Solent Grange Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service since registration under the new provider. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to safe care and treatment, consent and governance. This was because care was not always delivered in line with best practice or legal frameworks.

This service scored 46 (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 always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Care planning and assessment processes did not always ensure people’s needs were accurately identified, recorded and kept under review. We found gaps in relation to specific assessed risks and associated care plans. For example, 1 person had a history of repeated skin tears to the same hand alongside a contracture. Although a palm protector was in use, there was no contracture-specific risk assessment or care plan in place. This meant staff did not always have clear or comprehensive guidance to support safe and effective care, increasing the risk of avoidable harm.

We also found that care records were not always updated when people’s needs changed. One person who had been recently admitted to the service was unable to communicate effectively due to language barriers and relied on key words, signs and body language. However, their communication care plan had not been reviewed since admission and still stated they could communicate effectively in English. This demonstrated that care records were not consistently updated to reflect changes in communication ability, increasing the risk that staff may not respond appropriately to their communication requirements.

Feedback from people and relatives about involvement in care planning was mixed. Some relatives described positive involvement, with 1 stating, “I was involved in this from day 1, and it is very much tailored to [person’s] needs.” However, other relatives told us they had limited involvement or understanding of care plans, including 1 who told us, “I have never seen it and don’t know if it sets out all [Person’s] needs.” Most people we spoke with were not aware of their care plans. This demonstrated that people were not consistently involved in the assessment and review of their needs, reducing opportunities for person-centred care.

Despite these concerns, staff demonstrated a good understanding of people’s needs in practice and were able to describe people’s preferences, risks and support requirements. Staff were observed delivering care in line with this knowledge, and the service relied on a small group of regular agency staff, which the registered manager told us supported continuity of care. The provider also told us they had begun reviewing and updating care plans, starting with the 10 highest risk people, and had introduced a care plan tracker. This demonstrated some early steps were being taken to improve assessment processes, although these had not yet been fully embedded or demonstrated sustained effectiveness.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People were not consistently supported in line with evidence-based guidance, placing them at risk of avoidable harm. During the inspection, we observed people were not always provided with food and fluids in accordance with their assessed International Dysphagia Diet Standardisation Initiative (IDDSI) levels. For example, 1 person prescribed an IDDSI Level 6 diet was served food exceeding the recommended particle size, and another person prescribed IDDSI Level 2 thickened fluids was observed receiving fluids that staff identified as Level 1. This demonstrated that assessed nutritional and swallowing risks, were not consistently managed in line with recognised guidance, increasing the risk of choking or aspiration.

Risk management plans based on nationally recognised tools were not always followed in practice. The Malnutrition Universal Screening Tool (MUST) and Waterlow assessments were used to identify risks relating to nutrition and skin integrity; however, identified risks were not consistently acted upon. For example, 1 person assessed as being at very high risk of skin deterioration required repositioning every 4 hours. Records showed repeated gaps in repositioning, with intervals of more than 5 hours and up to 10 hours between interventions, and no documented refusals or clinical rationale. This increased the risk of avoidable pressure damage due to inconsistent adherence to care planning requirements.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Communication between staff and across teams was not always effective in ensuring people received consistent care. We found inconsistencies in information held by different departments, particularly between care staff and kitchen staff, which resulted in prescribed modified diets not always being followed for some people. This demonstrated that information about people’s dietary needs was not consistently shared or applied across services, increasing the risk of people receiving inappropriate food and drink.

We also found that handover processes did not always provide sufficient detail to ensure continuity of care. During a care staff handover, a person was described as complaining of pain, but no further context or follow-up information was provided. In contrast, nursing handovers contained more detailed clinical information. This reduced assurance that critical clinical information was consistently communicated across shifts, increasing the risk of delays or inconsistencies in responding to people’s needs.

There was limited evidence of fully up-to-date shared documentation to support continuity between services. Hospital passports were not always fully completed or reflective of people’s current health, communication and care needs. This meant that essential information may not always be available when people moved between services, increasing the risk of delays or inappropriate care during transitions.

