TLC Rehab

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence on how the service provided safe care and treatment, and evidence that people were protected from abuse and avoidable harm. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. We found breaches of regulation in relation to this key question.

The service did not provide safe care. Incidents were not reported or investigated thoroughly, and the service did not take proportionate actions in response to the incidents or share lessons learned. There service did not have a clear model of care, and the standard operating procedure was not up-to-date. There was no inclusion or exclusion criteria, and clients who should have been excluded, for example as they had a history of seizures, had been inappropriately admitted. The service did not have key policies and procedures in place to keep clients safe. Some staff had not received training in safeguarding that was of a level appropriate to their role. The service had not made any safeguarding referrals since they registered, and we found multiple safeguarding incidents that were reportable. The service had some blanket restrictions in place that were not clearly documented including restricted kitchen access. The service did not manage all risks to patients, specifically risks relating to seizures, self- harm and sexual safety. All clients had basic plans around unexpected exits, motivation to change and recovery. The service did not sufficiently monitor and mitigate risks around the security of the premises. The service had not carried out safety checks on any fire safety equipment. The service had a lack of oversight of several staffing areas, including safe recruitment processes, staff training, supervision and appraisal. The service was visibly clean, well-decorated, had good furnishings and was broadly fit for purpose. The service did not ensure that staff were competent in medicines administration, and did not monitor or safely mitigate against medicines incidents.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated, reported thoroughly, and lessons learned to continually identify and embed good practices.

Staff did not know which incidents to report and how to report them comprehensively. Since the service was registered in September 2024, staff at the service had recorded 19 incidents. Most incidents reported were not detailed comprehensively or were missing important details. This included missing client and staff names. This was in addition to the incident log itself missing key categories for staff to record information under, such as severity or impact, immediate actions taken, if a debrief was offered, and investigation details. Incidents included medicines, falls and injury, and the facilities. However, most incidents were categorised as ‘other’, although they could be related to a specific category. There was also no evidence of actions taken, comprehensive investigations taking place, and lessons learned, and learning identified was not proportionate to the severity of the incidents.

The service did not record all incidents that staff had reported. Staff told us about incidents that were not recorded on the incident log, that had been escalated to senior leaders. For example, staff told us that about a serious incident, that was not recorded on the incident log which involved a client discharging herself from the service unexpectedly overnight which subsequently resulted in her breaking a limb and injuring her eye. A fob system on the front door was implemented because of this, but neither the incident or actions taken were recorded on the incident log by the staff member or senior leader who was notified or who investigated the incident.

Staff did not receive feedback from the investigation of incidents, both internal and external to the service. We spoke with staff about incidents and reviewed the last three team meeting minutes. There was no evidence that staff received feedback from incidents, specifically medicines incidents, and all staff support medicines administration, including counsellors. Additionally, there was no evidence that changes had been made because of recorded incidents, thus no mitigations were put in place to protect clients from further harm. This placed clients at risk of avoidable harm from identified risks in past incidents which were not responded to and mitigated against.

Staff and clients were not debriefed after an incident. We saw no evidence that staff and clients had received a verbal or written debrief following any incident.

The service did not establish and maintain safe systems of care, in which safety is managed, monitored and assured. The service did not ensure continuity of care, including when people move between different services.

The service received referrals from self-funded clients.There was no clear inclusion and exclusion admissions criteria or evidence of this being considered against each referral. For example, we saw one client who had been admitted to the service who was not undergoing a detoxification, and who did not have a history of substance misuse. They told us that they were not attending the substance misuse related therapy sessions, as it was not appropriate for them. We saw a second client had been residing at the service for 3 months, but there was no evidence for why they were still at the service. Senior leaders were not aware of these factors.

In most records, we saw that staff received all essential information about the client to determine if the client’s needs could safely be met. However, in the record for 1 client, there was no GP summary. For another, there was no information about a previous admission for detox at a service outside the UK, apart from the fact it took place. This could place the client at risk of avoidable harm as there is no information on the effectiveness or concerns about previous treatment or their responses to it. Details on previous admissions are important in understanding the client’s previous and current risks, and whether they have met any of the service’s exclusion criteria such as seizures.

