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The Elms

Type Social Care Org Region North West Last inspected 24 Nov 2022

Overall rating: Inadequate  View full CQC report

Domain ratings

Five CQC key questions
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Inadequate

Earlier inspection findings

pre-2024 framework · 8 must-do 4 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8
Must do
Responsive
The provider must ensure staff provide people with individualised care which meets their needs.
Regulation: Regulation 9 (Person-centred care)
⚠ The provider had failed to ensure staff provided people with individualised care which met their needs.
Must-do action 2 of 8
Must do
Effective
The provider must ensure that necessary consent forms are always in place.
Regulation: Regulation 11 (Need for consent)
⚠ The provider had failed to ensure that necessary consent forms were always in place.
Must-do action 3 of 8
Must do
Safe
The provider must ensure systems and processes to prevent abuse of service users operate effectively.
Regulation: Regulation 13 (Safeguarding service users from abuse and improper treatment)
⚠ The provider had failed to ensure systems and processes to prevent abuse of service users operated effectively.
Must-do action 4 of 8
Must do
Safe
The provider must ensure all necessary processes are being followed and paperwork is in place regarding IPC.
Regulation: Regulation 12 (Safe care and treatment)
⚠ The provider had failed to ensure all necessary processes were being followed and paperwork was in place regarding IPC.
Must-do action 5 of 8
Must do
Safe
The provider must ensure risks are being appropriately assessed and managed.
Regulation: Regulation 12 (Safe care and treatment)
⚠ The provider had failed to ensure risks were being appropriately assessed and managed.
Must-do action 6 of 8
Must do
Safe
The provider must ensure medicines are being safely managed.
Regulation: Regulation 12 (Safe care and treatment)
⚠ The provider had failed to ensure medicines were being safely managed. This put people at risk of harm.
Must-do action 7 of 8
Must do
Well-led
The provider must ensure records are always in place, completed and up to date, quality assurance systems are robust, and processes are always being followed.
Regulation: Regulation 17 (Good governance)
⚠ Records were not always in place, completed and up to date, quality assurance systems were not robust, and processes were not always being followed. This put people at risk of harm.
Must-do action 8 of 8
Must do
Well-led
The registered manager must notify CQC of all reportable incidents.
Regulation: Regulation 18 (1) of the Care Quality Commission (Registration) Regulations 2009
⚠ A number of accidents and incidents had taken place at the service which CQC should have been notified about and had not been. The registered manager had failed to notify CQC of a number of incidents. This placed people at risk of harm.

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4
Should do
Safe
The provider should review their staffing levels to ensure appropriate support can be provided at all times.
Should-do action 2 of 4
Should do
Safe
The provider should review their recruitment processes to ensure new applicants are recruited safely.
Should-do action 3 of 4
Should do
Responsive
The provider should consider how they may better support people with activities that they wish to take part in and ensure that a consistent approach to this is maintained.
Should-do action 4 of 4
Should do
Responsive
The provider should ensure that the person responsible for dealing with complaints acts in line with the policy.

Location details

CQC ID: 1-10610299270
Local authority: Rochdale
Region: North West

Inspection report

Type: Comprehensive inspection
Date: 24 November 2022
Rating: Inadequate
Actions: 8 must-do 4 should-do
AI-extracted 17 Feb 2026