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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulations in relation to safe care and treatment, staffing, and fit and proper persons employed.

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.

Whilst the service had systems in place to report and respond to incidents, they did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service used an incident recording system that all staff could access. In addition, staff were required to detail incidents within each client’s care record. Managers received alerts when new incidents were reported.

When staff did report incidents, the incident reporting system was effective in supporting review by a manager, capturing detailed information about the incident and a section for learning.

Although we found that staff reported some incidents, staff did not identify and report all incidents. We identified 2 incidents that staff had not reported which could have led to potential harm and required review and actions to reduce the chance of them happening again.

In most incident records we viewed, we saw appropriate learning and action as a result of staff review and discussion. However, for 1 incident that involved a client and staff member, we did not. This area required further strengthening to ensure that risk of avoidable harm identified from past incidents was responded to and mitigated against to prevent future recurrence. We saw that staff did not update the client’s risk management plan, which would have meant further risks relating to their behaviour could have been mitigated more effectively. There was no evidence that a debrief was offered to staff or the client.

We saw evidence of improvements made based on learning from previous incidents. This process had improved since our last inspection, but needed to be better embedded to be fully effective. We reviewed staff meeting minutes for March 2026 and saw limited evidence of discussions about incidents and learning. Staff we spoke with were able to share limited examples of recent learning from incidents.

The duty of candour is a statutory duty that requires registered providers to act in an open and transparent way with people receiving care or treatment and includes specific requirements for certain notifiable safety incidents. Duty of candour was part of staff training and 75% of staff had completed it.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety effectively. They did not make sure there was continuity of care, including when people moved between different services.

The service received referrals from self-funding clients. The admission process was designed to ensure that essential information about the client was received. The service now had an admission policy with clear inclusion and exclusion criteria that it considered against each referral. Prior to admission, clients underwent a consultation to determine their suitability for the service.

During our assessment we found that 2 clients were admitted to the service despite meeting its exclusion criteria. This meant that the needs of these clients exceeded those that the service was able to meet safely. Additionally, the decision to continue one of these admissions was made by a staff member who had no clinical qualifications.

Staff did not involve all the necessary healthcare services to ensure patients had continuity of safe care, both within the service and post-discharge. Two clients were admitted to the service without a summary from their GP to verify their medical history prior to admission, and there was no record of the risks of this being clearly discussed with the clients. This was not in line with best practice guidance and the provider’s own admission policy which stated that staff must do all they can to obtain a GP summary on the day of admission. Because not all healthcare providers were aware of the clients’ changing physical health needs and potential drug interactions, this increased the risk of avoidable harm.

We saw evidence that discharge planning had improved. For example, 1 client was discharged with appropriate relapse prevention medications prescribed. Staff told us about giving clients harm minimisation advice and discussing any safeguarding issues on discharge. Naloxone (a life-saving medication used to rapidly reverse an opioid overdose) was provided to those at risk of experiencing an overdose. In 3 of 4 care records, there was evidence of planning for an unexpected treatment exit. There was an aftercare offer available which consisted of 3 follow-up calls with a therapist and weekly online meetings. Leaders told us they were planning to improve this provision further by developing a carer offer.

Although most staff were up to date with appropriate training and governance around safeguarding practice had been improved since our last inspection, safeguarding incidents were not always managed robustly or clearly identified by the staff group.

The provider’s systems to act on allegations or evidence of abuse needed further strengthening. Although staff recently reported a sexual safety incident involving a client and a member of staff, no further action was taken. The incident was not considered for a further safeguarding discussion. There was also no clear management plan for client and staff safety, and no evidence of consideration for referral or statutory notification to external bodies. Registered providers must notify CQC about certain incidents that affect people using or working within their service.

Staff had received mandatory safeguarding training. All staff were up to date with safeguarding adults and children levels 1 and 2. Compliance with level 3 training was 88% and compliance with preventing radicalisation was 95%. The service had appointed a safeguarding lead, however they had not yet completed the designated safeguarding lead training.

Since our last inspection, governance around reviewing safeguarding processes had been put in place. Staff completed a monthly safeguarding audit which examined the details and management of safeguarding concerns.

