TLC Rehab

Date of on-site assessment: 29 April – 30 April 2026. Further assessment activity, such as telephone calls with staff members and clients, took place up until 15 May 2026.

TLC Rehab is a residential substance misuse rehabilitation service for adults based in Barnet, north London. The service offers medically assisted detoxification treatment for alcohol, opiates and non-opiates. It is an independent service for self-funded clients, run by Apex Wellness Solutions Ltd.

TLC Rehab registered with CQC in September 2024 to provide the regulated activities of Treatment of disease, disorder or injury and Accommodation for persons who require treatment for substance misuse. At the time of our assessment, the service did not have a Registered Manager, although one was confirmed in post shortly after our assessment visit concluded.

The service offers mixed-sex accommodation for up to 10 people. At the time of our inspection, 7 clients were admitted to the service.

We carried out a short-term announced site visit on 29 and 30 April 2026 as part of a comprehensive assessment. This means we covered all key questions and quality statements. We have combined the scores for these to achieve the overall rating. We have rated the service as requires improvement.

This was our third inspection of this service. During our initial assessment in April 2025, we found serious concerns and multiple breaches of regulations. We took urgent enforcement action and issued a Section 31 Letter of Intent relating to a range of governance and safety issues. At that time, we also issued a warning notice relating to medicines management. During our second assessment in July 2025, the provider was unable to demonstrate sufficient progress in addressing the areas of concern. The issues within the warning notice had not been addressed and the warning notice remained in place. As a result of the assessment in July 2025, we took urgent enforcement action by imposing conditions on the provider’s registration. At both previous assessments, we rated the service inadequate.

We undertook this current assessment to check whether the issues in the warning notice had been addressed and what progress the provider had made in improving overall governance and safety. We found that several areas had improved, but some risks remained and some areas needed further embedding.

At this current inspection, we found that the provider was in breach of regulations in relation to safe care and treatment, good governance, staffing, and fit and proper persons employed:

• Regulation 12: Safe care and treatment. Staff did not always provide safe care and treatment in line with national guidance. Medicines were not always prescribed safely. The provider had not ensured that its prescriber liaised with clients’ GPs consistently to make sure that care and treatment remained safe. Potential risks to people using the service were not identified, assessed and mitigated where needed. The provider had not ensured that staff had followed its policy for admissions to the service. This meant that the service was not able to meet the needs of all clients safely. Not all safety incidents were documented and investigated appropriately.
• Regulation 17: Good governance. There was no clinical lead role within the service to oversee and drive continuous improvement and provide expert guidance to the team. Decisions about some client admissions had been made by a non-clinical staff member, resulting in inappropriate admissions.
• Regulation 18: Staffing. Nurses did not receive appropriate clinical supervision or continuing professional development. There was no written contract for the employment of doctors and no contingency arrangements for continuity of care during their absences.
• Regulation 19: Fit and proper persons employed. The provider had not established a process to check that all staff it employed were of good character and had the necessary qualifications, competence, skills and experience, or were registered with the relevant professional body where such registration was required.

We took enforcement action as a result of this inspection. We issued warning notices on 11 May 2026 in relation to safe care and treatment, staffing, and fit and proper persons employed. The provider is required to become compliant with these warning notices by 20 July 2026.

We also found other areas where practice needed improving. We saw some gaps in clients’ assessments, such as previous treatment history not being explored and the absence of relevant blood tests. It was not always clear whether clients had been assessed by the doctor remotely or face-to-face, in line with the provider’s policy. There was limited evidence of harm reduction advice being provided to clients. Fire evacuation drills had not been carried out since March 2025. Although overall compliance with training was between 75% and 95%, this varied for individual staff members and some training courses. The Oliver McGowan mandatory training on learning disability and autism was included in the provider’s optional training instead of mandatory training. Actions identified in the external health and safety review in January 2026 remained outstanding. The service did not routinely work with external organisations and did not participate in research, quality improvement or accreditation schemes.

We found several areas where improvements had been made since our last assessment. Clients’ recovery plans that we viewed were personalised, holistic and recovery-oriented, with evidence of client involvement. We saw tangible improvements in the service’s governance systems and in how staff used them. The service had improved its systems to manage environmental risks. This included improved fire safety management, having a risk register and business continuity plan in place, and improvements to the security of the premises. The new operational managers demonstrated a good understanding and oversight of the service. Staff said that the improvements in governance helped them in performing their roles. Staff meeting structure had improved and weekly community meetings were taking place. There were now appropriate policies and procedures in place, including clear inclusion and exclusion criteria for admissions to the service. Discharge planning process had improved. The service had implemented a range of audits to monitor the quality and safety of the service. The service now ensured that staff received competency assessments, training, managerial supervision and appraisal. The service collected data such as outcome measures to monitor how effective the service was. Managers had access to information needed to support them in their role, such as audits, performance and staffing data.

This was the second assessment for this newly registered service. We first inspected the service in April 2025. We found multiple concerns during the April 2025 assessment across all five domains which still remained during this July 2025 assessment. We informed the provider of our serious concerns during and immediately after this assessment.

In April 2025, we sent a letter of intent (notice of CQC’s intention to take urgent action) to the provider about our concerns in relation to; the model of care, inclusion and exclusion criteria, outcomes measures, discharge planning, safeguarding, risk management of clients, policies and procedures, incidents and complaints, safe staffing, security of premises, fire safety, governance and the directors. The provider sent us an action plan to address our concerns outlining how the concerns would be addressed within set timeframes.

