Malvern Hills District Council (18 009 593)

Category : Adult care services > Disabled facilities grants

Decision : Upheld

Decision date : 14 Oct 2019

The Ombudsman's final decision:

Summary: Mr G complains about disabled facilities grant works undertaken on his home in 2014/5. We find fault by the Council in not knowing of Mr G’s complaint until 2018, when it should have known sooner. This caused injustice to Mr G in time and trouble spent using the wrong complaint procedure. The Council has agreed action we consider will provide for a fair remedy to the complaint, explained at the end of this statement.

The complaint

  1. I have called the complainant ‘Mr G’. He complains on his own behalf and that of his wife and adult son, who I will call ‘Mrs G’ and ‘Mr H’. Mr G’s complaint concerns work undertaken to the family home in 2015 under a Disabled Facilities Grant (DFG). Mr G says:
  • The scope of grant works approved under the DFG were inadequate.
  • Work undertaken by contractors was of a poor standard and did not comply with Building Regulations.
  • The work approved and undertaken does not meet the needs of Mrs G or Mr H.
  1. Mr G says this results in Mrs G and Mr H having a property which does not meet their needs and still needs significant adaptations to do so.

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What I have investigated

  1. I have partially considered Mr G’s complaint. I cannot consider all Mr G’s complaints about quality of works for reasons explained at the end of this statement. Nor can I consider the actions of the Occupational Therapy service, relevant to the events covered by this complaint, for reasons explained at the end of this statement.

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The Ombudsman’s role and powers

  1. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  2. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  3. We cannot investigate the actions of bodies such as registered social landlords, unless they are providing services on behalf of a council. (Local Government Act 1974, sections 25 and 34A, as amended)
  4. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  5. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. Before issuing my decision in this case I considered the following:
  • Mr G’s written complaint to the Ombudsman and further information he provided including in emails, telephone conversations and in a visit to his home.
  • Details of a complaint Mr G made to his landlord, a registered social housing provider, which included a decision made by the independent Housing Ombudsman Service (HOS).
  • Information provided by the Council in reply to written enquiries.
  • Relevant law and guidance as set out in the text below.
  • Comments made by Mr G and the Council in response to a draft decision which set out my provisional thinking about the complaint.

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What I found

Law and guidance on adaptations

  1. Local housing authorities, such as district councils, have responsibility for providing DFGs under the Housing Grants, Construction and Regeneration Act 1996. They will do so based on assessments of need, usually carried out by Occupational Therapists (OTs). Mostly, it is County Councils which provide OT services as part of their wider responsibility to meet care needs, which for adults fall under the Care Act 2014.
  2. The purpose of a DFG is to help disabled people have access to and around their home, as well as making buildings safe for them to use. The Council can approve a DFG to the value of £30000. There is no limit on the number of DFGs a Council can approve to one household over time. A local authority also can fund works to a property over the DFG limit, at its discretion. This is under powers granted by Article 3 of the Regulatory Reform (Housing Assistance) (England and Wales) Order 2002. A council can decline to award a DFG if it is not “reasonable or practicable” to provide adaptations; for example, because it is not cost-effective or impractical because of property layout.
  3. Many local authorities work with Home Improvement Agencies (HIAs) to deliver DFGs. A HIA is a locally-based, usually not-for-profit organisation run by a voluntary agency, housing association, council or private company. Their role is to help disabled or elderly people maintain independence in their homes. Part of their role is to identify households which may be eligible for DFGs and help deliver those, acting as an agent for the applicant. I have considered advice contained “Home Adaptations for Disabled People; A detailed guide to related legislation guidance and good practice”. This is published by the Home Adaptations Consortium, a consortium of multiple charities and professional organisations who work in this area. This encourages the use of HIAs to deliver DFGs. But it is not compulsory to use a HIA.
  4. In their role as the applicant’s agent, the HIA will manage contractors to make sure grant works complete successfully. Guidance we published for local authorities in 2016 said “the Council should still carry out regular inspections”, but “the responsibility for ensuring work is carried out properly lies with the HIA and applicant”. (Making a house a home: Local Authorities and disabled adaptations – March 2016)
  5. Section 37(4) of the Housing Grant, Construction and Regeneration Act 1996 makes payments of DFGs conditional on works “being executed to the satisfaction of the authority”.
  6. The Home Adaptations Consortium Guidance says: “All major adaptation work needs to be visited by a supervising officer at least once whilst they are in progress and where work continues beyond a week, more often”.
  7. The guidance also says disabled people must have the right to complain about services. It says that if a complainant is unhappy with DFG works they must know of their right to complain to this organisation.

