Peabody Trust (202128489)

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REPORT

COMPLAINT 202128489

Peabody Trust

22 February 2024


Our approach

The Housing Ombudsman’s approach to investigating and determining complaints is to decide what is fair in all the circumstances of the case. This is set out in the Housing Act 1996 and the Housing Ombudsman Scheme (the Scheme). The Ombudsman considers the evidence and looks to see if there has been any ‘maladministration’, for example, whether the landlord has failed to keep to the law, followed proper procedure, followed good practice, or behaved in a reasonable and competent manner.

Both the resident and the landlord have submitted information to the Ombudsman, and this has been carefully considered. Their accounts of what has happened are summarised below. This report is not an exhaustive description of all the events that have occurred in relation to this case, but an outline of the key issues as a background to the investigation’s findings.

The complaint

  1. The complaint is about the landlord’s handling of the resident’s:
    1. Reports of a leak.
    2. Reports of damp and mould following the leak.
    3. Formal complaint.
  2. The Ombudsman has also considered the landlord’s knowledge and information management.

Background and summary of events

Background

  1. The resident is an assured tenant of the property, which is a 3-bedroom house. The landlord is a housing association. The resident has told the landlord and this Service that she has physical and mental health conditions and is disabled, however, the landlord has said it does not have these recorded.
  2. The landlord has been unable to provide a copy of the resident’s tenancy agreement. However, section 11 of the Landlord and Tenant Act 1985 inserts into the tenancy a clause that the landlord is to keep in repair the structure and exterior of the property, and to keep in repair and proper working order the installations for the supply of water.
  3. Under the landlord’s repairs policy it sets out 6 repair categorisations with different timeframes. It will attend emergency repairs within 4 hours, will complete non-urgent repairs within 28 days and specialist works within 60 days. Under the policy the landlord is responsible for repairing roofs and leaks, and the resident is responsible for internal decoration. The landlord introduced a damp and mould policy in February 2023, which was after the events leading up to the complaint.
  4. The Housing Act 2004 introduced the Housing Health and Safety Rating System (HHSRS). One of the 29 identified hazards is damp and mould. Landlords have an obligation to minimise or remove the identified hazards.
  5. Under the landlord’s complaints procedure, the landlord defines a complaint as an expression of dissatisfaction. It has a 2-stage process. It will acknowledge stage 1 complaints within 3 working days and will respond within 10 working days. When it cannot it will explain this to the resident and say when it will respond. The landlord will acknowledge stage 2 complaints within 3 working days and respond within 15 working days. The landlord has not provided a copy of its complaints policy in use at the time to this Service. It has provided its current updated policy.
  6. The Housing Ombudsman’s Complaint Handling Code (the Code) sets out how a landlord should respond to complaints. Under paragraph 5.1 a landlord should respond to a stage 1 complaint within 10 working days. If it needs a further 10 working days in exceptional circumstances, it must contact the resident to explain this. Any further delay beyond this must be agreed with the resident. The landlord should address all elements of the resident’s complaint within its response (paragraph 5.8). It should escalate the complaint if asked to do so by the resident (paragraph 5.10) and should respond within 20 working days (paragraph 5.13).
  7. Under the landlord’s compensation policy it can consider offering compensation for service failure, which resulted in a delay or additional costs for the resident. It also says “an appropriate remedy should always include a sincere and well worded apology” and it will ‘make good’ decoration following a repair. The policy sets out example compensation amount bands and the criteria for these amounts.
  8. The Housing Ombudsman’s spotlight report on Knowledge and Information Management sets out 21 recommendations to help landlords improve their management of knowledge and information. These include developing an organisational key data recording standard to set out the minimum standard to which data must be entered in the landlord’s databases.

