Solent Grange Nursing 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.

This is the first assessment for this service since registration under the new provider. This key question has been rated requires improvement. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, governance and staffing. This was because systems and processes were not effective in identifying, assessing and mitigating risks to people, resulting in continued exposure to avoidable harm.

This service scored 41 (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 based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Governance arrangements did not ensure learning from accidents, incidents and complaints was used to prevent recurrence. Although the provider had systems to record and review accidents and incidents, there was no thematic analysis to identify patterns or emerging risks. Lessons learnt records were not sufficiently robust to demonstrate how learning had been embedded into practice. Similarly, complaints were recorded and tracked, but there was no evidence that outcomes were reviewed to identify wider learning. As a result, the provider could not demonstrate that learning was consistently used to improve practice and reduce the risk of similar issues recurring.

The provider did not consistently respond to identified risks by implementing effective preventative action. For example, concerns relating to bed rail safety were identified on 14 March 2026 and recorded within the service improvement plan. Despite this, a person experienced a bed entrapment incident on 21 March 2026, resulting in bruising. During the inspection we identified further concerns regarding bed rail safety, including inappropriate use of bed rails, missing bed rail bumpers and bumpers that did not provide full coverage. This demonstrated that identified risks were not effectively translated into sustained preventative controls.

Learning from complaints was not consistently translated into improvements in practice. A complaint received from a relative in March 2026 highlighted delays in the administration of time-specific medicines. During the inspection, we found 2 people continued to receive time-specific medicines outside their prescribed intervals. This demonstrated that learning from complaints was not consistently embedded into operational practice.

Following our inspection feedback, the provider took immediate action by completing a service-wide review of bed rail use, removing inappropriate bed rails and introducing interim risk assessments with increased monitoring for people requiring full-length bumpers while replacement equipment was obtained. The registered manager also told us they were reintroducing thematic reviews and strengthening arrangements for capturing lessons learnt following changes within the leadership team. This demonstrated a willingness to respond to identified concerns, although these improvements were at an early stage and their effectiveness had not yet been established.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had effective systems to support safe transitions into the service. Records showed comprehensive pre-admission assessments were completed before people moved into the service, enabling staff to understand people's needs, preferences and risks. Staff told us they had access to this information before admission and discussed people's needs during handovers and staff meetings. This ensured staff had the information they needed to provide consistent and safe care from the point people joined the service.

People and their relatives spoke positively about their experience of moving into the service. One relative told us, "They explained everything to us and showed us around," while another told us, "The move there went extremely smoothly." This demonstrated that people and those important to them felt well informed and supported throughout the transition process, helping to promote confidence and continuity of care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Systems to monitor safeguarding concerns were not sufficiently effective to identify patterns, assure practice or reduce the risk of repeated harm. The provider had notified us of 43 unexplained injuries over a 12-month period, including multiple incidents of unexplained bruising. However, they could not demonstrate these incidents had been subject to robust investigation, trend analysis or oversight to identify underlying causes. Although lessons learnt records from March 2025 identified moving and handling practice as a possible contributory factor, unexplained injuries continued to occur, and the provider could not demonstrate how staff competency in moving and handling had been assessed or monitored in response. In addition, the safeguarding tracker recorded the reason for referrals and the date reported but did not consistently record outcomes, thematic reviews, lessons learnt or all closed concerns. This meant opportunities to identify recurring risks and embed learning were missed, increasing the risk of avoidable harm.

People and their relatives told us they felt safe using the service and did not raise safeguarding concerns. One person who had recently moved into the service told us, "I am now starting to feel safe again." A healthcare professional told us, "All safeguarding issues have been highlighted to me rather than me having a concern." This demonstrated that people and partner agencies had confidence in staff to recognise and report safeguarding concerns, supporting people's safety.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that 19 people were subject to DoLS, with a further 17 people awaiting assessment and authorisation. We found that DoLS conditions were being met.