However, there was some evidence of effective joint working with external professionals. Care records showed referrals to healthcare professionals were made when required, and input from external agencies was documented to support people’s care. An external healthcare professional told us they visited the service weekly and had worked with staff to improve assessment processes by introducing designated staff per unit to improve familiarity with people. This demonstrated some positive partnership working that supported improved coordination of care, although this was not consistently reflected across all areas of communication within the service.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People’s access to and follow-up from healthcare services was not always consistently effective. Staff supported people to attend routine health appointments, including optician and dental reviews, as well as specialist services such as diabetic eye screening and mental health reviews. However, records showed that follow-up actions were not always completed in a timely or effective way. For example, during our inspection a person told us they had tooth pain, which we escalated to staff. Records demonstrated that an appointment had been arranged prior to our visit, however, the person refused to attend and there was no evidence of further follow-up or alternative arrangements. This demonstrated a lack of consistent escalation and follow-up of unresolved health needs, increasing the risk of deterioration in people’s health.

We also found that preventative health monitoring and actions were not always consistently effective. Although people were supported to engage in activities promoting wellbeing, including boxercise, chair-based hockey and social activities, care records showed that health concerns were not always escalated or reviewed when needed. This meant staff did not always take sufficient action to support early intervention and prevent potential deterioration in people’s physical health, reducing opportunities to support healthier outcomes.

However, people described positive experiences of day-to-day wellbeing support. People and relatives told us staff encouraged engagement in activities and supported routines that promoted social interaction and physical activity. One person told us, “I am getting more of a social side now,” and relatives described positive experiences including regular care such as foot care, glasses checks and participation in exercise-based activities. This demonstrated that staff supported people’s general wellbeing through engagement and activity, although this was not always consistently linked to effective ongoing health management or follow-up care.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Systems to monitor clinical outcomes were not consistently effective in ensuring people received safe and timely care. One person’s care plan required daily clinical observations for 72 hours when antibiotics were prescribed. The person commenced antibiotic treatment for an infection on 23 April 2026, however, records reviewed on 1 May 2026 showed the last set of clinical observations had been completed on 14 April 2026, with no evidence of monitoring following the start of treatment. This demonstrated a failure in ongoing clinical monitoring during periods of increased risk.

We also found that escalation processes for abnormal clinical findings were not consistently followed. One person’s care plan stated that blood glucose readings above 15 mmol/L should be escalated to a GP or NHS 111. Records showed multiple elevated readings from February 2026 to April 2026. However, there was no evidence these results had been escalated in line with the care plan. This demonstrated that escalation protocols were not consistently embedded into practice, increasing the risk of avoidable deterioration in the person’s health.

However, we found no evidence this had resulted in harm to people and people and relatives also described some positive outcomes from care and support. One relative told us that following hospital discharge, staff worked closely with external professionals and supported the person to improve their mobility and quality of life, including moving from a palliative care pathway to using a wheelchair. Another relative described improvement in mental health outcomes due to coordinated care between staff and external partners. This demonstrated that where care was effectively coordinated, people experienced meaningful improvements in outcomes, although this was not consistently achieved across the service.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Mental capacity and best interest decision-making processes were not consistently completed in line with the requirements of the Mental Capacity Act 2005. We found multiple examples where assessments covered several decisions rather than being completed for specific decisions. In other cases, assessments did not clearly evidence how people had been supported to understand, retain or communicate information relevant to decisions being made. We also found instances where best interest decisions started from a presumption of restriction rather than clearly identifying the specific decision required. In some records, best interest documentation appeared duplicated with only names changed. This increased the risk that decisions were not fully compliant with the Mental Capacity Act 2005.

We also found inconsistencies in documentation relating to consent. For example, 1 person’s bed rail risk assessment recorded that consent had been given for bed rails; however, a consent form dated 5 June 2024 indicated the person had only consented to living in an environment with a locked door and did not evidence consent specific to bed rail use. In addition, consent documentation did not consistently include clear explanations of options, risks or alternatives considered. This meant it was not always clear whether people had been fully supported to make informed decisions about their care and treatment, increasing the risk that consent may not be valid or informed.

However, people told us they were supported to make day-to-day decisions and that staff respected their choices in practice. One person told us, “Yes, I am always given the choice,” and a relative told us, “If they are going to do something, they will always ask [Person] first.” During the inspection, we observed staff offering people choices about aspects of their daily care, including food and who supported them. This demonstrated that, in day-to-day practice, people were supported to exercise choice and control, although this was not always consistently underpinned by robust documentation of consent and capacity.