The inspection took place on May 2018 and 5 June 2018 and was unannounced.

Genesis Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Genesis Care Home accommodates up to 42 people in one purpose built building. On the days of our inspection there were 40 people living at the home. Genesis Care Home is a three storey building with single bedrooms that all have ensuite facilities. Each floor has a lounge and dining area and a passenger lift is available.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers they are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection the home was rated Good. At this inspection we found the home remained Good. The home is rated Good as it met all the requirements of the fundamental standards.

Safe and robust recruitment procedures were in place and sufficient staff were employed to meet people's assessed needs. All staff had completed an induction and completed mandatory training for their roles. Staff supervision took place regularly and also an annual appraisal. Staff attended team meetings.

People's needs were assessed prior to moving in to the home and this information was used to develop risk assessments and person centred care plans. These documents were regularly reviewed and updated as required. People were offered choice and their independence promoted where possible.

People's needs that related to age, disability, religion or other protected characteristics were considered throughout the assessment stage and care planning development.

The dining experience at the home was positive. People were complimentary about the food and drink and told us they were always offered a choice. Staff offered appropriate support as required and demonstrated good interaction throughout mealtimes.

We observed people being treated with dignity and respect. Positive interactions between people and staff were consistently observed throughout our visit. Staff were caring and demonstrated kindness and empathy.

Activities were available for people to participate in if they chose to and they told us they enjoyed these.

A safeguarding policy and procedure was in place. Staff had received training in safeguarding and were confident to raise any concerns they had.

The registered provider had medication policies and procedures were in the place. medicines were ordered, stored, administered and disposed of in accordance with good practice guidelines.

Governance systems were in place and included regular audits of key areas across the home. The information from the audits was analysed to identify areas for development and improvement and these areas were actioned in a timely manner.

The home operated in accordance with the principles of the Mental Capacity Act 2005 (MCA). Records showed that capacity assessments were in place when required. Consent was sought for care and treatment.

A complaints procedure was in place and people and their relatives told us they knew how to raise a concern or complaint.

Genesis Care Home was well maintained and all equipment was regularly serviced. All required health and safety checks and documentation were in place as well as fire safety equipment checks.

The inspection was unannounced and took place on the 18 February 2015.

The last inspection took place on the 18 September 2014 when Genesis Care Home was found not to be meeting a number of regulatory requirements which apply to this kind of home.  As a consequence we issued the registered provider with four warning notices and three compliance actions. These were in relation to safeguarding people from abuse, staffing, assessing and monitoring the quality of the service, record keeping, staff training, the care and welfare of people and the premises.

Following the inspection the registered manager sent us an action plan explaining how the warning notices and compliance actions would be met and by when.

During this latest inspection we found that all of the issues had been addressed.

Genesis has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Genesis is a three-storey purpose built care home for people over 65 years of age. The home is owned by Winnie Care (Macclesfield) Ltd and is located in Macclesfield. It is close to the local shops and other community facilities. There are three floors with 42 single bedrooms all of which have en-suite facilities. Each floor has a lounge and dining area and access between floors is by a passenger lift or one of the staircases. On the day of our inspection there were 28 people, including two people in hospital living in the home.

We asked people using the service if they felt safe at Genesis and they said that they did. Comments included; “I suffer from anxiety and very severe panic attacks. That‘s one of the reasons I‘m here. I feel really safe and happy here. Occasionally, they’re a bit pressed [for time] but on the whole, they do extremely well”, “Oh, I’m safe and happy here, I just need to be kept an eye on. If I ring my bell, they soon come. They help me with my bath, nobody has a bath by themselves”, “I’m very happy here. The staff are lovely here”, “I‘m quite comfortable here, I‘ve enjoyed it here” and “As happy as I can be. Yes, I feel safe here. I couldn‘t manage my own medicine, the staff look after that”.

Visitors we spoke with told us, “It’s always clean here, it’s a nice environment. They’ve tightened up on security, you now have to sign in/out. You didn’t used to have to, this is a recent thing” and “As a family, we’re all very happy. Security wise there’s no problem”.

