As part of our recovery plan, we promised to carry out an in-depth review of what went wrong and why in relation to the tragic death of Awaab Ishak. We promised to share recommendations for improvement and to implement those recommendations.

  • Background

    The review examined the governance, risk, control, and assurance processes and practices, as well as the events that led to and followed from Awaab Ishak’s death. The lessons learnt review was commissioned by our Board to facilitate reflection, learning and improvement and underpin how we further develop our ways of working.

    The review looked in detail at the background and the context for ‘why’. We’ve already started to take action against many of the points raised in the review.

  • What did the review find?

    The review reaffirmed the finding of the coroner that our systems and processes were not joined up and teams were working in silos. We are now working hard to join up systems, processes, and teams.

    Our strategy and our Board’s focus had moved sharply away from core landlord services and quality homes to development and regeneration with the advent of the 2018-21 Together Strategy and its focus on regeneration and growth. We were not sufficiently focussed on our tenants. We are now focussing on the provision of good quality, safe homes and excellent, listening, tenant and customer services.

    Damp and mould were seen through the lenses of ‘lifestyle’ and disrepair costs and that clouded judgement. We now proactively check our homes for damp and mould. ‘Lifestyle’ is no longer an accepted term at RBH and we proactively challenge any use of this term.

    Data analysis and scrutiny were not part of our DNA. There was a lack of understanding of the strategic importance of data analysis to support decision making and there was no triangulation of datasets to identify cross-cutting themes. We are commencing our data
    improvement journey.

    Our (then) Board was skilled and experienced, but there was no recruitment to fill an identified skills gap in property management and maintenance either in 2019 or 2021. Since December 2022, our Board has been completely renewed on a skills basis and it now has the skills needed at this point in our development.

    Repairs-related performance reporting to Board was very limited. The only repairs related key performance indicators (KPIs) were ‘repairs completed on time’ and ‘repairs completed right first time’. Where insight and scrutiny were needed, they were lacking. New key performance indicators have been developed and a tenant services report is now a standing item at each Board meeting.

    There was no committee of the Board scrutinising tenant facing matters. Our Board has recently approved the formation of a Tenant Services Committee as a sub-committee of the Board – this committee will scrutinise all tenant facing matters. It will be made up of Board members and tenants.

    Channels for tenants to communicate their concerns, formal and informal, were reduced over the period to 2020 and beyond. Scrutiny groups that had been in place to review tenant-facing matters were also disbanded. This was in expectation of the implementation of a new Engagement Strategy in 2020, but some key elements of that strategy were not progressed. Tenant panels are now being reintroduced, community drop-ins have been reinstated and neighbourhood patches with a dedicated Neighbourhood Housing Officer have been reintroduced.

    The culture and values of RBH did not support a modern, customer service and tenant focussed approach. Tenants and front-line services did not feel listened to. The culture of RBH has already started to change with tenant focus at its centre. We intend to review our strategy and values following the appointment of our new permanent Chief Executive.

    Our governance framework was overly complex and our processes over-engineered. Making it work absorbed excessive time and administrative effort. Our governance framework and our governance processes will be simplified and streamlined.

    Risk management did not drive the business. Risk management processes are being revised as part of our recovery plan.

    Our compliance and assurance framework was carefully constructed. On the face of it, it was a rigorous, well-thought through framework that would have been expected to have identified the emergence of any material issues, but it did not. The methodology for assessing compliance with regulatory standards will be revised to capture actual, not theoretical, compliance.

    Our Board took assurance from externally provided reports that were commissioned in response to the death of Awaab Ishak, but the scope of those reviews was narrow and so provided inadequate assurance. The Board also took assurance from the outcome of the Regulator’s In-Depth Assessment (2021) and regulatory referral outcome letters. It is the Board’s responsibility to remain mindful of the potential risks of over-reliance on externally sourced assurance and regulatory processes where the outcomes are positive. The scope of any future externally provided reviews needs to be carefully considered and the work carried out by individuals with the requisite breadth of expertise and experience.

    The report makes a number of other recommendations which focus on improving our services. They include end to end quality assurance and quality control processes for calls to the contact centre and for repairs carried out.