Relevant Council Policy and Procedures

  1. All the district councils in Worcestershire have commissioned a HIA to help deliver DFG works in the County.
  2. The HIA uses a managing agent which is a Housing Association (RSL). That RSL is also Mr and Mrs G’s landlord.
  3. The first contract between the Worcestershire district councils and the HIA began in 2010. This stressed DFG awards remained at the Council’s sole discretion.
  4. It said the HIA should provide the Council with “details of any complaints, including how these have been resolved, if substantiated”. It also said the HIA should “advise the Council of any service complaints that are not resolved to the complainant’s satisfaction under the complaints procedure and have regard to the Council’s views when deciding the most appropriate course of action”. It also said the HIA would “co-operate with any investigation under the appropriate complaints procedures of the relevant participating partner” (i.e. one conducted by the relevant District Council).
  5. Worcestershire district councils entered a new agreement with the HIA in 2015. This stresses the HIA contracts with the customer and there must be separate contract between customer and contractor. It says the HIA must have a “robust complaints procedure” and deal with all complaints promptly and efficiently.
  6. The RSL acting as agent for the HIA had a complaint procedure in force in 2015. This said complainants dissatisfied with its investigation could escalate their complaints to the independent Housing Ombudsman Service (HOS). In 2017 the HIA introduced its own complaint procedure. This provides for the HIA to investigate complaints first but that it will refer complainants who remain dissatisfied to the relevant district council.
  7. The Council has provided a flow-chart which describes the procedure followed in approving DFG grants. There is no requirement in that for officers of the Council to visit during DFG works. It delegates authorisation of DFGs to officers from the HIA. The Council comments that its officers would only visit in person where specifically asked.

