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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment as people’s risks had not always been assessed and their medicines were not always managed safely. The service was also in breach relating to fit and proper persons employed due to unsafe staff recruitment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Sufficient improvements had not been made following our previous inspection. Leaders did not consistently work with people to identify, assess and manage risks. They did not always ensure care records clearly documented risks or provided staff with sufficient guidance to support people safely. While leaders considered risks during assessments, including those relating to personal care, moving and handling, environmental safety and people's health conditions, they did not always complete or maintain comprehensive risk assessments.

The provider also did always identify, assess and plan for some known risks. For example, risk assessments did not always address fire safety, environmental hazards, pressure care needs or the safe use of manual handling equipment. As a result, staff did not always have up to date information and the guidance they needed to reduce risks and provide safe care.

However, people told us they felt safe and supported by the staff who regularly provided their care. Staff demonstrated a good understanding of people's individual needs and could describe how they supported people safely in line with known risks. The provider informed us they would make changes to people’s records.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Improvements had not been made following our previous inspection. The provider failed to operate robust recruitment processes and did not always complete mandatory pre-employment checks in line with current legislation. For example, employment histories were not fully recorded and evidence of past conduct while working in health and social care settings had not been obtained in line with current legislation.

The provider also did not ensure they had received the outcome of staff’s criminal record checks before allowing staff to work unsupervised. This placed people at risk of receiving care from unsuitable staff. The provider took immediate action during the inspection to address this risk.

Most people told us they were satisfied with the timing of their care visits. However, 1 relative reported inconsistency in call times, which affected the person's care and support. Records also showed staff did not always remain for the full duration of the allocated visit. One relative told us: "The only thing that I would say is that the carers don't always stay for the time they should. If dad is to have 45 minutes, then they should stay for that time. They could spend it talking with dad. Sometimes the teatime and nighttime ones are in and out. This isn't right." The provider told us they would investigate the concerns raised.

Leaders ensured most staff completed relevant training and had access to supervision and competency assessments to support their development. However, they did not consistently maintain these systems. Records showed gaps in training compliance, including in key areas such as dementia and diabetes care. Leaders acknowledged these shortfalls and informed us they would ensure all staff completed dementia and diabetes training following the assessment.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Leaders did not always ensure medicines were managed safely and met people's needs, preferences and capacities. Staff did not consistently involve people in planning and reviewing their medicines support. Although leaders had made some improvements since the last inspection, they had not embedded these sufficiently to ensure the safe management of medicines.

Risk to people relating to their medicines had not always been assessed. For example, some people were prescribed medicines that thinned their blood and increased their risk of bleeding and bruising if they fell l or sustained a head injury. This risk had not been assessed and planned for. Staff also supported people prescribed emollient creams without risk assessments identifying the associated fire risks. This meant staff did not always have clear guidance to manage medicine related risks safely.

Staff did not consistently maintain accurate medicines administration records (MARs). Records contained gaps and did not always demonstrate people received their medicines as prescribed. For example, records for prescribed pain relief medicines showed staff did not always leave the required four-hour interval between doses. One relative told us, "The morning and lunchtime carers are fine, but sometimes the teatime and nighttime ones change the times. Sometimes they come early or are late. The teatime one can come anywhere between 5pm and 6pm. This affects the time dad gets his meds, especially if they come at 6pm then come again at 9pm, that's just three hours. They don't always tell us."

Records did not show staff had received appropriate medicines training and competency assessments before administering medicines. Although leaders and staff told us they had completed training, records did not provide assurance all staff had the knowledge, skills and competency required to administer medicines safely.