Fire safety - existing care homes: practical guidance

Guidance for those who have responsibility under the Fire (Scotland) Act 2005 for ensuring fire safety in care homes in Scotland.

This document is part of a collection

Chapter 4: Managing Fire Safety

83. A management commitment to fire safety is essential to assist with achieving suitable fire safety standards in premises and in maintaining a staff culture of fire safety. It is important to promote to staff that the concept of ‘care’ includes care from fire.

Fire Safety Policy

84. There should be a clearly defined fire safety policy which includes arrangements for planning, organisation, control, monitoring and review of fire safety measures:

  • Planning - adopting a systematic approach which identifies priorities and objectives.
  • Organisation - having a structure with the aim of ensuring improvement in fire safety performance.
  • Control - ensuring decisions for achieving fire safety are implemented as planned.
  • Monitoring and review - constant development of policies and approaches.

85. There should be one named individual with overall responsibility for the coordination of fire safety management within each premises. In multi-site organisations there is a need to establish responsibility for fire safety within the organisation as a whole and arrangements for monitoring the management of fire safety in all premises.

Emergency Fire Action Plan

86. An emergency fire action plan sets out the action that staff and other people in the premises should take in the event of a fire. It is a management responsibility to have in place a comprehensive emergency fire action plan specific to the premises and to have in place arrangements to implement the plan. Table 2 shows a checklist relevant to a care home emergency fire action plan.

Table 2 - Emergency Fire Action Plan Checklist

  • How people will be warned if there is a fire.
  • What staff should do if they discover a fire.
  • What staff should do in the event of a fire or the fire alarm actuating.
  • The arrangements for calling the Fire and Rescue Service.
  • The action to be taken by the person in charge when the fire alarm activates or a fire is discovered.
  • Arrangements for fighting fire by staff.
  • Any processes or power supplies that need to be stopped or isolated.
  • The procedure to be followed to evacuate the premises by staff (and by any other persons present), taking into account the personal evacuation needs of individual residents.
  • Procedures for meeting the Fire and Rescue Service and passing on details of the incident, whether all persons are accounted for and the presence of any special dangers.
  • In the case of progressive evacuation, the emergency arrangements should it be necessary to evacuate all of the residents.
  • Where residents should assemble or be taken after they have left the premises and procedures for checking whether the premises have been evacuated.
  • Contingency arrangements to move evacuated residents to short-term shelter and to ensure continuity of welfare and care.

87. There should be an adequate number of trained persons responsible for supervising and implementing the emergency fire action plan at all times of day or night. Emergency evacuation is a management responsibility and the plan should not rely on the attendance of the Fire and Rescue Service to work.

88. The emergency fire action plan should provide that staff do not delay the summoning of the Fire and Rescue Service when the premises fire warning system actuates and indicates a fire.

89. Staff should be aware of the emergency fire action plan through their training and instruction. Staff notices containing extracts of the emergency fire action plan should be permanently displayed in appropriate positions in the building. These notices should contain sufficient instructions for staff on their actions in the event of fire. Notices need to be in a format understood by staff. There may also be a need for notices designed specifically for residents and visitors.

90. Where practical, an overview of the evacuation arrangements should be communicated to those residents who will comprehend, so that they are aware of the planned procedure for their evacuation. This may assist with a more organised evacuation.

Fire safety information and training

91. The actions of staff are crucial to the safety of residents in care homes. It is essential that staff know what they have to do to safeguard themselves and others on the premises and to have an awareness of the importance of their actions including risk reduction, maintenance of fire safety measures and action if there is a fire.

92. All staff (including shift workers, cleaners, volunteers, temporary and agency staff) should be given information, instruction and training on the action to be taken in case of fire and the measures to be taken or observed on the premises.

93. Training of each member of staff should take place as soon as possible after they are appointed and after that, at a frequency which will ensure that they remain familiar with procedures. The specific fire safety training needs of any young persons employed should be considered.

94. Fire safety training should be specific to the care home. Table 3 shows a care home staff training checklist. What is important is not simply the fact that staff training has taken place, but that the training is effective and that staff have knowledge and understanding of what they should do in the event of fire and also actions to prevent fire. It is therefore necessary to include assurance to confirm staff understanding. This could be achieved by incorporating a post-training check to confirm whether staff have understood and assimilated the training.

