We carried out a comprehensive inspection of Pinkney Services Limited on 5 and 6 April 2018.

Pinkney Services Limited is a domiciliary care agency. The service provides support to adults and younger adults with learning disabilities or autistic spectrum disorder. It provides personal care to people living in their own houses and flats in the community and to people in supported living arrangements.

Supported living is where people receive support so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support. Where the service does provide any wider social care, we also take this into account. At the time of the inspection the service was supporting seven people.

Pinkney Services Limited has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This was the first inspection of the service since it was registered with the Care Quality Commission (CQC) in December 2016.

Medicines were not always being safely managed. Recording of administration of people’s medicines was an area of practice that required improvement to make sure people were safe from the risk of avoidable harm. The service had not always supported people who received support to maintain a clean and hygienic home environment to manage and prevent risks of infection.

Following a period of temporary management cover while the registered manager had been absent, management of quality, risks, staff performance and regulatory requirements had not been always been effective. The service did not always consistently involve and engage with people, the public and staff to gain their views and input on how to develop the service.

The service had not submitted notifications of events that had occurred in line with CQC registration requirements, such as incidents involving the Police and allegations of abuse.

Quality assurance and information governance systems were not always effective. Quality and safety issues had not always been identified. Where these had been recognised, these had not always been acted on in a timely manner. There was no formal development plan in place to allow the service to continuously review, learn and improve the quality of its support.

The registered manager had a clear vision for the service to deliver high quality care that empowered people with learning disabilities and autism to be independent and achieve what they wanted from life. However, staff had not always had support to take account for their performance and know what was expected of them to fulfil their responsibilities. Staff did not always work collaboratively or effectively.

Management were not always seen as visible and approachable by staff. Some staff found the feedback from members of the management team had been inconsistent and was not always constructive. Some staff felt unsupported and not always confident information was shared with them in a timely and transparent manner.

People had been assessed for risks to their well-being. People were involved with making choices during their risk management processes and any restrictions on their freedom were kept to minimum. Some people’s risk assessments lacked details about control m