Solent Grange Nursing 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.

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 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 was in breach of legal regulation in relation to governance. This was because governance systems were not consistently effective in identifying, monitoring and improving quality and safety.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider did not have a clearly defined or consistently embedded organisational vision or values. The Statement of Purpose did not set out a clear vision or values, and following the recent change in provider, governance arrangements and organisational systems had not yet been fully embedded. This meant the provider could not demonstrate that its vision, values and strategic priorities had been clearly communicated and embedded across the service.

However, staff described a generally positive culture within the service. Staff told us there was strong teamwork, openness to change and a supportive environment. This showed that although the day-to-day culture was positive, the provider's strategic direction had not yet been fully embedded.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

We found concerns regarding leadership assurance processes. Although recruitment processes were generally compliant with Schedule 3 requirements, leaders relied on agency providers to complete key vetting checks, including right to work documentation. This created a gap in provider-level assurance over agency staff compliance. The registered manager could not demonstrate how they assured themselves that staff deployed by agencies had appropriate right to work status. This meant there was not always clear provider assurance that safe recruitment processes were consistently applied across all staff groups.

Daily walkarounds were completed, and records demonstrated that leaders acted with honesty and integrity, including applying the duty of candour when required. This provided some assurance of visible leadership and transparency at service level. This demonstrated some positive leadership behaviours and visibility within the service, supporting transparency and oversight in day-to-day operations.

The service had experienced recent leadership changes, including the appointment of a new deputy manager. The registered manager told us these changes had affected governance arrangements, but work was underway to embed new structures and strengthen accountability.

Staff described leaders as supportive, approachable and caring, with comments including, “They really do treat us as people not just a number,” and “Both the registered manager and deputy manager are great.” This demonstrated that, despite governance concerns, staff experienced supportive leadership at operational level. However, this positive operational leadership was not consistently reflected in governance assurance systems.

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

The registered manager had an open-door approach, and staff, people and relatives told us they felt able to raise concerns. This supported a culture of openness at operational level. Staff described feeling encouraged to speak up, with 1 stating, “I feel I have a voice,” and another saying, “Yes, we are encouraged to speak up if we feel we have to.” This indicated psychological safety within frontline teams and demonstrated that staff felt able to raise concerns without fear of negative consequences.

People and relatives also told us they felt confident concerns would be listened to and addressed in a timely way. This indicated that the provider had created an environment where people felt able to share feedback and raise issues. This supported openness and communication within the service.

However, while there was strong evidence of speaking up, this was not always matched by consistent evidence of structured organisational learning from feedback

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had systems in place to support workforce equality, diversity and inclusion. Staff supervisions, appraisals and team meetings were carried out, supporting engagement and professional development. This demonstrated that structured processes were in place to support staff development and inclusion.

Staff feedback was consistently positive regarding equality and inclusion. Staff described a diverse workforce where people worked well together and felt included. One staff member told us, “We have a very diverse culture at Solent Grange but we all work together and the management work very hard so that we all feel included.” Another told us, “This is the best place I have worked where I am supported like others, regardless of my culture or ethnicity.” This demonstrated that inclusion was not only policy-based but embedded in day-to-day staff experience.

The provider also had policies and training in place to support equality, diversity and inclusion, and reasonable adjustments were implemented where required. This demonstrated that systems were in place to support inclusive practice and promote fairness across the workforce.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not consistently effective in identifying and addressing known risks. This resulted in repeated exposure of shortfalls across key service areas. The provider’s service improvement plan included actions in response to identified concerns; however, these actions were not always completed in a timely way. Audit processes, including medication, infection prevention and control, and health and safety audits, did not consistently include clear action plans or evidence of sign-off. This reduced assurance that identified risks were being systematically closed.

We found repeated shortfalls across audits that had not been effectively resolved over time. For example, medication audits from January to March showed recurring issues that were not consistently signed off or actioned. Health and safety audits also failed to identify issues that were found during inspection. This indicated a lack of effective audit escalation and follow-through and demonstrated that governance systems were not effective in ensuring sustained improvement in practice.

We also found that concerns identified in a previous internal quality assurance visit in February 2026 had not been fully addressed. Issues identified in relation to record keeping, staffing, medicines management and risk monitoring were still present at the time of inspection. This demonstrated failings in the provider’s ability to embed learning into sustained practice improvement.

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.

The provider demonstrated some effective partnership working with external organisations. The registered manager held a leadership role within the local care partnership, supporting collaboration across the wider sector. This demonstrated engagement with system-level improvement and contribution to local health and care networks.

The service also worked with community groups to support people’s engagement in local activities. For example, partnership working enabled 22 people to attend and participate in a local community event. This demonstrated effective use of community partnerships to promote social inclusion.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Although the provider undertook audits and quality monitoring visits, these did not consistently lead to sustained improvement in outcomes for people. Identified issues were recorded, but actions were not always implemented or completed, resulting in repeated concerns being identified over time. This demonstrated that learning from monitoring activity was not consistently translated into improvements in practice.

Staff had access to training and professional development opportunities. However, there was limited evidence that learning from training, incidents or feedback was consistently embedded into practice to improve care delivery. This meant opportunities to improve services through learning were not fully explored.

Overall, this demonstrated that systems for monitoring, evaluating and improving the service were not effective in driving sustained improvement or innovation across the service.