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Sanctuary Housing Association (202302230)

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REPORT

COMPLAINT 202302230

Sanctuary Housing Association

28 July 2025

Amended 11 August 2025

 

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 was about the landlord’s response to the resident’s reports about her water system and water quality.

Background

  1. The resident occupied a two-bedroom house. The resident reported several health concerns in their complaint correspondence. The landlord had also recorded a number of health concerns. The concerns included:
    1. The resident had been diagnosed with cancer, she had had chemotherapy, had a suppressed immune deficiency and had undergone treatment not long before April 2023.
    2. The resident needed to bathe regularly due to skin infections.
    3. She had several lung conditions and, on a date unknown, suffered “a severe lung infection”. While she said she had “beat” cancer, she remained “severely immunodeficient”.
  2. Her hot water system included an Air Source Heat Pump (ASHP). According to the energy saving trust, Air source heat pumps: costs, savings and benefits – Energy Saving Trust an ASHP transfers heat from the outside air to the water in the property’s central heating system. It can also heat water stored in a hot water cylinder for hot taps, showers, and baths.
  3. The landlord provided us with extracts of its repair reports from 9 December 2022.
  4. On 4 April 2023 the resident reported that the hot water was intermittent.
  5. On 6 April 2023, the resident made a complaint as follows:
    1. The landlord had constantly failed to provide safe hot water.
    2. Previous contractors stated it was due to the installation of the AHSP.
    3. The landlord had sent unqualified operatives. The specialist contractor who attended to carry out an infection risk test only took one sample of water that he said was only 45 degrees.
    4. The system did not do “infection cycles”. It had failed the last 11 years to service and maintain her heating and hot water. This was a health risk as the water was not heating up.
    5. She was diagnosed with cancer. She was on long-term antibiotics. Her puppy was also seriously ill.
  6. Between 14 and 23 April 2023, the resident both directly and through her councillor made a number of reports as follows:
    1. The system had never been serviced and had caused multiple health issues. She and her puppy had been tested for pseudomonas aeruginosa. (“PA”). Her granddaughter had developed a follicle rash. The resident considered this was due to the ASHP. Her consultant had advised it was due to the water quality.
    2. Her hot water provision was intermittent. The ASHP had never been serviced.
    3. She had recently had treatment for cancer.
    4. She requested temporary accommodation and, later on, a move.
  7. On 29 June 2023 the landlord wrote with its Stage 1 response as follows:
    1. The complaint was about issues with water hygiene and delays for this to be assessed. The issue had been ongoing since 2021.
    2. It would only investigate issues over the previous 6 months.
    3. It apologised that it had not communicated the result of a water quality test raised on 21 April 2023 until 23 June 2023.
    4. The results had came back as negative, the water sample had very low counts of bacteria in the water (which was acceptable) and zero PA.
    5. It was upholding her complaint.
    6. It offered £75 consisting of:
      1. £50 for the delays in getting result information and relaying this back and for any stress or inconvenience this may have caused
      2. £25 for delays in communication and for her time spent contacting the landlord regarding the repair and complaint.
  8. On 29 November 2023 the resident asked to escalate her complaint on the basis that the hot water did not heat to a temperature that killed bacteria.
  9. On 27 December 2023 the landlord wrote with its Stage 2 response as follows:
    1. It apologised for the delay to the stage one response. On 24 August 2023 it received notification that she had not received the response to her complaint. It also apologised for the mishandling of her communication when she asked to escalate the complaint on 10 November 2023. The escalation was not recorded correctly and therefore was not acknowledged within its timescale. It apologised.
    2. Under its complaints policy it was not “appropriate” for an issue to be investigated that was more than six months old, unless there was evidence that this had been raised to staff and no action had been taken. It had therefore based its investigation from 4 April 2023.
    3. It set out a chronology of events and what steps it took. Those events were supported by the landlord’s evidence.
    4. It suggested that it would review the complaint once the works were scheduled in. It would then consider the full impact of the time taken for the works to be undertaken and any inconvenience caused. It would write to her again when the works were scheduled in to be completed, to explain the proposed resolution. It would keep her updated on progress and would provide a further response once the works were scheduled for completion. It apologised for this further delay.
  10. On 10 January 2024 the landlord wrote to the resident as follows:
    1. It had ordered a new heat pump. The individual contractor the resident had requested would fit it himself within the following 2 weeks.
    2. It offered compensation of £778 consisting of:
      1. Loss of facilities between 24 May 2023 and 12 June 2023 at £3 per day: £60.
      2. Loss of facilities between 27 October 2023 and 18 December 2023 at £3 per day: £159.
      3. Delay in providing a response at stage 1 £150.
      4. Delay in providing a response at stage 2 £150.
      5. Temporary heater payment 28 October to 13 December 2023 £184.
      6. Delay in providing result of water testing £75.
  11. The resident wrote to the landlord stating she had water damage to her laminate flooring, the heat pump was expensive to run and the humidity levels in the property were high. She wanted a copy of the manufacturer’s report of an inspection of 16 September 2023.
  12. The landlord arranged to replace the pump. According to an email from the landlord to the resident of 2 February 2024, the works had been completed. The landlord carried out further water quality tests in 2024 and 2025.