Summary of events

  1. The resident reported a leak from her roof on or around 5 May 2021. This is not disputed by the landlord, but it has not provided any evidence of the report to this Service.
  2. The landlord’s contractor attended on 20 May 2021 but did not report back to the landlord until 10 June 2021. The contractor erected scaffolding on 21 August 2021 and carried out a further inspection of the roof on 23 August 2021. The events following the resident’s report are not disputed, but the landlord has not provided any evidence of what took place to this Service.
  3. On 8 November 2022 the landlord’s records say it booked an appointment for its surveyor and the contractor to attend on 16 November 2021. The following day the landlord raised a job for the contractor to quote for the works identified. The landlord’s records show that its contractor completed the roof works on 13 December 2021, but reported that further works were needed to the chimney on 18 December 2021. The landlord approved the works, and these were completed on 30 December 2021.
  4. The resident called the contractor on 2 January 2022 and said there was a leak coming through the ceiling and her external overflow pipe was flowing. The contractor attended that night, although the resident disputes having agreed to an appointment. There is dispute over who called the landlord’s out of hours service, but it attended and discovered a problem with a ball valve in a water tank in the loft, and this is what had caused the overflow and leak. The out of hours contractor repaired the issue. The landlord has not provided any records for its out of hours repair.
  5. The resident used the landlord’s online complaints form to make a stage 1 complaint on 8 February 2022. She said she had been trying to contact the landlord since 5 January 2022 and had not been able to. The scaffolding had been up for over 6 months, and she still believed there was a leak into her bedroom. She said the landlord was not communicating with her and mentioned her health conditions and that the stress of the repairs was making them worse.
  6. The resident used the landlord’s online complaints form again on 23 February 2022 to make a second complaint. She said she had already made her complaint and spoken to the landlord, but nothing had happened since. The landlord has not provided any evidence of its contact with the resident following her complaint. The landlord emailed the resident on 25 February 2022 and said her repair was already “open and actively being addressed” by its surveying team.
  7. The resident called the landlord on 17 March 2022 to chase her repair and her complaint response. In an internal note the landlord said it had passed her enquiry to its disrepair team to respond to her solicitor. (The resident had previously raised a disrepair claim for other matters which was settled in 2020.) On 23 March 2022 the resident used the landlord’s online complaints form again to make a third complaint. She said she still had not had any contact from the landlord’s surveying team, no appointments, and no updates. The scaffolding was still up, and she still had a leak.
  8. After being contacted by the resident the Ombudsman emailed the landlord on 21 April 2021 and asked it to provide a stage 1 response. The landlord called the resident the following day. Its note of the call says the resident said her roof leaked when it rained, and the scaffolding was still up. She said the landlord attended on 15 February 2022 to inspect; however, the landlord has not provided any evidence of this. She said she had not had any communication from the landlord. She also said the contractor had damaged her garden storage boxes and had caused the water tank leak in the loft. In response, the landlord sent an internal email to ask what it needed to do to resolve the leak.
  9. Between 25 and 29 April 2022 the landlord exchanged emails with the contractor. It asked the contractor to carry out and film a test to check if the roof was leaking, and if no leak was found, to strike, or take down, the scaffolding. The landlord emailed the resident to confirm an appointment, and the contractor attended. The contractor emailed the landlord, and said the roof was in good condition with no leak. It also said the resident agreed there was no leak, but that she wanted the landlord to repair the damp and mould in the property. The landlord raised a repair for damp and mould.
  10. The landlord’s contractor attended to inspect the damp and mould on 11 May 2022 and reported back on 24 May 2022 that the landlord should check for a leak. It said the leak had caused a big bow in the ceiling, that the ceiling would need to be taken down and replaced, and that there was still scaffolding up.
  11. On 20 June 2022 the landlord called the resident and its note of the call says she was unhappy about its lack of communication. She said the damp patches in her bedroom were getting worse and there was a strong smell of damp. She also said the scaffolding was still up and had been for over a year. The landlord said it had asked if it could arrange a drone survey. Following the call, the resident emailed the landlord and asked to escalate her complaint to stage 2.
  12. On the same day the landlord emailed the contractor about the scaffolding. The contractor replied that it had had a no access but the resident had disputed this. It said it would arrange another date to strike the scaffolding. The landlord also discussed the repairs in internal emails, with it concluding that the damp issues in the bedroom were due to the previous “extensive leak” from the water tank in the loft, which had been resolved.
  13. On 21 June 2022 the contractor emailed the landlord to confirm it had struck the scaffolding that day. It also said it had water tested the roof on 28 April 2022 and there was no leak (no evidence has been provided to this Service of a water test on this date). The landlord raised a new repair to detect for a leak.
  14. Also on 21 June 2022 the landlord provided its stage 1 complaint response to the resident. It said:
    1. It was an update to her complaint, as she had asked to escalate to stage 2.
    2. Its contractor inspected her roof and loft on 28 April 2022 and did not find any leaks.
    3. Its contractor had attended to strike the scaffolding but there had been a no access, and it would arrange another date.
    4. It had spoken to her, and she had agreed there was no leak, but the staining on her bedroom ceiling was getting darker. It had recommended a drone survey.
    5. It had a compensation policy for service failure, but it would calculate any compensation once the repairs were complete. It also reminded her that she was in rent arrears and any compensation would be offset.
    6. Her complaint had been escalated to stage 2, but she could still contact the Ombudsman for advice if she wished.
  15. The landlord emailed the resident on 27 June 2022 to acknowledge her stage 2 complaint and advise that it aimed to respond within 15 working days.
  16. On 29 June 2022 the landlord’s contractor attended to search for a leak. It reported back that it had checked the water tank in the loft and all pipework, and there was no leak. It also said a leak had affected the ceiling and walls of the bedroom below.
  17. The landlord called and emailed the resident on 14 July 2022 to apologise for its delay in communications since it acknowledged her stage 2 complaint. It said the due date for its response was 18 July 2022, but it may need to extend this by a further 10 working days and it would agree any further extension with her.
  18. On 5 August 2022 the landlord provided it stage 2 response, in which it:
    1. Set out the background to the complaint, involving the roof leak and water tank leak.
    2. Confirmed it had recorded her complaint after she used its online form on 8 February 2022, but it had not passed this to the correct team until 4 April 2022.
    3. Said while it had suggested a drone survey in its stage 1 response, its surveyor was confident this was not needed and so this did not take place.
    4. Confirmed it was confident there was no ongoing leak, but accepted that decoration works may be needed for the bedroom, and it would inspect this prior to any works.
    5. Admitted that it had not completed the roofing works within its 60-day policy timeframe and agreed it had left scaffolding in place for too long.
    6. Said it had inspected the water damage and agreed to repair the ceiling and redecorate the bedroom within 30 days.
    7. Apologised for the delays in its complaints handling and offered £150 compensation for its delays at stages 1 and 2.
    8. Offered £80 compensation for the damaged garden storage boxes.
    9. Offered £350 compensation for the delays in completing the roof repair and £150 for the delay in removing the scaffolding, totalling £500, which it said was “beyond [its] current published maximum for such failures.”
    10. Offered a total of £730 compensation, with £650 being credited to her rent account which was in arrears, and only £80 for the storage boxes to be paid to her directly.
    11. Gave details on how to contact this Service.

