London & Quadrant Housing Trust (L&Q) (202216813)
REPORT
COMPLAINT 202216813
London & Quadrant Housing Trust (L&Q)
22 March 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
- The complaint is about the landlord’s:
- Handling of reports of damp and mould in the property.
- Complaint handling.
Background
- The resident is an assured tenant. She lives with her 3 children, who are 11 years and below. She has lived at the property since 2013. The property is a 2 bed ground floor flat. The household had several vulnerabilities, including asthma amongst the children and mental health conditions for the resident. The landlord was aware of these vulnerabilities.
- The records show the resident reported problems with damp and mould in the property since November 2013. She had support services act on her behalf in January 2014, as there were concerns about the impact mould had on her daughter’s health. Some remedial works were conducted (including mould wash and the installation of fans). Further inspections and remedial works were conducted in 2016. There was a flood in the property in September 2017 that caused damage throughout the property.
- Following the leak in 2017, the resident made regular reports made of damp and mould in the kitchen and bedroom. The landlord’s records show it addressed related repairs in 2018, 2019 and 2020. In March 2021, the resident reported that the walls were wet and crumbling. She said that her daughter had been admitted to hospital because of the damp and mould in June 2021. In response, the landlord completed a mould wash in the bedroom room and recorded that the area had been affected by a leak. On 18 June 2021, a survey was requested to the bedroom wall as the plaster was crumbling due to issues with damp.
- The landlord recorded that the living room wall was crumbling on 1 July 2021. There were no further repairs recorded until 17 February 2022 when the landlord conducted a survey of the property. It found:
- There was water saturation in the property from the basement below that required further investigation.
- The property had visible mould/mildew throughout.
- There was evidence of water ingress behind the bath.
- The bathroom windows needed repair.
- The bathroom extractor fan was not working.
- The condensation unit in the hallway needed a new filter.
- There was a leak from the boiler in the airing cupboard causing damp and damage to the adjacent wall.
- The hallway programmer was not functioning properly.
- On 18 March 2022, the landlord’s specialist damp contractor inspected the property. It recommended that the condensation unit in the hallway was repaired. It did not find evidence of damp resulting from issues with the basement. It did not make any proposals to conduct specialist damp proofing or remedial works. The condensation unit was repaired on 22 March 2022.
- Mould washes were done throughout the property on 5 July and 16 September 2022. On 14 October 2022, the landlord’s records refer to the plaster in the bedroom coming away from the wall.
- On 18 October 2022, the resident complained to the landlord. She said:
- There was “severe” mould in the bedroom. She and her children could no longer sleep in the room and she was using the living room as a bedroom as a result.
- She had been told 2 years prior to allow the wall to dry out, but it was worse than before.
- The mould had destroyed most of her belongings. She was unable to afford to replace them.
- The carpet was black and soaking wet.
- The sofa was covered in mould and had to be cleaned daily.
- She had 3 young children living with her. Two of the resident’s 3 young children had asthma.
- She wanted to move home but was unable to move through mutual exchange as the property was in a poor condition.
- She felt the landlord had neglected her and the property for the previous 10 years. It did not seem to care that her children’s home had been destroyed.
- She felt the landlord was unable to sort out the problems.
- The landlord issued its stage 1 response on 20 October 2022. It said:
- Arrangement had been made for the plaster to be repaired on 18 October 2022.
- It had inspected the property previously and been unable to conclude the cause. A further inspection was raised for 25 October 2022 to investigate the cause of the damp/mould.
- A dehumidifier would be delivered to the property once the cause of the damp/mould was identified. It would reimburse the resident’s energy costs for the use of the dehumidifier.
- It had recently repaired a leak in the neighbouring property for a waste pipe in the kitchen. It wanted the resident to confirm if this was the room that backed onto her bedroom.
- It told the resident to make a claim either through her own contents insurance, or through the landlord’s public liability insurance. It gave details on how she could do both.
- The resident called the Ombudsman on 1 November 2022. She said the mould was visible in her neighbour’s home. The property was freezing cold and smelled mouldy. Even her clothes smelled of mould. She was using air fresheners to cover the smell. She was worried the problem was under the property and could cause significant damage. The landlord had not sent a surveyor to the property. She had received the dehumidifiers. She wanted to move from the property as she was not confident the landlord would ever fix the problem. The resident was advised to escalate her complaint with the landlord.
