Islington Council (202210745)

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REPORT

COMPLAINT 202210745

Islington Council

7 July 2023

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

The complaint relates to:
1. The landlord’s management of the mutual exchange process.
2. The landlord’s management of the major works transfer process.
3. The landlord’s handling of the resident’s complaint.

Background

The resident has a secure tenancy and the property in question is a two bedroom flat on the ground floor of a converted house. The landlord noted that the resident was receiving significant in patient medical treatment during this period and the resident had indicated that their mental health was effected by the situation.
In September 2021, the resident applied for a mutual exchange to the property. Following an inspection, damp and mould works were noted as being outstanding but the resident agreed to the exchange on the basis of there being works agreed by the landlord to address this repairing need.
Following the completion of the mutual exchange in January 2022, the property was found to have structural damage, which led to the resident having to move out. The resident’s complaint was and is that the landlord failed to identify or communicate this prior to completion of the mutual exchange which led to her having to move into temporary accommodation.
The landlord’s mutual exchange policy says the following:
1. It “has 42 days to respond to an application for an exchange”.
2. “A letter to the incoming tenant will be sent following the inspection to advise them of any alterations that the current tenant has made.”
3. Where it “has serious concerns about the conditions of the property, a surveyor should be asked to undertake an inspection and report back.”
The landlord’s major works transfer procedure says the following:
1. “If the resident is moving in(on) a temporary basis, they will continue to be liable for rent in their permanent home.”
2. “The resident will be advised that they should bid for suitable properties.”
The landlord operated a three-stage complaints procedure (updated December 2020) at the time of the resident’s complaint:
1. Stage 1 – The first stage is investigated and responded to locally by the service area in which the complaint originated. A full investigation will be conducted and a final response will be sent within 21 calendar days of receipt.
2. Stage 2 – Chief Executive’s stage this second stage of the complaints procedure gives the customer the right to request that an investigation of their complaint is undertaken by the Corporate Customer Service Team on behalf of the Chief Executive. A full response is provided to the customer within 28 calendar days of receiving the complaint (excluding bank holidays).
3. The complaints procedure further states that “the reasons for a request for an investigation at the Chief Executive stage and any new supporting evidence must be looked at by the receiving officer/service with a view to review the stage one investigation and its findings. This can be dealt with as a stage one review and must be acknowledged within 3 working days and completed within 10 working days of receiving the new information”.

