All inspections: Freestones Residential Care Home

Date of Assessment: 27, 29 and 30 July 2026. 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 18 people in residence.

This was a focussed assessment carried out to ensure compliance with previous enforcement action taken against the service for breaches of regulation in relation to safe care and treatment, consent to care and the governance and oversight of the service. We assessed the key questions: Safe, Effective and Well led, which contain the breach.

We found the provider was no longer in breach of regulation related to consent to care.However, sufficient improvements were not made, and the provider remains in breach of regulation relating to safe care and treatment and governance of the service.

During the assessment, we spoke with people using the service, their relatives, visiting professional and staff at different levels. We also reviewed people’s care records and staff record, audits and records relating to the management of the service. 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.

The provider had introduced governance and oversight systems; however, these were not fully effective in identifying and addressing concerns. Audits had failed to identify the risks and issues found during this assessment, and some concerns from the previous assessment remained unresolved. Ongoing weaknesses in governance, auditing, and leadership oversight resulted in repeated issues relating to record keeping, compliance, and risk management, reducing assurance that improvements had been sustained.

The provider had made improvements to the premises, infection prevention and control practices, and fire safety, including updating personal emergency evacuation plans. However, some risks remained. While maintenance staff addressed identified issues, regular checks and audits did not always identify new environmental risks, reducing assurance that these were being managed effectively.

The provider had transitioned to a digital care system. Risks to people were assessed and managed, and care plans were personalised, providing staff with clear guidance to support people safely. However, monitoring records were not always fully completed, and inconsistencies in daily care records reduced assurance that information was accurate and reliable.

Some improvements had been made to medicines management, including the introduction of protocols for 'as required' medicines. However, concerns identified at the previous assessment remained. Medicines with a short shelf life were not always dated when opened, and medicine fridge temperatures were not consistently monitored to ensure medicines remained safe to use. Staff had received medicines training, but competency assessments were still being completed.

The provider had made improvement and was working within the principles of the Mental Capacity Act. Systems in place ensured accidents and incidents were monitored and if any lessons could be learnt to keep people safe and improve practice.

Staff were recruited safely and there were enough staff to meet people’s care needs. Staff training had been updated although for some staff and the provider their training was not up to date. Staff understood their responsibilities to protect people from abuse.

Staff were happy and enjoyed their work and caring for people. They felt supported by leaders found the quality lead “Easy to talk to and explained things.”

Overall, we found evidence that some improvements had been made in response to our enforcement action, however, these had not yet been fully embedded into practice and further work was needed to achieve and sustain improvement.

The overall rating for this service remains ‘requires improvement’.

As the provider remained in breach of regulations at this assessment, we have published this information on our website. We will continue to monitor the service and carry out a further assessment to determine whether sufficient improvements have been made to achieve and maintain compliance with the regulations.

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.

Freestones Residential Care Home is a residential care home providing accommodation and personal care for up to 20 older people and people living with dementia. On the day of inspection there were 17 people living in the service.

We found the following examples of good practice.

Safe arrangements were in place for visitors to the service including relatives and friends, professionals and others. This included a booking system, rapid LFD testing, showing evidence of vaccination, temperature checks and sign in process.

Isolation, cohorting and zoning were used to manage the risk of infection spread. This meant people self-isolated in their rooms when necessary. If this was not possible, people were supported to safely use communal areas. Safe admissions procedures were in place when people moved into the service.

Lounge and dining areas were set out in a way to make best use of the space available. Enhanced cleaning and disinfection of all areas of the service continued to take place to reduce the risk of cross contamination.

There was plenty of personal protective equipment (PPE) including masks, gloves, aprons and hand sanitiser available. PPE stations were located around the service. Used PPE was disposed of safely in clinical bins. Checks took place to ensure staff maintained good hand hygiene practice and put on and took off PPE properly.

A regular programme of testing for COVID-19 was in place for staff and people who lived in the service. This meant swift action could be taken if anyone received a positive test result.

There were no agency staff working in the service which meant fewer staff coming in and out of the building. This helped keep people safe. The staff team worked together to cover any gaps in the rota.

The registered manager had good oversight of infection prevention and control processes. They undertook regular quality assurance checks. Policies and procedures were in place and up to date, which supported good practice in all areas of infection prevention and control.

Freestones Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Freestones Residential Care Home accommodates up to 20 people in one adapted building. At the time of this inspection, 19 people were using the service.

At our last inspection in January 2016, we rated the service ‘Good’. At this inspection, we found the evidence continued to support the rating of ‘Good’ and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People and relatives felt safe with the staff providing their care and support. Staff were aware of their responsibilities for keeping people safe from any form of abuse and avoidable harm. The registered manager understood their responsibilities to keep people safe, they had notified the local safeguarding authority and Care Quality Commission (CQC) of safeguarding concerns and carried out investigations as required.

Staff recruitment procedures continued ensure that appropriate pre-employment checks were carried out to assure staff were suitable to work at the service. The staffing arrangements met the individual dependency needs of people currently using the service.

Staff had the appropriate skills, competency and knowledge to meet people’s individual needs. Health and safety training followed current relevant national guidance to prevention and control of infection.

On-going support and one to one supervision was provided for staff to reflect on their practice and promote self-development.

People received their medicines safely and staff supported people to access support from healthcare professionals when required, to ensure people continued to receive coordinated care and support.

The registered manager / registered provider and staff understood the Mental Capacity Act, 2005 (MCA) legislation and followed this in practice.

The environment was clean, and repairs and refurbishment works took place to the building, both internally and externally. Routine safety checks were carried out on the fire, water, gas and electrical systems.

