Tarik Drakes
PFD Report
All Responded
Ref: 2023-0091Deceased
All 1 response received
· Deadline: 10 May 2023
Response Status
Responses
1 of 1
56-Day Deadline
10 May 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. During the inquest evidence was heard that:
i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely.
ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions.
iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please.
iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time.
v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns.
vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was the out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment.
vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner.
viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead.
2. I have concerns with regard to the following:
i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents.
i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely.
ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions.
iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please.
iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time.
v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns.
vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was the out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment.
vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner.
viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead.
2. I have concerns with regard to the following:
i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents.
Responses
Response received
View full response
Dear Mrs Griffin,
I am writing in response to your letter dated 15th March where you set out your concerns arising from the inquest into the death of Mr Tarik Drakes. You asked that BCHA take action regarding the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge with consideration being given to reviewing the current levels of staffing and supervision at the placement. Firstly, we would like to extend our condolences to the family of Mr Drakes, we have also reached out to them directly to provide the opportunity to meet with us if they have any further questions.
1.1 Relating to the service provision. As you are aware from the inquest, the service at Dorset Lodge provides housing with some support. The support that we provide is directly commissioned by Bournemouth, Christchurch and Poole Council (BCP)which consists of temporary housing for people experiencing homelessness. The service is not an exclusive accommodation to support drugs and alcohol addictions, although some customers are experiencing these issues. Customers can find themselves homeless because of many issues and quite often require a range of different supports from various statutory and non-statutory agencies. BCHA is commissioned to provide customers with Housing related support. Support workers do not undertake care planning as the service is not regulated with CQC. Housing related support consists of support to apply for benefits, move on accommodation and sign posting to other services which can support broader customer needs. The purpose of the support is to help customers to gain independence, so they are better able to move on into permanent accommodation and maintain a tenancy.
The funding commissioned provides support staff to be on site from 8.00am until 8.00pm Monday to Friday. As part of this review process, we have met with Colleagues from BCP Housing and Commissioning team, BCP Adult Social Care and We are with you, all of whom played a role in supporting Mr Drakes while he was a resident of Dorset Lodge. There is a partnership approach to assessing customers suitability for the accommodation and risk assessing customer's needs. This is done through link meetings with BCP Housing Teams and with other housing providers to discuss the best possible placement. At the referral phase information is gathered on what support agencies are involved with the customer to address their broader health and wellbeing needs. Both new referrals and existing placements are discussed to assess whether needs have changed and if other agencies are required to support. This could include adult social care or drug and alcohol services where relevant. The Council is in the process of reviewing the Link meetings and will be taking into account this report to reflect on any improvements which can be made to this process and the management of risk through this forum. In addition, We are With You have agreed to attend Link meetings to ensure Drug and Alcohol related issues are further discussed and supported at the referral stage. Link meetings are an operational meeting held on a fortnightly basis to provide a forum for providers to share good practice, challenges and discuss individual cases that may be at risk of losing their tenancy or needing to move on from their current service.
Adult Social Care have offered to support these meetings if appropriate to support risk management. This support can also facilitate escalation where agencies may not have consistent attendance to professionals / Multi Agency Risk Management meetings or where further support is needed. ‘We Are with You Drug and Alcohol Service have also committed to sending a representative for future meetings.
Dorset Lodge is not commissioned to provide support or keyworking over the weekend. The Saturday role is an ‘added value’ role. The role is an activity coordination role to give customers something to do over the weekend. E.g. the role may undertake cooking activities or arts and crafts. This role is not funded and is used ad hoc throughout the year. Customers who are referred and assessed to live at Dorset Lodge are deemed through link meetings as suitable for the level of support available. Alternative 24/7 staffed accommodation is available for those with greater needs at St Pauls in Bournemouth. Customers also have a right to choose where they live and determine what support they would like to engage with. Customers' needs and risks can change over time, link meetings and professional meetings provide an opportunity to respond to this risk based on the expertise of those supporting the individual. Through review of Mr Drakes support alternative 24/7 accommodation was considered numerous
times however this was either deemed as unsuitable by his social worker nor was it accepted by Mr Drakes.