- The landlord conducted a “clean and shield” of the entire property on the same day.
- The resident called the Ombudsman on 1 December 2022. She said that her neighbour had a basement that went underneath her property. The neighbour had issues with leaking in the basement that she believed may be the cause of the damp/mould. The landlord had sent a surveyor to the address 2 weeks before, who said there was evidence of rising damp. It would be arranging a drain survey, but she had not been given an appointment. The resident was asked to pursue her complaint and provide the outcome to the Ombudsman.
- In January 2023, the landlord arranged to hack off the wall plaster in the bedroom and supply a dehumidifier to dry the walls prior to plastering. It recorded that there was a leak coming from underneath the property. It was unclear what the cause of the leak was, but it was recorded as an uncontainable leak. It arranged for a mould wash to the bedroom walls and a survey of the property.
- On 1 February 2023, the resident called the Ombudsman. She said that she had no response to her complaints from the landlord. We wrote to the landlord and asked them to issue a stage 2 response. It acknowledged the request and agreed to issue a response by 22 February 2023.
- On 7 February 2023, the landlord inspected the property. It found a leak entering the rear of the property that may have been caused by external ground works or tanking in the basement. The drains were checked and appeared to be “ok”. There was mould recorded behind the sofa and along the window wall adjoining with the neighbouring property. An order was requested to inspect the drains further.
- The resident called the landlord on 11 February 2023. She said that some of the plaster had been taken off the walls because of the repair work. She was living in one room with her 3 children.
- On 21 February 2023, the landlord asked to extend the deadline to issue its stage 2 response to 28 February 2023. It said that the case was complex and required information from multiple departments.
- On 28 February 2023, the landlord issued its stage 2 response. It outlined the residents complaint as:
- The problems with water ingress were ongoing.
- There was damp/mould in the bedroom.
- The resident wanted the landlord to decant her until it identified and repaired the cause.
- The response summarised a chronology of events from 19 October 2022 onwards. It included events that were not evident to the Ombudsman from the landlord’s records. It said:
- The resident asked for her complaint to be escalated to stage 2 on 11 November 2022. She felt ignored so she contacted the Ombudsman on 8 December 2022.
- A second complaint was raised on 15 December 2022, saying that the problems with damp/mould had been ongoing since February 2013. The resident was scared about the impact the damp had on her daughter who had “extreme asthma”.
- A further complaint was raised on 28 December 2022. The resident was “sick and tired of calling and making complaints”. She said the property was “falling down” and the walls and carpets were “dripping wet”. The whole room was covered in mould and her children’s chests were the worst they had been.
- The landlord sent a progress update to the resident on 29 December 2022. It apologised for the lack of response and gave her £50 in vouchers as a goodwill gesture.
- On 12 January 2023, the resident said the plaster had been taken down in the bedroom, leaving the wall as bare bricks. There was water coming through the ground in the bedroom.
- The landlord called the resident on 17 January 2023 to discuss her request for stage 2.
- A surveyor assessed the condition of the bedroom on 7 February 2023.
- On 13 February 2023, the landlord’s contractor assessed the bedroom. It said the bedroom needed to be cleared of all furniture so that it could conduct repairs.
- On 15 February 2023, the resident sent photographs of the property condition to the landlord. She was unhappy with the conditions she was living in.
- The landlord considered decanting the resident on 16 February 2023. It made the decision to decant the resident on 22 February 2023.
- The landlord apologised for the time taken to resolve the issues with water ingress, damp, and mould. It said:
- There was evidence of damp/mould dating back “a number of years”. The resident had to chase repairs and report unsatisfactory living conditions on several occasions. It had raised repairs to investigate and resolve the issue, but it had been unable to get to the root of the problem. It apologised for the frustration and inconvenience caused.
- The resident told it that she was struggling to cope with the impact on her mental health. She also raised concerns about the impact of the conditions on her children’s physical health.
- It had made a safeguarding referral on 9 February 2023 for a specialist to support the resident. Additional mental health support was offered.
- It had inspected the property and scheduled repairs from specialist contractors.
