Horizon Care (South West) Ltd

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• 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 Inadequate. At this assessment the rating has remained 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; medicines; safeguarding; person centred care; governance and notifications.

This service scored 31 (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 listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At this assessment we found opportunities to learn from incidents and accidents continued to be missed. For example, following serious incidents there were no investigation records available to evidence they had been formally reviewed. In addition, no ‘lessons learned’ documentation or meetings were in place to ensure learning was shared with staff, for example where incidents may have been preventable and where learning would have benefited both staff and people using the service.

Concerns about safety were not consistently listened to or acted upon. When people raised complaints not all aspects of their concerns were acknowledged or addressed. This minimised the voice of people speaking up about their safety and care.

There was not an open and transparent learning culture in relation to safety events. When we asked the provider how specific safety events had been shared with staff, they confirmed these events not been shared, limiting opportunities for shared learning and ongoing improvement.

Although the service had begun to make improvements, progress had been slow and insufficient- particularly in implementing the safety and quality changes that had been clearly identified and shared with the provider at the previous assessment.

The provider did not work well with people and health 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.

At our previous assessment we found the service relied on information from commissioning agencies when setting up packages of care rather than completing individual risk assessments and care plans with people. At this assessment the registered manager told us the service had begun completing risk assessments 2 weeks earlier. At the time of our visit only one completed risk assessment was available on the electronic system for staff to access. Care plans were also in the process of being developed, but only 14 were available to staff. This meant staff had no access to current information about peoples’ needs when supporting them.

The registered manager was working to drive improvements at the service and, in response to feedback, given during this assessment increased the number of completed risk assessments and care plans uploaded to the electronic system. However, the slow progress meant staff continued to rely on outdated information from commissioners when delivering care, increasing the risk that people’s current needs and risks were not being accurately identified, assessed or effectively managed.

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.

The registered manager had taken steps to improve safeguarding processes, and a safeguarding lead was now in place at the service. However, these improvements were not fully embedded or effective in practice, which meant people remained at risk of avoidable harm.

Safeguarding concerns and incidents of potential abuse were not consistently documented, investigated or escalated to the appropriate local safeguarding authority or CQC. For example, we saw concerns about neglect by care staff which had been raised by family members. There was no evidence they had been escalated, investigated or any consideration given to future or wider risks to other service users.

The provider’s oversight of safeguarding concerns and accidents and incidents remained ineffective because safeguarding logs were not consistently completed and were not up to date. 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.

However, we received positive feedback from people who told us they felt safe with the carers supporting them. Comments included, “I feel safe with the carers that come in” and “I feel very safe as the carers are all so obliging and nice, willing to do anything to help me which gives me confidence.”

Staff were aware of their responsibilities in relation to safeguarding people and were able to describe how they recognised, recorded and escalated concerns.

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.

At the previous assessment we found risk assessments were not in place for known risks. At this assessment, some risk assessments had been written, however, they had not been uploaded to the provider’s electronic operatingsystem. This meant staff still did not have guidance or information about people’s risks. For example, people living with diabetes, people whose skin integrity was at risk of deterioration, and people who required support in relation to their behaviour or health conditions. People therefore continued to be placed at risk of avoidable harm. The provider told us they had delayed completing this work while waiting to recruit a registered manager, who was now in post and had begun addressing these issues. However, this delay meant risks were still not being effectively managed.

Risk assessments and care plans were not always updated when new risks became apparent. For example, concerns had been raised about the abuse of a vulnerable person by their informal carer, as well as the carer’s abusive attitude towards care staff. There was no risk assessment in place to guide staff on how to manage this situation safely, and the risk was not documented in the persons care plan.

Risks to staff had not always been assessed. We reviewed an incident where staff were significantly affected, but there had been no updated risk assessment, care plan or learning shared with staff about how to recognise or prevent this type of risky behaviour in future.

Incidents and accidents were not routinely audited and records were incomplete. For example, reviewing the accident book we found that after an incident, details had not been used to update the relevant risk assessment or care plan. This also demonstrated a lack of effective oversight and learning following incidents.

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

Although environmental risk assessments were in the process of being completed, they were not yet available to staff for the majority of people supported by the service. As a result, staff did not consistently have access to the information needed to manage risks related to the environment.

Since coming into post on 10 December 2025 the registered manager had developed a new risk assessment format, which included clearer information about environmental risks, and identified potential hazards both inside and outside people’s homes. Once available to staff the new risk assessments would provide guidance on how to minimise a range of risks, including those related to clutter, trip hazards, pets, and unsafe food storage.