Information about safeguarding, boundaries and sexual safety was included in the client welcome pack.

Staff we spoke with demonstrated awareness of how to recognise individuals at risk of or suffering harm. Staff knew how to report their concerns. The safeguarding lead shared examples of discussing relevant cases with the local authority. However, although we saw that safeguarding was discussed in a recent team meeting, most staff could not share examples of recent safeguarding cases and how these were managed.

Staff followed safe arrangements for people visiting clients at the service. Rooms were available that could be reserved for visits, or visits could take place off-site.

There were some restrictions in place within the service, which were proportionate and necessary to maintain a healthy and safe environment. These were now clearly outlined in the client welcome pack. For example, no psychoactive substances or gambling were permitted on the premises.

Whilst the service had systems in place to assess and manage individual risk, they did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled them to do the things that mattered to them.

We reviewed 4 care and treatment records. All contained risk assessments and risk management plans, although these were not always up to date or covered every area of risk comprehensively. In 3 records, we saw management plans were kept up-to-date, but for 1 client there was no evidence of updates to their risk management following incidents that had been reported. Three records included plans for an unexpected treatment exit.

Most clients we spoke with reported feeling safe at the service. Clients could raise their concerns at weekly community meetings. However, some clients shared concerns about inappropriate behaviour from a peer which they had raised with managers but this had not led to change. This was impacting their experience at the service.

Three clients told us that staff did not always carry out searches of bags when returning to the service from visiting the local area, in line with provider policy. Staff did not always carry these searches out immediately at the time of return, which they should have done. This created opportunities for items to be brought into the service without staff knowledge. Clients raised this as an area of concern, which we fed back to the service on the day of the assessment. The service said they would be addressed immediately, through discussions with staff and reinforcement of the importance of these searches.

Staff involved patients in care planning and risk assessment. There was evidence of personalised planning and client voice in the records we viewed.

Staff we spoke with were aware of the risks specific to the client group they supported. Most staff were trained in administering Naloxone (a life-saving medication to rapidly reverse an opioid overdose), immediate life support, management of seizures and anaphylaxis awareness. Approximately 75% of eligible staff had been trained in completing observations.

The client welcome pack outlined the arrangements for safety and security within the service and provided details of emergency helplines.

Although we saw a significant improvement in how the service detected and controlled potential risks in the care environment since our last inspection, there were a small number of areas that still needed addressing.

Two areas of improvement were needed in the management of a safe environment. The service had a health and safety review by an external provider in January 2026 which identified actions for completion. There was no evidence of their completion and these actions remained outstanding at the time of our inspection. Staff had not carried out any fire evacuation drills since March 2025. This meant that staff familiarity with emergency evacuation procedures, which is routinely developed through regular fire drills, may be limited.

Overall, however, we saw improved systems to manage fire safety. The service had appropriate policies and procedures in place. Essential fire safety information was included in the client welcome pack. There were information boards for clients, staff and visitors in communal spaces about what to do in an emergency, giving clear instruction for fire assembly points. Fire assembly points were clearly signposted in areas outside of the building. The service carried out monthly fire safety audits. We saw that these were completed for the 6 months leading up to our inspection, with compliance rates over 95%. A fire risk assessment was in place and the necessary checks were completed regularly, with records kept. Compliance with fire safety training was 100% and nominated staff were trained as fire wardens and in the use of fire extinguishers.

The service offered mixed-sex accommodation. Each client had access to their own bedroom with an en-suite bathroom. Clients had keys to their rooms and could lock them when not in use. All clients could lock their rooms from the inside. There were 2 double occupancy rooms, and the service had now implemented a risk assessment for room sharing. Staff audited whether this risk assessment had been carried out and took actions where an audit showed improvements in this area were needed. We saw that 1 client had declined to share a room and opted to have a single room, based on their needs and preferences.

The service environment was functional and appropriately furnished. Staff carried out regular environmental risk assessments and completed relevant training. Staff received training in health, safety and welfare and compliance was 88%.

There were appropriate arrangements to monitor gas safety. Following our feedback, managers said they would place an additional carbon monoxide detector in the kitchen area.

