Cocoon Residential Rehab

On this page

• 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

This meant 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.

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

The service was in breach of regulation 17 in relation to good governance. Leaders did not ensure governance processes were in place. Leaders did not have oversight of medication administration processes and did not ensure incidents were investigated. Leaders did not have oversight of staff training, supervision or appraisal compliance. Safeguarding processes were not always robust.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

However, leaders responded to concerns found during inspection and developed an action plan to address the issues we found.

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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders had a clear vision and strategy in place. Leaders were re-branding the service at the time of our inspection and the providers name had changed from Druglink to Cocoon. We reviewed the service’s 3 year strategy and found there was a clear vision on identity, with the service name change representing transformation and long term change. There were also strategic priorities, which included quality of services, workforce development, evidence of impact, financial resilience and residential rehab development.

Staff we spoke with had and understanding of the strategy and described the services rebrand to the name “cocoon” as the service being a shield for people in treatment. This meant leaders had communicated their strategy with staff.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which The service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders did not always demonstrate they had the knowledge and experience to ensure the quality of clinical care and treatment was delivered safely and effectively. We requested training senior leaders had completed but did not receive this. Therefore, it was not clear what training senior leaders had completed.

Managers had not completed all required training for their role. Two managers had completed the care certificate, which equips staff with skills and knowledge needed for the role. Managers were in the process of being booked onto leadership training.

However, some leaders had worked within substance misuse for many years. Leaders were able to tell us areas that needed improvement. For example, leaders told us that they needed to improve their key performance indicator monitoring and were introducing a new system to do this.

Staff told us leaders were supportive and approachable. Some staff said leaders were visible in the service.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

People in treatment told us concerns were not immediately actioned. For example, when people raised concerns about maintenance of the environment, they were not immediately actioned.

However, leaders ensured there was a process for staff to raise concerns. The provider had a whistleblowing policy. This explained steps for staff to take if they had a concern and actions that would be taken. The policy was last reviewed in June 2022. Staff we spoke with told us they felt able to raise concerns with managers.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders did not ensure staff were trained in equality, diversity and inclusion.

However, the service had an equality, diversity and inclusion policy. There were staff members from different cultural backgrounds. Some members of the staff team had lived experience of substance misuse and were representative of people in treatment.

Staff we spoke with told us they would be able to work flexibly if requested.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders did not ensure governance processes were in place. Leaders had not embedded effective meetings, where discussions about risk could take place. For example, effective multi-disciplinary meetings were not taking place with a prescriber.

Leaders did not have oversight of medication management and incidents. There were repeated medication errors and investigations were not completed. Learning was not identified and implemented following an incident. We found there had been 16 medication errors or near misses since January 2026. Failure to identify, investigate and learn from incidents puts people at risk of ongoing and avoidable harm.

Leaders did not have oversight of staff training. For example, no bank staff had completed training in safeguarding adults or children. Mandatory training compliance was low and new staff were not always inducted. This meant that managers did not have oversight of staff training, which was essential to deliver safe care and treatment.

Leaders did not have processes in place to ensure staff had regular supervision and appraisals. Supervision compliance was 30% and therefore it was not clear how issues relating to performance were addressed and monitored.

Leaders did not provide evidence of a safeguarding log prior to April 2026. It was not always clear how leaders identified, actioned and monitored safeguarding concerns. Failure to act on safeguarding concerns puts people at risk of avoidable harm.

Leaders did not have a process for duty of candour. Leaders could not provide evidence of duty of candour following an incident.

Leaders were in the process of implementing new key performance indicator (KPI) monitoring systems at the time of our inspection. Leaders had a weekly action plan, which listed service priorities, such as clinical governance actions, programme development and service delivery as their current monitoring system. Leaders sent a copy of the service’s new KPI monitoring tracker, which was not yet in use.

However, governance meetings were held quarterly. There was evidence of discussion about admissions, staffing levels and incidents that had occurred. Actions were identified and previous actions reviewed and updated.

Leaders ensured some audits were completed. We found an anti-ligature audit and environmental checklists were completed. There was also evidence of a defibrillator audit being completed. Prior to our inspection, Leaders had commissioned a CQC mock inspection. This highlighted some areas of concern that were found at our inspection. For example, the mock inspection highlighted that ligature cutters were not available. Processes for accessing ligature cutters had not been embedded at our inspection. Whilst Leaders had commissioned a mock inspection, action had not been taken to embed new processes to improve safety.

Leaders ensured there was a business continuity plan in place. The service’s emergency information document had contact details for services that might be needed in an emergency. This included gas and water emergency contacts.

There was a service risk register in place. This included risks such as “higher acuity clients needing more clinical input”. Risk mitigation included reviewing admission criteria, ensuring staffing aligned with acuity and escalating cases. Another risk included an increase in safeguarding incidents. Mitigation was increased management oversight and safeguarding supervision. We did not see this mitigation had been implemented.

We raised concerns about governance processes with the provider and an immediate action plan was put in place. The provider implemented weekly governance and safety oversight reviews, recovery plan and risk review meetings and daily safety huddles, as well as other immediate actions to improve governance processes and safety of people in treatment.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders ensured there was collaborative working with other services. We found that referrals to support services, such as domestic abuse charities, housing, counselling and mental health teams had been completed. The service also signposted people to groups and substance misuse support groups on discharge from rehab. This meant that joint working was taking place to support people in their recovery.

We received feedback from stakeholders. A service that worked collaboratively with Cocoon rehab told us there was a “lovely atmosphere” and people who had been in treatment felt supported and had only positive feedback about the service.

There was a service level agreement in place from January 2022 to March 2026 with a local service for the provision of naloxone. This outlined the processes for training, ordering, storage and record keeping. The service level agreement needed renewing, and the provider told us this would be actioned.

There had been partnership working with a local GP surgery, where the GP prescribed under a shared care agreement. The aim was to create a clear pathway for people with suspected attention deficit hyperactivity disorder (ADHD) diagnosis. However, this had to be suspended due to the service’s consultant psychiatrist leaving. Leaders told us they were planning to re-instate the pathway in the future.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders did not ensure learning from incidents was implemented.

However, the service implemented a 90-day improvement plan for their rehabilitation and detox service. This included a plan to increase staffing, training, governance and environmental improvements, with actions and a date for completion.

The provider demonstrated some creative approaches to working with people. The “Child Of” programme was a weekly art intervention, where people were able to access peer support and mentorship.

The provider sent evidence of emails of future partnership with a university for clinical psychology students. However, this collaboration was not yet in place.