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Universal Care - Beaconsfield Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 31 December 2016

We undertook an announced inspection of Universal Care Beaconsfield on 23 and 25 November 2016.

Universal Care provides a range of services to assist people in their own homes. Support ranged from day to day assistance and the provisions of personal care for people. On the day of our inspection 269 people used the service.

There was a registered manager in post. 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 and relatives told us they felt people were safe. Staff understood their responsibilities in relation to safeguarding people. However the provider had failed to act timely to gain assurance that staff understood their responsibilities when they could not access people’s homes.

Staff had received regular training to make sure they stayed up-to-date with recognising and reporting safety concerns. The service had systems in place to notify the appropriate authorities where concerns were identified. People received their medicine as prescribed.

People benefitted from caring relationships with the staff. People and their relatives were involved in their care and people’s independence was actively promoted. Relatives told us people’s dignity was promoted.

Where risks to people had been identified risk assessments were in place and action had been taken to manage these risks. Staff sought people’s consent and involved them in their care where ever possible.

There were sufficient staff deployed to meet people’s needs. The service had safe recruitment procedures and conducted background checks to ensure staff were suitable for their role.

People were supported with their nutrition and their preferences were respected. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

People and relatives told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided. Learning needs were identified and action taken to make improvements which promoted people’s safety and quality of life. Systems were in place that ensured people were protected against the risks of unsafe or inappropriate care. However the provider had not adequately managed a recent safeguarding incident as their investigation was not robust.

Staff spoke positively about the support they received from the registered manager. Staff supervision and other meetings were scheduled as were annual appraisals. Staff told us the registered manager and their managers were approachable and there was a good level of communication within the service. However, meetings were not always recorded to enable the provider to ensure areas raised were addressed and recorded.

Relatives told us the service was friendly, responsive and well managed. Relatives knew the registered manager and staff and spoke positively about them. The service sought people’s views and opinions but did not always act on them. However, people told us they did not always have the opportunity to provide feedback on the service provided.

We have made a recommendation that the provider review their action plan following the safeguarding incident to ensure all actions have been taken to ensure people are safe when care workers are unable to access people’s property.

Inspection areas


Requires improvement

Updated 31 December 2016

The service was not always safe.

Staff knew how to identify potential abuse and raise concerns but a recent safeguarding incident had not been well managed by the provider.

There were sufficient staff deployed to meet people’s needs and keep them safe.

Risks to people were identified and risk assessments in place to manage the risks. Staff followed guidance relating to management of risks.

People and their relatives told us people were safe.

People had their medicine as prescribed.



Updated 31 December 2016

The service was effective.

People were supported by staff who had the training and knowledge to support them effectively.

Staff received support and supervision and had access to further training and development.

People had access to healthcare services and people’s nutrition was well maintained.



Updated 31 December 2016

The service was caring.

Staff were kind, compassionate and respectful and treated people with dignity and respect which promoted their wellbeing.

Staff gave people the time to express their wishes and respected the decisions they made. People and their relatives were involved in their care.

The provider and staff promoted people’s independence.



Updated 31 December 2016

The service was responsive.

Care plans were personalised and gave clear guidance for staff on how to support people.

People and their relatives knew how to raise concerns and were confident action would be taken.

People’s needs were assessed prior to receiving any care to make sure their needs could be met.


Requires improvement

Updated 31 December 2016

The service was not always well-led.

The service had systems in place to monitor the quality of service. However the provider had not responded to these concerns. Records were not maintained to enable the manager to act on areas raised by staff.

There was a positive workplace culture and the registered manager shared learning and looked for continuous improvement.

Staff knew how to raise concerns.