Cocoon Residential 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 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.

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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Leaders did not have an incident log to record incidents, themes and actions taken. There were 30 incidents from January to May 2026. Incidents had been recorded but no action had been taken to further investigate or draw learning from incidents to prevent recurrence. We found an incident relating to a medication error for a drug liable to misuse and no incident report had been completed. We received 2 incident summary reports for March 2026 and April 2026, which gave an overview of incidents for the month. There was a brief description of the incident, themes identified, action taken and outstanding actions. Learning was generic and not related to specific incidents that had occurred. For example, learning on 1 incident report stated that “regular risk assessments” were essential. It was unclear which incident this related to, and regular risk reviews were not taking place. Failure to record incidents, identify themes and implement learning puts people at risk of ongoing harm.

We requested evidence of learning from incidents being shared within the service. Leaders were not able to provide evidence of learning from incidents being shared. Failure to identify and share learning from incidents puts people at risk of ongoing harm.

Leaders did not embed the duty of candour processes. Duty of candour is a professional obligation to be open and transparent when things go wrong. We requested duty of candour records and leaders were not able to provide this. During our assessment we found evidence of medication errors and incidents that required duty of candour.

We requested complaints and compliments from the provider. We were sent an overview of complaints from April 2026. We found that there were 2 incidents relating to staff conduct. The provider took action following concerns being raised, by issuing a formal warning and then dismissing the member of staff. This meant the provider reviewed and acted on complaints.

We reviewed 3 compliments from people who had been in treatment at Cocoon Residential Rehab. One person stated that their experience was “invaluable” and another thanked staff for their support.

The provider had a complaints policy in place, which outlined stages of the complaints procedure. This outlined the process for making a complaint. This policy was last reviewed in May 2026.

Most staff we spoke with knew how to report an incident. Staff told us they would raise a concern with their manager and complete an incident form.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, when people came into the service.

Leaders did not ensure admission processes were safe. Risk assessments were not updated on admission to the service and recovery plans were not completed. This meant that staff were not aware of, or able to mitigate risks. Following our inspection immediate action was taken to ensure people’s safety. Leaders implemented an admission, risk and clinical governance audit for oversight of admission processes.

Leaders ensured there were policies in place to identify suitability for the service, however different exclusions to the service were included in 3 policies or criteria. This included a screening policy, opiate detox policy and detox exclusion guidance. Therefore, exclusion criteria and a person’s suitability for treatment was not always clear.

A review of incidents identified people within the service with complex health needs such as liver related complications. Staff told us that complex cases were not accepted at Cocoon Residential Rehab. It was not clear if these admissions were within the services admission criteria and what mitigation was in place to manage risk.

However, there was an admission policy. This outlined processes for admission, such as completion of admission paperwork and checking belongings. This was last reviewed in May 2026. Following our assessment the service updated their admission and induction standing operating procedure. This outlined processes for staff to follow pre-admission, assessing clinical risk, making people comfortable on admission and detoxification processes.

Leaders ensured there was a discharge policy in place. This outlined procedures for staff to follow on completion of treatment, planned or unplanned exits from treatment. For example, the policy stated where consent had been given family members should be contacted. There was also discharge and collection of personal property policy. This policy identified processes for collection, storage and disposal of personal belongings

Staff ensured some discharge processes were in place. We found detailed discharge reports had been completed and sent to funders. Discharge reports gave a summary of treatment, possible risks after discharge and included a detailed continuing care plan. This meant there was communication and continuity of care with external services.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Leaders did not always ensure safeguarding processes were followed. We reviewed complaints and identified a concern relating to staff conduct where appropriate safeguarding actions had not been taken. Failure to identify, log, investigate and take action on safeguarding concerns puts people at risk of avoidable harm.

Safeguarding concerns were logged within a quality assurance management tool, which began recording safeguarding incidents from April 2026. Staff had completed safeguarding referrals where required. For example, where there was a concern about financial abuse, actions included a safeguarding referral. There was no evidence of safeguarding concerns being logged prior to this date. This meant it was not clear if appropriate safeguarding actions were being taken prior to April 2026.

