Southern Housing (202317874)

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REPORT

COMPLAINT 202317874

Southern Housing Group Limited

29 July 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:
    1. The resident’s reports of carbon monoxide in the property.
    2. The associated complaint.

Background

  1. The resident has an assured tenancy agreement for a second-floor studio flat that commenced on 30 August 1999. The landlord said it knows the resident has anxiety. As a result, the resident required communication by email and letter.
  2. On 17 July 2023, the resident reported that her carbon monoxide detector sounded when she was cooking, so she called the gas supplier. When the gas supplier attended, they found harmful levels of carbon monoxide when she was cooking. This was because there was no ventilation in the kitchen, and she could not reach the kitchen window to open it. As a result, the supplier isolated the gas supply, and she had no cooking facilities.
  3. The resident told the landlord on 18 July 2023 that her gas supply had been isolated and she was without cooking facilities. The resident also raised a formal complaint in which she said:
    1. There was a lack of ventilation in the kitchen.
    2. The gas had been switched off because the carbon monoxide alarm went off, and she had no hot water.
    3. The alarm was fitted last year, and the previous gas safety check only lasted 10 minutes and did not identify an issue.
    4. The poor ventilation had been making the resident ill.
    5. She said that she wanted to be moved out of the building for her safety and that all contact for repairs needed to be made by email.
    6. She asked to be compensated for loss of earnings.
  4. The landlord inspected the property the next day and said it had raised a job to fit permanent ventilation, but it did not have a date for when it would do this. It said the resident would be contacted as soon as possible when a contractor was available. Between 21 July 2023 and 1 August 2023, the resident emailed and called the landlord to chase the work. On 25 July 2023, the landlord chased its contractor for a date and asked it to schedule the work directly with the resident. It also passed the resident’s reports to its gas team.
  5. The landlord issued its stage 1 response on 31 August 2023. It said:
    1. It had assessed the resident’s carbon monoxide detector, and it was working correctly.
    2. The gas build up was due to lack of ventilation while cooking on the gas appliance.
    3. It would ask its ventilator contractor to contact the resident to address her mobility concerns about not being able to open the window. It offered an appointment for 14 September 2023.
    4. It would not rehouse the resident because the issue was not with the carbon monoxide detector’s functionality. The contractor had only identified difficulty with the resident accessing the windows.
    5. It would not compensate the resident for loss of earnings, but it would offer the resident £50 for time, trouble, and inconvenience.
  6. The resident escalated her complaint on 7 September 2023 because:
    1. The frequency of the alarms sounding was the root of the issue because she could not cook in the kitchen without it going off.
    2. There was a carbon monoxide leakage over a month ago, and ventilation has not been addressed since. This meant she could not use the kitchen.
    3. The lack of ventilation caused her asthma to worsen.
    4. She would not accept the £50 because she wanted the landlord to cover the costs incurred to order food and wasted appointments.
    5. She wanted to be rehoused because the ventilation issue was a wider issue in the property that had been unresolved and ongoing for several years, and this was the best solution.
  7. The landlord tried to assess the property on 14, 19, 28 and 29 September 2023 but said it could not gain access.
  8. The landlord issued its stage 2 response on 16 October 2023. It said:
    1. The resident’s carbon monoxide alarm was working correctly, and the issue was a gas build-up due to a lack of ventilation when she was cooking.
    2. Its contractor attended on 14 and 29 September 2023 to rectify the ventilation issues but could not gain access.
    3. It proposed installing an extractor fan in the kitchen and assessing the ventilation further. It gave three dates in October 2023 to complete this.
    4. It signposted the resident to alternative housing options to help her with a further move through a mutual exchange or through its waiting list.
    5. It would offer further compensation, if upon a site visit, the resident was unable to open the kitchen window. However, it would not provide compensation for loss of wages.

