Horizon Care (South West) Ltd

“We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.”

“This assessment was unannounced and carried out to follow up on the warning notices issued at our last assessment relating to safe care and treatment, safeguarding and governance. We completed onsite visits on 25 March 2026, 7 April 2026 and 8 April 2026. We assessed all quality statements under the 5 key questions: Safe, Effective, Caring, Responsive and Well-led. The provider was previously in breach of 9 legal regulations in relation to safeguarding, safe care and treatment, person-centred care, consent, staffing, dignity and respect, notifications, governance and fit and proper persons employed. At this assessment the warning notices had not been met. We found continued breaches of 6 legal regulations related to safeguarding, safe care and treatment, person-centred care, consent, notifications and governance. At this assessment, the overall rating was Requires Improvement.”

“Although some improvements had been made since the previous assessment there remained significant shortfalls in the standard of care being delivered.”

“Risk assessments and care plans were in the process of being completed with people however, at the time of this assessment, the majority remained outstanding with very few accessible to staff on the provider’s electronic operating system. As a result, staff did not consistently have the information required to deliver safe and person-centred care. Where risk assessments and care plans had been completed, they did not always reflect people’s current risks and care needs.”

“Medicines management remained inconsistent, as medicines administration records (MAR) did not always clearly demonstrate safe administration, staff lacked clear guidance, best practice was not consistently followed, and no formal auditing process was in place.”

“The provider had taken steps to improve safeguarding procedures since the previous assessment. However, they were still not robust which placed people at risk of harm.”

“The service did not consistently recognise or meet individuals’ equality and diversity needs or uphold peoples’ human rights.”

“There had been some improvement in call times and visit durations being at the time and length agreed, however further improvement was needed. Many staff reported insufficient travel time between visits impacting on call times. Some people reported this was impacting on their wellbeing. The registered manager was encouraging care staff to ‘slow down’ and spend meaningful time with people rather than just completing tasks and rushing to the next visit.”

“Improvements had been made to staff support overall which was reflected in feedback received. Staff meetings had taken place and staff told us they felt better supported. However, they still lacked regular supervision to reflect on their practice and maintain their wellbeing. While periodic ‘spot checks’ of staff practice were carried out, these were not fully effective in assessing staff competency.”

“Since coming into post on 10 December 2025 the registered manager had begun developing systems to monitor and improve how the service…”