CQC Fire Safety Action Plan for 2017 -Residential Care Homes

On the 27th June, The Care Quality Commission (CQC) wrote to all Registered Care Homes encouraging them to review their fire safety arrangements and ensure that they discharge their fire safety responsibilities, as imposed under The Regulatory Reform (Fire Safety) Order 2005.

Within their letter the CQC suggested that Care Homes should pay particular attention to their Fire Risk Assessment and whether it considers higher risk residents such as those with mobility impairment or learning disability.

The letter also reminds Care Providers that ‘The Order includes a range of absolute duties ranging from providing information and training to employees, through to ensuring that premises and any equipment provided in connection with firefighting, fire detection and warning or emergency routes and exits are covered by a suitable system of maintenance by a competent person’.

Other actions recently implemented by the CQC include, the updating of their inspectors ‘tier 4’ guidance for fire safety.

Future action intended includes:-

  • Recording the number of fire safety issues identified by their inspectors
  • Reviewing arrangements for liaising with Fire Services where they have concerns
  • Providing further fire safety training and information for their inspectors

Whilst the CQCs clearly intends to drive improvements in fire safety, there is currently no recommendation for the mandatory registration of Fire Risk Assessors who operate within the Care Sector, as is the case in Northern Ireland.

How can Care Homes ensure that they measure up to the CQCs expectations?

Fire Safety Policies and Procedures

Documented policies and procedures are vital to ensure consistency of approach across Care Home Groups, making sure that everyone knows what is expected of them and to act as a source of information that can be referred to for specific risks e.g. smoking (including e-cigarettes), residents who use oxygen, acceptable arrangements for charging hoist batteries, arrangement for events such as barbeques or firework displays etc.

Fire Risk Assessment

As the CQC quite rightly recognise, having a good Fire Risk Assessment in place is critical. When critically reviewing your Fire Risk Assessment, the key things to consider include:-

  • When was the assessment carried out? Things change quickly in Care Homes, not only do staff and residents come and go, but rooms are often ‘re-purposed’ which can cause problems. It’s recommended that Fire Risk Assessments are reviewed at least annually.
  • Who carried out the Fire Risk Assessment? Home Managers are experts at providing Care, however, they are unlikely to know a great deal about fire safety legislation/guidance and are therefore unlikely to be competent Fire Risk Assessors. Similarly, a Contractor who provides firefighting equipment or similar may have a very limited knowledge of fire prevention. To reduce the risk of having in place a Fire Risk Assessment that is not ‘suitable and sufficient’, consider appointing a registered Fire Risk Assessor who has been scrutinised and deemed competent by an independent industry body such as the Institute of Fire Engineers (IFE). The IFE’s register of assessors can be found at: http://www.ife.org.uk/Fire-Risk-Assessors-Register
  • Does your Fire Risk Assessment consider the residents within the building and not just the building itself? A comprehensive Fire Risk Assessment should flag up issues around residents such as those who smoke and their competency to do so safely, the location of any bariatric residents, who may need a wheelchair or an evacuation mat within their bedroom for escape purposes, the distances that high risk residents may have to travel to reach a place of relative safety, whether or not the residents have a history of fire starting etc. ‘Generic’ assessments intended to cover all building types are not usually adequate for Care Homes.
  • Does your assessment check that suitable ongoing maintenance of fire safety and other equipment that may cause a fire is being undertaken within recognised time frames and that remedial work is being carried out?

Staff Training

Staff are unlikely to respond as required in a fire situation, unless they have received suitable training. All staff should receive a minimum level of fire safety training, those with more fire safety responsibilities should receive additional training (usually known as either, Fire Warden or Fire Marshal Training).

When reviewing your training arrangements, consider:-

  • How many Fire Wardens/Marshals do you have? All staff who may be required to co-ordinate an evacuation of the Home in a fire scenario should receive additional training. The number of Fire Wardens available should also consider periods of holidays and sickness. As a guide, the typical number for a 40 bedroom older persons’ Care Home is likely to be around 6 members of staff and should always include the Home Manager.
  • Was the Fire Warden training received Care Sector specific? There’s little value educating your staff about how to evacuate low risk premises such as a shop, office or similar; if progressive evacuation wasn’t mentioned, the training would not be adequate.

Maintenance of Fire Safety and Other Systems

It’s important to look after what you’ve already got in place and ensure that it’s suitable maintained. One way of keeping up to date with regular maintenance is to put service agreements in place for items such as your 5 year fixed electrical test, PAT testing, Gas appliances (boiler, cookers, laundry dryers etc), passenger lifts, fire alarm system, sprinklers, emergency lighting, ventilation systems, firefighting equipment etc.

Emergency Planning in Case of Fire

In the event of a fire within the Home, there needs to a suitable evacuation strategy in place and this needs to be known and practiced by staff (usually progressive evacuation). Your evacuation strategy should consider key issues such as the location of fire compartments within the building, the type of fire alarm system in place, the location of evacuation aids and the location of particularly high risk residents e.g. bariatrics.   The last thing you want to happen upon the raising of the alarm is for all of your staff to exit the building and leave the residents within the Home; staff need to remain in the Home and help with the evacuation of the residents.

Personal Emergency Evacuation Plans (PEEPs)

In Care Homes, the majority of the residents are likely to require at least some form of staff assistance in case of fire. The PEEPs are intended to identify the evacuation needs of each individual within the Home and need to be kept up to date to recognise changes in health, medication etc.


Care Homes are unique and diverse environments that cater for vulnerable people; they also have unique fire safety arrangements such as progressive evacuation.

To convince the CQC that the fire safety arrangements at your Care Home are suitable, your ‘whole package’ of measures will need to be reviewed (and the review process documented) and action must be taken where deficiencies are found.

Help and Advice

Marpal have been providing high quality Health & Safety advice within the Care Sector since 2004 and have a wealth of experience. Free to download templates for PEEPs and Smokers Fire Risk Assessments are available on our website www.marpal.co.uk/fire-safety-downloads ; we also carry out Fire Risk Assessments, Evacuation Strategies, Care Sector Specific Fire Warden Training and develop fire safety policies and procedures.

For further details or assistance with your Fire Safety requirements, please contact Adrian Gouldin on 01332 668877 or via email at [email protected].