TLC Rehab

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.