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 was operating. At the time of this assessment, these systems were not fully effective.

A more comprehensive training programme had been introduced, which better equipped staff to meet the needs of the people they supported.

There had been improvements in daily care records since the previous inspection. The provider’s new electronic operating system prompted staff to record more detailed information about the support provided. This allowed greater oversight of the effectiveness and safety of care delivery and improved information sharing with external professionals.

Recruitment processes were being strengthened and were now more effective in ensuring staff were suitably skilled and safe to work with vulnerable people.

The provider was working to create a more positive and transparent culture. This had led to more constructive relationships with people, staff and external professionals, however further work was needed to ensure people were considered in a dignified and respectful way.

The provider continued to work collaboratively with the local authority and CQC to improve the effectiveness and safety of the service and ensure they met regulatory requirements.

This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.