The Out of Hours Service (OOH) service consists of Repairs and Maintenance for anything deemed Emergency / Critical e.g., Flood/Gas Leaks and in addition there is a Night Response Team (NRT) which is a concierge and security service funded through service charges. This service is a responsive service where customers can call for assistance with security matters or when there are any incidents e.g., Anti-Social Behaviour. There are 2 people on shift each night covering a small number of properties. There is an answerphone service where customers can leave a message and request a call back if the night officers are busy / engaged. Details of OOH services and the level of provision is provided to customers as part of their sign up to the service. A welcome pack is provided with relevant details. Signs are also in situ in communal areas.
The NRT service undertake a perimeter check where possible nightly across the properties that are covered. This consists of a walk around the building, checking any safety issues, ensuring doors are closed and secured, emergency lighting is working, barriers are working, no damage and no intruders in the vicinity. At some services, the NRT have also supported customers who have been locked out of the building to gain entrance when available. This is supported at Dorset Lodge on occasion. CCTV is not ‘monitored’ through the night but there is currently remote access which can be viewed/accessed if required. We are currently undertaking a review of our NRT offer which we hope will allow for greater physical presence across sites through the evening. NRT have been asked to be present as an additional measure at Dorset Lodge for a couple of hours per night where possible due to a recent increase in activity during March of visitors and some concerns of ASB (Anti-Social Behaviour) which are not related to the concerns highlighted in the inquest of Mr Drakes. This is to determine where this is happening and who is responsible so action can be taken where appropriate. As an organisation we do this as a matter of course when concerns are made known to us. This was identified through routine night checks.
Since this increased presence we have seen a decrease in unauthorised visitors at Dorset Lodge and no recent reports of ASB. In liaising with the Police, they have also corroborated this. The Police have informed us that the Homelessness community tend to travel around properties which are linked to their community to find places to congregate in the evenings. Due to the increased physical presence of the NRT this has been a deterrent. As mentioned earlier as part of the NRT development we will be working to enhance evening presence as we know this is working well.
1.2 Relating to Agency staff support. When a support worker is on leave, where possible key worker sessions are allocated to another member of the team in the first instance.
Agency members do not routinely undertake key working as normally this cover is short term, ad hoc and may not be a consistent person. However, they do still offer housing related support to customers during their shift. This would normally consist of support with forms, signposting, assisting with phone calls and meetings, dealing with ASB and escalating any issues/concerns. As a temporary one-off placement traditional ‘key working’ is not undertaken as the agency worker would not have access to the history records or have a built relationship with customers.
BCHA has an internal relief bank which are BCHA employed staff who cover vacancies and sickness. The benefits of relief workers are that they undertake all BCHA training, are more consistent and familiar with services and have access to BCHA systems and records. In the first instance cover is preferred from the relief bank rather than agency due to this. We are aiming to increase our relief offer which will improve customers experience during period of staff absence.
Where we know that cover is needed more long term (e.g., while recruiting) and relief is unavailable we aim to secure agency staff on longer term contracts. In these scenarios we are able to offer internal BCHA training and give access to our systems which allows agency workers to undertake key working. All of our agency staff are secured through regulated providers.
Recruitment and retention are a key focus for the BCHA Executive and Board – a report on the issues and impact of this is discussed as part of risk management meetings and is monitored closely by the Director responsible for People Services. The relief and agency bank management has recently merged into the HR department to better align to our recruitment and retention planning. This will allow us to be even more responsive in planning for gaps as we are aware of them.
Unfortunately, the inquest did not hear fully the support offered to Mr Drakes. In the year leading up to Mr Drakes death there were 113 Support Plans completed by BCHA. There were also numerous risk assessments, outcomes stars and meetings with professionals. Mr Drakes was also being supported by BCP Housing, We Are With You and Adult Social Care and was discussed regularly at link meetings. Mr Drakes case was taken 10 times to the BCHA Homelessness Prevention Panel, where support to maintain his tenancy was provided. Although we can see there had been agency cover at Dorset Lodge throughout Mr Drakes stay there is no evidence that this impacted on his support and contacts were consistent. There is also evidence that both Senior Practitioners had been active in supporting case management.
Through reflecting on Mr Drakes support we feel that there would be benefits in focusing on how we can enhance our work with partners and escalate where agencies do not attend professionals’ meetings. We have already discussed this with Adult Social Care (ASC) and will be making an amendment to our procedures on this. ASC have also offered further support and guidance to agencies on how to escalate issues and develop further understanding of the process to this. We are also rolling out safeguarding training for managers which will reinforce this action.
