Archived: Universal Care Services Leicester

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk.

Universal Care Services – Leicester provides personal care to people living in their own homes. On the day of the inspection the registered manager informed us that 41 people were receiving a personal care service from the agency.

This inspection took place on 13 September 2017. The inspection was announced as we needed to be sure that someone was available to carry out the inspection with us.

At our last inspection in 23 February 2017 the service was not meeting regulations with regard to having systems in place to ensure quality services. We followed up these issues and found some improvements had been made, though further improvements were needed to show that people did receive a quality service.

A registered manager was 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 and associated Regulations about how the service is run.

Risk assessments were not consistently in place to protect people from risks to their health and welfare.

Calls to provide care to some people were not always at the agreed and assessed times, which meant people's safety had not been comprehensively promoted to ensure they received care at the times they needed.

People and relatives we spoke with told us they thought the service ensured that people received safe personal care from staff.

Most people and relatives were satisfied with how the service was run, though there were concerns about missed care calls and calls not being on time. Not all staff felt they were supported in their work by the senior management of the service.

Notifications of concern had been reported to us, as legally required, to enable us to consider whether we needed to carry out an early inspection of the service. Management had not comprehensively carried out audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service.

The service was still in breach of one of the regulations of the Health and Social Care Act 2008 and remains rated as Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report

A registered manager was not 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 and associated Regulations about how the service is run. The current manager and the regional manager stated that the application for registered manager was to be submitted in the near future. This issue will be monitored by us as it is a condition of the registration of the service that there is a registered manager in post.

On this inspection we found breaches of regulations with regard to comprehensively protecting people's safety and ensuring quality services were always provided to people. Please refer to the report for details of these breaches.

Notifications of concern had not been reported to us, as legally required, to enable us to consider whether we needed to carry out an early inspection of the service. Management have not comprehensively this carried out audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service.

Risk assessments were not consistently in place to protect people from risks to their health and welfare. Staff recruitment checks were not always in place to protect people from receiving personal care from unsuitable staff.

Calls to provide care to people were not always at the agreed and assessed times, which meant people safety had not been comprehensively promoted to ensure they received care at the times they needed.

People and relatives we spoke with told us they thought the service ensured that people received safe personal care from staff. Staff had been trained in safeguarding (protecting people from abuse) and staff understood their responsibilities in this area.

We saw that medicines were, in the main, supplied safely and on time, to protect people’s health needs.

Staff had received training to ensure they had skills and knowledge to meet people's needs, though this had not covered some relevant issues.

Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choices about how they lived their lives. Assessments of people's capacity to make decisions were not in place to determine whether they needed extra protections in place.

People and relatives we spoke with all told us that staff were friendly, kind, positive and caring. They told us they had been involved in making decisions about how and what personal care was needed to meet their needs.

Care plans were individual to the people using the service to ensure that their needs were met though this did not include all relevant information such as all of people's preferences, likes and dislikes.

People and relatives told us they would tell staff or management if they had any concerns, they were confident these would be properly followed up. Most people and relatives were satisfied with how the service was run, though there were concerns about missed calls and other calls not being on time. Staff felt they were supported in their work by the senior management of the service.