Post complaint procedure

  1. The landlord produced a report on 20 October 2023, which investigated the carbon monoxide levels at the property. It noted:
    1. The kitchen had failed the “room test” with the window shut. Conversely, with the window open, the kitchen had passed the “room test.”
    2. The resident was unable to open the kitchen window when she cooked because it was too heavy, and she could not reach the catches.
    3. It deemed there was an immediate danger because the resident was unable to open the window due to design and weight, so it disconnected the cooker from the gas supply.
    4. It issued an immediate danger notice and said the window needed to be addressed so the resident could access it before the cooker could be reconnected.
    5. The current carbon monoxide alarm was incorrectly placed so a new alarm was installed.
    6. At the time of the visit, the resident’s windows were being measured for replacement.
  2. The landlord tried to gain access to the property again on 6 November 2023. Its operative said it tried to call ahead, but as the resident did not answer, they cancelled the appointment due to the previous lack of access.
  3. In March 2024, the landlord conducted an inspection related to a previously agreed major works plan to replace the windows in the resident’s block of flats. The resident was notified of this in September 2022, with works due to be completed by March 2023. This included the kitchen window in the scope of work. The landlord had tried to decant the resident in April 2024 and May 2024 for these works to be attended to. The resident explained that the work had not started at the time of writing this report, and the dates provided for the decant were not convenient for her.
  4. The resident referred her complaint to the Ombudsman because:
    1. She felt the landlord had not responded to her original report about the carbon monoxide levels appropriately.
    2. The landlord failed to install any ventilation.
    3. She wanted increased compensation to recognise the time, trouble, distress, and inconvenience of this situation because the landlord had not treated the issue seriously.

Assessment and findings

Scope of the investigation

  1. The resident notified the landlord separately of issues with the windows and general ventilation concerns across the property. She said that these issues had been ongoing for several years. The Ombudsman investigated this complaint under case reference 202114016. The landlord was ordered to assess the windows in the property and write to the resident to explain if it intended to carry out further repairs.
  2. Paragraph 42(l) states: “The Ombudsman may not consider complaints which, in the Ombudsman’s opinion: seek to raise again matters which the Housing Ombudsman or any other Ombudsman has already decided upon.”
  3. While this investigation is unable to comment on the issues determined previously by this service, it is noted that the former investigation did not include reference to the kitchen window in relation to a means of ventilation to prevent dangerous levels of carbon monoxide in the property. Therefore, this investigation will not comment on the general state of repair of the windows or associated repairs raised as a result of the resident’s former complaint. This is because those issues have already been investigated and determined by the Ombudsman. We will look at how the landlord handled the reports that the window could not be used for ventilation.

