Archived: Fitzwilliam Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and safe staffing. Improvements were not found at this assessment, and the provider remained in breach of these regulations. The provider was also in breach of legal regulations relating to the premises and environment.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff did not fully involve people in managing their individual risks. Staff recorded incidents of distress on specialist event notes, aimed at recording distress and identifying the cause. This information should be used to help people and staff reflect on how to minimise future risks and distress. However, event forms were not completed, resulting in no analysis of information, evidence of involvement with people and additional measures taken to minimise risk to people.

Staff told us they were not supported to reflect on lessons learnt and records around analysing incidents and accidents did not record trends and lessons learnt. The manager told us this was recorded on monthly KPI audits. However, we found these listed actions rather than demonstrated how staff were supported to reflect on the incident and identify lessons to be learnt. A staff member told us, “If there's an incident, such as assaults, staff have to go back on shift straight after talking to the police. They don't get debriefs or checked to make sure they're ok to carry on. They have to carry on. Staff are excellent, but not management.” Another staff member told us, “Incidents are documented on care notes, then the manager is called. I have never had learning from incidents shared.” Other staff told us there were no consequences for anyone's actions. They said they were not allowed to use restraint and there was no support after incidents, no chats or de-brief and no monitoring charts done.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. Professionals told us they struggled to gain requested information and care plans. This meant important information was not always shared effectively.

The provider did not always manage or monitor people’s safety. For example, risk assessments were not always in place or updated and there were no details for contacting various health professionals involved in a person’s care.

The provider did not always make sure there was continuity of care, including when people moved between different services. Records were not consistently maintained and there was contradictory guidance about how to manage people’s health conditions taken from sources that were not considered best practice.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Feedback from people about whether they felt safe varied. People living downstairs were generally positive about their care, although there were some concerns raised about people still sometimes accessing their bedrooms making them feel unsafe. People upstairs told us they did not always feel safe due to the actions of other people living at the service and the numbers of staff available when incidents occurred. One person told us, “No [I do not feel safe], because there are too many [people intimidating me]. I am doing really well now and don’t want to spoil that as I feel I could end up losing my placement if I break the rules. The manager gave me a set of rules and told me if I break them, I will have to leave.”

Staff's understanding of safeguarding and what abuse looked like was mixed. Most staff were unsure of who they could report concerns to outside of the company and a number of safeguarding incidents had not been reported to CQC. A staff member told us, “Safeguarding is lacking. Lots of issues aren't taken seriously. A couple of people self-harm, 1 who is very suicidal. The main support they get is from phoning 111. They are meant to have 1:1 hours each week but have never had that. It is seen as inconvenience by the manager if staff spend time chatting with [people]. I think several [people] are inappropriately placed.”

Some people wished to have romantic relationships but were considered vulnerable and at risk of exploitation of others. However, where these risks had been identified there was a lack of information about how staff had engaged people in discussions around sexual safety and intimacy needs. People’s risk assessments, care plans, and subsequent daily care notes indicated a lack of robust engagement with people and relevant health professionals in this area. Care notes identified where inappropriate sexual behaviour had occurred in communal areas, however this was not investigated and measures had not been taken to safeguard people. Staff had not received training in supporting conversations around relationships and sexual safety with vulnerable people. Where people had alleged abuse, whilst these concerns were shared with external agencies, such as the police, this had not resulted in the provider increasing oversight and support for all people involved, including updating risk and care plans. This left people at continued risk of exploitation of others.

People with a risk of overdose but free to leave the service, had not been involved in discussions about how to keep themselves safe. For example, whether staff could request to search their belongings on return, if they had concerns about deteriorating mental health.

Staff had recorded in event records where people had pushed and threatened abuse towards others at the service. However, these records remained incomplete and did not identify the causes to the event or how staff were safeguarding and would continue to safeguard people from abuse. The manager did not always report or investigate safeguarding concerns following altercations between people at the service.

People’s mental capacity had been assessed but the records were brief and lacked information to evidence how the person was supported to try and understand the decision being discussed. It also lacked evidence about what was asked of the person to determine their understanding and what their responses were. DoLS authorisations were in place or applied for, however, they did not mention the locked doors downstairs in all cases. These were doors to individual units on the ground floor which were now locked following concerns raised at the previous inspection by people, about people living with dementia coming into their bedrooms. People’s mental capacity assessments did not always evidence how people and those important to them/independent professionals were supported or involved in the process and what their understanding and views were.

The CQC received repeated concerns from the police service about the safety of people living at the service, staff skill to support people in crisis and the openness of the manager to provide requested CCTV and other evidence to support their investigations into safeguarding incidents.

