TLC Rehab

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service did not have a clear vision; it was a specialised substance misuse service, but had admitted clients who did not need this service. Leaders did not demonstrate the knowledge, skills and experience needed to deliver services effectively. Leaders had overlooked multiple areas of fundamental standards, including policies and procedures, fire safety, staff supervision and training, risk management of clients and the management of incidents. Senior leaders did not have a clear understanding, oversight or proactive governance framework. The service had no collaboration with other agencies.

This service scored 32 (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 shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

This is the first inspection of the service since it registered in September 2024. The service did not have a clear vision, direction or culture. The service stated it was a specialised substance misuse rehabilitation service, specialising in detox, but had admitted clients who did not require a detox.

The provider’s senior leadership team had not successfully communicated the provider’s vision and values to the frontline staff in this service. Team meetings did not have an agenda item, or document any discussion about visions, values or strategy. Staff did not have the opportunity to contribute to discussions about the strategy for the service, especially where the service was changing. Staff told us that during the inspection a senior leader told them that they were planning to expand the service. Staff told us they had not heard this before and were not clear how the service could be expanded.

Although senior staff described providing a non 12 step programme for substance misuse, staff could not clearly describe what this meant and how the care delivered was in line with this approach.

Leaders did not demonstrate the knowledge, skills and experience needed to deliver services effectively.

The service had four senior leaders which included three Directors; the Registered Manager, Nominated Individual and Company Director, and a Quality Assurance Consultant. Directors did not all have the appropriate qualifications, competence, skills and experience which were necessary for their role. Senior leaders had overlooked or were unaware of multiple areas of fundamental standards. This included policies and procedures, fire safety, staff supervision, and the management of incidents, especially medicines incidents. Senior leaders had not been aware that there were shortfalls in the service regarding safe recruitment processes for staff, risk management for clients, and discharge planning. However, clients and staff did state that the senior leaders worked hard and were approachable.

We informed the provider of our serious concerns during and immediately after this inspection. 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 leadership of the service. The provider sent us an action plan to address our concerns, and to provide assurances of how the risks identified have already been removed or are immediately being removed within a certain timeframe. Since our inspection, the provider has advertised for a new Registered Manager. We will re-inspect this service in the near future to ensure the changes have been implemented.

The service did not create a positive culture where people feel that they can speak up and that their voice will be heard.

Staff said they felt confident in raising concerns about poor professional practice or inappropriate conduct, however, there were insufficient policies or practice in place to support this appropriately. The service did not have a whistleblowing policy in place, or equivalent. The service did not have a Freedom to Speak Up Guardian. The pathway for managing staff concerns was not documented well, clearly investigated, or evidenced that feedback was provided to staff about the outcome or lessons learned.

Additionally, we saw evidence that staff had reported to senior leaders around concerns around admissions happening all at one time, as they could be distracting to staff at key points of the day such as medicine’s administration time but saw no evidence that senior leaders were putting processes in place to ensure this occurred.

The service did not always value diversity in their workforce. The service did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were no key policies and procedures in place in relation to Equality, Diversity and Inclusion. There were no equality and diversity champions within the service e.g. LGBT+, BME etc.

There was no evidence about whether staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. We did not see evidence of managers putting reasonable adjustments in place for staff members to help them carry out their role.

The service employed a diverse team of staff from international backgrounds. Staff did not raise any concerns about discrimination.

The service did not have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

Senior leaders did not have a clear understanding, oversight or embedded governance systems for the service. This included the model of care, client risks, policies and procedures, managing mixed-sex accommodation, safeguarding, incidents, complaints, risk management, maintaining a safe and secure environment, fire safety, safe staff recruitment, staff training, supervision, and medicines management.

The service did not carry out any governance meetings. There was only a monthly team meeting, which followed a basic agenda and did not share any data on the service or lessons learned from incidents or complaints raised by clients or staff from the previous month. We found no evidence that lessons learned were shared with staff efficiently or that senior leaders had implemented recommendations. For example, all staff support medicines administration, but some staff we spoke to were unaware of the multiple medicines incidents that have occurred in the service, which also involved controlled drugs.

The service did not have a risk register. We identified multiple areas of risk for the service, including, but not limited to, compliance with fire regulations, risk management of clients, mixed-sex accommodation, staff supervision and training, and policies and procedures.

The service did not have plans for emergencies. The service did not have a business continuity plan in place to cover eventualities such as adverse weather or a flu outbreak. The service did not have personal emergency evacuation plans (PEEPS) for clients in the event of a fire.

Staff did not undertake appropriate audits to ensure safe and quality care was being provided. Audits that did take place, were not carried out at the required frequency or correctly. For example, only one monthly medicines audit had taken place in the 8 months since the service had been registered, but there were multiple medicines incidents. The weekly health and safety audit had identified that fire safety equipment and processes were in place, but the service had not conducted one fire safety check since the service registered. Thus, the audits were not sufficient to provide assurance to senior leaders, and there was no evidence that senior leaders had acted on any results when needed.

Senior leaders did not have access to information to support them with their management role. This included information on the performance of the service, staffing and client care.

Staff could not explain how they were working to deliver care and treatment within the client’s cost of care and treatment. For example, the service advertises free aftercare group sessions, as part of any admission cost. However, staff told us that some counsellors work privately outside of the service, and that sometimes clients continue working with those counsellors after they have left the service. Senior leaders told us this is booked and paid directly to TLC rehab, who then pays the counselling staff. It is unclear how this is arranged, if this is part of the aftercare package, and if not, why payment goes through TLC Rehab, instead of directly to the counsellors.

The service did not understand their duty to collaborate and work in partnership. The service did not share information and learning with partners and collaborate for improvement.

The service did not work well with other agencies such as health and social care professionals and the local authority safeguarding team. Since the service registered it has not made any safeguarding referrals to the local authority, despite there being a need to. We also saw clients who would benefit from alternative placements due to the primary concern for treatment not being related to substance misuse, but poor mental health. The provider should consider how they will collaborate with key agencies to discuss their inspection action plan, progress that has been made, and any remaining actions.

Clients and staff told us that they could meet with members of the provider’s senior leadership team to give feedback. However, we saw poor evidence of monitoring and investigating feedback and updating clients and staff with the outcomes or lessons learned.

The service did not focus on continuous learning, innovation and improvement.

There was one quality improvement (QI) project in the service. This was around implementing the not 12-step model approach to addiction. However, the service had been open for 8 months, and the model of care was still not clear or embedded.

The service did not share lessons learnt with staff or implement actions following incidents.

Staff have not participated in national audits relevant to the service.

The service has not participated in accreditation schemes relevant to the service.