Jah-Jireh Charity Homes Wigan

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of regulation 12 regarding safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

At our last inspection in November 2022, the service was rated requires improvement in the well-led question due to there being a breach of regulation 17 regarding good governance. We found similar concerns at this inspection, which meant the service was not always learning from and making improvements to ensure compliance with regulations.

Where people had an accident or incident, a log was maintained about what happened and any actions taken, for example, referrals to the safeguarding team if harm had occurred to a person. The management team regularly analysed accidents and incidents to identify any emerging themes or patterns in order to improve the care provided. These findings were then shared with the staff team.

Staff knew about what action to take when if any serious incidents were to occur. One member of staff said, “I would press the emergency buzzer, assess the situation, and do initial assessment while waiting for other staff. I would begin first aid if needed and give reassurance and explain to the nurse what happened and follow their direction. We have a system to record the incident as there is an incident form on this which gives prompts to use.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked in partnership with other professionals such as GP's, dietitians and speech and language therapy (SaLT) to support people to access healthcare when they needed it. One person said, “They have brought health professionals to me such as the doctor and a chiropodist.” A relative also said, “The doctor and podiatrist visit her. They try to give her healthy food and they encourage her to drink.”

The management team and staff demonstrated that when a person's needs changed, they promptly engaged with several services to ensure the person's needs were fully met and understood. For example, people were referred to SaLT if there were any concerns regarding choking, or the dietician if people had experienced weight loss.

People living at the home and relatives told us the service was safe. One person said, “Because of my faith I feel safe here. The staff are trustworthy too and I have faith in them.” Another person said, “I am safe, as I can follow my religion here and the staff are very supportive to me.” A relative added, “My wife is safe and is supported very well by the staff. The staff are diligent, they constantly pop in her room to check on her.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We found some people had restrictions in place including the use of sensor mats/bed rails in people’s rooms. Decision specific mental capacity assessments had not been completed to ensure these were in people’s best interests. The home manager told us these were to be completed after the inspection.

A DoLS tracker was used to monitor the status of any authorisations. We found DoLS applications were made to relevant local authority where necessary and conditions monitored. Staff understood about DoLS and the MCA, however training compliance was only 55% according to the training matrix. The home manager told us they intended for staff who were behind with any training to come into the home for this to be completed. Training was also to be discussed during the next staff meeting.

A log of all safeguarding referrals was maintained, along with any actions taken. Staff understood safeguarding and what may constitute abuse. One member of staff said, “It is to ensure people are protected from all kinds of abuse.” Safeguarding training compliance was at 84% at the time of our inspection.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at how risks were managed including those related to skin integrity, falls/mobility and nutrition/hydration. Several people living at the home were at risk of skin integrity and used equipment such as pressure relieving cushions and airflow mattresses. We checked a sample of people’s mattresses and found overall they were maintained at the correct setting. We spoke with the home manager about the importance of this being clearly detailed in people’s care plans, as this was not clearly documented.

In some people’s care plans, it stated they needed to be re-positioned every 4-6 hours, although records didn’t always reflect this was completed within these timescales. Any gaps in re-positioning charts were to be cascaded to staff to ensure these records were properly maintained.

Where people were at risk of choking, we saw they had been referred to speech and language therapy (SaLT) for further advice. This included providing people with thickened fluids and pureed meals, which we observed being given to people during the inspection.

Fluid records did not always reflect that thickener (used to prevent the risk of choking) was added to people’s drinks. Some people also had fluid targets of approximately 1500mls per day, on some days this was recorded as low as 400mls, without a reason given why the target hadn’t been achieved.

People had mobility care plans in place which explained any required actions to be completed by staff. One person’s care plan it stated they were required to always be wearing appropriate footwear, however when we saw them, they only had socks on. We raised this with staff who said this person often went to their room alone and took them off, although they would monitor this moving forwards.

