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Exeter City Council (202214034)

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REPORT

COMPLAINT 202214034

Exeter City Council

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:
    1. Leaks, damp, and mould at the resident’s property.
    2. Internal and external repairs at the resident’s property.
    3. The resident’s decant from her property.

Background

  1. The resident is a tenant of the landlord of a 3-bedroom house, where she lives with her 3 young children and several pet dogs. The landlord has no vulnerabilities recorded for the resident, but she reports that 2 of her children have mental health conditions, and that she experienced mental ill-health during the complaint.
  2. The resident reported to the landlord in November 2021 that water was leaking into the side of her property. It therefore arranged for its surveyor to inspect the property in November 2021, and they raised works in the property’s garden to address the water penetration and other garden issues. These repairs included removing soil from the back of the resident’s property and the gable, as well as filling in a hole and forming a concrete garden path in her garden. However, the landlord was then chased on behalf of the resident in January 2022 to both carry out the above works and provide her with a garden gate.
  3. The landlord subsequently recorded in March 2022 that there were outstanding plasterboard repairs in a variety of places in the resident’s property. It then inspected the property in April 2022 and found mud at the side over the damp proof membrane, as well as discussing the need for a side garden gate. The landlord also discussed the need to decant the resident for the above works at her property, but it noted that it would be difficult to provide enough space for her family and pets. She nevertheless reported her concerns to it in May 2022 about outstanding garden, side gate, electrical, and heating repairs at her property since 2019. The resident was therefore anxious about her children’s and pets’ safety from the garden’s access to the street without a gate and from the property’s electrics, as well as about cold in her property.
  4. The landlord then discussed resolving the resident’s above concerns in June 2022, but it noted that it only had a 1-bedroom decant property available for her at that time. It therefore accepted a stage 1 complaint from her and completed the plasterboard repairs at her property in June 2022. The landlord also raised works to install gates at the side and front of the property, replaster and redecorate walls, repair holes from a leak in a ceiling and walls, and treat mould in and redecorate 2 bedrooms. The resident added that there was a dripping bathroom tap and no hallway light at her property, and damaged belongings from a previous leak. She explained that she and 2 of her children experienced mental ill-health from the outstanding repairs at the property.
  5. The landlord subsequently carried out electrical plug socket and hallway lighting works at the resident’s property in June 2022. However, it recorded that it still did not have a decant property large enough for her family and pets for the length of the remaining repairs at her property. The resident therefore booked and paid a total of £1,573 for her own decant at first a caravan and then a lodge until July 2022. The landlord subsequently responded to her stage 1 complaint by apologising for a delay to its works from its surveyor being away. It confirmed that it had raised the above repairs at the resident’s property and fitted a side garden gate, and that it would respond to her separately for her reports about her heating and damages from a leak.
  6. The landlord explained that the resident’s family’s size and pets meant that it would have been reasonably practical for it to decant them outside of the holiday season, which would have delayed the above repairs. This was to ensure it spent its money responsibly. The landlord said that the resident had therefore arranged her own decant to allow these works to happen sooner. It nevertheless agreed that it should have resolved the above repairs much sooner because she had raised them earlier. The landlord also acknowledged the impact on the resident and her family, apologised for any lack of empathy, partially upheld her complaint, and offered her £300 compensation under the Ombudsman’s remedies guidance.
  7. The landlord subsequently repaired holes in a ceiling and walls at the resident’s property and treated mould in and redecorated 2 of her bedrooms in July 2022. It then completed works to remove soil, fill in a hole, and form a concrete path in the property’s garden in July 2022. However, the resident declined the landlord’s above compensation offer due to the impact that she reported from its repair delays on her and her children’s mental health and finances. She added that her property had been left open to an intruder, and that it was difficult for her to receive postal deliveries, due to the garden being open and her pets getting out. The resident also explained that works were still outstanding to complete plastering, decorating, and fit utility room cupboards and coat hooks after her decant, and she asked to be reimbursed by the landlord for both her caravan and lodge decants.
  8. The landlord therefore initially offered the resident another £507 to reimburse her caravan decant in July 2022. It nevertheless said that it could not justify paying for her subsequent lodge decant as a local authority. This was because the resident had declined the landlord’s first decant offer, it had then told her that it would postpone her decant and works until after the holidays, and it could not justify a holiday let for non-urgent works. It therefore accepted a final stage complaint from her, which it responded to in August 2022. The landlord apologised for its repair delays that were below its usual standard, which were also partly due to COVID-19 pandemic supply chain and contractor backlogs.
  9. The landlord added that the resident had arranged her own decant after it had offered to find her other decant properties during the holidays. However, it outlined that she was unable to continue to use her caravan decant, as this did not allow her pets, and so she moved to a lodge. The landlord therefore did not consider that it could reimburse the resident for a caravan she had booked in error that it was not a party to. Although it instead offered to reimburse her £1,066 for the lodge, and to increase its previous compensation offer to £700. This was for the impact of the landlord’s repair delays on the resident and her family, as well as for some of her reported costs and lost income and coat hooks, but not for utility room cupboards that she had previously declined.
  10. The landlord subsequently completed wall replastering and redecorating at the resident’s property in August 2022, side and front gate works in September 2022, and dripping bathroom tap repairs in November 2022. She nevertheless complained to the Ombudsman about the handling of the above works and decant, which she requested a reimbursement of both of her decants for, as well as damages for her family’s mental ill-health and belongings. The landlord then confirmed that it had paid the resident the above lodge reimbursement and increased compensation, and that it had completed all of her property’s repairs.