The alarm

  1. The landlord has a duty under section 9A of the Landlord and Tenant Act 1985 to ensure properties are fit for human habitation. A property is unfit for human habitation if it is not reasonably suitable for occupation because of a defect relating to ventilation, lack of facilities for preparing food, or hazards found under the Housing Health and Safety Rating System.
  2. The Smoke and Carbon Monoxide Alarm (England) Regulations 2022 make it a legal obligation for landlords to ensure carbon monoxide alarms are fitted in rooms being used, wholly or partly, as ‘living accommodation’ and rooms which contain fixed combustion appliances. Landlords are required to repair or replace them once it is informed and it is found that detectors are faulty.
  3. The Regulator of Social Housing states in its Safety and Quality Standard that all registered providers must identify and meet all legal requirements that relate to the health and safety of tenants in their homes and communal areas. Registered providers must ensure that all required actions arising from legally required health and safety assessments are carried out within appropriate timescales.
  4. The landlord’s repairs policy states it will carry out repairs to make safe an emergency repair within 6 hours. If further repairs are required, it will arrange an appointment as soon as possible at a time to suit residents. The landlord’s gas safety policy notes that it will check the function of carbon monoxide alarms during annual gas service and safety check visits.
  5. The landlord carried out a gas safety check on 26 June 2023. This noted the gas installations at the property were satisfactory, and no remedial action was required. The Ombudsman considers the landlord demonstrated it adhered to its statutory duty under the Smoke and Carbon Monoxide Alarm (England) Regulations 2022 and its repairs policy because it had conducted its yearly assessment for gas safety for 2023.
  6. The gas had been turned off by her gas supplier when the resident initially reported her concerns on 18 July 2023. The landlord arranged for a contractor to attend to inspect the property on 19 July 2023. This was appropriate in the circumstances because it acted on the resident’s report as it would an emergency repair.
  7. During the inspection, the contractor found that permanent ventilation was required as the gas cooker triggered the alarm when used. As the resident was not able to open the window, a permanent vent was required in the kitchen to assist with the removal of cooker gases.
  8. The resident contacted the landlord on 21 July 2023. She said:
    1. During the appointment, the contractor advised her that the window would be fixed the day after they had logged their report.
    2. She said she had been told to be home for the visit, but no visit had occurred.
    3. She had chased the landlord, and they had given her an appointment for a surveyor to look at the problem on 2 August 2023, but this was after 6 phone calls and a failed callback from a manager.
  9. The landlord apologised to the resident and said a job had been raised to fit permanent ventilation, but no date had been given for this. However, she would be contacted as soon as possible with an appointment. The Ombudsman considers the landlord did not act in accordance with its repairs policy because, at this stage, it was not treating the works as a priority, given the serious nature of the issue.
  10. The report relating to the contractor’s findings on 19 July 2023 did not contain reference to advice being given to the resident about a further timescale for the completion of further works. In addition, it did not mention works relating to the “window” but more widely “ventilation.” As a result, the evidence does not reflect the advice the resident said she received. Therefore, the Ombudsman is unable to find fault with this element of the resident’s complaint.
  11. The repair records at the time noted the landlord raised a job on 20 July 2023 for an “inspection of lack of ventilation in the kitchen.” However, this was cancelled the same day because it was noted “work was being carried out on a different order.” The repair logs did not contain any detail relating to the separate order the landlord had since raised for the ventilation.
  12. The Ombudsman is unable to conclude the landlord monitored or actioned the recommendation from its contractor. This was poor record keeping and appeared to be the origin of the initial delay the resident experienced, which caused her time and trouble in chasing the repairs.
  13. The landlord said it chased its contractor on 25 July 2023 for a date that it would visit the resident and asked it to contact the resident directly. The landlord did not provide evidence of it taking this action. Therefore, the Ombudsman is unable to verify it did this. This was a failure because the landlord failed to demonstrate it was monitoring the remedial action immediately after its contractor’s report.
  14. The resident re-reported there was a carbon monoxide leak at her property on two further occasions between 1 August and 17 August 2023. During this time, she said:
    1. The landlord had shown no regard for the resident or the seriousness of the issue at her property.
    2. The landlord needed to contact her through email because she did not use her phone very often.
    3. She would like to be moved out of the building for her own safety.
  15. The landlord’s repair records show the landlord raised a job for an inspection for the ventilation in the kitchen on 29 August 2023. This was noted as cancelled on 15 September 2023. The landlord provided a timeline of the events for the lifetime of this complaint. Within this, it noted that on 30 August 2023, it was struggling with gaining access to the property or to agree dates with the resident to attend.
  16. The evidence provided did not show any attempts by the landlord to contact the resident between 25 July 2023 and 30 August 2023. This was evidence of poor record keeping which meant the Ombudsman was unable to conclude the landlord was monitoring or actioning the resident’s report during this time. The resident said this caused uncertainty because she did not know what the landlord intended to do or when. She said she felt the landlord had not responded proportionately to the issue because it failed to act on a serious health and safety hazard. It would have been reasonable for the landlord to have provided regular updates to the resident and considered the resident’s request to be decanted temporarily while it fixed the issue.
  17. As part of its stage 1 response on 21 August 2023, the landlord offered the resident an appointment to assess the ventilation at the property for 14 September 2023 in writing. As the resident did not confirm this appointment, the landlord contacted her on 8 September 2023 for confirmation. It is unclear if the resident ever accepted this appointment. The Ombudsman considers the landlord acted appropriately at this time because it offered the resident an appointment through her preferred method of communication.
  18. The landlord’s timeline noted it had attempted to access the property on 11 September, 14 September, and 29 September 2023. The evidence shows the landlord left calling cards for each of these attempts. The evidence does not demonstrate that the landlord notified the resident of these appointments in writing prior to them taking place.
