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. The concerns that we found in April 2025 had not been sufficiently addressed and remained in place. We found breaches of regulation in relation to this key question.

Clients had been admitted without full information from the GP and medical history, which is not best practice, and several clients had been admitted to hospital with deteriorating health needs. Incidents were not reported or investigated thoroughly, and the service did not take proportionate actions in response to the incidents or share lessons learned. Our concerns around medicines management had not been addressed and we saw some of these concerns repeated, which indicated no learning had taken place. The service had a lack of oversight of several staffing areas, including staff training and supervision.

We have not awarded this service a score for Safe.

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

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.

During our assessment in April 2025, we found concerns under this quality statement. During this inspection, we found that most concerns had not been addressed, although a small number of areas were improved.

During this inspection we found that staff could explain what incidents to report. Staff were required to notify senior leaders of incidents, who were then responsible for recording them in an incident log and carrying out any necessary investigations. We found a delay in the recording of and investigation of multiple incidents, a lack of urgency to implement mitigations to risks, and a lack of support for the clients around the incidents. For example, there had been an incident in the previous weeks involving a young person from next door accessing the garden and attempting to sell drugs to the clients. Clients stated that this impacted their well-being. Senior leaders had not included this incident in the log, no investigation had taken place, and no immediate mitigations were made to reduce further avoidable harm or to support clients. These concerns around the security of the premises from the neighbouring service were raised during our inspection in April 2025 and the provider outlined actions they planned to take by July 2025, but these had not been actioned.

Since our assessment in April 2025, the service had made improvements to the format of its incident log. However, it was still missing key sections, such as if a debrief was offered to clients and staff and any investigation details. The categories for incidents were not as clear as they could be, and several incidents were classed as ‘other’, which made analysis of themes harder. Since April 2025, the service had recorded 8 incidents. Of those, 2 were classed as ‘accident or illness requiring hospital treatment’, and 6 were classed as ‘other’. Three of these were related to falls, 1 was related to physical health concerns requiring hospital treatment, and 1 incident was related to security of the premises. We saw no evidence that staff and clients had received a verbal or written debrief following any incident. No incidents listed were noted to have had investigations, and there were no investigation reports available. We saw some evidence of lessons learned from certain incidents being discussed in team meeting minutes, but it was not clear what specific changes or improvements staff were required to make, or how the service would put in place mitigations 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.

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.

During our assessment in April 2025, we found concerns under this quality statement. These concerns remained during this assessment.

The service received referrals from self-funded clients. The service’s referral and admission process did not always ensure that essential information about the client was received and assessed to determine if the client’s needs could safely be met by the service. We saw records of 5 clients who had been admitted without their GP summary and examples where medicines had been prescribed without this GP summary being available. Some of these clients went on to have hospital admissions due to physical health deterioration. In the records we looked at, since April 2025, 3 clients were admitted to hospital with physical health complications during their care. For one of these clients, there was no pre-admission paperwork, no GP summary and no care plan or risk assessment available in the care records, prior to the incident. Clients were at risk of avoidable harm.

The service did not always follow its own inclusion and exclusion admissions criteria against each referral. We saw clients who had a history of seizures and uncontrolled diabetes admitted to the service, despite this meeting the exclusion criteria. There was no evidence of recognition or multidisciplinary discussion about this. We saw physical health complications and hospital admissions related to some of these patients.

The service did not involve the necessary healthcare and social care services to ensure patients had continuity of safe care both within the service and post discharge. We saw no evidence of professionals such as occupational therapists or community teams being involved in people’s care or discharge planning.

The service model of care remained unclear in some places. The standard operating procedure (SOP) had not been updated sufficiently following concerns raised about it during our April 2025 inspection. It still outlined that non-clinical staff would be involved in final decision making about admissions, which is outside of their clinical competency, and it did not clearly outline the reasons why something was listed as an exclusion criteria and could not be managed safely by the service.