Assessment and findings

Scope of investigation

  1. The resident has complained that the landlord’s handling of leaks, damp, mould, repairs, and her decant has affected her and her family’s mental health, which is very concerning. It is also of concern that she has explained that the above works and issues at her property were outstanding from at least 2019 onwards, and that she experienced belongings damaged by a previous leak and cold from a lack of radiators. However, in accordance with the Scheme, the Ombudsman may not consider complaints made prior to having exhausted the landlord’s complaints procedure. Under the Scheme, we also may not consider complaints that were not brought to the landlord’s attention as a formal complaint within a reasonable period of normally within 6 months of the matters arising, or where the outcome is not within our authority to provide.
  2. Therefore, this investigation does not consider the effect of the landlord’s actions or omissions on the resident’s and her family’s mental health, or on her damaged belongings. This is because the Ombudsman does not have the authority to determine liability for or award damages for these matters in the way that a court or insurer might. This investigation also does not consider the events in the resident’s case from prior to November 2021, as issues from before that date did not arise within a reasonable period of within 6 months of her complaint to the landlord in May 2022. There is additionally no evidence that her reports to it of cold from a lack of radiators, which it agreed to respond to her about separately, have exhausted its complaints procedure yet, and so this is not considered by this investigation either.

Leaks, damp, and mould

  1. The landlord’s handbook for tenants confirms that it is responsible for repairing and maintaining the structure and exterior of the resident’s property. Its responsive repairs policy obliges it to repair wall and ceiling plasterwork and external brickwork within 5 working days as urgent repairs. The landlord’s guide to damp in your home advises its residents to contact it for a surveyor’s inspection if they are unable to prevent damp or mould, including as a result of failed damp proof courses in properties.
  2. The landlord’s damp/condensation reports policy requires it to book surveyor’s inspections within 10 calendar days of initial damp and mould reports after noting any vulnerabilities. It is to fully investigate the problem, treat any areas of mould, and arrange repairs as soon as is practical within an appropriate timescale. The landlord’s damp and condensation policy obliges it to follow up with its residents 3 months after the initial damp or mould report to ensure that the issue has been resolved. It is required to listen to its residents, take their concerns seriously, and ensure that their health and wellbeing is maintained.
  3. The landlord’s summary of recommendations for senior management for the Ombudsman’s spotlight report on damp and mould (the spotlight report recommendations) includes the following. It states that it has a zero-tolerance approach to damp and mould interventions, as it triages any damp or mould reports to ensure concise accurate records are kept of the issue to help the remedial action proposed. The landlord also says that it avoids solely placing the onus on residents by working with them and using surveys and plans of works to investigate the causes and resolve the problem within 10 calendar days for treatment as well as surveys.
  4. The landlord responded to the resident’s report of water leaking into the side of her property on 2 November 2021 by arranging a surveyor’s inspection on 26 November 2021. Although its responsive repairs policy obliged it to repair such potential external brickwork repairs within 5 working days as urgent repairs, it was understandable that it arranged the inspection instead. This is because the landlord’s guide to damp in your home advised the resident to contact it for a surveyor’s inspection if she was unable to prevent damp as a result of a failed damp proof course. This was supported by its November 2021 and subsequent 11 April 2022 inspections finding soil and mud at the back, gable, and side of her property over the damp proof membrane, which needed to be removed.
  5. It was also understandable that the landlord did not begin works to address the water leaking into the resident’s property within 10 calendar days of her report of this, as required by the spotlight report recommendations. This is due to the fact that its April 2022 inspection of the property identified that the above soil and mud removal and other works required her family and pets to be decanted to allow it to complete these repairs. The landlord additionally logged further works at the resident’s property on 8 June 2022 that needed to be carried out while she was decanted. These included replastering and redecorating the hallway, stairs, and landing walls, kitchen ceiling and utility room wall hole repairs from a leak, and mould treatment and redecoration in 2 bedrooms.