The service regularly assessed potential ligature risks in the environment and had policies to mitigate these risks. This included individual risk assessments, risk management plans and different levels of observations for clients with different needs. Ligature cutters were easily accessible and staff knew where these were.

The service had access to emergency medicines which staff checked and stored appropriately. There was also a defibrillator available with instructions for use. First aid kits and body fluid spillage kits were available, with contents which were in date. The staff carried out monthly medical equipment audits, with over 94% compliance in the 6 months before our inspection.

Non-alcohol-based hand sanitiser was now provided in communal areas. We raised this in our previous inspections as this could pose risks to clients admitted for alcohol treatment.

Clients could raise maintenance issues in weekly community meetings. Clients told us that some issues had been fixed while some still required attention, for example water leaking from a shower onto a bedroom floor.

There was adequate space for the number of clients within the service, including a group and individual therapy rooms. There was a communal bathroom available on the ground floor which had a bath that clients could use. There was a garden that was accessible to clients with a covered table and seating area.

During our previous inspections we identified concerns around safe recruitment processes, staff training, supervision and appraisal. At this inspection, although we saw some improvements in this area, ongoing concerns remained. There was no clinical lead in place, which was impacting several other areas of ensuring safe and effective practice.

We were concerned that despite providing medically assisted treatment, the service had no clinical leadership role in place. Although the service engaged the services of 2 doctors, this arrangement was informal, with no written contract for their employment. The doctors provided assessment and prescribing input, but were not employed in a clinical lead role. A clinical lead provides clear clinical leadership (guiding, influencing, and improving clinical practice to deliver safe, effective, and high-quality patient care), ensures consistent quality of care, supports staff development and coordinates service delivery effectively across the team.

There were no arrangements for clinical supervision or audits to ensure that clinical practice adhered to best practice guidance. The service had briefly employed a lead nurse, who recently left this role and there were no plans to replace them. The nurses employed by the service did not receive clinical supervision or professional development to enable them to carry out the duties they were employed to perform within the service. There was no oversight of the doctors’ prescribing. This meant that the provider had failed to determine and review the appropriate leadership requirements and staff supervision needs required to safely meet the needs of clients.

The service had not established or followed safer recruitment processes. For one staff member, we saw no evidence of a risk assessment required in line with safe recruitment practice. The need for this had not been considered in the provider’s safer recruitment policy. For another staff member, there was a lack of evidence to clearly demonstrate their right to work in the UK. There was no documentation available on the doctors working for the service such as proof of identity, satisfactory evidence of conduct in previous employment, evidence of continued professional registration or appropriate indemnity cover.

It was not clear what contingency arrangements were in place for continuity of care during planned or unplanned absences of the main assessing and prescribing doctor. Some of the clients we spoke with told us they had not met the doctor face-to-face, and some said they found it difficult to speak with the doctor when needed.

Compliance with training was between 75% and 95% overall. However, this varied for individual members of staff. For example, 2 staff members had not completed any of the training assigned to them that the provider described as continuing professional development (CPD) training. There was no evidence of mandatory training completion for the doctors working at the service. Although 80% of staff had completed the Oliver McGowan mandatory training on learning disability and autism, this training was listed as part of the provider’s CPD instead of mandatory training. The Health and Care Act 2022 introduced a statutory requirement that registered providers must ensure their staff receive this training.

New staff now completed a structured induction programme. We spoke with a new member of staff who confirmed that their induction was ongoing. However, records showed that week 1 and month 1 induction checks were outstanding for 2 employees, although their day 1 and month 6 induction checks had been marked as complete.

The service had seen high staff turnover at 36% in the 6 months before our inspection. During our visit, the service was fully staffed. Two new operational leaders were recently appointed as the Registered Manager and Nominated Individual, both of whom were knowledgeable and appropriately experienced.

There were sufficient nursing and support staff to meet the needs of the clients. The team was a combination of directly employed staff and independent practitioners. It included nurses, doctors, healthcare assistants, recovery workers, therapists and managers. A self-employed nutritionist visited the service once a week.

Since our last inspection we saw there had been improvements in some areas. The service now had arrangements to monitor that staff received competency assessments, training, supervision and appraisal. Competency assessment audits demonstrated improvement in compliance from 58% in November 2025 to 100% in February 2026.