Assessment and findings

Scope of this investigation

  1. The resident’s complaint was that the issues with the ASHP and water quality was putting her at risk. It was not disputed, that she was at higher risk of infection due to her being a cancer patient. The government website Pseudomonas aeruginosa: guidance, data and analysis – GOV.UK advises that PA “rarely affects healthy individuals. It can cause a wide range of infections, particularly in those with a weakened immune system, for example cancer patients.” The resident stated that she was tested positive for PA because of the ASHP.
  2. We are unable to draw conclusions on the causation of, or liability for, impacts on health. This is because claims of personal injury must, ultimately, be decided by courts of law who can consider medical evidence and make legally binding findings. Nonetheless, consideration has been given to the general distress and inconvenience which the situation may have caused the resident. The Ombudsman can assess how a landlord has dealt with reports it has received, and assess whether the landlord has followed proper procedure, good practice, and behaved reasonably, taking account of all the circumstances of the case.

The landlord’s response to the resident’s reports about her water system and water quality.

  1. The landlord’s national compliance coordinator for water hygiene had noted internally in May 2025 that, as the property was a house, the water supply was mains water. Its approach that the mains water was the responsibility of the water company was reasonable, as the landlord has no control over it until it enters a property.
  2. Where there were concerns, good practice would entail the landlord arranging testing for and monitoring the water quality, addressing what was within its control, namely the outlets such as taps and the water tank, and investigating the cause of higher readings of bacteria levels.
  3. The report logs, contractor reports and emails showed that the landlord took a number of actions following the resident’s reports of 4 to 18 April 2023. This was reasonable. However, there were delays. The steps included:
    1. An engineer attended the property on 21 April 2023. They reported that the water was heating correctly and did not require servicing. According the contractor’s job sheet of 21 April 2023, the immersion heater was faulty and needed replacement. It was stopping the system achieve the disinfection function. The element required replacing. According to the landlord’s records the job was not raised until 5 June 2024. This was an unreasonable and unexplained delay. However, according to the landlord’s records, hot water was accessible from the ASHP in meantime.
    2. Also on 21 April 2023, the landlord’s area manager raised a job for water sampling to include testing for bacteria PA. The landlord received the results on 12 May 2023 and shared it with its specialist teams internally for checking. On 23 May 2023, it summarised that the TVC count would come from the mains or the tap which may have food waste. The TVC count is a measurement used to estimate total number of living microorganisms. On 1 June 2023, its specialist team also noted the water sample had very low counts of bacteria in the water (which was acceptable) and no PA. The landlord did not update the resident until 23 June 2023. While a significant delay, the landlord wanted to be sure of understanding the results before sharing them. That was reasonable. It was reasonable that the landlord acknowledged and apologised for its delay in its Stage 2 complaint response.
    3. The landlord involved its wellbeing team, because of the resident’s health conditions. The evidence showed that the wellbeing officer monitored the works and progress. This was reasonable as it showed that the landlord gave consideration to the resident’s health conditions.
    4. On 26 April 2023, the landlord discussed seeking alternative permanent housing. The resident did not feel an exchange would be appropriate or what the local authority could offer was suitable.
    5. Internally, the landlord noted on 18 April 2023 that it was aware that the condensate pipe needed checking and the contractor might need to replace it. Its contractor attended on 24 May 2023 to review the thermostatic control and identified that the primary pipework was leaking and undersized and needs replacing. That had caused damage to the heat exchanger. The cylinder was also showing multiple leaks. It raised works to replace undersized pipework, replace the potable vessel, refill the system with glycol and inspect for leaks. It was reasonable to raise the works on 31 May 2024. However, the works were not carried out on 27 and 28 June 2023. This was an unreasonable overall delay, given the landlord had been aware of the potential issue in mid-April 2023, particularly in the resident’s circumstances.
  4. The resident had a number of further concerns as follows:
    1. On 2 June 2023 she had no hot water. The immersion did not heat it up sufficiently. She had reported a toxic chemical leak to the fire service on 2 June 2023.
    2. On 6 June 2023 that she had a suppressed immune system, her water was not safe and the water was not sufficiently hot.
    3. On 8 June 2023 its contractors had told her the liquid she had reported as toxic was not antifreeze but a particular substance. A third party had sent the resident a leaflet which said the substance was a poison and it should be cleaned using special precautions. On 13 June 2023, the landlord concluded that the leak of green liquid was glycol not anti-freeze. It was also dry therefore not an active leak. According to specialist commercial websites, glycol is used as a general term for a non-toxic substance used in anti-freeze. The term was also used for ethylene glycol which can be toxic. The landlord told the resident the liquid was not “anti-freeze” but glycol. This was not a clear or sufficient explanation. That was unreasonable as it did not provide the reassurance that she required.
  5. In response, the landlord took the following steps over the period of 10 to 14 June 2023 as follows:
    1. It arranged for an engineer to visit “urgently” to address her concern and follow up with a letter. We have not seen evidence of that visit or follow-up letter. We are not satisfied that the landlord provided a suitable explanation or at all.
    2. The landlord offered the resident temporary accommodation with meals from 9 June to 12 June 2023. The landlord funded taxis to and from the hotel during 16 to 19 June 2023 so she could bathe. That was reasonable.
    3. Its specialist contractor attended on 13 June 2023 and reinstated the hot water. The contractor reported that the hot water was at 50c but was likely to lose pressure and therefore hot water again..
    4. On or around 10 June 2023, the landlord fitted an electric shower. However, as at 19 August 2023, the evidence indicated that it had not been plumbed in. This was unreasonable.
  6. The records show the resident made further reports. The landlord attended but no leaks were identified.
    1. On 30 June 2023, the resident reported the cylinder was still leaking. The landlord responded reasonably. On 4 July 2023, a contractor attended and reported that there was no leak, only historical stains. It was reasonable that the landlord attended shortly after the resident’s report. As it was not an active leak, there was no evidence of an obligation to address a leak.
    2. On 7 July 2023 the resident contacted the landlord as she believed her drinking water was not safe and that she had had a further leak from the ASHP. The landlord raised a job to address the leak, works were approved but the nature of the works is not clear.
    3. On 6 September 2023, the resident made a fresh report of leaks. According to the landlord’s repair records of the same day there were no leaks.
