Horizon Care (South West) Ltd

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Requires improvement

• Responsive

  Inadequate

• Well-led

  Inadequate

Our view of the service

Date of assessment: 23 September 2025 to 7 October 2025.

Horizon Care (South West) Ltd is a domiciliary care agency. It provides personal care to people living in their own homes. Not everyone using the service received a regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. We carried out this assessment as we had received some information of concern. At the time of this assessment, 236 people were receiving personal care from the service. We carried out onsite and offsite assessments. We assessed all quality statements under the 5 key questions: Safe, Effective, Caring, Responsive and Well-led. We found 9 breaches of the legal regulations in relation to safeguarding, safe care and treatment, person-centred care, consent, staffing, dignity and respect, notifications, governance and fit and proper persons employed. At this assessment, the overall rating was Inadequate.

We found significant shortfalls in the standard of care being delivered. Risk assessments and care plans were not routinely completed with people or reviewed. Consequently, staff did not have the information necessary to provide safe and person-centred care, and care plans did not always reflect people’s current care needs.

Daily care records contained minimal information, undermining the ability of both the provider and external professionals to evaluate the effectiveness and safety of care. People’s medicines were not always managed safely.

Safeguarding procedures were not robust, placing people at risk of harm. Staff were not allocated travel time between visits. This meant people did not consistently receive their support at the times and for the duration commissioned, and visits could be rushed.

There was insufficient evidence staff had received all required training to allow them to meet people’s individual needs safely. Staff also lacked regular supervision and support to reflect on their practice and maintain their well-being.

Concerns raised were not consistently acknowledged or acted upon, and the provider did not always demonstrate a responsive approach to resolving issues. Recruitment processes failed to ensure staff were suitably skilled and safe to work with vulnerable people.

The service did not always recognise or meet individuals’ equality and diversity needs or uphold people’s human rights. The provider did not supply accurate, accessible, and up-to-date information in formats tailored to the communication preferences and needs of service users.

The provider did not have effective systems in place to monitor how the service was operating and as a result had not identified that people were being exposed to a significant risk of harm. They had not always worked effectively with external organisations to monitor and review the safety and quality of care.

The provider expressed a commitment to working collaboratively with the local authority and CQC to improve the effectiveness and safety of the service and ensure they met regulatory requirements.

Many staff expressed positive views about the support they received and the overall management of the service. We heard about examples of person-centred care which had met people’s individual needs. We observed some compassionate and caring practice from a long-standing member of staff. They had developed a trusting relationship with the people they were supporting and had a detailed understanding of their needs and preferences.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

We received mixed feedback from people using the service and their relatives. Several people reported not always feeling safe when supported by staff. One relative described how staff wouldn’t assist their family member when they were struggling to mobilise. Another relative expressed concern about their family member being left on the commode despite having difficulty balancing and noted that staff were reluctant to return when called. The person felt that staff could sometimes be a bit impatient with them. Concerns were raised about staff knowledge and understanding of individual risks, and the support required to keep people safe. This was particularly evident when people were supported by an inconsistent staff team or newly recruited staff. However, where people were supported by more experienced staff, their feedback was positive. They were more confident that care staff knew what they were doing, and this made a difference.
People did not always receive their care and support as agreed. Several people reported staff frequently did not arrive on time, did not stay for the full length of the visit, and often rushed through tasks. One relative said, “I have to make sure they do apply [topical medication] because they are so busy, and they can be a bit rushed when they come.” Another commented, “I end up doing the breakfast before they get there; I’ve asked them to get here earlier so that they can do all of that, but often the office says they can't do this, or they can't do that, they’re hopeless, very disorganised, not helpful at all.”
People told us they had not been involved in the planning and review of their care. The service relied on information from commissioning agencies when setting up a package of care. They did not routinely complete risk assessments and care plans with people prior to the service starting or review them. They relied on care staff to raise any issues once the care package had started.
Feedback about the kindness and compassion of care staff was mixed. Some people said staff were rushed and disengaged. Comments included, “They mostly don't ask how I am… they come in, rush about and are gone” and, “Some of them don't even speak to you or introduce themselves. They just let themselves in and start with what they need to do.” Other people described staff as kind, respectful, and caring. Positive comments included, “Staff are nice caring people” and “They make [family member] laugh… all the ones she's got are lovely.”
Some people told us they had not raised concerns with the service because they lacked confidence their views would be respected or taken seriously. There were also fears of negative repercussions. One person said, “The office staff on the phone always seemed to be a bit bad tempered and not very patient. That's also why I'm not very keen to complain in case they stop me from having any care.” Another added, “They seem to brush things off.” Despite these concerns, there were examples of good practice and responsiveness. One relative shared, “They do phone me if they're worried about anything and they also phone the office to let them know for example if [family member] seems a little under the weather.” People were also positive about the community manager, who was described as approachable and responsive. One person said, “Yes, I did feel that she listened to what I had to say, and I feel that they would try to sort out any problems.”