Summary of events

On 27 September 2021, the landlord received a mutual exchange application form from the resident.
On 6 December 2021, the Tenancy Officer (TO) conducted an inspection of the exchange partner’s property, as part of the mutual exchange process. Within the inspection report, it identified damp in the master bedroom, bathroom and utility area. It also found visible mould in the master bedroom and condensation in the second bedroom. The report noted that the damp and mould was part of an ongoing complaint with the mutual exchange partner.
On 9 December 2021, the landlord issued a stage one complaint response to the mutual exchange partner, regarding works to address the damp and mould in the property. The complaint was raised, as the exchange partner had been told on 21 September 2021, that external repairs to address the cause of the damp and mould would need to be addressed before it would carry out the internal work. The landlord said that this was the normal process for this kind of work but in this instance it would arrange for the internal work to be carried out. The landlord also confirmed that it had not reported the required external works to the freeholders of the building. It said it had experienced issues in contacting them but confirmed that it had since made contact around the required work.
On 4 January 2022, the landlord contacted the resident to agree a date for the exchange documents to be signed. It proposed a meeting on 10 January 2022 for the tenancy to start on 17 January 2022.
The resident contacted the landlord on 6 January 2022 around the damp and mould repairs. They advised they had spoken to the exchange partner and were concerned that none of the previously agreed work had been completed. The landlord confirmed that these works were due to start soon and it provided a work reference number.
Landlords emails show that it confirmed this work was due to start on 13 January 2022, with a return to finish the work on 7 February 2022.
On 10 January 2022, there was a meeting between the landlord and the resident’s daughter. Discussions took place around the outstanding works at the property but the mutual exchange was not signed at this meeting.
The resident emailed the landlord on 11 January 2022 to chase the external works linked to the damp and mould. The landlord said that it had chased the freeholders around completing these works but it could only be done via email, as it did not have a contact number for them.
On 13 January 2022, the resident emailed the landlord following a visit from it’s contractor. They said that the contractor had turned up with anti mould treatment but said that the scale of the work would mean they could not complete it during that visit, as they would need assistance. The contractor explained that the kitchen units needed to be removed to treat the wall behind them and they could not treat the damp in the bedroom, as fitted wardrobes had been installed on the wall, so they would need to be removed. The resident also advised that there was cracked glass in three windows, rotting frames and broken extractor fans.
Following this email, a member of the repair team attended to discuss the repair issues. The resident emailed the TO following this visit and asked about boiler issues identified during the visit. The landlord responded “You are not yet a tenant….once the mutual exchange is completed, you will have access to the repairs service to chase up these works.” They followed this with “let me know if you wish to complete the sign up on Monday 17th or move back to your substantial property” at previous address.
In an internal email, the member of the repair team that attended the property on 13 January 2022 reported that the property “has a lot of defects which were not identified.” The same person commented that the resident had “left her perfect flat/house and come to a dump in short.” They listed the defects in the property as:
1. “Leaking guttering and downpipe.”
2. “Mould below kitchen w/top units will need to be remove or the backs remove to gain access.”
3. “Boiler not working.”
4. “Fitted furniture in bedroom and kitchen unsafe needs to be removed this will give us access to treat the mould.”
In another email dated 14 January 2022, the landlord requested that a joint inspection be carried out with the contractor to determine the required works. On the same day, the resident’s daughter emailed the landlord to raise concerns around the currently outstanding works. They said that a surveyor had attended later in the day on 13 January 2022 and further damp and mould was found following the removal of the fitted units in the bedroom. She raised further concerns as the gas supply had been capped the day before, following a gas safety check. The resident’s daughter requested reassurance about the completion of the required works, prior to completing the mutual exchange, as they felt the resident could not move in prior to completion. In an internal email, the landlord indicated that it had been made aware that the resident and the exchange partner had already moved into each other’s properties, without signing the mutual exchange assignment.
On 19 January 2022, the landlord confirmed that the external work requests had been sent to the freeholders. It explained that internal works would then be placed on hold until 4 February 2022, to allow the external cause of the damp to be addressed first. The landlord then proposed that the mutual exchange be signed on 24 January 2022. Within that email, it explained that if the assignment documents were not signed, both the resident and the exchange partner would need to move back to the properties for which they held a tenancy.
On 24 January 2022, the TO emailed the resident and advised “the freeholder of the property has asked if I can mark out the areas affected by the damp on the floorplan.” The TO then asked “are you able to please advise?” The resident responded later that day and detailed the areas of the property that showed signs of damp.
The mutual exchange assignment was signed by the residents on 24 January 2022 with an effective date of 31 January 2022. The landlord exchanged emails with the freeholders to chase up the external works, it explained that the resident did not wish to live in the property until the works were completed.
On 30 January 2022, the freeholder confirmed that it was in the process of arranging the external works. Within its email, it said that it had been made aware, in an email dated 23 January 2022, that a chimney breast had been removed from the property by the previous tenant. This Service has not had sight of that email. The freeholders raised concerns around potential structural damage and requested that the council arrange a structural investigation and any associated remedial works.
In an email dated 31 January 2022, the landlord informed the resident that due to the works that were required, they would be unable to live in the property until they were completed. The resident responded and agreed to an offer of temporary accommodation, as they were currently staying with their daughter’s family, in an overcrowded property.
On 2 February 2022, the resident attended a viewing of the temporary accommodation it had proposed. They declined the offer, as they said it was unsuitable and did not meet their requirements.
On 4 February 2022 and 9 February 2022, the resident rejected temporary accommodation viewings due to location factors. They had specified that it needed to be within walking distance of a specific area, due to work and family commitments. The landlord and a letting agent both advised the resident that properties in that locality were not often available.
On 16 February 2022, the resident logged a complaint with the landlord as it had taken credit from the rent account at their previous property and transferred it to the new property. The resident asked for it to be returned to her bank account as they did not feel they should pay rent as they were unable to reside at the new property.
On 18 February 2022, a structural survey report was provided to the landlord following it’s instruction to a specialist contractor. This detailed the work that would be required to reinstate the structural integrity at the property following the chimney breast removal. The landlord identified that the freeholder would be responsible for this work.
Given that it could not offer a timeframe for the completion of works, and as it noted that the property may be disposed of, the resident was told they would need to complete a major works transfer to a different permanent property. On 24 February 2022, internal landlord emails show that the resident had refused a further offer of temporary accommodation following a viewing.
On 2 March 2022, the landlord issued it’s stage one complaint response. The complaint was not upheld. Within the response it acknowledged that the property had been classed as uninhabitable following identification of the chimney breast removal. It also said:
1. The resident was the “registered tenant and liable for the rent payments” at the property.
2. As the resident had not made any payments for the property “the £600 credit that was transferred from your former rent account has been used to cover the weekly charges.”
3. All relevant checks were completed prior to the mutual exchange and the structural issues were identified following it.
4. It was currently “attempting to organise for you to stay temporary accommodation while major works are underway” as “this would allow a nil charge to be applied to the rent account” for the property.
5. Temporary accommodation offers had been declined and the resident had said they would stay with their daughter until something more suitable was found.
6. Temporary accommodation in the area was in short supply and it was struggling to find any that met their requirements.
7. It could not offer a timeframe for the repairs at the property as the responsibility was with the freeholder and in view of this the decision had been made that the resident would not be able to return to the property.
8. It said that a major works transfer (MWT) should be undertaken and a like for like property be identified for the resident. Once this was agreed, it said it would issue a promissory letter to show that a like for like property would be offered and the resident’s liability for rent payments at the current property would cease.
The resident responded to the stage one complaint on the same day and requested an escalation. Their reasons were:
1. The accommodation offered to date was unsuitable when taking into account their requirements.
2. They were currently having to stay in their daughters studio flat as their property was uninhabitable.
3. They did not agree with paying rent on a property they could not live in.