For one patient, we saw they had been admitted for care, despite having a history of seizures. This meant the client was at serious risk of not receiving the level of care needed, in relation to this risk.

The service did not have a clear model of care. The standard operating procedure (SOP) submitted for the registration of this service, notes a doctor is part of the core staff group, which for substance misuse services indicates a ‘medically managed’ model of care. However, during the inspection, we found this is not the case, and private prescribing doctors are used as and when required, and that 24-hour nursing is in place instead. This would indicate a ‘medially monitored’ model of care. The provider must ensure that their SOP is up to date and reflects the current model of care delivered at the service.

There were minimal policies and procedures for this type of service, and they were stored inconsistently both as paper and electronic versions. There were 26 in total. There were no key policies and procedures in place in relation to, but not limited to, Health and safety; Whistleblowing; Equality, Diversity and Inclusion; Self-harm and suicide prevention; Business continuity plan; Fire safety and emergency evacuation; First aid; The General Data Protection Regulation (GDPR), Confidentiality and data protection; Training and development; and Code of conducts for staff and clients. Furthermore, there was no assurance that staff had read, understood and followed the existing policies and procedures, as a read and sign sheet was completed by only 1 member of staff for 13 of the paper policies.

The service did not ensure that clients were only discharged if they had a discharge or aftercare plan in place. There were no comprehensive discharge plans in place for clients, and the aftercare tab on the electronic system was blank, including that of a client who was being discharged the following day. We did not see evidence of a collaborative approach to discharge or transfer, where the views of clients, their relatives and relevant professionals were considered. Multiple clients had returned to the service following a period of care and treatment. It was unclear what outcomes measures were used following the end of their first admission, to subsequently result in them being readmitted.

Most staff received training in safeguarding children and adults (Level 1 and 2); however, the training matrix did not indicate when staff completed the courses or when training was due to renewal. We did not see any evidence that the Registered Manager and Nominated Individual had completed any training in safeguarding. Senior leaders must complete safeguarding training that is of a level appropriate to their role.

Staff had a lack of knowledge of safeguarding, including the identification of what is a safeguarding incident and safeguarding pathways throughout the service. Additionally, one senior leader was unsure whether there was a safeguarding adult’s policy, and whether it existed in an electronic version only. There was an electronic version of a safeguarding adult’s policy, but no evidence that staff had read or understood it.

Since registration in September 2024, no safeguarding referrals had been made. Senior leaders were not aware and did not report all safeguarding incidents to external bodies, such as the local authority and CQC. We found multiple safeguarding incidents, that had not been reported to the local authority or CQC. For example, one client had some concerns noted about being under the influence of alcohol, whilst looking after their child at home, without another responsible adult present. Senior leaders were unaware that this should be raised as a safeguarding alert.

Staff followed safe procedures for children visiting the service. No one under the age of 18 was allowed to visit the service.

Use of restrictive interventions

Since the service registered in September 2024, there had been no incidents of restrictive interventions, including oral medicines, rapid tranquilisation, physical interventions or restraint.

Senior leaders told us the service had no blanket restrictions. However, we saw that some blanket restrictions were in place. Some of the restrictions were included in the client’s treatment agreement. These included restrictions on visitors and restrictions around unescorted community access. Clients were required to agree to these restrictions as part of their treatment agreement. However, we also observed the front door was locked, which was accessible by a fob that only staff had access to. The client treatment agreement did not detail that this was a locked residential service. There were also prohibited items, but these were not clearly documented in the admission pack or throughout the service. We could not see evidence that restrictions or prohibited items were discussed, as the service did not hold community meetings and there was no signage to detail the restrictions in place or explanations to why. The service had outside space that clients could access without restriction.