We found people had appropriate equipment in place to aid their mobility such as zimmer frames and wheelchairs which we observed being used by people during the inspection. Some people required bed rails to reduce the risk of falls from bed and we observed these in place where necessary.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found parts of the environment were not always well maintained. This included stained and torn carpets, as well as damaged walls and ceilings in parts of the home. We noted the environment in the residential/nursing unit of the building differed significantly in appearance to the dementia unit which had modern furnishings and a more homely place for people to live. We were told there was a home improvement plan in place where these areas were to be addressed.

Some risks around the home were not always effectively mitigated. This included not all wardrobes being secured to walls which presented the risk of them falling on people. Arrangements were made for these to be fitted during the inspection. Radiators didn’t have protective guards on them which could place people at risk of burns and scalds. Plans were put in place for these to be installed.

We also observed several bedroom doors, which were fire doors, were held open with items like chairs and tables. This could stop them from closing properly in the event of a fire. The home manager said all fire doors had since been checked, and this area would be monitored during daily walkarounds. We recommend the fire risk assessment is kept under review to ensure these areas of concern can be safely managed.

Regular safety checks were carried out of the building including gas safety, electrical installation, fire equipment. Additional work was required to the passenger lift and we saw evidence that this had been scheduled for completion.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff supervisions and appraisals had fallen behind in 2025. There had been a change in management at the home earlier in the year, which had been one of the main reasons these weren’t being held as required. The home manager told us plans had now been put in place for these to re-commence by the end of October 2025.

Training was generally up to date and staff said they received enough training to support them in their role. Some training courses were flagged as needing to be completed ‘urgently’ and the home manager had made arrangements for the relevant staff to complete these and for it to be discussed at the next team meeting.

Weekly staffing rotas were in place and a dependency tool was used to determine how many staff were needed. Staff we spoke to generally felt there were enough staff to care for people. One member of staff said, “We seem to have enough and although we use agency there are enough around.” Another member of staff said, “I work both days and night and feel we have more than enough.”

Some people said they felt agency staff weren’t always as reliable and had to wait for their call bell to be answered at times. One person said, “They do bring agency staff in, some are good, some not so good. If I use my call bell sometimes, I do have to wait quite a while to be seen to, so I am sure they are short of staff at times.” Another person said, “I feel the staffing ratio is being met, but weekend staffing ratios need to be looked at. However, sometimes when I buzz for them, they can take a very long time to get to me. I am going to raise this issue at the next resident meeting. The manager is aware and she says she is working on it.”

Staff were recruited safely with appropriate checks in place to assess the candidate's suitability to work with vulnerable adults. This included obtaining references, evidence of right to work and DBS checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We found the home to be clean, tidy and observed domestic staff carrying out their work during the assessment. Toilets and bathrooms were equipped with appropriate hand hygiene facilities such as paper towels, liquid soap and foot operated pedal bins. Hand sanitiser was available in the home and posters were displayed to encourage compliance.

There was an up-to-date policy on the control of infection, prevention and control (IPC) which staff could refer to if needed. Staff were trained in IPC and had access to personal protective equipment (PPE) which we saw it being work for tasks such as completed personal care.

Nobody raised any concerns with us about the cleanliness of the home during our inspection.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicine administration records including those for Controlled Drugs showed people received their medicines as prescribed. People who had been prescribed medicines on a when required basis had written plans in place to inform the care staff of how and when it was appropriate to administer these medicines.

A system was in place for recording where on the body skin patches containing medicines were being applied. These records were able to show these patches were being rotated around the different skin sites to comply with the manufacturer’s guidance. When people were refusing their medicines, their mental capacity was assessed, recorded and they were supported appropriately.

Information was available on how to prepare and administered these medicines which had been checked by an appropriate healthcare professional. Where people needed to have their medicines administered directly into their stomach through a tube, the information about how to prepare these medicines was available. However, this information had not been consolidated into a robust written protocol to inform staff on how to administer these medicines safely and consistently.

People wishing to self-administer were supported to do so and the necessary checks and balances were in place to ensure this was carried out safely. All medicines were stored securely and at the correct temperature.

Staff that administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely.