Southend-on-Sea City Council (202218411)

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REPORT

COMPLAINT 202218411

Southend-on-Sea City Council

29 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 resident’s complaint is about the landlord’s handling of the:
    1. property condition at the time of being let;
    2. rent charged.

Background

  1. The resident held an assured shorthold tenancy agreement for her initial property that began on 7 February 2022. It was for a 2-bedroom ground floor flat that was located in a high-rise block of flats that consisted of 10 floors. The landlord is a local authority. The resident terminated her initial tenancy on 24 April 2022 after having been granted a permanent move to a decanted property. Her new tenancy agreement with the landlord began on 25 April 2022.
  2. The landlord had recorded that the resident’s daughter had vulnerabilities that impacted her mobility and mental health.
  3. The tenancy agreement states that the landlord is responsible for the maintenance of:
    1. “Walls, covering and so on (major repairs only).”
    2. Baths, basins, toilets, and shower trays.
    3. Gas boilers.
  4. The landlord’s voids process states that it will:
    1. Clean void properties to meet the landlord’s lettable standards.
    2. Sweep, mop, and vacuum all flooring, remove all marks to the walls, and thoroughly clean and disinfect bathrooms and wet room flooring.
    3. Check all rooms for damp, including rising, penetrating, and condensation. Any problems identified “should be dealt with as necessary to eliminate the problem.”
    4. Ensure the WC is in a good and clean sanitary condition and firmly fixed. When in poor condition, this will be replaced.
    5. Check all pipework taps, plugs, and chains.
    6. Ensure that rooms in its properties will “be free from damp, mould staining, obscene graffiti, layers of fat, etc.”
    7. Only carry out redecoration to general needs properties under exceptional circumstances. Redecorations will generally be carried out by incoming residents using the redecoration allowances given.
  5. The landlord’s social housing allocations policy states if an applicant refuses an offer of social housing, the local authority will:
    1. contact them to offer support and assistance and verify the applicant’s circumstances.
    2. review the applicant’s banding and need for re-housing if they refuse 3 offers of accommodation within a 12-month period.
    3. suspend or cancel the application if the applicant is owed a full statutory homeless duty, that duty will be discharged (cease) if they turn down a suitable offer of accommodation.
  6. The landlord’s compensation policy states that it covers loss of amenities, costs for alternative heating, delays in completing repairs that affect health and safety, and failures in its “customer service in its own right.” It also states:
    1. It would pay for loss of complete heating – 10% of the weekly rent after 24 hours, provided that no reasonable substitute was offered to the resident. Compensation for loss of heating is excluded between 1 June and 30 September.
    2. It would pay for loss of hot water – 10% of the weekly rent after 24 hours, provided no reasonable substitute was offered to the resident.
    3. Where a customer is able to establish that they have been disadvantaged due to a failure by the customer service of the landlord, it can agree to authorise an ex-gratia payment of up to £250 for the individual affected.
    4. Its policy did not cover It does not cover decants or temporary moves.
    5. It will not pay compensation for “stress following any incident or failure of service.” The landlord’s policy has changed since the resident’s complaint, and it now considers distress as a result of the impact of its service failures.
  7. The landlord’s suggestions, compliments, and complaints policy at the time of the resident’s complaint states that it had a 2 stage complaints process. However, it also said that it had a zero stage for “informal complaints.” The zero stage has since been removed from the landlord’s policy and process. It committed to providing its stage 1 response within 10 working days and its stage 2 response within 20 working days.
  8. Its decant and management move procedure states that:
    1. A decant can be considered when a property is not habitable, this includes where there is “a major damp problem” within the property.
    2. Residents will be required to continue paying the rent and any service charges on the property where the permanent tenancy is held. The resident is also responsible for all bills and utility charges for both properties. No rent or service charges will be raised for the decanted property.
    3. It can recommend that a resident remains in the decanted property by submitting a report to senior management for consideration. If agreed the resident will need to sign a termination form to end their tenancy agreement for the permanent property. They will then need to sign a new tenancy agreement for the decanted property. Once completed, rent and service charges will then be raised for the decanted property from the date the new tenancy is signed.
    4. If a resident is being decanted due to major repairs, arrangements should be made or confirmed by the landlord to remove all of the resident’s personal belongings to and from the decanted property.

