Horizon Care (South West) Ltd

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• 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.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance and making notifications.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider did not demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and the people using the service. The service lacked a person-centred approach and did not adequately uphold individuals’ rights.

Systems for gathering and responding to feedback from both people and staff were ineffective and action had not always been taken when concerns were raised. People reported responses to problems were not always helpful, and changes were not sustained.

Systems in place to monitor the quality and safety of care were ineffective. This meant the provider did not understand the issues impacting people using the service, placing them at risk of poor care.

Although regular observations of practice were completed with staff, they did not receive individual face to face supervision and there were no staff meetings. This meant opportunities for staff to engage in learning, reflection, and contribute to the development of the service were limited.

The Director told us they were aware of these failings. They expressed a commitment to addressing them, and “creating a service that people wanted with a person-centred approach.”
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We were not assured the provider and management team possessed the necessary skills and knowledge to effectively lead and oversee the service. Although they had experience in delivering care, their ability to provide robust oversight and strategic management was limited. They lacked awareness of regulatory requirements and did not demonstrate inclusive behaviours. This limited their ability to lead a service that promotes equality, diversity, and compliance with legal standards.

While the management team maintained regular communication with staff supporting people in the community, they did not ensure risks were always effectively managed, that people’s rights were consistently upheld, or concerns were always appropriately investigated. Although many staff described the management team as approachable, they did not receive sufficient support in their roles, and their practice was not effectively monitored to ensure quality and safety.

Leadership of the service was not effective. The provider failed to establish and implement a robust governance framework, which meant key shortfalls, such as inadequate risk assessments and poor management of safeguarding concerns, were not identified or addressed. As a result, risks within the service were not well understood or managed, increasing the possibility of unsafe and poor quality care.
 

People did not always feel they could speak up and their voice would be heard.

We found there was a closed culture at the service with a lack of provider level scrutiny and oversight. The service had a whistleblowing policy. However, some staff told us they did not feel able to speak up about unsafe practice, leading to a lack of transparency. This was also true of some people we spoke with during the assessment, who were afraid they would lose their care package if they raised a concern.

The Directors were aware of these issues and had begun taking proactive steps to address them. This included introducing an anonymous satisfaction survey for people using the service and implementing a ‘whistleblowing app’ to support care staff in raising concerns safely and confidentially.
 

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback about the fairness and inclusivity of the staff culture. Some staff reported working conditions were challenging. This was largely due to the lack of paid travel time and not being compensated for working beyond their scheduled hours, despite needing to do so to deliver the commissioned care. Conversely, staff also noted if visits were completed more quickly and they finished early, they still received the same pay for the day. This arrangement appeared to encourage some staff to rush visits, potentially compromising the quality of care. Other staff reported their working hours were not always consistent, making it hard to budget and pay bills.

Staff did not always receive the support they were entitled to under disability legislation, particularly in relation to risk assessments and reasonable adjustments. This lack of compliance had a direct impact on staff wellbeing.

The service employed a number of sponsored staff from overseas. These staff spoke positively about the support they had received and valued the opportunities to develop their skills and progress in their careers. One member of staff said, “I see myself growing with Horizon, I feel supported and enjoy my role.”

The Directors told us they provided additional support to staff where needed, including tailored training and practical resources. For example, staff with dyslexia were offered extra assistance, and laptops were made available to those who required them. These measures aimed to promote inclusion and ensure staff could carry out their roles effectively.
 

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.

The provider did not have an effective business continuity plan in place, to ensure vulnerable clients would continue to be supported safely during unexpected events impacting normal operations.
Governance processes were not effective in ensuring people’s safety, protecting their rights, or ensuring staff had the necessary skills to meet people’s needs. As a result, the systems in place did not drive improvement, failed to identify the concerns highlighted during this assessment, and could not be relied upon to monitor quality or manage risk. Significant issues were identified across multiple areas of the service including person-centred care, safeguarding, training, recruitment, supervision, recording, visit times and duration, complaints management, Mental Capacity Act (MCA), care planning, risk management and the management of people’s medicines. These widespread shortfalls reflected a lack of effective oversight and accountability, increasing the risk of poor outcomes for people using the service.

The provider had failed to notify CQC of significant changes, events and incidents affecting the service and the people who used it. This is a legal requirement under the Health and Social Care Act 2008. Failure to submit statutory notifications compromises transparency, regulatory oversight, and the ability to safeguard people effectively.
 

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

There was a lack of cooperation between the service and external agencies, as confirmed by the local authority and other professionals during the assessment. The provider had refused to share requested documentation and failed to supply essential information needed for care package reviews. This lack of transparency hindered multi-agency working and compromised the ability to ensure safe, coordinated care.

Additionally, the service did not always respond when the Care Quality Commission (CQC) raised safeguarding concerns and requested reassurance and evidence of investigation and oversight. This undermined the ability of CQC to monitor the safety of the service and protect people from harm.

During the assessment, the provider made a commitment to work more openly and collaboratively with external agencies to improve the quality and safety of the service.
 

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.

The absence of robust governance processes and oversight resulted in the provider not identifying the service failings highlighted during this assessment. There was no formal Service Improvement Plan in place to systematically identify areas requiring improvement, detail the necessary actions, assign clear responsibilities, or set achievable timescales. Consequently, the quality of service delivery had not been adequately monitored, potential risks to individuals were not consistently recognised, and opportunities for learning and continuous improvement were missed.

The Director had recently begun to work with the local authority Quality Assurance and Improvement Team to develop a quality improvement programme. They expressed a commitment to working collaboratively to improve the effectiveness and safety of the service, ensuring they met regulatory standards and reflected best practice.