The resident wanted the landlord to find a suitable property that met their requirements, until they could move back into their property following the repairs.

On 3 March 2022, the landlord acknowledged the escalation of the complaint and advised it would provide a response by 17 March 2022.
On 17 March 2022, the landlord provided a ‘stage one review’ response. Within its response it said it maintained that there were no service failures and it “adequately addressed all of the points raised in the stage one complaint.” The landlord explained that given the resident’s demands for a suitable property, it had struggled to find one in a specific area. The landlord also acknowledged that the resident had since moved back into the property and advised the resident to “strongly reconsider your housing options” as “the property is not fit to reside in.”
The resident responded the same day and requested escalation of the complaint. This was acknowledged by the landlord, it stated that the complaint will be passed for investigation at the Chief Executive complaint stage of it’s process.
On 29 March 2022, the landlord contacted the resident to advise that they have a property close by that could be a temporary solution until it finds one that meets their demands. The resident accepted this offer, on the condition that a promissory note would be provided to indicate that the landlord would offer a more suitable property, once available.
On 18 April 2022, the resident moved into the temporary property.
On 20 May 2022, the landlord provided confirmation that the current property was a temporary accommodation whilst a like for like property or new build property was sought. This was defined as a “two bedroom street property or new build” in two particular postcodes. It stated that “when a suitable one is found, it will be offered to you.” It then says that the resident needed to surrender the tenancy at the previous property.
On 23 May 2022, the landlord provided the Chief Executive stage complaint response. Within the response it:
1. Acknowledged the delay in it providing a response. It offered a payment of £75 in recognition of the delay.
2. Explained that following its review, it would apply a zero rent charge for the period that they held a tenancy at the previous property. It advised that any payments made towards the rent would be refunded.
3. Stated that at the time of the initial inspection in December 2021, fitted wardrobes were covering the area of the chimney breast. It said “therefore, the unauthorised removal of the chimney breast and any structural issues could not have been identified.” It then said the inspection “would also have been unable to identify damp and mould behind the fitted kitchen units.”
4. Apologised for the property having been deemed uninhabitable and said “I find no evidence to support your assertion the council is at fault and the ME inspection was inadequate.” It said that the resident was made fully aware of the damp and mould issues prior to signing for the property. It said “the council could not have foreseen the structural issues masked by the fitted wardrobes, or the additional mould and damp masked by the fitted kitchen units.”
5. Explained that it had struggled to find a temporary property that was acceptable for the resident.
6. Found “no grounds to uphold your complaint, or to award compensation for any service failure by the Housing Service.”
On 24 May 2022, the resident responded to the complaint response and explained that they were not happy with the findings of the investigation.