The provider did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Since coming into post the registered manager had taken action to improve the safety and effectiveness of staffing at the service. However, some planned actions had not yet been completed or were not yet fully effective.

At the previous assessment we found people were at risk of not having their needs met, because care staff had no allocated travel time between visits. This meant care visits could be rushed and did not always take place at the times or for the duration commissioned. Since then, staff had been allocated 5 minutes of travel time between each call and were encouraged to slow down and spend time with people. The provider had also improved oversight of visit timings through the introduction of a new system for staff to sign in and out. Our analysis of call data showed some improvement in call times since the previous assessment, although further improvement was needed. One person explained that inconsistent and unpredictable visit times had affected their diabetes management, as they were unable to eat until they were seated in their chair. Other people commented, “My timings are just hopeless, and the office don’t listen and don’t take any notice”; “I do have a problem with the timings and can sometimes be sitting here just waiting for them” and “The carers are often late, don’t let me know and sometimes only stay 10-15 minutes.” Several members of staff told us although the situation had improved, the 5 minutes of travel time was not enough to get to all the visits on time and stay for the time commissioned.

At the previous assessment we found there was insufficient support for staff through face-to-face supervisions or opportunities for reflection and professional development. At this assessment we found that although the registered manager had devised a supervision template for face-to-face supervision, this had not yet been implemented. The provider’s service improvement plan had identified this as an action to be completed by 15 December 2025. Despite this staff were positive about the support they received and confirmed periodic spot checks were completed to check their practice. One member of staff told us, “I have supervision with supervisors sometimes. They check my equipment, PPE, observe everything that I do with a client. They give me feedback at the end of it. It’s a chance to check my practices and learn more.”

Following the previous assessment the provider had reviewed staff training provision. New training modules had been introduced to ensure staff, including the management team, received all the training necessary to meet people’s individual needs. This included diabetes management, mental capacity and learning disability/autism. People told us staff were well trained. One person commented, “They are trained well. It’s a lot better than it used to be.” Staff confirmed the improved training schedule and told us it had improved their practice.

The provider was reviewing recruitment processes to ensure staff were recruited safely and suitable to work with vulnerable people. Disclosure and Barring Service (DBS) checks were to be reviewed every 3 years to ensure they remained up to date. Application forms had been amended to request a full employment history in line with the requirements of Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was being sought retrospectively for existing staff but had not yet been completed. The provider was developing a tracker to improve oversight of recruitment processes and documentation.

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.

Staff had received training in infection prevention (IPC). Additional training was being arranged through an external IPC specialist, who had identified some areas for improvement in staff practice. The registered manager told us they had strengthened their observations of staff IPC practice to include more detailed prompts. Spot check records were designed to capture information such as what personal protective equipment (PPE) the carer was wearing, whether it was changed at the correct times, when it was changed and how it was disposed of. However, the spot check records we reviewed were not effective because they did not include this level of detail. Recorded comments were largely minimal, for example, “Yes full PPE”

People told us staff used PPE correctly and provided safe, hygienic support. This was confirmed by our observations of staff practice. Comments included, “Very hygienic always, especially around my catheter care. Excellent, very highly professional service. PPE always worn” and “PPE always worn, very good hygiene always in the kitchen and bathroom.”

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

Since coming into post, the registered manager had introduced an electronic medicines administration system to record routine medicines administration. Paper‑based records continued to be used in people’s homes for medicines requiring additional security.

The electronic system provided improved oversight of day‑to‑day medicines administration however, people remained at risk because there were no formal, systematic processes in place to audit the safety and quality of medicines management. During this assessment, we identified multiple concerns relating to medicines administration. There was no evidence these concerns had been identified by the provider or that action had been taken to address them.

Medicines administration records (MAR) contained conflicting and unclear information about whether the person had received their prescribed medication. For example, care staff at the same visit, referring to the same medication, had recorded different outcomes or not recorded an outcome at all. We found medicines were being left out for people to take later without a risk assessment in place or documented agreement from the person. This is not in line with best practice guidance. There was no evidence action had been taken when people had not received their prescribed medication when staff had documented that it had ‘run out’.

There were no protocols or policy guidance for medications to be taken ‘as required’ (PRN). Protocols are required to guide staff on when such medicines should be administered. This increased the risk of inappropriate or unsafe medicines administration because care staff did not have clear, consistent instructions to support safe decision‑making.

The provider did not have effective competency checks to ensure staff had the knowledge and skills to administer medicines safely. Medicine administration was observed during the provider’s spot checks, but the records we reviewed contained minimal information about staff knowledge and competence. Recorded comments included, “Other carer put cream on bottom. Medication” and “Checked, oversee [service user] taken tablets.”