Solent Lodge

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

We assessed 6 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was 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 2 regulations relating to safe care and treatment and staffing.

This service scored 47 (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 have a proactive and positive culture of safety. Incidents were not investigated thoroughly, and lessons were not learnt to identify and embed good practice. Although the provider was open to feedback and demonstrated a wish to address concerns found during our inspection, we could not be assured shortfalls would be identified independently. In addition, we found opportunities for learning in response to feedback were missed. For example, when we shared feedback with the manager about observations of staff practice that could have been more respectful.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not have effective systems or processes to identify or report safeguarding concerns. There was not a clear understanding of the Mental Capacity Act 2005 (MCA), and we could not be assured restrictions to reduce risk, such as a keypad lock restricting access to the kitchen, were the least restrictive option. We saw an example of a safeguarding concern being reported to the local safeguarding authority. However, this had not been notified to CQC as required.

Although we found shortfalls, people and their relatives told us they felt safe and we observed mostly positive interactions between people and staff.

The provider did not always work well with people to understand, assess and manage risks.

Risks to be people were not always assessed or reduced. For example, staff told us a person was at risk of constipation and could describe some signs the person may show if they were constipated. Although they told us this would be reported to the GP, we found entries in daily records where these signs had been recorded but no further action had been taken. After our site visits, we received a risk assessment dated 04 March 2025, and bowel movement monitoring records that started on the evening of 20 February 2025. A manager confirmed this was not in place before this date.

However, some risks to people were assessed and reduced. For example, in relation to eating and drinking, and we saw a person being supported in line with their risk assessment.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff, who received effective supervision and development.

Staff completed a range of training courses on topics that were relevant to people’s support needs. However, no face-to-face training was provided, and we found staff had sometimes completed up to 9 e-learning courses, covering many different areas of care, in 1 day. The provider was unable to demonstrate, and we could not be assured, training for staff in supporting people with a learning disability and autistic people met best practice guidance. Competency checks and supervisions were not completed and recorded to assess staff competence, whether learning was applied or to identify any additional learning needs. This was not in line with the provider’s own policies and meant we could not be assured staff were supported to have the skills or knowledge to safely carry out their roles.

A manager told us staff needed to complete their medicines online training course and be “watched doing it [administering medicines] a couple of times” before they could administer medicines independently. We received a training matrix that showed 1 new staff member had completed this course on 26 February 2025. However, records showed they had administered medicines on at least 5 occasions between 28 January and 11 February 2025.

We received mixed feedback about staffing levels. Staffing levels were set at 2 staff during the day, and 1 at night. However, the provider did not assess people’s dependency levels to inform and determine safe staffing levels, which meant we could not be assured these were sufficient. A person’s needs had recently increased, and the home was seeking funding for additional staff to ensure they could support people safely. However, this had not yet been implemented and we could not be assured actions were taken to support people safely to reduce risk to people while waiting for this.

Staff recruitment files did not always contain all information in line with the legal requirements to ensure safe recruitment.

Systems and processes were not in place to ensure the risk of infection was always assessed or managed safely.

The home appeared generally clean, and people and their relatives shared positive feedback about cleanliness and hygiene. However, cleaning schedules stated, ‘all daily jobs done’ but there was no record of what daily tasks were completed. There were no records for tasks that need to be completed less often, such as quarterly shower head de-scaling to reduce the risk of legionella. Food temperatures were checked, but logs were not always clear what the temperature was, what food it applied to, or what temperatures would be considered unsafe. Infection control audits were not completed in line with the provider’s policy. This meant we could not be assured any risks or shortfalls would be identified or fixed.

Medicines were not managed safely. When people were prescribed ‘when required’ (PRN) medicines for agitation, we could not be assured they were always administered as prescribed, or as a last resort. For example, a person’s PRN protocol included guidance for staff on signs of agitation and ways to support the person before administering PRN medicine as a last resort. However, we found multiple records that stated the reason for administration as ‘being unsettled’, and for ‘hyperactivity’ on 7 occasions. This was not recorded on the person’s PRN protocol or medicines administration record as a prescribed reason for administering the medicine. This meant we could not be assured the person had received their medicine as prescribed and exposed them to a risk of harm.

Medicines audits were not effective and did not identify errors and shortfalls. For example, records showed 1 person did not have 1 of their prescribed liquid medicines for 7 days. A manager told us this was because they had run out of stock. However, an audit completed 2 days before the stock ran out stated all medicines were available with stock remaining and confirming quantities on the medicines administration record (MAR) were accurate. In addition, the manager told us 1 bottle of the medicine should last for the full 4-week medicines stock cycle. However, they had run out of stock after 16 days. They had not identified this as a concern or investigated how this had happened, to prevent recurrence. Another person’s records showed they were administered a second dose of their PRN medicine without leaving the required 4-hour gap on 2 occasions, and another 2 occasions when they had been administered a higher dose than prescribed. However, audits had not identified these concerns and recorded PRN medicines had been administered according to the care plan.