The service had made some improvements to their policies and procedures. There were now policies relating to mixed sex accommodation, sexual safety, health and safety, fire safety and first aid. The service had also received assurances that staff had read and understood certain policies and procedures through read and sign sheets. However, key policies were still missing including whistleblowing; equality, diversity and inclusion; self-harm and suicide prevention; business continuity plan; training and development; and code of conducts for staff and clients.

As part of the action plan relating to the April 2025 inspection, the service planned to develop a new discharge policy, which would clearly outline how staff planned for and managed discharge, including any unplanned discharges. During this inspection, this documentation was not available and there was no evidence it had been created. There was also no evidence of discharge audits being developed and deployed, in line with this action plan. 7 of 9 client records we looked at did not include clear and detailed discharge planning information.

During our assessment in April 2025, we found concerns under this quality statement. These concerns remained during this assessment.

Most staff received training in safeguarding children and adults (Level 1 and 2). 6 of 9 staff had received training in safeguarding children and adults level 3.

In our April 2025 assessment, we found that staff had a lack of knowledge of safeguarding, including the identification of what is a safeguarding incident and safeguarding pathways throughout the service. To address this, the service planned to develop and carry out competency assessments in safeguarding to ensure they had appropriate knowledge for their role, by 30 May 2025. During this inspection, we found that these had taken place for three staff, but 6 remained outstanding.

There were safeguarding policies related to adults and children and evidence that staff had read or understood them, through a read and sign sheet. There were also safeguarding flowcharts to help staff follow the safeguarding pathway.

In April 2025, we found that the service had not made any safeguarding referrals to the local authority, despite there being a need to. During this inspection, we saw this had improved, and where staff had identified a safeguarding concern, this was referred to the local authority appropriately. Since our assessment in April 2025, the service had made one safeguarding referral to the local authority. The service had notified CQC of this referral.

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

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

In our April 2025 inspection, we found that information about some restrictions on clients using the service needed to be made clearer to clients. For example, that the front door of the service is locked and could only be opened by staff, and a clear list of any prohibited items shared. During this inspection, there was no evidence that the service had put in place actions it had outlined to address this. There was no signage to detail the restrictions in place or explanations to why, and we could not see evidence that restrictions or prohibited items were discussed with clients during their admission.

We reviewed the care records for 9 clients who were currently using the service or recently discharged.

Staff completed a variety of risk assessments for clients on admission, but these were not always kept up-to-date or hold all relevant information. The assessments carried out included an overall risk assessment, drug/alcohol assessment, physical health assessment and mental health assessment. In 2 records, we saw that staff did not update these after an incident took place. This meant they may not have the most up-to-date information about risk or how to manage and mitigate this. For 2 clients, we saw risks identified that did not have suitable plans in place for management. For example, one person who needed support with housing, and one person who needed an additional falls assessment to help manage their mobility appropriately. For 1 patient, a physical health condition that was referenced in other parts of their notes was not clear in their risk assessment and did not have a management plan in place, which it should have done. For another patient, their severe allergy was not made clear in all the appropriate areas of their care notes.

At the inspection in April 2025, we found no records of aftercare or discharge for patients. During this inspection, we saw 1 client had clear information about their discharge plans recorded. For others, we did not see clear information recorded. This included information about triggers for individuals that may lead to unplanned discharges, or how staff could manage this. After this inspection, the service stated information around planning for discharge was in the patient care records, but acknowledged the structure and clarity of discharge information could be improved.

The service employed an advocacy service that clients could access. Information about this and how to access it was only available in the admission packs.

Since our assessment in April 2025, the service had made some changes to address concerns we identified. There were some areas that needed more work.

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. The garden was large, accessible and used for informal activities.

