TLC Rehab

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people's needs. This key question has been rated requires improvement. This meant people's needs were not always met. We found breaches of regulation in relation to this key question.

Most clients received responsive care and treatment that met their needs. However, we saw no evidence that the service had considered personal preferences, interests or wishes. Some clients had sexual safety concerns around mixed sex accommodation and the service did not put in place appropriate mitigations. Staff supported clients to maintain contact with relatives. The service provided accessible information on the service, however there was no information on blanket restrictions. Senior leaders did not make all notifications to external bodies as required. Clients knew how to raise concerns, however the service poorly monitored complaints received. The service did not consistently hold community meetings, which clients requested. The service did not ensure clients had a discharge or aftercare plan in place.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The service did not always make sure people were at the centre of their care and treatment choices and did not always decide, in partnership with them, how to respond to any relevant changes in their needs.

Most clients received responsive care and support that met their needs. For example, clients received an appropriate detox regime, one-to-one counselling and some psychosocial groups. However, one client did not meet the service’s inclusion criteria, was not undergoing a detox, or attending most of the psychosocial groups, and was experiencing mental health concerns, which was not best met by this service. Additionally, two clients had sexual safety concerns around mixed sex accommodation, but they still resided at the service with no mitigations in place. We also found no evidence in care records that care was personalised or that it reflected the client’s personal preferences or wishes.

The therapy and nursing team met with clients to understand their views on care and treatment. These discussions took place in their one-to-one meetings. Staff monitored clients’ conditions and discussed any changes at handover meetings.

Quality Statement Score: 2

Staff supported clients to maintain contact with their families and carers. Clients were able to communicate via their mobile phones and laptops. Clients told us that their family and relatives were able to visit, according to the service’s visitor’s policy.

The service did not provide clients with information about or access to education and work opportunities as part of their care and treatment at the service, or as part of their discharge plan.

The service did not join up with other services to ensure continuity in people’s care and treatment. We saw no evidence that the service had made referrals to mental health services, or the local authority to ensure clients would receive joined-up care.

The service did not always provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs or make required notifications to external bodies, such as CQC.

Staff made sure clients could access information on the service and activities. This was provided in the welcome pack and notice boards throughout the service. This information was presented in standard English. However, there wasn't information displayed on blanket restrictions such as restricted kitchen access.

Staff had access to the equipment and information technology needed to do their work. However, the office was based on the third floor and was not accessible by the service's lift, making access difficult for staff with mobility needs. There was no policy in place around information governance, to ensure that systems and processes followed policy regarding the confidentiality of client records.

Senior leaders did not have access to information to support them with their management role. There were no clinical governance meetings. There were no performance indicators of the service, staffing and client care.

Senior leaders did not make all notifications to external bodies as required. The service did not submit all notifications to the Care Quality Commission (CQC) in accordance with the requirements of their registration. The service had not submitted any safeguarding referrals to the local authority. We saw multiple safeguarding incidents that were not reported to the local authority or CQC. Additionally, we saw medicines incidents that were not reported to CQC.

The service did not always make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support and receive an appropriate response.

Clients knew how to complain or raise concerns and had access to the complaint’s procedure. We saw the complaints procedure on the noticeboard and in the admissions pack.

Since the service registered in September 2024, the service had recorded 10 complaints. However, we found poor monitoring of complaints. The complaint log did not contain all required categories, such as response timeframe, or lessons learned. Complaint logs were not logged in detail, and there was no record for September- November 2024. In one complaint, which was also received to CQC, we saw that the provider had not investigated the listed areas of concern and had not responded sufficiently to the complainant. The provider had deemed the complaint as ‘not upheld’, but there was no evidence the areas outlined had been examined, as they should have been. The provider did not log specific details, detail how the complaint was investigated and how or what part was found to not be upheld.

We found no evidence that clients or staff received feedback on the outcome of investigations of complaints and acted on the findings. For example, 5 complaints related to poor quality food, which span from October 2024 to February 2025. Most of the outcome’s state, hire a new chef, but there are no details to indicate that the provider has acted on this.

The service environment met the accessibility needs of its current clients. The service was based across three floors. The service had a lift to ensure clients with mobility issues could have equity in access. The service had multiple ground floor bedrooms if required. However, the top floor was not accessible by the lift, and this is where clients caried out their urine tests. Staff told us that urine tests would take place in another part of the service if a client had mobility impairments preventing them from using stairs.

The service had nursing care 24/7. The service utilised a private doctor as and when required. In the event of an emergency, clients would be required to attend the emergency department at a hospital that was within a reasonable travelling distance.

The service did not actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes.

Staff within the service did not always promote a culture in which the people using the service felt empowered to give their views. The service held inconsistent community meetings, which clients stated they required to discuss key topics such as the environment and food choices. Clients did not have a regular session with a keyworker.

The provider had not undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were not trained in equality, diversity, inclusion and human rights (EDIHR) and the service had no policy in relation to EDIHR.

The service did not support people to plan for important life changes, so they can have enough time to make informed decisions about their future.

Clients were not supported to understand and make decisions about their future care and support, including those relating to potential medical and psychological needs. There were no discharge plans in place for any of the clients residing at the service, including a client who was being discharged the following day. We did not see evidence of the team working collaboratively with clients and their carers when planning for each client’s discharge and return to their local area. We found no evidence that staff liaised with other services or evidence that appropriate arrangements were in place to sustain the client’s abstinence from substance or to maintain good mental health.