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Universal Care Agency Ltd Requires improvement

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

Inspection Summary

Overall summary & rating

Requires improvement

Updated 28 October 2021

About the service

Universal Care Agency is a provider of community home care services providing personal care to seven people aged 65 and over at the time of the 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

The provider had not taken appropriate steps to improve the service and to ensure people received safer care. An action plan was in place to address the warning notice served by CQC at our previous inspection. However, none of the requirements of the warning notice had been met.

Risk assessments and care plans did not always provide guidance to staff about how to support

people effectively. Care plans and risk assessments did not always contain enough detail about people’s specific medical conditions.

‘As required’ medicine records were not always in place. Where they were in place, they did not include enough detail to guide staff as to their appropriate use.

Quality assurance systems had not been effective in identifying the concerns we found at this inspection or fully addressed concerns from our last inspection.

This was a targeted inspection that considered medicines management, safe care and treatment and governance. Based on our inspection of these areas we were not assured the provider was meeting the Regulations.

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 requires improvement (published 13 August 2021) and there were two breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made, and the provider was still in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains Requires Improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines management, risk management and good governance at this inspection.

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.

Inspection areas


Requires improvement

Updated 28 October 2021

Inspected but not rated.



Updated 28 October 2021



Updated 28 October 2021



Updated 28 October 2021


Requires improvement

Updated 28 October 2021

Inspected but not rated