  7. On 16 September 2023, the contractor attended the property with a representative of the manufacturer’s. Though we requested a copy of the report, we have not seen it or the outcome of the report. We have not seen the landlord’s explanation for not doing so. It was unreasonable for the landlord not to report the outcome of the inspection as the resident required reassurance. We will make an order accordingly.
  8. On 2 November 2023 the landlord raised a job to replace the ASHP as urgent. While it is not clear what prompted this decision at that time, given the previous issues, this was reasonable. The resident did not want the same contractors to quote or install the new ASHP. This caused a delay. We do not attribute fault to the landlord for the delay as it was largely due to the resident’s request not to use the landlord’s usual contractors for the installation but a specified person.
  9. The landlord took the following reasonable actions after the resident’s report on 26 November 2023 of water ingress and damp/mould from the leaking ASHP. She also asked for a temporary move and reported that the damp and mould was causing coughs, sleep issues and poor health.
    1. The well-being team remained involved regarding the damp and mould.
    2. On 7 December 2023, the landlord raised a water test for legionella or other bacteria including PA The test took place on 12 December 2023.
    3. The landlord arranged a surveyor inspection on 13 December 2023. This was reasonable in particular as it brought the appointment forward. The surveyor reported back that no damp was detected and the water meter was “not spinning”. The survey identified that there was a small damp spot in the cupboard for the cylinder but there were no signs around the outside unit, nothing that would give off high concentrates of fumes, and that the system pressure was holding. No mould was identified during the visit. While the resident remained concerned there were significant leaks under the flooring, so that she did not turn on her hot water and heating system, it is likely any significant leaks would have been detected by an inspection of damp. The landlord was entitled to rely on that inspection.
    4. The landlord arranged for a further water test which took place on 12 December 2023. It tested for a range of bacteria including PA. This was reasonable. The outcomes ranged between low and high risk. Where high and medium risk, it recommended taking a re-sample is taken and a disinfection of the system may be required. No PA was detected but coliform was. We do not have any evidence of what the landlord did as a result of the test or what it communicated to the resident.
    5. It was reasonable that the landlord arranged a temporary move from 18 December to 9 January 2024 and arranged a taxi for the resident to go to her son’s on Christmas day. According to internal correspondence and the resident, this was due to the results of the water test. The Stage 2 letter stated that it was due to her concerns over the heating system and reluctance to turn it on. The discrepancy was unhelpful. However, the evidence indicated the resident was aware of the reason for the temporary move
    6. The landlord accommodated the resident’s request. It arranged for a specific individual rather that its contactor to carry out works and placed an order for a new heat pump and pipework. By 2 February 2024, the works were carried out.
  10. The landlord undertook a number of further water quality tests with variable outcomes. This was reasonable. None showed the presence of legionella or PA but they showed the presence of coliform. The results recommended further tests and a disinfect. In one instance, it concluded that the water was not hot enough. On 20 March 2024, it raised works to undertake cleaning, disinfecting and post works sampling. We have seen evidence that following a water test of 20 June 2024 outlets were cleaned, descaled and disinfected.
  11. On 7 February 2025, while the water company was responsible for the mains water, it arranged testing. It suggested a visit by a plumber to check the water tank and check the taps for limescale and retest. The test of 28 February 2025 detected coliform in 2 outlets. While it raised works to change the taps and flush the water through, we do not know what works were carried out. The test detected no coliform. However the test of 4 May 2025 identified a fail.
  12. We appreciate the difficulties for the landlord in determining how the coliform entered the sealed water system. The evidence showed that following the resident raising concerns, the landlord took a number of steps. It carried out water tests. It carried out works to the immersion heater and ASHP to ensure the temperature was high enough and to ensure the disinfection cycle worked on the ASHP. It also replaced the taps which may have been the source of the coliform. It investigated but did not find any evidence of leaks. Moreover, it arranged a number of temporary moves. A specific team monitored the works. This demonstrated that it appreciated the resident’s circumstances and health conditions.
  13. The evidence showed that there were considerable issues with the ASHP and cylinder. The landlord responded to the resident’s reports, arranged inspections however, there were delays and to the works themselves. In addition, it was not clear whether the ASHP was serviced regularly or at all and this was not addressed in the complaint response.
  14. We are not clear what action the landlord took and what it communicated to the resident when there were concerning results in the water tests. While those tests occurred after the conclusion of the landlord’s internal complaint process, the tests are directly relevant to the resident’s complaint and part of the resolution that it had committed to in its final response. This was unreasonable given her concerns and anxiety about her health issues. We will, therefore, make an order that the landlord provides an explanation of those tests, and what works it carried out as a result and assurances of future regular tests.
  15. The resident was understandably very concerned about the water quality and that it was at a sufficient temperature to keep it safe. While carrying out the repairs should be the principal focus for a landlord, it is also important for a person’s well-being to provide information and reassurance. Here the resident had a serious health condition which could be impacted by poor water quality. We have highlighted in this report occasions when the landlord did not provide sufficient information and evidence of its safety and explanation of the works it carried out.
  16. It was reasonable of the landlord to review the complaint after the works were scheduled in. The compensation in the amount of £778 addressed its complaint handling, loss of facilities, delay to providing the water test report and a temporary heater payment. Those elements in themselves were reasonable. It had offered £75 compensation which included £50 for the delay in providing the results of the water test in June 2023. However, the compensation did not recognise the delays highlighted in this investigation, the resident’s distress inconvenience from April 2024 to November 2024 in particular given her health conditions. In the circumstances, we find maladministration.
  17. The landlord limited the scope of the Stage 1 complaint to 6 months. While this should not be a strict timescale, this was reasonable. However the landlord limited its Stage 2 response for the same period which meant it only reviewed the period going back to April 2023 and not sooner. This was unreasonable as the resident had made her original complaint in April 2023. Therefore, by its own policy, the landlord should have gone back to September 2022, 6 months before her complaint. However, in practice, we did not see evidence this impacted the resident.

