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. Leaders had not created supportive environments in which to work.

The concerns that we found in April 2025 had not been sufficiently addressed and remained in place. The senior leaders had failed to take action against the action plan they had put in place.

Leaders did not demonstrate the knowledge, skills and experience needed to deliver services effectively. Senior leaders did not have a clear understanding, oversight or proactive approach to an effective governance framework. There remained a lack of clear oversight and systems for safe admission, in ensuring appropriate information was available and appropriate staff were involved in final decision making. There remained lack of oversight of staff training, staff competence, poor audit practice, incident reporting and investigation.

We have not awarded this service a score for Well-led.

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

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 communities.

There was no evidence to demonstrate how the senior leaders communicated their vision and strategy for the service to staff. Therapy staff were able to describe their approach and what was delivered to clients at the service. In general, staff did not have the opportunity to contribute to discussions about the strategy for the service.

During the inspection staff described a poor leadership culture and a lack of support from leaders. Leaders said they were present on site several times a week, but the signing in book indicated this was not the case.

A new general manager had started at the service two weeks before the inspection, but no information had been shared with them about the details of the previous inspection. The service action plan to address areas of concern had not been shared with them.

Staff told us they felt supported by the direct peers and enjoyed working with them. They said they often observed the clinical staff meeting the values of the service in their interactions with staff, and this was the case throughout our inspection.

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.

The senior staff had failed to deliver most actions on their action plan, which was put together to address concerns raised in April 2025. Despite being made aware of significant shortfalls, senior leaders had not taken appropriate action to address them. Shortfalls remained in multiple areas of fundamental standards. This included safe admission, safe care processes, discharge documentation, risk management, governance processes policies and procedures, fire safety, oversight of staff training, supervision and competence, and the management of incidents.

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

In April 2025 we found that there were insufficient policies or practice in place around to support staff to raise concerns about care. During this inspection, we found this had not been addressed effectively. 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.

Staff said they felt able to speak up if something was not right. However, staff we spoke with said concerns they raised were not always responded to clearly or in a timely way. We saw no records of actions senior staff had taken in response to staff raising concerns.

The service did not clearly work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

In April 2025, we found 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. During this inspection, we did not see evidence that this had been addressed.

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

Our concerns from April 2025 remained in place. Senior leaders continued to demonstrate that they did not have a clear understanding of or oversight of effective governance systems for the service.

Regular governance meetings were not taking place. The process for reporting, reviewing, investigating and learning from incidents was not effective. Staff did not undertake appropriate audits to ensure safe and quality care was being provided and the senior leaders had not developed the suite of audits they outlined in their action plan. Examples of audits that had not been developed included weekly and monthly admissions audits, risk assessment audits, incident and complaints audits. Several checklists that the service planned to create had not been created in time with their own deadline. For example, an admissions checklist.

The service did not yet have a risk register. The service did not have a business continuity plan in place to cover eventualities such as adverse weather or a flu outbreak.

The systems and processes to oversee training compliance were not effective. Information did not clearly outline when training had taken place and when it was due to renewal. In one staff file, we saw they had completed over 20 training courses electronically in 1 day. This had not been identified by the service as an area for concern.

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

The service had not made sufficient changes to the inclusion and exclusion criteria, to outline clearly why someone could not be cared for safely in that environment. As a result, the service had accepted referrals from some clients who were at risk of avoidable harm, due to the service not being able to safely meet their needs. In discussion with the senior managers, they acknowledged that some of these patients should not have been admitted.

The senior leaders planned to carry out a monthly governance audit, but this had only taken place once, on 30 May 2025.

There were several key policies still not available. These were related to whistleblowing; equality, diversity and inclusion; self-harm and suicide prevention; business continuity plan; The General Data Protection Regulation (GDPR), confidentiality and data protection; training and development; and code of conducts for staff and clients.

The service had not worked to gain a clear picture of the local services that it would engage with that could offer ongoing support to its clients. The service had not engaged services that may support clients with ongoing needs.

The service did not have positive or well embedded practices around learning, innovation and improvement.

When incidents occurred, these were not always investigated. This meant no areas of learning were identified, were not shared with staff, and could not be embedded into the service to improve care.

Staff did not participate in national audits relevant to the service.

The service did not participate in accreditation schemes relevant to the service.

There was one quality improvement project in the service. This was around implementing the alternative to 12-step model approach to addiction.

The service had not managed to carry out several points within its action plan, to make improvements to the service.