Table 3 - Fire safety training checklist

  • Instruction on the operation of the fire alarm control panel, with particular attention to the information displayed and how to interpret this information.
  • The action to take on discovering a fire.
  • How to raise the alarm of fire.
  • The action to take upon hearing the fire alarm.
  • The arrangements for calling the Fire and Rescue Service.
  • The significant findings of the fire safety risk assessments.
  • The measures that have been put in place to reduce the risk from fire.
  • The identity of people nominated with responsibilities for fire safety.
  • Any special arrangements for serious and imminent danger to persons from fire.
  • The procedures for alerting visitors including, where appropriate, directing them to exits.
  • The measures in place to ensure a safe escape from the building and how they will operate.
  • The personal evacuation needs unique to each resident.
  • The evacuation procedures for everyone in the building to reach an assembly point at a safe place.
  • The principle of progressive evacuation (if used in the premises).
  • The fire prevention and fire safety measures and procedures in the premises and where they impact on staff and others in the building.
  • The location and use of fire-fighting equipment.
  • The location of the escape routes, especially those not in regular use.
  • How to open all doors on escape routes, including the use of any emergency fastenings (and locks where appropriate).
  • The purpose of fire doors and the importance of keeping fire doors closed to prevent the spread of fire, heat and smoke.
  • The importance of good housekeeping.
  • The risks from flammable materials used or stored on the premises.
  • The precautions to be taken to minimise and control the risks, with particular attention to their role in reducing and controlling fuel and ignition sources.
  • The need for staff to report defects in fire safety measures.

95. The knowledge and understanding that employees require will be guided by the role and function the member of staff is expected to fulfil. Staff should be given details of the findings of the fire safety risk assessments. Those who have a supervisory role should receive additional training which will enable them to discharge their specific responsibility.

96. Those staff who may require to physically move or assist residents during an evacuation, should receive manual handling training on the method of achieving this and should be familiar with the use of any evacuation aids or equipment provided for this purpose.

97. A record should be kept of individual staff member training. Records should include the date and time, content, duration, trainer, and assurance check, as evidence that adequate training has been given.

98. Fire safety law specifically requires that information on risks and fire safety measures be notified to workers in the premises from outside agencies or undertakings and their employers; and to the parents of any child not over school age who may be employed to work on the premises.

99. Written information may need to be issued to staff whenever there is a change in the risk from fire, where changes have been made to the emergency fire action plan or other fire safety measures, or where working practices or people’s responsibilities have changed. This includes temporary changes such as when contractors’ work is in progress. Written instructions should be concise, comprehensible and relevant and should be in a form that can be understood, taking account of those with differing abilities such as sight impairment, learning difficulties and those who do not use English as their first language.

Fire Drills

100. Staff may not follow appropriate action in an emergency if they have never experienced that action. Fire drills should be carried out to check that staff understand and are familiar with the operation of the emergency fire action plan, to evaluate effectiveness and identify any weaknesses in the plan.

101. The frequency of drills for each building should reflect the level of risk. Fire drills should take place at least twice a year. Each member of staff should participate at least once a year. During drills, fire scenarios should be introduced to reflect what could occur in a fire and problems that staff may be faced with, such as an escape route unusable due to fire.

102. During drills, a member of staff who is told of the supposed outbreak should operate the fire alarm and the staff should then rehearse the routine as fully as possible. The degree of resident participation in a fire drill will depend on the nature of residents and their capability. Some fire drills should take place when staffing levels are at their minimum.

103. Where there is the possibility that someone may misinterpret the fire drill and call SFRS, it will be appropriate to inform SFRS prior to the commencement and on conclusion of a drill in order to prevent its unnecessary attendance. If the fire warning system is connected to a remote alarm receiving centre, the receiving centre should be informed (to prevent the Fire and Rescue Service being called) and then advised when the drill is terminated.

104. When carrying out a fire drill it may prove helpful to:

  • Circulate details and inform staff of their participation. ‘Surprise drills’ will not normally be appropriate in certain care homes, particularly with high and medium dependency residents; health and safety risks will outweigh the benefits.
  • Ensure that any equipment which is in use, such as cookers, can be made safe by isolating or turning off controls.
  • Inform visitors if they are present.
  • Nominate observers to assess the appropriateness of actions and identify problems; such as communication difficulties; the use of a frequently used route instead of the most appropriate escape route; and difficulties with door fastenings.

105. Where the evacuation strategy involves immediate evacuation, the drill should include a roll-call at the designated assembly point(s), noting any persons who are unaccounted for. In a fire situation, this information would be passed to the Fire and Rescue Service on arrival.

106. The results of the fire drill should be recorded, discussed with staff, and action should be taken to address any issues which have arisen.

Maintenance of Fire Safety Measures

107. There should be regular checks, periodic servicing and maintenance of the physical fire safety measures. Any defects which occur should be put right as quickly as possible, though there may be a need for contingency plans when life safety systems such as fire-warning systems or sprinklers are defective.

