49 Alumhurst Road Also known as Nightingale House

We undertook a focused inspection of Pebble Lodge following recent incidents related to the safe domain. One sadly included a fatality using a fixed ligature point.

During this inspection we found:

• Staff were knowledgeable around the identification and management of the risks of the young people and how they were managed and mitigated where possible.
• Young people’s risk assessments were thorough and up to date, with evidence of the young person’s input. Staff completed daily environment checks to assess risks in the environment, and they had a ligature risk management plan detailing the risks.
• Staffing levels were good, with staff stating they rarely felt short staffed. Whenever shifts were unfilled, the service used bank staff to cover these shifts and ensured the staff knew the ward and how it ran. Staff demonstrated awareness of how to raise a safeguarding alert.
• Restraint levels had fallen significantly between 1 January 2018 and 31 December 2018, in comparison to the last 12 months, from 123 to 47. Staff stated that restraint was used as a last resort.
• The environment was clean and well maintained, there was a well looked after clinic room. There was a low stimulus room to help young people with their mood.

However:

• The service had a number of fixed ligature points, such as en-suite doors, ceiling mounted fire alarms and radiator covers. Although the trust had identified and managed ligature risks well, and had ordered collapsible doors to replace the high-risk doors, they did not have a clear timeline to complete the intended work.