Archived: Fitzwilliam Care Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider was previously in breach of the legal regulation in relation to person centred care. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 36 (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 did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. People’s assessments and care plan interventions for management of mental health conditions were poor. In some cases, risk assessments referring to poor mental health and anxiety documented either contradictory information or no risk, despite numerous references within other assessments that a person experienced periods of poor mental health and distress.

People with a history of anxiety, particularly where it had led to withdrawal from social situations and activities, and had the potential to affect physical health, did not have personalised care plans that reflected the specific impact on their wellbeing or provided guidance for staff on how to offer appropriate support. Instead, documentation merely included generic links to websites about anxiety, which did not equip staff with the necessary information to deliver person-centred care.

People’s care plans relating to physical conditions and how to manage these safely, were written in a person-centred way. Staff could access the care plans and understand how people liked to be supported with certain personal care tasks such as washing and dressing.

People who might require them had not had their sensory needs considered or assessed. If people have hyper or hypo sensitivities, this could significantly impact how they need to be supported to cope with their environment and could have a negative effect for their mental health. One person told us they struggled with sensitivity to light and found the lighting on the service very difficult to cope with. Another person told us they had sensitivity to noise. A relative told us their family member had a sensitivity to touch and smell. These had not been identified in people’s care plans and there were no strategies identified to support people to cope.

Language used in care plans promoted a lack of respectful tone and equity. Terms such as challenging behaviour, toileting, resistance to care and 'well-behaved' were unhelpful and did not support staff to recognise the function of a person’s reaction or responses when distressed or unwell.

Daily notes reviewed demonstrated a lack of structure for people and a lack of opportunity for learning or social interaction. There was also a lack of understanding of what constituted an activity and a lack of information about why something was assumed to be a 'social/physical/emotional benefit'. For example, one person spent a day smoking in their bedroom or the balcony and then walking around the unit knocking on other people's doors asking for cigarettes. This was logged in their care notes as an activity having a social benefit.

The manager told us people could spend their time in group activities, with visitors or having chats as well as the opportunity to go out into the community utilising the new minibus. However, 1 person told us, “Could not ask for better staff but they are restricted in what they can do concerning trips or outings. Do not know why but look at the back of the menu on the table, it says activities, but it is for June and the activity board is empty.” We could also only find evidence of the new minibus being used twice since it’s purchase in June 2025. A person said, “I really would like to go out and yesterday they opened the lounge door a little, fresh air smells nice.” One relative told us, “[People] don’t do a lot of activities and there is no entertainment. [Managers] don’t want to employ an activity person. People watch the TV”.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

People told us they felt they did not always receive the care and treatment they needed.One person told us, “I said that once and to the manager [about doing my activity] and they said the [staff] would be taking me, but the [staff] didn’t know. And that is where the problem is, the manager promises a lot, but it never happens, they don’t arrange it.” A relative said, “I would not have put my [family member] in there if the mental health unit had been there. One [person] came down really angry and the receptionist had to deal with them. Now, [my family member] will only go down to reception for a cup of tea and cake once they have checked who is there first. There are often mental health residents standing outside and it can be a bit awkward.”

A professional told us, “Core 1:1 hours have been a concern. This has been previously discussed around ensuring that the home is documenting 1:1 hours that are taking place along with ensuring that [documentation is clear].”

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Information on menus and notice boards were not always up to date, which meant people did not always know what was on offer. People's daily care records named other people living at the service and negative interactions. This was not in line with best practice around data protection as these were personal notes. Language used in case notes was at times condescending, for example, ‘[They] were well behaved’.

Most relatives felt communication was poor and relevant information about their family member was not always shared with them. One relative said, “[Staff] don’t keep you in the loop. Things like falls they tell me, but other smaller things I am not told about and I find out when I see the bruises, usually because [my family member] has had a knock.” Another relative told us, “Nobody is telling me anything. It always felt like you don’t need to know. The last time I got any information about [my family member] was early September. I don’t get told if [my family member’s] not well or if they have seen the doctor.”

We observed a staff member who was attempting to source systems to support language that used a combination of signs, symbols and pictures. This was to aid communication for a person who struggled to communicate verbally. This was a positive initiative by the staff member; however, this person had not been referred for specialist professional advice and support such as a Speech and Language Therapist and there was no plan in place to ensure structure for learning for all staff alongside the person to ensure all staff could use the communication system and understand any signs being used.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. The provider had recently had meetings with those who wanted them and there was a suggestions box in reception. Minutes of relative’s meetings shared with us by the manager referenced events from 2024 as if they were current day and about to take place. This meant we could not be confident these were correct.

Staff did not involve people in decisions about their care or tell them what had changed as a result. People and relatives told us they had not attended care planning meetings. People told us they were not aware of their care plans.

Not everyone felt comfortable to raise concerns or confident that action would be taken to resolve them. One relative told us, “My complaint was not acknowledged.” A staff member told us, “I know we get complaints, as the manager will say, ‘Please make sure so and so's notes are extra good at the moment, as they've put in a complaint’.”

Staff recorded peoples expressed words of distress, such as wanting to harm themselves, but the language used was dismissive. People who had clear indicators of declining mental health recorded, could not be confident that staff would monitor this well or take action when these indicators were identified. This left people at serious risk of avoidable harm.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it. Most people confirmed they were able to see the doctor or other medical professionals if they needed but not everyone could access local community facilities when they wanted to.

We received concerns from the police service about people in distress in the local community and staff not being available to support at the time they needed it. Record keeping was inconsistent about outcomes and any follow up in these instances.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. People were supported to access local health services but there was no evidence of how their experiences were reviewed or analysed. It was unclear how people were being supported to discuss what outcomes they wanted to achieve or how staff were supporting them to achieve these. People and relatives told us they had little to no involvement in reviews of care.

Whilst there were opportunities for people to be involved in social engagement, this did not always interest people, and it was unclear if any alternatives were offered. As a result of sometimes going longer periods of time without staff interaction, people’s experiences at the service were sometimes not as positive as they could be. Safeguarding incidents not being identified, people not being supported by trained and competent staff and people not always being supported in a person-centred way or with dignity and respect as explained through this report, meant people were not always supported to have good outcomes or experiences.

A relative told us, “[My family member] was showing signs of neglect, they were not getting their hair cut, even though I was leaving the money for it and their nails were like claws. I wrote a letter complaining and they said they would try and do more and keep to appointments, but they have not kept to any of it. In the home [my family member] was depressed but now [having been elsewhere] they are back to their happy, cheeky self.”

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future. People who wished to discuss plans for the end of their life or serious illness had done so and this was recorded in their care plans. However, there was a lack of planning for people about how to stay healthy and future care and treatment plans. This meant people had no aspirations recorded or had limited information about how to stay healthy and well.

Some people told us they wished to move into more independent living accommodation in the future but there was no evidence staff were involved or supporting people to understand and plan for this process. Staff were not supporting people to develop independent living skills or supporting them to develop practicable and meaningful goals to achieve their aims.