In the report, the Ombudsman issued 85 findings in 33 cases with a maladministration rate of 88%. The investigation started last year following several cases involving severe maladministration.

Among the cases were instances such as windows that could not be closed to make properties secure, part of a window frame falling out of a property into a garden below, ceiling debris falling onto the head of a young child, and residents complaining of feeling unsafe in their buildings.

Overall, the Ombudsman made 138 orders to make things right. It identified two key themes and made recommendations to improve in those areas:

• Repair handling – There were multiple failings in this area, such as the landlord not hitting emergency or routine repairs timescales. Not following procedures also had a detrimental impact on residents with incorrect contractors being sent, repairs incomplete, and issues reoccurring. The landlord also was not routinely updating records in a timely manner which meant there was often confusion about the status of the repair or whether works had taken place. The landlord also suffered from issues with its contractors, either not sending the correct operative or performance and quality being called into question. When it terminated the contract of one contractor, residents suffered between the transition and the lack of focus on residents’ complaints was a missed opportunity to recover poor service. Additionally, a lack of a vulnerabilities policy, or a failure to follow it if it existed, has resulted in vulnerable residents being left in properties that impacted their physical and mental health.
• Complaint handling – The landlord’s complaints procedure was not compliant with the Complaint Handling Code, meaning it initially failed to escalate 40% of cases investigated, and in 3 of these cases, it only did so after Ombudsman involvement. There were also extensive delays in many of the responses. These did not always provide an adequate level of detail, address each point, or were incorrect or contradictory of previous responses. The landlord sometimes failed to action the promises made in the responses. On top of this, it did not appear to follow its own compensation policy and the difference between initial offer and final compensation payment was sometimes significant.

The Ombudsman has recommended that the landlord undertakes several improvements in these two areas including updating its repairs and maintenance handbook, creating a knowledge and information management framework for all stages of the repairs process, and reviewing its whole complaints procedure to ensure it is compliant with the Complaint Handling Code.

The Ombudsman said it will work with the landlord until it has assurances that it has complied with the recommendations and is embedding these changes into practice.

Richard Blakeway, Housing Ombudsman, said: “Social housing provides vital services and the leadership of the landlord should be commended for the proactive and positive approach it has taken to learn from this investigation.

“The landlord appeared to be operating in crisis management mode for a number of years. Central to this investigation is the handling the short-term impact of the removal of a contractor when some residents were living with unacceptable service failures that required redress. This provides cautionary evidence for other landlords.

“The human impact of multiple and repeated failures in service delivery is apparent throughout our report.

“In some cases, those failures led to residents feeling anything but secure in their homes and on the streets – windows that could not be closed to make properties secure, part of a window frame falling out of a property into a garden below, ceiling debris falling onto the head of a young child, and residents complaining of feeling unsafe in their buildings.

“Our investigation reveals how many residents said that they felt the ongoing issues were having a detrimental impact on their mental wellbeing; others advised their physical health was declining as a result of the disrepair, and for others, there was also fear of being injured as a result of the ongoing repairs.

“There were also financial implications as residents had to spend additional money to keep their properties heated during the winter months, with some residents choosing to pay for their own independent inspections in order to progress the repairs.

“It is encouraging to see that the landlord has already made significant changes to its structure and processes in key areas.

“This demonstrates how complaints can be essential to make social housing better and give landlords a clear picture of where improvements need to be made. As our Complaint Handling Code becomes statutory, it is essential landlords use this opportunity to make learning from complaints routine and put the right resources into complaint handling.”

Hammersmith and Fulham Council said it has already sought to make changes and improvements in the areas identified.

A spokesperson said: “We are truly sorry and reiterate our deepest regrets to those residents affected. We have apologised, compensated, and worked hard to rectify where we let people down.

“The Housing Ombudsman has recognised the transformational change we are making and our continued ambition to improve. We strive for consistently high-quality, fair, and compassionate services. We want everyone to have a safe, decent warm home in a diverse and thriving community.

“We have worked closely with the Ombudsman to put things right. The Ombudsman has noted our leadership’s positive approach to learning from this investigation, building on improvements that we as a council had already begun. We fully accept its report findings and will deliver its recommendations.

“Our commitment is underlined by establishing a Chief Executive led Taskforce to strengthen our housing services and leadership team. It is also delivering an ambitious £729m programme to modernise our ageing housing stock.”