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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 carried out on 6 March 2020

During a routine inspection

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 carried out on 21 August 2019

During a routine inspection

About the service

Universal Care Beaconsfield provides care in people’s own homes. It provides a service to older adults and young disabled adults. Approximately 200 people were receiving care at the time of our 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

People told us they felt safe using the service and spoke positively about the support they received. People felt their privacy, dignity and independence were respected. They expressed a high level of satisfaction in a recent independent survey and would recommend the service to others.

People who used the service and staff described a positive culture at the service. Staff said there was good teamwork and an inclusive workplace. They told us they would feel confident in raising any concerns with managers.

The service was responsive to people’s changing needs. We saw examples where people had been referred to other agencies so their needs could be re-assessed. There was also liaison with family members. People’s complaints were investigated by the service and responded to promptly and an apology given.

We found the service had not always taken appropriate measures to protect people from the risk of avoidable harm. People’s care plans did not always contain guidance care workers needed to support people with their health conditions. This placed people at risk of ineffective and unsafe care. There were also no end of life care plans, to make sure people’s needs and wishes were recorded.

Where people were supported with their medicines, we found records had not been always been maintained to an acceptable standard. The service had not ensured care workers had been properly assessed and observed before they were permitted to handle people’s medicines, to ensure this was done safely.

Staff had received training on safeguarding people from abuse. People we spoke with and staff we contacted did not express any concerns. We found some instances where the service had not made referral to the local authority, to report safeguarding incidents. This meant the service was not always following proper procedures to protect people and alerting statutory agencies.

Robust recruitment practice was not always followed. A care worker had been allowed to start on a basic level Disclosure and Barring Service (DBS) check, rather than enhanced level. This checks for criminal convictions and inclusion on lists of people unsuitable to work with vulnerable people. There was no risk assessment, supervision or checks of the care worker until their enhanced DBS check was completed. This potentially placed people the care worker supported at risk of harm.

Staff said they felt supported. They said there were back-up systems for them to contact a manager or senior if they needed advice. New workers completed an induction which included training the provider considered mandatory. However, care workers were not observed and assessed in the workplace to ensure they provided appropriate levels of support. We found patterns of supervision varied. Some new care workers had not received supervision or other support until after three or five months of working. We did not see any evidence of appraisals being undertaken to discuss staff performance and their developmental needs.

Care was not being provided in line with the Mental Capacity Act (2005). The service had not always obtained verification of Lasting Power of Attorney documents, so it could be assured of consulting people who had legal authority to act on others’ behalf. There were also no records of the service holding best interest meetings where people lacked capacity. Therefore we could not be certain people were supported to have maximum choice and control of their lives and were

Inspection carried out on 11 June 2018

During a routine inspection

The previous inspection took place in November 2016. The overall rating from that inspection was requires improvement. This announced inspection took place on 11, 13 and 14 June 2018. This is the second consecutive time the service has been rated Requires Improvement.

At the last inspection on 23 and 25 November 2016, we made recommendations for the provider to make improvements in record keeping in relation to safeguarding investigations. We also raised concerns as meetings between staff and managers were not always documented.

During this inspection we found records related to safeguarding concerns were up to date, however we had concerns related to a lack of knowledge and understanding of staff regarding the correct safeguarding procedure to follow. Records related to meetings between staff and managers were in place, however, the frequency of these meetings was not in line with the providers policy.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults, younger disabled adults and children. At the time of our inspection it was providing care to 218 people.

Not everyone using Universal Care – Beaconsfield receives a regulated activity. CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

The service had a registered manager in place. 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, their relatives and professionals were generally very positive about the service provided.

However, we had concerns about the safety of the recruitment system for employing new staff as not all relevant checks had been undertaken.

Care plans and risk assessments did not all contain relevant up to date and accurate information. This placed both people and the staff at risk of harm or injury.

Medicines were not safely managed, staff did not always receive up to date training and their competency was not always assessed. There were no effective medicine audits in place to protect people from harm.

People were not always protected from the risk of abuse, as staff training was not regularly up dated. Staff were not aware of how or who to report concerns of abuse to.

Training for staff was not comprehensive, and did not cover the areas they required to carry out their role. Support for staff through one to one supervisions and spot checks were not carried out in line with the provider’s policy.

