Learning from severe maladministration report – January 2025

Taking the key lessons from our severe maladministration decisions.

About this report

A core purpose of social housing is to provide decent, affordable homes to people who may have long-term health needs.

For decades landlords have helped millions of people who may otherwise have experienced poorer housing conditions.

But this achievement should not obscure the significant failings identified in this report and the searching questions it presents to landlords about handling requests from residents with disabilities, adaptations, and mental health needs.

While the focus of several cases is on disabilities and other physical health needs, the impact on resident’s mental health is also present. Understandably, both can be relevant when handling a complaint.

Our response to mental health as a society is changing and social landlords should be at the forefront of evolving services to meet different mental health needs – about 40% of social tenants report mental health concerns. However, in some cases the landlords are open about their inability to respond to these needs, and it strongly suggests, as was evidenced in our Spotlight on attitudes, respect and rights – relationship of equals last year, that stronger frameworks and staff support are
needed around handling mental health.

We hope this casework review helps landlords to learn from complaints alongside the insight being provided through our Centre for Learning to foster fairer, better services.

Learning from severe maladministration report (PDF)

Adaptations

The first area of focus is making Occupational Therapist (OT) referrals. When looking at installing aids and adaptations in a resident’s home, often an OT will be involved. Whether through referral or commission, these reports should be taken seriously and implemented where reasonably practicable.

Cases highlighted in the full report relating to adaptations:

  • Rooftop Housing Group 202317069*
  • Kingston upon Thames Council 202221617*
  • L&Q 202202357*
  • Longhurst Group 202221733
  • Lambeth Council 202208047
  • Southwark Council 202310781*
  • Clarion 202234071*

Key learning related to adaptations

Occupational therapists

Landlords should review whether an occupational therapist is needed to visit a home based on either a request from a resident or knowledge about their individual circumstances. Good practice is to do this early to understand what may be required to make the home suitable. Special consideration should be given where the landlord is aware at point of letting household circumstances that make this relevant and landlords should also consider any mitigations needed if there are delays to an assessment.

It is good practice and appropriate for the OT to attend the property viewing and contribute their professional opinion. Once the assessment is complete and the landlord is in receipt of the report, it should complete a feasibility survey and benchmark this against any relevant policies. The outcome of this should be communicated with the resident.

It may be that the adaptations are not possible for structural reasons due to the dimensions and layout of the property or may be cost prohibitive. However, landlords have a responsibility to assess the feasibility of the adaptions and make informed decisions whether or not to proceed with them.

It is also vital that residents are afforded respect by decisions being communicated in a timely way, clear explanations given, and expectations managed appropriately.

In the event that a feasibility assessment concludes that the majority of the adaptations are not possible, landlords should continue working with the resident and the OT to find a suitable alternative property.

If there are disagreements about what is holding up work, landlords should engage with the resident local partners in a proactive manner to find a resolution.

Adaptations being carried out

Adaptations are key to make sure residents are able to live an independent and fulfilling life in their homes. Landlords should have an effective adaptations policy in place, that allows both its staff and residents to understand the expectations surrounding this issue.

Any policy should at least think about the extent of the work required, availability of alternative accommodation, length of the time the adaptation would be needed, if there are other ways to meet the needs of the resident, if a temporary move (or decant) may be required, and what the procedure is for rejecting an adaptation whether on the grounds of feasibility or practicality.

This all helps to manage the expectations of a resident and will also help with timescales for implementation. Landlords should make sure that throughout the process, residents and any key third parties are kept up to date to reduce frustration or miscommunication.

This extends to operatives and other groups such as external architects or surveyors that may be involved in the process. These visits should be factored into plans and not delay the schedule of works.

Landlords considering temporary moves should look at the Ombudsman’s severe maladministration report on this topic for more learning around handling these effectively and sensitively.

If the adaptations are unable to be completed, it is a landlord’s responsibility to decide and inform the resident of this in a timely manner. The resident would then have the knowledge to make informed choices about their future.

Centre for Learning resources

Attitudes, respect and rights key topics page

Knowledge and information management key topics page

Decants key topics page

Communication: responding effectively to vulnerabilities

When an issue is reported to a landlord, it must decide how best to act to resolve the situation. This can vary considerably from person to person and depending on any vulnerability that may be present within the household.

What may seem like a smaller issue to some, may be a much more serious and urgent to others who are in a vulnerable position. It is important landlords know the residents that live in their homes, so they are able to effectively respond to issues.

Cases highlighted in the full report:

  • Southern Housing 202303097*
  • Somerset Council 202305160*
  • Bristol City Council 202118413
  • Sovereign Network Group 202224092
  • VIVID 202228772*

Key learning on responding effectively to vulnerabilities

The Ombudsman’s Spotlight report on attitudes, respect and rights emphasises that a landlords’ attitude to vulnerabilities is vital, with a need to recognise, adjust and respond to its residents’ individual circumstances.

Under section 20 of the Equality Act 2010, landlords have a responsibility to make reasonable adjustments for residents who are at a substantial disadvantage compared to residents who do not have a disability. Landlords must make sure all staff are trained to fully understand the obligations and responsibilities towards vulnerable and disabled residents. This extends to contractors too.

Communication

There are several key learning points in communication that landlords should consider. Landlords should take into account any vulnerability disclosed to make sure a sensitive and coordinated approach and offers of support being tailored to the individual.

This can include agreeing a formal communication plan, with a preferred method of communication, regular updates being provided, a single point of contact if necessary, and pre-appointment communication if required.

Record keeping

Another key aspect of responding effectively to vulnerabilities is record keeping. Having accurate records allows landlords to have a greater oversight of any issues that a resident may face and an understanding on how that will impact them. It also can mean less repeat or failed visits to a resident’s home, which can reduce anxiety that residents may feel.

Prioritisation

When a resident with a vulnerability raises an issue, landlords must risk assess the impact this could have on that particular household and how urgent the response needs to be. A small issue may be far more severe for a household containing vulnerabilities due to the impact it can have.

While making sure that landlords are aware of the key issues facing a vulnerable resident right from the start of the process, landlords should also maintain regular contact with the household to see if the response needs to be adapted to suit the current impact. Landlords should also consider whether it needs a dedicated policy to handle vulnerabilities and where one exists, whether it is being fulfilled in practice.

Centre for Learning resources

Other cases in the report relating to responding effectively to vulnerabilities:

  • Sanctuary 202122141, 202117413*
  • Welwyn Hatfield 202122294
  • L&Q 202206761, 202205276*, 202220133*
  • Barking and Dagenham Council 202301004*
  • Clarion 202200854*
  • Onward Homes 201911513*
  • Bromford 202210049*
  • Longhurst Group 202303652
  • Westminster City Council 202121186
  • Islington Council 202303995*

Other cases in the report that relating to adaptations:

  • North Yorkshire Council 202221966
  • Southwark Council 202209262
  • Hyde Group 202220591*
  • Cornwall Council 202101272*
  • Inquilab 201906579
  • Lambeth Council 202207742
  • Folkestone and Hythe Council 202337199

Learning from severe maladministration report

Download the full learning from severe maladministration report to see the case studies in more detail.

Learning from severe maladminsitration full report (PDF)

The full report contains distressing references, including to suicide and self-harm.

Samaritans contact details

When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch

*All decisions are anonymised so residents’ names are not used, but landlords are named. In some cases, we may decide not to publish a decision if it is not in the resident’s or landlord’s interest or the resident’s anonymity may be compromised.

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