Universal Care Agency Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider reviewed shortfalls and ensured learning was shared with the team through team correspondence and supervision. The provider had systems in place to review accidents and incidents. People and their relatives shared their views about the service being provided; the provider had reviewed this feedback and used the information to drive improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed prior to them receiving a service from Universal Care Agency Ltd. The person and their relatives, and external health and social care professionals were involved with assessments and reviews of care when required. This helped ensure the service was able to provide continued safe care and support to people.

If required, information about people’s care could be made available to healthcare professionals, for example should they be admitted to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns where required.

People and relatives told us they felt very safe with the staff, and they were treated well and with respect. Comments included, “The staff treat both of us very well and [person] does feel very safe”, “All the carers treat me extremely well and I feel very safe when they visit me” and “I am treated very well and always feel very safe with them in my home. If I didn’t feel safe, I would contact the manager.”

The provider told us there had been no safeguarding incidents since our last inspection, and our review of evidence supported this. Although no recent safeguarding incidents had occurred, the provider was able to demonstrate they understood their responsibility to report safeguarding concerns and had systems in place to ensure concerns were investigated and actions taken as required.

The provider had a safeguarding policy in place which detailed the systems and processes to safeguard people from the risk of abuse. This was understood by the provider and staff. Safeguarding training was provided, and staff demonstrated they knew how to ensure people were protected from potential harm and actions they should take should concerns be identified. A staff member told us, “I have had safeguarding training, if I had any concerns I would report them to the manager.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives felt staff understood specific risks to people and said these were managed well. A relative told us, “[Person] is at risk of falls. I think the staff are very skilled at enabling [person] to walk carefully and use their frame correctly.” Another relative told us how their loved one was at risk of falls, choking, infections and dehydration. They said, “All carers are aware of [person’s] needs and provide safe support.” A person told us, “Staff are skilled and knowledgeable and do make sure they protect me from having any falls.”

Care plans and risk assessments relating to people's health conditions and support needs were in place and included relevant information to keep people safe from harm. Risk assessments and care plans covered a range of areas including, falls management, catheter care, constipation, diabetes and epilepsy. Risk assessments and care plans had been regularly reviewed and updated where required.

Staff confirmed they received clear and detailed guidance in relation to mitigating known risks to people. Staff demonstrated an understanding of people’s needs and how to support people safely considering their specific risks.

The provider detected and controlled potential risks in relation to the environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider assessed people’s homes for risks and took action to ensure people, staff and visitors remained safe.

The provider had not ensured safe recruitment practices.

We could not be assured safe recruitment processes were in place. We reviewed 3 staff recruitment records and found staff had been employed into the service without having all the required pre-employment checks in line with the statutory requirements. For example, employment history was not fully recorded and references and evidence of past conduct while working in health and social care settings had not been obtained in line with Schedule 3. These concerns had not been identified through the providers auditing system. The provider agreed to address these issues.

However, the provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were sufficient numbers of staff to keep people safe and ensure they received their care at a time most suitable to them. One person said, “They [staff] do arrive more or less on time and do all as expected. I do not feel rushed in any way.” Another person said, “Staffing levels seem to be excellent throughout the week, evenings and at weekends.” A relative told us, “The call times are varied due to various reasons, but they tend to arrive at times we have agreed, and they do stay the full time period and do all that is needed to be done.” All people and relatives spoken with also confirmed they received care from regular staff who knew them well.

Staff told us they felt staffing numbers were sufficient to meet the needs of people using the service. One said, "When we have been short our group would pick up shifts whenever we can and help each other out.” Another member of staff commented, “There is enough of us.”

Systems were in place to quickly identify if care visits were late so none were missed. Staff rotas demonstrated there were enough skilled and competent staff to ensure they could safely support people who used the service. New staff completed an induction period, which included shadowing more experienced staff to get to know people, as well as covering the necessary training. Information received from the provider demonstrated staff were provided with effective support, supervision and personal development.

Staff had received training to equip them in their role and to ensure they could provide safe care to people. People and relatives described the staff having the skills required to provide them with safe and effective care. Comments from people and relatives included, “The carers are very well trained with the hoist” and, “The carers are very skilled and knowledgeable and support to a high standard.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had received training in infection prevention and control, including food hygiene. People and relatives confirmed staff used personal protective equipment (PPE) such as aprons and gloves when providing care. People and relatives also confirmed staff left their homes clean and tidy following the completion of care and support tasks.

The provider completed regular competency assessments and spot checks of staff practice. This helped the provider to monitor staff were working in accordance with infection, prevention and control (IPC) procedures to keep people safe.

IPC policies and procedures were in place and these reflected current best practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified an issue with recording on the medicine administration record (MAR) for some people where records indicated prescribed medicines had not been taken and there had been no follow-up by the service. On investigation by the provider, we received assurance there had been no gaps in these people taking their prescribed medicines. The provider shared updates to the records and confirmation of action taken to prevent a reoccurrence of this issue.

Guidance for staff on the application of topical creams (used to prevent or alleviate skin conditions) was not always in place. This meant we could not be assured all creams were administered consistently or as needed.

Most people told us they or their relatives managed their medicines. People who were supported by staff told us they received their medicine safely and as prescribed. A person said, “The carers get the tablets out each time I need them and place it in a small pot, and I take them while they are with me daily.”

People’s care records detailed information about people’s medicines including who was responsible for administration and collection.

Staff had completed training in the safe management of medicines and the provider regularly observed their practice to ensure they were doing this safely.