Leaders did not ensure staff were trained in safeguarding. Safeguarding adult training compliance was 42% and safeguarding children training compliance was 35%. Following our inspection, leaders told us a safeguarding action plan had been put in place.

There was a safeguarding adults policy, which was last reviewed in January 2026 and a safeguarding children’s policy, which was last reviewed in November 2022. This was due for review in November 2024. The policies outlined the service manager’s responsibilities and recovery workers responsibilities for safeguarding adults and children. The service had a designated safeguarding lead.

Staff told us they would report safeguarding concerns to the safeguarding lead.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not ensure risk assessments and risk management plans were reviewed. We reviewed 5 care records throughout our assessment. We found that risk assessments were not always completed on admission to the service. We also found risk assessments were not always reviewed during admission and risk management plans were blank. We requested urgent action following our inspection and the provider ensured all risk assessments and risk management plans were reviewed. Failure to identify and mitigate risk puts people at risk of avoidable harm.

We found some evidence that people were given harm reduction advice on discharge from the service. For example, we found that people with previous opiate use had been offered naloxone on discharge from the service. People were given information on support services and groups in their local area. While discharge plans were detailed, we did not see that discussions took place prior to discharge on the risks of changes in tolerance levels and ways to minimise risk in the event of a relapse.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Leaders did not ensure the environment was safe. Systems were not in place to manage the risk of mixed sex accommodation. At the time of our inspection there was 1 female in treatment. Sleeping accommodation and bathroom facilities were not segregated for females and the individual raised concerns about not feeling safe in the environment. Guidance on regulation 10 states that “people using services should not have to share sleeping accommodation with others of the opposite sex, and should have access to segregated bathroom and toilet facilities without passing through opposite-sex areas to reach their own facilities.” This meant that processes were not in place to mitigate risks present in same sex accommodation. We raised this as an urgent concern with the provider and action was taken to ensure that females had access to safe accommodation. This included an immediate review of bedroom and bathroom allocation. Leaders also reviewed the services mixed sex accommodation risk assessment and a mixed- sex accommodation policy was to be implemented.

Staff were not able to locate naloxone on request. Naloxone is an emergency medicine used to treat an opiate overdose. Lack of process to ensure staff are aware of and able to access naloxone puts patients at risk of avoidable harm. Following our inspection leaders ensured that staff were trained and able to locate naloxone in an emergency.

Staff were not able to identify or locate ligature cutters on request. We found evidence that people had experienced suicidal thoughts while at the service. Staff did not ensure processes were in place to mitigate risk of self-harm or suicide. This meant people were at risk of avoidable harm. Following our inspection ligature cutters were appropriately placed and emergency equipment location posters were placed around the building.

Staff has access to a clinic room. Staff told us that people had physical health examinations completed by a GP prior to admission and complex detoxes were not accepted at Cocoon Residential rehab. An examination couch was not present in the clinic room because physical health examinations did not take place at the service.

Leaders ensured there was a ligature risk assessment. This included potential ligature risks and mitigation. For example, ligature risks for people’s bedrooms included potential ligature points, a risk rating and mitigation of staff observing regularly.

Leaders ensured there was a fire risk assessment. However, there were some outstanding actions to be completed following the services’ fire risk assessment in June 2025. This included flammable materials to be removed from the outside of the building. A monthly fire door check was also completed, which identified that the door to the group room needed to be replaced.

Managers completed a monthly first aid stock expiry check. Most items within the first aid kit were within the expiry date. However, sterile dressings were recorded as having no expiry date.

Leaders reviewed the service’s sexual safety and relationship policy following our inspection. The policy included actions that should be taken where there was unwanted sexual behaviour. This included the designated safeguarding lead being informed and an investigation to be completed.

During our inspection we observed call bells in bedrooms. There was a disabled access bedroom and there were mobility aids, such as a shower chair in the bathroom.