The service did not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We reviewed the care records for all 7 clients' residing at the service. Staff completed a variety of risk assessments for most clients on admission, and these were up to date. These included an overall risk assessment, drug/alcohol assessment, physical health assessment and mental health assessment. However, all clients had very brief plans around unexpected exits, motivation to change, harm reduction advice, recovery and aftercare. For example, recovery plans were separated for medical, nursing and therapy, and all located in a different part of the care record. None of the recovery plans referenced recovery, or short to long term goals and steps to reach these goals. We saw a tab on the electronic record system called aftercare; however, we found no records on aftercare or discharge here for any of the 7 clients, and one client was leaving the next day.

For one client, we saw key pieces of information missing from multiple assessments, which could have resulted in avoidable harm. For example, in their mental health assessment, it stated that the client had been hospitalised for 2 days in the last month due to seizures. Staff had not updated the risk assessment and guidance around the frequency of observations, or any other mitigations to ensure they remained safe during any potential seizures. Additionally, due to an incident, care notes stated that this client has a noted preference for reacting more negatively to male staff than female staff. Guidance around how staff would reduce incidents and risks towards male clients or male staff was not assessed or documented. Furthermore, the urine toxicology report stated an elicit substance was found in their system. However, this was not referenced in the medical assessment, nursing notes or treatment plan. There was no GP summary on file for this client.

The service had a lack of knowledge and management of risks relating to mixed-sex accommodation and sexual safety. Although bedrooms were ensuite, the service did not have gender specific lounges or female only corridors. There was no mixed-sex accommodation or sexual safety policies and procedures in place. We found two incidents which required the service to actively manage sexual safety risks. For example, following an incident, one client was advised to have contact with females only. Secondly, one client was admitted with a pending allegation of sexual assault, and no risk assessment was in place to ensure the safety of clients and staff, and most senior leaders were unaware of this risk when we raised it with them.

The service admission pack signposted clients on how they could provide feedback on their care, complaints or compliments to the service. The service did not hold a community meeting where clients could provide feedback regularly.

The service employed an advocacy service that clients could access, although information about this and how to access it was only available in the admission packs, rather than on posters throughout the service.

The service did not detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

The service consisted of 6 single rooms, and 2 double occupancy rooms, all with en-suite bathrooms. Clients had access to an outdoor space, a shared lounge, a dining area and meeting rooms. Although the garden was large, accessible and used for informal activities, many clients told us that it was bare and lacked dedicated therapeutic facilities such as equipment to carry out physical exercise. However, clients told us there had been positive discussions with senior leaders about the development of an on-site gym.

The service did not sufficiently monitor and manage environmental risks. The service had completed an environmental risk assessment in April 2024, prior to its registration. This identified most hazard areas such as infection control, fire, falls, food safety and Control of Substances Hazardous to Health (COSHH). However, the risk assessment did not include ligatures, and we observed potential ligature anchor points through the service. Although the service stated it did not admit services users with suicide risks, some clients had previous attempts of self-harm, and it was documented in a handover document that a client had suicidal ideation.

The service did not sufficiently monitor and mitigate risks around the security of the premises. The environmental risk assessment did not include the security of the premises. Although there was CCTV in place to maintain visibility of communal spaces inside and some external spaces, there was not always a member of staff observing the live CCTV footage. We observed that the service was not secure from members of the public and the neighbouring service.The service is based next to another service supporting vulnerable young people. Part of this neighbouring property is based in the provider’s garden. There were three ground floor windows of this neighbouring service that clients from each service could access, posing significant risks to clients in both services. Additionally, TLC rehab clients had ash trays resting on these windowsills, which could be a fire risk. Some of the fence between the two services was low and made of weak bamboo which could be climbed or removed by clients in either service. The back door was not always locked overnight. The service did not have a front gate and had two ground floor front facing bedrooms with windows that could be opened wide enough for items to be passed through.

