Universal Care Agency Ltd

Updated 11 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by one inspector.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post. The registered manager is also the nominated individual for the provider organisation. A nominated individual is a person who is responsible for supervising the management of the service on behalf of the provider. This means they alone are legally responsible for how the service is run and for the quality and safety of the care provided. In this report, we will refer to them as the registered person.

Notice of inspection

We gave the service short notice of the inspection. This was because it is a small service and we needed to be sure that the registered person would be in the office to support the inspection.

Inspection activity started on 22 August 2022 and ended on 30 August 2022. We visited the location’s office on 25 August 2022.

What we did before inspection

Before the inspection we reviewed the information we had received about the service, including previous inspection reports and action plans. We used the information the provider sent us in the provider information return (PIR). This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with one relative about their experience of the care provided. We spoke with two staff members which included the registered person and a senior care worker. We reviewed a range of records. This included three people’s care records and one person’s medication record. We looked at one staff file in relation to recruitment. A variety of records relating to the management of the service, including quality assurance systems were reviewed.

Updated 11 November 2022

About the service

Universal Care Agency is a provider of community home care services providing personal care to three people aged 65 and over at the time of the inspection. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

People’s experience of using this service and what we found

Quality assurance processes had not identified concerns or driven sufficient improvement relating to service quality. Records were not always complete or reflective of people’s current needs. Action was not taken when people fed back about their care. The lack of robust quality assurance meant people were at risk of receiving poor quality care.

We have made a recommendation in relation to people’s care records and risk assessments. This is because risk assessments and care plans were not always up to date or complete. This meant people were at increased risk of harm. However, people were supported by a consistent staff team who knew them well which reduced the risk of people receiving unsafe care.

The providers infection control policy did not provide enough guidance for staff and we found staff were not undertaking COVID-19 testing in accordance with Government guidance at the time of the inspection. Staff demonstrated they wore Personal Protective Equipment appropriately.

Improvement was needed in relation to a medicine record and the safe recruitment of staff. The registered person told us how they planned to make these necessary improvements.

The registered person told us of the difficulty they had regarding the recruitment and retention of staff. This had resulted in them having to stop providing care to some people. The registered person and staff member felt there was enough staff to support the people they currently cared for.

The provider had a safeguarding policy that was understood by staff. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 August 2021). There were two breaches of regulation in relation to safe care and treatment and good governance.

We issued a warning notice requiring the provider to make improvements regarding the safe care and treatment of people and the governance of the service.

We undertook an inspection to confirm the provider met legal requirements (published 28 October 2021). Not enough progress had been made and an extension was given due to the providers circumstances. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

You can read these reports, by selecting the ‘all reports’ link for Universal Care Agency on our website at www.cqc.org.uk.

At this inspection, we identified one breach of regulation in relation to good governance. Due to the small number of people being supported we did not have enough evidence to make a judgement about medicines management. We found some improvement regarding risk management had been made and the provider was no longer in breach of the regulation relating to this. However, further improvement was still needed.

Why we inspected

We undertook this focused inspection to confirm the provider now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection.

This service has been rated requires improvement for the last seven consecutive inspections. The service remains rated requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the Safe and Well led sections of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified one breach in relation to good governance. We made a recommendation in relation to risk management.

Follow up

We have imposed a condition on the providers registration which requires them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements are being made to quality and safety of the service.

We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.