This unannounced inspection took place on 29 November 2018. This was the first inspection of the service since it registered with the Care Quality Commission to deliver regulated activity to people in January 2018.

Horizon Retreat is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation and personal care for up to six people with mental health needs. At the time of our inspection there were six people living in the service, one of whom had been admitted to hospital.

The service had a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People who presented with behaviours which may challenge were not supported appropriately. Risk assessments did not cover all of the behaviours people could present with. Care records did not provide staff with guidance on managing escalating behaviours and staff did not receive any training in the management of people’s behavioural support needs. The provider did not always operate safe recruitment practices, as not all staff files contained appropriate employment references.

People received their medicines safely in line with the prescriber’s instructions. Medicines were stored securely. Staff followed appropriate food safety and infection prevention procedures.

People did not always receive effective care because staff were not trained to meet all of their needs. However, people’s needs were assessed with input from healthcare professionals and staff were supervised. People were supported to eat and drink sufficiently. Staff treated people in line with mental capacity legislation and ensured they had on-going access to healthcare services.

Staff were caring towards people and promoted their independence. Care records were personalised and enabled staff to learn about people’s backgrounds and what was important to them. People’s privacy was respected and staff treated people with dignity.

Staff provided people with person centred care. People were involved in developing their care plans and in reviewing them. Staff monitored and responded to changes in people’s mental health needs and supported people to participate in activities.

The service was inadequately led. The registered manager failed to plan to keep people and staff safe. This was because known risks were not assessed adequately and staff did not receive the appropriate support required to manage problematic behaviours in line with best practice. Where serious incidents occurred at the service the registered manager failed in their legal responsibility to submit timely notifications to CQC. The registered manager failed to ensure all staff were safe and suitable by obtaining appropriate references.

During this inspection, we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.