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Background: Since the 1990s, the relocation of psychiatric patients from long-stay institutions to community-based supported living has increased globally. However, most evidence on suitable residential services comes from high-income countries, with little from low- and middle-income contexts. This study explored the experiences of residents and carers in three residential care homes for people living with serious mental illness in Sedibeng District, South Africa. Methods: Three organisations were purposefully selected as in-depth case studies. Ninety-one face-to-face qualitative interviews were conducted with service providers, residents, and family members between October 2022 and June 2023. Findings: Residents described severe psychosocial disability when living with families, but improved functioning in residential homes. Organisations 1 and 3 operated small 3-4-roomed houses in township areas, accommodating 21 and 40 residents respectively, who had community access and social interaction. In Organisation 3, residents formed romantic relationships, undertook paid work, and lived semi-independently. Organisation 2, a repurposed school-like building with four large dormitories for 86 residents, imposed strict movement controls; medication was used to manage behaviour, and caregivers reported safety concerns. Conclusions: Smaller residential homes offer more autonomy and integration than large dormitory-style facilities. Policies and funding should support smaller, community-based supported accommodation for people with serious mental illness.