- It considered the impact of the repairs on the resident and the time works were expected to take. It was necessary to temporarily decant the resident while works were complete. She was given advice on how to keep a record of her expense. It offered to pay a meal allowance £10 per day for her, and £5 per day for her children while in temporary accommodation.
- The resident had been let down by its complaint handling as she had to chase the complaint several times. It apologised for the delays in completing the repairs and the undue inconvenience and distress this may have caused.
- It considered the resident’s vulnerabilities and impact the repairs had on her. It recognised that the resident had been unable to use her bedroom and the distress and inconvenience this caused. It considered the resident’s time and effort contacting it to report and chase repairs.
- It offered the resident £1,554 in compensation. This was comprised of:
- £684 for loss of bedroom.
- £550 for distress and inconvenience.
- £300 for time and effort.
- £20 for missed appointment.
- The landlord said it would offset any arrears from the compensation and pay the remaining balance to her.
- The landlord directed the resident to its liability and insurance team to pursue a claim for damages or ill health. It gave details for the Citizens Advice to assist her with this claim.
- It would progress the decant and contact the resident separately about this matter.
- The resident contacted the Ombudsman on 12 April 2023. She said that the work had not started. She continued not to use the bedroom because it was full of mould. She had instructed a solicitor to instigate a disrepair claim against the landlord.
- On 11 May 2023, the landlord inspected the property. It raised repair orders to:
- Plaster the bare brick walls with waterproof plaster.
- Complete a mould wash to the window wall.
- Replace 4 m of skirting board.
- Decorate the room.
- Install underlay and carpet.
- The landlord’s records show the following repairs were complete in the bedroom on 2 August 2023:
- The brick wall had been prepared with a bonding agent.
- The walls had been plastered and mould washed.
- Replaced the underlay and carpet.
- The walls had been painted.
- On 5 December 2023, the landlord identified a leak coming from underneath the flooring in the property. The walls and flooring were wet. The paint was bubbling on the walls. On 14 December 2023, it determined that a hot water pipe was leaking under the floor following the installation of a new boiler in November 2023.
- The resident contacted the Ombudsman on 22 and 24 January 2024. She said the underlying problems had not been repaired. She was not decanted in 2023. The damp and mould had returned to the hallway, kitchen and bedroom. The new carpets were damp and smelly. She had been without hot water since November 2023. She was tired and frustrated. She felt the landlord did not care about the impact on her and her family.
Assessment and findings
Scope of the investigation
- Following the allocation of this case to the Ombudsman, the resident reported a loss of hot water to the landlord. She states that she had been without hot water since November 2023. In accordance with paragraph 42(c) of the Housing Ombudsman’s Scheme these reports have not been considered as part of this investigation. This is because the matter was not brought to the attention of the landlord as a formal complaint. The resident may wish to rise this to the landlord.
- The records show that the resident has been reporting problems with damp and mould to the landlord since 2013. For this investigation, the Ombudsman has considered the landlord’s handling of these reports in line with its response to the formal complaint. The records show the resident reporting problems with the walls being wet and crumbling since March 2021. As such, we have considered reports from March 2021 onwards.
- Unlike a court, we cannot establish liability or award damages. As a result, the Ombudsman cannot determine whether the delays to complete repairs impacted the family’s health. However, we can consider the overall distress and inconvenience that the issues in this case have caused. A determination relating to damages caused to the resident’s health and property is more appropriate for the courts. The resident may wish to pursue this in a legal setting. It is noted that in its stage 1 response, the landlord advised the resident to claim against her own contents insurance. It said that if she did not have any in place, she could contact the landlord’s insurance team who consider public liability claims.
Policy and procedures
- The landlord introduced its healthy homes policy in 2020. This says that when a resident reports damp and mould, the landlord will:
- Respond to the resident within 5 working days.
- Make a referral to its contractor to assess the property within 20 working days.
- The contractor will carry out a “clean and shield”, treating the damp and mould, and making recommendations for follow up work when needed. Follow up jobs are then passed to its contractors. Works may include improving ventilation, insultation and windows. The timeframe and duration of the repair will depend on the severity of the issue.
- The landlord operated a 2 stage complaint process. It states that it will acknowledge complaints at both stages within 5 working days. It will issue a stage 1 response within 10 working days and stage 2 within 20 working days. Each response can be extended by 10 working days with the consent of the complainant.
