CH20-Fire Safety and Evacuation Procedures
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Registration Number: {{org_field_registration_no}}
CH20-Fire Safety and Evacuation Procedures
1. Purpose
The purpose of this policy is to ensure that fire safety measures and evacuation procedures in our care home are robust, effective and fully compliant with the Health and Social Care Act 2008 and associated regulations, including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – particularly Regulation 12 (Safe care and treatment) and Regulation 15 (Premises and equipment). It also ensures compliance with fire safety legislation, including the Regulatory Reform (Fire Safety) Order 2005 as amended by the Fire Safety Act 2021 and the Building Safety Act 2022, and, where applicable, the Fire Safety (England) Regulations 2022. Our priority is to protect the lives of people we support, staff, visitors, and contractors by implementing proactive fire prevention strategies, rigorous safety checks, and well-rehearsed emergency evacuation plans.
Through this policy we demonstrate how we meet the CQC Fundamental Standards – in particular that care and treatment are provided in a safe way, that the environment and equipment are safe, and that we have effective systems to assess, manage and reduce fire-related risks in line with CQC’s current single assessment framework (Safe and Well-Led key questions).
Fires in care settings pose a significant risk due to the vulnerability of individuals who may have limited mobility, cognitive impairments, or medical conditions. It is our duty to ensure that all reasonable steps are taken to prevent fire hazards, and that in the event of a fire, there is a safe, structured, and well-executed evacuation process.
This policy outlines how our care home:
- Implements fire prevention measures to reduce risks.
- Conducts regular fire risk assessments and safety audits.
- Provides fire safety training to all staff members.
- Ensures evacuation procedures are clear, effective, and rehearsed.
- Complies with CQC and fire safety legislation, including the Regulatory Reform (Fire Safety) Order 2005.
2. Scope
This policy applies to:
- All staff members, including management, care workers, housekeeping, and maintenance teams.
- People we support, ensuring they receive tailored support during evacuations.
- Visitors, families, and contractors, ensuring they are aware of fire safety procedures.
- Regulatory bodies, including CQC and the Fire and Rescue Service, demonstrating our commitment to compliance.
This policy covers:
- Fire prevention strategies.
- Fire risk assessments and safety checks.
- Emergency evacuation procedures.
- Training and drills.
- Roles and responsibilities in fire safety management.
3. Related Policies
This policy aligns with:
- CH11 – Safe Care and Treatment Policy, ensuring safety is a core part of care delivery.
- CH16 – Health and Safety at Work Policy, covering workplace safety standards.
- CH19 – Emergency and Business Continuity Plan, ensuring preparedness for emergencies.
- CH25 – Notification of Other Incidents Policy, outlining procedures for reporting fire-related incidents.
4. Policy Statement
We are committed to ensuring the highest levels of fire safety in our care home. We take proactive measures to prevent fires, conduct regular fire drills, and provide staff with the training they need to act quickly and safely in an emergency.
To achieve this, we ensure that:
- Fire safety measures are in place and regularly reviewed.
- Evacuation plans are clear, effective, and tailored to individual needs.
- Staff are trained to respond to fire incidents efficiently.
- Fire risk assessments are carried out and updated as needed.
- People we support, staff, and visitors are aware of fire safety protocols.
5. Implementation – How We Manage Fire Safety Efficiently
5.1 Fire Prevention Measures
Fire prevention is the first line of defence against potential fire hazards. Our care home takes the following preventative steps:
- Regular fire safety checks, including testing alarms, emergency lighting, and fire extinguishers.
- Ensuring fire doors remain unobstructed and in good working condition to prevent fire spread.
- Strict no-smoking policies, with designated smoking areas located away from the building.
- Safe storage of flammable materials, such as cleaning chemicals and oxygen supplies.
- Routine PAT (Portable Appliance Testing) for electrical equipment to prevent faults and fire risks.
- Adequate staffing levels, ensuring staff can respond quickly to fire risks.
- Clear kitchen safety protocols, reducing the risk of cooking-related fires.
We work closely with local fire authorities to ensure our fire prevention strategies remain up to date with the latest fire safety guidance.