BCP will be considering the role of a strategic meeting where cases which are complex can be discussed and be escalated to, both Social Care and We are with You are supportive of this approach.
1.3 Entry and Exit monitoring.
Dorset Lodge is not a secure unit setting and customers are free to have friends and family visit their home to ensure they have a social circle and do not feel isolated. The license agreement allows for visitors and these guests are the responsibility of the tenant during this time. The license agreement is clear on the rules around visitors and ASB related matters and the tenants' responsibilities regarding this. During staffed times visitors are not monitored by staff and tenants are required to greet guests when they arrive.
Residents at Dorset Lodge often still have connections with the Homeless community. On occasion (e.g., when the weather is adverse) customers may allow access to those rough sleeping. In these circumstances we work closely with rough sleeper outreach teams / St Mungos to seek emergency support. BCHA also offer SWEP (Severe Weather Emergency Placements) to those in need at an additional service where customers are supported to emergency access. In rare circumstances it would be expected that customers contact the police if there are unwanted guests, they are also able to notify NRT who will respond when they are able to. Customers are also encouraged to report any concerns regarding ASB so this can be investigated in line with policies. A greater presence of NRT onsite also helps to tackle this.
Tenancy Officers have reminded customers of their license agreements and the action they should take to report ASB. There are regular House Meetings where H&S and Issues can be discussed and/or through key working. We are reviewing our policy on House Meetings and will be introducing a new consistent agenda and guidelines for undertaking house meetings as part of our quality assurance work. This will offer further opportunities to discuss any onsite issues. We will also be further focussed on developing our relationships with partners to support the wider community and signpost those who are rough sleeping and looking for shelter.
1.4 Issues with ASB, access and welfare checks.
Dorset Lodge is not a secure living facility and there is no requirement on site for customers to complete a signing in book, guests are always the responsibility of tenants. As an HMO there is no requirement for a signing in book for fire safety reasons. Dorset Lodge is fully fire compliant as per legislation.
Illegal Drug use is not permitted at Dorset Lodge, and this is stipulated within the license agreement. As an organisation we recognise that some of our customers are in active addiction or have a history of this. At the referral stage we work with housing colleagues to discuss risks and mitigations so that we are able to accept people safely. We expect any drug use to be offsite and provide sharps bins for safe disposal. We also work with other specialist agencies who support customers more broadly with their needs. We have recently reviewed licenses with customers to remind them of the expectations while accommodated at Dorset Lodge.
Staff are trained in how to administer Naloxone and customers are also supported by We are with you to access Naloxone and supported on administration methods. Customers are advised at sign up that staff may administer Naloxone if they believe, and overdose has occurred.
Welfare checks are undertaken throughout the day as an opportunity to ‘check in’ with customers, introduce staff between handover shifts and offer support. These check-ins also serve as an opportunity to support those experiencing isolation and encourage involvement in activities. A welfare check log is completed which records when customers are seen and spoken too.
Welfare checks of three times per day is a historical routine and for Dorset Lodge which had never changed even when the service was remodelled to a Monday to Friday offer his is in part as it also serves as an opportunity to chat with customers and is something that customers have become used to as part of the daily routine. We understand that the language of ‘welfare checks’ and their current structured delivery of Monday – Friday 3 times per day and not at weekends seems contradictory to a low support service. We have discussed this with commissioners and will be adjusting the language around this, so it better reflects our approach and their purpose.
We are reviewing all personal safety plans with our customers to remind them of their arrangements/strategies for support out of hours. This is done periodically through key working or when risk changes however we are undertaking an additional focused review on this with our current customers.
A letter has been issued to customers to remind them of their responsibilities as per their license conditions. In addition to the additional NRT support mentioned above, additional meetings will be held with all residents by the Housing officer to discuss ASB issues and reporting of this. Regular meetings are also available from Housing Officer and Senior Practitioner to review ASB and associated actions are also undertaken through monthly House Meetings.
1.5 Room security.
The room was secured on Monday 14th April when staff were present, and a full lock change was undertaken on 17th November. Normally we would be contacted by Police or Residents when an
incident occurs – we would then send out a contractor straight away to secure premises. In this instance we were not notified which is highly unusual. We understand that the Police did not attend at the weekend and the first visit was on 17th November although they were notified of security breaches on the 12th November by a customer.