108. The maintenance and testing of some systems and equipment will fall within the recommendations of a British Standard. Examples of testing and maintenance are given below. Experience in individual premises may show that other maintenance and testing regimes may be appropriate. Six-monthly and annual tests may normally be carried out by a person with specialist knowledge, usually via a service contract.

Escape routes and doors

  • Daily walk through to check escape routes are clear of obstructions and combustible materials, and that self-closing doors are not wedged open.
  • Weekly check of escape routes, safety signs and notices, exit securing mechanism; and door self-closing devices.
  • Monthly check that fire doors are in good working order: inspect doors for warping or distortion, fire-resisting glazed panels are in good condition and secure in their frame, and that intumescent strips and smoke seals are in good condition.

Portable fire-fighting equipment

  • Monthly visual check of fire extinguishers and hose reels to ensure no obvious faults.
  • Annual maintenance.

Fire warning system

  • Daily check of the control and indicating equipment to ensure the system is operational.
  • Weekly test by activating a manual call point (usually by inserting a test key). This checks that the control equipment is capable of receiving a signal and in turn, activating the sounders. A different call point is used for each successive weekly test. Call points can be numbered to assist with sequential testing. It is good practice to test the alarm at the same time each week, but also to ensure that shift workers are given the opportunity to hear the alarm. During test, the alarm should not operate for too long so there is a distinction between a test and an unplanned actuation. Check that the test causes the operation or disabling of other features such as electrically powered locks, the release of doors on hold-open devices, the operation of doors on swing free arms and automatic opening doors reverting to manual operation. Where the system is connected to an alarm receiving centre, the centre should be notified prior to and on completion of the test.
  • Six-monthly servicing and preventive maintenance.

Emergency lighting

  • Monthly functional test of all emergency light fittings at a time when, following the test, the lighting will not be immediately required. Test methods vary; some systems have self-testing facilities that reduce routine checks to a minimum.
  • Annual maintenance and full discharge test (care should be taken not to leave the home without emergency lighting during the night).

Suppression system

  • Annual inspection and test.


  • Maintenance at least every two years.

Third-party Certification

109. Other than where work is exempt, any work to the building must comply with the building regulations irrespective of whether or not a building warrant is required. Products must be able to fulfil the requirements of the building standards in the particular circumstances of their use. Building regulations requires that materials, fittings, and components used should be suitable for their purpose, correctly used or applied, and sufficiently durable, taking account of normal maintenance practices to meet these regulations.

110. Fire protection products should be fit for their purpose and properly installed and maintained, while installation and maintenance contractors should be competent. Third-party certification, where a reputable certification body independently checks competencies and processes and that standards are being met, is one method of providing a reasonable assurance of quality of products and services, provided that the certification body itself is a competent evaluator. Accreditation by UKAS [2] is an indication that a third-party certification body is a competent evaluator. Products and services that are not third-party approved by an accredited body are not necessarily less reliable, but accredited third-party certification can offer assurance.

111. There are third-party certification schemes for various fire protection products, including emergency lighting, fire warning systems and fire-fighting equipment which can add reassurance for design, installation and maintenance.

Recording Information and Keeping Records

112. Paragraph 55 explains when certain fire safety records must be kept. The records are:

  • The significant findings from the fire safety risk assessment.
  • The resulting fire safety measures and action to be taken.
  • Persons who are especially at risk.
  • Fire safety arrangements for the effective planning, organisation, control, monitoring and review of the fire safety measures.

113. As part of the requirement to record fire safety arrangements, this should include a record of the results of maintenance and testing. These could be either electronic or paper based and retained for at least three years for possible audit by the enforcing authority.

Manual for staff

114. It is valuable for a simple fire safety manual for staff to be prepared, in which fire safety measures are shown and responsibilities are set out. As a guide for reference, this will assist with staff awareness, fire safety arrangements and the maintenance of fire safety measures. Features which could be shown by plan in the manual are:

  • The layout of the premises, escape routes, doorways, walls, partitions, corridors, stairways etc, including fire-resisting structure and self-closing fire doors.
  • The extent of compartments and sub-compartments.
  • The location of ventilation system dampers.
  • Details of the fire-fighting equipment.
  • The location of fire alarm call points and control equipment.
  • The extent and type of automatic fire detectors.
  • The location of emergency lighting equipment and any exit route signs.
  • The location of automatic life safety fire suppression systems and the location of the shut-off valve.
  • The location of the main electrical supply switch, the main water shut-off valve and, where appropriate, the main gas or oil shut-off valves.
  • Details of facilities that are provided to assist fire-fighters.



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