The service had a safeguarding procedure in place. This was designed to ensure that any possible problems that arose were dealt with openly and people were protected from possible harm.

We looked at the files for the two most recently appointed staff members to check that effective recruitment procedures had been completed. We found that the appropriate checks had been made to ensure that they were suitable to work with vulnerable adults.

We asked staff members about training and they all confirmed that they received regular training throughout the year and that it was up to date.

The service had a range of policies and procedures which helped staff refer to good practice and included guidance on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

There was a flexible menu in place which provided a good variety of food to the people using the service.

The five care plans we looked at all explained what each person’s care needs were. Although the plans were being reviewed monthly so staff would know what changes, if any, had been made we did find that some of the reviews were limited, for example, the only note in the review stated, ‘outcome met’.

Meetings for the people using the service were taking place and we saw the minutes from the most recent meeting that had been held on the 4 February 2015. Topics discussed included, meals and activities plus feedback from any topics discussed at the previous meeting.

Staff members we spoke with were positive about how the home was being managed. Throughout the inspection we observed them interacting with each other in a professional manner.

We undertook a responsive inspection of Genesis Care Home on 18 September 2014 because we had received information of concern regarding poor safeguarding arrangements for people who lived in the home and low staffing levels (particularly at night) that were putting people at risk from harm.

During the inspection we spoke with seven members of staff. Some were on duty in the home and some we spoke with on the telephone. We also spoke with seven of the people who lived in the home and two of their relatives.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We had been told prior to our inspection that an incident had occurred where a person who lived in the home had behaved in an abusive manner. We were able to confirm that this had occurred and had not been dealt with in line with safeguarding procedures. We looked at the systems that had been put in place following this incident and were not satisfied that people were being protected from potential harm or abuse. We contacted the local authority safeguarding unit to share our concerns and to ensure that appropriate steps were taken to protect the people who lived in the home.

Prior to our inspection we had received information of concern that told us that staffing levels were very low at the home and there were regular times when there were not enough staff on duty to meet the needs of the people who lived in the home.

We asked the deputy manager and they told us that the agreed staffing levels were six staff on the morning shift, four staff on the afternoon shift and three staff on the night shift. We looked at the rotas for the six weeks prior to the inspection and we saw that these staffing levels were often not maintained. We saw that there were regular night shifts that were covered by only two members of staff. We were aware that there were a small number of people living in the home who required two staff to support them with their personal care needs. This meant that if staff needed to support them during the night this left the rest of the building unattended. We asked if a dependency tool was used to monitor and evaluate the changing needs of people to ensure that staffing levels were maintained at adequate levels. We were told that there were no tools used and the staffing levels had been the same for years but were currently not maintained.

Is the service effective?

We asked about staff support and supervision sessions and were told that these did not take place. We looked at the supervision records for 11 staff and saw that only three of them had received one supervision this year and some had never had any supervision sessions. We saw that some appraisals had taken place but that most of these were over a year ago.

We asked about training and staff told us that training did not often take place due to staff shortages. We spoke with one of the senior care staff who was also the home's staff trainer. They told us that training was often cancelled due to time and staff constraints. They were constantly working on the rota which left no time for training.

Is the service caring?

During our inspection we spoke with seven people who lived in the home and two of their relatives. All of them spoke very highly about the staff and the care that they received but significant concerns were raised about staff shortages. People told us that the staff worked very hard to meet their needs. Comments we received included; "I have really good relationships with the staff but they work too hard and never get a minute to chat" and "The staff are very busy and very kind. They do so much for us and they are run ragged and it's not fair on them."

Throughout the day of our inspection we observed staff interacting with people who lived in the home. We saw warm, positive interactions. It was obvious that the staff had very close relationships with the people that they were caring for. We saw that people were treated with dignity and respect and were also having a laugh and a joke with the staff. One person who lived in the home said to us "I love it here. I've acquired a selection of daughters."