Another professional told us, “[A person] was reported to Safeguarding by us in June due to poor communication from the care home staff. They failed to inform us of bruising and injury (due to a series of unreported falls) and failure to identify possible signs of [illness]. There are a couple of other historical cases that spring to mind where residents were referred to us but we were not kept informed of falls or injuries likely to affect our treatment decisions. At least one of these also went through safeguarding as a result of general neglect. [There is a long standing issue of] poor communication from staff at the care home (carer and manager alike).”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

While care plans and risk assessment had improved for the people downstairs, additional information about people's health conditions was not person centred to show the impact on that individual and did not always follow current best practice guidelines. Risk assessments for people upstairs were not always in place for all risks, had not all been updated, despite significant changes to risks having occurred and those that had, often had contradictory information or lacked good guidance for staff. A staff member told us, “There's meant to be risk assessments in place but there's not the staff to sort that half the time. [We] learn by trial and error. We're often pinching staff from downstairs [as there is not enough].”

People’s risk assessments and care plans did not tell staff how they should manage peoples identified risks. Some people identified risks of abuse, distress causing risk to self and others were identified as high and had the potential to lead to avoidable harm. However, instructions of how staff identify triggers to risk, recorded risk and took action to minimise risk were significantly lacking.

Some people had a history of self-harming behaviour and expressing wish to end their lives. Some people had expressed these feelings to staff. However, staff records in care notes were dismissive and did not explore why people were expressing these concerns. Staff completed event records to document risk behaviours, but other than a description, the documents were blank and did not identify triggers, how to mitigate risk or what staff did to support people. People identified with a risk of causing themselves harm did not have a crisis management care plan in place to detail when and who staff should contact in declining health.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment, while clean and tidy and generally well maintained, lacked dementia friendly signage and design to support people to orientate themselves and prevent the risk of falls and distress.

People with a risk of causing themselves harm were often recorded as citing active risk whilst in their bedrooms. On one occasion we saw documentation in care notes that a person had used a chair under their door handle to prevent staff entering. On another occasion the master key had broken in the door of a person’s room preventing staff access, while the person threatened to harm themselves. The provider had not used these incidents to consider whether the existing environment was safe.

People at risk of harm from falls only had toilet frames instead of grab rails or other devices in their bathrooms. The manager and provider did not evidence how this had been considered in risk assessments. We expect all risks to be assessed and individual measures to reduce those risks identified and sourced to ensure people's safety and well-being.

The fire alarm panel displayed a fault throughout all inspection visits. The manager told us an engineer had been sourced but could not provide evidence of their visit and the fire fault remained a risk to people’s safety.

Two doors on 1 of the upstairs units were faulty, 1 leading to the dining room did not fit the frame and did not close unless pushed with great force. The other leading to the corridor of a unit had a broken lock mechanism with wires showing at the front top of the door. A provider audit showed this had been identified on 22 September 2025 but had still not been repaired on 9 October 2025. The manager was unable to tell us when it was due to be repaired or replaced.

The call bell system did not have a function for monitoring the efficiency of response times, so it was unclear how effective this was.

Relatives were concerned about the security of the building and people’s safety for those who were unsafe to leave without staff support. A relative told us, “I know the code to the front door so I don’t have a problem getting in. I went and visited [recently] and found the front door wide open and no one on reception. At a resident meeting in June the manager said they would arrange for relatives to go through the staff door or give them the code. The manager says they are going to do [things] and never does any of them.”

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Staff had received positive behaviour training but the provider had not ensured staff understood or embedded this training into practice. Staff documentation and management of people in distress was poor.

Staffing levels and/or deployment was still insufficient to ensure people could be supported to go out when they chose to or receive the appropriate level of support at times of crisis. A relative told us, “It’s been difficult. The home has deteriorated in the last 3 or 4 months in that the staff are rushed off their feet. [My family member] has to wait a while to go to the loo.” Another relative said, “There has been a decline in the care home. They are seriously understaffed, the phone is not answered, you have to wait for the door to be opened for you when you arrive and leave and getting people to attend to [my family member] is difficult.”

A staff member said, “People aren't getting their 1:1 time given to them but are told they are. [It is] letting [people] down and it's making the job hard. Some people are on constant 1:1 24/7, but for others, they're not getting the hours they're meant to. When inspections happen, there's lying to make it look different so it looks like we're better staffed than we are. It's not true.”

