Date of assessment 8 April to 6 May 2025. Universal Care Agency Ltd is a domiciliary care agency that provides care and support to people living in their own homes. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. There were several areas of improvement seen during this assessment from our last inspection, including but not limited to; more detailed care plans and risk assessments, more structured provider oversight and additional systems and processes to help ensure the quality and safety of the service. Although improvements were found, the pace of progress had been slow. Not all systems were robust which meant we could not be fully assured the provider understood how to apply the regulations. For example, audits in relation to staff recruitment did not identify the lack of completed pre-employment checks in line with the statutory requirements and systems in place to ensure safe administration of medicine were not robust in demonstrating medicines had been administered as required. Additionally, action plans in place had been slow to develop to an appropriate standard, which had resulted in delays to improvements being made. Some areas required further work, and more time was needed to embed the changes into practice and ensure they were sustained. These issues were all discussed with the provider who confirmed they would be addressed. Based on the findings of this assessment the service has been given an overall rating of good. However, we found a continued breach of regulation in relation to good governance. We will continue to monitor the service.
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safe:Insufficient evidence to ratewell-led:Insufficient evidence to rate
This targeted inspection of Universal Care Agency Ltd found the provider in continued breach of Regulations 12 and 17, with persistent failures in medication management, risk assessment detail, staff competency checks, and governance auditing. No improvements from the previous warning notice had been fully met, and CQC proposed to impose conditions on the provider.
Concerns (8)
criticalMedication management: “'As required' medicines protocol guided staff to administer three different amounts...It was not clear what the prescribed dose was, or when it should be administered.”
criticalMedication management: “Where a medication had been reduced by a medical professional this had not been identified on the MAR chart...We have raised a safeguarding referral about this.”
criticalStaff competency: “At the last inspection staff had not had their competency to administer medicines assessed. At this inspection staff had still not had their competency to administer medicines assessed.”
criticalCare planning: “Care plans continued to fail to contain enough information about people's specific medical conditions...one person's care plan identified they had chronic kidney disease stage three, however, there was no information about this condition.”
criticalCare planning: “One person's care plan said they had a specific medical syndrome. There was no other information relating to this condition. We asked two staff members...they told us, 'I am sorry, I don't know.'”
criticalGovernance: “Quality assurance audits were not in place for example, to check the quality and accuracy of care plans, risk assessments and medicines records.”
criticalRecord keeping: “There were no MAR charts, PRN records, body maps or cream charts for any of these people however, a relative told us, 'Staff administer creams...they fill in a chart.'”
moderateGovernance: “The registered manager told us, 'I have done medication checks, I just haven't documented them.' Any checks undertaken had failed to identify the concerns we found.”
Strengths
· Some relatives were very positive: 'The service is first class, carers turn up on time, they ensure flat tidy and clean and make beds.'
· One relative reported: '[Person] used to have pressure sores, they are cleared up now, they do a fantastic job.'
· Relatives praised the registered manager's honesty, intelligence and integrity, and the quality of care workers.
· One care plan identified as insufficient at the last inspection had been updated to include details of the person's medical conditions.
· Two 'as required' medication protocols had been introduced since the previous inspection, representing some progress.
Quality-Statement breakdown (3)
safe: Assessing risk, safety monitoring and managementInsufficient evidence to rate
safe: Using medicines safelyInsufficient evidence to rate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInsufficient evidence to rate
Universal Care Agency Ltd was rated Requires Improvement overall following a focused inspection of Safe and Well-led domains, with Well-led downgraded to Inadequate due to a continued breach of Regulation 17 for failing to maintain effective governance systems and accurate records. This was the service's seventh consecutive Requires Improvement rating, and the CQC imposed a registration condition requiring monthly improvement reports.
Concerns (7)
criticalGovernance: “The failure to have effective systems in place to assess, monitor and improve the quality and safety of the service and to maintain accurate and complete records was a continued breach of Regulation 17”
criticalLeadership: “The registered person did not demonstrate a robust understanding of how to comply with regulation and sufficient improvement had not been made.”
moderateRecord keeping: “Records were not always detailed or up to date. This included people's risk assessments, care plans and medicine records.”
moderateCare planning: “risk assessments had not been put in place regarding people's health conditions. These included conditions such cellulitis, chronic kidney disease stage three and diverticular disease.”
moderateInfection control: “Staff were not testing for COVID-19 in line with Government guidance... detailed guidance about areas relating to COVID-19 such as testing and the use of PPE was not available.”
minorMedication management: “The medicine record provided guidance about where on the body the cream should be applied but not how frequently. This meant there was risk the cream was not being applied at the times the person needed.”
minorPerson-centred care: “the provider had not always acted on people's feedback to make improvements for them.”
Strengths
· People were supported by a consistent staff team who knew them well, reducing the risk of unsafe care.
· Safeguarding policy was understood by staff, and staff demonstrated sound understanding of safeguarding procedures.
· Staff had access to appropriate PPE and described wearing aprons, gloves and masks when visiting people.
· Staff competency assessments for medicines administration had been completed since the last inspection.
· A relative described staff as 'wonderful' and was 'very happy' with the service.