Handling of reports of damp and mould in the property.
- Sections 11 and 9A of the Landlord and Tenant Act 1985 require the landlord to keep the structure and exterior of the resident’s property in repair, and to ensure that the property is fit for human habitation throughout her tenancy. Landlords are required to look at the condition of properties using a risk assessment approach called the Housing Health and Safety Rating System (HHSRS). HHSRS does not set out any minimum standards, but it is concerned with avoiding, or minimising potential hazards.
- Damp and mould are potential category 1 hazards that fall within the scope of HHSRS. Landlords should be aware of their obligations under HHSRS. They are expected to conduct additional monitoring of a property where potential hazards are identified. There is an increased risk of harm to the resident, as the damp and mould were present in the bedrooms of the property. The landlord’s records show that the resident had been reporting issues with damp and mould in the property frequently since she moved into the property.
- The above timeline suggests the landlord was aware of a persistent damp and mould problem at the property from around March 2021. This is when the resident said that her son was hospitalised as a result of breathing difficulties. This should have highlighted a serious risk of harm to the landlord. Its response is unclear from the records available to the Ombudsman. However, they do show that on 18 June 2021, the landlord determined that a survey was required as the plaster was crumbling in the bedroom. The records are unclear if a survey was conducted earlier than 10 February 2022. It should have assessed the property within 20 working days. The landlord has been unable to demonstrate it acted appropriately in line with its policy.
- The landlord should have identified that there was a pattern of reports earlier in the timeline. The Ombudsman’s Spotlight Report on Damp and Mould (published October 2021) provides recommendations for landlords, including that they should:
- “Adopt a zero-tolerance approach to damp and mould interventions. Landlords should review their current strategy and consider whether their approach will achieve this”.
- “Landlords should implement a data driven, risk-based approach with respect to damp and mould. This will reduce over reliance on residents to report issues, help landlords identify hidden issues and support landlords to anticipate and prioritise interventions before a complaint or disrepair claim is made”.
- “Landlords should ensure that their responses to reports of damp and mould are timely and reflect the urgency of the issue”.
- “Landlords should ensure that they clearly and regularly communicate with their residents regarding actions taken or otherwise to resolve reports of damp and mould”.
- “Ensure they treat residents reporting damp and mould with respect and empathy. The distress and inconvenience experienced by residents in this area is some of the most profound we have seen, and this needs to be reflected in the tone and approach of the complaint handling”.
- During the survey on 10 February 2022, the landlord found a leak entering the rear of the property. It recognised that a specialist assessment was required and arranged for an inspection that took place on 18 March 2022. This was around 26 working days later. The contractor made a recommendation for a repair but did not find evidence of damp resulting from issues with the basement. It did not make any proposals to conduct specialist damp proofing or remedial works. It’s decision to arrange a specialist assessment was in line with its policy, however there was a short delay in conducting the assessment. The landlord’s response did not reflect the urgency of the issue.
- The landlord acted on the reports provided by its contractor. It promptly repaired the condensation unit within 5 working days. There were no category 1 hazards reported by the contractor. It was reasonable to schedule mould wash treatments in the circumstances.
- Despite the findings of the assessments, the resident reported problems with damp and mould throughout the property in July 2022. The landlord arranged for mould washes throughout the property on 5 July and 16 September 2022. It was reasonable to schedule these washes. However, there was evidence of a recurring problem. As mentioned, damp and mould are potential hazards within the scope of the HHSRS. The landlord should have arranged for a more detailed inspection of the property. It had a responsibility to keep the property in repair and ensure it was fit for human habitation.
- When the resident complained in October 2022, she said that the plaster had started coming away from the wall. The floor was “soaking wet” and she had started living in one room of the property. The resident raised the issue with the walls as a health and safety concern, and she could not make use of the room due to this. The resident said she and her children had to start living in one room. The landlord sought to address the cause of the damp and mould and scheduled a survey of the property in its stage 1 response on 20 October 2022. It said that it would arrange for a further survey of the property and provide dehumidifiers to dry out the property. It assessed the property on 1 November 2022 and conducted a “clean and shield”. This was around 8 working days later and within the timescales set out in landlord’s policy and procedures.