Summary of events

  1. From the evidence provided the property had been empty (void) since September 2021 until 7 February 2022 when the resident’s tenancy started. The landlord’s contractors completed void handover documents for the property on 6 October 2021. There has been no evidence seen by this Service to confirm that the landlord carried out a post inspection to the property after this date or prior, to it being let to the resident.
  2. The resident collected the keys to the property on 4 February 2022 with the view of moving her belongings in on that date, although her tenancy began on 7 February 2022.
  3. On 7 February 2022 the resident contacted the landlord to report multiple repairs. There has been no evidence seen by this Service to confirm the landlord’s attendance or completion of the repairs following the resident’s report. The repairs that were reported by the resident were:
    1. The wet room shower was not draining away. This had led to a flood in the hallway, causing damage.
    2. There was a leak at the back of the toilet.
    3. The light switch in the hallway and the light fitting were not working. The resident reported having received an electric shock from the switch.
    4. No heating or hot water since 4 February 2022. The landlord recorded that the gas needed to be uncapped and a boiler test was needed.
  4. On 17 February 2022 the landlord attended the resident’s property to carry out a new tenancy visit. During the visit, the landlord inspected the property and carried out a tenancy sustainment assessment survey. This survey included a RAG (red, amber, green) rating. The landlord recorded a red rating on the survey. The survey said:
    1. The property was in “very poor condition.” The landlord asked for a further inspection to be carried out by another member of its staff to assess if it met its lettable standard.
    2. The resident said that she was unhappy with the property condition when she moved in and rated it to be in poor condition.
    3. The resident felt that the landlord could improve its service by letting properties that were of a lettable standard.
  5. On 18 February 2022 the resident made a further report to the landlord of having no heating or hot water. There has been no evidence seen by this Service to show if the resident had been without heating and hot water since her previous report on 7 February 2022, or if this was an intermittent fault. There has also been no evidence seen to confirm the actions taken by the landlord in response to the resident’s further report.
  6. On 22 February 2022 the landlord carried out a further inspection of the resident’s property. It again recorded that it was “in poor condition.” Its report stated:
    1. There were issues with damp throughout the property, and it would arrange for a further investigation to be carried out.
    2. It had offered the resident the option to move to another property as a temporary decant, with the possibility of making it permanent through a management move. However, if the resident wished to stay in her property, it would be able to carry out the works around her.
    3. The resident had initially said that she would like to remain in the property but said that she would be willing to look at the alternative property the landlord had offered her.
    4. The resident had advised that she had had to go over to Universal Credit benefit claim and that they would be conducting further checks. These were due to her personal circumstances, having fled domestic violence.
    5. The resident was aware that she could apply for an advance on her Universal Credit, and the landlord did not expect her to pay full rent at that time.
  7. On 24 February 2022 the resident met with the landlord to view the temporary decant property that the landlord was offering. The landlord reported that the resident was happy with the property she had viewed and it would look to arrange for a removals company to move the resident to the decant property. Once the resident had moved into the decant property, it would submit a management report with the aim of making her move permanent.
  8. On 28 February 2022 the resident contacted the landlord to discuss her application with Universal Credit. She raised concerns that the landlord may look to evict her due to Universal Credit having not been able to update her on her application for assistance with her rent. The landlord’s records show that it assured her that it would not be looking to evict her and that it wanted to work with her to resolve the matter. It also advised the resident that once she was in receipt of Universal Credit, she would need to pay £501.47 plus an additional £16.75 towards her rent arrears. The resident confirmed that she would update the landlord further on the situation by 28 March 2022.
  9. The landlord wrote to the resident on 9 March 2022 to confirm that the temporary decant application had been granted. The resident signed the licence agreement for the decant property the following day, for the agreement to begin on 16 March 2022. The landlord’s communication advised:
    1. It was a temporary move, and a secure tenancy for the decant property would not be created.
    2. The resident was permitted to live at the property as a licensee, and she was responsible for paying the rent on the property that she was decanted from, not the property she had been decanted to.
    3. The resident had been granted the temporary accommodation while the landlord carried out an assessment of whether it would be safe for her to return.
    4. The landlord had agreed to cover the resident’s removal costs between the 2 properties.
  10. On 22 March 2022 the landlord completed a management transfer report for the resident to remain in the property that she had been decanted to. It stated:
    1. The purpose of the report was to recommend that the resident and her daughter be allowed to remain in the property that they had been decanted to under an assured shorthold tenancy.
    2. The resident said that she had accepted the original property as she had been worried that if she had refused to accept it, she would not have been offered another property.
    3. When it had visited the resident on 17 February 2022 it was shown around the property and made aware of the outstanding repairs, the excrement on the walls that had been painted over, as well as the damp that was throughout the property. As a result of its visit, it had asked for an inspection of the property to be carried out.
    4. When an inspection had been carried out, “considerable concern” was raised by the landlord’s member of staff in relation to the damp within the property. It was suggested that the resident be decanted as it “could take a while to treat.”
    5. It had visited the resident at the decanted property on 22 March 2022. It said that the resident’s daughter suffered with functional neurological disorder (FND), and she suffered from fits that were mostly brought on by stress. The resident told the landlord that while at the original property, her daughter had suffered 3 to 4 fits every day. Since living at the decant property, she had suffered 2 fits all week.