Additionally, mitigations detailed throughout the environmental assessment were not appropriate or were not carried out in practice. For example, the COSHH assessment stated that cleaning products should be stored in the counselling room drawers. There was no secure or fire-resistant cupboard that was suitable to store cleaning products, and we saw cleaning products, including 70% alcohol-based substances, stacked on the floors of the office. This may pose a risk for clients with addiction histories and should be reviewed as there are effective non-alcohol-based alternatives. There were also large packs of cleaning products which were not stored safely to prevent combustion if there was a fire in the office. This was of particular concern as we found the service to be non-compliant with the Fire Safety Order 2005. The fire safety logbook was blank, and the registered manager confirmed there had been no fire safety checks for the service since registration. This meant that none of the fire alarms, smoke detectors, call points, fire doors, emergency lighting or firefighting equipment, had been tested since the service opened in September 2024. There were no personal emergency evacuation plans (PEEPS) in place to support clients who would require supporting during an emergency evacuation, particularly those in the early stages of their detox regime. Fire safety measures were installed, as required for registration, but staff were unaware of how to test it and did not have appropriate tools or knowledge to test it whilst we were on-site. Audits around fire equipment noted incorrectly, that equipment was in working order. We were legally obligated to notify the London Fire Brigade who attended on-site to ensure the service was safe overnight. A comprehensive fire inspection is scheduled to be conducted by the London Fire Brigade, in the near future.

Staff did not have access to alarms to alert colleagues to an emergency and clients had a nurse call system fitted in their bedrooms which were no longer in use. Clients told us they were not sure what the call system was for, and they weren’t sure it worked. The provider should consider removing the unused nurse call system and fitting a suitable system for clients to notify staff in the event of an emergency.

The service had enough staff to support patients. However, they did not receive effective support, supervision and development.

The service had sufficient nursing and support staff to meet the needs of the clients. At the time of our inspection, TLC Rehab had capacity for 10 clients. Managers had calculated the number of nurses and health care assistants required. The staffing establishment was complete, with 24- hour nursing in place. Clients reported that staff were generally available, approachable and responsive to their needs. Clients told us that staffing levels allowed clients to have regular time with staff, including most activities.

The core staff group as detailed in the service’s statement of purpose did not match the core staffing group working in the service. The statement of purpose, which is used to register a service with CQC, stated that a doctor was part of the core staff team, indicating a medically managed service. Senior leaders told us that Doctors used were paid as and when required, and did not form part of the daily staffing mix. The service was managed by 24/7 nursing instead, indicating a medically monitored type of service.

The service had no vacancies. However, the service was using two agency nurses regularly. There was no evidence if these agency staff received an induction, appropriate HR checks or appropriate competency assessments, such as a medicine’s competency assessment. We were aware that one of these nurses was currently barred from future shifts at the service following a medicines incident. We saw no evidence that these nurses had a staff folder at the service.

The service had a lack of oversight of several staffing areas. These included safe staff recruitment processes, staff training, staff supervision and appraisal. Some staff only had 1 of 2 required references, references only from friends rather than employers, 1 of 2 required forms of identification and qualification certificates in different languages that had not been translated by the service.

There was no staff training matrix to have oversight of what training had been completed, and which staff still had training outstanding. There was minimal evidence of supervision, however leaders told us this happened three monthly. There were no competency assessments for staff duties appropriate to their role. Staff records were documented both in paper form and electronic forms, but the information on each did not match up.

The service assessed and managed the risk of infection, detect and control the risk of it spreading.

The service was visibly clean, well-decorated, had good furnishings and was broadly fit for purpose. External cleaners attended the service three times a week and cleaning records were up to date; however not all cleaning records were dated. Support staff completed daily cleaning tasks, however some high foot-fall areas such as the communal stairs had gathered a lot of dirt from outside. Client’s laundry was carried out by staff.

Most staff had completed infection prevention and control training, however there were no completion dates. The service followed infection control policy, including handwashing. However, we observed 70% alcohol-based hand sanitiser, which could cause problems for those with addiction problems.

Food was cooked by an employed chef; however, we observed that staff were involved with the handling of food and not all staff had completed food hygiene and food safety training.

We saw that food was stored in line with food safety standards. The service had allergy stickers, food date stickers, and guidance on safe storage was present on the kitchen walls. The kitchen had restricted access, but the clients had a fridge and microwave in the communal dining area.