Is the service responsive?

Examination of care records showed that care plans had not always been updated to reflect people's current personal and healthcare needs. For example, we saw one person in the home whom we had observed required significant support from staff to meet their personal care and mobility needs and to support them to eat and drink. We looked at their care records and saw that they had not been updated to meet their current needs and had not been evaluated since March 2014. We were concerned as their needs had changed considerably but the records did not reflect any of these changes.

Is the service well led?

During our inspection we were not able to access any audit information as the staff were not aware of where the information was stored. We spoke with the manager the following day and they emailed us the most up to date audits. We saw that the last care plan audits had been carried out in February 2013. We were concerned as the care plans were very poor and the lack of monitoring had contributed to this as regular audits would have highlighted the issues. There were no audits in place to monitor staff supervision or training. Regular monitoring of these would have identified the lack of both taking place for the staff.

We saw that no staff team meetings were taking place and the last meeting for people who lived in the home had been held in December 2013. The activities programme we saw said that a 'resident's forum' took place on a monthly basis but there were no records to evidence that these were taking place.

During our inspection we spoke to eight people who lived in the home. The majority of them were very complimentary about the care they received and the staff who supported them. One person said; "The staff are lovely. They can't do enough for you." Another person said; "I've been here a while. The staff are very kind, I can't fault them and it's very smooth flowing here."

We looked at the food provided in the home and the way the home met people's nutritional needs and we found that on the whole they did this well. People who lived in the home said that the food was very good and they enjoyed it.

We looked at the arrangements in place to protect people from harm and abuse. We found that the staff knew what they would do if they had some concerns.

During this inspection we looked at the support available for staff as at our previous inspection we had some concerns. We found that the support for staff had improved and they were receiving more supervision and training.

We looked at the home's systems for ensuring that they provided a quality service. We found that these were generally good and that the systems relating to monitoring the care provided were completed on a monthly basis.

Following our previous inspection on 21 February 2013, the service had given us an action plan to show us the improvements they were going to make to support staff more effectively.

We spoke to the manager of the home and five members of staff and found that this action plan had not been followed and the appropriate changes had not been made. The staff are still not receiving appropriate support to enable them to do their jobs effectively.

We found that staff are not receiving supervision, most staff have not had appraisals and team meetings are not taking place on a regular basis.

We found that people’s consent to their care was sought. We found that people’s best interests were protected if they were unable to give consent or make decisions for themselves. A relative said, “The staff keep me informed about my mum….I have reviewed the care plan with the manager.”

We found that individual care plans and risk assessments were in place and that people’s needs were being met. A relative told us, “My mum was ill and said she didn’t want to go to hospital. The staff looked after her here with help from the district nurses and she was fine.”

A visiting district nurse told us the staff team were co-operative and always willing to follow care instructions and guidance.

We found that staff were trained and supported to provide safe and effective care to residents. We found that staff did not have access to regular, planned supervision sessions or appraisals.

There was a suitable and sufficient range of equipment in place to safely meet people’s needs and promote their independence.

We found that a suitable system was in place for people to make complaints both within and outside of the service.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. The manager at the home was not registered with the Care Quality Commission.

We spoke with twelve of the people who lived at Genesis and a visiting relative. Those people that were able to say spoke positively about the home and the people who were working there.

Comments included; “I have settled in, the staff are very good, it is quite excellent”, “The carers are lovely, they always treat me with respect”, “I have porridge for breakfast but like a bacon butty on a Saturday and Sunday”, “The food is excellent, the cutlery is always properly washed, I am really fussy about this” , “The staff members are very good; they always treat us with respect and we enjoy a laugh”, “Wonderful staff, no complaints, it’s a good home”, “The staff are looking after me well”.

The visiting family member we spoke to said; “The home was recommended to me by friends, the staff members seem very caring and welcoming, they are always smiling”.

Before we visited the home we spoke with Cheshire East contracts monitoring officers. They told us that they did not have any concerns about the home.