About the service:

Pebble Mill is a care home that provides nursing and personal care for older people, most of whom are living with dementia. At the time of the inspection, 36 people lived at the service. The accommodation is organised into three floors, each with its own communal areas.

People’s experience of using this service:

People did not always receive safe and effective care that was personalised to their needs. Some people had not received their medication as it was not in stock and staff did not always follow care plans to ensure people’s safety when helping people to move. Staff did not respond in a timely way when people used their call bells to request assistance.

Senior staff did not keep an oversight of day to day practice which meant that issues that were identified at this inspection had not been addressed. The service did not notify us of Deprivation of Liberty Safeguards applications that had been granted as required.

There were enough staff on duty to keep people safe and the provider carried out checks on new staff to make sure they were suitable to work in the home.

The home was spacious, well-decorated and clean and people had the opportunity to spend time alone or with visitors in privacy. People were generally happy with the food and individual preferences were catered for. People did not always have the opportunity to have a drink when they wanted one.

Staff showed compassion and were patient with people when they were upset or distressed but did not always take the opportunity to spend time talking and interacting with people. People did not always have the opportunity to express how they wanted their care delivered which meant they did not always receive care that was personalised.

The provider responded promptly to any concerns and complaints that were received and worked well with other agencies to promote people’s health and ensured people were well supported at the end of their life.

Some audits and checks were effective in highlighting gaps in record keeping and practice and where gaps had been identified, action had been taken to improve the quality of care and support. The provider and registered manager were open and honest throughout the inspection and were committed to address the issues highlighted at this inspection.

More information is in the detailed findings below.

Rating at last inspection:

This was our first inspection of this service since their registration in March 2018.

Why we inspected:

This was a planned inspection.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up:

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

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