Archived: Universal Complex Care

Updated 13 January 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was announced. Due to the pandemic, we gave a short period notice of the inspection to enable us to collate as much information as possible virtually to minimise the time spent by the inspection team visiting the provider’s office.

Inspection activity started on 25 November 2021 and ended on 14 December 2021. We visited the office location on 8 December 2021.

What we did before the inspection

We reviewed information we had held about the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with one person and two relatives about their experience of the care provided. We spoke with five members of staff including the registered manager, qualified nurses and care workers.

We reviewed a range of records. This included four people’s care records. We looked at five staff files in relation to recruitment, training and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at staff training data and the providers quality assurance records. We reviewed feedback received from three care workers and two professionals.

Updated 13 January 2022

About the service

Universal Complex Care is a domiciliary care agency providing personal care to people living in their own homes. At the time of inspection, six people were using the service.

CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

People’s experience of using this service and what we found

The provider’s governance arrangements did not provide assurance the service was well led, and regulatory requirements were being met. Quality assurance systems were not robust and had not identified the shortfalls we found during our inspection.

Newly appointed staff had not always been recruited in a safe way as gaps in employment histories had not been checked and suitable references taken up with previous employers. The provider could not provide assurance that checks with the Disclosure and Barring Service (DBS) had been completed prior to staff working at the service.

Where required, people were supported with the administration of medicine, however the systems in place for the safe management of medicines required improvement.

Information relating to people’s individual risks were assessed and written guidance in place for staff to follow to keep people safe. However, these did not always contain detailed guidance for staff to follow.

We have made a recommendation the provider review their risk and care recording processes.

Staff had received safeguarding training and knew how to act on any concerns.

There were enough staff to meet people’s needs. People were supported by a consistent team of staff who had received relevant training to meet their specific health conditions.

People were complimentary about the kind, caring attitude of staff. People’s dignity and privacy was respected, and their independence promoted.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff enjoyed working at the service and felt valued and supported.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 19 October 2020 and this is the first inspection.

Why we inspected

This was a planned inspection based on the length of time the service was registered and when they commenced providing a regulated activity.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified three breaches in relation to safe care and treatment, safe recruitment and how the service is led.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.