Horizon Care (South West) Ltd

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 Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, person centred care, staffing, governance and notifications.

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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not always respond to complaints and concerns. There was a defensive culture when issues were raised, with people using the service often being blamed for the issues. This was acknowledged by one of the Directors who expressed a willingness to change the culture.

Safety concerns raised with the service had not always been listened to or addressed. One person commented, “The worst thing about this company is that they have so many different carers coming to look after my husband: it's hard to have any continuity of care… I don't really know who's doing what…I used to call [the office] up to a few months ago, but we haven't had very positive responses from the office staff”.

Some staff felt able to raise safety concerns and were confident the service would act. This was not the case for all staff, however. One member of staff told us several people had raised concerns about communication with staff who did not have English as a first language. “They have told me that they dread these visits as they can't say what they need help with.” The member of staff had raised their concerns with the service but was unaware of any action taken.

There were no auditing or quality assurance processes in place to reduce risks to people using the service, drive improvement and enable a learning culture.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

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. One person told us they started with the service after an assessment by a healthcare professional. The service did not complete their own assessment, “They just rang me and told me when and where care would start. It was some weeks after care started before I found out that they produce a roster, which they now send me; but I had to ask for that”.

The provider failed to collaborate effectively with other agencies to ensure people received safe care. This was corroborated by the local authority, which commissioned 90% of the care packages. The provider had declined to share documentation when requested and did not supply essential information needed for care package reviews.
 

The provider did not work well with people and healthcare 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.

Some people told us they did not always feel safe with the carers supporting them. One relative described how their family member struggled to mobilise, “but the staff won't help, although eventually they have to help her if she can't do it.” Another relative told us their family member had difficulty balancing when staff left them on the commode, but staff were reluctant to come back when called. The person felt staff could sometimes be a bit impatient with them.

Other people described staff as friendly, respectful and caring, and said they felt safe with them. Comments included, “Staff are nice, caring people” and “There are quite a few different carers who come. The ones that I've met, I did feel that she is safe with.”

People were at risk because the provider did not always follow local authority safeguarding recommendations, for example, reviewing one person’s care plan and adding reminders for staff to lock the front door on leaving.

Safeguarding concerns and incidents of potential abuse were not always documented, escalated and referred to the appropriate local safeguarding authority. Staff told us they rang the office with any concerns but did not record them as this was the manager’s role. The local authority confirmed they had received ‘multiple’ safeguarding referrals between September 2024 and October 2025 involving the service, with just one raised by the service themselves. The service had not notified CQC of any safeguarding incidents, as they are legally required to do.

The provider had no oversight of safeguarding concerns or accidents and incidents. This meant they were unable to review the effectiveness of their processes to check the timely and accurate recording of concerns, whether appropriate actions were taken, and any outcomes, patterns and trends.

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.

While staff generally felt they had sufficient information to support people safely, risk assessments were not completed for all known risks, in breach of the provider’s own risk assessment policy. This meant staff did not always have the necessary guidance to deliver safe and appropriate care. For example, one person living with a dementia required support to move safely, yet their care plan did not include a moving and handling risk assessment to guide staff.

Concerns were raised by people using the service and their relatives about staff understanding of individual risks and the support required. One relative commented: “Staff need to be looking for things such as spots on [family member’s] back. They should put cream on, and a lot of them just don't do that; they don't show any sort of skills. For example, they're letting [family member] wash themselves when they're supposed to be doing that.”

People felt regular and more experienced staff were better equipped to support them safely. One relative described how staff assisted their family member with showering but often left them unattended to carry out other tasks, despite the person being at risk of falls. They commented, “Sometimes a carer will come who knows what they’re doing, and that makes a difference.” Another person said, “My relative has had multiple strokes over the last few years, but I'm not sure how much most of the carers really understand about a stroke… I'm always glad when it's one of the more experienced carers who comes.”

The provider did not always detect and control potential risks in the care environment.

The service did not consistently carry out environmental risk assessments for each person prior to delivering care. 90% of care packages were commissioned by the local authority, and the provider relied solely on the initial information supplied by them, rather than conducting their own assessments. For private clients, initial assessments were completed by the service, but these contained limited detail regarding environmental risks. As a result, potential hazards within people’s homes were not always identified, leaving individuals at risk and staff without the necessary guidance to manage those risks safely.

