Updated 2 September 2025
Date of Assessment: 24 and 25 September 2025 and 3 October 2025. Freestones Residential Care Home is a residential care home providing support for up to 20 older people, including those living with dementia. At the time of this assessment, there were 17 people in residence. This assessment was prompted in part due to concerns raised around the quality of care people received, staffing and the management of the service and an aged rating of the service. We identified 3 breaches of regulation relating to people receiving safe care and treatment, consent to care and governance of the service.
We spoke with people who used the service and relatives. We spoke with staff including the provider, who was the registered manager, the deputy manager, senior care staff and care staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We looked at people’s care records and multiple monitoring records including medicine records. We also looked at staff files and multiple management records including policies and procedures
We identified risks to people were not always assessed, managed or monitored to ensure people were safe and protected from harm. Care plans were not up to date and lacked guidance for staff to provide safe care. Systems to monitor and review risks to people and their care plans was not effective. Whilst people received their medicines as prescribed, this was not the case for people who required ‘as required’ medicines. All these issues placed people at risk of harm. Whilst some action was taken by the provider we could not be assured people were safe
Risks relating to fire safety, infection prevention and control and environmental risks had not been identified by the provider through internal checks and audit. All these issues placed people at risk of harm. Whilst some action was taken by the provider we could not be assured people were safe.
We saw staff sought people’s concerns before they were supported. However, staff did not support them in the least restrictive way possible and in their best interests, which put people at risk of unlawful restrictions on their lives.
Although the provider knew people well and spent significant time in the home, management oversight systems, governance arrangements and audits, were not robust and had not been used effectively to assess, monitor and improve the quality and safety for all aspects of the service. This placed people at risk of harm. Concerns were identified in relation to people’s assessed needs, health risks and inaccurate care plans and gaps in the monitoring records, consent to care, environmental risks, staff training and competence, and audits showed these were not fully effective. Opportunities to learn lessons and drive improvements were missed.
People were supported by kind and caring staff who treated them with respect and compassion. Staff knew people well and they sought advice from healthcare professionals when people health was of concern. People were provided with food and drinks of their choice and modified meals were provided as needed. We saw staff worked together to promote people’s comfort and wellbeing.
Staff were recruited safely and there were enough staff to meet people’s care needs. Safeguarding procedures were in place, and staff understood their responsibilities to protect people from abuse. Most staff felt supported. Staff training was up to date; however, some staff training had lapsed but there were no plans in place to address this.
We have asked the provider for an action plan in response to some of the concerns identified at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.