Events after the end of the landlord’s complaints procedure

  1. The landlord’s contractor made an appointment to quote for the decorating works on 11 August 2022, and it provided its quote that day. The resident emailed the landlord following this and said she was told the works would take 4 days and she would not be able to use her bedroom. She said she had back and hip conditions and could not sleep on a sofa for that time. The landlord replied the following day and said it would not offer her a decant as she would be able to sleep in her bedroom. It said it could do the works or ask the contractors to stagger the work over a period of 2 weeks. It said it did not expect her to sleep on a sofa.
  2. The landlord asked the contractor to hold off booking the works in on 15 August 2022, as the resident was seeking advice. The landlord has not provided any evidence to this Service to explain how it knew this.
  3. On 14 December 2022 the resident emailed the landlord and said she had not been given a start date for the works. The landlord emailed the contractor and asked it to book the works in. The contractor replied and said it had spoken to the resident, but she had refused a scoping appointment. It said it needed to reinspect as a long time had passed since it quoted for the works. The resident chased for an appointment again on 5 January 2023 and the contractor booked one for 12 January 2023. However, the contractor told the landlord that the resident had refused the works on that date.
  4. The resident has told the Ombudsman that she did not refuse works on 12 January 2023. She said she is disabled, did not want to sleep in her bedroom with paint fumes and dust, but also could not sleep on her sofa. She said she has been living with, and sleeping in a room with, damp for over 2 and a half years. As at the date of this report the decoration works had still not been completed.

