Horizons Care Limited received an overall rating of Requires Improvement at its first CQC inspection, with breaches of Regulations 12 and 17 identified due to missing risk assessments, significant medication management failures, and an absence of governance audit systems. Staff and leadership were praised for their caring approach and positive culture, but urgent improvements to medicines oversight, risk documentation and quality monitoring are required.
Concerns (7)
criticalCare planning: “Not all risks to people had been assessed. We found 2 people had missing risk assessments and mitigating strategies for known risks.”
criticalMedication management: “When people were prescribed 'as required' (PRN) medicines, protocols were not in place to document when, why and the dosage of medicines should be given.”
criticalMedication management: “1 person's MAR did not have the dosage of a medicine recorded...there were 7 days when another medicine had not been signed to evidence it had been administered.”
criticalGovernance: “Systems and processes were not in place to audit medicine records to identify any issues or concerns.”
criticalGovernance: “The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
moderateRecord keeping: “We found no evidence of systems and processes being in place to audit records or check all information was up to date, factual and relevant.”
minorPerson-centred care: “Care plans required more person centred information within them to support new staff to understand and get to know people and their needs.”
Strengths
· Staff were recruited safely with pre-employment checks including DBS and references completed.
· People and relatives consistently praised staff as kind, caring, attentive and responsive.
· Staff received appropriate training including manual handling, dementia, MCA, and infection prevention and control.
· People were protected from abuse with systems, policies, training and body mapping in place.
· The registered manager was visible, approachable and supportive, leading by example and working directly with people.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; Supporting people to live healthier lives and access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood