- Care home
Archived: Fitzwilliam Care Centre
We cancelled the provider registration on Mablethorpe Care Limited on 14 August 2026 because the registered provider failed to ensure they were providing safe, effective and person centred care. Risks to people were not identified or assessed. Medicines were not managed safely. Consent to care was not always sought or recorded and restrictions to people's movement were not implemented inline with the principles of the Mental Capacity Act 2005. Governance systems did not support effective oversight of the care, the environment or of staff skills gaps and development needs at Fitzwilliam Care Centre
We served a warning notice on Mablethorpe Care Limited on 2 July 2025 for failing to meet the regulations related to ensuring systems and processes were in place to assess, monitor and drive improvement in the quality and safety of the services provided. The health and safety of people using the service, the safe management of medicines and failure to manage risks that may arise during the delivery of the service at Fitzwilliam Care Centre.
Assessment report published 30 July 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
People were overall positive about the quality of their care. There was mixed feedback about whether people felt safe. Some people told us they felt very safe due to the staff team. However, other people told us they felt unsafe due to some staff and people living with dementia who would enter their bedrooms day and night when confused about where they were. People and relative told us they were not fully involved in planning their care. Several people described how staff treated them kindly and made sure any personal care was done sensitively, preserving their privacy and dignity. However, other people told us there was not always enough staff in the mornings and weekends, which meant they had to wait for support. They said the service provided some activities to keep people physically and mentally active but most people were distressed that they were unable to go outside of the home and into the local community. Some people could not directly tell us about their experience. We used a structured observation tool to assess whether they received good care. This approach showed people were included and listened to and staff consistently interacted positively with them. People did not all feel able to complain as they told us they feared repercussions. People knew staff well but people was unable to say who the manager or owner was. While people expressed general satisfaction with their care and treatment, our assessment found elements of care did not meet the expected standards and this placed people at risk of avoidable harm.