Assessment and findings

The landlord’s handling of the resident’s reports of a leak

  1. Following the resident’s report of a roof leak on or around 5 May 2021 the landlord accepted it was responsible for the repair under its repairs policy and legislation. It arranged for a contractor to attend, but this did not happen until 20 May 2021, some 11 working days later. It would have been reasonable for the landlord to have treated an ingress of water as an emergency under its policy, so it should have attended to inspect within 4 hours, and not doing so was a failing.
  2. It took the landlord’s contractor a further 14 working days to provide its report and there is no evidence the landlord chased it within this period, which it should have. There was a further delay of 52 working days before scaffolding was erected, which was unreasonable. By this point 77 working days had already passed since the resident reported the leak, exceeding the landlord’s policy timeframe of 60 working days for specialist works, which roofing would be classed as, and was a clear failure. Roof works were ultimately completed after 157 working days, in breach of policy, and this was an unacceptable delay.
  3. It is not clear why the resident reported the second leak to the contractor rather than the landlord. She said she also called the landlord and its out of hours contractor attended and repaired the leaking water tank that day, within its emergency repair timeframe under its policy.
  4. Within the resident’s stage 1 complaint of 8 February 2022, she said she had not been able to contact the landlord about her leak and scaffolding was still up. The landlord had not addressed her fears about an ongoing leak, or arranged remedial decoration works. It did not carry out a water test until the end of April 2022 but still delayed in striking the scaffolding until 21 June 2022, which were both unreasonable delays which did not give the resident confidence the leak had been fixed.
  5. In its stage 1 response the landlord said it was confident there was no leak, however also said it would ask for a drone survey to confirm, again displaying a lack of consistency and confidence in the previous works and tests carried out. It checked for a leak again on 29 June 2022, but helpfully reported back that remedial internal works were needed.
  6. The landlord accepted within its stage 2 response that it had not completed the roofing repair within its 60-day timeframe, and that it had left the scaffolding up for too long. It offered £500 compensation, and explicitly said this amount was beyond its maximum. The resident had told this Service that this statement influenced her to accept the compensation offered. While it is possible the landlord’s motive was to show it took is failings seriously but awarding a higher amount, the resident said it felt more like she had to accept the offer. While she knew she could bring her complaint to this Service, it would have been helpful if the landlord had explicitly stated within its response, that acceptance of compensation did not prevent the resident from approaching the Ombudsman.
  7. In relation to the failures identified, the Ombudsman’s role is to consider whether the redress offered by the landlord put things right and resolved the resident’s complaint satisfactorily in the circumstances. In considering this the Ombudsman takes into account whether the landlord’s offer of redress was in line with the Ombudsman’s Dispute Resolution Principles: Be Fair, Put Things Right and Learn from Outcomes, as well as our own guidance on remedies.
  8. The resident had been left with a leaking roof for over half a year, which was an unreasonable and unacceptable period of time. While the landlord did resolve her water tank leak promptly and within its policy timeframe, in failing to remove the scaffolding or address the internal decoration (considered below) the resident was left with little confidence that the leaks had been resolved. There was severe maladministration. An order has been made that the landlord pay an additional £1,000 compensation to reflect the distress, inconvenience, time and trouble caused to the resident.

The landlord’s handling of the resident’s reports of damp and mould following a leak

