Fitzwilliam Care Centre in Mablethorpe put into special measures

A care home in Lincolnshire has had its rating downgraded from requires improvement to inadequate.

The Fitzwilliam Care Centre in Mablethorpe has been placed into special measures by the Care Quality Commission in order to protect residents and ensure steps are made to improve its services.

An inspection took place in October 2025.

During this time, the home was supporting people who were living with dementia, people with mental health conditions and people living with physical disabilities.

What inspectors found:

The Fitzwilliam Care Home was rated inadequate in every area including whether it was safe, effective, caring, responsive, or well-led.

Safety: people were not consistently safe.

• Medicine management showed progress but there were stock errors and missed doses
• The environment was not dementia-friendly
• There were hazards such as broken doors and fire alarm faults
• There was inconsistent safeguarding
• Training was not adequate for staff
• Staff didn't have adequate skills in consent or mental health monitoring

Effectiveness

• Daily notes lacked context
• Nutrition and hydration monitoring was inconsistent
• Care plans didn't properly reflect residents' needs

Care: service was not consistently caring

• Independence was not always promoted
• Some staff reported high pressure and poor mental health
• However, some staff said they felt supported
• Some people and relatives described staff as dismissive

Responsiveness

• Outings and activities were limited
• Documentation sometimes used disrespectful language
• Some people feared speaking up

Ineffective leadership

• The manager lacked understanding of regulatory responsibilities and best practice
• It operated without a registered manager
• There were safeguarding concerns
• Audits were poorly overseen and missed risks
• However staff reported good diversity and respect

"...we were saddened to learn that people who lived upstairs in the mental health units didn’t feel safe"

Greg Rielly, CQC’s deputy director of adult social care for the East Midlands, said: “When we inspected Fitzwilliam Care Centre, we found the service had deteriorated significantly since our last visit. People weren’t being kept safe due to poor leadership which was impacting on every aspect of the lives of people who called it home.

“People’s feedback on staff interactions depended on where they lived in the home. Older people who lived downstairs were generally satisfied, but we were saddened to learn that people who lived upstairs in the mental health units didn’t feel safe or supported due to the actions of other people living in the home and the small number of staff on hand when incidents occurred. Some people were working with their social workers to move to other places to live because of this.

“Staff lacked skills in mental health monitoring and were dismissive in care notes when dealing with people who expressed repeated feelings of self-harming behaviours and a desire to end their lives. Staff didn’t explore why they were expressing these concerns or how to identify triggers for risk behaviours.

“People were also worried about their medicines not being properly managed. During our checks, we found stock balance errors for 9 out of 15 people who might have been receiving the wrong doses, increasing their risk of ill health. One person had also run out of multiple medicines, posing a risk to their mental health. When staff raised the issue of medicines, they told us managers brushed their concerns under the carpet.

“Despite improvements to recruitment, staffing levels were still insufficient for safe care during outings or emergencies. Even the police had reported concerns to us about staff not being available to support people in distress in the local community, putting themselves and others at risk of harm.

“We have told leaders where we expect to see rapid and widespread improvements. We will return to check on their progress and have begun the process of using our regulatory powers further which Fitzwilliam Care Centre has the right to appeal.”

Response from Fitzwilliam Care Home

We have contacted the care home for a response.

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