’t feel like my job would be in danger.”

Another staff member recounted how they had a disagreement with a staff member and they sorted it through open and honest communication to ensure that they focused on what mattered most “the people.” The manager supported us in this, and everything was sorted out immediately.

The provider had policies in place to support whistleblowing and freedom to speak up.
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

When we carried out our assessment of the service, we noted that the provider had a diverse and varied workforce. Recruitment practices were followed based on guidance of equality and inclusion. The provider also had policies and procedures in place to cover this.

When we asked a staff member about equality, they told us, “Everyone has equal right no matter the circumstance, you have to give everyone respect and look after everyone the same way. No matter, the colour, language disability all have equal rights.” Another staff member told us that “Generally everyone gets on well together.”
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. We found concerns around governance procedures for example we found that issues highlighted in weekly fire and control of substances hazardous to health (COSHH) audits were not reviewed and actioned appropriately by management. We reviewed 2 months’ worth of these audits and found that management routinely signed these to show as reviewed however issues highlighted and actions taken were left blank. The service was unable to show how these audits led to service improvement and were effective.

We found that actions recommended on monthly infection prevention and control (IPC) audits for November and December 2025 highlighted needed actions. These were once again signed as reviewed however the part of the audits that highlighted actions taken was left blank. We found that recommended actions in the audit had not been completed despite first being identified 2 months prior.

When we conducted random medicines check on 3 people’s medicines, we found that stock counts did not tally for 1 person’s medicine despite weekly and monthly audits. Weekly audits were not structured and were conducted at random, this meant that not all people’s medicines were effectively audited and provided limited oversight.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

A social worker who supports a person at the service told us “They work collaboratively with me and listen to ideas from me. For example, I suggested a local farm area that would be good for my [person] as she would not have to mobilise much but could still see animals and have an ice cream in summer, enjoying different scenery. They took note of this and stated that they would action this accordingly. The increase in wanting to go into community with my service user is huge progress, so we have worked collaboratively to increase 1:1 hours for community access. 1:1 Logs were provided in a timely and efficient manner.”

They also told us regarding care needs and reviews “They email when they feel a review of care needs is required and give evidence as to why they think this.”
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe practice.

In addition to points raised elsewhere in this report we found that the provider did not always learn from feedback or improve areas identified as concerns. For example, the local authority conducted a compliance inspection in July 2025 and highlighted areas of concern these included governance, staff recruitment files, compliance around MCA and DoLS and medicines oversight. We found some of these 6 months later, whilst some improvements had been made there was still significant shortfalls which had not been addressed in a timely manner.