Determination

  1. In accordance with Paragraph 52 of the Housing Ombudsman Scheme, there was maladministration in relation to the landlord’s response to the resident’s reports about her water system and water quality.

Orders

  1. The Ombudsman makes the following orders:
    1. Within 4 weeks, the landlord should pay the resident the sum of £300 in addition to the compensation of £75 offered in its Stage 1 and £778 offered on 10 January 2024 in recognition of the distress and inconvenience, given her health concerns.
    2. Within 4 weeks, the landlord should provide the resident, with a copy to the Ombudsman:
      1. A summary of the water quality tests carried out from December 2023 onwards, with an explanation of the works the landlord has carried out as a result and why.
      2. The manufacturer’s report, failing which a summary of the outcome following a visit to the property on 16 September 2023.
      3. An assurance that the landlord will continue to commission tests of the water quality at reasonable intervals and if there is still evidence of coliform an investigation of the cause including of the immersion tank.
    3. Within 4 weeks, a suitably qualified member of staff such as the repairs supervisor and/or member of the health and safety team should arrange to meet with the resident to discuss any remaining concerns.
    4. Within 6 weeks, the landlord should follow up the meeting with a letter confirming what was discussed and what actions, if any, the landlord would take about the water quality, with a copy to the Ombudsman.
  2. The landlord should confirm compliance with the above orders to the Housing Ombudsman Service within 4 weeks of this report.