Solace Care Solutions Limited

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.

At our last assessment we rated this key question requires improvement and there was a breach of the legal requirement in relation to risk management. Improvements were found in this area at this assessment and the provider was no long in breach of regulation relating to risk management.

At this assessment the rating has remained as 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 legal regulation in relation to management of medicines.

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. For example, there had been incidents of a similar nature, placing a person at risk of harm. However, the provider had not taken effective steps to reduce the likelihood of recurrence. A professional told us that the provider had not notified them directly of this.

The provider did not always investigate incidents and complaints appropriately. A relative had raised concerns, however the outcome of the investigation was not communicated in a professional manner. When a family contacted the provider about an incident, they were signposted by them to complete a formal complaint form. The family then did not complete and return the provider’s complaint form. However, records showed that the provider had then noted that no complaint had been received, and that the family were satisfied with the provider’s response. This did not ensure complaints received were always taken seriously, investigated or actions taken to improve outcomes for people.

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

People did not always experience safe care. We found appropriate action was not taken by the provider, following incidents occurring which placed a person at significant risk, and had not reported to the relevant agencies. The provider did not have a proactive culture in which safety concerns were investigated and reported thoroughly. This did not provide assurance that the provider understood safeguarding procedures and did not have effective systems in place, always ensuring peoples safety whilst protecting them from potential harm or abuse.

Risk assessments were now in place to manage individual risk. The provider and staff demonstrated a good understanding of people’s individual care needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider carried out environmental risk assessments, ensuring care was provided in a safe environment for the person and care staff.

Recruitment practices were not always robust and required strengthening to ensure staff were recruited safely. At the time of the initial onsite assessment visit, the provider was unable to evidence that all the required employment checks were in place. The provider told us this was due to problems accessing electronic records, due to changes to their IT system.

When we returned to the service, a staff members recruitment records reviewed were not fully complete. For example, there was no appropriate evidence in the recruitment file of a Disclosure and Barring Service (DBS) check having been carried out. This information helps employers make safer recruitment decisions. We raised the shortfalls in relation to recruitment checks with the provider and they advised these would be addressed and a DBS application was made.

The provider did not have effective measures in place to manage the risk of infection spreading. The provider did not always assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Improvements were needed to ensure people were consistently protected from the risk of infection spread. During the assessment onsite visits, we observed the provider who regularly carried out personal care tasks had long artificial nails, which was also not in line with their own handwashing procedures. This stated, ‘Nails must be short and clean and free from nail varnish and false nails.’ We shared this with the provider who stated that they would revisit the hand hygiene policy.

Medicines management was not effective, and we found a breach of regulation in relation to this. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People’s medicines administration information was not consistently and accurately recorded. For example, we found staff had incorrectly transcribed information onto the medicines administration records (MAR). The dosage instructions for one medication had been incorrectly transcribed as 200mg when it should have been 20mg. We also found details on how to administer medicines missing. This did not ensure people received their medicines safely and as prescribed. Where MARs are handwritten, it is good practice for the handwritten entries to be checked by another member of staff for accuracy. We found no evidence people had been harmed due to these issues however, the lack of oversight and management of medicines placed people at risk of potential harm.

Gaps were also found on the MAR with no indication, whether prescribed medicines had been administered, or refused by the person. This did not demonstrate medicines were always administered appropriately. The providers three monthly medication monitoring audit dated 10th February 2025 had not identified these issues.