  6. Therefore, the need to decant the resident’s household for the above repairs meant that it was appropriate that the landlord did not begin these works within the 10 calendar days required by the spotlight report recommendations. However, it was still responsible for unreasonable delays in response to her reports of leaks, damp, and mould at her property. The landlord was obliged by both its damp/condensation reports policy and the spotlight report recommendations to arrange the initial surveyor’s inspection of the property within 10 calendar days in November 2021. It nevertheless took 24 calendar days to arrange the inspection instead, without explaining to the resident why it took this long to do so at the time, which was inappropriate.
  7. The landlord then logged broken plasterboard works at the resident’s property on 21 March 2022 that did not need her to be decanted, and so these were completed before her decant on 8 June 2022. As no explanation was given to her at the time for this delay either, it was unreasonable that the wall and ceiling plasterwork repairs were not completed within the responsive repairs policy’s 5-working-day urgent repair timescale for this, but 52 working days later. Moreover, while it was understandable that the landlord had to wait for the resident to be decanted for it to complete the other works at her property outlined above, it did not carry out some of these repairs until after she had returned from her decant, which was inappropriate.
  8. The resident returned from the decant to her property on 1 July 2022, but the landlord did not complete the above soil and mud removal works there until after her return on 8 July 2022. It also did not replaster and redecorate the property’s hallway, stairs, and landing walls until after she had returned on 9 August 2022. The fact that the landlord only carried out the above repairs after the resident returned from her decant indicated that it may have been able to do so sooner and before she was decanted. This meant that it was unreasonable that it did not follow the spotlight report recommendations’ 10-calendar-day timescale for it to begin such repairs, and that it instead did so 8 months after her November 2021 report, and 2 months after its June 2022 repair log, respectively.
  9. The landlord nevertheless did appropriately repair kitchen ceiling and utility room wall holes and treat and redecorate over mould in 2 bedrooms during the resident’s decant on 1 July 2022. However, its above delays in handling her other leak, damp, and mould reports meant that it was reasonable that its complaint responses apologised for the delays. The landlord also appropriately explained to the resident that there had been an unforeseen delay from its surveyor’s absence. It additionally outlined that its repair delays had been partly due to COVID-19 pandemic supply chain and contractor backlogs beyond its control, and so it subsequently gave her an explanation for the delays, which was suitable.
  10. Moreover, the landlord went on to pay the resident £700 compensation for reasons including that it agreed that the above delays to its works were not acceptable, and for the resulting impact on the resident and her family. It calculated its above compensation award by using the Ombudsman’s remedies guidance, which recommends this range of compensation for failures that had a significant impact on her, and this was also in line with its compensation housing management policy. Although it is additionally noted that the landlord’s compensation payment included the resident’s repair and decant complaints, as well as her leaks, damp, and mould complaint, but that this did not break down the level of compensation awarded for each complaint individually.
  11. Therefore, it would be more reasonable to consider that the landlord awarded the resident approximately £233 compensation for her leaks, damp, and mould complaint, as 1 of her 3 complaints that it paid a total of £700 compensation for. As such, it offered her compensation for this complaint that was at the lower end of the Ombudsman’s remedies guidance’s recommendation for failures that adversely affected the resident for its above delayed leak, damp, and mould works totalling over a year. Given the extent of the distress and inconvenience that the resident and her family would have experienced from such an extended period of repair delays, the landlord’s compensation award did not quite reflect the detriment to them or was quite proportionate to its above failings.
  12. Therefore, the landlord has been ordered below to pay the resident £100 additional compensation in recognition of the extent of the leak, damp, and mould delays and late explanations for these identified by this investigation, in line with the Ombudsman’s remedies guidance. This order has taken into account the need for her to be decanted for some of these works, and the fact that some of its delays were for reasons beyond its control, as outlined above.
  13. The landlord has also been ordered to write to the resident to apologise to her for the further leak, damp, and mould failures identified by this investigation. It has been recommended below to review its staff’s and contractors’ training needs in relation to handling leaks, damp, and mould to ensure that reports of these are responded to with timely inspections, works, and updates in every case in the future.

