You are here

Universal Care - Beaconsfield Inadequate

We are carrying out a review of quality at Universal Care - Beaconsfield. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 13 May 2020

About the service

Universal Care – Beaconsfield is registered to provide personal care and support to people in their own homes. 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. At the time of the inspection the service supported over 200 people.

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

People continued to be placed at risk of harm due to a lack of systems to promote safe care and treatment.

Potential risks to people were not routinely and consistently assessed. Staff were not always aware how to promote people’s safety. People who required support with medicine administration were not always supported in a safe manner.

The provider and registered manager had failed to act on all previous concerns raised and did not routinely have adequate measures in place to ensure people were protected from potential harm. Quality monitoring systems were either ineffective or not in place. We found repeated and continued breaches of the regulations. Legal requirements as stated in the provider’s registration were not routinely complied with. For instance the provider failed to inform us of events it was legally required to do so.

People were not always supported to have maximum choice and control of their lives and staff; the policies and systems in the service did not routinely support this practice. We found staff did not always comply with the Mental Capacity Act 2005.

People’s privacy and dignity was not routinely upheld. We were informed personal information had been shared with people who were not legally entitled to received it. We asked the provider to refer themselves to the Information Commissioner Office, following a data protection breach.

People told us they had developed a good relationship with staff comments included “They are lovely, brilliant”, “I found them excellent” and” I’m very happy.”

People and their relatives told us they knew how to make a complaint and would not hesitate to contact the office.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 1 October 2019) At this inspection enough improvement had not been made/sustained and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.


We have identified continued breaches in relation to risk management, record keeping related to medicines and staff training. The provider failed to notify CQC of certain events, to comply with the Mental Capacity Act 2005 and to monitor and improve the quality of the service to people. We have identified a further breach of regulations as the provider failed to notify us of changes to directors of the limited company.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.


Inspection areas



Updated 13 May 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 13 May 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 13 May 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 13 May 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 13 May 2020

The service was not well-led.

Details are in our well-Led findings below.