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 requires improvement. At this assessment the provider had not made sufficient improvements, and the rating has remained 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 50 (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 made some improvements to the promoting a culture of safety, based on openness and honesty. Staff recognised and reported safety incidents, and lessons learned were shared. However, similar issues continued to occur in some areas, indicating that learning was not always fully embedded into practice.

Staff told us following our last assessment learning and action had been taken. For instance, one staff member told us, “PEEPS (Personal emergency evacuation plans) have a lot more information.”

The provider had implemented a digital care system to enable real-time recording of incidents and accidents. Incidents, including falls, bruising, wounds and medication errors, were analysed to identify trends and patterns. Actions to reduce risks included GP referrals and reinforcing preventative measures. For example, one relative described measures introduced to reduce the risk of falls, saying, “[Person name] had a period of falling over as they kept getting up out of the chair. [Person name] has a [crash] mat by their bed and a [sensor] mat on their seat.”

Staff meeting minutes showed reminders and incidents were discussed. However, there was limited documented evidence showing how learning from specific incidents and investigations was consistently shared with the wider staff team and improved outcomes for people.

Learning and oversight systems were not consistently embedded. Recurring and new issues, were not always identified or escalated through staff reporting, audits, or management oversight, demonstrating the need to strengthen and effective embedding of learning into practice.

The provider worked with people and healthcare partners to promote continuity of care, including when people moved between different services.

Following the transition to a digital care system, people's records included information about their medicines, health, and care needs. However, the 'About Me' section, which provides important information for emergency services, such as communication needs, potential distress caused by unfamiliar people, and guidance on how best to support the person, had not been completed for everyone. The provider assured us this would be addressed.

Staff knew how to access people’s information and share relevant information with emergency services and during hospital transfers. Records demonstrated effective partnership working with healthcare professionals to review people's needs and support smooth transitions between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider shared concerns promptly and took appropriate action to manage risks. For example, skin injuries and wounds were escalated and managed appropriately, demonstrating that issues affecting people's health and safety were identified and responded to in a timely way.

People told us they felt safe with the staff and the care provided. One person said, “I don’t feel unsafe.” Relatives were also confident that their family members were safe.

Staff understood their safeguarding responsibilities, knew how to raise concerns, and were confident leaders would act. However, staff feedback and training records showed that some safeguarding refresher training was overdue. Although no impact on people was identified, it was unclear what action the provider was taking to ensure all staff maintained up to date safeguarding knowledge.

The service had systems in place to keep people safe and protect them from harm and abuse. The provider had also applied for Deprivation of Liberty Safeguards (DoLS) where required, and any conditions attached to authorised DoLS were being adhered to.

The provider did not always manage risks. Staff did not always provide care to meet people’s planned care needs to keep them safe.

People told us their needs were met. Although most relatives felt staff met their family member's needs, feedback was mixed. One relative said, “[Person name] is very well cared for,” and described measures that had been put in place to reduce the risk of falls. However, another relative told us the call bell was often out of reach, meaning their family member “Would just shout,” for assistance. A further relative expressed concerns about social interaction and engagement commenting, “No one comes in to [Person name] just in the lounge, occasionally they have a singer, but not in here (room).” They added, “Even if [Person name] has the remote for the TV, they won’t think or know to change channels.” This feedback indicated the relative was unsure how risks associated with social isolation and a lack of meaningful engagement were being addressed.

Since our last assessment the provider had transitioned to a digital care system and risk to people had been reviewed. These were individual and care plans provided guidance for staff to meet people’s needs. However, although falls risks had been assessed, care plans did not always provide staff clear and consistent guidance about how identified risks should be reduced. There were incomplete sections about individuals, which meant new or agency staff may not have had access to important information about people's preferences, routines, communication needs, and what mattered most to them, increasing the risk that care was not delivered in a personalised way.

Monitoring records were not always completed consistently. For example, there were gaps in bowel movement and personal care records. This reduced assurance that changes in people's health and wellbeing would be identified, monitored, and acted upon in a timely.

Staff told us they had received some training including fire safety training. Feedback on training and competency was mixed. Following the site inspection, the provider shared the updated training records. However, these continued to show gaps in mandatory refresher training. For example, while most staff had completed manual handling e-learning, not all had completed the required practical training. This indicated that training compliance was not yet fully embedded.

These concerns demonstrate that sufficient improvements have not been made since the last assessment, particularly in ensuring effective managerial oversight and that people's needs are consistently met safely.

Despite this staff were knowledgeable of people’s needs and feedback from most people and relatives confirmed this. We observed staff supported people to safely move around using equipment safely and guiding people to return to their bedroom. People’s personal emergency evacuation plans had been updated and included clear instruction to enable staff to support people in multiple emergency circumstances.

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

The provider had addressed most of the issues identified at the previous assessment to improve people's safety. However, some risks remained. For example, damaged flooring in a bedroom and unsealed doors, which increased the risk of infection spread, had not been fully addressed. The quality lead advised that all pull cords had been replaced, but we found one that remained frayed.

