Jah Jireh Maryport

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 service was in breach of the legal regulation in relation to the safe management of people’s medicines.

This service scored 53 (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.

We found evidence that staff recorded accidents and incidents appropriately however these were not always followed up on. There was a lack of regular review and analysis of these records. There was no evidence to demonstrate that learning from incidents was identified or that actions were taken to reduce the risk of reoccurrence. For example, although accidents and incidents were logged by the provider, there was no action taken to identify patterns or trends which could lead to ongoing risk of harm to people.

However, people and their relatives told us they felt able to raise concerns with staff and were confident that these would be addressed.

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.

We found that people and their families were involved in pre-admission assessments, alongside appropriate professionals, to ensure people’s needs could be safely met before admission. The provider worked in partnership with people and relevant healthcare professionals to support safe systems of care.

We found there was evidence of good transitions from other care homes into Jah Jireh.

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. The provider did not always share concerns quickly and appropriately.

Some staff told us they were not confident in following safeguarding procedures. However, staff told us they completed safeguarding training and understood how to identify signs of potential abuse.

The provider’s safeguarding recording systems required strengthening to ensure there was a full and complete audit trail of incidents.

Where people were unable to consent to their care, the provider had informed the local authority of any restrictions used to keep people safe. Appropriate legal authorisation had been obtained through the Deprivation of Liberty Safeguards (DOLS) process.

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 found risk assessments were not always completed. For example, someone who was not aware of the potential risk of being outside alone was able to leave the home through an open door. Following the incident an updated risk assessment was not completed.

Staff we spoke with knew people well and their individual care needs, including areas of risk. We observed safe working practices, such as moving and handling of people. Families generally told us they were happy with the care provided for their relatives.

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 identified gaps in the provider’s arrangements to maintain a safe environment. There was no recorded evidence that fire drills had been carried out, and no clear evacuation plan was in place. The fire evacuation information available lacked sufficient detail, outlining exit routes only and not describing the actions staff should take in the event of a fire. This could pose a risk to people’s safety in the event of a fire.

We found daily environmental safety checks had not been consistently completed since 2025. In addition, water temperature checks were not being completed on a weekly basis to reduce the risk of scalding and Legionella.

Routine servicing records of the systems including fire systems and electrical systems were up to date.

The provider 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.

We identified that governance arrangements in relation to staff recruitment required strengthening. Not all staff recruitment files contained the required pre‑employment documentation. For example, 1 staff file did not include a Disclosure and Barring Service (DBS) check or other evidence to provide assurance the person was suitable to work with vulnerable people.

The home had a stable work force and did not use agency staff.

A person told us, “There is always staff around to help you.” Another person told us, “The girls are alright, they come if you call them, well eventually.”

We found evidence that staff received supervision to support them in their role although there was a lack of appraisal information. Staff told us they completed mandatory training through online e‑learning. Staff were supported in their wish to undertake the care certificate.

We reviewed staffing levels within the home and found these were sufficient to meet people’s needs. The home did not use a dependency tool and used their own knowledge to identify how many staff would be needed on shift

Staff told us there was always someone available to provide support, and they described managers as approachable and respectful. Staff said they enjoyed working at the home and felt their role made a positive difference to people’s lives

An out of hours rota was in place with management or senior cover each night of the week.

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.

Families told us they were satisfied with the level of cleanliness within the home. We observed that personal protective equipment (PPE) and hand sanitiser were readily available throughout the service to support good infection prevention practices.

The provider completed Infection Prevention Control (IPC) and environmental cleaning audits, including checks of PPE availability, dispenser use and general area cleanliness.

Cleaning schedules and checklists were in place and completed to support the ongoing cleanliness of the environment. Food was stored appropriately in large fridges and freezers located in a separate area near the kitchen, and temperature monitoring records were maintained.

We found evidence of some staff not following the homes IPC bare below the elbows policy.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We identified gaps in medicines management systems that required improvement. One person living with diabetes did not have an identified diabetes care plan in place to guide blood glucose monitoring or the management of their condition. The lack of a care plan could lead to significant medical risks for the person.

When required (PRN) medication protocols were in place; however, these lacked sufficient detail to ensure medicines were administered safely and consistently, including clear guidance on indications, frequency and when further advice should be sought. Observation of PRN medication dispensing indicated that protocols were not always being followed.

During our inspection there was no evidence that ambient temperature checks were being undertaken in the medicines room, this meant we were not assured medicines would be safe, effective or stable. This was immediately addressed by the provider.

Appropriate authorisation of covert medication administration was seen within a care record; however, this did not clearly specify the method or route of administration, which is required to ensure medicines are given safely and in line with best practice.

Some staff were unaware of the risk for people following falls, who were on anticoagulants. This meant there was a risk people may not receive correct medical attention when required, posing a risk to their health and wellbeing.

The provider informed us they would take immediate action on the concerns raised.