- However, there was a period of around 2 months before the landlord conducted further repairs. The resident reported that the walls were “dripping wet” and everything was covered in mould in December 2022. The resident informed the Ombudsman she did not make use of the room throughout this period.
- On 12 January 2023 the landlord hacked off plaster from the bedroom wall, leaving it bare brick. Its records show that it found evidence of a leak coming from underneath the property during this work. It arranged a further inspection once it found evidence of a leak on 2 February 2023, which was around 15 working days later. The resident described still being unable to use the room. The landlord should have inspected the property promptly. It took an unreasonable amount of time to visit the property. It did not appropriately consider the impact of the living conditions on the resident.
- The landlord made a commitment to decant the resident while it completed the works to the property on 22 February 2023. She had highlighted her and her families vulnerabilities throughout the timeline. She had expressed how severe the impact had already been on her and her children. This was a reasonable decision based on the extensive works that were required and the impact these could have on the resident.
- It is important for landlord to maintain the commitments set out in its complaint handling. Landlords should ensure that they comply with the Ombudsman’s complaint handling principles: ‘Be Fair, Put Things Right, and Learn from Outcomes”.
- In its stage 2 response, the landlord recognised there had been delays updating the resident between October 2022 and February 2023. It recognised that it had been unable to resolve the substantive problem for several years. It considered that the resident had lost the use of the bedroom and the distress and inconvenience these works had caused. Its offer of £1,004 (excluding the £550 distress and inconvenience for complaint handling) did not reflect the distress and inconvenience caused. The landlord’s compensation would have been more accurate if it attempted to quantify the impact on the resident. There was a substantial period the resident had reported problems with damp and mould. She was left for an unreasonable period without full use of the property. Its offer did not put things right in the circumstances.
- The landlord did not set out a clear plan how it would identify the cause of the damp, or how it planned to rectify the substantive issue. There was an unreasonable delay following the landlord’s final response to inspect and schedule repairs. The timeline shows that the resident chased the landlord in April 2023 and it inspected the property on 11 May 2023. This was around 49 working days later. This caused further detriment to the resident. The landlord failed to use its complaint handling as an effective tool to put things right for the resident.
- The landlord did not follow through with its promise. It did not decant the resident and she was left to live in one room while the landlord conducted major works in the property. The landlord did not share its rationale for this decision with the resident. It was unreasonable to provide this expectation, then fail in its commitment. The landlord should have decanted the resident before completing works. This added to the resident’s frustration and distress with the landlord. It also shows that it did not take a customer focused approach in this instance and added to her loss of confidence in the landlord. This also further demonstrates the landlord’s poor communication with the resident.
- As a result of the landlord’s unreasonable delays, the resident was left without the full use of her bedroom between October 2022 and August 2023. The records show that there were issues with wet and crumbling walls from March 2021. The landlord took around 2 years to complete serious works to the bedroom wall. During that time, the resident had to make lifestyle changes to mitigate the impact of its failings. She told the landlord from 18 October 2022 that she had to share 1 bedroom with her 3 children. These were significant levels of disruption for a prolonged period.
- It is not possible for this service to determine whether the rooms were completely or partially unusable for the period. So, we have considered a compensation amount based on the lack of use of the bedroom between October 2022 and August 2023. We have considered the inconvenience and disruption caused while works were complete after the landlord failed to decant the resident between March and August 2023. An order has been made below for the landlord to pay the resident £1,350 in relation to the loss of use of the rooms. This additional compensation is awarded in recognition of the inconvenience caused to her and her family by not having full use of the property. It is not a rent refund or intended to be an exact calculation of rent paid for that period.
- The Ombudsman finds severe maladministration in the landlord’s handling of this case. The landlord recognised many of its failings in its final response to the resident. It was reasonable to direct the resident to make a claim against its liability insurance. However, it did not proactively manage this case. It did not demonstrate that it assessed the risk to the resident or considered how it might prioritise the works. It did not provide regular updates to the resident. It failed to identify/rectify the underlying cause of damp and mould for around 2 years. It made a commitment to decant the resident to conduct works in the property, that it did not follow through with. The landlord must pay the resident compensation of £2,400. This replaces the landlord’s previous offer and is comprised of:
- £1,350 for the loss of use of rooms in the property.
- £750 for distress and inconvenience
- £300 for time and trouble reporting and chasing repairs.
