Freestones Residential Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways in how risks to people and medicines were managed.

This service scored 41 (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 always have a proactive and positive culture of safety where incidents were always investigated. Lessons were not always learnt to continually identify and embed good practice.

The provider told us about lessons learnt following a person admitted to the service in an emergency. Staff told us feedback about lessons learnt mixed. Staff understood their responsibility to report incidents and accidents. These were documented in people’s care records. However, risk assessments were not always reviewed following incidents or changes in health to establish if the person required additional support.

The provider told us they had oversight of incidents, accidents, complaints and safeguarding concerns, but they were unable to show if any patterns were identified so action could be taken to prevent recurrence. They acknowledged oversight needed to improve and showed a willingness to learn and improve. For instance, they took positive action to some concerns we found during our inspection visit, such as discarded a damaged footstool, and arranged for window restrictors to be fitted to protect people from the risk falling from height and from unwanted intruders once these concerns were identified and brought to their attention by inspectors.

People and relatives were confident to raised concerns or share their views with the staff and the provider, contributing to a culture of openness. They were confident concerns would be taken seriously and addressed. Staff told us working collaboratively with health professionals to provide the care people needed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety, to make sure there was continuity of care.

People’s needs were assessed before they moved to the service. Information gathered from the person, their relative and from hospitals or community teams was used to plan their care. People’s care records contained a hospital transfer template to enable staff to complete when required. Record keeping was not always clear or consistent, or kept up to date. For example, a person with pressure injury had been discharged from hospital, however their care plan had not been updated since. This meant the person was at risk of receiving inappropriate care because information was not accurate or consistent.

People told us the transition to the home was good. A relative said, “We did the assessment together, so [Provider] knew what [Person name] needs were and support we think they needed. It's the best thing that's happened [Person name] living here. Everything was arranged from a taxi to move them here and their bedroom, just as they would like it.” Staff told us they worked with a range of health and social care professionals to meet people’s needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 share concerns quickly and appropriately.

People and relatives said they felt safe with the staff and the care provided. One person told us, “I do feel very safe here, I wouldn’t be here if I feel otherwise. I do like this place because staff are good at listening and respecting me as customer. I feel valued as person.” Relatives told us they had no concerns about how staff protected their family member from the risk of abuse. A relative said, "I can't fault the care; [Person name] is safe and cared for as if they were looking after their nan.”

A safeguarding policy was in place to help guide staff on how to recognise and react to any potential safeguarding incident. Staff understood their responsibilities and described how they would report any poor practice or suspected abuse. The provider told us and records showed a safeguarding referral had been made appropriately and action was taken to prevent further risk.

The provider did not consistently act in accordance with the principles within the Mental Capacity Act 2005 and protect people from unlawful restrictions. A person had restrictions in place to keep them safe, but there was no evidence this had been discussed with the person’s representative and no evidence of a best interest decision undertaken. Where people had authorised Deprivation of Liberty Safeguards (DoLS) with conditions; their care plans did not reflect how staff were to support the person safely. The provider had no oversight to monitor DoLS and to ensure conditions were met. This meant people had experienced or were at risk of unlawful restrictions placed on their lives. Please refer to Consent to care, section.

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.

Systems and processes were not robust enough to ensure risks to people were appropriately identified, managed and mitigated. Assessments and care plans lacked adequate details of people’s individual needs and the care they required. Some risks to people had not been assessed and where people were at high risk of harm, such as risks of falling, and developing pressure wounds and infections there was limited or no instructions for staff to follow. We found shortfalls in how risk associated with people’s skin condition and catheter care was managed. For example, the care plan for a person with a pressure sore had no instruction for staff regarding wound management regime, such as positional changes and application of barrier creams to prevent further skin damage. The lack of instructions for staff to follow increased risk to people’s health.