We reviewed equipment calibration records and all equipment had been calibrated. However, there were two items that needed to be replaced. The service had a defibrillator onsite, which was regularly audited.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

At the time of inspection the team consisted of; Registered Manager, team leader, senior practitioner, therapy lead, medication lead, 2 therapists, 2 recovery workers, 2 weekend workers and 2 night workers. Some members of staff were new to the team. Prescribing appointments were completed online with a GP with specialist interest in addiction. There were no nursing staff at the service.

Following inspection in October 2022, the provider was told they should make sure staff were up to date with mandatory training. We reviewed the services’ training matrix and found gaps in mandatory training. There were 5 bank staff that had not completed any mandatory training. There were 3 new starters that had not completed mandatory training and 4 staff members that had not completed induction. At the time of our inspection, no staff had completed training in basic life support or first aid. The provider put an action plan in place to ensure all staff were appropriately trained.

Following inspection in October 2022, the service were told they should ensure all staff receive regular supervision. At this inspection supervision compliance was 30% and appraisal compliance was 60% for all staff, including bank staff. This meant that staff were not always appropriately supported by leaders.

The provider had capped admissions to 5 people due to staffing shortages. We reviewed the staffing rota and found one staff member had completed a 16.5 hour shift on 1 staff rota. Failure to allow staff adequate breaks can put people at risk of avoidable harm.

We reviewed staff files to check recruitment processes were safe. All staff members files that we reviewed had appropriate disclosure and barring service (DBS) checks in place.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The environment was mostly clean. Cleaning at Cocoon Residential Rehab was a therapeutic task and therefore people in service were responsible for maintaining cleanliness. The service had a weekly duties checklist, which stated people responsible cooking and cleaning. We observed the kitchen being cleaned during inspection.

We observed food such as large bags of potatoes, stored on the floor in the dining room. Leaders told us this was due to lack of storage space in the kitchen. Following our inspection leaders told us this would be stored in a more suitable location.

At inspection in October 2022, the service were told they should ensure infection prevention and control risk posed by the toilet in the clinic room was rectified. At this inspection we observed a toilet used for drug screening in the clinic room. The toilet had a door, however the door of the vestibule around the toilet had been removed due to space. Therefore there was 1 door between the toilet and medication preparation area.

There was an infection prevention and control policy in place, which was last reviewed in 2022. This detailed infection prevention and control procedures. There was also a clinical waste risk assessment and disposal policy and a sharps policy for staff to follow.

We scored the service 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Leaders did not ensure safe processes were in place to safely manage medicines. We found medication errors for drugs liable for misuse that had not been reported or investigated. For example, there was a medication discrepancy for diazepam, where the count was 7 tablets, however records stated 9 tablets. There was a medication error for chlordiazepoxide, where 4 tablets were recorded missing. There was no incident report or documentation of this discrepancy. Failure to investigate medication errors and discrepancies puts people at risk of avoidable harm. In addition, failure to identify learning from incidents means that risk of harm is ongoing.

Leaders did not ensure medicines reconciliation processes were robust. We requested medicines reconciliation, where discrepancies had been found and identified further concerns relating to reconciliation of medicines. For example, we found stock recording errors for medications for 3 people in treatment. Failure to safely manage medicines put people at risk of ongoing and avoidable harm.

Leaders did not always ensure safe processes were in place to monitor transport of controlled drugs. Managers told us that lock safe bags were used to transport controlled drugs from the pharmacy to the service. However, there was no documentation in place at the time of inspection to record transportation of controlled drugs. Following our inspection, leaders told us that a controlled drugs collection record would be implemented.

Leaders ensured there was a detailed medication policy, which was approved in May 2026. The policy included pre-admission screening and clinical assessments that should be completed and a process to verify prescribed medications. The policy also included safe storage of medications, administration of medication, controlled drugs PRN guidance.

The provider has a service level agreement with another provider for the use of naloxone. The service level agreement had expired and the service told us they would ensure this was renewed. Staff told us naloxone was given to people where needed on discharge from the service.