Assessment and findings

The landlord’s management of the mutual exchange process.

The mutual exchange application was received by the landlord on 28 September 2021. The landlord’s mutual exchange policy says that it should provide a response within 42 days. The application was recorded as being accepted on 6 December 2021, 69 days after the application was made. The policy at that time does state that due to COVID-19 it may be unable to meet this timeframe, which was reasonable given the circumstances. However, this Service has not had sight of any evidence to show that the landlord kept the resident informed during that time. This would have been reasonable for it to do, given the delay. Further to this, the inspection report detailed the application as being made on 2 November 2021. These suggest failings in the landlord’s record keeping and management of the process.
The resident’s complaint was that the inspection on 6 December 2021, carried out as part of the mutual exchange process, was not sufficiently comprehensive. Leading to them taking on a tenancy for a property in good faith, that on the day the tenancy started, was then classed as uninhabitable. The landlord said in its complaint response that at the time of the inspection, the fitted units meant that ”removal of the chimney breast and any structural issues could not have been identified.”
Although it may not have been obvious from a visual inspection, it was incorrect to state that the alteration could not have been identified during the inspection. Had the landlord utilised photographic records or notes around the makeup of the property from a previous void inspection, it would have been able to identify that the resident had removed the chimney breast and installed the fitted wardrobes. Further to this, the inspection form had a section to detail any tenant alterations. One of the options was ‘Fireplace’ which was detailed as ‘N/A’. Given that the floorplan for the property showed two fireplaces/chimney breasts, this would mean that even with the removal of the chimney breast in the bedroom, there would have still been one fireplace/chimney breast in the property to pass comment on. Therefore, ‘N/A’ should not have been a valid answer to that section. It is the view of this Service that an adequate inspection was not carried out on 6 December 2021.
There is a concern that inspection was undertaken by the TO, who’s suitability and skill set may not have been sufficient to identify potential alterations during the initial inspection. Had the alteration been identified at the time, it could have led to the identification of the structural issues prior to the completion of the mutual exchange and prevented the resident finding themselves temporarily without a home.
The mutual exchange policy says that the resident should have received a letter following the inspection that detailed any alterations made to the property. It is clear that in this case, no such letter was provided, as the landlord failed to identify and note the alteration.
The initial inspection was not the only opportunity that the landlord had to identify the potential structural issues prior to the completion of the mutual exchange. In the resident’s email from the morning of 13 January 2022, they advised that the contractor who attended said the wardrobes would need to be removed. An email from the resident’s daughter, dated 14 January 2022, said that the fitted wardrobes had been removed. These emails suggest the fitted wardrobes were removed later on either 13 or 14 January 2022. The removal of the fitted wardrobes would have exposed the walls behind and shown the gap in the plasterwork where the chimney breast had once been.
The structural survey from February 2022 had photographs which show the exposed brickwork from the removal, with the walls either side plastered. This shows that once the wardrobes were removed, it would have had clear evidence of the chimney breast removal, or enough reason to raise questions around a potential alteration to the property. The mutual exchange policy says that if the landlord “has serious concerns about the condition of a property, a surveyor should be asked to undertake an inspection and report back.” In their email dated 14 January 2022, the resident’s daughter said a surveyor attended on the same day the day the wardrobes were removed, which would have to be either 13 or 14 January 2022. It would be reasonable to assume that whoever they had attend should identify that this had happened, alerting the landlord to an alteration having been made to the property. At this point, a further review should have been undertaken with a delay being placed on the mutual exchange, pending the outcome of a structural survey. It is the view of this Service that the landlord failed to identify the chimney breast removal when it was provided with an opportunity to do so. Had this been noted, this would also have allowed an opportunity for the mutual exchange to have been stopped or delayed pending investigation. This would have prevented the resident from being placed in the unenviable position of leaving their home of several years only to be told their new home was uninhabitable on the day she took over the tenancy.
It is clear from the internal emails in January 2022, that the landlord was made aware of several defects within the property that were not listed on the inspection. The description of the property as “a dump” and some of the defects being described as “unsafe” by its own repair staff, raises concerns around it’s decision to allow the transfer to progress. Based on its findings subsequent to the inspection, it would have been reasonable for the landlord to complete a new and more thorough inspection at the property. Had it done this and detailed all outstanding repairs and the issues it had since identified, the resident would have been in a position to make an informed decision on progressing with the exchange.
The mutual exchange policy does say that the incoming resident agrees to taking on the property in the knowledge of the findings of its inspection. In this instance, the resident was clearly aware of the damp and mould issues. However, the landlord had not identified the alteration during the inspection or during the damp and mould review in January 2022. In view of this, it would be unreasonable to say that the resident was able to make an informed decision around progressing the mutual exchange. When considering the failings in the management of this process, cumulatively this amounts to severe maladministration.