Compliance with quarterly managerial supervision was 90% in February 2026 and appraisals had been completed by all eligible staff (6 in total).

Whilst there had been improvements from the previous inspection, the service did not always keep shared spaces as clean as they should be.

During our visit, the care environment appeared mostly clean and well-maintained.

All staff had completed the mandatory infection and prevention control (IPC) training. The service carried out a food safety audit, showing an increase in compliance from 81% in October 2025 to over 96% in 2026. However, food safety training completion was 60%.

The service employed an external contractor to carry out daily cleaning. Cleaning records we viewed were up to date and demonstrated that all areas were cleaned regularly. However, some clients we spoke with reported dissatisfaction with the standard of cleaning within the service. Clients said there had been occasions when cleaning of shared spaces was not always thorough, for example used tissues being left on the ground for 3 days. One client said they would have preferred personal spaces, such as bathrooms and bedrooms, to be cleaned more regularly.

Staff carried out other appropriate checks to detect and prevent the spread of infections. A Legionella risk assessment had been carried out, and regular monitoring of the water systems took place.

Whilst we found that the service had addressed areas of concern relating to training and documentation from a previous inspection, during this inspection we identified concerns relating to safe practice. We did see that medicines were stored appropriately.

At our initial assessment in April 2025, we found serious concerns relating to medicines management. We took enforcement action and issued a warning notice. At that time, staff had not been suitably trained in the provider’s medicines management policy, medicines errors were not documented appropriately, and leaders did not have oversight of medicines management. During our assessment in July 2025, we found the provider had not demonstrated sufficient progress in addressing the issues within the warning notice. At this current assessment, the provider had demonstrated adequate improvement in these areas and was now compliant with the specific concerns outlined in the warning notice. Staff received appropriate training in the provider’s medicines management policy and reported medicines errors appropriately.

During the current assessment we found several areas that needed improving to ensure safe and effective practice. We saw examples where assessments and prescribing had not taken place in line with best practice guidance or the provider’s own policy. Two clients were admitted to the service without evidence that the service had attempted to request a summary from the GP to verify their medical history. One of these clients had a new medicine prescribed. The provider’s policy stated that staff should do all they can to obtain a GP summary upon admission. Not having information from the GP meant that all healthcare professionals involved in clients’ care were not aware of their changing physical health needs and potential drug interactions. For one person, a new medicine was initiated due to an elevated blood pressure reading. However, it was unclear from the notes whether the client was already taking medicines for this, whether the blood pressure was persistently elevated and whether prescribing for physical health fell within the provider’s remit.

Another client was prescribed a medicine for an unlicensed indication, or outside the product licences, known as ‘off label’ use. There was no clear rationale for this prescribing decision and no evidence of informed consent from the client documented in the care record, which was not in line with national guidance.

Most consultations were done remotely, and we found evidence that some prescribing took place without a consultation, with information and symptom management being relayed between a client and remote prescriber by a staff nurse.

Clients we spoke with gave mixed feedback about how their medicines were managed. For example, 2 clients described several occasions when staff had not been clear about what time specific medicines were to be administered, causing confusion both for clients and nursing staff. One client said they had different information from different staff about the medicines they were receiving.

We did find that the service had made several improvements in the governance arrangements around medicines since our last inspection. Management staff now carried out medicines management and medical equipment audits, including ensuring medicines errors were reported. These highlighted areas for improvement or non-compliance with provider policy. However, it was not clear who took a lead role in embedding improved clinical practice based on the audit outcomes, as there was no clinical lead role for the service. A separate, one-off audit conducted in December 2025 highlighted some issues in relation to the treatment room. The findings of the audit were not shared or acted on. Managers advised they were not aware of the audit, and the staff member responsible had since left. During our assessment, we did not see evidence of any clinical or prescribing audits.

We saw that medicines were stored appropriately. Medicines prescribed for clients (their own medicines as well as those prescribed by the provider) were stored in a locked cupboard. The keys were kept with the nurse on duty. Each client had their own clearly labelled container. Controlled drugs (CDs) were stored in a separate cupboard. A CD register was kept and checked daily. A random CD check showed no discrepancies. An emergency medicines kit and emergency equipment were available on site.