- Care home
Freestones Residential Care Home
We served a Warning Notice on Mrs Claire Louise Davidson & Mr Karl James Davidson for failing to meet the regulations related to safe care and treatment and good governance at Freestones Residential Care Home.
Assessment report published 30 October 2026
Contents
Ratings
Our view of the service
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.
People's experience of this service
People living at the service appeared comfortable and relaxed in their environment. Our observations and feedback indicated that people were happy with the staff and the support they received.People were supported by staff who knew them well. We observed warm and caring interactions between staff and people including offering reassurance and support when required.
People told us staff treated them with kindness and respect. Relatives told us they felt able to approach staff and leaders and were kept informed about important issues relating to their family member.
We observed in the afternoon staff were able to spend meaningful time with individuals. People chose to watch television, spend time with their visitors or have a nap. One relative told us, “There is quite a lot of isolation, not really any stimulation.” We observed there were limited activities provision and reduced opportunities for meaningful engagement and social stimulation.
People’s feedback about the choice and quality of meals provided was mixed.
People told us staff ensured they could see the GP when required and records confirmed people were referred to healthcare services when required.
We found inconsistencies in areas such as monitoring and leadership oversight which reduced assurance that people’s needs were always met in a consistent and person-centred way.