Scrutiny fire safety interim report 24 feb 16

Internal Affairs for

Adactus500 Scrutiny Panel

Fire Safety: Interim Report

24 February 2016

Shehnaz Akhtar Page 2

Internal Affairs for Adactus500 Scrutiny Panel

Contents Page

Project background ................................................................................................................................. 3

1. Compliance with The Regualtory Reform (Fire Safety) Order 2005 ........................................................ 3

2. Fire risk assessments .............................................................................................................................. 4

3. Fire safety measures (prevention, detection, warning and escape) ....................................................... 5

4. Arrangements for vulnerable people living in Retirement Living accommodation ................................ 8

5. Servicing of fire safety equipment .......................................................................................................... 8

6. Promoting fire safety ............................................................................................................................. 9

7. Evacuate or Stay Put? .............................................................................................................................. 9

8. Staff training ......................................................................................................................................... 10

What we liked ........................................................................................................................................ 11

What concerned us? .............................................................................................................................. 11

What we could look at next .................................................................................................................. 11

Appendix:

Staff Interviews ..................................................................................................................................... 12

Spot check – Fire Risk Register .............................................................................................................. 13

Spot check – Fire Management File ...................................................................................................... 13

Spot check – Electrical checks in voids .................................................................................................. 14

Spot check – Site Visits .......................................................................................................................... 14



Scrutiny Review: Fire Safety)

Interim Report

The Project

Business Plan Key Risk: Tenant injury or death due to a fire.

Background

This topic was first scrutinised in 2013 when several recommendations were made by the scrutiny

panel. This scrutiny is a revisit to determine if fire safety in the Group’s properties has improved.

The Lakanal House fire in July 2009 was in a high rise block of flats that caused fatalities. The

immediate aftermath was a wake-up call to social landlords about their responsibilities and

particularly about the implication for them of a major piece of legislation – the Regulatory Reform

(Fire Safety) Order 2005 (RRO) that covers general fire safety. It applies to all non-domestic

premises, including the internal communal areas of schemes, hostels, blocks of flats, houses in

multiple occupation, offices and depots.

Under the RRO, the Group has a responsibility to carry out a fire risk assessment at all premises

with an internal communal area to ensure that adequate and appropriate fire safety measures are

in place to minimise the risk of injury or loss of life in the event of a fire.

What we wanted to know

How do we ensure residents are safeguarded against the risk of injury or death due to a fire

incident?

What we looked at

• Compliance with the fire safety regulations - The Regulatory Reform (Fire Safety) Order 2005

• Arrangements for carrying out fire risk assessments

• Fire prevention, detection, warning and escape measures

• System for recording fire safety management

• Special arrangements for vulnerable people

• Servicing of fire prevention/detection equipment

• Methods of promoting fire safety to residents

• Evacuate or ‘stay put’ policy

What we found

1. Compliance with the Regulatory Reform (Fire Safety) Order 2005



• Under the Regulatory Reform (Fire Safety) Order 2005, the Group has a responsibility to carry

out a fire risk assessment (FRA) and implement and maintain a fire management plan at each

relevant property.

• To ensure compliance with the RRO the Group has in place policies and procedures for fire

safety management.

The Chief Executive is the Responsible Person for ensuring the Group complies with all fire

safety related legislation and regulatory requirements. The Asset Management department

are responsible for the day to day management of fire safety.

2. Fire Risk Assessments

a. Properties managed by the Group

• A Fire Risk Register (FRR) is maintained by the Health & Safety team. It contains details of

properties where the Group has a legal responsibility to carry out a fire risk assessment, the

assessment date, and when the next assessment is due. There are currently 370 properties

that require a fire risk assessment (including office premises and agency managed properties).

• A Fire Risk Assessment (FRA) involves visiting the relevant property to assess and check

various aspects of fire safety for example; possible sources of fire, and that escape routes are

kept clear. The results of the FRA are documented in a report and if any findings are made

they are shown as significant findings and recommendations for improvement.

• Fire risk assessments were originally carried out by an external assessor and periodically

reviewed by an inhouse Asset Management Inspector. In September 2015, the Group

tendered for a new external fire risk assessor to ensure value for money and fire risk

assessments are now completed by an independent assessor who is a fully qualified

experienced professional.

