Universal Care Services Coleshill was rated Requires Improvement overall (with Safe rated Inadequate) following a September 2017 inspection, with four regulatory breaches identified covering staffing, medicines management, complaints handling, and governance. The service deteriorated sharply after a doubling of service users in April 2017 and the departure of the registered manager in May 2017, resulting in widespread missed and late visits, unsafe medicines administration, outdated care plans, and a near-complete breakdown of quality oversight.
Concerns (12)
criticalStaffing levels: “one staff member had been allocated an additional 53 care calls in one week during August 2017”
criticalMissed or late visits: “I had to crawl to the toilet and sat in my own urine for twenty minutes”
criticalMedication management: “They sign the MAR to say they have given the inhaler when they have not, or they don't sign the MAR at all”
criticalGovernance: “Most MAR sheets had not been returned to the office for auditing since May 2017”
criticalComplaints handling: “complaint had been made in August 2017 regarding missed and late care calls... this complaint had not been recorded”
criticalStaff competency: “new staff are not signed off (as competent to administer medicines) but are still doing medication”
criticalSafeguarding: “concern had been recorded but there was limited detail about the actions taken or agreed. This meant we could not be assured the person was safe.”
moderateRecord keeping: “care plans had not always been updated to reflect people's needs... person no longer had a catheter. The person's care plan had not been updated.”
moderateSupervision / appraisal: “Staff told us they had not had the opportunity to meet individually with senior staff since the previous manager left”
moderateLeadership: “No one wants to take responsibility for what is going on... New manager is not approachable. Probably, because we never see them.”
moderateCare planning: “person now needed to be cared for in bed due to deterioration in their health... care plan recorded, 'I would like to be left in my armchair'”
moderateCommunication with families: “I phone the office and no-one answers, they don't phone to tell you your call is not happening. There is no communication.”
Strengths
· Regular, familiar care workers were praised for treating people with kindness, dignity and respect
· Staff received safeguarding training and understood their responsibilities to protect people from abuse
· Staff recruitment processes were safe, including DBS checks and reference verification
· Some care plans contained detailed, clear guidance for staff on supporting people with medical equipment
· Staff proactively communicated with each other informally to try to ensure people were not left without care
Quality-Statement breakdown (17)
safe: Staffing levels and deploymentInadequate
safe: Medicines managementInadequate
safe: Risk assessmentRequires improvement
safe: SafeguardingRequires improvement
safe: RecruitmentGood
effective: Staff induction and competency checksRequires improvement
effective: Supervision and appraisalRequires improvement
Universal Care Services Coleshill was rated Requires Improvement across all five key questions at this June 2018 inspection, with two continued regulatory breaches under Regulations 12 and 17, the latter resulting in a Warning Notice for inadequate governance. While some improvements had been made since the previous Inadequate safety rating, persistent failures in medicines management, missed/late visits, risk assessment, and ineffective quality monitoring systems left people at continued risk.
Concerns (14)
criticalMedication management: “one person had, on one day, been given a 2.5mg dose of their blood thinning medicine instead of 2mg and following this error, there was no evidence of medical advice being sought”
criticalMissed or late visits: “My morning call is meant to be 08.30 – 09.30, but they arrived at 13.30. I should then have a call between 16.30 and 18.30, but they came at midnight.”
criticalGovernance: “Regulation 17 HSCA RA Regulations 2014 Good governance — Warning Notice issued. Provider did not always assess, monitor, improve the quality and safety of the services.”
criticalSafeguarding: “the local authority had written to the provider regarding one safeguarding incident and had requested a response by 24 May 2018. No response was included in the records.”
moderateIncident learning: “accident and incident reports were not consistently logged at the office and there was no overall system in place for accident analysis and actions were not always taken”
moderateCare planning: “one relative told us their family member's care plan was '75% incorrect'... stated their family member lived with dementia, when in fact they had a totally different health condition.”
moderatePerson-centred care: “Office staff scheduling care calls to people did not always respect people's preferences for their care staff to be a specific gender. 'I've had men shower me. It's out of order.'”
