Freestones Residential Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality inclusion and engagement. However, management arrangements did not always ensure effective systems were in place to meet the needs of people and their communities.

The provider was also the registered manager. They had a clear vision and values of what good care should look like and had worked hard to foster a caring and homely environment. Staff understood and shared the same values, and they were committed to ensuring people received safe, good-quality care. For example, we saw staff undertaking safe moving and handling procedures and being respectful and kind to people.

Staff told us the leadership and training was not always effective, and this impacted on their ability to do the job well. They told us the provider oversight had deteriorated but they were committed to supporting the provider to meet the needs of people and to keep them safe. This was evident from the shortfalls we identified that further improvements were needed in relation the internal monitoring systems.

Although the provider promoted an open and inclusive culture leadership and management oversight was not always effective.

The provider, who was the registered manager, was committed and passionate about providing a quality service. They told us the plans to strengthen the management structure had been challenging. They had invested in the care home and were in the process of implementing an electronic care system.

Staff described the provider as approachable and willing to listen to feedback. However, some staff told us communication and follow-up information was not always clear. This meant staff did not always feel supported in their roles or confident that concerns would be acted on promptly.

The registered manager had not always notified CQC about events which they are legally required to do so, for instance, when a deprivation of liberty safeguard (DoLS) had been authorised by the supervisory authority. This was share with the local authority. Although we raised this with the provider, they have not submitted the required notifications.

Despite the shortfalls we identified, the provider was at the care home most days and provided on-call advice and support to staff. The provider demonstrated openness and honesty, which was evident from emails to relatives in relation to incidents. The provider was responsive to feedback and had started to address some of the urgent risks in relation to the environment and medicines. However, this demonstrated oversight systems needed to improve to enable the provider to ensure leadership was effective.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider promoted whistleblowing procedures and encouraged staff to speak up. Their policy directed people on where to go externally and how to raise concerns anonymously.

Staff told us the provider and senior staff were approachable and visible within the service. They felt able to raise issues directly and receive feedback on what action had been taken afterwards.

Relatives told us any concerns raise with the provider were acted on promptly. Regular meetings gave staff and residents an opportunity to share ideas, raise issues and discuss improvements.

The provider had recorded, investigated and responded to concerns that CQC had referred to them to investigate in relation to staffing, leadership and food. Duty of candour was evident.

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.

The provider ensured equality of opportunity and experience for the staff was in place, for example, recognised when staff needed additional support and responded appropriately. Staff felt they were treated equally with regards to their protected characteristics, for instance flexible working patterns to support with mental wellbeing and caring responsibilities. Some staff felt they were not always ‘valued’ or respected. This was shared with the provider. Although they assured us, they had been supported and valued staff, and they will look at ways to improve this.

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 did not keep their knowledge up to date with current best practice or sought advice from appropriate external agencies to manage effectively. For example, working with the principles of the Mental Capacity Act 2005. Despite having good relations with the local authority opportunities were missed to participate in ‘registered manager forums’ to learn and share good practice. Furthermore, the provider did not always notify CQC about events they were legally required to do so. This was all raised with the provider to address.

Although the provider spent a significant amount of time in the home and knew individuals well, their oversight and governance system and processes were not effective to ensure safe practice. For example, there was insufficient oversight of people’s care, risks and monitoring records, medicines management, monitoring of restrictive practices and the environment amongst others. A sample of the audits completed were not reliable or effective as the issues we found had not been identified. There was limited scrutiny by the provider to ensure audits were completed as expected. There was no oversight staff training was kept up to date and staff were fully equipped and understood the additional responsibilities for their role. There was no system to analyse call bell logs to ensure staff were responsive. The provider analysed accidents and incidents but there was limited evidence recorded of the action taken to prevent recurrence. The provider has been told to make improvements in this area.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We received positive feedback from the local authority and professionals about the provider and the quality of service provided. One professional described how the provider had worked with the relative to improve their nutrition intake by providing part-blended diet which had improved their overall health. They also told us the provider and staff did not fully understand their principles of the Mental Capacity Act 20025 and their responsibilities and additional training offered had been accepted.

Feedback we received prior to our inspection visit was mostly positive. One professional comment included, “When visiting Freestones the Residents always appear content and well kempt. Communication between myself, the care home staff and the manager is overall satisfactory.”

We spoke with the visiting local authority quality monitoring officer; they described the provider and staff as kind and responsive. They planned to carry out a full quality monitoring visit in November 2025.

Following our inspection visit we received feedback from the Fire Service, in response to the concerns we had raised. They told us the provider was responsive, and some recommendations were made. The Health Protection Agency had awarded food hygiene rating of 5 stars in February 2025. We shared our inspection findings with them.

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.

The provider did not always recognise, identify and understand how to make improvements happen. The shortfalls we identified during our inspection visit were not identified. Whilst some action was taken by the provider, we were not assured what plans were in place to address the remaining issues.

The governance and oversight relied heavily on reactive a response, such as responding to concerns rather than proactive approach based on monitoring quality, performance and effective tools such to monitor the progress of improvements. The provider demonstrated willingness to improve, but systems to support continuous learning and sustained improvement were not yet fully effective or consistently applied.