• Although there is a legal requirement for a fire risk assessment to be completed, there is no

set frequency for carrying out a review; it is at the discretion of each organisation.

• Prior to January 2016 the frequency of reassessments was determined by the risk rating of

the property and the requirements of Supporting People funding; supported housing/hostel

properties were assessed annually, medium risk properties were assessed every three years

(general needs, tower blocks, sheltered housing and agency managed), and low risk every five

years (offices and depots). This process was reviewed in January 2016 and since then

reassessments will take place every five years for offices and depots, three years for general

needs and sheltered properties, and annually for tower blocks and supported and agency

managed housing. It is anticipated that all properties that require a fire risk assessment

review will have a new one completed by the new assessor by the end of the year.

• A general review of the Fire Risk Register revealed some properties had gone past their next

assessment date. Investigation revealed the ‘fire’ component within the computer system

(which triggers the next assessment date) had been revised to correspond with the new

process. Therefore properties that previously were assessed every three years showed an

overdue assessment date as the timescale for review had been reduced to annual for

example, agency managed housing.



• The Fire Risk Register categorises properties as CAT1, CAT2, SNC, and general needs. A review

revealed that a number of supported and sheltered properties had been categorised as

general needs. Therefore according to this the next assessment date for supported properties

will follow three years from the last assessment instead of being done annually (sheltered

properties are currently done three yearly so the change in procedure does not affect the

timescale). Those that are out of date are due to the last assessment being reviewed by the

Asset Management Inspector in year three and the review date not being reflected on QL.

The Health & Safety Manager confirmed that a full audit has recently been completed to

ensure that the timescales for review were accurate.

3. Fire safety measures (prevention, detection, warning and escape)

• The Group’s properties are split into three categories:

1) Staffed – Sheltered & Supported housing, Extra Care, Hostels, and the Group’s offices.

2) General needs properties - terraced, semi-detached and detached houses, high rise

tower blocks and flats.

3) Agency managed – property owned by the Group leased to and managed by other

organisations.

How fire safety is managed depends on the type of property:

a. Staffed Properties (Sheltered & Supported housing, Hostels and Extra Care)

• The scheme co-ordinator, scheme manager or support worker is responsible for carrying out

fire safety checks at the property consisting of daily, weekly and monthly checks:

o Daily means of escape checks to ensure that all escape routes, staircases, corridors

and doorways are free from obstruction, fire signage is clearly visible, potentially

flammable substances are stored correctly, refuse is stored correctly and does not

increase the risk of arson, fire fighting equipment is correctly positioned and easily

accessible, fire evacuation procedures are current and on display for all staff and

residents to access, fire doors are in good condition, fitted with a functional door

closer and make a full seal with the frame, refuse chutes are in good condition and

make a full seal with the frame, and that fire doors can be easily opened.

o Daily inspection of the fire alarm system panel to ensure normal operation.

o Weekly test of the fire alarm system using a different call point each week in rotation

confirming audibility of the alarm and function of door release mechanisms and

smoke/heat detectors.

o Weekly inspection of fire fighting equipment, ensuring it is in proper position, has not

been discharged, lost pressure (in the case of extinguishers fitted with a pressure

indicator) or suffered obvious damage.

o Weekly inspection of emergency lighting to ensure the LED in every lamp in a

maintained system is lit and indicators of central power supply are operating

correctly.



o Monthly test of central battery systems, self contained luminaries and internally

illuminated signs to ensure functionality during a simulated failure of the supply to

the normal lighting system for a period sufficient only to ensure that each lamp is

illuminated (the period of simulated failure should not exceed one quarter of the

rated duration of the system).

• One of the recommendations made in the previous fire safety scrutiny in 2013 was that fire

safety checks be completed using an iPad. A review revealed this recommendation has been

implemented and is working well. Fire safety checks are now recorded on a portable

computer (a tablet) and saved electronically.

• A spot check of ten properties revealed that fire safety checks had been completed on a

tablet and saved electronically.

• A site visit at two sheltered schemes revealed that all actions resulting from the previous fire

risk assessment had been completed.