People were involved in planning their on-going care and support. The care plans were person centred and provided staff with appropriate guidance on meeting their diverse range of needs.

People using the service, relatives and staff had good relationships. People and relatives were very complimentary of the care and attention, the staff provided. People were treated with kindness, compassion, dignity and respect and staff provided their care and support in keeping with their wishes and preferences.

Feedback from people, relatives and staff was used to drive continuous improvement of the service. The complaints policy was made available to people and relatives so they knew how to raise any concerns and complaints.

Regular audits continually monitored the quality of the service, based on the audit findings the registered manager / registered provider took appropriate action to address and rectify any shortfalls. The registered manager / registered manager had informed the Care Quality Commission (CQC), of notifiable events and incidents, as required by law.

The inspection took place on 11 and 15 January 2016 and was unannounced. The service is registered to provide accommodation and personal care without nursing, for up to 19 older people including people living with dementia. On the day of the inspection 19 people were using the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The staff had a good understanding of what constituted abuse and of the safeguarding procedures to follow should they need to report any abuse.

Risks were appropriately managed to ensure that people were supported to make choices and take risks.

Staff had been recruited following safe and robust procedures and there were sufficient numbers of suitable staff available to keep people safe and meet their needs.

Systems were in place to monitor accidents and incidents so that preventative action could be taken to reduce the number of occurrences.

Robust arrangements were in place for the safe administration and management of medicines.

Staff had the skills and knowledge needed to support people appropriately and had regular training updates to maintain their skills. A programme of staff supervision and annual appraisals enabled the staff to reflect on their work practice and plan their learning and development needs.

People’s consent was sought before providing their care and treatment. People who lacked capacity to make decisions were supported following the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People benefitted from having a balanced and varied diet. Their dietary needs were monitored and advice was sought from appropriate health professionals when needed.

People had regular access to healthcare professionals and were supported to attend health appointments.

Staff treated people with kindness and compassion, dignity and respect.

People had individualised and detailed care plans in place, which reflected their needs and choices on how they wanted their care and support to be provided.

Social, leisure and purposeful activities were provided for people to meet their individual needs and aspirations.

People and their representatives were encouraged to provide feedback on the service; complaints were taken seriously and responded to immediately.

The service was led by a registered manager who continually strived to provide a good quality service. The vision and values of the service were person-centred. People and their representatives were supported to be involved and in control of their care.

Effective management systems were in place to continually monitor the quality of the service.

The inspection was carried out by one inspector. We gathered evidence to help us to answer out five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

Is the service caring?

The people we spoke with were positive about the way they were cared for and supported. A relative told us: "The girls are fantastic; they are very caring". People were cared for by kind and attentive staff. We observed people asking staff to do things for them. Staff responded to the requests promptly and efficiently. The home was supported by a team of health and social care professionals who worked closely with staff in providing people's and care needs.

Is the service responsive?

When people who lived in the home made suggestions for changes these were actioned as far as practically possible. The service worked well with external health professionals to make sure people received good standards of care. we spoke with a community nurse who told us they made regular visits to people who used the service and that staff always carried out any instructions given to them.

Is the service safe?

People were treated with dignity and respect by staff. People told us they felt safe and we observed a relaxed atmosphere. The registered manager showed us the medicines checks they carried out twice a month to protect people from receiving inappropriate medications. Systems were in place to ensure that people were not put at unnecessary risk of developing infections. There were risk management plans in place for people and health and safety. We noted that there were enough staff allocated to care for people and ensure their safety.

Is the service effective?

People's health and care needs had been assessed and care plans were in place. There was evidence of people and or their relatives being involved with the development and regular reviews of care plans. Staff encouraged and supported people in leading interesting and enriched lifestyles. The people we spoke with and relatives all said they received the standard of care that matched their needs.

Is the service well led?

The service had a quality assurance system in place that involved people who lived in the home, visitors and all staff. Records showed us that improvements had been made when they were identified through monitoring processes. Staff told us they were clear about their roles and responsibilities. Staff were actively encouraged to undergo training to ensure they possessed the knowledge and skills to carry out their roles.

People who used the service told us that they liked living at the home. A person who used the service told us 'I am really happy here, the staff always have time for me, it is a great place.' One relative told us, "The staff are really good, they have to deal with so much." A relative of another person who used the service told us, "The whole place is fantastic from the manager downwards they give a great service.'

We found that staff were attentive to people's needs and that staff spoke to people they supported in a calm, polite and reassuring manner.

During our visit people told us that staff treated them with respect and encouraged them to make choices about their day to day life. People told us, and we heard, staff speak with them in a kind and respectful manner. A visitor we spoke with explained how the manager was always available and was a fantastic listener. Other people we spoke with told us "the care here is very good and they are very friendly, much better than my last home." Another person said "smashing care it is lovely here, good without exception" and "the manager is very, very good." A relative told us that they were very happy.

We found that the home was a safe and caring environment for the people who used the service.

We spoke with four people who were able to comment on the care they receive from staff. They told us they were content living at Freestones and said the staff are kind and attentive. They all said the staff are polite and respectful, especially when helping them with their personal care.

Comments included, for example;

' 'The carers are lovely, you could not wish for better.'

' 'They do a really good job looking after us all.'

' 'I am happy to stay in my room, it is my choice though. It suits me.'

Freestones Residential Care Home

All Inspections

During an assessment under our new approach

During an assessment under our new approach

28 February 2022

During an inspection looking at part of the service

23 January 2018

During a routine inspection

11 January 2016

During a routine inspection

12 May 2014

During a routine inspection

29 May 2013

During a routine inspection

7 November 2012

During a routine inspection

15 August 2011

During a routine inspection