Internal and external repairs

  1. The landlord’s handbook for tenants confirms that it is responsible for repairing and maintaining the exterior, bathroom fixtures, and electrical wiring at the resident’s property. It states that she is responsible for any fencing and garden maintenance at her property. The landlord’s responsive repairs policy obliges it to repair light fittings, faulty electrical sockets, and faulty taps within 5 working days as urgent repairs. It is required to repair boundary fencing, posts, gates, and footpaths leading to front or rear doors within 20 working days as routine repairs.
  2. The landlord responded to repairs that it logged on 26 November 2021 to fill in a hole and form a concrete path in the resident’s garden by completing these works over 7 months later on 8 July 2022. It then began discussing the need for a side garden gate with her, and for her to be decanted for the above repairs, from 11 April 2022, and it stated that it fitted the gate almost 3 months later on 1 July 2022.
  3. The landlord also raised works to install a front garden gate at the resident’s property on 8 June 2022 that it fitted over 3 months later on 20 September 2022. She additionally reported electrical socket and hallway lighting repairs at the property on 20 May and 10 June 2022, respectively, that it completed 23 and 10 working days later, respectively, on 24 June 2022. Moreover, the resident reported a dripping bathroom tap to the landlord on 10 June 2022 that it repaired 5 months later on 10 November 2022.
  4. The landlord therefore completed the above exterior, footpath, gate, electrical socket, lighting, and tap works at the resident’s property that its handbook for tenants and responsive repairs policy obliged it to, which was appropriate. However, it did not carry out these works within any of the policy’s timescales for it to do so. This is because the landlord’s garden hole, concrete path, and gate installation repairs were due within its policy’s 20-working-day routine repair timescale, but these took it a total of approximately 13 months to complete. Its electrical socket, hallway lighting, and bathroom tap works were also due within the policy’s 5-working-day urgent repair timescale, but it took a total of approximately 6 months to repair these.
  5. It is also noted that the resident reported that the above electrical socket and hallway lighting repair delays made her anxious for her children’s and pets’ safety from electric shocks and falling over, respectively. It is additionally noted that she explained that she had anxiety from the length of time that it took to install side and front garden gates at the property due to concerns for her children’s and pets’ safety from their access to the street without such gates, and from an intruder. The resident also reported being inconvenienced by her difficulty in receiving postal deliveries from the risk of her pets getting out when her garden was open. Although the landlord’s handbook for tenants did make her responsible for garden maintenance, which it did as a goodwill gesture.
  6. It is nevertheless noted that the landlord’s above electrical socket, hallway lighting, and side garden gate installation at the resident’s property were carried out while she was decanted in June to July 2022. Whereas its above garden hole, concrete path, front gate, and bathroom tap works were completed after her decant in July, September, and November 2022. This indicated that the repairs that the landlord subsequently carried out did not necessarily need to have the resident decanted for these to be done. This meant that it would have been unreasonable for it to have waited for her decant before it completed the subsequent works, and to have attributed these repair delays to the decant, as well as adding to her above distress and inconvenience from the delays.
  7. It was therefore reasonable that, as outlined in the previous section of this report, the landlord apologised to the resident for its above delayed works and gave her reasons other than her decant for the delays. It explained that there had been an unforeseen delay from its surveyor’s absence, as well as delays partly due to COVID-19 pandemic supply chain and contractor backlogs. It was suitable that the landlord gave the resident an explanation for these delays, and it partly paid her a total of £700 compensation in recognition of above repair delays, in addition to its handling of leaks, damp, and mould and her decant.
  8. As also outlined in the previous section of this report, however, approximately £233 compensation was awarded by the landlord for the share of the resident’s internal and external repairs complaint, as 1 of her 3 above complaints. This meant that it paid her compensation that did not quite reflect the detriment to her family or was quite proportionate to its above failings, in line with the Ombudsman’s remedies guidance. This is because the above share of the award was at the lower end of compensation for failures that adversely affected the resident recommended by our guidance. Whereas she experienced some extended unnecessary internal and external repair delays from the landlord, which caused her potentially avoidable anxiety, distress, and inconvenience.
  9. The landlord has therefore also been ordered below to pay the resident £100 additional compensation in recognition of the extent of the internal and external repair delays and resulting anxiety, distress, and inconvenience identified by this investigation. This order, too, has taken into account the need for her to be decanted for some of these works, and the fact that some of its delays were for reasons beyond its control, as outlined above. The landlord has additionally been ordered to write to the resident to apologise to her for the further internal and external repair failures identified by this investigation. It has been recommended below to review its staff’s and contractors’ training needs in relation to its responsive repairs policy’s timescales to ensure that these are met in every case in the future, unless there is a good reason not to.