• A spot check revealed all corridors and escape routes were free from obstruction, the fire

doors were kept closed, the emergency lighting was working, and clear signage was displayed

on each landing.

• Evidence was seen of a colour coded PEEPS list retained in the key safe, and a copy placed by

the fire panel.

• A floor plan was displayed by the fire panel showing the colour coded zones to aid persons

not familiar with the building attending in an emergency to find their way around.

• Signage was effective although it was thought that one scheme would benefit from an

additional exit sign above one of their doors.

b. General needs (houses, bungalows, high rise tower blocks and flats)

• Mobile Caretakers are responsible for carrying out fire safety checks at properties with a

communal area. They are trained to identify any breaches in the communal areas which

would be detrimental to the fire integrity of the building:

o Fortnightly means of escape checks to ensure that all escape routes, staircases,

corridors and doorways are free from obstruction, fire signage is clearly visible,

potentially flammable substances are stored correctly, refuse is stored correctly and

does not increase the risk of arson, fire fighting equipment is correctly positioned and

easily accessible, fire evacuation procedures are current and on display for all staff and

residents to access, fire doors are in good condition, fitted with a functional door

closer and make a full seal with the frame, refuse chutes are in good condition and

make a full seal with the frame, fire doors can be easily opened.

o Fortnightly inspection of the fire alarm system panel to ensure normal operation.

o Fortnightly test of the fire alarm system using a different call point each week in

rotation, confirming audibility of the alarm and function of door release mechanisms

and smoke/heat detectors.

o Fortnightly inspection of emergency lighting to ensure the LED in every lamp in a

maintained system is lit and indicators of central power supply are operating correctly.



o Monthly test of central battery systems, self contained luminaries and internally

illuminated signs to ensure functionality during a simulated failure of the supply to the

normal lighting system for a period sufficient only to ensure that each lamp is

illuminated (the period of simulated failure should not exceed one quarter of the rated

duration of the system).

• A spot check verified that fire safety checks were being completed using a PDA (a hand-held

device) which automatically updates the checks onto the general needs Fire Management

database.

• Fire safety checks include a regular inspection to ensure communal areas and escape routes

are clear and emergency lighting, heat detectors and smoke alarms are working correctly.

• No general needs properties have fire extinguishers as residents are not trained to use the

equipment.

• In high rise tower blocks quarterly audits are completed by the Neighbourhood Services

Manager to ensure that caretakers are carrying out the appropriate checks. Evidence was

seen of completed audits.

• A spot check at two general needs properties revealed that actions arising from their fire risk

assessments had been completed.

• A spot check revealed all corridors and escape routes were free from obstruction, the fire

doors were kept closed, the emergency lighting was working, and clear signage was displayed

on each landing.

c. Agency managed

• These properties are owned by the Group but managed by other organisations.

• Adactus provides the fire detection/prevention equipment to these properties for example,

fire detectors, extinguishers, and emergency lights.

• Agency staff are responsible for carrying out fire safety checks at these properties, the checks

are the same as for staffed schemes listed above in (a).

• An annual audit is conducted by the Operations Manager (agency managed) to ensure

compliance; evidence of an audit check was seen.

• The Care Quality Commission who is the independent regulator for health and social care in

England carry out their own assessments on how these properties are being run in relation to

health and safety and also in meeting the needs of disabled residents.

• A site visit at three agency managed properties revealed that most of the recommendations

from the previous fire risk assessment had been completed. At one property access could not

be gained to the service riser cupboard therefore it was not possible to verify that the action

had been completed.

• Fire Management Files were available at all three properties checked that included a copy of

their fire risk assessment.

• The spot check revealed a number of issues at all three schemes:

Scheme 1 – the issues were:



o A fire door was found shut with two sliding bolts, a Yale lock and a thumb turn lock (a

fire exit should only have one keyless lock on it).

o One fire door did not close tight to its rebates.

o There was no evidence (in the Fire Management File) that daily checks on escape

routes or weekly emergency lights checks were being carried out. This was confirmed

by evidence seen of items retained in the corridors (step ladder and a floor board).