A laptop was taken from Mr Drakes room by another customer for safekeeping and it is believed that this is in police possession. Sharps boxes are supplied to customers to dispose of needles for health and safety purposes. Responses relating to drug use can be found further in section1.4.
We have discussed OOH arrangements with customers again and asked that they contact OOH Repairs and Maintenance or NRT if there are any incidents during the evenings and weekends. We will also be doing more work to remind customers of how to get in touch out of hours across all of our stock. Signage has been further improved in the reception area of Dorset Lodge to this effect.
1.6 Issues with accessing the OOH number and entry to the building.
We do not know exactly what time the family tried to call the OOH number on Monday 14th November or what number they called and have been unable to investigate this at the time of writing this report. We have reached out to the family to offer to meet with them so we can investigate this and any other questions they may have.
The NRT number is listed outside of the property but is only answered between 8pm and 8am. The number listed outside is the correct NRT number and is a working number. This has been tried on several occasions. As mentioned previously the NRT is staffed by two members of staff who cover a number of premises. There is an answerphone option to leave a message for a call to be returned.
As with all HMO’s and unstaffed properties, customers can let emergency services in if needed. There is a pad on the front door to call through to other homes. It would not be possible to allow free access into the building for security reasons. This would not be a unique situation for emergency services and is reflective of other HMOs/Apartments without staff or security on site. Dorset Lodge is able to be opened remotely by NRT also if they are contacted and are available.
We currently have a quarterly meeting with the Fire Service to look at prevention and joined up working. Our lead for Housing will be reaching out to Police and Ambulance colleagues to see if we can set up a similar joined up meeting to develop our relationships and see if there is more, we can put in place OOH.
1.7 The incident occurring over the weekend when staff were not onsite.
Moving Mr Drakes to a 24/7 staffed site had been considered and there were reasons why this was not deemed suitable by Mr Drakes and his multi-agency support. Mr Drakes’ housing status was a regular feature of discussions and review both with partners and with Mr Drakes. Mr Drakes also expressed his preference to remain at Dorset Lodge.
At a recent partnership meeting with We Are With You and The Social Care Manager of the team which was supporting Mr Drakes we further reflected on the challenges with a move and Mr Drakes stay at Dorset Lodge. We Are With You confirmed that overdose and Naloxone use / administration is spoken to with clients by clinicians as a standard risk management feature as part of their support and can be prescribed for use by friends of customers who use opiates and other close circles of support should they overdose. We Ae With you have agreed to be part of link meetings moving forwards which will also help in suitability of placements right at the outset of the referral stage.
There is an out of hours duty team for adult social care which can also support with increased risk over the evening and weekends for those who are not based in 24/7 services. This can be factored into risk management planning. This is something which can be further considered through strategic partnership meetings moving forwards. Risk is often dynamic with circumstances changing for individuals from month to month. We will be further working with our partners on how we manage this dynamic risk through link and strategic meetings.
1.8 Professionals meeting not going ahead.
BCHA did organise a professionals meeting on 9th September for Mr Drakes, the purpose of the meeting was to discuss Mr Drakes maintaining his tenancy. A regular feature of this meeting would have also included his support needs and the relevance of 24/7 placement. BCP Housing, Social Worker and We Are With You (Substance Support) were not able to attend. The meeting for Mr Drakes was not rearranged immediately as the risk around his tenancy had been mitigated and was no longer an issue. Although the meeting did not go ahead there were subsequent conversations on Mr Drakes housing & needs between the professional's group on an individual basis.
Mr Drakes social worker did not feel it was appropriate to place him in a high support unit such as t this ran a risk of escalating his drug use even further and came with additional risks As mentioned earlier link meetings are being reviewed to offer enhanced support re escalation. We have also provided safeguarding managers training for service managers and above to ensure escalation routes are clear and happen in a timely way.
All of the actions which have been included in the review have been incorporated into a Quality Improvement plan for the service which has been agreed and shared with BCP commissioners. These actions will be monitored as part of team development plans and commissioning meetings. We believe that the additional information provided, coupled with the actions we are taking alongside our partner agencies, Adult Social Care and We Are With You, address the concerns which you highlighted.
