Horizon Care (South West) Ltd

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• 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 – 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 Inadequate. At this assessment the rating has changed to Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

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

This service scored 42 (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 always make sure people’s care and treatment was effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

At the previous assessment people expressed concern about whether staff understood their support needs. At this assessment we received some positive feedback, but some concerns remained. For example, one person explained that care staff did not always support their family member into their chair correctly, despite guidance being recorded in the care plan. Other people commented, “I have to remind the carers to walk behind him when he walks to the chair, as his mobility is poor and he could fall; they do not always do this” and “They apply creams after his shower, but I sometimes have to remind them.”

The service had begun to review care plans; however we found inconsistencies in some of the newly created documents. For example, one person’s care plan stated in one section that they were a Type 1 insulin‑dependent diabetic, while another section described them as having Type 2 diabetes. In addition, neither the care plan nor the associated risk assessment contained information about how the person’s blood glucose levels were monitored, how staff should recognise and respond to episodes of high or low blood sugar, or how the person’s foot health should be monitored. This meant staff did not have clear, consistent guidance to support the person safely in relation to their diabetes.

At the previous assessment we found people had not been involved in the development or review of care plans. We found significant improvements since the registered manager started in post, in the approach to reviewing people's needs and recording them. Staff told us, “Clients are getting more reviews. They have risk assessments. They are being reviewed at the moment and added to the electronic operating system. The clients seem to like this. When the supervisor came, they asked the client if they were happy, if the carers were kind and caring and doing the job well. “

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.

Although the service had made improvements in some areas, it was still not following best‑practice guidance in key aspects of people’s support, including diabetes care, skin integrity, and medicines administration. For example, staff were not following National Institute for Health and Care Excellence (NICE) guidance for the safe administration of medicines in a home setting. NICE guidelines are detailed recommendations on how specific conditions should be diagnosed, treated, and managed. These guidelines are developed by panels of healthcare experts, using the latest research to determine what constitutes safe, effective, and ethical care. Neither the provider nor the registered manager had identified this shortfall.

In care plans and risk assessments that had been recently created, there remained a lack of clear guidance for staff on how to support people if they became unwell or required assistance relating to a medical condition. This potentially placed people at risk of avoidable harm.

Care plans continued to lack person‑centred detail about people’s nutrition and hydration needs and associated health conditions, and 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 however, their care plan contained no guidance to support staff to provide care in line with NICE guidance. There were no risk assessments or care plans relating to dietary needs, emergency protocols, or foot‑care routines. The absence of emergency protocols meant staff may not respond effectively to diabetic emergencies, increasing the risk of harm. The lack of a foot‑care routine meant the person was at risk of developing foot ulcers and infections.

The provider worked well across teams and services to support people.

Systems and processes for sharing information about people across the staff team and with external professionals had improved since the previous assessment. We had positive feedback from one professional who shared that the service had been open to suggestions and worked alongside them to try and make improvements.

Information available for external professionals had improved since the new electronic operating system had been introduced by the registered manager. This enabled better sharing of concerns and more effective reviewing of the quality of commissioned care.

The service could demonstrate how they were referring on to health professionals where needed in a timely way. All of these improvements were in early stages, and the registered manager and provider acknowledged they would need to be embedded.

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.

At the previous assessment people’s risk assessments and care plans did not contain the guidance staff needed to support people’s health and wellbeing. Although risk assessments and care plans were in the process of being reviewed and updated, at the time of this assessment the majority were not accessible to staff because they had not been uploaded to the providers electronic operating system. In addition, newly created risk assessments and care plans did not consistently include the information required to support people to lead healthier lives. For example, one person had health needs that required monitoring and prompt escalation in the event of deterioration however, their care plans contained no guidance to support staff to recognise signs that the person was becoming unwell or to know what action to take. Other people’s risk assessments and care plans did not identify significant risks to their health and safety. For example, there was no consideration of the risks associated with the use of paraffin-based emollients for a person who smoked, or the increased fire risk for a person who used oxygen. This demonstrated a lack of awareness and understanding of the severity and complexity of people’s health needs.

Staff were aware of escalation processes if they had concerns about people’s wellbeing. Records showed referrals had been made appropriately to external health and social care professionals if required.

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

At the previous assessment people and relatives told us their care was not routinely reviewed with them. The provider was now in the process of reviewing and updating all existing care plans. One person told us, “[Family member] has a Care Plan in place, updated after a management review in October. It’s a better system now.”

Since coming into post the registered manager had begun to develop quality assurance systems and auditing processes with the support of the local authority quality assurance and improvement team. These had not yet been embedded and were not fully effective at the time of this assessment.

Satisfaction surveys had been completed by staff and some people using the service. The results had been analysed and used to identify areas for improvement. This demonstrated improved engagement and informed a better understanding of the quality of the care being delivered.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

At this assessment we found people continued to be at risk of not having their human rights upheld because the provider did not have robust processes in place to ensure the principles of the Mental Capacity Act (MCA) 2005 were understood and applied in care planning and care delivery.

Assessments of service users’ mental capacity were not documented and there was no evidence of a best interest decision making process. For example, the care plan for one person, living with dementia, documented they had memory loss and were unable to make decisions about any aspect of their life. It was recorded they could decline care and become aggressive when being supported by care staff. Despite this there was no recorded assessment of mental capacity, no evidence of decision specific best interest decisions and no Power of Attorney identified (a legal document that allows an individual to appoint trusted persons to make decisions on their behalf should they lose mental capacity) This meant there was insufficient assurance that care was being delivered lawfully, in the person’s best interests, or in line with their rights under the MCA (2005).

At this assessment the providers mandatory training programme included the MCA (2005) and staff had completed this training. However, feedback from staff and the leadership team indicated that further training and support was required to strengthen understanding and ensure the Act was applied effectively in practice.