- Care home
Archived: 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 24 December 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
During the inspection, we spoke with 13 people who lived at the service and 19 relatives. We also observed how people and staff interacted and the support they received. Feedback we received was mixed and varied greatly from people who lived downstairs in the older people units to those who lived upstairs in the mental health units.
Some people downstairs expressed some concerns about staffing levels, quality of care, food and how people spent their time. They also expressed dissatisfaction with a lack of communication from the manager and some staff. However, other people living downstairs told us they were happy living at the service, were treated well by the staff team and felt safe. While people living downstairs expressed general satisfaction with their care, our assessment found that although some improvements had been made, care did not meet the expected standards.
Feedback from people living upstairs was all negative. They did not feel safe or supported and some people told us they were actively making plans with their social worker to move to alternative services.
People did not always feel able to raise concerns or complaints as they did not always feel confident, they would be listened to, or confident appropriate action would be taken. People told us they felt communication was poor and they were concerned about issues with medicines not being managed safely.
Most people were not aware of their care plans and told us they had little or no involvement in reviewing their care and treatment. When people needed support due to feeling distressed, some people told us they could not always access this support when they needed it.
People told us there was a lack of meaningful ways to spend their time and staff did not encourage them to learn new skills to develop their independence.