Tarik Drakes

Rachel C Griffin  
The Coroner’s Office for the County of Dorset. 
Civic Centre, 
Bourne Avenue, 
Bournemouth 
BH2 6DY 

17th May 2023 

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.  

Yours sincerely,  

Chief Operating Officer