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.

The concerns that we found in April 2025 had not been sufficiently addressed and remained in place.

Most clients received responsive care and treatment that met their needs. However, we saw limited evidence that the service had considered personal preferences, interests or wishes. The service provided accessible information on the service and had made some improvements to information provided, but had not improved how information about the locked door and restricted kitchen access was shared with patients. Clients knew how to raise concerns, however the service monitored complaints poorly. The service did not consistently hold community meetings, which clients had previously requested. Discharge documentation was not structured, clear and easy to locate.

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 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.

In the care records we looked at, we saw a variation in how personalised records were. We saw some examples where records were personalised and reflected the client’s personal preferences or wishes. For example, personalised treatment goals written clearly. We saw others where more personalised information would have supported better care. For example, more information about personal triggers and how staff could respond to these.

Two chefs worked at the service and delivered a different meal plan each week. They could amend the menu if requested. They were able to cater for different dietary needs and had clear information about allergies.

Staff supported clients to maintain contact with their families and carers. Clients were able to communicate via their mobile phones and laptops.

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 other stakeholders to ensure clients would receive joined-up care.

Staff provided clients general information on the service and activities through a welcome pack and notice boards throughout the service. This information was presented in standard English, but staff could source this in other languages or formats if needed. Since the April 2025 assessment, the service had updated the client information pack to include information about keys to bedrooms and safe spaces for possessions.

Staff had access to the equipment and information technology needed to do their work.

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 complaints procedure. We saw the complaints procedure on the noticeboard and in the admissions pack.

In April 2025, we found poor monitoring and investigation of complaints. During this inspection we found this had not improved. Senior leaders told us that there had been no complaints since April 2025 and there were none on the complaints log. However, in other documentation relating to patient care, we saw references to patient complaints. Some of these complaints referred to staff conduct and patients feeling unsafe. One member of staff told us patients had complained to them about aspects of their care recently, and this had not been recorded as a formal complaint by senior staff.

We found no evidence that clients or staff received feedback on the outcome of investigations of complaints and acted on the findings.

The service had a website with clear information about what it offered and how to make a self-referral, but it did not have clear procedures for staff to follow when the service could not meet someone's needs. For example, what information to share about why their needs could not be met and alternative pathways or services. Senior leaders confirmed they did not record data about referrals it could not accept, and were not able to describe what information would be given to these people to advise on alternative pathways or services. For clients that had been accepted, they were able to access the service in a timescale that suited them.

The service was not proactive in collecting information about the community it serviced, in order to improve access for marginalised groups.

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.

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

Concerns identified in April 2025 remained.

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 wanted, in order to discuss key topics such as the environment and food choices. The service had decided not to implement these more frequently since April 2025, despite receiving this feedback.

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 actively support people to understand and make decisions about their future care and support, including those relating to potential medical and psychological needs.

Concerns relating to this area identified in April 2025 remained. The service could not provide evidence that the actions required in their action plan had been done.

Most clients records we reviewed did not have clear discharge plans in place. There was no clear evidence that the team working collaboratively with clients and their carers when planning for each client’s discharge and return to their local area.