The service did not ensure that medicines and treatments were safe and met people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

Staff were not competent or suitably trained in the provider's policy of medicines management. There was no evidence that staff had read, understood or follow the provider's `Medicines Management Policy'. The paper and electronic versions of the policy had a `read and sign' sheet at the front, which no staff members had signed. There was no evidence that staff had completed medicines competency assessments. There were no medicines competency assessments for any staff in their paper based or electronic staff folders. On the day of inspection, we also found no evidence that staff had completed medicines training. Following the inspection, on review of the staff training matrix, it details that all staff apart from the nominated individual have completed online medicines training, but there are no dates of completion, thus we cannot verify that this information is correct. Additionally, staff told us that the nominated individual was the authorised staff member to transport controlled drugs to and from the service and community pharmacy, however he had not completed any medicines training.

The service did not monitor and mitigate medicines incidents. We saw evidence of multiple medicines errors due to staff incompetencies. For example, on 29/12/24, an unnamed client was administered their medication on the wrong date. On 29/03/25, Client A was given the wrong dose of the medicine Diazepam on two occasions. The contributing factor was listed as `nurse not reading the prescribed dose on the box'. The following day, on 30/03/25, a nurse carried out the administration of a schedule 3 controlled drug for Client A, without a second member of staff present, which was not in line with the provider's Medicines Management Policy.

Medicines errors were not comprehensively documented, thoroughly investigated, and actions were not taken to prevent a future occurrence. We reviewed the service's incident log which detailed 7 medicines errors between November 2024 to the date of the inspection. None of these 7 medicines incidents evidenced that an investigation took place, any investigation outcomes, or changes made to prevent a future occurrence. For example, on 29/12/24, a medicine error listed does not detail the client's name, staff name, the medicine name or dose, or any learning, which it should have done. Another example, on 24/01/25, a medicines error listed states that the client's prescription had run out. It does not state what the medicine/s were or what action was taken following this. On 10/04/24, two separate medicines incidents, for two separate clients, do not detail staff names, the medicines name or dose. The learning listed is `more training required' but does not state any details around which staff would require additional training, when it would be, or any further action to prevent this occurring again.

Leaders had no oversight to ensure the proper and safe management of medicines, and identified risks were not managed appropriately. The service stated they carried out monthly medicine's audits. During our inspection we found only 1 monthly medicines audit, carried out on 26/2/25, had been completed since the service was registered in September 2024. The medicines incident log dated, 24/01/25, states that an action would be to carry out a medicines audit to prevent future incidents. We found no evidence that this audit took place shortly after the incident to ensure concerns raised were mitigated in a timely manner.

The provider did not have systems in place to share learning from medicines related incidences to prevent the reoccurrence of medicines related errors. We reviewed three team meeting minutes for January, February and March 2025. Although incidents were a regular agenda item in staff meetings, there was no evidence that learning from medicines-related incidents was discussed or shared with staff. Most staff we spoke with who are involved in medicines administration, were also unaware of recent medicines incidents in the service.

However, medicines and controlled stationary were stored securely when not in use and the clinic room was clean and orderly. When prescriptions were written by the prescribing doctors, they were sent electronically to the pharmacy to be dispensed. A copy of the original prescription was posted or taken in by hand to the pharmacy when staff collected the medicine. Staff scanned and added the prescription to the client's medical record. When private pink CD prescriptions were used by the prescribing doctors, the doctors kept their own records of their use including serials number of the prescriptions. The service did not have oversight of this.

Staff could access some emergency medicines easily and these were checked regularly. We saw 4 naloxone injections stored in the CD cupboard. Additionally, only the registered manager had received training in naloxone. However, the service noted that if a client required emergency medical attention, the service would call for an ambulance or the client would be supported to attend the local accident and emergency centre.

Consent was gained from people to access people's relevant medical history prior to the provision of prescriptions or medicines and information was routinely shared with people's regular GP. We found a GP summary on file for 6 of 7 clients. Medical staff stated that nursing staff kept people's medicines related care notes up to date and contacted the doctors to discuss the progress of each client. Staff stated that formal MDTs were not carried out, however all prescribers communicated with each other regularly via email.