The management walk-around provided a further check on the premises. However, when issues were identified, it was not always evident if these had been followed up to ensure action taken was satisfactory. At the time of the inspection, a heatwave was in effect. Several freestanding fans were in use and staff ensured they were positioned safely to avoid creating trip hazards.

Although the provider was aware of previously identified shortfalls and had an action plan in place to address concerns raised by CQC and the local authority, internal audits and daily management walk-arounds had not identified all outstanding issues or emerging risks.

Following our inspection, the director responsible for the premises took immediate action and provided evidence that the damaged flooring had been made safe and sealant had been applied to the bathroom furniture.

Despite these concerns, appropriate equipment was available to meet people's needs. Improved record keeping for the maintenance and servicing of the premises, equipment and fire safety. The provider had updated the business continuity plans which covered all eventualities such as managing outbreaks, loss of power, fire and other emergencies.

The provider made sure new staff were recruited safely. Staffing levels were managed, and they worked well together to meet people’s needs. Whilst some action had been taken to improve staff training gaps in training and competencies remained.

People and relatives spoke positively about the staff. One person said, “The staff are spot on, I would never say anything about them, they are all so lovely, I want them to know I love them.” Relatives described staff were kind, caring and approachable.

We saw there were enough staff to meet people’s when needed. However, feedback from people and relatives was mixed. One person said staff could be busy at times, and they sometimes had to wait for support while staff assisted others. A relative said, “Sometimes not and sometimes plenty” and “Sometimes they could do with a few more, if they are dealing with other people and [Person name] wants the toilet they have to wait. [Person name] has [continence aid] but they still like to go properly.”

Rotas showed that planned staffing levels were generally maintained through the use of agency staff. Staff told us they enjoyed their roles and were committed to providing good care; however, some raised concerns about staffing arrangements. Staff reported that evening shifts could be short-staffed, requiring agency cover, and that rotas were not always issued in advance, making it difficult to plan their work schedules.

New staff were recruited safely, including completing Disclosure and Barring Service (DBS) checks. However, DBS checks were not routinely renewed. The provider told us staff completed self-declarations instead, although these were not always evidence in staff files. Following discussion, the provider took action to improve the recording and oversight of self-declarations and was exploring the introduction of DBS renewals.

Records confirmed new staff completed induction and mandatory training relevant to their roles. Staff told us they had received training since the last assessment; however, some reported not all essential refresher training, and competency assessments had been completed, which was supported by training records we received after our inspection visit.

Staff told us they felt supported, received regular supervision, and attended staff meetings.

Overall, we found some improvements in staffing arrangements. However, further work was needed to ensure all staff completed required refresher training and competency assessments to support the delivery of safe and effective care.

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 addressed most of the issues identified at the previous assessment to improve people's safety. The home was generally clean, and staff used personal protective equipment (PPE) appropriately. However, some risks remained. These were discussed with the director responsible for the premises, who confirmed action had been taken following the inspection and assured us that outstanding issues would be addressed.

A cleaner had been recruited with specific responsibilities. However, there were no effective checks in place to monitor whether the required cleaning standards were being met.

The provider completed regular audits and daily management walk-arounds to monitor hygiene, cleanliness and staff practice. Despite this, some risks had not been identified, including damaged pull cords, people’s undergarments being hung to dry on a water-damaged fire exit push bar, and an uncovered jug of squash left in a communal lounge throughout the day. Cleaning standards were not consistently maintained, with cobwebs and dead insects observed on window sills. A relative also reported routinely cleaning dust, dirt, and insects from their family member's bedroom.

The provider had invested in new crockery, kettles, and toasters. The chef used appropriate PPE, including a hairnet, during food preparation. However, staff were observed entering the kitchen without PPE. Food and milk stored in the fridge were dated when opened, but no fridge thermometers were in place, meaning recorded temperatures could not be verified.

An infection prevention and control audit completed in July 2026, score was below the provider's target of 85%. Issues identified included missed night cleaning tasks, dirty areas, and evidence of cobwebs and insects, and only 45% of staff had completed infection prevention and control training. This reflected staff feedback and training records, which showed some mandatory training was not up to date.

Overall, although some improvements had been made, the provider had not taken sufficient action to fully address risks relating to infection, prevention and control, demonstrating people were not consistently protected from the risk of infections and infectious diseases.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had made some improvements to medicines management since the previous assessment. The digital care system included information about people’s medicines, allergies, and the support they required. Appropriate assessments and legal authorisation were in place where medicines were administered covertly, and protocols were available for 'as required' (PRN) medicines.

Medicines were generally stored safely, and records showed people usually received their medicines as prescribed. However, some concerns remained. Staff did not consistently record the effectiveness of PRN medicines, medicines with a limited shelf life were not always dated when opened, and fridge temperature records contained gaps and had not always been escalated when outside the safe range. In addition, one person had not consistently received medicines to support bowel management, and staff had not recognised or escalated the associated risks.

Although staff had received medicines training and we observed medicines being administered in line with good practice, not all staff had completed a medicines competency assessment. These issues had not been identified through existing audits, reducing assurance that medicines were always managed safely and effectively.