Complaint handling.
- In reaching a decision about the resident’s complaint we consider whether the landlord followed proper procedure, good practice, and acted in a reasonable way. Our duty is to determine complaints by what is, in the Ombudsman’s opinion, fair in all circumstances of the case.
- The evidence shows the landlord’s complaint at stage 1 was issued in line with the timescales set out in its policy and procedures. It demonstrated intention to address the substantive issues with repairs. It directed the resident to make a claim for damage to her property through its insurance. This was reasonable and showed that it recognised the impact. However, it did not address the resident’s concerns about rehousing. It should have given some advice and guidance regarding this request.
- The records are unclear when the resident made a request to escalate her complaint to stage 2. The evidence provided by the landlord did not include the requests it refers to from 15 and 28 December 2022. It has been difficult to understand what issues were raised again to the landlord on these dates as a result. In the absence of evidence, we have assessed the response to the concerns the resident laid out in her initial complaint. We have also considered the issues referred to by the landlord in its stage 2 response. The landlord should have systems in place to maintain accurate records. Good record keeping is essential to evidence the action the landlord has taken which then aids in its service delivery, enabling it to respond professionally when something goes wrong.
- There was a delay of around 50 working days from the escalation request the landlord referred to from 15 December 2022 and its final response on 28 February 2023. This was a considerable delay and would have increased the resident’s frustration and distress as a result. The landlord issued this response after being contacted by the Ombudsman on 1 February 2023. It treated the resident unfairly and she took additional time and trouble making a complaint to the Ombudsman.
- The landlord’s stage 2 response recognised the delays in its complaint handling. It’s timeline was detailed and showed its reasoning and understanding of the complaint. It apologised for the delays in its complaint handling and communication with the resident. In reflection of the impact the issues had on the resident, it made referrals to additional support. It also directed her towards providers who could assist her with an insurance claim for damages. It was reasonable to make these recommendations and was evidence the landlord was looking to be fair and put things right.
- The landlord apologised for the inconvenience caused and for the time taken to chase repairs. However, it did not provide additional compensation for its complaint handling. The compensation offered related to the substantive issues with repairs. The landlord should have offered some compensation for its complaint handling failures. It’s apology was reasonable but did not put things right in the circumstances.
- Overall, the Ombudsman finds maladministration in the landlord’s complaint handling. Its responses broadly sought to address the substantive issues. It considered the impact the issues had on the resident and her family. However, it did not keep clear or accurate records for its decision making. It did not fully address the delays to issue its stage 2 response. There was avoidable time and trouble caused by the delays. It should pay £250 compensation for its complaint handling failures.
Determination
- In accordance with paragraph 52 of the Scheme, there was:
- Severe Maladministration in the landlord’s handling of reports of damp and mould in the property
- Maladministration in the landlord’s complaint handling.
Orders
- Within 4 weeks of the date of this report, the landlord is ordered to:
- Provide a written apology to the resident from the chief executive for the failings identified in this report. A copy of the letter to be sent to the Ombudsman.
- Arrange for an independent surveyor to inspect the resident’s property. The surveyor must produce a report identifying the cause of the damp, recommendations to remedy this and a schedule of works. A copy of this report must be shared with the Ombudsman and resident.
- Complete an inspection to establish whether the property is habitable for the resident and her family. It should consider the resident’s circumstances and conduct a risk assessment. It should consider if a decant is necessary and share the findings with the resident and the Ombudsman.
- Pay the resident compensation of £2,650. This amount replaces the landlord’s previous compensation of £1,554 awarded in February 2023. If the landlord has already paid the resident compensation set out at stage 2, this should be deducted from the compensation ordered. The compensation is comprised of:
- £1,350 for the loss of use of rooms in the property.
- £750 for distress and inconvenience
- £300 for time and trouble reporting and chasing repairs.
- £250 for complaint handling failures.
- Within 8 weeks of this report, the landlord is ordered to:
- Conduct a case review by a director independent of the service area and findings shared with the governing board. It should consider whether previous actions (such as the approach to complex cases) are sufficient to prevent similar failings in future. A copy of this review to be shared with the Ombudsman.
- The landlord is to provide evidence of compliance with the above orders to this Service within the timescales set out above.