5.2 Fire Risk Assessments
A suitable and sufficient fire risk assessment is carried out and recorded in writing by a competent person, in line with government guidance for residential care premises and the Regulatory Reform (Fire Safety) Order 2005 (as amended). The assessment is formally reviewed at least annually and sooner whenever:
- there are changes to the building structure, layout, use or occupancy (including changes to dependency levels of people we support);
- there is a significant fire-related incident, near miss, enforcement notice or new national guidance; or
- routine checks identify any significant deterioration in fire precautions (for example, fire doors, alarms or compartmentation).
The assessment specifically considers: night-time staffing, progressive horizontal evacuation options, the mobility, cognitive and sensory needs of people we support, use and storage of medical oxygen or other flammable materials, charging of mobility equipment, smoking arrangements, kitchen risks and any other identified hazards. The resulting fire risk action plan is prioritised, has clear timescales and responsible persons, and is monitored to completion through our health and safety governance processes.
5.3 Fire Safety Equipment and Maintenance
We maintain all fire safety systems so they remain effective and reliable, in line with relevant British Standards and the manufacturer’s instructions. This includes:
- Fire alarm and detection systems designed, installed and maintained in accordance with BS 5839, with weekly functional tests and periodic inspections by a competent contractor.
- Emergency escape lighting designed, tested and maintained in accordance with BS 5266 to ensure safe evacuation if normal lighting fails.
- Portable fire extinguishers selected, located and maintained in accordance with BS 5306, with annual servicing by a competent contractor and visual checks by staff.
- Any sprinkler or fixed fire suppression systems, where provided, tested and serviced at the recommended intervals.
- Fire doors and door-closing devices checked routinely to ensure they close fully, are not wedged open and provide the intended level of protection. Any damage or defects are reported and rectified without delay.
We keep clear, up-to-date records of all inspection, testing, maintenance and remedial work, and make them available to enforcing authorities (CQC, Fire and Rescue Service, local authority) on request.
Where the building meets the definition of a higher-risk building under the Building Safety Act 2022, fire safety maintenance and record-keeping also support our building safety case and any requirements placed on the accountable person(s) by the Building Safety Regulator.
5.4 Evacuation Procedures
In the event of fire, life safety is our overriding priority. Our evacuation strategy is based on the findings of the fire risk assessment and may include progressive horizontal evacuation, full evacuation or a combination of both. The strategy is clearly documented, regularly reviewed and agreed with the Fire and Rescue Service as needed.
Key principles are:
- Immediate activation of the fire alarm and prompt call to the Fire and Rescue Service (999) on discovering or suspecting a fire.
- Staff following pre-designated roles (for example, fire warden/marshal, sweepers, person in charge of roll-call, person liaising with emergency services).
- Use of progressive horizontal evacuation where people we support rely on staff assistance, moving them away from the fire into adjacent compartments or safe refuges before further movement towards final exits if needed.
- Strict control of doors (closing fire doors behind evacuees, never using lifts unless specifically designed and authorised for evacuation).
- Clear, unobstructed escape routes and well-signed, pre-agreed external assembly points where roll-call is taken and information about any missing persons is confirmed.
Each person we support has a current Personal Emergency Evacuation Plan (PEEP) or a general evacuation plan where appropriate, setting out the help they need to evacuate safely at any time of day or night. PEEPs are reviewed at least annually and earlier whenever a person’s needs or mobility change.
5.5 Fire Safety Training for Staff
All staff, including agency and temporary staff, receive fire safety training at induction and refresher training at least annually. Training is proportionate to their role and covers:
- basic fire science and common causes of fire in care homes;
- fire prevention and good housekeeping, including smoking controls, safe use of oxygen and safe charging/parking of mobility equipment;
- recognition of fire safety defects and how to report them;
- the fire alarm system, means of escape and the home’s agreed evacuation strategy (including progressive horizontal evacuation where applicable);
- how to support people with mobility, sensory or cognitive impairments, using their PEEPs;
- safe use of portable fire-fighting equipment, where appropriate; and
- their individual responsibilities in an emergency, including at night and when staffing levels are reduced.
