Root cause analysis of non-compliance

1. Purpose and approach

1.1 The Regulator of Social Housing (RSH) requires the council to undertake a root cause analysis as part of our response to the C3 Regulatory Judgement. This analysis seeks to understand why the council did not fully comply with the RSH Safety and Quality Standard and how to ensure failings are not repeated. 

1.2 The findings go beyond operational errors to highlight systemic and cultural challenges that have built up over time. While some actions have already been taken, the analysis has created a clearer picture of what needs to change – structurally, culturally and in day-to-day delivery – to achieve lasting compliance and better serve residents.

1.3 Our objective is to address the systemic challenges that have contributed to non-compliance and to ensure that all residents live in safe, high-quality homes.  This is in line with: our Council Plan (2023 to 2027) priorities Homes for Everyone, and A responsive Council with Well-Run Services; Housing Strategy (2024-29) priority of Improving Housing Quality including by: investing in building and fire safety to meet duties under the Building Safety Act; ensuring the Council complies with social housing regulations; and reducing the backlog of housing repairs.

1.4 The root cause analysis in this report has used three main sources of insight:

· Information and data review: including compliance performance, resident feedback, historic audit trails, and complaints.

· Interviews: structured conversations with Housing leadership, corporate colleagues and compliance leads, service managers, and technical experts.

· Structured Workshops: Facilitated using the ‘Five Whys’ reflect deeper than the symptoms for non-compliance.

1.5 The Council continues to engage in deep reflection about our learning in terms of our response to the Regulatory Judgement, emerging events and our actions to address the identified issues and ensure ongoing compliance. Continuous improvement means that the analysis is an ongoing process as a tool for shared learning and a starting point for building the improvement plan together with our Housing and relevant corporate teams, residents, and elected members.

2. Summary of what the Root Cause Analysis Tells Us

2.1 Our root cause analysis identifies six interdependent themes, presented in the diagram below as a layered system:

· At its foundation lies Resident Voice, where a hierarchical culture focused on national policy initiatives and organisational priorities was not always responsive to resident concerns.

· Leadership & Culture provides the platform for effective governance and decision-making; however, organisational culture sometimes disempowered staff, created psychological unsafety, delayed escalation of issues, and diluted responsibility for managing risk through ambiguity and fragmentation.

· Data Quality & Use is critical to sustainable compliance but was undermined by inconsistent maintenance of records, poor data quality, and systems that did not communicate or integrate effectively – weakening assurance about stock condition, maintenance and investment activity, and long-term decision-making.

· Workforce Capacity & Capability is essential for action; however, key roles were at times unfilled or underpowered, and frontline staff did not consistently feel empowered to escalate concerns or act confidently.

· Prioritisation & Focus ensures that resources are aligned with long-term asset and compliance resilience; however, short-term decisions, limited forecasting, and underinvestment undermined the council’s ability to strengthen these areas.

· Responsibility for Compliance and Adaptation requires proactive monitoring and response to emerging risks; however, a reactive compliance model missed early warning signs and did not adapt quickly enough to new duties and standards.

2.2 In practice, while elements of this system were in place, inconsistency across these layers contributed to vulnerabilities. Strengthening each layer and reinforcing the links between them is critical to embedding lasting improvement.

Diagram 2: Mapping of causes leading to non-compliance and backlogs

2.3 These are not isolated themes. They interact and reinforce one another: incomplete and poor quality data undermines decision-making; unclear roles delay action and escalation; short-term fixes crowd out strategic planning. The entire system depends on coordination, learning, and shared responsibility.  Using the themes as a framework helps us move beyond individual failures – to address the deeper conditions that have enabled non-compliance to arise – and to design change that lasts.

3. Next steps: from analysis to action

3.1 The root cause analysis builds on actions taken so far and the shared commitment to understand what must change to support a consistent focus on compliance in terms of safety, sustained maintenance and proactive investment in the quality of the housing stock, and a steadfast commitment to resident-centred planning and delivery.

3.2 To inform the alignment of improvement plans for our Creating Great Homes Together Improvement Programme, the six themes from our root cause analysis have been reframed as priorities for organisational change.  We are adopting a strengths-based approach that focuses on learning from and addressing areas for development, as well as systems that support us to be a great landlord. 

3.3 The themes are reimagined below in terms of what we aim to become over the coming months:

· Leadership and culture: We will ensure consistent, robust leadership and clarity around when and how concerns are escalated, so that issues are surfaced early and addressed decisively.

· Data quality and use of data: Reliable, well maintained electronic records will underpin planning, assurance and sound decision making.  Strong management systems and procedures will safeguard the accuracy, completeness and quality of our data and its effective use to inform and support compliance and our Improvement Programme.  

· Workforce capacity and capability: Skilled, confident staff are our most valuable resource.  We will: invest in staff development including apprenticeships, technical skills, particularly in areas like fire safety, surveying and data analysis; design structures that create capacity for leadership development in all tiers of management; support  a culture of trust and empowerment that enables action to be taken and areas of concern to be raised without fear of blame: and, use digital solutions for transactional/administrative activities so that staff have time to plan and focus on relational activities.

· Prioritisation and focus: With finite resources, we will take a risk-based approach to ensure that effort and investment are aligned to fulfil all of our compliance duties, Improvement Plan and resident impact.

· Responsibilities for compliance: We will define clear roles and accountabilities for stock quality, safety and compliance.  Risk management must move beyond silos. Joined-up teams, and meaningful resident involvement will strengthen trust and meaningful engagement between staff and residents.

· Managing contracts: We will take a stronger client role, ensuring contractors are clear on expectations.  Given the scale of works required to maintain and improve the council’s housing stock, there will be times that third parties will be required in terms of capacity and/or expertise to support the council in fulfilling its compliance duties.  A strong client function should first clearly scope out the requirements for the contractor about what we need in terms of their services, and then the specification and terms and conditions in the contract/s must be actively managed. Robust contract management ensures that the direct (specified works) and indirect (social value) benefits from the contracting arrangement are realised for the residents and wider community.

3.4 Our goal is not only to meet regulatory expectations but to create a culture and system change that supports staff to listen to and work proactively with a diverse range of tenants and leaseholders so that our residents live in safe, good quality homes and neighbourhoods.

3.5 Our approach to finalising the improvement programme includes:

· Workshops for residents and staff, co-producing together the responses to the issues raised in this report

· A one council approach to learning within cross-cutting themes (e.g. data, contract management, asset planning) to test and learn identified solutions

· The programme will be overseen by the Housing Compliance Board for operational delivery, and strategic oversight will be by the directorate's Delivery and Improvement Board which is being created to include frontline staff as part of the membership.

3.6 The Improvement Programme will be co-produced by July 2025 under the leadership of the Corporate Director for Homes and Adult Social Care.