Background and key facts

  1. Mr and Mrs G and Mr H live in a three bed house rented from a registered social landlord (a housing association). The house is of a kind known as a ‘Wates Construction’ house built in the post-war period of concrete and steel construction.
  2. Both Mrs G and Mr H have a disability. They have a condition causing greater impact over time affecting their mobility. Both Mrs G and Mr H sometimes use a wheelchair. Mrs G’s mobility is more severely affected at the current time.
  3. Mr G acts as carer for both Mrs G and Mr H. He also has disability following a stroke and dyslexia. He also has mental health illness. Before becoming disabled Mr H used to work in the construction industry.
  4. In June 2012 an Occupational Therapist (OT) recommended Mrs G needed adaptations to help her live safely in her home. Their report identified risks in Mrs G using the bath and toilet in the property, on the first floor. It suggested she also needed a wheelchair ramp, a possible widening of the front door and a stairlift.
  5. In 2013 Mr and Mrs G entered discussions with the HIA about the adaptations needed to their home. Mr and Mrs G wanted those discussions to include consideration of extending the property front and back. This would provide a porch area at the front to store a wheelchair or mobility scooter and a downstairs bedroom and level access shower room for Mrs G to the rear. The discussions also included widening the front door and putting in a stair-lift or through-floor lift.
  6. Emails from 2013 suggest the RSL had concerns about whether a Wates construction home could support a through-floor lift or ground floor extension. An email sent from a surveyor explained the property would need extra structural changes for a ground floor extension.
  7. In April 2013 a second OT report recommended Mrs G needed a level access shower, a stairlift and a ramp. Further emails suggest the RSL did not consider they could fit a stairlift in the property because of the width of the stairs
  8. In August 2013 the OT changed their recommendation to also include a downstairs toilet with wash-hand basin.
  9. In January 2014 the HIA recorded Mrs G ‘happy to proceed’ with the DFG. In September 2014 Mrs G entered a contract with the HIA that the DFG works would provide:
  • Provision of a level access shower (on the first floor of the property)
  • A ground floor toilet and wash hand basin
  • A ramp to low level threshold front door.
  1. The contract said the HIA would act as Mrs G’s agent in carrying out the DFG works. The contract explained the HIA would invoice the Council for the DFG works on completion. Also, that Mrs G would enter a separate contract with contractors with the HIA entitled to “exercise all the customer’s rights to give instructions to the contractor”.
  2. In early October 2014 the Council approved the DFG to cover the works itemised in paragraph 32. Emails between the OT service and the HIA show before works began, the OT confirmed that a “low access” shower would meet Mrs G’s needs rather than level access. The HIA wrote to Mrs G. Their letter confirmed a contractor was in place and the cost of the grant agreed. The letter said the HIA would pay the contractor when satisfied with the work undertaken.
  3. Mrs G entered the separate contract with the contractor in mid-October 2014. This contained a clause saying the HIA instructed the contractor. It said the works completed when there were “no apparent defects that prevent the operation and/or use of the installation” and the “work carried out to reasonable satisfaction of [the HIA]”.
  4. Work began during October 2014. As well as the DFG works the RSL carried out changes to Mr and Mrs G’s kitchen, fitting a new floor and units. It also reconfigured the kitchen by changing the internal doorway entrance; something needed to fit the new downstairs toilet and wash hand basin which blocked off the former entrance hall. The contractor had one specification of works to cover both the DFG works and the kitchen works.
  5. During October 2014 the HIA exchanged emails with the Council seeking approval for minor amendments to the DFG. This included fitting a handrail to the disabled access ramp and a different shower seat.
  6. Throughout the works Mr G kept in regular contact with the HIA. He became increasingly dissatisfied with the standard of work undertaken both on the DFG works and work on the kitchen undertaken by the contractor.
  7. Mr G raised his dissatisfaction with the HIA and at the end of November 2014. A meeting took place at Mr and Mrs G’s house to discuss progress of works and to agree what remaining work needed completion. Representatives from the HIA and contractor attended as well as an OT and a social worker from the County Council.
  8. During December 2014 communications between Mr G and the HIA continued. He asked the HIA not to pay the contractor until it completed the works. Its emails suggest Mr G by now prevented the contractor returning to complete works. The HIA agreed to get an opinion from the manufacturer about whether the contractor correctly installed the downstairs toilet. It also drew up a list of outstanding snagging items.
  9. In late December 2014 the HIA sent an email to the Council explaining Mr G’s unhappiness with the work undertaken by the contractor. It said the contractor did not agree with Mr G about the outstanding work needed. It asked the Council if it had a view on the approach it should take and sent a further email in early January 2015 expanding on the dispute. There is no record of the Council’s response.
