Archived: Fitzwilliam Care Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was previously in breach of the legal regulation in relation to good governance. 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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider did have a framework and policy to state their values and the provider’s Statement of Purpose stated they provided experienced registered nurses and people were supported by a skilled team of health workers. In addition, that their values and aims included a personalised and holistic care plan, regular reviews and promoted community links ensuring people could spend their time inside and outside of the home. However, the provider failed to provide this model of care in an effective way and did not equip the staff team with the necessary skills, training and knowledge to deliver this. They were not providing the regulated of TDDI and did not employ registered nurses in a nursing role.

There was now documented evidence of regular discussions or meetings between the provider, the management team and staff to share a clear understanding of the specialised service the provider aimed to deliver. However, the staff we spoke with and manager were not all clear on the ethos and values of the service as stated and described in the mission statement of their policy. The absence of a clear, shared direction meant people received a poor standard of care based on their assessed needs and risks.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Staff within the service did not have the skills, knowledge, experience and credibility to lead effectively, which led to a lack of openness and honesty. The provider told us the manager was overwhelmed with the additional scrutiny the service was receiving from other agencies. A relative told us, “The manager is nice but quite forgetful, I have to remind them of things, they say what you want to know and is not always honest. I asked if [my family member] had ever been [supported incorrectly] after the last [CQC] report, the manager said they would look into it and never got back to me. They are learning as they are going along, they are approachable.” Another relative said, “The manager is not at all hands on, I have never seen them on the floor. You can go and see them but I don’t hold much faith in what they tell you.”

There had been a high turnover of managers in the last 18 months which had created instability and had significantly impacted on the quality of care provided. During the assessment the provider told us they had recognised improvements were needed and had employed the services of a consultancy company to address the failings they were aware of, and which we identified and support the manager. However, we found whilst there was a lot of activity little progress was made to improve care or develop the skills and knowledge gaps of the manager. A relative said, “In many ways they are doing a lot right, but it is management and administration that are the problem.” Another relative told us, “My beef is with management, they are absent, the upstairs mental health [unit] is where their focus is.” This meant that while people and relatives understood the changes taking place, they did not all have confidence that the improvements would be implement and sustained to improve the quality of care.

People did not always feel they could speak up and that their voice would be heard. Some staff told us they feared they would lose their job if they raised concerns and their identity was disclosed. Some staff did speak positively about the manager, but not all. Relatives and staff told us the manager listened to them but then did not act. A relative said, “I don’t feel the manager is open to people’s concerns, it’s a waste of time talking to them as they will just lie and blag; they talk a good talk but never follow anything up. I think they think everything is wonderful, but they need to take off their rose-coloured spectacles. They can’t hide upstairs.” Another relative told us, “They don’t ring you back, they don’t email you back; I was promised a phone call [2 months ago] and I’m still waiting.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Their workforce was diverse and this was encouraged. Staff felt there was good diversity and respect of cultures and religious beliefs. They told us how people and other staff were supported to understand different cultures. The providers policies demonstrated a fair and equitable approach.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had not ensured where people had complex mental health needs and were presenting in high levels of risk to themselves and others, these needs had been robustly addressed in care planning. Where risk had been identified there was a lack of information about how staff should support people.

There was currently no registered manager, although a nominated individual was now in place. This meant the service had been without a registered manager since 07 February 2024. Having a registered manager is a condition of registration for the provider.

The provider was currently in breach of a condition on their registration that does not allow them to support autistic people or people with learning disabilities, where this is their primary care need.

There had been 41 allegations of abuse or poor care or self-neglect reported to the commission since the last inspection. 14 of these concerns were confirmed as escalating to section 42 enquiries with the local authority. The manager confirmed in most cases they had not submitted notifications for these to the CQC and in discussion it became clear the manager did not understand the requirement and procedure for notifying reportable events. This was a concern as it meant CQC were unable to effectively risk assess the service outside of inspections and have oversight of incidents and allegations of abuse or be aware of how these were being managed. The manager also demonstrated a lack of understanding of when duty of candour would apply. This meant we could not be confidence they would apply duty of candour and be transparent when things went wrong.

We found there was a lack of transparency from the manager at times throughout the inspection process and an unwillingness to accept responsibility for plans or processes not in place that placed people at risk of avoidable harm. This was echoed in feedback from multiple external professionals we spoke with and gave cause for further concern about the safe management of the service.

Audits were taking place at manager level following the provider reinstating a schedule of checks. However, these were mainly completed by the deputy manager and showed no evidence of manager oversight. The section for manager comments/review and sign off and been left blank in each one we reviewed. They also failed to identify some of the concerns we found about the quality of records and outcomes for medicines, care plans and risk management and did not record lessons learnt or actions taken to reduce future risk.

There was no evidence of in person audits, sampling of records or evidence of observations of care and quality taking place at provider level. This also included meetings with the management team where requirements and actions were discussed and delegated.

There was an improvement plan in place created and updated by the local authority. Only 2 out of 17 actions had so far been completed with 4 actions outstanding in relation to staff training.

Areas from the previous warning notices served had mostly been completed for the breach of safe care and treatment in relation to care plans for people downstairs but not all and we found significant concerns about people’s safety for the people living upstairs. Medicines were also still not compliant upstairs. We continued to have significant concerns in relation to the areas listed in the breach of regulation related to good governance, of which we are not assured.

Feedback from staff was mixed about the management of the service. Some staff had concerns about care plans and risk assessments not being updated and not learning from complaints and concerns. Feedback from relatives included, “It is not a well-run home, all the good staff are leaving, the care is not as it was, there is a lack of communication from management, dreadful food.”

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement in a timely way. One professional told us, “I have been working with the home since November 2024; while working with them, I have found difficulty in obtaining information, this has mainly been around poor practice evidence and evidence to support the developments within the improvement plan and finding myself chasing for requested documentation. Regarding the improvement plan, some positive steps have been made, this has been around [as and when required medicine] protocols. During our engagements with the home, there has been some slow progress with improving of care plans, risk assessments and risk management for the residents while in the home. Advice, support and guidance have been provided for the home, the home have stated that they are working on this and trying to ensure that all relevant and current information is in place. These are being reviewed regularly during weekly visits that are taking place.”

Another professional told us of a positive outcome but where they remained concerned about the management of the service. They told us, “Fitzwilliam has had some positive outcomes for individuals, one person in particular was admitted in complete burn out. This impacted on their ability to manage daily needs: their stress was through the roof and affected their capacity to make decisions around their care. Since their admission to Fitzwilliam, they have really turned a corner and they have built secure and positive relationships with staff to the point whereby their independence is maximised. They are generally very happy and has remained out of a hospital setting since their admission. Unfortunately, there have been some issues with how the setting is managed; reports are on-going about medication errors, documentation is not being of a standard that promotes good quality and there are communication issues. I would recommend further management training and in house training around the MCA, DoLS and mental health needs to all staff. Additionally, the quality-of-care plans and risk assessments require further improvement.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There had been a significant lack of oversight of events which occurred at Fitzwilliam Care Centre. There had been no analysis to learn from accidents and incidents or identify opportunities for improvement. Quality assurance systems were either poorly completed or ineffective, which limited the providers ability to drive improvements to enhance quality of life for people using the service.

Staff were able to request additional training where they felt this was needed. The manager told us they had plans for future training for staff around mental health and sexual safety and relationships with a consultancy company who was supporting them, but these had not yet taken place and there were no dates booked.

There was a system in place to gather or share feedback from people, family members, or staff, but there was no evidence of learning being shared or implemented from this information.