Cocoon Residential Rehab

This meant we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating has changed to inadequate.

The service was in breach of regulation 12 in relation to safe care and treatment, regulation 18 in relation to staffing and regulation 20 in relation to duty of candour. Leaders did not identify and share learning following an incident. Duty of candour processes were not followed where it should have been applied. Failure to learn from incidents puts people at risk of ongoing harm.

Leaders did not ensure risk assessments were reviewed on admission to the service. Risk assessments were not reviewed during treatment and risk management plans were not completed. Failure to identify and mitigate risk puts people at risk of avoidable harm.

Safeguarding processes were not robust. The services safeguarding log recorded safeguarding incidents from April 2026. It was unclear how leaders recorded safeguarding incidents prior to this. Safeguarding children and safeguarding adults training compliance was low. Failure to implement robust safeguarding procedures puts people at risk of ongoing abuse.

Leaders did not ensure the environment was safe. Systems were not in place to manage risk of same sex accommodation. Staff were not able to tell us the location of naloxone (an emergency medicine used in opiate overdose). Staff did not know the location of ligature cutters.

Medication errors were not recorded or investigated. Medicines reconciliation processes were not robust and did not account for missing medications. This meant people were not safe and at risk of avoidable harm.

Leaders did not ensure staff had completed mandatory training. Supervision and appraisal compliance was low. This meant that staff were not supported to meet the needs of people in treatment.

Leaders did not ensure learning from incidents was identified and shared with the wider team. This meant people were at risk of ongoing harm.

We raised concerns with the provider following our inspection and immediate action was taken to ensure safety of people in treatment.