I am writing in response to your letter dated 15th March where you set out your concerns arising from the inquest into the death of Mr Tarik Drakes. You asked that BCHA take action regarding the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge with consideration being given to reviewing the current levels of staffing and supervision at the placement. Firstly, we would like to extend our condolences to the family of Mr Drakes, we have also reached out to them directly to provide the opportunity to meet with us if they have any further questions.
1.1 Relating to the service provision. As you are aware from the inquest, the service at Dorset Lodge provides housing with some support. The support that we provide is directly commissioned by Bournemouth, Christchurch and Poole Council (BCP)which consists of temporary housing for people experiencing homelessness. The service is not an exclusive accommodation to support drugs and alcohol addictions, although some customers are experiencing these issues. Customers can find themselves homeless because of many issues and quite often require a range of different supports from various statutory and non-statutory agencies. BCHA is commissioned to provide customers with Housing related support. Support workers do not undertake care planning as the service is not regulated with CQC. Housing related support consists of support to apply for benefits, move on accommodation and sign posting to other services which can support broader customer needs. The purpose of the support is to help customers to gain independence, so they are better able to move on into permanent accommodation and maintain a tenancy.
The funding commissioned provides support staff to be on site from 8.00am until 8.00pm Monday to Friday. As part of this review process, we have met with Colleagues from BCP Housing and Commissioning team, BCP Adult Social Care and We are with you, all of whom played a role in supporting Mr Drakes while he was a resident of Dorset Lodge. There is a partnership approach to assessing customers suitability for the accommodation and risk assessing customer's needs. This is done through link meetings with BCP Housing Teams and with other housing providers to discuss the best possible placement. At the referral phase information is gathered on what support agencies are involved with the customer to address their broader health and wellbeing needs. Both new referrals and existing placements are discussed to assess whether needs have changed and if other agencies are required to support. This could include adult social care or drug and alcohol services where relevant. The Council is in the process of reviewing the Link meetings and will be taking into account this report to reflect on any improvements which can be made to this process and the management of risk through this forum. In addition, We are With You have agreed to attend Link meetings to ensure Drug and Alcohol related issues are further discussed and supported at the referral stage. Link meetings are an operational meeting held on a fortnightly basis to provide a forum for providers to share good practice, challenges and discuss individual cases that may be at risk of losing their tenancy or needing to move on from their current service.
Adult Social Care have offered to support these meetings if appropriate to support risk management. This support can also facilitate escalation where agencies may not have consistent attendance to professionals / Multi Agency Risk Management meetings or where further support is needed. ‘We Are with You Drug and Alcohol Service have also committed to sending a representative for future meetings.
Dorset Lodge is not commissioned to provide support or keyworking over the weekend. The Saturday role is an ‘added value’ role. The role is an activity coordination role to give customers something to do over the weekend. E.g. the role may undertake cooking activities or arts and crafts. This role is not funded and is used ad hoc throughout the year. Customers who are referred and assessed to live at Dorset Lodge are deemed through link meetings as suitable for the level of support available. Alternative 24/7 staffed accommodation is available for those with greater needs at St Pauls in Bournemouth. Customers also have a right to choose where they live and determine what support they would like to engage with. Customers' needs and risks can change over time, link meetings and professional meetings provide an opportunity to respond to this risk based on the expertise of those supporting the individual. Through review of Mr Drakes support alternative 24/7 accommodation was considered numerous
times however this was either deemed as unsuitable by his social worker nor was it accepted by Mr Drakes.
The Out of Hours Service (OOH) service consists of Repairs and Maintenance for anything deemed Emergency / Critical e.g., Flood/Gas Leaks and in addition there is a Night Response Team (NRT) which is a concierge and security service funded through service charges. This service is a responsive service where customers can call for assistance with security matters or when there are any incidents e.g., Anti-Social Behaviour. There are 2 people on shift each night covering a small number of properties. There is an answerphone service where customers can leave a message and request a call back if the night officers are busy / engaged. Details of OOH services and the level of provision is provided to customers as part of their sign up to the service. A welcome pack is provided with relevant details. Signs are also in situ in communal areas.