The service reviewed and improved its environmental risk assessment in May 2025. This now identified most hazard areas such as infection control, fire, falls, food safety and Control of Substances Hazardous to Health (COSHH), as well as areas that were missing in our April 2025 inspection, including mixed sex accommodation risks. The service had also assessed and put in place a ligatures risk assessment and installed a buzzer on the door from the garden. However, no action had been taken to assess the risk of using 70% alcohol-based hand gels that were available in communal areas. This may pose a risk for clients with addiction histories.

During this inspection we found some improvements with the management of products under COSHH. There was a secure, fire resistant, locked cupboard located in the staff office. We saw individual product sheets for items stored under COSHH.

Several concerns remained in place and insufficient action had been taken to address them. The service was still not secure from members of the public and the neighbouring service. Plans to install a fence between the services had not been carried out by the planned date, and no other mitigations had been put in place to address risks identified for clients in each service. There was no evidence that an action to create and implement a night-time security checklist had been done. Staff we spoke with did not know where to record risk assessments around the sharing of rooms.

During our April 2025 assessment, we found significant concerns around the management of fire safety and the service were non-compliant with the Fire Safety Order 2005. Since that assessment, the London Fire Brigade had inspected the service and systems to ensure they were in working order. Some areas for improvement in fire safety management remained, and had not been successfully embedded. Although there had been some checks recorded in the fire log book, these were inconsistent and it was unclear what needed to be checked and when. Fire assembly posters were located on the service walls, but they had not been completed with information on where the fire assembly point was located. There were no personal emergency evacuation plans (PEEPS) in place to support clients who would require support during an emergency evacuation, particularly those in the early stages of their detox regime.

Staff said they carried an alarm and radio they could use to alert colleagues to an emergency. Patients did not have access to an alarm to alert others to an emergency. A wall alarm system was fitted throughout the service in bedrooms and communal areas, but was not functioning.

The service had ligature cutters, but these were not in a clear and labelled location. During the inspection, the 3 members of staff asked to locate them, could not locate them easily. The ligature cutters did not have a designated location which was labelled clearly, which they should have done, to ensure staff knew where to get them in an emergency.

At the inspection in April 2025, we found the service had a lack of oversight of several staffing areas. These included safe staff recruitment processes, staff training, staff supervision and appraisal. During this inspection, the service had taken limited action to address this, and concerns remained. Several areas of the service action plan had not been completed.

It remained the case that the service did not have a clear and accessible training matrix available for senior staff to know what training was required to be completed when, and by which staff. Information that was available did not clearly indicate when staff completed courses or when training was due for renewal. The service did not have a document outlining the minimum training requirements for staff. Staff had not received specific training that would support them in their role, such as supporting someone receiving care for substance misuse and managing mental health concerns in their service setting.

Although there was no clear supervision matrix for oversight of supervision taking place, staff told us they had supervision at regular intervals. We saw 2 supervision forms with headings guiding the supervisor in what to discuss.

The service had no vacancies. However, the service used a small number of agency nurses regularly. As we found in April 2025, we still saw no evidence to give assurances that they had received an appropriate induction and competency assessments. A folder was put together for one member of agency staff during our inspection.

In April 2025 we found that there were no competency assessments for staff duties appropriate to their role. As part of the service action plan, the service said each member of staff would have had their competency assessed for a range of areas by the end of June 2025. The information provided to us during the current inspection showed large gaps in the completion of these competency assessments. Staff acknowledged the positive work done by the quality lead in this area, but senior leaders had not planned the work effectively, to ensure it was completed by the deadline they had set.

The service had sufficient nursing and support staff to meet the needs of the clients. Managers had calculated the number of nurses and health care assistants required and the staffing establishment was complete, with 24- hour nursing in place.

The service did not always assess and manage the risk of infection and detect and control the risk of it spreading, as well as it could have done.

The service was mostly clean, well-decorated, had good furnishings and was broadly fit for purpose. External cleaners attended the service three times a week and kept cleaning records which were up-to-date. However, we observed the ground floor bath and areas of the kitchen to be visibly dirty. Senior leaders were aware of concerns around the cleanliness of the kitchen and had spoken to the chef around this. Senior leaders told us that a deep clean for the service had been booked.