    6. The cost of moving the resident and her daughter had been a considerable expense at £600, and the resident had paid for her cooker to be installed. It recommended that, to save more expense and distress, the resident be granted an assured shorthold tenancy for the decant property.
  11. The resident called the landlord on 1 April 2022 to discuss her rent account. She advised that Universal Credit had not been paying her the correct amount, and she had also applied for discretionary housing payment. The resident said that she would pay the landlord the amount that she had received from Universal Credit, although it would not cover the amount she owed for the service charges. The landlord advised the resident to speak with Universal Credit to ensure she received the correct payment from them the following month. It also confirmed the minimum payment that it needed to be made by the resident and agreed to call her the following week to gain a further update.
  12. On 7 April 2022 the landlord carried out a further inspection to the resident’s original property. It reported that it had found high moisture levels within the property. It said that the evidence found suggested that there had been a significant water leak in the past that had caused damage to the skirting and plaster. It stated the resident had said that “foul water poured from the area of the WC pipe connection, which corresponded with the use of the bathroom above.” It also reported that there were very high moisture readings recorded over most of the areas in the property.
  13. On 24 April 2022 the resident completed a tenancy termination form to end her previous tenancy. The landlord recorded on the resident’s rent account notes that she had a new tenancy agreement for the property that she was decanted to, under a management move.
  14. On 16 June 2022 the landlord recorded that all the works to the resident’s previous property had been completed.
  15. The landlord wrote to the resident on 8 July 2022 to advise of an outstanding balance of £791.80 on her rent account from her previous property. It asked her to contact its specialist income management team or pay the full amount owed within 3 days. The resident called the landlord on 12 July 2022 and said that she had been surprised to receive the landlord’s communication as “she was advised that she wouldn’t be charged as she was management moved, given the extremely poor condition of the property.” The landlord advised the resident to “write in,” and when she did, it would pass this on to the appropriate team.
  16. The resident made her complaint to the landlord on 14 July 2022. The landlord called the resident to confirm receipt of her complaint on 21 July 2022 and sent a formal acknowledgement to her the next day. It advised that it provide its response within 10 working days.
  17. The landlord provided its stage 1 complaint response to the resident on 2 August 2022, which was within its policy timescales. It said:
    1. It apologised for the standard of the property when it had been let to the resident.
    2. It had identified that there had been a previous leak that had been undetected. This had resulted in a build-up of water on the floor, which had then caused damp to “come up the walls.”
    3. It had transpired that there had been a leak from the property above the resident, which had caused “some damp issues higher up,” although it did not specify the areas that had been impacted.
    4. The issues had been resolved in the property, although “this did not help you in the time of moving in.”
    5. It reviewed when the resident began her tenancy at her original property to when she had been moved to the decanted property. It provided details of the resident’s rent account, including the rent that was due and the amounts the resident had paid. The landlord highlighted weekly dates beginning 7 February 2022 until 7 March 2022. These dates were when the resident had resided at the original property. It said that it would remove the charges for those 5 weeks, leaving her with an outstanding balance of £232.50 that she needed to pay.
  18. The resident requested her complaint be escalated to stage 2 of the landlord’s complaints process on 4 August 2022. While the landlord escalated the resident’s complaint the following day, this Service has not seen evidence of this having been acknowledged with the resident. In the resident’s escalation request, she told the landlord in 2 separate emails that:
    1. It had not acknowledged that the property had “not been fit for human habitation.”
    2. She felt it was unfair for her to have to pay rent for the property.
    3. It had been “fully aware of the damp in the flat,” and it had never been addressed.
    4. It had not carried out a proper inspection, as it “would have seen the entire flat was covered in black, fluffy mould.”
    5. Her daughter was vulnerable, and as she had not had access to heating or hot water, it had made her daughter “extremely ill.”
  19. The landlord provided its stage 2 complaint response on 2 September 2022. It said:
    1. It had acknowledged in its stage 1 complaint response that the standard of the property had not been in line with its policy, but it had not apologised to the resident for this. It said that it wanted to take “the opportunity to rectify this.”
    2. Its stage 1 complaint response had explained that there had been a previous leak that had been undetected and that it had been unaware of the damage caused to the resident’s property.
    3. Its stage 1 complaint response had clarified the approach it had used in relation to the rent charges on both properties, and it had adhered to its policies.
    4. It appreciated that “the whole situation has been difficult for you and your family.” In recognition of this, it said that the balance on the resident’s rent account would be reduced to £116.25. It asked the resident to confirm her agreement with its offer, and it said that it would credit her rent account to reflect this.
  20. On 13 September 2022 the landlord’s notes on the resident’s rent account stated that a rent adjustment was made to her account, and it was credited with £116.50, although there has been no evidence seen by this Service to show the resident accepted the landlord’s offer.
  21. Between 22 and 24 September 2022 there were communications between the resident and the landlord in relation to her rent account. From the evidence seen by this Service, it has not been clear as to what agreement, if any, had been made with the resident in relation to any arrears on her rent account.
  22. On 16 November 2022 the resident brought her complaint to this Service. The resident said:
    1. She had been told that the property had been a “void property,” and after 5 weeks, she had to be moved to another property.
    2. That the landlord had charged rent for her current property and her previous one simultaneously. This had caused and continued to cause her financial hardship and stress. She cannot afford to pay this and feels that she should not be paying for a void property.
  23. On 1 February 2023 the landlord wrote to the resident to confirm that she had cleared the rent account for the original property.