  10. During January 2015 a further visit took place to Mr G’s house with Mr and Mrs G present with a representative of the HIA and the contractor. Among the actions agreed after the meeting was the HIA decided to pay the contractor most of the money agreed for the DFG work. The Council says that it approved payment of the DFG subject to the HIA agreeing to address any snagging items and ensuring completion of works.
  11. Matters remained at an impasse into 2015. In March 2015 the HIA refused Mr G’s suggestion it find the contractors in breach of contract. It obtained a report from the manufacturer suggesting the contractor had fitted the downstairs toilet acceptably. In May 2015 contractors briefly returned to the house to complete snagging works but Mr G again asked them to leave. I have seen a copy of the December 2014 snagging list containing comments by the contractor suggesting they undertook some work on the list, but not all.
  12. The Council has a letter on its files from the HIA dated May 2015 suggesting that it considered the works on Mr and Mrs G’s house had completed. To my knowledge the contractor received payment in full for the works.
  13. In June 2015 Mr G made a complaint to the HIA. It went through all stages of the RSL’s complaint procedure. There is no record to suggest the Council knew of the complaint. Or that the HIA or the RSL involved the Council in its investigation of the complaint. The RSL’s investigation considered the following:
  • The HIA’s involvement from 2013 onward in considering the scope of the DFG and other work needed.
  • The specification of works given to the contractor.
  • Whether Mrs G was under undue pressure to enter contracts with the HIA or contractor.
  • The quality of work undertaken on Mr and Mrs G’s home, including the DFG works. Also, the conduct of the contractors.
  • The fitting of the downstairs toilet and whether it complied with the manufacturer’s instructions. Also, whether it was fit for purpose for Mrs G’s use.
  • Whether the ramp was safe to use.
  1. In 2017 Mr G had completed all stages of the RSL complaint procedure. He contacted the HOS about his complaint. The HOS decision found no fault in the RSL’s actions. It found that it followed proper process:
  • In considering the scope of adaptations approved.
  • In the scope of the works undertaken.
  • In its management of the work undertaken.
  1. During this investigation Mr G brought to my attention a paper produced by the Council’s Overview and Scrutiny Task and Finish Group in June 2013. This considered the Council’s policies and procedures to support older and disabled people to live independently in their own homes. The report noted the Council’s decision to devolve DFG administration to the HIA. It also noted a potential ‘conflict of interest’ with HIA staff supervised by the RSL. The report’s authors stated; “the investigation left us with the feeling the Council had somehow lost control”.
  2. In 2018, before we began our investigation of this complaint, the Council considered it under its complaint procedure. As part of its consideration the Council asked one of its officers to visit Mr and Mrs G to consider their current housing. The housing officer considers Mr and Mrs G’s home “unsuitable in the medium to longer term” because of Mrs G’s and Mr H’s needs. They commented that while Mrs G might benefit from a single-storey extension, that might not benefit Mr H. The Council suggested Mr and Mrs G consider moving instead to ground level, wheelchair accessible accommodation.
  3. Mr and Mrs G are unwilling to consider moving. They have lived in their home for over 20 years and are settled in the community. Their GP supports their view that a move will be harmful to the family. Mr G’s registered mental health nurse notes that Mr G has a local support network and would not want him to lose that.
  4. When I visited Mr G in January 2019 he said their continuing dissatisfaction was as follows:
  • The family consider the ramp to the front door not completed properly with sharp edges. Its construction did not follow the detailed specification of works with it built on an inadequate foundation.
  • That despite the ramp, wheelchair access for Mrs G and Mr H is problematic. This is because of its width, a lip on the base of the front door and because the door hinges to the left. Consequently they have limited room in the lobby area on entering the house. Neither Mrs G or Mr H can manoeuvre a wheelchair in that space.
  • They maintain the downstairs toilet was not fitted correctly. The toilet uses a pump and so needs an electric supply. Mr G says the socket is not waterproof.
  • The door to the downstairs toilet opens inward. Mrs G will not use the room because if she fell she does not think that anyone could open the door.
  • That upstairs shower is not level access as it has a lip around the base. The room has issues with condensation and mould, something Mr G assigns to the original fitting.
  1. Mr G has also explained that he does not consider the works comply with Building Regulations. In April 2017 he separately contacted the Council about this. A Building Inspector visited Mr G’s home and issued a building certificate saying there was “evidence, but not conclusive evidence” the requirements in the certificate were complied with. The certificate covers the downstairs toilet and wash hand basin only. In separate comments, the Building Inspector has told our investigation they had “no adverse comments” about its installation.
  2. Mr and Mrs G also remain unhappy with some aspects of the kitchen works.