Scheme 2 - the issues were:

o A gas bottle was stored in a room in the basement; gas bottles should be stored

securely outside in a well ventilated area.

o A television was stored under the stairs.

Scheme 3 – the issues were:

o Storage of electric fires in the electric meter room.

o Riser cupboard doors were unlocked (a key was not available).

o The fire panel key was kept close to the fire panel and not secured in, for example, a

key safe to prevent unwanted access.

o The key for the electric meter room was hung up by the back door and we were able

to access these without the agency staff’s permission.

• On return to the office the Health & Safety Officer notified the Operations Manager (Agency)

of these issues and raised repair orders to remove the excess locks on the door, to refit the

faulty fire door so it closes properly, and for a key safe to be fitted.

4. Arrangements for vulnerable people living in Retirement Living accommodation

• Special arrangements are made for vulnerable groups of people. Residents who need support

with evacuation have a personal emergency evacuation plan (PEEP).

• Some properties have an integrated emergency alarm system that can be triggered by the

resident pulling a cord in their home or pressing a pendant that they can choose to wear. On

triggering an alarm a connection is made to Eldercare who provides a telecare service.

• If the alarm activates whilst the Scheme Co-ordinator is off site then Eldercare will be directly

notified. Eldercare identifies the nature of the emergency and makes arrangements with the

emergency services and family members to ensure that appropriate help is on its way. They

will ask a mobile warden to attend to the scheme to assist with the evacuation of the

property and ensure that the Fire Service is aware of the location of the PEEPS list. The

warden will take a register of evacuated people and advise the Fire Service of any residents

who cannot be accounted for (if applicable – some may be stay put). This service is provided

24 hours a day, seven days a week.

• In the event of an unwanted activation (for example a false alarm due to smoke), Eldercare

will inform residents on the PEEPS of this via intercom and will attend the property to

deactivate the alarm if the Scheme Co-ordinator is off site.



5. Servicing of fire safety equipment

• A regular programme of servicing is carried out on fire equipment in properties. Servicing

takes place every six months, quarterly, or annually depending on the type of equipment and

is done by a specialist fire safety consultant.

• General needs properties with a gas supply are fitted with a smoke alarm that is serviced as

part of the annual gas servicing programme. A spot check carried out in the recent gas safety

scrutiny confirmed this was being done.

• The Electric and Services Contract Manager confirmed that properties without a gas supply

are sent a letter annually advising them to check their smoke alarm. There are approximately

nine hundred properties without gas.

• Electrical checks are required in void properties to ensure the electrical installation is safe

before a tenant moves in. A spot check of five void properties let in February 2016 revealed

that electrical checks had been completed.

• Electrical checks are also carried out in common areas every 5 years and in tenanted

properties every 10 years.

6. Promoting fire safety

• All residents are given information on fire safety through various communication channels for

example, at sign-up, leaflets, inhouse magazine, and discussions of fire safety issues at

resident meetings (focus groups).

• All new tenants are provided with an information pack that contains a fire safety guide. It

provides general information on planning an escape route, what to do in the event of a fire,

how to reduce the risk of fire in the home, cooking safely in the kitchen, how to use electrical

appliances safely, and advice surrounding smoking in the home and lighting candles.

• For agency managed properties the evacuation plan is discussed with residents when they

move into the scheme.

• Residents in high rise blocks are given clear advice about what to do in the event of a fire at

induction.

• A six monthly evacuation drill is carried out at properties (excluding general needs and those

properties implementing a stay put policy) to ensure residents are aware of what to do and

where to assemble in the event of a fire.

• The fire safety guidance prohibits the use of a barbecue, chiminea, fire pit, and portable fire

for properties with balconies.

• A referral service is available where residents can ask for a home inspection by the fire service

who can fit smoke alarms, check that the property is fire safe, give advice on cooking tips and

general fire safety in the home, and help plan an escape route.

• A full page article on fire safety was featured in the winter/spring inhouse magazine 2015.

• Information on fire safety was not available on the Adactus website.

7. Evacuate or stay put?



• The current policy is to evacuate the building on sound of the fire alarm unless this has been

amended to ‘stay put’ following the advice of the new fire risk assessment that considers the

construction and design of the building, and based on this states what the appropriate fire

emergency plan is for that property; full evacuation or stay put.