Assessment and findings

Property condition

  1. The landlord’s voids process states that it will clean its void properties to meet its lettable standards. It committed to checking all pipe work, removing all marks from the walls, and ensuring that rooms in its properties will be free from damp and mould staining. It states that any problems identified “should be dealt with as necessary to eliminate the problem. However, it does not provide a timeframe for how long a property can remain empty before a further inspection must be done prior to it being re-let. It states that it would only carry out redecoration to its general needs properties under exceptional circumstances, and any redecoration would generally be carried out by incoming residents using the redecoration allowances provided by the landlord.
  2. The landlord has not disputed that the condition of the property when let was not to its lettable standards. Where there are admitted failings by a landlord, this Service’s role is to consider whether the redress offered by the landlord put things right and resolved the resident’s complaint satisfactorily, and whether it was fair in all the circumstances of the case. In considering this, we take into account whether its offer of redress was in line with our dispute resolution principles(to be fair, put things right, and learn from outcomes), our remedies guidance, and its compensation policy.
  3. Between the commencement of the resident’s initial tenancy agreement on 7 February 2022 to 21 February 2022, it was reported to the landlord twice that she had no heating or hot water. The landlord recorded both of the resident’s reports. It raised works on the first report that the gas to the property needed to be uncapped following the resident having moved into the property. While the landlord recorded both of these reports and others as emergency repairs, there has been no evidence seen of when it completed any of the repairs raised. This was poor record keeping by the landlord. Its repairs recording should be robust and detailed, showing clearly when repairs have been raised as well as when they were completed. As a result of the landlord’s poor record keeping this Service has been unable to determine if the works had been carried within an appropriate timescales or in line with the landlord’s repairs policy.
  4. The Ombudsman’s spotlight report on Knowledge and Information Management (KIM) states that, “failings to create and record information accurately results in landlords not taking appropriate and timely action, missing opportunities to identify that actions were wrong or inadequate, and contributing to inadequate communication and redress.” The landlord should take the opportunity, if it had not done so already, to review and self-assess against the spotlight report to identify any areas in need of improvement. The report can be found on the Housing Ombudsman’s website.
  5. When the landlord visited the resident on 17 February 2022 it identified that the property was in poor condition. It was reasonable for the landlord to have requested a further inspection be carried out to gain a second opinion. The landlord did not record any concerns raised by either its member of staff or the resident at her remaining in the property while waiting for the further inspection to be carried out. When the inspection took place 3 working days later, the landlord offered the resident the option of being decanted, but it also advised that should the resident not wish to move, then it would be able to carry out the works while she remained in the property. This was reasonable action taken by the landlord.
  6. In its stage 1 complaint response, the landlord apologised for the condition of the property when it was let. It confirmed that it had identified leaks and the problem in the property had now been resolved, but acknowledged that this had not helped the resident at the time of her having moved in. The landlord advised the resident that it would be crediting her rent account with the 5 weeks’ rent as charged during her time at the property. When the resident signed the tenancy agreement for the property, she accepted her obligation to pay rent for it. The resident said that she thought that if she did not accept the property, she would not be offered another one, although no evidence has been seen that she discussed this with the landlord. It would have been reasonable for the resident to have spoken to the landlord giving it the opportunity to clarify the options available to her. The landlord took reasonable action in crediting the resident’s rent account with the full rent for her time there. However, it did not show consideration for any distress or inconvenience that had been caused to the resident during this time.
