- Residential substance misuse service
TLC Rehab
Assessment report published 16 January 2026
Contents
Ratings - Residential substance misuse services
Our view of the service
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.
People's experience of this service
As this inspection focused on the completion of the service action plan, no clients were directly interviewed as part of this inspection. The service shared client feedback they had collected, which described a positive experience at the service.
During and after the inspection, the service shared client feedback they had collected, which described a positive experience at the service. The service had collected 28 client feedback forms between April 2025 and July 2025 and all rated the service as good or outstanding across the questionnaire domains of safe, effective, caring, responsive and well-led care.