People with catheters and fluid monitoring was not well managed. Monitoring records were not completed accurately and consistently. For example, the care plan for a person with a catheter did not include instructions to enable staff to provide appropriate support and recognise potential risks. The fluid intake and urine output was not always documented. The lack of accurate, reliable and inconsistent information about a person’s hydration needs and continence needs increased risks to health such as infections, blocked catheter and dehydration. People’s care plans were lacked sufficient information to enable staff to recognise potential health issue and when to escalate concerns and seek medical attention. For instance, a person’s records showed they can go 7 days without a bowel movement. how people living with dementia expressed pain or discomfort. Although the person was prescribed medication to be administration as requited, the medication records indicted the person was not offered the medication. Staff told us and records confirmed no other medical attention was sought. This increased the risk to the person’s health. These concerns contribute to the breach of regulation in relation to safe care and treatment and demonstrated a lack of consistent managerial oversight to ensure people’s needs were being met.

People’s personal emergency evacuation plans (PEEP) contained inconsistent and vague information for staff to follow in multiple emergency circumstances. Staff had been trained in fire safety. However, staff told us they had not been trained to use the evac-sledge. Due to the serious risks, we made a referral to the Fire Service. They conducted an inspection and recommended some improvements to the fire safety arrangements.

People and relatives were confident staff were trained for their role and to support people safely. A person said, “I have to use standing aid for going to toilet, it’s in my room all the time so it’s there when I need it; all equipment is there. I feel comfortable when using it.” We observed staff using moving and handling equipment safely. A relative said, “Knowing their mobility issues, their room is equipped with grab bars and higher toilet seat.”

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

We found environmental risks which included rusty grab rail and damaged floor covering. A number of windows on the ground floor did not have restrictors fitted. This was a risk of people climbing out and falling from height, and risk of unwanted intruders entering the care home. One person said, “What can be improved is for sure – carpets please; with fresh paint coat and new carpet this place will be pretty much perfect.” Staff continued to use chipped and damaged crockery which increased the risk if injury and spreading infections or infectious diseases. A staff member told us, “This place could do with a bit of decorating; for example, there's different flooring and carpet. Where the floor is damaged, they put a different shade of flooring which fixes it but it’s not nice.” Staff were unable to confirm how long these risks had existed. Routine maintenance, fire and health and safety checks were not reliable as the issues we found had not been identified. These issues were raised with the provider, and some action was taken such as window restrictors had been installed and installed a new grab rail in one room. The provider needs to strengthen the oversight and monitoring of environmental risks.

People’s personal emergency evacuation plans found in their care plans was inconsistent and vague. There was no emergency grab bag with names of people and the level of support they needed to leave the building. Staff were trained in fire safety and regular fire tests were carried out. However, staff told us they had not conducted practical fire drills, and they were not confident to support people to leave the premises in an emergency. These concerns were raised with the provider and the Fire Service. When we returned on the third day of the inspection visit the provider showed us a list of people with details of the support they needed to leave the premises in an emergency.

Bedrooms, dining room and lounges were generally clean. There was a small courtyard with seating, which people could use on warmer days. Bathrooms and toilets were clearly marked. A person told us, “[Person name] room is on the first floor; they use the stair lift and staff will operate to make sure they get up or down safely.”

People and relatives were mostly happy with the home environment. A person told us, “What could be different; it’s a tricky question but I would like that bathroom to be a bit bigger. It can be a little crowded in there with all my equipment, but that is just something unavoidable. I had a small bathroom in my own home, so I learned to manage.” A relative said, “[Person name] has got a lovely room, decorated and makes it homely for them. There’s a bookcase in their room. it's always clean and tidy.”

The provider made sure there were enough staff to meet people’s needs. The provider made sure new staff were recruited safely. The provider did not always make sure staff training, effective support, supervision and development. Staff worked well to provide safe care that met people’s individual needs.

People and relatives spoke positively about the staff. Their comments included, “Staff are very good, and they try to calm them when upset or take them to their room,” and “I sometimes feel that there is not enough staff and sometimes that there is. I can only say by what I hear around that all care homes need more carers. I personally don’t wait that long and once I am settled for a day staff comes and check on me all the time.” Relatives described the home as calm and friendly and said staff were approachable and kind. A relative said, “Staff are friendly and always willing to help [Person name] and me.”