The landlord’s management of the major works transfer process.

Having made the resident aware that they would temporarily need to move out of the property, the landlord would be expected to offer alternative temporary or permanent accommodation. The resident said they were currently staying with their daughter in a studio property, but them staying there meant it was then overcrowded. Two days after telling the resident they would need to move out, the landlord made an offer of temporary accommodation. Although it was a smaller property than their current property, it was within the specific postcode that the resident had requested. However, this offer was refused. Although it was understandable that the resident would want any offer to meet their specific requirements, this would not always be possible given the timeframe and availability. The landlord had offered a similar type of property to the one the resident was staying in with their daughter, in the desired postcode that they had asked for. It is the view of this Service that on this occasion, the landlord provided a reasonable option of temporary accommodation to the resident, within a reasonable timeframe.
The landlord made two other further offers of temporary accommodation properties but the resident declined to view them due to their location. It was made clear to the resident on several occasions that their requirements would be difficult to meet.
Following the structural survey on 18 February 2022, the landlord proposed a major works transfer to the resident, meaning they would need a permanent transfer. It made this decision as the required works were the responsibility of the freeholder and it could not provide any timeframe for the completion of the required works. The landlord also noted that it may dispose of the property. As the landlord decided the resident should not return to their property, it then applied for further temporary accommodation. The resident rejected this offer on 24 February 2022, as it was not within one of the three postcodes they requested. Given the circumstances, it is understandable that the resident would seek a property similar to their own and within a desired locality. However, it would be unrealistic to assume that specific demands can be catered for quickly.
The major works transfer policy says that if a resident requires this kind of transfer, it should begin bidding on properties. It says that the landlord may become involved using the ‘Supported Choice’ process, if a property was not found within three months. Within their correspondence, the resident said that they did not want to bid on properties, acknowledging that they would be difficult to find.
Within the stage one complaint response, the landlord said that it would continue to seek properties that met the resident’s requirements. It reiterated that “temporary accommodation in the borough is in short supply and high demand, therefore it is very difficult to meet specific demands.” However, an offer of temporary accommodation was proposed and accepted by the resident, within six weeks of the structural survey being carried out. It is the view of this Service that the landlord has acted outside of it’s own policy by assisting the resident in finding temporary accommodation matching their requirements within a reasonable timeframe. The landlord then provided a promissory letter that once a suitable like for like property, meeting their demands, can be sourced it would offer it to them. When considering the management of this process, this Service finds no maladministration.

The landlord’s handling of the resident’s complaint.

The landlord investigated the complaint across three stages. In each instance, the findings are worded in a different way, with each contradicting other responses:
1. In its stage one response it said “it was found at the time of the mutual exchange inspection that they had removed a chimney breast without permission”.
2. Its stage one review it said “following a mutual exchange it was identified that the exchanged property….was not fit for habitation as a result of structural damages caused by the outgoing tenant after the standard inspection.”
3. The stage two response said “the property was found to be uninhabitable after the exchange took place.”

Each of these responses provides a different version of when the alteration was identified. The first would indicate that it was identified on 6 December 2021, the second suggests the alteration was made after 6 December 2021 and the third response suggests that it was not aware of the alteration until after the exchange took place. When the alteration was identified is such a key factor in the complaint, having been given three different versions of events does not give any reassurance around it’s investigation or the findings. This would be frustrating for the resident, given the position they are in at that time.