• The full evacuation policy requires all residents to proceed to the assembly point when the

communal fire detection and alarm system sounds, or if a fire is discovered in the building.

• Some buildings are built in such a way as to protect people in it if a fire breaks out for

example, purpose built flats; each flat is an independent, fire-resisting compartment, within

which a fire is expected to be contained for up to 60 minutes. This facilitates a stay put policy,

in which only the occupants of the flat where there is a fire need to evacuate, while it is safe

for other residents to remain within their own flat.

• The new strategy is to fire risk assess all properties that require a fire risk assessment by the

end of 2016. Following each new assessment in general needs properties the Health & Safety

team ensures that all residents in the relevant scheme are informed of the Fire Emergency

Plan for their property (sheltered, supported and agency managed residents will be informed

via the relevant employee for example, the scheme coordinator). Evidence was seen of a copy

of a letter and Fire Emergency Plan sent to residents at one scheme.

8. Staff Training

• Fire marshal and fire management file training is provided to staff that require it as part of

their role. The aim of the training is to give staff a greater understanding of fire risks in the

property and be able to evacuate the premises effectively. Training includes identifying the

causes of fire, the correct way to tackle a fire using the fire extinguishers available, and

completing the fire management files

• Scheme Managers are trained as fire marshals and can help with evacuation in the event of a

fire.

• All staff in supported housing and some staff in sheltered housing are trained fire marshals.

• Caretakers who complete checks (and Mobile Caretakers) are also provided with fire marshal

and fire management file training.

• Adactus has recently set up e-learning (learning facilitated and supported through the use of

information and communications technology). The courses available include:

o Fire warden training

o Fire safety essentials

o Evacuation procedures



What we liked:

•••• Fire risk assessments are completed for all properties that should have one done.

•••• The new process ensures all properties that require a fire risk assessment review will have a

new one completed in 2016.

•••• Fire safety equipment is provided to properties in accordance with regulations and is

checked, serviced and maintained regularly.

•••• Emergency lighting and signage is provided, checked and serviced regularly.

•••• Ownership for completing fire safety checks is placed on scheme co-ordinators, support

workers and caretakers.

•••• Ownership for ensuring electrical inspections are undertaken and legislation and approved

codes of practice is met is placed on the Electric and Service Contracts Manager.

•••• Measures are in place to ensure vulnerable residents living in Retirement Living

accommodation who require assistance with evacuation are supported.

•••• All new tenants are provided with an information pack on fire safety.

•••• Fire safety was featured in the inhouse magazine in spring 2015.

•••• Void properties undergo an electrical check before being let.

•••• Fire marshal and fire management file training is provided to staff who require this as part

of their role.

What concerned us?

• The Fire Risk Register showed a number of properties were overdue a reassessment due to

the change in procedure.

• Fire safety advice is not available on the Adactus website.

• Daily and weekly checks not carried out at one agency managed.

• A fire door was kept shut with sliding bolts.

What we could look at next?

• Process for actioning remedial work following a fire risk assessment.

• Timescales for completing actions arising from fire risk assessment.

• Further spot checks at various types of properties.

• Case study of recent fires.



Appendix

Staff Interviews

The following interviews were carried out with staff:

Name Role Date

interviewed

Topics covered

Ruth Woodyatt Group Health & Safety

Manager

26/1/16 Fire Risk Assessments

Fire Risk Register

Fire emergency plan

Remedial work

Usha Arya Operations Manager

(sheltered and supported)

27/1/16 Fire safety management in

sheltered/supported

schemes

Raising awareness

Vulnerable people

Dean Wall Voids & Lettings Manager 1/2/16 Void properties

Fire safety information

Smoke detectors

Electric checks

Lorna

Cumberbirch

Operations Manager

(Retirement Living)

2/2/16

10/2/16

Fire safety measures in

sheltered/supported

schemes

Electronic checks register

Ron Devine Electric & Service Contract

Manager

8/2/16 Electrical checks

Servicing of equipment;

emergency lighting/exits,

hard wired smoke alarms,

Carol Hamilton Operations Manager

(Agency)

9/2/16 Agency managed properties

Fire management audits

Delroy Kerr Neighbourhood Services

Manager (Miles Platting)

10/2/16 High risk tower blocks

Fire safety management

Fire safety check audits

David Holmes Estate Services Manager 12/2/16 Fire safety checks (PDA)

Fire Management File

Jennifer Thorburn Health & Safety Officer 12/2/16

19/2/16

Electronic checks register

Fire Risk Assessments

Site Visits (audits)



1. Spot check – Fire Risk Register

What we wanted to check

We wanted to establish if the Fire Risk Register was up to date and showed the correct ‘next

assessment date’.

