Archived: Fitzwilliam Care Centre

Date of assessment: 1 to 24 October 2025. We visited the service on 1, 5, 6, 7 and 9 October 2025. Fitzwilliam Care Centre is a residential care home specialising in providing support to older people, people who were living with dementia, people with mental health conditions and people living with physical disabilities. Several people who lived in Fitzwilliam Care Centre had additional support needs because of alcohol and/or drug misuse.

At the time of the inspection there were 18 people being supported on the ground floor. 23 people living on the first floor were living with complex mental health conditions. However, only 11 of the people on the first floor were being supported with the regulated activity of personal care. CQC only look at people’s records if they are in receipt of the regulated activity.

The provider was registered to provide the regulatory activity of treatment for disease and disorder (TDDI). However, the provider has now had this removed during the inspection as they were not delivering this in practice.

An assessment has been undertaken of a service that is used by autistic people or people with a learning disability but is not registered as a specialist service. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgments 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.

We carried out this inspection to follow up on actions we had told the provider to take at our previous inspection. We also followed up on new concerns we received about the support provided for people. We shared these concerns with the provider and commissioners of that care.

The provider was previously in breach of the legal regulations in relation to person centredcare, safe care and treatment, governance and safe staffing. Sufficient improvements were not found at this inspection, and the provider remains in breach of these regulations. ​At this inspection we found the provider was in breach of 9 legal regulations. New breaches of regulation included consent, safe environments, safeguarding, failure to report notifiable events and failure to comply with conditions of the provider registration.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People were not consistently safe. Recruitment had improved, but staffing remained insufficient for safe care, especially during outings or emergencies. Medicines management showed progress, but stock errors and missed doses continued, risking incorrect administration. Clinical procedures like PEG care lacked oversight by competent staff. The environment was clean but not dementia-friendly, with unresolved hazards such as broken doors and fire alarm faults. Safeguarding was inconsistent, with incidents under reported and little evidence of learning. Staff lacked skills in consent, mental health monitoring, and distress response. Care plans and risk assessments were not person-centred or consistently accurate. Training lacked competency checks and follow-up.

Care was not always effective. Needs were assessed before admission, but care plans often failed to reflect this. Health outcomes were recorded, but daily notes lacked context and a holistic approach. Nutrition and hydration monitoring was inconsistent, putting vulnerable people at risk. Staff knew when to seek external advice, but care plans lacked contact details. Professionals raised concerns about documentation and transparency, though some improvements were noted.

The service was not consistently caring. Some people and relatives described staff as kind, while others reported dismissive behaviour and unmet needs. Independence and meaningful choices were not always promoted, especially around meals and activities. Staff experiences varied, with some feeling supported and others reporting high pressure and poor mental health due to workload.

Care was not always responsive. Outings and activities were limited despite available resources. Planned staffing changes to support engagement were not implemented. Some people feared speaking up. Sensory needs were unassessed, and care plans lacked detail and person-centred approaches. Documentation sometimes used disrespectful language. Health services were accessed, but experiences were not reviewed, and involvement in planning was minimal. End-of-life wishes were documented, but future health planning was absent.

Leadership remained ineffective. The manager lacked understanding of regulatory responsibilities and best practice. Audits were poorly overseen and missed key risks, though provider-level audits had been introduced. Only part of the improvement plan was completed. The service operated without a registered manager and supported individuals outside its registration scope. Safeguarding concerns persisted, with failures to notify CQC and limited understanding of duty of candour. Staff reported good diversity and respect for cultural and religious beliefs.

Date of assessment: 12 May and 19 June 2025. We visited the location on 12, 20 and 22 May 2025. The service is a residential care home providing support to adults of all ages living with dementia, mental health conditions and physical disabilities. This assessment was prompted by risks we were made aware of in relation to medicines, quality of care, staffing, risk management, good governance and safeguarding. An assessment has been undertaken of a service that is used by autistic people or people with a learning disability but is not registered as a specialist service. We have assessed the service against ‘Right support, right care, right culture’ (RSRCRC) 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.

There had been changes in the management team resulting in instability of management. There was no evidence of effective oversight of the service at provider level. The service did not have a registered manager and the nominated individual who also acted as manager left the service during the assessment. There was a new manager in post who was in the process of applying to CQC to become registered. The management team had been working with local authority professionals to make improvements and develop a better understanding of what good care looked like.

People were not always protected and kept safe. Managers investigated incidents but lessons learnt and measures to reduce future risk were not always recorded. The provider did not always have a good learning culture and some people told us they did not feel able raise concerns. Risks were not always identified or managed safely and staff did not always understand how to safely support people to reduce the risk of avoidable harm. Staff did not manage medicines well and people were not always involved in planning any changes.

The facilities and equipment met people’s needs, were clean and well-maintained, however, the building was being reviewed for structural concerns and was not designed or decorated in ways that supported people living with dementia.

We observed some positive interactions between people and staff and saw that people were treated with kindness. However, there were not always enough staff with the right skills, qualifications and experience available at busy times, which resulted in delays to care needs being met. Managers made sure staff received training but there was no evidence this was followed up to check staff knowledge and practice except for medicines and moving and handling. Staff told us they felt supported by managers and diversity and equality was promoted

People had enough to eat and drink and were supported to stay healthy and access health professionals as required.

The provider was in breach of the legal regulations relating to ensuring the environment, care and staffing were safely delivered. We also found concerns in the effectiveness of the quality assurance systems and manager and provider oversight of the service. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. We have asked the provider for an action plan in response to the concerns found at this assessment.