  7. The landlord acknowledged that it had been a “difficult time” for the resident and her daughter in its stage 2 response. It did not dispute its stage 1 complaint response or that the property condition had not been to its lettable standards. In its response, it offered an additional credit to the resident’s rent account of £116.25 in recognition of the impact caused to the resident. While the landlord acknowledged that the resident and her daughter had been through a difficult time, its offer was not reflective of the impact to them both. It did not evidence that it had considered:
    1. the significant distress and inconvenience that had been caused in the resident having to move into the property in a poor state and without heating and hot water, only to have had to relocate 5 weeks later. It also did not consider the changes the resident would have had to make due to her moving, such as making relevant people aware of her change of address and circumstances.
    2. the impact of having to live in a property that had damp and mould in or consider the impact or inconvenience of the additional repairs that the resident had reported while living there.
    3. The impact had on the resident’s daughter knowing that she had vulnerabilities with her mobility and mental health.
    4. The resident had advised she had recently fled domestic violence.
  8. It asked her to confirm that she was agreement with its offer before it would credit her rent account. From the evidence seen by this Service, the resident’s account was credited although evidence of the resident’s acceptance has not been seen. However, it would be reasonable for the landlord to have credited the resident’s account without the need for her acceptance. The total amount of financial redress paid by the landlord in its complaint responses totalled £675.55. It is the view of this Service that the remedies landlords provide should, as far as possible, put a resident back in the position they would have been in had the failure in service not occurred. It was appropriate that the landlord made a further offer of redress to the resident to acknowledge the difficulties incurred.
  9. The landlord covered the cost of moving the resident to another property in line with its decant and management move policy. In its request for a permanent move for the resident, it stated that the resident had incurred the cost of having to reinstall her cooker in the decanted property. While it has not been clear to this Service if the resident had paid to have her cooker installed at the initial property, it would be reasonable to expect the landlord to have spoken with the resident about the cost of its reinstallation if the resident had to pay for this a second time.
  10. It was not disputed that the property was let while not meeting the landlord’s lettable standards. The landlord acknowledged and apologised for this. It would be reasonable for the landlord to have a suitable void inspection regime, to manage post void work sign off and to manage longer term voids. There is no evidence that the landlord visited the property during the 4 months it remained empty after its void handover, to undertake security checks or to carryout compliance activities such as flushes of its water system prior to reletting. These were missed opportunities to have identified the property’s poor condition prior to it having been let.
  11. The landlord was aware that of the resident’s personal circumstances. It knew that both her and her daughter were fleeing domestic violence, and that her daughter had both mobility, and mental health issues. These were aggravating factors in the impact caused to them both after having moved into both the original property and the decant property also. While the landlord acknowledged that the resident had been through a “difficult time” it did not show consideration to the aggravated impact had on the resident and her daughter, when providing its responses.
  12. In summary, it was not disputed that the property was not to a lettable standard. The landlord acted reasonably to credit the resident’s rent account with the full rent amount for the time she occupied the initial property. While it acknowledged the “difficult time” incurred by the resident and her daughter, its offer of financial redress was not reflective of the impact to them. It voids process failed to ensure the property of a lettable standard, its repairs record keeping was not robust, its offer of financial redress did not reflect the impact to the resident or her daughter. As a result, maladministration has been found in relation to the landlord’s handling of the property condition. This Service orders the landlord to pay the resident £1100 in compensation, this is broken down by £559.30 (5 weeks rent for the original property) and £540.70 for distress and inconvenience caused. This is within the range of compensation the Ombudsman can award for maladministration, particularly where there are aggravating factors which would justify an uplift, such as when a particularly vulnerable resident is impacted.

