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.

The service remained in breach of legal regulations in relation to good governance.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders did not consistently demonstrate an understanding of the context in which the provider delivered care, treatment and support. They did not always have the skills, knowledge, experience or credibility required to provide effective leadership and oversight.

While leaders promoted positive values and a supportive culture across the workforce, the service's history and the concerns identified during this assessment demonstrated they had not consistently led the service effectively. Leaders had not driven improvements sufficiently promptly to ensure people received safe, high-quality care.

During this assessment, we identified breaches of legal regulations relating to safe care and treatment, good governance, including record-keeping, and fit and proper persons employed. The provider had not identified or addressed all of these concerns through their governance and monitoring processes before the assessment. As a result, leaders had not taken timely action to mitigate risks and further improvement was required and needed to further develop their skills, knowledge and oversight to effectively monitor the quality and safety of the service.

We also found inconsistencies in leaders' understanding and oversight of record-keeping and risk management processes, including those relating to environmental risks and medicines management.

We remained concerned the provider had not fully embedded an understanding of regulatory requirements and had not maintained improvements made at the last inspection. The slow pace of improvement and the continued concerns identified during this assessment demonstrated the provider had not yet established effective oversight to achieve and sustain compliance with the regulations.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not establish clear responsibilities, roles, systems of accountability or effective governance arrangements. Leaders did not consistently use information about risk, performance and outcomes to monitor the quality and safety of the service or share information appropriately when required.

The provider did not operate effective quality assurance systems to identify and address risks and quality concerns and to ensure they met their regulatory requirements. The provider was required to submit an action plan monthly to CQC to show how improvements were being made following the continued concerns in relation to governance. However, these action plans had not brought about the required improvement. Audits and monitoring processes failed to identify several issues found during this assessment, including continued concerns relating to staff recruitment, medicines management, risk assessments and record-keeping. For example, although the provider completed medicines audits, these failed to identify the shortfalls we found in medicines management. This demonstrated leaders had not effectively monitored medicines practices or assured themselves systems were operated safely.

Following concerns identified at previous inspections, leaders did not complete audits of staff recruitment processes. As a result, they failed to identify ongoing recruitment shortfalls before this assessment. This meant staff worked in people's homes without all the necessary checks in place to demonstrate they were suitable and safe to carry out their roles.

The provider did not consistently maintain complete, accurate and robust records. Care plans did not always contain clear guidance for staff on how to manage and reduce identified risks. As a result, staff did not always have access to the information they needed to provide safe and consistent care. Whilst some records contained sufficient detail, most lacked the information necessary to support people's safety and wellbeing.

Since previous inspections, leaders had taken steps to strengthen governance arrangements. These improvements included introducing provider governance meetings and completing health and safety audits. However, further work was required to demonstrate sustained improvement and ensure the service maintained safe, effective governance arrangements.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not consistently promote continuous learning, innovation and improvement across the organisation and wider system. Leaders did not always encourage creative approaches to delivering equitable experiences, outcomes and quality of life for people, and they did not consistently contribute to the development of safe and effective practice.

Although leaders demonstrated a willingness to improve, ineffective risk management and quality assurance systems limited their ability to identify learning opportunities and areas requiring development. As a result, leaders did not maintain effective oversight of service shortfalls and did not consistently take timely action to drive improvement.

At the time of this assessment, leaders had begun taking action to address concerns identified during previous CQC inspections. However, progress had been slow, and delays in developing and implementing an improvement plan had slowed the pace of required improvements. Whilst leaders had established an action plan to support ongoing improvement, actions remained in progress at the time of this assessment.