Universal Care Agency Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate and found 1 breach of the legal regulation in relation to good governance. At this assessment, although we found some improvements had been made, the service remained in breach of the legal regulation in relation to good governance.

The rating at this assessment has improved to requires improvement. The provider continued to make improvements to address the shortfalls identified at our last assessment. More time was needed to ensure these were embedded into practice and sustained.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision, values and strategic goals of the service and how their role helped to achieve them.

We found people were supported to be part of their communities and the service promoted people to make their own choices and have control of their lives. The provider and staff spoken with demonstrated they cared about the people they supported, their relatives and each other as a staff team.

There was evidence of improved auditing processes and more streamlined and organised oversight of people’s care to ensure all people had the same opportunities. Care records, and discussions with the provider, staff, people and relatives demonstrated people received person-centred care.

We could not be assured the provider understood the context in which care, treatment and support should be delivered.

Although the provider encouraged a positive culture and values in their workforce and organisation, the service history demonstrated the leaders did not have the skills, knowledge, experience and credibility to lead effectively.

At this assessment the provider clearly demonstrated they had an ethos and passion to ensure they provided good, high-quality care for people but recognised they still required support and guidance to do this. We continued to have concerns that the substantive leadership team did not fully understand the requirements of the regulations, due to the slow pace of improvement.

Although we found continued shortfalls in the running of the service, people and relatives were exceptionally positive about the provider, staff and the overall running of the service. When we asked people and relatives for their thoughts on the service and management of the agency comments included, “It is very well run and managed”, “It is excellent” and, “It seems to run smoothly enough.” Where asked, all people and relatives told us they would recommend the service to others.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

All people and relatives spoken with told us they were provided with opportunities to discuss standards of care, their views, any issues they had and to raise concerns at any time with the provider. All were confident they would be listened to and actions taken where required. As well as face to face meetings the provider gathered feedback from people and staff through surveys, which were completed on a regular basis. The provider used the information gathered to improve care and support for people and to promote staff development.

Staff told us they were provided with opportunities to share their views about the overall running of the service and any issues, concerns or training requirements they had through regular 1 to 1 supervision and regular contact with the provider.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider shared how they supported staff to the best of their ability and tried to work around their personal commitments.

All the staff spoken with felt they were treated fairly, said the service was managed well and confirmed it was a good organisation to work for.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Not all systems were robust which meant we could not be fully assured the provider understood how to apply the regulations. For example, an audit had been completed in relation to staff recruitment, yet this audit failed to recognise the shortfalls we found in relation to the lack of completed pre-employment checks in line with the statutory requirements.

Additionally, the systems in place to ensure safe administration of medicine including topical creams and oral medicine were not robust in demonstrating medicines had been administered as required. Action plans in place had been slow to develop to an appropriate standard. This has resulted in delays to improvements being made and the need for continued guidance and support from outside agencies and others to help ensure appropriate governance.

At this assessment we found some improvements had been made to the overall governance of the service. However, although improvements were noted which included but was not limited to, more detailed care plans and risk assessments, more structured provider oversight and additional systems and processes to help ensure the quality and safety of the service, some areas required further work to ensure continued improvement and safety is maintained.

The provider had developed clearer systems and processes to help ensure they understood their responsibilities. However, although the provider had commissioned a consultant to provide them with support, this was a recent and temporary arrangement which meant we could not be assured changes made would be sustained as the provider continued to undertake the majority of the roles and responsibilities for the service.

At the time of our assessment there had been no incidents that fit the remit of the duty of candour regulation, however the provider was able to demonstrate an understanding of this regulation and described how and when this would be applied. The provider also demonstrated they understood their responsibilities in relation to their regulatory requirements around notifiable incidents.

Despite the length of time since our last assessment, the changes made and being made were very much in their infancy and would need to be sustained and embedded into practice. Therefore, we will check for sustained improvement at our next assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. Feedback from a professional described the provider as being “open to the discussions” about service improvements.

People and relatives gave examples of the service working in partnership with other agencies, including community and specialist nursing services and occupational therapists.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At the time of this assessment, we found the provider was acting to make improvements following CQC’s findings at previous inspections. However, these improvements had been slow to progress. Although there was now an action plan in place to support with continued improvements, the development of this had been slow and this had delayed required improvements. This action plan and the completion of actions was ongoing at the time of this assessment.

Governance processes and audit systems had been and were being developed and put in place to help ensure the safe running of the service. These systems helped the provider to identify issues and concerns, and act on these to drive ongoing improvement. Systems were in place to analyse incidents, monitor quality and inform learning and improvements.

People and relatives confirmed they were asked for feedback via feedback surveys and from face-to-face discussions with the provider and staff. This supported the provider to identify areas of learning from past and current practice.

Although at this assessment we found some improvements had been made in relation to systems and processes regarding the completion of audits and provider oversight to ensure people received safe, effective and person-centred care, the improvements made were in their infancy and needed to be embedded into practice and sustained. Therefore, we will check for sustained improvement at our next assessment.