The NRT service undertake a perimeter check where possible nightly across the properties that are covered. This consists of a walk around the building, checking any safety issues, ensuring doors are closed and secured, emergency lighting is working, barriers are working, no damage and no intruders in the vicinity. At some services, the NRT have also supported customers who have been locked out of the building to gain entrance when available. This is supported at Dorset Lodge on occasion. CCTV is not ‘monitored’ through the night but there is currently remote access which can be viewed/accessed if required. We are currently undertaking a review of our NRT offer which we hope will allow for greater physical presence across sites through the evening. NRT have been asked to be present as an additional measure at Dorset Lodge for a couple of hours per night where possible due to a recent increase in activity during March of visitors and some concerns of ASB (Anti-Social Behaviour) which are not related to the concerns highlighted in the inquest of Mr Drakes. This is to determine where this is happening and who is responsible so action can be taken where appropriate. As an organisation we do this as a matter of course when concerns are made known to us. This was identified through routine night checks.
Since this increased presence we have seen a decrease in unauthorised visitors at Dorset Lodge and no recent reports of ASB. In liaising with the Police, they have also corroborated this. The Police have informed us that the Homelessness community tend to travel around properties which are linked to their community to find places to congregate in the evenings. Due to the increased physical presence of the NRT this has been a deterrent. As mentioned earlier as part of the NRT development we will be working to enhance evening presence as we know this is working well.
1.2 Relating to Agency staff support. When a support worker is on leave, where possible key worker sessions are allocated to another member of the team in the first instance.
Agency members do not routinely undertake key working as normally this cover is short term, ad hoc and may not be a consistent person. However, they do still offer housing related support to customers during their shift. This would normally consist of support with forms, signposting, assisting with phone calls and meetings, dealing with ASB and escalating any issues/concerns. As a temporary one-off placement traditional ‘key working’ is not undertaken as the agency worker would not have access to the history records or have a built relationship with customers.
BCHA has an internal relief bank which are BCHA employed staff who cover vacancies and sickness. The benefits of relief workers are that they undertake all BCHA training, are more consistent and familiar with services and have access to BCHA systems and records. In the first instance cover is preferred from the relief bank rather than agency due to this. We are aiming to increase our relief offer which will improve customers experience during period of staff absence.
Where we know that cover is needed more long term (e.g., while recruiting) and relief is unavailable we aim to secure agency staff on longer term contracts. In these scenarios we are able to offer internal BCHA training and give access to our systems which allows agency workers to undertake key working. All of our agency staff are secured through regulated providers.
Recruitment and retention are a key focus for the BCHA Executive and Board – a report on the issues and impact of this is discussed as part of risk management meetings and is monitored closely by the Director responsible for People Services. The relief and agency bank management has recently merged into the HR department to better align to our recruitment and retention planning. This will allow us to be even more responsive in planning for gaps as we are aware of them.
Unfortunately, the inquest did not hear fully the support offered to Mr Drakes. In the year leading up to Mr Drakes death there were 113 Support Plans completed by BCHA. There were also numerous risk assessments, outcomes stars and meetings with professionals. Mr Drakes was also being supported by BCP Housing, We Are With You and Adult Social Care and was discussed regularly at link meetings. Mr Drakes case was taken 10 times to the BCHA Homelessness Prevention Panel, where support to maintain his tenancy was provided. Although we can see there had been agency cover at Dorset Lodge throughout Mr Drakes stay there is no evidence that this impacted on his support and contacts were consistent. There is also evidence that both Senior Practitioners had been active in supporting case management.
Through reflecting on Mr Drakes support we feel that there would be benefits in focusing on how we can enhance our work with partners and escalate where agencies do not attend professionals’ meetings. We have already discussed this with Adult Social Care (ASC) and will be making an amendment to our procedures on this. ASC have also offered further support and guidance to agencies on how to escalate issues and develop further understanding of the process to this. We are also rolling out safeguarding training for managers which will reinforce this action.
BCP will be considering the role of a strategic meeting where cases which are complex can be discussed and be escalated to, both Social Care and We are with You are supportive of this approach.
1.3 Entry and Exit monitoring.
Dorset Lodge is not a secure unit setting and customers are free to have friends and family visit their home to ensure they have a social circle and do not feel isolated. The license agreement allows for visitors and these guests are the responsibility of the tenant during this time. The license agreement is clear on the rules around visitors and ASB related matters and the tenants' responsibilities regarding this. During staffed times visitors are not monitored by staff and tenants are required to greet guests when they arrive.