Decant

  1. The landlord’s decanting policy states the general rule is that its residents should not be out of pocket as the result of a decant, including temporarily so that work can be carried out. If no suitable vacant decant properties are available then it may temporarily accommodate residents in hotels on a bed and breakfast basis. The landlord is obliged to visit residents if decants are necessary to discuss matters including what it will pay for, and what compensation residents are entitled to. It is required to make an agreement in advance about providing funds for food if a temporary decant to a hotel is necessary, as well as to identify additional needs such as for young children. The landlord is obliged to make suitable alternative decant accommodation available, taking into account and meeting residents’ housing needs.
  2. The landlord began discussing the need to temporarily decant the resident to allow it to complete the outstanding works at her property that required her household’s absence from 11 April 2022 onwards. It acted in line with its decanting policy by considering decanting her itself in a vacant decant property, but it noted on the above date that it would be difficult for it to provide enough space for her family and pets. It was therefore understandable that the landlord did not decant the resident at that time because the policy required it to do so to suitable alternative accommodation, taking into account and meeting her needs, which required space for all of her household. This is particularly because it identified that it only had a 1-bedroom decant property available for them on 6 June 2022.
  3. This meant that it was appropriate that the landlord did not decant the resident to a 1-bedroom property, as her household, including her 3 young children and pets, instead needed a suitable decant from her 3-bedroom property. This is especially due to the fact that it identified on 10 June 2022 that the decant also needed to include her partner and might need to take up to 3 weeks. However, it is of concern that there is no evidence that the landlord also followed its decanting policy by therefore considering a temporary hotel bed and breakfast decant for the resident’s household in the absence of a suitable vacant decant property for them from its own stock. This meant that she paid £1,573 to book her own caravan and then lodge decant from 24 June to 1 July 2022.
  4. It is noted that it is likely that it would also have been difficult for the landlord to find a suitable hotel bed and breakfast decant for a household of the size of the resident’s, together with her pets, although she found them a suitable lodge. It is additionally noted that its complaint responses explained that she had decided to arrange her own decant to allow the repairs at her property to happen sooner. This was because the landlord declined to decant the resident in June to July 2022, as it considered that doing so during the holiday season was not practical for it. It added that, as a local authority, it could not justify paying for a holiday let for her family and pets for non-urgent works.
  5. The landlord therefore subsequently only reimbursed the resident’s £1,066 lodge decant costs, and not her £507 caravan decant. It also explained that this was because she had booked a caravan that did not allow pets in error that it was not a party to, and so it could not see that it was responsible for reimbursing her for this. It is nevertheless concerning that, as outlined in the previous sections of this report, the landlord delayed carrying out repairs at the resident’s property contrary to its published timescales for reasons including the need to decant her for these works. Whereas some of these repairs may not have needed her to have been decanted, being completed after she returned from her decant, and so unnecessary repair delays by it may have contributed to her arranging her own decant, and the above resulting error.
  6. The landlord also contributed to the resident arranging her own decant with its above lack of consideration of a temporary hotel bed and breakfast decant for her household because of the cost of a holiday let. It was relevant for it to consider the cost of decanting her, as it was a local authority with limited public funds that it had to justify spending. However, the landlord’s decanting policy stated that the resident should not be out of pocket as a result of her decant. This meant that it was reasonable that it reimbursed her suitable lodge decant. It was additionally understandable that the landlord did not reimburse the resident’s mistaken caravan decant, as it was not directly responsible for the error in booking this.
  7. The landlord nevertheless inappropriately contributed to the resident booking her own decant, as outlined above. There is also no evidence that it followed its decanting policy’s requirements for her decant by discussing with her in advance what it would pay for, what compensation she was entitled to, or what funds it would provide her for food. This was unreasonable and further contributed to resident arranging her own decant, and her resulting error. This is because she did not receive confirmation in advance as to what the landlord would reimburse her for, so that she could book the decant accordingly.
  8. It was therefore appropriate that the landlord’s complaint responses apologised to the resident for the above repair delays resulting in her decant, as well as that it subsequently paid her £700 compensation to recognise the impact of this on her and her family. As outlined in the previous sections of this report, however, an approximately £233 share of the compensation was awarded to her for her decant complaint, as 1 of her 3 above complaints. This meant that the landlord’s compensation payment did not fully address the detriment to the resident or was proportionate to the failings identified by this investigation from its poor handling of her decant, in line with the Ombudsman’s remedies guidance.
  9. The landlord’s compensation award was instead at the lower end of the compensation recommended by the Ombudsman’s remedies guidance for failures that adversely affected the resident. This is also due to the fact that she was left £507 out of pocket by her decant, contrary to its decanting policy, which she explained had affected her finances. It is additionally noted that the landlord initially offered to reimburse the resident for this on 7 July 2022, which raised a legitimate expectation on her part that it would do so, but it subsequently declined to.
  10. The landlord has therefore also been ordered below to pay the resident £300 additional compensation in recognition of the detriment caused to her by its poor handling of her decant. This order has taken into account the fact that it was not directly responsible for the error in booking her caravan decant. The landlord has additionally been ordered to write to the resident to apologise to her for the further failures in its handling of her decant identified by this investigation. It has been recommended below to review its staff’s training needs in relation to its decanting policy to ensure that this is followed in every case in the future.