Rent account

  1. The landlord’s decant and management move procedure states that residents will be required to continue paying the rent and any service charges on the property where the permanent tenancy is held when they have been temporarily decanted from a property. No rent or service charges will be raised for the decanted property.
  2. The landlord’s decant and management move policy is clear in stating which property the resident will pay rent for when being decanted to a temporary property. It states that it will continue to charge rent for the property the resident has a permanent tenancy for. The resident advised this Service that she had been charged rent by the landlord for both properties simultaneously. There has been no evidence seen by this Service to show that the resident had been charged for both properties at the same time. The resident was charged rent for the property that she had a permanent tenancy for while living in the decant property under a temporary agreement. Once the resident’s new permanent agreement for the decant property commenced, the rent charge for her original property ceased.
  3. The resident reported to this Service that she incurred and continued to incur financial hardship and stress as a result of the situation with her rent account. In the initial discussions the resident had with the landlord, she advised of incorrect payments being made to her by Universal Credit. While the landlord cannot be held accountable for errors made by Universal Credit, it was in regular communications with the resident regarding the situation, and it continued to keep communications with the resident open. It assured her that it wanted to work with her to resolve the issues. This Service is aware of communications between the landlord and the resident following the resident’s complaint having exhausted its complaints process. The landlord offered the resident an affordable arrangement to help with her arrears, and on 1 February 2023 the landlord confirmed the resident’s arrears to have been cleared.
  4. In summary, there has been no evidence seen by this Service to suggest that the resident was being charged rent for 2 properties simultaneously. The landlord kept communications with the resident open in relation to her arrears and reassured her that it wanted to work with her to resolve the arrears that she had. The landlord acted in accordance with its policy, and this Service has found there to have been no maladministration in the landlord’s handling of the rent account.

Determination (decision)

  1. In accordance with paragraph 52 of the Scheme, there was maladministration in the landlords handling of the property condition.
  2. In accordance with paragraph 52 of the Scheme, there was no maladministration in the landlord’s handling of the rent charged.

Reasons

  1. The landlord failed to provide appropriate financial redress when acknowledging the property condition.
  2. The landlord’s failed to ensure its property was of a lettable standard.
  3. The financial redress offered was not reflective of the distress and inconvenience caused to the resident.
  4. The landlord followed its procedure when applying rent to the resident’s rent account.
  5. The landlord ensured it kept communications with the resident open with the aim of resolving the arrears on the resident’s rent account.

Orders and recommendations

Orders

  1. The landlord must comply with the orders below and provide evidence to this Service of its compliance within 4 weeks of the date of this report.
  2. The landlord must write to the resident to apologise for the service failure identified in this report.
  3. The landlord must pay the resident in total £1100 compensation for the Service failures identified in this report. This is inclusive of the 675.55 already credited to the resident’s rent account. The remaining £424.45 should be paid directly to the resident.
  4. The landlord must conduct a review of this case and what went wrong in the void and lettings process. The landlord must provide a report to this Service outlining its findings and action plan following the review.