Most staff had completed infection prevention and control training Levels 1 and 2, however there were no completion or renewal dates available. Only 1 senior leader was listed to have completed the training.

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. A newly recruited service manager had recognised a need for cleaning wipes and gloves for staff when preparing food and had recently implemented this.

We saw that food was mostly 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. However weekly infection control audits had identified that food labels were not always used on all opened food items. Audits also identified that the Food Standards Agency Manual was not always completed daily. Despite audits identifying these concerns, no actions were listed or evidenced that it had been shared with the staff team.

Clients were not able to access the kitchen, but there was a fridge and microwave in the communal dining area that they could use to store and heat food.

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.

During our assessment in April 2025, we found significant concerns under this quality statement. We served a warning notice around the safe management of medicines. During this assessment we did not see evidence of improvements and the warning notice had not been compiled with. We also found additional concerns during this inspection which we raised with the provider at the time. The warning notice outlined that we found evidence that staff were not all suitably trained in the provider's policy of medicines management, medicine errors were not comprehensively documented, thoroughly investigated, and actions were not taken to prevent future occurrence. It also outlined that leaders did not have oversight to ensure proper and safe management of medicines and did not manage identified risks appropriately.

The service had a medicines policy with processes for ordering, storing, administering and disposing of medication, but staff did not always follow this.

Medicines were not always administered in line with national guidance and legislation. During our assessment in April 2025, we identified incidents where staff had left medicines unattended in the presence of clients, which is not safe practice. During this current inspection, we saw this happen again. We observed one occasions where a nurse left medicines unattended with a client, and these were medicines belonging to another client. We observed two other administrations and saw that staff were not always consistent in following the correct procedure and checked the client’s name, their date of birth and allergies. For one client, the nurse only checked the client’s name. This was a concern as this client had a severe allergy.

The service did not always record client’s allergies on the administration record. Staff told us that the mitigation was that there are pictures of the clients on the system. However, we have concerns about the recording of allergies on the allergy tab since we saw that one client had a severe allergy, but this was not clear from the administration page.

Staff were provided with online medicines training, however there were no dates of completion or renewal, or levels of the qualification. No staff had their medicines competencies assessed following the last inspection. This was listed as an item on the provider’s action plan following our assessment in April 2025, but the registered manager confirmed this had not been done.

Despite the service medicines policy stating that clients could not self administer medicines using a dossete box (containers with separate compartments for days and times of the day, which can assist people with taking their medicines), we saw that one client had made up their own dosette box. We were told that the nurse had observed and supported this patient to make up this box from the original medicine’s packs, but there was no record of this. We could not find a risk assessment or care plan around this, and this did not follow the provider policy. This meant there was a risk that the client was not being appropriately supported to take their medicines safely and not all staff may have been aware of this arrangement or how to support this safely.

The service did not have an appropriate medicines lead, who was responsible for ensuring safe practice and reviewing and learning from medicines related incidents. Medicines errors were not thoroughly investigated, and actions were not taken to prevent a future occurrence.

Senior leaders had created and completed some medicines audits in line with the service’s policy. However, none of the senior leaders had a clinical background, leading to concerns around the effectiveness of these audits. The audits had not been completed consistently since our inspection in April 2025.

There was information available to staff in the nursing room on how to deal with emergencies. The service had access to emergency medicines and equipment such as Naloxone, EpiPens and defibrillators in case of emergency. They also had hypoglycaemia kits. However, glucose gels were found to be out of date. Staff could not clearly state who was responsible for checking these. Fortunately, there were no insulin dependent diabetics in the service so there was no immediate risk to people.

There were no identified issues with ordering or storing medicines. We saw that the service ensured that people had enough medicines. Medicines for disposal were segregated and sent back to the pharmacy. This was logged.

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 Controlled Drugs 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.

We saw that information about care being delivered was routinely shared with people’s regular GP.