CQC report explained · a nursing home
What the CQC found at Jah-Jireh Charity Homes Wigan
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found safe, effective and person-centred care, but quality checks and records were not reliable enough.
Inspectors visited on 22 November and continued their inspection activity until 2 December 2022. They spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files, training information and management records.
The home was rated Good for Safe and Effective. People and relatives said care was safe and person-centred. Staff understood safeguarding, recruitment checks were completed, medicines were generally managed safely, infection control was effective, and staff training and induction were good.
The home was rated Requires Improvement for Well-led and remained in breach of Regulation 17. Audits had improved since the previous inspection but still missed important problems, including inconsistent care records, incomplete fire risk actions and gaps in medicines records. The overall rating remained Requires Improvement, and this was the third consecutive inspection with that rating.
Safeguarding
Staff understood how to recognise and report abuse, and the home had systems for managing safeguarding concerns.
“The provider had robust systems in place to manage any safeguarding concerns.” from the report
Person-centred support
People's preferences were recorded, and inspectors found that the home's support reflected people's faith and individual choices.
“People's likes, dislikes and preferences were clearly identified in their care plans and records.” from the report
Staff preparation
Staff had a structured induction and good training compliance. People and relatives recognised staff's skills and experience.
“Staffs compliance with training was good and their skill and experience was recognised by people and relatives.” from the report
Communication with relatives
Relatives said they were kept informed when things went wrong and received updates by phone or email.
“They always inform me of things by a phone call or by e-mail.” from the report
Weak quality checks
seriousAudits did not identify several problems, and actions in the improvement plan were not always completed on time. This was the reason for the Regulation 17 breach.
“The provider had failed to implement effective systems and processes to monitor, assess and manage the quality of service provided.” from the report
Incomplete care records
needs fixingSome related care plans and records gave different information, including about repositioning and nutrition. Inspectors recommended that care plans be reviewed for consistency.
“In some areas further detail was needed and information across related care and support plans wasn't always consistent.” from the report
Medicine recording gaps
needs fixingMedicine administration was generally safe, but some records for as-required medicines, creams and patches were incomplete.
“We identified some people's medication records had minor gaps particularly in relation to people's 'as required medication' and application body maps for people who had creams applied regularly and transdermal patches.” from the report
Uncompleted safety actions
needs fixingSome actions from the latest fire risk assessment had not been completed when inspectors visited. The provider later supplied timescales for completing them.
“We found actions highlighted in the providers most recent fire risk assessment had not all been completed.” from the report
- 01What has been completed from the action plan for the fire risk assessment, and how do you check that these actions stay up to date?
- 02How are you now checking that care plans and related records contain the same information?
- 03How do you audit records for as-required medicines, creams and transdermal patches?
- 04What changes have been made so problems found through audits are dealt with within the planned timescales?
- 05How do you ensure staffing levels allow staff to monitor people who are at risk of falls?
This inspection looked at Safe and Effective and reviewed Well-led; Caring and Responsive were not rated, and the report says ratings for key questions not inspected were carried over from the last comprehensive inspection. This explanation was written from the published report of 27 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Jah-Jireh Charity Homes Wigan was rated Requires Improvement; inspectors found caring staff and enough staff on duty, but weak monitoring and late DoLS applications created risks.
This was an announced focused inspection on 8 July 2021. Inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, recruitment files, training information and management records.
People said they felt safe and were positive about the care. Staffing, safeguarding, infection control, equipment checks, healthcare support and food were generally good. However, the home did not have an up-to-date fire risk assessment at the time of inspection, medicines audits were too infrequent, and some meals were left untouched while people waited for support.
The home was rated Requires Improvement overall, with Safe, Effective and Well-led also rated Requires Improvement. Caring and Responsive were not assessed during this focused inspection, so their previous ratings were carried forward when the overall rating was calculated. The home had also been rated Requires Improvement at the previous inspection.
People felt safe
People and relatives told inspectors they felt safe. Staff had safeguarding training and knew how to report concerns.
“People felt safe living at the home and in the company of care staff.” from the report
Staffing
Inspectors found enough staff to meet people's needs, and recruitment checks had been completed.
“Enough staff were deployed to meet people's needs.” from the report
Healthcare support
People were supported to access health professionals when needed, and information from appointments was recorded.
“People received support to stay well and access medical services as required.” from the report
Food and choice
People and relatives were positive about the meals and choices available. Modified diets were provided according to care plans.
“People and relatives spoke positively about the meals provided, confirming they received enough to eat and drink.” from the report
Supportive management
People and staff described the management as visible, approachable and supportive.
“People told us the registered manager and business manager were visible and approachable.” from the report
Late DoLS applications
seriousThe home did not reliably monitor expiry dates or submit reapplications on time. Two authorisations had expired more than a month before new applications were made.
“Two DoLS had expired over a month before reapplications had occurred.” from the report
Weak quality checks
seriousThe audit system did not reliably identify or address problems. This included medicines discrepancies, late DoLS applications, care plan issues and the missing fire risk assessment.
“The provider had failed to ensure systems and processes to monitor the safety and quality of service provision were not robust.” from the report
Fire risk assessment
needs fixingThe home could not show that a robust fire risk assessment had been completed during the inspection. An accredited company was booked afterwards.
“However, the home was unable to demonstrate a robust fire risk assessment had been completed.” from the report
Support at mealtimes
needs fixingUpstairs, one member of staff was left to supervise and support 11 people while another delivered meals to rooms. Some meals remained untouched for some time.
“As a result, meals sat in front of people untouched for some time, until they could be supported or encouraged to eat.” from the report
- 01What changes have you made to ensure DoLS applications and reapplications are submitted before existing authorisations expire?
- 02When was the new fire risk assessment completed, and what actions did it identify?
- 03How often are medicines audits and stock checks now completed, and how are errors followed up?
- 04How do you ensure enough staff are available to support everyone during upstairs mealtimes?
- 05What new audit system is in place to identify and correct care plan, medicines and safety problems?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 11 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Jah-Jireh Charity Homes Wigan
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Jah-Jireh Charity Homes Wigan →
- August 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Jah-Jireh Charity Homes Wigan →
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Wigan
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 92 can care for a couple. 11 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“He developed a close affinity with Terence, spending time talking with him before he retired to bed and looking after his needs during the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.