  1. The resident had a water damaged bedroom ceiling since her roof leak started in May 2021. The water damage was made worse by a leak from the water tank in her loft in December 2021, the damage spread to the walls, and she has told this Service that her hallway ceiling has also been damaged.
  2. It is accepted industry practice that a landlord is to repair internal damage following a leak. Although under the landlord’s repairs policy the resident is responsible for decoration, under its compensation policy the landlord says that it will ‘make good’ decoration following a repair. The landlord was placed on notice of the need to repair and make good the internal water damage when it became aware of a leak in May 2021, and again following the leak in December 2021. However, it failed to raise or carry out any repairs for this. The resident has said the landlord inspected in February 2022, but failed to raise any remedial works at that time.
  3. The landlord was also explicitly told of the need to repair the resident’s bedroom by its contractor in April 2022 when it said she wanted to report the damp and mould. It correctly raised a repair for its contractor to inspect on 11 May 2022, but did not chase up the report before one was provided almost a month after the resident reported damp and mould, which was an unreasonable delay.
  4. The landlord failed to take any action until it spoke to the resident on 20 June 2022, around a month after its contractor reported back. The resident told it the damp was getting worse, and 9 days later its contractor confirmed the water damage and damp. The landlord did nothing further until it issued its stage 2 response on 5 August 2022, in which it said it would both inspect and had inspected the damage, which it would repair within 30 days. It did not give any explanation for why it had not raised or completed the repairs sooner and that was also a failing.
  5. On 11 August 2022 the landlord’s contractor visited to quote for the works. The resident emailed the landlord as she was concerned about not being able to use her bedroom for the 4 days the works were going to take. She clearly explained that she did not want to sleep in the room breathing in dust and paint fumes, but also could not sleep on her sofa due to her mobility disability, however the landlord refused to offer a decant. The landlord did not show that it had taken into account the resident’s disability, as it was required to under the Equality Act 2010, as it quoted its standard practice. The landlord should have considered making a reasonable adjustment to allow for a decant and not doing so was a failing.
  6. While the landlord was correct to ask its contractor to wait before booking an appointment, as the resident was seeking advice, it did not follow this up with the resident or the contractor. Only when the resident emailed it in December 2022 did the landlord try again to arrange the works, when it should have been more proactive. The landlord said the resident refused the works in January 2023, however, the resident has told the Ombudsman that this was not true. In any event, the landlord should have continued to try to resolve the issue.
  7. The disabled resident has been left with a water damaged and damp ceiling and bedroom walls, for a period to date of nearly 3 years. She has had to sleep in her bedroom, as she had nowhere else suitable to sleep. The landlord did not follow its policy, and neglected its obligations to remove or reduce the risks posed by damp and mould under the HHSRS. The resident has also told this Service she had not been able to fully use the room and has not been able to replace her wardrobe as the wall is damp. She feels like the landlord has forgotten her.
  8. Within its stage 1 and 2 responses the landlord failed to address its failings in carrying out remedial, or making good, works to the bedroom or hallway and that was a further failing. Overall, there was severe maladministration, which caused the resident further distress, frustration, and inconvenience. To reflect this an order has been made that the landlord pay £1,500 compensation, which is in line with the Ombudsman’s remedies guidance.

The landlord’s handling of the resident’s formal complaint

  1. The resident used the landlord’s online complaints form to make her stage 1 complaint on 8 February 2022. The landlord however admitted in its stage 2 response that it did not pass the complaint to the correct department until 4 April 2022. It failed to follow its complaints procedure as it did not acknowledge the complaint and did not respond within 10 working days, which is also a breach of paragraph 5.1 of the Code.
  2. After the resident made 2 further complaints using the landlord’s online form, the landlord still failed to acknowledge the complaint made on 8 February 2022, to raise one or 2 new complaints, or to realise its mistakes. This demonstrated that its complaints procedure and processes were simply not working and was a significant failure in its complaints handling. Only after the Ombudsman emailed the landlord on 21 April 2022 did it contact the resident about her complaint.
  3. The landlord provided its stage 1 response on 21 June 2021, which was 41 working days after it was contacted by this Service, and 92 working days after the resident made her complaint. This was an unacceptable and inexcusable delay, and the landlord failed to address it within its stage 1 response which was a further failing. The response also failed to address the complaint, in breach of paragraph 5.8 of the Code, and referred to itself as an update. Unconventionally the landlord agreed to escalate the complaint before it had issued its stage 1 response.
  4. Despite stating within its stage 1 response that it had escalated the complaint, the landlord failed to acknowledge the escalation within its 3 working day procedure timeframe. It acknowledged the escalation on 27 June 2022, and emailed the resident again on 14 July 2022 to say it needed an extension of time, although was already over its 15-day procedure timeframe by that point from the date the resident escalated the complaint. The landlord provided its stage 2 response 34 days after escalation, exceeding its procedure and paragraph 5.13 of the Code and that was a failing.
  5. Within its stage 2 response the landlord admitted its failing in relation to the delay in its stage 1 and 2 responses. It accepted that it had taken too long to fix the roof and had left scaffolding up for too long but did not mention its failings in remedial or making good works. Within its compensation policy the landlord says it should always provide a “sincere and well worded apology” where appropriate. With its stage 2 response the landlord failed to do this. It did not provide any apology and, while it did offer compensation, the nature of its offer was insincere and businesslike. It also failed to demonstrate the Ombudsman’s Dispute Resolution Principles: be fair, put things right, and learn from outcomes. The landlord failed to do this on all counts.
  6. Regarding its handling of the complaint the landlord offered £150 compensation. It did not say how it would prevent similar failings from reoccurring or demonstrate that it wanted to put things right for the additional distress, inconvenience, time and trouble caused to the resident. There was severe maladministration, and an order has been made that the landlord pay additional compensation of £600.