The stage two complaint response was issued almost ten weeks after the escalation request. This significantly exceeds the twenty eight calendar days specified in the complaint policy, or the twenty days detailed on its website. It made a reasonable offer of £75 for the delay in providing a response. However, it failed to make the resident aware of the delay in it providing a response, once it knew it could not provide one in line with it’s complaint policy. If the landlord was aware that it’s response will be late, it could take steps to set the resident’s expectations around when it would provide a response. This kind of delay would be understandable if delaying the response was key to the outcome of the complaint. However, this was not the case as the decision had been maintained and no new information was provided or outlined in the response.
Although the landlord responded to both the stage one and stage one review’s in line with its set timeframes, it’s complaint investigations and management lacked adequate diligence, completeness and resulted in inadequate findings. These findings are around the key issue within the resident’s complaint and the landlord has failed to acknowledge it’s failings that led to the resident being in the position they were in. The landlord then failed to provide a response to the stage two complaint in line with its set timeframes and still failed to identify it’s failings. Based on the position it took, the landlord said that it could not uphold the complaint and said that no compensation would be awarded. Given this Service’s findings, this was incorrect and compensation should have been awarded. Considering the failings in management of the complaint, this Service finds that there was maladministration.

Determination (decision)

In accordance with Section 52 of the Housing Ombudsman Scheme, there was severe maladministration in the landlord’s management of the mutual exchange process.
In accordance with Section 52 of the Housing Ombudsman Scheme, there was no maladministration in the landlord’s management of the major works transfer process.
In accordance with Section 52 of the Housing Ombudsman Scheme, there was maladministration in the landlord’s handling of the resident’s complaint.

Reasons

The landlord’s management of the mutual exchange process.

It is the view of this Service that the landlord failed to complete adequate checks during the inspection that took place as part of the mutual exchange process. It then failed to identify the alteration after the wardrobes were removed, exposing the area of chimney breast removal. The landlord then allowed the mutual exchange process to complete, despite having sufficient opportunity to identify an alteration or defects that should have caused it to either inspect it again, delay the exchange or delay it pending further investigation. These failings led to the resident finding herself being told that she cannot live in the property, on the day her tenancy started at the property. This led to several months of distress and uncertainty around where they could live at a time when they thought they had found a home that was perfect for their needs. The resident remains in a temporary home to this day, due to these failings.

The landlord’s management of the major works transfer process.

The landlord offered temporary accommodation within two days of informing the resident of the requirement for them to move out. Once it was it aware that this would need to be permanent, it made another offer within a few days. On several occasions the resident rejected offers, as the properties did not meet their demands. The landlord has made the resident aware of the limitations around available properties, given the resident’s demands, and acted in line with its policy until a property was found.

The landlord’s handling of the resident’s complaint.

The landlord provided inconsistent findings throughout the process which call into question it’s investigations. It did not acknowledge it’s failings which led to the complaint being made and maintains throughout that the resident had no complaint to uphold. Further to this, it provided a response to the stage two complaint significantly outside it’s own timeframes with no updates throughout the delay to advise the resident of when it would provide a response.

Orders and recommendations

The landlord’s management of the mutual exchange process.

The landlord should make a payment of £800 directly to the resident within four weeks of the date of this report in respect of the distress and inconvenience caused by the landlord’s management of the mutual exchange process.

The landlord’s handling of the resident’s complaint.

The landlord should make a payment of £400 directly to the resident within four weeks of the date of this report in respect of the inconvenience, time and trouble in respect of it’s handling of the resident’s complaint.
The landlord should also make the payment of £75 proposed in its stage two response, if this has not already been provided. If required, this should also be provided within four weeks of the date of this report.
To initiate and complete a review of the learning in this case and advise this Service of it’s intentions within four weeks of the date of this report. At minimum this review must include:
1. Enhancements to it’s inspection regime and cohesion across services in respect of mutual exchange applications.
2. Ensure it has in place additional oversight and quality assurance of its complaint investigations and findings.
The landlord must then bring into it’s operations any identified improvements within three months of the date of this report.