Staff training was mostly eLearning with limited evidence of competency checks for areas other than medicines. Medicine competency assessments deemed staff as competent; however, the manager told us the significant amount of errors in the medicines records was due to staff incorrectly recorded medications during administration. A staff member told us, “Everybody should be trained in my eyes. I have not had any training as part of this job. We would benefit for everyone to be trained.”

There was some follow up in supervision about areas of practice to improve upon, mainly for staff who worked downstairs but not for most. Some staff now had development plans in place but these were brief and did not highlight future aspirations or evidence how these would be achieved or how outcomes would be measured. Staff told us no-one discussed their learning with them. Supervision records we reviewed showed a lack of meaningful discussion or measurable objectives being set.

Recruitment processes were in place. There were two minor gaps in records which were rectified while the inspector was still onsite.

The provider assessed the risk of infection and shared concerns with appropriate agencies promptly. However, the provider did not always detect and control the risk of it spreading. For example, there was no information in care plans about how they managed or supported people to manage cuts and wounds, which placed people at risk of infection developing.

While we found no concerns in terms of the cleanliness of the service or how staff used personal protective equipment (PPE). Relatives told us they found concerns of this nature. A relative told us, “[My family member] came back from a hospital stay in a hospital gown and when I visited I found the soiled gown stuffed up a corner. A week later I visited and it was soiled behind the toilet, when I mentioned it staff did come in and clean it up.” Another relative told us of concerns they had about their family member’s bedroom. They said, “There is an overwhelming smell of urine, and the cleanliness of the carpet, shelves, and table is inadequate and unhygienic.”

The provider did not ensure medicines and treatments were safe or aligned with people’s needs, capacities, and preferences. People were not involved in planning. At the previous inspection, concerns were raised about safe care for a person requiring a PEG tube for all fluids and medicines. This delegated nursing task required clinical oversight and competency sign-off by a health professional. The manager stated this had been sourced but could not evidence any competency assessments or confirm a date for the nurse’s visit, only that they would attend “when they had time.” This placed the person at risk of harm if staff were not correctly trained.

Checks of stock balances for 15 people revealed inaccuracies for 9, meaning we could not be assured correct doses were administered. Failure to maintain accurate balances increased the risk of ill health.

Medicines management varied between floors. Downstairs showed improvement, with previous concerns addressed regarding medicine instructions, recording of temperatures, dates for opened liquids, and protocols for “as required” medicines. Controlled drugs were managed appropriately, with records showing regular balance checks in line with national guidance.

Staff qualified to handle medicines regularly completed checks to make sure that procedures were followed. However, the shortfalls we found during the inspection had not been identified.

We continued to find some inaccuracies of stock balances downstairs. A relative told us, “There have been issues around [my family member’s] medication. At one point they actually ran out, even though we had warned [staff] they were running out. I would also say the dispensing of medication is done more to the requirements of the staff than the requirements of [people]. [My family member] is supposed to have a tablet 30 minutes before a meal and often it is given to them in the middle of a meal.” Another relative had concerns about staff practice for administering medicines. They said, “I was there once when a member of staff just poured [my family member’s] medication into their mouth and called them ‘a good [child]’. It was so patronising and [my family member] is capable of doing that themself. I spoke to the manager who said they would have a word, but I was there the other day and [staff] did exactly the same.”

Upstairs, we identified significant concerns with the safe management of medicines, including high-risk medicines for epilepsy and mental health conditions. One person had run out of multiple medicines, posing a risk to their mental health. Stock balances were manually adjusted in the electronic system by the manager or delegated staff when incorrect stock balances were identified. The manager’s explanation that errors were due to staff input was insufficient. In 1 case, a record showing 250 tablets was dismissed as an admin mistake, with no evidence to support this. Although the manager investigated errors, root causes were not identified and no lessons were recorded to prevent recurrence.

Staff were unable to explain codes used in records and gave incorrect information about how medicines were returned to the pharmacy. The manager could not account for discrepancies in the system. During checks, 168 tablets for one person and 28 for another were missing. These were eventually located with inspector assistance, demonstrating unsafe storage and recording practices.

Staff were also concerned about medicines within the service. A staff member told us, “Medicines management needs to be sorted out. Ordering and communication about medication is [very poor]. I spoke with the manager about my concerns; they were brushed under the carpet and made out it was staff's fault. There's just not the training, teamwork or structure here. Medicines counts have started recently due to inspections. We had a 20-minute online course to learn how to do medicines counts. I am aware some [people] miss out on medicine or medicine goes missing. Sometimes staff don't sign it onto the system properly when it's delivered.”