CROSS Safety Report
Lack of fire safety competence in care home setting
Overview
A fire and rescue service is concerned about the lack of competence of maintenance personnel working in care homes. This is following two incidents where poor electrical and fire door maintenance put residents at risk.
Key Learning Outcomes
For responsible persons (RP):
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The UK's fire safety regulations1 all require a structured and effective fire safety management regime to prevent relevant persons from being exposed to risks such as those described in this report
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Persons responsible for the fire safety arrangements of a premises must ensure that staff undertaking work that involves any of the fire safety systems or equipment are competent to do so
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Electrical maintenance or electrical installations should only be carried out by competent persons
1 These are the Regulatory Reform (Fire Safety) Order 2005 (as amended) (FSO), The Fire Safety Regulations (Northern Ireland) 2010 and The Fire Safety (Scotland) Regulations 2006.
For fire and rescue services:
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Where modifications are recommended for an existing, nominal fire door, further guidance may need to be communicated to RPs about the competence of contractors undertaking these works
For care regulators:
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Care regulators should ensure fire safety competence is embedded into the whole range of persons with duties in a care home. This includes managers, care staff, fire risk assessors and maintenance staff
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Inspection regimes for care regulators and fire and rescue services should target the risk. Care homes are high risk occupancies, where staff competence is critical
Full Report
Find out more about the Full Report
The Full Report below has been submitted to CROSS and describes the reporter’s experience. The text has been edited for clarity and to ensure anonymity and confidentiality by removing any identifiable details. If you would like to know more about our secure reporting process or submit a report yourself, please visit the reporting to CROSS-UK page.
The reporter highlights that the lives of vulnerable residents rely heavily upon many critical fire safety elements:
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Competent management of systems, staff, and procedures
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Well trained care staff to carry out an evacuation in the event of a fire
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Well maintained fire safety premises infrastructure
The reporter is concerned that maintenance personnel working in care homes are carrying out works they are not qualified for, nor competent to do, and provides two example incidents:
Unsafe electrical installation
The first incidence was an electrical installation that was found to be faulty following an emergency call to a care home specialising in end of life and palliative care. The firefighters discovered that the electrical connections for a light fitting had been shorting, causing overheating and smoke.
The installation was later confirmed by a qualified electrician to have been clearly undertaken by an unqualified maintenance person. The reporter states that the responsible person for this and four other care homes were sent an official letter reminding them of their responsibilities under the Fire Safety Order, and to investigate who was responsible for the dangerous works, and urgently requesting they review the wiring in all their premises where this maintenance person worked. The letter also recommended that the RP suggest to the maintenance person that they do not attempt any further work for which they were not qualified or competent.
Inadequate fire door remediation
The second incidence occurred following a fire safety inspection in a care home for residents over 65. One of the recommendations of the initial inspection was to upgrade the fire doors by fitting them with intumescent strips and cold smoke seals.
A follow up inspection of the remedial works found that the intumescent strips and cold smoke seals were incorrectly fitted to the door frame. The combined strip and seals were fitted to a channel, that was routed incorrectly, into the corner of the frame. The reporter suggests that in the event of a fire, the intumescent strip would swell and effectively lever the door open and allow passage of fire and smoke into the means of escape, compromising the evacuation. The door and frame were described as 'relatively old but substantial' and (if the combined strip and seal had been fitted correctly) would likely have given the level of protection required. Instead, they lost integrity and are now unfit for purpose.
The reporter is concerned that unqualified maintenance personnel are carrying out repairs to safety critical systems and installations with the potential for serious injury or loss of life.
Both safety cases appear to have arisen due to the lack of competence and knowledge of the maintenance personnel, and a similar lack of knowledge in the managers who permitted them to carry out the repairs. The reporter suggests the underlying cause is either "well-meaning maintenance personnel and naïve managers allowing unqualified people to carry out repairs to essential fire safety infrastructure, or an attempt to save money".
The reporter has addressed these issues locally under the Regulatory Reform (Fire Safety) Order 2005 (as amended). However, they also wish to express grave concerns to the care sector that some of the most vulnerable people in society are living in premises where they are not as safe as they should be.
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Expert Panel Comments
Expert Panels comment on the reports we receive. They use their experience to help you understand what can be learned from the reports. If you would like to know more, please visit the CROSS-UK Expert Panels page.
A structured and effective fire safety management regime
A structured and effective fire safety management regime under the Regulatory Reform (Fire Safety) Order 2005 (as amended) is critical to the safety of vulnerable residents. This is similarly true for nations covered by the UK’s other fire safety regulations.
The Panel expressed clear concern regarding the management and maintenance of care homes, and the lack of understanding of what is required to maintain fire safety. These two incidents exemplify the issue of managers employing a general maintenance person to undertake safety critical work.
Competence of maintenance staff
There was an apparent lack of competence by the maintenance personnel who undertook such installations. They failed to display sufficient competence to perform the tasks appropriately or, indeed, to identify that they should not even be attempting them.
Care home providers undoubtedly face challenges in maintaining compliance with every area of their responsibility. However, the financial issues facing care home providers should not mean they get such work done cheaply and compromise on competence.
There is a critical need for competent staff and personnel across the care sector, as it is sometimes these smaller issues that can align to create a far bigger, and potentially tragic incident.
Competence of fire risk assessors
A competent fire risk assessor critically challenging installation, testing and maintenance records should uncover these failings. The Panel points to some best practices by The Regulation and Quality Improvement Authority (RQIA), the care home regulator in Northern Ireland, including the requirement for all fire risk assessments in care homes (including residential and nursing homes) to be undertaken by fire risk assessors holding third part accreditation. RQIA has also been proactive in issuing communications to responsible persons regarding inspections of roof voids.
Care home regulators and fire and rescue services (FRS) have a role
There is an ongoing duty of both the FRS and care home regulators to continue to explain the issues, the potential consequences (such as injuries, deaths and legal repercussions) and the expected standards.
Inspection regimes should target the risk. Care homes are high risk occupancies where staff competence is critical. This means that where there is high staff turnover, RPs may need to continually assess, train, and confirm staff understanding of their roles under the local fire safety regime e.g., FSO.
The care regulators should ensure that consideration of fire safety matters is included within an inspection regime. It is suggested a campaign by fire and rescue services and the respective UK care regulators could be developed to target RPs of care homes, to offer advice on their responsibilities and how to manage fire safety. This would need to be well structured to ensure it was easy to navigate and cover specific topics.
If the FRS take enforcement action this needs to be publicised to raise awareness and learning across the industry. The care regulator would likely be the best conduit for this communication.