My findings

The Ombudsman’s jurisdiction

  1. Mr and Mrs G’s complaint invites us first to consider events between 2012 and May 2015. These dates mark the period between the first suggestion Mrs G needed adaptations in her home through to when contractors left Mr and Mrs G’s home having carried out work.
  2. Clearly all this is a ‘late complaint’ as defined in paragraph 4 above. However, I have taken the view that we can investigate it.
  3. The evidence in this case shows the Council had no awareness of Mr G’s complaint until 2018 (I explore this matter further below). However, between 2015 and 2017 Mr G had pursued a complaint about the works to the family home with the RSL (who act for the HIA) and the HOS. I find this was because all his direct dealings in 2015 were with RSL employees. They either acted for the RSL as agent for the HIA or as his landlord. I have seen no evidence they signposted Mr G to Council complaint procedures or this office. Or that they alerted the Council directly to Mr G’s complaint.
  4. This resulted in Mr G pursuing all his grievances through a single-track complaint procedure. This was inappropriate as that procedure could not look at the Council’s role in events. But it was not Mr G’s fault he followed this route as he had no reason to think he was not following the correct procedure. There are special reasons therefore to exercise discretion to investigate Mr G’s complaint.

On the substance of the complaint

  1. There is no barrier on local authorities working with HIAs to deliver home improvements. I noted in this case the Council did not directly inspect the works undertaken on Mr and Mrs G’s home. However, I find it could delegate that inspection to the HIA under the terms of its contract with it.
  2. I find the Council had some awareness while the contractor was at Mr and Mrs G’s home, of Mr G’s dissatisfaction with the progress of the DFG works. But it did not know of his complaint following the works completing to the satisfaction of the HIA and its decision to pay the contractor. Complaints about DFGs should be signposted to local authorities and consequently to this office. I consider the Council should have been aware of Mr G’s complaint therefore. But Mr G’s complaint did not follow the correct procedure in 2015. It was the HIA that failed to ensure Mr G had that access. But the Council must bear responsibility for that as the HIA acted for the Council and its contract should have ensured this did not happen. So the fault still lies with the Council.
  3. I also consider there was fault in how the Council considered Mr G’s complaint in 2018. I make no criticism of the Council wanting to spend some focus on considering the family’s current housing needs. But this should not have been at the expense of neglecting their complaint about the grant works undertaken in 2014-2015. The Council should have explored the themes I have explored in this statement.
  4. I note the Council’s correspondence in 2018 raised the prospect of Mr and Mrs G potentially moving home as a way of meeting the household’s needs. I considered this could imply the Council was ruling out consideration of whether another DFG might meet their needs instead. I noted the family’s strong wish to remain living where they are and the support of their medical practitioners in that objective. Although I also recognise there may be barriers to further adaptations and follow the housing officer’s thinking on this matter. I understand concerns expressed about the potential scope of works needed and the constraints of the house. But the place for testing these issues is through starting again the DFG procedure, to consider afresh the family’s needs. The Council has reassured me it will not seek to prevent this consideration.
  5. I have gone on next to consider the consequences of the Council’s faults. I do not consider an earlier investigation by the Council into the critical 2014-15 period would necessarily have led to any different result in how the work completed. I understand Mr G’s concerns about the downstairs toilet and wash hand basin fitting. But the evidence does not support his view these were fitted inappropriately, even if they were not fitted directly in line with the manufacturer’s instructions. Both the manufacturers and the Council’s Building Inspector have raised no concerns. I consider it unlikely therefore the Council would have asked for significant changes in 2015. Whether it now meets Mrs G’s needs is a different matter, but one I consider can only be addressed through a fresh assessment.
  6. I also understand Mr G’s concerns about the ramp to his property. But I note in 2015 Mrs G’s OT considered the fitting satisfactory. So, I am not persuaded it was not fit for purpose then. If it remains so, whether because of the passage of time or because of a change in Mrs G’s and Mr H’s health, would be a matter for a fresh assessment. This would include consideration of their ability to access the house by the front door. Similarly, Mr G’s concerns about the changes made to the upstairs bathroom. I am satisfied that in 2014-15 the OT service considered a ‘low access’ front door and shower could meet Mrs G’s needs. The Council would have no reason to question their judgement in this matter, which informs all decisions on the scope of DFG works.
  7. I also note here Mrs G entered a contract with the HIA giving it the responsibility to decide when building works had completed satisfactory. So, Mr and Mrs G delegated their rights to say when they were satisfied with the works and when the contractor should be paid. I understand with hindsight Mr and Mrs G regret entering a contract with both the HIA and the contractor. But I do not consider there is any evidence that suggests fault by the Council contributed to them entering that contract.
  8. On balance however I consider the Council might have helped bring some resolution to Mr G’s concerns sooner. It causes some frustration that Mr and Mrs G did not receive advice from the Council in 2015 explaining why it approved the DFG works or its view on the disputes around the fitness of the work. The HIA, acting for the Council could also have lessened significantly the time and trouble Mr G has spent in pursuing his complaint by signposting him to the correct procedure. For these reasons I find Mr and Mrs G caused injustice by the Council’s faults.
  9. Before turning to the action agreed to remedy this complaint, I must also consider other parts of the complaint. Specifically, Mr G’s concerns about why it took so long for a decision about the scope of works and if these were adequate.
  10. I do not consider I can uphold these parts of the complaint. Council records are clearly limited and there are no officers left at the Council who worked in grant administration at that time. But Mr G’s records suggest lengthy discussions about the scope of the work involved staff from the HIA, RSL and County Council Occupational Therapy. I recognise Mr G has a concern the HIA faced a conflict of interest here. Because officers working for the HIA work for the same RSL that is his landlord (the issue identified by the Council’s overview and scrutiny committee in 2013). The emails reveal the landlord had some concerns with some suggestions made about the scope of works. Mr G considers the RSL then put pressure on the OT to scale back their recommendations. He considers the HIA either supported the RSL in that objective or did intervene to protect Mrs G’s interests.
  11. However, I did not consider I could conclude that on the evidence available,. I noted Mr and Mrs G entered into a contractual agreement for the scope of works at the time and did not complain. In addition, I considered any complaint the final works recommended were inadequate would be against the OT service. Because the scope of what DFG works ultimately approved rests on the authority of the OT service recommending the works they consider needed. That is outside the scope of this investigation.
  12. Finally, I note Mr G’s concern the works undertaken did not meet with Building Regulations. The application presented by the HIA did not suggest it needed Building Regulation approval except for the downstairs toilet, which the Council later approved. I understand Mr G’s concern that some of the construction may not meet the standards set out in current Building Regulations. However, in so far as these apply to disabled adaptations the current standards only took effect in 2015, after work on his home began. I consider there is insufficient evidence to suggest a failure to meet standards in force at the time work began on his home. I also consider it would serve no benefit to consider this matter further when the focus should now be on considering what further adaptations the property may need to meet the family’s needs.