Following our inspection feedback, the provider told us they had begun introducing staff competency assessments and were reintroducing thematic reviews with the support of the new deputy manager. While these actions were at an early stage, they demonstrated the provider had recognised the need to strengthen safeguarding oversight alongside the positive safeguarding culture described by staff, people and external partners.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments did not consistently provide staff with accurate or reliable information to manage people's risks safely. We found multiple risk assessments contained contradictory information, lacked sufficient detail or did not include clear guidance for staff about when risks should be escalated. For example, 1 person's falls risk assessment stated they did not have a diagnosis of dementia, which contradicted their care plan and other risk assessments. Another person's nutritional risk assessment identified depression, although this was not reflected within their medical history and there was no associated mental health care plan. This meant staff did not always have consistent information to support safe decision-making, increasing the risk of people receiving inappropriate or inconsistent care.

The provider did not consistently ensure identified risk reduction measures were implemented in practice. One person experienced 4 unwitnessed falls between March and April 2026, including a fall resulting in a head injury. Following incident reviews, the provider identified actions including the use of a sensor mat and hourly observations to reduce the risk of further falls. However, during our inspection we observed the person's sensor mat positioned away from them while they mobilised independently on the opposite side of the room. This demonstrated a failure to consistently implement agreed risk mitigation measures in practice, increasing the risk of avoidable harm.

We found similar concerns in relation to another person assessed as being at very high risk of falls. Their care plan identified the use of a sensor mat to alert staff when they moved. During 1 observation, the sensor mat was positioned beside the bed while the person was seated elsewhere in the room. On a second occasion, the sensor mat was unplugged while the person was lying in bed. This meant equipment intended to reduce risk was not consistently used as planned, limiting its effectiveness in protecting people from harm.

Following our inspection feedback, the registered manager told us they had already sourced wireless sensor equipment for a person known to unplug monitoring devices. They also told us the provider intended to undertake a service-wide review of sensor equipment and risk assessments to strengthen risk management arrangements. These actions demonstrated the provider had recognised the need to improve how risks were assessed and managed, although these improvements had not yet been embedded or shown to be effective.

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.

Systems to identify and address environmental risks were not consistently effective. Health and safety checks were completed, however, identified risks were not acted upon in a timely manner. Records showed broken seals on multiple fire extinguishers had been identified between January and April 2026, and repeated fire door inspections had identified gaps in fire doors since March 2026. Although these concerns had been escalated to the registered manager and provider, there was no evidence that remedial action, interim control measures or risk assessments had been implemented at the time of our inspection. This indicated that identified environmental risks were not consistently escalated into timely remedial action.

The provider did not always ensure the environment reflected its own risk assessments. During the inspection, we observed 3 free-standing radiators in people's bedrooms without protective covers, contrary to the provider's environmental risk assessment. This demonstrated a lack of alignment between documented risk assessments and actual environmental controls. Following our feedback, the registered manager arranged for the radiators to be removed immediately. This demonstrated the provider responded promptly once concerns were identified, reducing the immediate risk to people.

People and their relatives told us they felt safe living at the service. One person told us, "I feel safe here," and a relative commented, "[Person] finds the home nice and safe." This demonstrated people generally felt protected within their environment, despite the environmental oversight shortfalls identified during the inspection.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing deployment did not consistently enable people to receive timely care and support. Staff told us they were often unable to respond promptly to call bells during the night when providing double-handed personal care. They explained that if a call bell activated while they were supporting another person, they had to rely on the nurse to respond. However, the nurse was also responsible for administering medicines and covering multiple floors. Staff also told us standard call bells only sounded on the relevant floor unless activated as an emergency. This meant people were at risk of delays in receiving assistance and having their care needs met.

The provider's systems for monitoring call bell response times and staffing effectiveness were not sufficiently robust. Weekly call bell audits were completed manually during daytime hours only, despite staff identifying concerns during the night. Monthly audit data from January to May 2026 showed multiple occasions where call bells remained unanswered for up to 5 minutes, including 1 response time of 20 minutes. These findings, together with staff concerns about night-time responsiveness, demonstrated that staffing deployment did not consistently ensure people received timely assistance.

Additionally, staffing deployment was not based on a comprehensive assessment of people's needs, as the dependency tool did not sufficiently consider factors such as incident trends, call bell demand, the frequency of interventions or periods of increased risk. This indicated that staffing allocation was not fully informed by dynamic assessment of risk and demand which meant the provider could not be assured staffing levels and deployment consistently reflected people's changing needs or risks.