  19. The evidence does show the resident had told the landlord in August 2023 and on 26 September 2023 that she wanted the landlord to contact her in writing regarding any appointments. The landlord had accepted this position because it added a note to its systems to that effect. 
  20. The Ombudsman considers the landlord did not act reasonably in relation to the appointments between 11 September and 29 September 2023. This is because it failed to consider the communication preferences of the resident. This likely resulted in a missed opportunity to access the property at an earlier stage which caused further delay because the resident said she did not often use her phone and as a result had not picked up the landlord’s communications. This caused further time and trouble for the resident because she had to chase the landlord to take further action and re-explain the need for communications to be made in writing.
  21. In addition, had the landlord encountered difficulties gaining access the Ombudsman would have expected, given the seriousness of the issue, to seek legal advice about how it could lawfully enter the property to make a lasting and effective fix. This is because the issue had the potential to impact not only the resident but other residents in the block. There is no evidence the landlord did this or that it considered the impact of the carbon monoxide levels on other residents. As a result of this omission, the landlord did not act appropriately because it allowed carbon monoxide levels to continue to gather unabated at the property for longer than was necessary.
  22. The landlord conducted a survey on 20 October 2023, as detailed in paragraph 10 of this report. The survey confirmed there was inadequate ventilation in the kitchen with the window closed. As this was an immediate danger, it disconnected the cooker from the gas supply and issued a warning notice. This was 3 months after the resident’s initial report and was a failure to apply the timeframes in its repairs policy. This was a significant and unreasonable delay by the landlord in conducting an inspection.
  23. The resident wrote to the landlord on 26 October 2023 and explained that:
    1. Her gas had been turned off at the time of the survey to prevent carbon monoxide poisoning.
    2. This was the second time the gas had been turned off.
    3. Her concerns over the ventilation being unresolved for a prolonged period.
    4. This had impacted her ability to cook.
    5. She had incurred additional costs in getting takeaways and asking friends and family to deliver meals to her.
  24. The landlord apologised for this and asked if the resident had contacted the landlord’s own surveyor to attend as per its stage 2 response. It also said it had not disconnected the gas appliance and asked the resident for confirmation on who took this action.
  25. It is concerning to note that the landlord was unaware, at the time the resident contacted it, that it had, in fact, commissioned the survey on 20 October 2023 and been issued a warning notice. This indicated the relevant departments had failed to share important information or lacked access to up to date files which impacted the landlord’s ability to respond to the resident accordingly.
  26. Further, the Ombudsman would have expected the landlord’s response to any warning notice concerning the gas supply to have been prioritised as an emergency. There was no evidence this occurred. Therefore, the landlord failed to demonstrate it had taken the warning notice seriously or that it had monitored and actioned the report as a priority. In addition, there is no evidence the landlord considered whether the property was fit for habitation under its statutory duty or tried to mitigate this by offering the resident a decant property.
  27. The evidence supplied does not confirm between 18 July 2023 and 20 October 2023 when the resident’s appliance was reconnected to the gas supply. This is a failure in record keeping because the landlord should have demonstrated any actions it took within its repair logs. In any event, it is the opinion of the Ombudsman that the resident was left in a property with intermittent dangerous levels of carbon monoxide for a period of 3 months at the point of the survey. This is a significant failure and shows a disregard by the landlord to ensure its property was fit for habitation.
  28. The Housing Health and Safety Rating System details that inadequate ventilation in relation to carbon monoxide can have an impact on the health of residents. This includes the inability of blood to take up oxygen, which can cause headaches, dizziness, nausea, unconsciousness, and death. The preventative measures that landlords should take to reduce harm to residents are ensuring:
    1. adequate air supply for gas appliances
    2. adequate ventilation in rooms with gas appliances
    3. properly situated carbon monoxide detectors.
  29. The evidence shows the landlord was aware that it needed to install permanent ventilation at the property as early as 18 July 2023. There is no evidence at the time of writing this report that this occurred. Although the landlord made attempts to access the property, it did not communicate its appointments in a manner it had agreed with the resident.
  30. Overall, there was severe maladministration with this element of the complaint because there were a series of significant failings by the landlord. The cumulative effect of these failures had a seriously detrimental impact on the resident. In summary, the landlord failed to:
    1. Ensure that the property was fit for habitation and that all required actions arising from legally required health and safety assessments were carried out within appropriate timescales because:
      1. The landlord failed to demonstrate that it monitored or actioned the installation of permanent ventilation after the visit on 19 July 2023.
      2. The landlord took 3 months to conduct a survey on 20 October 2023 and the survey did not yield any further results than those of the inspection on 19 July 2023.
      3. The landlord failed to act on the warning notice issued on 20 October 2023 as an emergency or to consider how it could protect the resident by offering a decant property.
      4. The landlord failed to consider further enforcement action it could take when it identified it was struggling to access the property.
    2. Act in accordance with its repairs policy to ensure that follow on works for the installation of ventilation were carried out within a reasonable time. This is because the landlord failed to demonstrate:
      1. It attempted to contact the resident between 25 July 2023 and 30 August 2023 to carry out a ventilation inspection.
      2. It considered legal advice when it identified it was having difficulty accessing the property.
    3. Adhere to the resident’s communication preferences which caused appointments for follow on works to be ineffective and missed opportunities to access the property to affect a repair between August and September 2023.
    4. Maintain adequate records:
      1. That were accessible to relevant staff members to enable it to respond accordingly to the resident.
      2. For when the gas supply was reconnected to the gas appliance between 18 July 2023 and 20 October 2023.
  31. There was a risk to the resident’s health and safety in this case. In the Ombudsman’s view, the landlord did not take that as seriously as it should have done, by unreasonably delaying the installation of ventilation and ensuring the window could be accessed and opened for better ventilation. There is no evidence the landlord considered the impact on the other residents in the building.