This current inspection took place to assess progress against the action plan. We found a significant lack of progress against the plan. As a result, we imposed conditions on the registration of the service (please see the assessment summary section above).

In April 2025 we also served a warning notice around the safe management of medicines. During this current inspection we saw the concerns had not been addressed and the service was not compliant with the notice.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service did not admit clients under the Mental Health Act 1983. All clients were self-funded.

Although the service did not admit clients under the Mental Health Act 1983, many people in residential substance misuse services have co-occurring mental health conditions (dual diagnosis) or mental health needs, where referral for assessment under the Mental Health Act may be required. Staff had not received training on how to support a client whose mental health was deteriorating in order to refer the person to crisis mental health services if needed. They did not know how the Mental Health Act might be used in these circumstances.

Mental Capacity Act

Most staff had a limited knowledge and understanding of the Mental Capacity Act 2005. In April 2025 we found that 2 of 13 staff had received training in the Mental Capacity Act 2005. There was no evidence that this had changed, at this inspection. The Registered Manager and Nominated Individual had not completed or been booked to receive this training. Clients who access residential substance misuse services can have fluctuating or impaired capacity when under the influence of substances. Staff working in substance misuse services should have received training in the Mental Capacity Act 2005 to ensure they have appropriate knowledge to undertake mental capacity assessments for clients who may have impaired capacity and will need to consent to a variety of decisions, including consent to detoxification, substitute prescribing, unplanned exits from treatment and sharing of information.

The provider had a policy on the Mental Capacity Act. At the last inspection we found no evidence that staff were aware of the policy and had access to it. During this inspection we saw that 9 staff had confirmed electronically that they had seen and read the policy.

The service did not have arrangements in place to monitor adherence to the Mental Capacity Act. There were no audits in regard to application of the Mental Capacity Act and no evidence of lessons learned.

Assessment Summary

Date of assessment: 23 April to 2 May 2025

TLC Rehab is a residential substance misuse rehabilitation service. It offered alcohol detoxification (detox), opiate detox, benzodiazepines (benzo) detox and residential substance misuse rehabilitation. The service had capacity for 10 clients. The accommodation was mixed-sex. There were 7 clients on the first day of this assessment inspection and 1 new admission on the second day.

We conducted this unannounced comprehensive assessment due to the service being newly registered. TLC Rehab was the only registered location for the provider and was for self-funding clients.

The overall rating for this service is inadequate. During this inspection we found 30 breaches of regulation. These breaches were found across all five domains. We took enforcement action and asked the provider for an action plan and immediate assurances around how they will ensure these breaches are met.

Action we have taken

We found multiple concerns during the inspection and 29 breaches of regulation. These breaches were found across all five domains.

• The provider must ensure that there are clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support, and that they act on information about risk, performance and outcomes.
• The provider must ensure that clear inclusion and exclusion criteria is in place and followed.
• The provider must ensure that comprehensive initial assessments of the client are carried out in a timely manner at admission or soon after.
• The provider must ensure that they carry out appropriate recruitment and induction processes for permanent staff and that these are evidenced in staff files.
• The provider must ensure all bank and agency staff have personnel files at the service to ensure that appropriate recruitment checks and training requirements have been completed, can be monitored and updated as required.
• The provider must ensure that staff receive training appropriate for this service type, at a level that is appropriate to their role. This includes training in safeguarding adults and children.
• The provider must ensure that staff have completed medicines training, at a level appropriate to their role and they are deemed competent to carry out this role.
• The provider must ensure that staff receive competency assessments appropriate to their role, in a timely manner, and that the provider has clear oversight of this.
• The provider must ensure that key policies and procedures are in place and have been read and understood by all staff.
• The provider must ensure they document, investigate, and mitigate medicines incidents and have oversight of this.
• The provider must ensure that the service is compliant with the Fire Safety Order 2005.
• The provider must ensure that clients have comprehensive risk assessments in place, with appropriate support in place to mitigate any risks.
• The provider must ensure that all information on previous admissions is recorded.
• The provider must ensure that the service has assessments, policies and processes in place to manage and mitigate risks around mixed sex accommodation and sexual safety.
• The provider must ensure that the environment is regularly reviewed, to identify and manage ligature risks, in the event that a client does express self-harm or suicidal ideation when at the service.
• The provider must ensure that clients who present with self-harm or suicidal ideation, are referred to appropriate services.
• The provider must ensure that clients have appropriate care plans in place, which detail recovery, harm reduction and goals.
• The provider must ensure that every incident is recorded, investigated and that proportionate action is taken in response to any failure identified in the incident.
• The provider must ensure that clients have discharge and aftercare plans in place, that are co-produced.
• The provider must ensure that staff receive supervision and appraisal appropriate to their role, in a timely manner and that they have clear oversight of this.
• The provider must ensure that all restrictions are detailed in the client's treatment agreement.
• The provider must ensure that all notifications required, are made to CQC without delay.
• The provider must ensure that their standard operating procedure is up to date and reflects the current model of care and core staff team, delivered at the service.
• The provider must ensure that staff receive food hygiene and food safety training, at a level appropriate to their role.
• The provider must improve the offering of food, to ensure it is of good quality, healthy and varied; and that clients are included in the menu planning and preparing of meals where risks allow.
• The provider must consider how clients can be supported to life healthy lives, by providing more opportunities for physical exercise.
• The provider must ensure the service has clear outcomes measures to ascertain successful treatment.
• The provider must ensure that staff receive and keep up to date with training on the Mental Capacity Act, at a level appropriate to their role.
• The provider must consider alternative hand sanitisers, that are alcohol free.