People's experiences reflected the concerns identified during the inspection. Relatives consistently told us there were insufficient staff, particularly during evenings and nights. One relative told us, "I think the ratio of staff should be higher," while another commented, "I think they are short staffed." A person told us, "There should be more staff on especially in the mornings at breakfast time." This demonstrated staffing arrangements did not consistently provide people with confidence that support would be available when needed.

Following our inspection feedback, the registered manager told us discussions had begun with the provider to review staffing deployment. In the interim, an additional member of night staff had been deployed, and call bell audits had increased to 3 times each week across a 24-hour period. These actions demonstrated the provider had recognised the concerns and begun to strengthen oversight, although it was too early to determine whether the changes would lead to sustained improvements for people.

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.

Systems to monitor and improve infection prevention and control were not consistently effective. We found gaps in cleaning schedules, with some records incomplete and actions not consistently signed off by leaders. Infection prevention and control audits were not consistently completed or signed off, and actions identified through audits were not always followed through. Although infection prevention and control training was underway, not all staff had completed the required training. This meant the provider could not be assured that infection prevention and control arrangements were consistently monitored or that identified improvements had been implemented to reduce the risk of infection.

We also received mixed feedback about cleanliness. While most people told us the service was clean, 2 relatives raised concerns. One relative reported finding human faeces in their family member's room, and another described finding dirty cups and items left in a room following a hospital admission. These concerns indicated that standards of cleanliness may not have been consistently maintained and affected some relatives' confidence in the safety of the environment.

However, we observed good infection prevention and control practices during the inspection. The service was generally clean and free from malodours, staff used appropriate personal protective equipment (PPE), and staff demonstrated a good understanding of how to prevent the spread of infection. Infection prevention and control policies reflected current guidance, and the annual infection prevention and control statement detailed infections over the previous 12 months together with actions taken in response. These findings showed that staff generally followed appropriate infection prevention and control practices during our inspection, despite the governance and monitoring shortfalls identified.

People's feedback was predominantly positive about the cleanliness of the service. One person told us, "It is always clean and tidy," and staff told us they were proud of the improvements made in this area. This demonstrated that, despite the governance shortfalls identified, people generally experienced a clean environment, and staff were committed to maintaining good standards of infection prevention and control.

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

Medicines were not always managed safely, placing people at risk of avoidable harm. During the inspection, we observed a staff member leaving medicines unattended on top of an unlocked medicines trolley while responding to another concern. We also identified 1 person who was prescribed pain relief and this medicine required a 4 Hour gap in between doses. However, records demonstrated that this medication had been administered at unsafe intervals, including doses given 1 hour and 50 minutes apart on 4 April 2026 and 2 hours and 50 minutes apart on 10 April 2026. This demonstrated medicines were not always administered or handled safely, increasing the risk of harm to people.

The provider did not consistently ensure time-specific medicines were administered in line with prescribing instructions. Records showed 1 person prescribed medicines at 4-hourly intervals experienced repeated delays during March and April 2026, with morning and evening doses administered outside the prescribed times by up to 2 hours and 15 minutes. Subsequent doses were not consistently adjusted following these delays. This meant people were at risk of not receiving the intended therapeutic benefit from their medicines.

Systems to support the safe administration of medicines were not sufficiently robust. We found PRN (as required) medicines protocols were incomplete for multiple people, with records lacking clear indications for use, maximum doses and guidance to support staff decision-making. Medication audits had identified incomplete PRN protocols and the need for medication training for 3 consecutive months; however, these findings had not been signed off or acted upon in a timely manner. This demonstrated governance arrangements had not effectively identified and addressed medicines risks, increasing the likelihood of repeated errors.

Following our inspection feedback, the registered manager told us they would begin discussions with the electronic medicines system provider to introduce alerts for time-specific medicines and pain relief intervals. They also told us completion of PRN protocols would be prioritised, alongside increased monitoring and medicines audits. These actions demonstrated the provider had recognised the need to strengthen medicines governance, although the improvements were at an early stage and their effectiveness had not yet been established.