Fire drills are held at least twice a year on each shift pattern so that all regular staff, including night staff, participate in at least one drill every 12 months. Training and drills are evaluated and recorded, and learning is fed back into risk assessments, procedures and supervision.
5.6 Reporting and Learning from Fire Incidents
All fire-related incidents, including false alarms and near misses, are reported immediately.
Report:
Verbally report the concern immediately to a staff member.
Send an email detailing the concern to the Registered Manager at: {{org_field_registered_manager_email}}.
Call the office to inform the Registered Manager at {{org_field_phone_no}}.
If the concern arises out of office hours, call the out-of-hours phone number: {{out_of_hours}}.
Website: {{org_field_website}} – using the contact form provided
The Registered Manager (or their nominee) ensures that:
- every fire-related incident (including alarm activations, unwanted fire signals, near misses and actual fires) is logged, reviewed and, where appropriate, investigated to identify root causes and learning;
- notifiable incidents are reported without delay to CQC in line with the Care Quality Commission (Registration) Regulations 2009, Regulation 18 (Notification of other incidents) – for example, where a fire, smoke or loss of essential utilities causes serious injury, death, or major disruption to the service;
- where relevant, incidents are also reported to the local Fire and Rescue Service, Health and Safety Executive (RIDDOR) and commissioners in line with legal and contractual requirements; and
- actions and learning from incidents, near misses, inspections or enforcement activity are shared with staff and built into training, supervision, audits and the fire risk assessment.
5.7 Responsible Person and Competent Persons
The Registered Provider and Registered Manager are the “responsible person(s)” for the purposes of the Regulatory Reform (Fire Safety) Order 2005 (as amended). They ensure that fire safety arrangements, including this policy and the fire risk assessment, are implemented, resourced and monitored.
Fire Safety Lead Name: {{org_field_the_fire_safety_lead_name}}
Fire Safety Lead Role: {{org_field_the_fire_safety_lead_role}}
The responsible person appoints one or more competent persons to assist in undertaking fire risk assessments, implementing preventive and protective measures and co-ordinating fire safety work. A “competent person” is someone with sufficient training, experience, knowledge and other qualities to properly carry out these duties. Where necessary, we obtain specialist external advice to ensure compliance with fire safety law and CQC requirements.
5.8 Information for People We Support, Families and Visitors
We make sure that people we support, their families and visitors receive clear, accessible information about what to do if there is a fire, the meaning of the fire alarm, escape routes and assembly points. This information is provided in formats that meet people’s communication needs (for example, easy read, large print or translated materials) and is reinforced through day-to-day conversations and reviews.
Where the Fire Safety (England) Regulations 2022 apply, we provide residents with the information required by those Regulations (for example, instructions on how to report a fire, the fire procedures and the importance of keeping fire doors closed), and we keep a record of the information given.
6. Compliance with CQC and Fire Safety Regulations
This policy supports compliance with:
- the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12 (Safe care and treatment) and Regulation 15 (Premises and equipment);
- the Care Quality Commission (Registration) Regulations 2009, including Regulation 18 (Notification of other incidents);
- the CQC Fundamental Standards and single assessment framework (particularly the Safe and Well-Led key questions and the “Safe environments” quality statement);
- the Regulatory Reform (Fire Safety) Order 2005 as amended, the Fire Safety Act 2021 and, where applicable, the Fire Safety (England) Regulations 2022; and
- relevant British Standards and national guidance for fire safety in residential care premises.
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7. Monitoring and Review
This policy is reviewed annually, or sooner if:
- Regulatory requirements change.
- A fire incident occurs, requiring updates to procedures.
- Staff or external fire safety experts identify improvement areas.
The Registered Manager is responsible for ensuring ongoing compliance and fire safety improvements.
We proactively monitor updates to CQC guidance, fire safety legislation and national best practice (for example, government and NFCC guidance on the Fire Safety (England) Regulations 2022 and residential care premises) and update this policy, the fire risk assessment and related procedures whenever there are relevant changes.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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