The landlord’s knowledge and information management

  1. A landlord should have systems in place to maintain accurate records of repair reports, responses, inspections, investigations, and communications. Good record keeping is vital to evidence the action a landlord has taken and failure to keep adequate records indicates that the landlord’s processes are not operating effectively. The landlord’s staff should be aware of a landlord’s record management policy and procedures and adhere to these.
  2. This report has identified where the landlord has not recorded its or its contractors’ actions or has not provided evidence to this Service. In addition, its poor management of its records meant that a stage 1 complaint was not passed to the correct department, and information was passed to an incorrect department, adding to complaint handling delays.
  3. Lack of accurate records hampered the landlord’s investigation at stage 1 and the Ombudsman’s investigation. It has also meant the Ombudsman has not been able to adjudicate on several points which are in dispute between the landlord and the resident. The landlord has also failed to record the resident’s disability or vulnerability on its system.
  4. There was maladministration, which caused further inconvenience, time and trouble to the resident. An order has been made, in line with the Ombudsman’s remedies guidance, that the landlord pay £100 compensation.

 

 

Determination (decision)

  1. In accordance with Paragraph 52 of the Scheme, there was severe maladministration in relation to the landlord’s handling of the resident’s:
    1. Reports of a leak.
    2. Reports of damp and mould following a leak.
    3. Formal complaint.
  2. In accordance with Paragraph 52 of the Scheme, there was maladministration in relation to the landlord’s knowledge and information management.

Reasons

  1. There was severe maladministration in the landlord’s handling of the resident’s reports of a leak as the landlord took an unreasonable amount of time to repair the roof, which was in excess of its policy timeframe. It also left scaffolding in place for too long and did not act promptly in response to the resident’s concerns about an ongoing leak. Its communications were poor, and this further caused the resident to question whether the repairs had been effective.
  2. There was severe maladministration in the landlord’s handling of the resident’s reports of damp and mould following a leak as the landlord did not repair the water damage and damp caused to the resident’s bedroom. It had notice of this damage following both the first and second leak but took no action until after its stage 2 response. It failed to consider the resident’s disability when refusing to offer a decant, failed to follow up on booking in the works and simply stopped trying to resolve the matter, which has left the resident sleeping in a damp bedroom for nearly 3 years.
  3. There was severe maladministration in the landlord’s handling of the complaint as it did not acknowledge or respond to the resident’s stage 1 or 2 complaints within its procedure timeframes or in line with the Code. It failed to recognise its mistakes when the resident made 2 further stage 1 complaints, or to raise these as complaints. Its stage 2 letter was insincere, and it failed to demonstrate the Ombudsman’s Dispute Resolution Principles.
  4. There was maladministration in the landlord’s knowledge and information management as the landlord failed to record or produce several documents which would have assisted its and the Ombudsman’s investigation. It failed to effectively manage its complaints information and also failed to record the resident’s disability and vulnerabilities.

 

Orders

  1. Within 4 weeks of the date of this report, the landlord is ordered to:
    1. Provide a written apology to the resident from its chief executive for the failures detailed in this report.
    2. Pay directly to the resident compensation of £3,200 made up of:
      1. £1,000 for the distress, inconvenience, time and trouble caused by its roofing repair failings.
      2. £1,500 for the distress, frustration, and inconvenience caused by its failings in handling the resident’s reports of damp.
      3. £600 for the additional distress, inconvenience, time and trouble caused to the resident by its complaints handling failings.
      4. £100 for the further inconvenience, time and trouble caused by its knowledge and information management failings.
    3. Find and offer to the resident a suitable decant property, or hotel accommodation, which meets her disability needs so that the works can be carried out.
    4. In conjunction with order c. above, to arrange to carry out the repair works to the bedroom and hallway and book in the works, to be fully completed within 2 months of the date of this report.
    5. Arrange further training for its complaints handling staff focusing on response timeframes and sincerity within its complaint responses. The landlord is to provide details of this training, or any previous relevant training, including when it will or did take place, to this Service.
    6. Update its records to record the resident’s vulnerabilities.
    7. Carry out a self-assessment against the recommendations within the Housing Ombudsman’s spotlight report on Knowledge and Information Management and provide the results of this assessment to this Service.
    8. Carry out a case review of this complaint and report the outcome of this review to its board and this Service.
    9. Confirm compliance with these orders to this Service.