Most staff told us there were enough people on duty to meet peoples’ needs. Staff were also expected to complete laundry and kitchen duties alongside their caring responsibilities. Some staff said this reduced the time available to support people. One staff member told us, “Sometimes there's a lot to do for staff and at the start of the shift we ask who wants to do the laundry and cleaning. [Registered manager] just wants staff to sort out who's doing what on the shift” and “I’d say at the moment it’s alright, because we have 2 empty rooms and a couple of the double rooms only have 1 person. When we’re at full capacity it can been challenging.”

New staff were recruited in line with safe recruitment processes, and pre-employment checks were completed. Staff received appropriate induction and training to meet people’s specific needs. We reviewed the staff training information received, most staff training was up to date. However, some staff training had lapsed in topics such as fire safety, infection prevention and control and Mental Capacity Act. The provider did not share any plans to demonstrate how they planned to address this. Although the provider told us all staff were supervised, the feedback received from staff was mixed. A staff member told us, “I’ve not had supervision since I started.” Other staff found supervisions were useful and they were confident to speak with the provider or their colleagues. The provider told us they were available to staff but acknowledged they had prioritised the new care planning system.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had not always ensured people living at the service and visitors were protected from the risk of spreading infectious diseases. However, several infection risks were identified during this inspection. These included porous wooden surfaces on the plinths of the raised toilets and sink in the laundry. There were damaged floor covering in bedrooms; one damaged area was covered with a mat, so it could not be seen. There were additional risks in relation to food safety. Food and drinks stored in the fridge was not always dated when opened to ensure it was safe to consume. Where food items had been dated when opened, these were not checked regularly, for instance, we found a jar of lemon curd opened in December 2024 and was still in use despite manufacturers recommendation to discard after 6 weeks once opened. The kitchen audits were not effective as chipped, damaged and stained crockery and jugs were found, which increased the risk to people’s health. These issues were raised with the provider. Although some action had been taken when we returned to complete the inspection visit, this indicated the need for increased infection control monitoring. Please refer to Safe Environment.

We found audits were not reliable as the issues we found had not been identified by the internal checks and audits. Furthermore, as staff duties covered both domestic and care duties the provider could not demonstrate infection control systems were fully effective to protect people from the risk of infections and infectious diseases.

Despite these shortfalls, we observed staff following infection prevention procedures in daily practice and using personal protective equipment appropriately. People told us staff supported them with personal hygiene needs. A person told us, “Its homely, and I have no issues with décor and how clean it is; its well clean for me.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found staff did not consistently and safely manage, administer medicines as prescribed and maintain accurate and reliable records. We found prescribed topical creams in use, which have a short shelf-life were not always dated when opened. This put people at risk of receiving creams that could be out of date.Some people were prescribed ‘as required’ medicines otherwise known as ‘pro re nata’ (PRN). Despite concerns expressed by staff about the lack of instructions, there were no PRN protocols in place to instruct staff, why, when and how to administer the medicine. This practice was not consistent with the medication procedure for administering PRN medicines. We also found when PRN medicines were administered, staff did not always record the effectiveness of the medicine. These concerns were raised with the provider; they told us they had been advised by the pharmacist 2 years ago PRN protocols were not required. This demonstrated lack of oversight and adhering to best practice guidance such as guidelines provided by the National Institute for Health and Care Excellence (NICE). The provider assured us they would review the archived PRN protocols to ensure they remained appropriate. When we returned to complete the inspection, PRN protocols were in place and staff had recorded the effectiveness when PRN medicines had been administered.

Medicines were stored safely and there were appropriate arrangements for medicines that needed to be refrigerated, the controlled drugs and the disposal of medicines. People told us they received their medicines as prescribed by trained staff. A person said, “I have my medications morning and evenings I know them all, today I needed also my inhaler, I felt better after. No issues with any of my medicine; always there on time.”

The latest medicine audits we were given were dated January and February 2025. These were basic and lacked sufficient scrutiny to ensure medicines were managed safely, for instance random checks of medicine administration records, PRN protocols instruction and staff practices remained consistent with the medicine management policy and procedure. There were improvements needed to the oversight of medicines management.