49 Alumhurst Road Also known as Nightingale House

Updated 16 May 2019

Pebble Lodge is an inpatient mental health ward (Tier 4) for children and young people, provided by Dorset Healthcare University NHS Foundation Trust. It is located at Alumhurst Road in Bournemouth, a location which also includes inpatient mental health services for adults and community mental health services for adults and children and young people.

Pebble Lodge has ten beds, is mixed-sex and treats young people aged between 12 and 18 years. It provides 24-hour specialist psychiatrist care and treatment for those

with emotional or mental health difficulties. Young people can be admitted informally or detained under the Mental Health Act (MHA) 1983. Pebble Lodge has an on-site school, the Quay school, that is registered with Ofsted (Office for standards in education, children's services and skills) and rated outstanding at its most recent Ofsted inspection in March 2015.

Pebble Lodge was previously inspected in November 2017. The service was rated as outstanding overall.

Updated 16 May 2019

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.