What we looked at

A copy of the Fire Risk Register was accessed from the database that details all the

Group’s properties that require a fire risk assessment. A general review revealed that a number of

properties appeared to be past the ‘next assessment date’. This was queried with the Health &

Safety Manager who explained that a new process for re-assessing properties was introduced in

January 2016. This change reduced the timescale for the review of FRAs for tower blocks and

agency managed properties from three years to one year therefore, many properties that were

previously on a three year cycle for review appear to be out of date, for example if the previous FRA

was completed on 1/1/2014, under the old system it would not be due for review until 1/1/2017.

Under the new system it was due 1/1/2015 and is therefore out of target. The Health and Safety

team and new fire risk assessor are working to ensure all properties have a current FRA by the end

of 2016 as per the new timescales.

What this means

All properties that require a fire risk assessment will have a new one completed by the new

independent assessor by the end of the year. On completion of the assessment the new dates will

be recorded on the Fire Risk Register that will bring it up to date.

2. Spot check – Fire Management Records


We wanted to determine if fire safety checks were completed and updated electronically.

What we looked at

A sample of ten properties were selected for testing from the Fire Risk Register including

supported, sheltered, agency managed and general needs properties. We accessed the Fire

Management records to establish if the appropriate fire safety checks were being completed by

scheme managers and mobile caretakers. All properties in the sample had a record of completed

daily escape route checks, weekly emergency lights, fire alarm point and fire door check, monthly

emergency lights and fire equipment check, and where applicable a six monthly evacuation drill.

What this means

The Fire Management File had been completed to show that checks had been carried out. Where a

problem had been identified it detailed what remedial action had been taken.



3. Spot check – Electrical check in voids


We wanted to know if electrical checks were completed in void properties before being let.

What we looked at

We ran a report that showed all new tenancy starts in a period. We selected a random sample of

five properties across different areas. We checked QL database to establish if an order had been

raised for an electrical test for each property. We checked the order number on QL to determine if

the electrical checks had been completed.

What this means

Electrical checks are being completed in void properties before they are let.

4. Spot check – Site Visits


We wanted to check that properties that are required to have a fire risk assessment (FRA) had one

and that appropriate fire safety checks were being done, and recommended actions were

complete.

What we looked at

We selected a sample of sheltered, supported, general needs, and agency managed properties from

the Fire Risk Register. We requested a copy of the fire risk assessment for each property from the

Health & Safety team. We carried out a spot check at each sample property to ensure that the

appropriate fire safety checks and recommended actions had been completed.

All of the properties sampled had a fire risk assessment completed by an independent fire risk

assessor that included a list of recommended actions. A check was carried out on the Fire

Management Files at agency managed schemes. Escape routes, fire doors, emergency lighting,

signage, and electric rooms were checked. Actions from the fire risk assessments were checked on

site to see if they had been completed.

What this means

Fire risk assessments are in place for all relevant properties. The sampled general needs and

sheltered and supported properties had no fire safety issues; an emergency plan was available on

each floor, emergency lighting was working, clear fire escape routes and ample signage. In the

retirement living properties there was also a fire zone checklist in the reception area that identifies

the zones, and a colour coded sheet to quickly identify the tenants are required stay put (PEEPs)

and in which zone.



Issues were found in agency managed properties. One property did not appear to carry out daily

escape route checks or a weekly emergency lighting check. Other issues include; a bolted fire door,

fire panel keys kept in close proximity of the fire panel, items stored under stairs, and electrical

items in the electric room.

Documents

Scrutiny fire safety interim report 24 feb 16