Horizon Care (South West) Ltd

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

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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to people’s safe care and treatment and consent.

This service scored 25 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People and their relatives told us they were not involved in the development or review of care plans. We reviewed 24 care and support plans and found no evidence of meaningful involvement from people or their relatives. Many contained conflicting information and lacked sufficient detail. One person said, “I’m not sure that there is a care plan although I guess there must be, and I don't recall any conversation about a review of the care plan.”

Care plans were not consistently reviewed when people’s circumstances changed. For example, during a visit, we reviewed a paper care plan in a person's home that had been completed over 2 years earlier. It stated the individual lived with their spouse, which was no longer accurate as the spouse had passed away. The person was living with dementia and did not always remember this change.

While staff reported they were provided with the information they needed to support people, we found care plans were a list of tasks to be completed. They lacked detail about how support should be delivered and did not reflect individual preferences. For example, “Assist with any personal care needed. Assist onto the commode.”

Several people expressed concerns about whether staff, particularly new staff, understood their support needs. In the providers’ 2025 satisfaction survey, one person wrote, “ALL carers should READ care plan. No breakfast put out and no med box opened, and no notes made.” Another person told us, “I have never felt unsafe, but I do have to tell any new staff what to do.”

The provider did not consistently supply accurate, up-to-date information in formats tailored to individuals’ communication preferences. For example, details about rotas and carer visits were provided online or via text message, making them inaccessible to people without a mobile phone, internet or computer access.
 

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.

Care plans lacked person-centred detail regarding people’s nutrition and hydration requirements, and associated health conditions. They did not reflect current evidence-based guidance. For example, one person with type 2 diabetes was receiving support from staff with food, fluids and personal care. Their care plan contained no guidance for staff to safely support them in line with NICE (National Institute for Health and Care Excellence) guidelines. There were no risk assessments in place or care plans related to dietary needs, emergency protocols or foot care routines. A lack of emergency protocols meant staff may not respond effectively to diabetic emergencies, increasing the risk of harm. The absence of a foot care routine meant the person was potentially at risk of foot ulcers and infections.
 

The provider did not work well across teams and services to support people.

Systems and processes for sharing information across the staff team and with external professionals were not effective. Daily care logs completed by care staff typically consisted of a checklist of tasks, with limited detail about the actual support provided. This meant staff and partner agencies were unable to clearly understand what had occurred during each care visit. For example, we reviewed 7 days of care logs for a person identified as being at risk of dehydration and skin breakdown. The logs included ‘Push fluids’, and ‘Check skin integrity’ as completed tasks. However, there was no record of how much fluid the person had consumed, which areas of skin had been checked, or the condition of the skin. This absence of detail prevented the provider and other professionals from monitoring the effectiveness of care and identifying any emerging concerns or changes in the person’s needs.

The local authority reported difficulties in reviewing the care packages they had commissioned. Care records contained little information about the time spent on tasks or details of the support given. As a result, they were unable to accurately assess whether the care delivered was appropriate and responsive to people’s current needs.
 

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

Staff told us they would contact the office if they had concerns about a person's health or in the event of a medical emergency. While this demonstrated an awareness of escalation processes, the guidance available to staff within care and risk management plans was minimal. This lack of detailed instruction limited staff ability to respond effectively to changes in people’s health and placed people at risk of harm and not having their needs met.

We found examples where insufficient guidance placed people at risk. The service supported one person in changing their colostomy bag. A colostomy bag is a pouch strapped to a person’s stomach to collect stools. We reviewed their care plan and found no risk assessments or guidance for staff, for example, relating to infection control, skin integrity or recognising signs of complications. This placed the person at risk of potential infection and unsafe care relating to their colostomy bag.

Similarly, care plans for people requiring support with nutrition and hydration were not clear about how staff should provide this support. For example, one person’s care plan noted they had acid reflux and needed to be cautious with their diet. However, it did not provide any specific guidance on which foods should be avoided or what dietary adjustments were needed to prevent discomfort. This limited staff ability to provide appropriate and safe nutritional support.
 

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

People and relatives told us their care was not routinely reviewed with them. Effective quality assurance systems were not in place and audits were not being completed. Opportunities for people to give feedback about the service were limited. A satisfaction survey had just been sent out for the first time in 2 years, indicating a lack of ongoing engagement with people using the service. As a result, the provider lacked an accurate and up to date understanding of the quality of care being delivered. This undermined their ability to identify concerns and make the necessary improvements.
Where people had raised concerns, they had not always been addressed. Feedback from the providers’ satisfaction survey included comments such as, “Have made numerous complaints, but when a different carer comes, they haven’t read the care plan”, and “When I ring the office, I get told ‘leave it with me’ but nothing changes.”
 

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.
We observed that staff asked for consent before providing support, and we received some positive feedback from people about this. However, we identified significant concerns regarding the provider’s understanding and application of the Mental Capacity Act 2005. (MCA). Staff demonstrated limited awareness of how to uphold individuals’ human rights under the MCA. As a result, some restrictive practices were in place without appropriate legal authorisation.

Care plans did not contain mental capacity assessments or best interest decisions in line with the provider’s own policy. The service confirmed they did not complete these assessments but referred to the Local Authority or GP if they were concerned. Where an assessment had been completed by an external professional, the information and best interest decision had not been incorporated into the care plan.

The care plan of a person living with dementia stated the person was “At high risk of self-neglect. Declines care.” There was no-one legally authorised to make decisions in the person’s best interests, and no record of decision specific capacity assessments or best interest decisions. The care plan advised “[Person’s name] lacks capacity to make care decisions” and instructed staff to administer care and medication regardless of the person’s wishes. The person’s rights were not protected because the care plan relied on a blanket statement that the person lacked capacity. It did not document any best interests decision-making process, despite there being no legally authorised person to make decisions on the person’s behalf. The plan instructed staff to administer care and medicines regardless of the person’s wishes, which breached MCA principles.

The provider’s mandatory training did not include the Mental Capacity Act 2005, and several staff members did not have a clear understanding of how the MCA applied to their daily practice. One staff member commented, “I vaguely know what the MCA is, I don’t recall if I have had training in it. There are people that are unable to make decisions about their care themselves. I know that the families are involved and that their needs are documented in the care plan. I can read by verbal and non-verbal responses if a person is consenting for me to deliver the care detailed in the care plan.”