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Universal Care Agency Ltd Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 April 2018

Universal Care Limited 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, people living with dementia, mental health impairments, physical disabilities, sensory impairment and younger adults. The domiciliary care agency office is situated within the Cosham area of Portsmouth.

This inspection was undertaken on the 6 and 12 March 2018. Not everyone using Universal Care Limited 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. At the time of the inspection 18 people were receiving a personal care service from Universal Care Limited.

This service was in Special Measures as the well led section of the report had been rated inadequate following two consecutive inspections. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements had been made and it is therefore no longer rated as inadequate overall or in any of the key questions. Therefore, this service has now been removed from Special Measures as per CQC’s Special Measures Policy.

Following the inspection in May 2017 three breaches of regulations were identified. At this inspection we found action had been taken to become compliant with these although further work was required to ensure the newly introduced quality assurance procedures were embedded in practice and identified all areas for improvement we found during the inspection.

The service did not have a registered manager at the time of the inspection. 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. The provider had appointed a person to manage the service who had applied to become registered with the Care Quality Commission. Their application was being assessed at the time of the inspection.

Some risks to people had been individually assessed and risk management plans were in place to mitigate these risks. However, records did not show that these had been reviewed and these did not cover all risks which had been identified during the assessment process.

At the time of the inspection staff were not administering oral medicines to anyone. Where staff were prompting people to take medicines recording systems were not in place. We have made a recommendation that the service follows best practice guidance and introduces appropriate recording tools for the administration and prompting of medicines including prescribed topical creams.

We received positive feedback from people about the service. People who used the service expressed satisfaction and spoke highly of the staff and provider’s representative. All the people and family members who were asked if they would recommend the service to others said they would.

People and their families told us they felt safe. Staff understood their safeguarding responsibilities and knew how to prevent, identify and report abuse.

Safe recruitment practices were followed and appropriate checks were undertaken, which helped make sure only suitable staff were employed to care for people in their own homes. There were sufficient numbers of care staff to maintain the schedule of visits and ensure a high level of continuity for people. Staff completed an induction programme and were appropriately supported in their work. Staff had received relevant training and arrangements were in place to refresh this regularly.


Inspection areas


Requires improvement

Updated 18 April 2018

The service was not always safe.

Not all individual and environmental risks to people and staff were assessed and plans put in place to mitigate those risks.

Care staff had received safeguarding training and were clear about their safeguarding responsibilities. The manager had not identified a safeguarding concern which we told them they should report to the local authority safeguarding team.

There were safe medication administration systems in place and people received their medicines when required, although records of prompting and administration were not always kept.

Recruitment procedures were followed to ensure staff were safe to work with people. Staffing levels were sufficient to take account of people's needs.

There were processes in place to enable the provider to monitor accidents, adverse incidents or near misses. These helped to identify any themes or trends, allowing timely investigations, potential learning and continual improvements in safety.


Requires improvement

Updated 18 April 2018

The service was not always effective.

The provider’s representative and manager were occasionally supporting people however they had not completed all their training. Supervisions and spot checks had not always been completed. Staff received an appropriate induction and on-going training to enable them to meet the needs of people using the service.

There was no process to seek permission to gain information about prescribed medicines or past medical history from people’s medical doctors. People were supported to access health professionals and staff acted when new medical needs were identified.

Staff sought consent from people before providing care and followed legislation designed to protect people's rights. People received consistent care from staff they knew and were supported with eating and drinking where required.



Updated 18 April 2018

The service was caring.

People said that staff treated them with kindness.

People’s dignity and privacy was respected at all times.

People were encouraged to remain as independent as possible.



Updated 18 April 2018

The service was responsive.

Care plans provided relevant information for care staff however where specific information was not available at the time of assessment action had not been taken to obtain this subsequently.

People were pleased with the care and support provided by staff as it met their individual needs.

The manager sought feedback from people using the service and had a process in place to deal with any complaints or concerns.

At the time of the inspection no one using the service was receiving end of life care. However the manager assured us that people would be supported to receive a comfortable, dignified and pain-free death.


Requires improvement

Updated 18 April 2018

The service was not always well led

There were systems in place to monitor the quality and safety of the service provided. However these were not yet fully embedded in practice and had not identified areas of concern we found during this inspection.

People and their families were positive about the service and told us they were very satisfied with the organisation and the running of the service.