# Universal Care Agency Ltd Universal Care Agency Ltd is a CQC-regulated home-care agency in Portsmouth. ## CQC Ratings | Key question | Rating | | --- | --- | | Overall | Good | | Safe | Good | | Effective | Good | | Caring | Good | | Responsive | Good | | Well-led | Requires improvement | Rating published: 11/06/2025 ## Practical info - Postcode: PO6 3UD - Registered manager: Agamasu, Victor - Local authority: Portsmouth - Region: South East - City: Portsmouth - Last CQC check: 11/Jun/2025 - 00:00 ## Inspection findings ### Other - Finding - Evidence: Two 'as required' medication protocols had been introduced since the previous inspection, representing some progress. - Published: 2023-10-18 - Finding - Evidence: One care plan identified as insufficient at the last inspection had been updated to include details of the person's medical conditions. - Published: 2023-10-18 - Finding - Evidence: Relatives praised the registered manager's honesty, intelligence and integrity, and the quality of care workers. - Published: 2023-10-18 - Finding - Evidence: One relative reported: '[Person] used to have pressure sores, they are cleared up now, they do a fantastic job.' - Published: 2023-10-18 - Finding - Evidence: Some relatives were very positive: 'The service is first class, carers turn up on time, they ensure flat tidy and clean and make beds.' - Published: 2023-10-18 - **record_keeping** _(critical)_ - Evidence: There were no MAR charts, PRN records, body maps or cream charts for any of these people however, a relative told us, 'Staff administer creams...they fill in a chart.' - Published: 2023-10-18 - **governance** _(moderate)_ - Evidence: The registered manager told us, 'I have done medication checks, I just haven't documented them.' Any checks undertaken had failed to identify the concerns we found. - Published: 2023-10-18 - **governance** _(critical)_ - Evidence: Quality assurance audits were not in place for example, to check the quality and accuracy of care plans, risk assessments and medicines records. - Published: 2023-10-18 - **care_planning** _(critical)_ - Evidence: One person's care plan said they had a specific medical syndrome. There was no other information relating to this condition. We asked two staff members...they told us, 'I am sorry, I don't know.' - Published: 2023-10-18 - **care_planning** _(critical)_ - Evidence: Care plans continued to fail to contain enough information about people's specific medical conditions...one person's care plan identified they had chronic kidney disease stage three, however, there was no information about this condition. - Published: 2023-10-18 - **staff_competency** _(critical)_ - Evidence: At the last inspection staff had not had their competency to administer medicines assessed. At this inspection staff had still not had their competency to administer medicines assessed. - Published: 2023-10-18 - **medication_management** _(critical)_ - Evidence: Where a medication had been reduced by a medical professional this had not been identified on the MAR chart...We have raised a safeguarding referral about this. - Published: 2023-10-18 - **medication_management** _(critical)_ - Evidence: 'As required' medicines protocol guided staff to administer three different amounts...It was not clear what the prescribed dose was, or when it should be administered. - Published: 2023-10-18 - Finding - Evidence: The service was working within the principles of the Mental Capacity Act. - Published: 2022-11-11 - Finding - Evidence: Some systems were in place including staff supervision and reviews of people's care. - Published: 2022-11-11 - Finding - Evidence: A relative described staff as 'wonderful' and was 'very happy' with the service. - Published: 2022-11-11 - Finding - Evidence: Staff competency assessments for medicines administration had been completed since the last inspection. - Published: 2022-11-11 - Finding - Evidence: Staff had access to appropriate PPE and described wearing aprons, gloves and masks when visiting people. - Published: 2022-11-11 - Finding - Evidence: Safeguarding policy was understood by staff, and staff demonstrated sound understanding of safeguarding procedures. - Published: 2022-11-11 - Finding - Evidence: People were supported by a consistent staff team who knew them well, reducing the risk of unsafe care. - Published: 2022-11-11 - **leadership** _(critical)_ - Evidence: The registered person did not demonstrate a robust understanding of how to comply with regulation and sufficient improvement had not been made. - Published: 2022-11-11 - **person_centred_care** _(minor)_ - Evidence: the provider had not always acted on people's feedback to make improvements for them. - Published: 2022-11-11 - **medication_management** _(minor)_ - Evidence: The medicine record provided guidance about where on the body the cream should be applied but not how frequently. This meant there was risk the cream was not being applied at the times the person needed. - Published: 2022-11-11 - **infection_control** _(moderate)_ - Evidence: Staff were not testing for COVID-19 in line with Government guidance... detailed guidance about areas relating to COVID-19 such as testing and the use of PPE was not available. - Published: 2022-11-11 - **care_planning** _(moderate)_ - Evidence: risk assessments had not been put in place regarding people's health conditions. These included conditions such cellulitis, chronic kidney disease stage three and diverticular disease. - Published: 2022-11-11 - **record_keeping** _(moderate)_ - Evidence: Records were not always detailed or up to date. This included people's risk assessments, care plans and medicine records. - Published: 2022-11-11 - **governance** _(critical)_ - Evidence: The failure to have effective systems in place to assess, monitor and improve the quality and safety of the service and to maintain accurate and complete records was a continued breach of Regulation 17 - Published: 2022-11-11 ### safe - Finding - Using medicines safely - Published: 2023-10-18 - Finding - Assessing risk, safety monitoring and management - Published: 2023-10-18 ### well_led - Finding - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements - Published: 2023-10-18 ## Source Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-317366018 HomeCare Compass is an independent guide and is not affiliated with the CQC.