moderateCommunication with families: “one relative who was POA to their family member... a staff member had visited their family member last weekend and asked them to sign a document that was also back-dated.”
moderateRecord keeping: “The provider only had records that ran from 1 May 2018 to 1 June 2018. When we asked for records pre-dating this, we were told these were not available because they did not have them.”
moderateComplaints handling: “People's complaints and concerns, however, were not used to improve the quality of the service. People did not always feel issues they raised were resolved because the same arose again.”
moderateInfection control: “They are wearing the same gloves they've had on to clean my commode... Staff don't wash their hands here, they tell me they have their own anti-bacterial wipe.”
moderateLeadership: “The service had not a registered manager in post registered with us since July 2017... manager, deputy manager and compliance manager were unable to tell us their clearly defined roles.”
moderateStaffing levels: “I have five minutes allocated between two visits to people and the distance between these people's addresses is at least a fifteen or twenty-minute drive.”
minorSupervision / appraisal: “records of communication were not always kept, despite messages having included important issues such as people's health and safety.”
Strengths
· Staff had received safeguarding training and understood what abuse was and how to report concerns
· Recruitment process included DBS checks and references to minimise risks to people's safety
· Staff worked within the principles of the Mental Capacity Act 2005 when undertaking personal care tasks
· Care staff supported people to eat and drink and liaised with healthcare professionals on their behalf
· Most people's care plans were personalised, including 'This is Me' profiles to help staff build rapport
Quality-Statement breakdown (19)
safe: Medicines managementRequires improvement
safe: Risk assessment and mitigationRequires improvement
safe: Missed and late calls / call monitoringRequires improvement
safe: SafeguardingRequires improvement
safe: RecruitmentGood
effective: Staff induction and trainingRequires improvement
This focused follow-up inspection of Universal Care Services Coleshill found sufficient improvements had been made to meet regulatory requirements following a June 2018 Warning Notice, though the service remained Requires Improvement due to ongoing missed and late care calls attributed to human error and a planned call monitoring enhancement not yet implemented.
Concerns (3)
moderateMissed or late visits: “during July and August 2018, the provider's records showed there had been 13 missed care calls.”
moderateGovernance: “Further improvements to the provider's call monitoring system was due to be implemented in October 2018...We were therefore unable to assess the effectiveness of this during this inspection.”
minorRecord keeping: “Some MARs we looked at had a few staff signature gaps and these had been investigated by the registered manager.”
Strengths
· People's medicines were handled safely by trained staff with improved medicine administration records.
· Sufficient staff were employed and rota scheduling improvements gave staff adequate travel time between calls.
· Risk management plans were more detailed and reviewed when needed, including fire safety referrals to local fire service.
· Quality monitoring systems improved with effective audits identifying areas for improvement and recording actions taken.
· Staff felt better supported through increased communication, team meetings and one-to-one supervision meetings.
safe:Goodeffective:Insufficient evidence to ratecaring:Insufficient evidence to rateresponsive:Insufficient evidence to ratewell-led:Good
Universal Care Services Coleshill, a domiciliary care agency serving 206 people, retained its overall Good rating following a pilot virtual inspection in November 2020, with well-led improving from Requires Improvement to Good. Minor record-keeping gaps and delayed supervision meetings were noted but no regulatory breaches were identified; the service demonstrated strong safeguarding, personalised care, and a robust COVID-19 response.
Concerns (4)
minorRecord keeping: “on some occasions staff had forgotten to complete the duplicate electronic medicine administration record.”
minorRecord keeping: “due to the pandemic, there had been a few occasions when there had been a delay in updating a change in care in the plan located in people's homes.”
minorSupervision / appraisal: “Staff told us their individual meetings were 'a bit behind' but recognised other support systems were in place.”
minorPerson-centred care: “A few people told us they had recently commenced new packages of care but had yet to be contacted by office staff to give their feedback on how things were going.”