The landlord’s complaint handling

  1. The Complaint Handling Code (‘the Code’) states:
    1. Stage 1 responses must be issued within 10 working days of acknowledgement.
    2. Stage 2 responses must be issued within 20 working days of the request to escalate.
  2. The landlord’s complaint policy reflects this.
  3. The landlord issued its complaint responses as follows:
    1. Stage 1 within 32 working days of the resident’s complaint.
    2. Stage 2 within 27 working days of the resident’s request to escalate.
  4. It is noted the landlord contacted the resident to explain it would be unable to issue its stage 1 response within the designated timeframes. This was appropriate because it notified the resident of its delay and provided a revised timeframe for its response, which was in accordance with the Code.
  5. The landlord stage 2 response was 7 working days outside of the timeframes stipulated in the Code. This was a service failure because it delayed the resident from escalating her complaint to the Ombudsman.
  6. The resident raised on several occasions during the complaints procedure that she was incurring additional costs because she did not have cooking facilities. This was due to the ventilation issues she was experiencing in the kitchen. The landlord did not respond to this element of the resident’s complaint. This was inappropriate because the Code states that landlords must address all points raised in the complaint and provide clear reasons for any decisions.
  7. The landlord was aware at the close of its stage 1 and stage 2 responses that it still needed to install ventilation at the property. Although it offered the resident appointments, there is no evidence it tracked this and actioned the works. This links into a missed opportunity, as noted at paragraph 36 of the report, to seek legal advice on its position regarding lawful entry to the property. This could have benefited other residents who may have been impacted by the carbon monoxide levels at the property.
  8. The Ombudsman would have expected the complaints procedure to remain active in the background of the complaint to coordinate the necessary teams and repairs and documented this through the repairs or complaints log. This was inappropriate because the Code states outstanding actions must still be tracked and actioned expeditiously with regular updates provided to the resident. This could have mitigated the time and trouble of the resident chasing the repairs through to conclusion.
  9. The landlord offered the resident £50 for her time, trouble, and inconvenience as part of its stage 1 response. In its final response it said it would assess if it owed the resident further compensation after it had conducted a site visit to confirm the resident was unable to open the kitchen window.
  10. The Ombudsman’s remedies guidance states that any remedy offered must reflect the extent of any service failures and the level of detriment caused to the resident as a result. It notes that factors to consider in formulating a remedy can include, but are not limited to:
    1. the length of time that a situation has been ongoing.
    2. the frequency with which something has occurred.
    3. the severity of any service failure or omission.
  11. The landlord’s complaint policy reflects this stance on remedies.
  12. The Ombudsman considers the landlord’s remedy did not take into account:
    1. the seriousness of the issue complained about.
    2. the extent of the delays and the failure to action the ventilation.
    3. the level of detriment to the resident because she had to live in a property with intermittent dangerous levels of carbon monoxide.
    4. its failure to communicate the repair appointments in line with her agreed preferences.
  13. These were elements that it should have been aware of as part of its investigation into the resident’s complaint. Further, there is no evidence the landlord conducted a site visit to confirm the resident was unable to open the kitchen window and re-assessed the compensatory offer. This was a failure to do what it said it would do.
  14. The complaint responses also missed an opportunity to demonstrate any more expansive learning it had identified in responding to priority repairs. Given the severity of the issue, the impact of this on the health and safety of the resident as well as potentially other residents in the block of flats, the Ombudsman would have expected a case review to determine what went wrong, the reasons why and how it would improve its service provision to prevent this from occurring in future.
  15. Overall, there was maladministration with this element of the complaint because:
    1. The landlord’s stage 2 response was not issued within the timeframes stipulated in the Code.
    2. The complaint responses did not answer all elements of the resident’s complaint.
    3. The complaints process failed to manage the outstanding ventilation installation or subsequent repair appointments.
    4. The landlord’s remedy was not proportionate to the failures it ought to have been aware of during the complaints process.
    5. The landlord failed to acknowledge its delays and the seriousness of the issue being complained about.
    6. The landlord failed to demonstrate any more comprehensive learning it had identified to improve its service provision.