Agreed action

  1. To remedy the injustice caused by this complaint the Council has agreed that within 20 working days of this decision it will:
  1. Apologise to Mr and Mrs G accepting the findings of this investigation.
  2. Pay them £500 in recognition of their injustice.
  1. The Council has also agreed in principle to do what it can to facilitate consideration of any further DFG application received requesting adaptations to benefit Mrs G and/or Mr K. Mr G wishes to make a further application himself for a DFG without reference to the HIA. This is his right. The Council has agreed that it will look to give the application what priority it can (while taking account of other applications it receives) and meet with Mr and Mrs G to explore matters such as
  • what information the Council will need to process an application from Mr G.
  • landlord consent, building regulation approval and planning permission.
  • what reasonable adjustments Mr G might need to navigate the application process.
  • how long the process might take, who will assess the application and so on.
  1. However, the Council points out it can only progress a further application once it receives a referral from Occupational Therapy services. It says that Mr and Mrs G’s family GP can initiate that referral. As this recommendation therefore hinges on the actions of individuals and organisations outside the Council’s control I cannot put a timescale on it completing. But I have advised Mr G that he may contact us again in the event he considers the Council is not acting as agreed.
  2. I am satisfied I do not need to make wider procedural recommendations in view of the passage of time and the revision of the HIA complaint procedure discussed above. I am satisfied that applicants now using the HIA who live within the Council’s district should be signposted to the Council in the event they are unhappy with the progress of their DFG application or the finished works.

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Final decision

  1. For reasons explained above I have upheld this complaint finding fault by the Council causing an injustice to Mr and Mrs G. The Council has agreed action to remedy the complaint that I consider provides for a fair outcome. So, I can now complete my investigation satisfied with its actions.

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Parts of the complaint that I did not investigate

  1. I cannot investigate Mr G’s complaint about the works to the kitchen of his home. Those works were undertaken by the RSL only in its capacity as his landlord. They did not form part of the DFG works. As such I have no jurisdiction to investigate them even though the same contractors worked at the same time on those works. The restriction on our powers, set out in paragraph 6 of this statement applies.
  2. I also cannot investigate the actions of OT services discussed in this decision statement as they are the responsibility of the County Council and not the District Council nor HIA working on its behalf.

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Investigator's decision on behalf of the Ombudsman

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