Determination

  1. In accordance with paragraph 52 of the Scheme, there was service failure by the landlord in its handling of:
    1. Leaks, damp, and mould at the resident’s property.
    2. Internal and external repairs at the resident’s property.
  2. In accordance with paragraph 52 of the Scheme, there was maladministration by the landlord in its handling of the resident’s decant from her property.

Orders and recommendations

Orders

  1. The landlord is ordered to:
    1. Pay the resident additional compensation totalling £500 within 4 weeks, which is broken down into:
      1. £100 in recognition of the extent of its leak, damp, and mould delays and late explanations for these.
      2. £100 in recognition of the extent of its internal and external repair delays and her resulting anxiety, distress, and inconvenience.
      3. £300 in recognition of the detriment caused to her by its poor handling of her decant.
    2. Write to the resident within 4 weeks to apologise for the further failures in its handling of leaks, damp and mould, internal and external repairs, and her decant identified by this investigation.
  2. The landlord shall contact the Ombudsman within 4 weeks to confirm that it has complied with the above orders and whether it will follow the below recommendations.

Recommendations

  1. It is recommended that the landlord:
    1. Review its staff’s and contractors’ training needs in relation to handling leaks, damp, and mould to ensure that reports of these are responded to with timely inspections, works, and updates in every case in the future.
    2. Review its staff’s and contractors’ training needs in relation to its responsive repairs policy’s timescales to ensure that these are met in every case in the future, unless there is a good reason not to.
    3. Review its staff’s training needs in relation to its decanting policy to ensure that this is followed in every case in the future.