Determination

  1. In accordance with paragraph 52 of the Scheme, there was severe maladministration in the landlord’s handling of reports of carbon monoxide in the resident’s property.
  2. In accordance with paragraph 52 of the Scheme, there was maladministration with the landlord’s handling of the resident’s complaint.

Orders

Orders

  1. Within 28 days of this determination, the Ombudsman orders the landlord to:
    1. Arrange for the CEO to call the resident to apologise for the failures found in this report. This is to be followed by a written apology.
    2. Pay the resident £2,650 compensation, comprised of:
      1. £1,000 for the resident’s loss of enjoyment of her kitchen because she was left in a property with intermittent dangerous levels of carbon monoxide between 18 July 2023 and 20 October 2023.
      2. £500 for the resident’s time, trouble, distress and inconvenience in chasing the repairs.
      3. £150 for the distress and inconvenience caused by the failures identified with the landlord’s complaint handling.
      4. £1,000 to contribute towards the cost of food in recognition of the additional expenses she incurred during the times between July 2023 and June 2024. This is because she did not have adequate cooking facilities when her gas appliance was disconnected.

This is in addition to the compensation offered to the resident during the complaint procedure. If it has not been paid, it must be paid to the resident.

  1. The landlord must assess any further compensation owed to the resident between November 2023 and the time the ventilation work to the resident’s kitchen is carried out. It must write to the resident with its calculation and the reasons behind this.
  2. The landlord must arrange for complaint handling training for relevant colleagues to address the failures found in relation to the complaint handling of this case.
  3. The landlord must conduct an urgent survey no later than 28 days from the date of this determination to determine if the property is habitable. The landlord must consider offering the resident a temporary or permanent decant while executing the necessary remedial work on the resident’s property. The landlord must share a copy of the survey with the resident and the Ombudsman within 5 days of receipt.
  4. The landlord must use its best endeavours to install permanent ventilation in the resident’s property within 28 days of the survey. If it encounters any issues preventing it from complying with this order, it must consider seeking legal advice to ensure it complies with its health and safety obligations.
  1. The landlord must provide evidence of compliance with these orders within 28 days of the date of this determination.
  2. Within 56 days of the date of this determination, the landlord must conduct a senior management review of the case under 54(g) of the Scheme to identify:
    1. If the carbon monoxide levels in the property may have had a detrimental impact on other residents in the block of flats. If so, it must write to them to apologise and offer a suitable remedy.
    2. Why it delayed in installing the ventilation required at the property.
    3. Why did it not adhere to the resident’s communication preferences despite agreeing to them and flagging this on its systems?
    4. Why was it unable to demonstrate, through its record-keeping, that it monitored and actioned the ventilation works?
    5. Why were relevant colleagues unaware of the landlord’s survey in October 2022 and the warning notice issued? Is this a wider record-keeping issue that must be investigated and acted upon?
    6. Why it did not prioritise the ongoing carbon monoxide reports.

The landlord must produce a report with its findings, including the actions it will take to improve its service provision and prevent these issues from recurring. The report must be presented to the senior leadership team, the Ombudsman, and the resident within 56 days of the date of this determination.