The service was not compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were not assisted to have maximum choice and control of their lives. There was a lack of training for staff and understanding by senior staff, to protect people from receiving inappropriate care.

People and their relatives described staff as caring, patient, and helpful. They gave us examples of how staff had gone above the call of duty to them.

The provider had failed to assess the service in relation to people with protected characteristics. They were not able to evidence how they were compliant with the Accessible Standards Framework. We have made a recommendation about this in the report.

People told us the staff protected their privacy and dignity when carrying out personal care.

The provider’s documentation showed how they appeared to respond appropriately to complaints, this was not always the view of the complainant. Staff were not sure how to respond to complaints, and they had received no training in how to do so. We have made a recom

Inspection carried out on 23 November 2016

During a routine inspection

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 carried out on 4 September 2014

During an inspection to make sure that the improvements required had been made

A single inspector carried out this inspection. When we visited the service 24 February 2014 we had concerns how one standard was managed. We set a compliance action for the provider to improve practice.

The provider sent us an action plan which outlined how they intended to become compliant.

We returned to the service on the 4 September 2014 to check if improvements had been made.

Below is a summary of what we found. The summary describes what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service effective?

We found the provider had responded to our concerns around staff support. We found staff were now receiving regular supervisions in line with the providers policy. A new training and recruitment manager had been recruited which allowed care managers time to undertake effective supervisions. We were provided with a new training policy which outlined which core training needed to be refreshed and how often. The provider was in the process of undertaking this requirement.

This meant the service was effective.

Inspection carried out on 24 February 2014

During a routine inspection

We received feedback from 21 people who used the service or their relatives. People described a high level of satisfaction with the standard of care provided. They told us care workers arrived at the time they expected them and stayed the required length of time. People reported good continuity of care, with the same team of care workers supporting them. They said they would communicate directly with the office if they had any concerns. Those people who had done so said any concerns had been addressed satisfactorily. Comments included �What they do for me is very satisfactory,� �No problems at all,� �Excellent,� and �My carers look after me very well.�

We found people�s needs were assessed and care was planned and delivered in line with their individual care plan. Care plans were in place for each person who used the service. We looked at a sample of seven people�s care plans. These showed people�s needs had been assessed and the support they required was identified. Risk assessments had been completed in each file we read and ensured care was delivered in a safe manner.

There were effective recruitment and selection processes in place at the service. We looked at four staff recruitment files. Each file contained the necessary checks and clearances. This ensured staff had the right skills and experience and were suitable to work with vulnerable people.

Staff had not consistently received the support they required. Records showed staff completed a structured induction which gave them a good foundation into the work they undertook. The core training needs for staff had not been identified subsequent to their induction. This meant staff did not have the opportunity to update and refresh their skills, to take account of changes to good practice.

We found variations to the pattern and frequency of staff supervision and appraisals. This meant staff had not received routine evaluation of their performance and development needs, to ensure they supported people appropriately.

The provider had an effective system to regularly assess and monitor the quality of service that people received. A satisfaction survey was conducted in 2013 by an external organisation. The findings of the survey were positive and showed the service had provided a high level of care most of the time, in people�s experiences.

Inspection carried out on 25 February 2013

During a routine inspection

People�s care needs had been assessed before a service was provided. This ensured the service was able to meet those needs. Care records addressed people�s individual care needs and the service to be offered. Care staff had the knowledge and skills required to provide a service which met people�s needs and enabled people to live as independently as possible in their own homes. The people we spoke with told us staff maintained good timekeeping, provided care and support as outlined in the care plan, maintained good relations with the person using the service and their families and took account of people�s wishes.

The people we spoke with expressed a good level of satisfaction with the service. They said it met their needs very well. Care staff provided good support and paid attention to detail. They said they had no concerns about the safety of their relative when receiving care from the service. Some people reported having had problems in communication with the office on occasions but those had not affected their overall favourable opinion of the care provided.

We found the service had arrangements in place to provide the care and support people required. Staff acted in accordance with people�s wishes. The service had procedures to protect people from the risk of abuse. People were looked after by staff who were appropriately trained and supported. The provider had arrangements for monitoring the quality of the service provided to people.