Strengths
· People felt safe with staff and reported no missed calls; consistent staffing enabled strong relationships between staff and people.
· Robust safeguarding processes in place with a safeguarding log recording investigations and outcomes.
· Time-critical medicines managed effectively with office monitoring to ensure timely administration.
· Strong COVID-19 response including a dedicated SWAT team, additional PPE, and Coronavirus Awareness training for all staff.
· Well-led service with well-regarded management support; well-led rating improved from Requires Improvement to Good.
Quality-Statement breakdown (15)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceInsufficient evidence to rate
caring: Ensuring people are well treated and supported; respecting equality and diversityInsufficient evidence to rate
Universal Care Services Coleshill was rated Good across all five key questions at its April 2016 inspection, with 93 people receiving domiciliary care. Minor shortfalls were noted in the consistency and completeness of care plan documentation, including recording of fluctuating mental capacity, but no regulatory breaches were identified.
Concerns (3)
minorCare planning: “information in people's care plans had not always been updated. The registered manager was aware of this and showed us the work they had been doing to update all care records.”
minorConsent / capacity: “two care plans for people we were told had fluctuating capacity. This was not clearly documented on care plans.”
minorCare planning: “some had not been fully completed, and included little information on people's life history, for example.”
Strengths
· People supported by a consistent, small group of staff who knew their preferences, likes and dislikes well.
· Medicines administered safely by trained and competency-assessed staff with regular senior checks of MAR sheets.
· Strong safeguarding culture with staff confident to escalate concerns including directly to CQC.
· Robust pre-employment checks including DBS and references before staff commenced work.
· Staff received induction, Care Certificate assessment, shadowing and 12-week sign-off before working independently.
Universal Care Services Coleshill improved from Requires Improvement to Good overall, with safe, effective, caring and responsive domains all rated Good following sustained improvements since the previous inspection. Well-led remains Requires Improvement due to insufficiently detailed audits, a failure to notify CQC of a police incident, and action plans lacking sufficient detail to address identified gaps in care plan usability and survey response rates.
Concerns (6)
criticalIncident learning: “we identified a police incident during January 2019, which they had not told us about...they acknowledged they had overlooked sending us the required notification.”
moderateGovernance: “audits of people's care logs did not always identify where improvement was needed. We saw a staff member had recorded safety concerns about one person and whilst actions had been taken, these had not been recorded”
moderateRecord keeping: “Whilst medicine administration records were checked, and individual actions taken when needed, there was no overall analysis audit record. This meant themes where improvement were not collated to form an action plan.”
moderatePerson-centred care: “when staff were asked whether peoples' care plans were easy to follow, 11 staff had replied 'no'. There was no action as to how the provider intended to address this staff response.”
moderateCommunication with families: “Results showed 53% of people felt they were not always dealt with in a prompt way...actions did not include how the provider intended to increase this [response rate].”
minorMissed or late visits: “There had been a small number of missed or late care calls because of human error. For example, a staff member had miss-read their rota.”
Strengths
· People felt safe and risks were assessed with detailed management plans in place to protect people from harm.
· Staff knew people well and demonstrated a kind, caring approach, with relatives describing staff as 'going the extra mile'.
· People received their medicines as prescribed and medicine administration records were routinely checked by supervisors.
· Care plans were personalised with 'This is Me' sections enabling staff to engage with people around their interests and hobbies.
· Staffing consistency improved, with people receiving regular familiar staff, particularly beneficial for those living with dementia.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
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: Healthcare professional liaisonGood
caring: Dignity, respect and person-centred approachRequires improvement
caring: Involvement in care planningRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careInsufficient evidence to rate
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesInsufficient evidence to rate
responsive: Meeting people's communication needsInsufficient evidence to rate
responsive: Supporting people to develop and maintain relationships to avoid social isolationInsufficient evidence to rate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
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 candour; working in partnership; continuous learningGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; 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: Supporting people to develop and maintain relationships to avoid social isolationGood
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: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement
well-led: Continuous learning and improving careGood