Residents at Dorset Lodge often still have connections with the Homeless community. On occasion (e.g., when the weather is adverse) customers may allow access to those rough sleeping. In these circumstances we work closely with rough sleeper outreach teams / St Mungos to seek emergency support. BCHA also offer SWEP (Severe Weather Emergency Placements) to those in need at an additional service where customers are supported to emergency access. In rare circumstances it would be expected that customers contact the police if there are unwanted guests, they are also able to notify NRT who will respond when they are able to. Customers are also encouraged to report any concerns regarding ASB so this can be investigated in line with policies. A greater presence of NRT onsite also helps to tackle this.
Tenancy Officers have reminded customers of their license agreements and the action they should take to report ASB. There are regular House Meetings where H&S and Issues can be discussed and/or through key working. We are reviewing our policy on House Meetings and will be introducing a new consistent agenda and guidelines for undertaking house meetings as part of our quality assurance work. This will offer further opportunities to discuss any onsite issues. We will also be further focussed on developing our relationships with partners to support the wider community and signpost those who are rough sleeping and looking for shelter.
1.4 Issues with ASB, access and welfare checks.
Dorset Lodge is not a secure living facility and there is no requirement on site for customers to complete a signing in book, guests are always the responsibility of tenants. As an HMO there is no requirement for a signing in book for fire safety reasons. Dorset Lodge is fully fire compliant as per legislation.
Illegal Drug use is not permitted at Dorset Lodge, and this is stipulated within the license agreement. As an organisation we recognise that some of our customers are in active addiction or have a history of this. At the referral stage we work with housing colleagues to discuss risks and mitigations so that we are able to accept people safely. We expect any drug use to be offsite and provide sharps bins for safe disposal. We also work with other specialist agencies who support customers more broadly with their needs. We have recently reviewed licenses with customers to remind them of the expectations while accommodated at Dorset Lodge.
Staff are trained in how to administer Naloxone and customers are also supported by We are with you to access Naloxone and supported on administration methods. Customers are advised at sign up that staff may administer Naloxone if they believe, and overdose has occurred.
Welfare checks are undertaken throughout the day as an opportunity to ‘check in’ with customers, introduce staff between handover shifts and offer support. These check-ins also serve as an opportunity to support those experiencing isolation and encourage involvement in activities. A welfare check log is completed which records when customers are seen and spoken too.
Welfare checks of three times per day is a historical routine and for Dorset Lodge which had never changed even when the service was remodelled to a Monday to Friday offer his is in part as it also serves as an opportunity to chat with customers and is something that customers have become used to as part of the daily routine. We understand that the language of ‘welfare checks’ and their current structured delivery of Monday – Friday 3 times per day and not at weekends seems contradictory to a low support service. We have discussed this with commissioners and will be adjusting the language around this, so it better reflects our approach and their purpose.
We are reviewing all personal safety plans with our customers to remind them of their arrangements/strategies for support out of hours. This is done periodically through key working or when risk changes however we are undertaking an additional focused review on this with our current customers.
A letter has been issued to customers to remind them of their responsibilities as per their license conditions. In addition to the additional NRT support mentioned above, additional meetings will be held with all residents by the Housing officer to discuss ASB issues and reporting of this. Regular meetings are also available from Housing Officer and Senior Practitioner to review ASB and associated actions are also undertaken through monthly House Meetings.
1.5 Room security.
The room was secured on Monday 14th April when staff were present, and a full lock change was undertaken on 17th November. Normally we would be contacted by Police or Residents when an
incident occurs – we would then send out a contractor straight away to secure premises. In this instance we were not notified which is highly unusual. We understand that the Police did not attend at the weekend and the first visit was on 17th November although they were notified of security breaches on the 12th November by a customer.
A laptop was taken from Mr Drakes room by another customer for safekeeping and it is believed that this is in police possession. Sharps boxes are supplied to customers to dispose of needles for health and safety purposes. Responses relating to drug use can be found further in section1.4.
We have discussed OOH arrangements with customers again and asked that they contact OOH Repairs and Maintenance or NRT if there are any incidents during the evenings and weekends. We will also be doing more work to remind customers of how to get in touch out of hours across all of our stock. Signage has been further improved in the reception area of Dorset Lodge to this effect.