One person, who lived alone, had dementia and macular degeneration. They had a history of falls in their house and garden. Their care plan listed tasks for staff to complete but lacked any environmental risk assessments to mitigate any risks, for example identifying and removing trip hazards. Another person with poor mobility required a stair lift, walking frame, and grab bar to mobilise and transfer safely. Although a risk assessment had been requested from an occupational therapist 3 months earlier, no environmental risk assessment had been included in the care plan. The only guidance provided to staff was: “Mobility top of stairs coming off the stair lift to the landing, be mindful of where you are standing.” This lacked detail and did not support staff in managing risks effectively.
 

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.

Staff had completed training in a range of general topics relevant to their roles and spoke positively about the quality of this training. However, the providers training matrix showed staff had not received all the training necessary to meet people’s individual needs safely. This included key areas such as catheter care, diabetes management, mental health, mental capacity, dementia, and learning disability/autism.

People receiving care expressed concerns about staff competence and knowledge. One person said, “I'm not sure how much training they get, but often when it's a new carer I have to guide them on what they need to do.” A relative commented that staff “could be better with the safety aspects,” explaining that their family member required a hoist for transfers and did not feel safe when being hoisted by staff. Another relative noted that while staff were caring and eager to help, they lacked practical skills in everyday tasks such as cooking simple meals or hanging washing. They often had to provide detailed instructions or demonstrate tasks themselves, attributing this to gaps in training, particularly around the practical and cultural aspects of domestic support.

Workforce planning was ineffective, and staff rotas were frequently subject to change. Staff were expected to work long hours, without allocated travel time between visits. One staff member told us, “No travel time provided. We are expected to travel within the service users’ visit time to get to the next visit.” The provider’s systems for monitoring care calls were ineffective. This led to care calls being missed, delivered at inappropriate times and significantly shortened to enable care workers to complete all scheduled visits. An analysis of call data over a 4 week period found 31% of calls were less than half the planned duration and 85% of calls had no travel time allocated.

The lack of allocated travel time meant visits could be rushed, placing people at risk of not having their needs met. One relative had raised concerns about the support provided to their family member who was declining care, including medication. They stated, “If [staff] are more encouraging and stay longer than 10 minutes [family member] may have time to wake up/come around to what is being asked of them.” Another relative told us they had to remind staff to apply topical medication, “which I have to make sure they do because they are so busy, and they can be a bit rushed when they come.”

Although regular observations of staff practice were carried out, there was insufficient support for staff through face-to-face supervisions or opportunities for reflection and professional development. This limited the provider’s ability to identify and address gaps in knowledge, skills, and confidence.

The provider did not have effective systems in place to make sure people were recruited safely. Recruitment records reviewed did not always contain references, and the provider had failed to request a full employment history, as legally required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This placed people at risk of receiving care from staff who may not be suitable to work in the care sector.
 

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.

The majority of people we spoke with were satisfied staff used protective equipment correctly and provided safe, hygienic support. They told us staff consistently wore gloves and aprons during visits and disposed of them properly after use. Staff had received training in infection prevention, and the provider observed the effectiveness of this during regular spot checks. Despite this, some people raised concerns that staff were not consistently managing the risk of infection. In the provider’s recent survey one person stated, “Supply the carers with full PPE at all times. Instead of the client supplying any PPE, if have any spare of our own at home.” Another person, whose immune system was compromised, told us staff did not always put on PPE before supporting them.

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

Medicine administration records (MAR) were paper-based and kept in people’s homes. The provider did not have robust systems and processes to routinely audit these records to check people were receiving their medicines safely and as prescribed. Instead, they relied on care staff to identify and escalate concerns. One person told us, “They have a pile of papers that carers fill in about the medication and creams that they give. Someone from the office is supposed to collect the papers, but no one does.”

The provider did not have effective oversight of medication errors or any actions taken to mitigate risk. They advised no recent errors had occurred, which was inaccurate. We identified 2 recent medication errors involving the same person. On both occasions, staff failed to record the administration of a controlled drug as legally required. The first error resulted in the person receiving an overdose, although no significant harm occurred. The second incident, involving a different staff member 4 weeks later, demonstrated actions taken to prevent recurrence were ineffective. This placed the person at ongoing risk of harm.

People did not consistently receive critical medication as prescribed due to staff not visiting at their commissioned times. This was confirmed by staff we spoke with, and people using the service. One member of staff said, “Time sensitive medications are in place for some service users. I know of times where visits have run late, and time sensitive medications are late.”