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 requires improvement. At this assessment the provider had not made sufficient improvements, and the rating has remained 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 remained 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 and culture focused on providing person-centred care, promoting people’s wellbeing and treating people with dignity and respect. The provider’s values promoted wellness, happiness and kindness.

The provider had invested in the service to drive improvements, including the introduction of a digital care system and some improvements were found since the last assessment of the service.

During the inspection, leaders were open and generally receptive to feedback. They promoted a homely environment and aimed to ensure people were supported by a familiar staff team to maintain continuity of care.

People spoke positively about staff and the care they received, and we observed positive engagement between staff, people, and their relatives. Most relatives were satisfied with their family member’s care. One relative told us, “The facilities are very homely, and the staff are approachable, making residents like [Person name] and us as family feel very comfortable living here.”

Staff understood their roles and responsibilities. They described good teamwork, effective communication and generally felt able to raise concerns. Staff enjoyed working at the service. One staff member told us, “I feel supported in my role and proud to be part of a caring team that genuinely wants the best for our residents,” demonstrating their commitment to providing caring and respectful support.

Overall, there was a positive and supportive culture within the service, with leaders and staff committed to provided person-centred care. However, further work was needed to strengthen oversight and ensure improvements were consistently embedded in practice.

Leaders understood the service and promoted its values. They had the skills and experience to lead with openness and honesty; however, this was not always effective, and concerns remained regarding the management of some risks to people.

The provider is the registered manager, and they were committed to delivering quality care. They were present at the service most days and provided on-call support to staff. The appointment of a quality lead had strengthened leadership and to improve the oversight. A new manager had been recruited to further support service improvement.

The provider understood their responsibilities in relation to Duty of Candour and had notified CQC about of significant events which they are legally required to do so.

Staff generally described the provider as approachable and supportive, although some were hesitant to seek support because they did not want to burden them. Staff spoke positively about the quality lead, describing them as ‘knowledgeable and supportive’, particularly in relation to communication, risk management, and leadership.

People and relatives also described the provider as approachable. One relative told us, “I would say they tried a couple of new managers but obviously didn’t work out but [Provider name] doesn’t seem to be around as much as they used to be.”

Some concerns identified during our assessment, including unresolved issues from the previous assessment and new risks relating to people's health and care, had not been identified through the daily management walk-around and the new oversight processes. This meant opportunities to reduce risks and drive improvement were missed.

Overall, leaders were approachable and supportive, and staff generally spoke positively about them. However, further improvements were needed to strengthen oversight and ensure risks and areas requiring improvement were consistently identified, monitored, and addressed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff described the provider and the quality lead as ‘approachable and supportive’. Most staff felt confident to raise concerns about people’s care or staffing concerns.

Staff meetings, supervision, and surveys provided opportunities for staff to raise issues and share feedback. While survey responses included positive comments, some concerns were raised about communication, short-notice shift cover, and areas for improvement. The survey results were still being reviewed by leaders. Despite this, staff demonstrated a commitment to providing good care and understood how to raise concerns through whistleblowing procedures when required.

People and relatives felt able to raise concerns with staff and management. Residents' meetings were held to share information and gather feedback. However, some people and relatives told us they could not recall attending meetings or being asked for their views.

The provider valued diversity in their workforce but did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff spoke positively about working at the service and enjoying their role. They felt respected and supported by colleagues. Whilst staff described there was an inclusive working environment, one staff member reported, support from leaders could be better, “Rather than staff being left to get on with it.”

Staff were recruited through fair recruitment processes and had access to training, supervision, and development opportunities. Staff told us the training provided them with the skills and knowledge to meet people's needs. However, staff reported they were expected to complete training in their own unpaid time, which did not promote equitable working practices and could have a negative impact on staff morale, engagement, and wellbeing.

The provider demonstrated a flexible approach to supporting staff, including accommodating family commitments. However, some staff reported they did not receive rotas sufficiently in advance, which affected their ability to maintain a healthy work-life balance.

The provider had strengthened the management, roles and governance systems. However, sufficient improvement, and effectiveness of oversight and monitoring risk, performance and outcomes was not fully embedded.

Some action had been taken in response to concerns identified at the previous assessment. For example, a digital care planning system had been introduced, audit processes and schedules were developed, maintenance and servicing records were in place, and incidents and accidents were being analysed. However, governance and oversight had not improved sufficiently, and previous concerns had not been fully addressed.

Audits were not always completed as scheduled and did not consistently identify shortfalls or lead to effective action. For example, audits failed to identify medicines management issues, unreliable monitoring records, and inconsistencies in daily care records. Actions arising from audits were not always completed or monitored to ensure improvements were sustained. As a result, audit processes were not effective in identifying and reducing risks to people's health, safety, and wellbeing.

Leaders did not always identify new risks or ensure previously identified environmental concerns had been fully addressed until these were brought to their attention. Daily management walkarounds were not always effective, and identified issues were not consistently followed up or resolved, including concerns relating to hygiene and cleanliness.

Staff told us care plans and personal emergency evacuation plans were up to date and detailed, and leaders shared feedback from audits, including areas where record keeping required improvement. However, although most staff had completed essential refresher training, this was not the case for some staff, including the provider. The provider had also not recognised the need to complete equality, diversity and inclusion training to support inclusive practice. This reduced assurance that leaders maintained the knowledge, skills, and oversight needed to monitor care effectively and manage risks.

Overall, although systems were in place to monitor the quality of the service, recurring issues identified during this and the previous assessment demonstrated that oversight remained ineffective. As a result, the provider could not be assured that risks were consistently identified and managed or that people always received safe, high-quality care.

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.

Following our assessment, we received positive feedback from the Fire Service, which demonstrated the provider had been responsive and had acted on recommendations made.

The provider worked in partnership with a range of external healthcare professionals to support people’s needs, with evidence of effective liaison and coordinated care. They included the GPs, district nurses, specialist services, and community-based professionals, to support people's care and wellbeing. Records showed staff contacted relevant professionals when people’s needs changed and were responsive to advice to support the delivery of care.

We sought feedback from external professionals; however, the only response received related to historical involvement with the service and did not reflect current practice.

The provider had systems in place to identify learning and make improvements. However, these did not always lead to effective or sustained improvements.

The quality lead analysed incidents and accidents, identified root causes, and shared learning with staff through meetings. However, learning was not consistently embedded in practice, as issues identified at the previous assessment, including weaknesses in governance, auditing, training, and provider oversight, had reoccurred. This reduced assurance that lessons had been learned and improvements sustained.

Leaders sought feedback from people and relatives and told us they had shared the findings from our previous assessment. However, not everyone could recall attending meetings or being asked for their views. While relatives were generally positive about the care provided, some identified areas for improvement, including staffing levels, menu choices and aspects of personal care. The provider was receptive to feedback and assured us action would be taken where needed.

The provider remained committed to improving the service and demonstrated a willingness to strengthen oversight, respond to emerging risks, and drive continuous improvement.