1.6 Issues with accessing the OOH number and entry to the building.
We do not know exactly what time the family tried to call the OOH number on Monday 14th November or what number they called and have been unable to investigate this at the time of writing this report. We have reached out to the family to offer to meet with them so we can investigate this and any other questions they may have.
The NRT number is listed outside of the property but is only answered between 8pm and 8am. The number listed outside is the correct NRT number and is a working number. This has been tried on several occasions. As mentioned previously the NRT is staffed by two members of staff who cover a number of premises. There is an answerphone option to leave a message for a call to be returned.
As with all HMO’s and unstaffed properties, customers can let emergency services in if needed. There is a pad on the front door to call through to other homes. It would not be possible to allow free access into the building for security reasons. This would not be a unique situation for emergency services and is reflective of other HMOs/Apartments without staff or security on site. Dorset Lodge is able to be opened remotely by NRT also if they are contacted and are available.
We currently have a quarterly meeting with the Fire Service to look at prevention and joined up working. Our lead for Housing will be reaching out to Police and Ambulance colleagues to see if we can set up a similar joined up meeting to develop our relationships and see if there is more, we can put in place OOH.
1.7 The incident occurring over the weekend when staff were not onsite.
Moving Mr Drakes to a 24/7 staffed site had been considered and there were reasons why this was not deemed suitable by Mr Drakes and his multi-agency support. Mr Drakes’ housing status was a regular feature of discussions and review both with partners and with Mr Drakes. Mr Drakes also expressed his preference to remain at Dorset Lodge.
At a recent partnership meeting with We Are With You and The Social Care Manager of the team which was supporting Mr Drakes we further reflected on the challenges with a move and Mr Drakes stay at Dorset Lodge. We Are With You confirmed that overdose and Naloxone use / administration is spoken to with clients by clinicians as a standard risk management feature as part of their support and can be prescribed for use by friends of customers who use opiates and other close circles of support should they overdose. We Ae With you have agreed to be part of link meetings moving forwards which will also help in suitability of placements right at the outset of the referral stage.
There is an out of hours duty team for adult social care which can also support with increased risk over the evening and weekends for those who are not based in 24/7 services. This can be factored into risk management planning. This is something which can be further considered through strategic partnership meetings moving forwards. Risk is often dynamic with circumstances changing for individuals from month to month. We will be further working with our partners on how we manage this dynamic risk through link and strategic meetings.
1.8 Professionals meeting not going ahead.
BCHA did organise a professionals meeting on 9th September for Mr Drakes, the purpose of the meeting was to discuss Mr Drakes maintaining his tenancy. A regular feature of this meeting would have also included his support needs and the relevance of 24/7 placement. BCP Housing, Social Worker and We Are With You (Substance Support) were not able to attend. The meeting for Mr Drakes was not rearranged immediately as the risk around his tenancy had been mitigated and was no longer an issue. Although the meeting did not go ahead there were subsequent conversations on Mr Drakes housing & needs between the professional's group on an individual basis.
Mr Drakes social worker did not feel it was appropriate to place him in a high support unit such as t this ran a risk of escalating his drug use even further and came with additional risks As mentioned earlier link meetings are being reviewed to offer enhanced support re escalation. We have also provided safeguarding managers training for service managers and above to ensure escalation routes are clear and happen in a timely way.
All of the actions which have been included in the review have been incorporated into a Quality Improvement plan for the service which has been agreed and shared with BCP commissioners. These actions will be monitored as part of team development plans and commissioning meetings. We believe that the additional information provided, coupled with the actions we are taking alongside our partner agencies, Adult Social Care and We Are With You, address the concerns which you highlighted.
Report Sections
Investigation and Inquest
On the 8th December 2022, an investigation was commenced into the death of Tarik Roger Drakes, born on the 25th November 1978. The investigation concluded at the end of the Inquest on the 14th March 2023. The Medical Cause of Death was: Ia Opiate toxicity The conclusion of the Inquest was drug related.
Circumstances of the Death
On the 12th November 2022 the deceased, who had a history of using heroin, was found in a collapsed and unresponsive condition in his room at his place of residence which was Room 14 Dorset Lodge, 10 Suffolk Road, Bournemouth. He was taken to the Royal Bournemouth Hospital, Bournemouth where he was found to be in multi organ failure and despite treatment his condition deteriorated, and he died on the 29th November 2022.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.