The London Fire Brigade published the findings of its in-depth inspections to ascertain the level of fire risk in care homes on 4 February 2019. 177 inspections were conducted culminating in the writing of a letter to every home demanding the urgent review of fire risk assessments, emergency plans and staff training.

Breaches identified by audit

The following are examples of breaches identified by the London Fire Brigade:

  • Inadequate or poorly maintained fire doors.
  • Widespread confusion about fire evacuation strategies. In 14% of homes there was evidence of poor planning or potential lack of staff to implement the plan.
  • Risk assessments being carried out by people who lack skill and experience – 45% were considered to be not suitable / not sufficiently comprehensive.
  • Poor staff training – some of which was on-line only.
  • Roofs being omitted from assessment. This is of particular concern in light of the incident at a Chestnut care home in 2017 in which two residents died, the voids in the roof permitting the fire to quickly engulf the building. Fire fighters found many residents in their rooms in bed and unable to move.

Fire safety risk assessments

As highlighted above, significant concern was expressed as regards the standard of fire safety risk assessments reviewed during inspection.

The following link to the national guidance in respect of Fire Safety Risk Assessment is included in the report:

In many cases the Brigade found fire risk assessments had been completed by in-house managers, many demonstrated that the assessor had a lack of understanding of basic fire safety principles. Providers may find the following link to guidance concerning the selection of competent risk assessors helpful:

For completeness, assessments completed by external assessors were also the subject of criticism in that they did not address evacuation strategy and staffing numbers in sufficient detail.

The London Fire Brigade’s Assistant Commissioner for Fire Safety, Dan Daly, has commented that ‘to make a proper fire risk assessment, you need to properly understand how fire can travel and develop, otherwise you’re just guessing your safety plan. You wouldn’t let an under-qualified surgeon operate on you, so why allow someone without the proper experience to undertake your fire risk assessment’. He fears the audit is ‘the tip of the iceberg’ and urges care homes to take note of the findings and learn lessons.

The CQC’s response

Debbie Ivanova, the Care Quality Commission’s (CQC) Deputy Chief Inspector of Adult Social Care for the London Region, has reiterated that where areas of concern are identified, these are shared with the local fire service as enforcer of fire safety and included in published reports. Noting that the findings influence ratings she adds ‘We know that good care home providers invest in proper and regular fire training for their staff, ensure that emergency plans are kept up-to-date, and carry out frequent checks of premises and equipment.’

As providers will be aware, fire safety is considered as part of the ‘Safe’ key line of enquiry. We have certainly seen a number of CQC inspection reports citing concerns regarding frequency of drills and insufficiently detailed person emergency evacuation plans.


In December 2018 Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) published a report summarising the findings of the first independent inspection of Regional Fire and Rescue Services (RFRS) in 12 years. Notably, there has been a 42% decline in fire audits undertaken in England since 2010/2011. As providers will be aware these assess compliance with the Regulatory Reform (Fire Safety) Order 2005. Providers may also be surprised to learn that 24 of 42 RFRS did not bring a single prosecution on 2017/2018 (there were 82 in total).

HM Inspector of Fire and Rescue Services, Zoe Billingham, has notes in the report’s foreword that budget reductions have fallen disproportionately in protection teams.

Dame Judith Hackitt’s Independent Review of Building Regulations and Fire Safety commissioned following the Grenfell Tower fire recommends increasing the role of the fire services in the safety of buildings. ‘Building a safer future: an implementation plan’, is a step change on the road map to delivering the recommendations and includes further consultation on a range of measures and creation of stronger and more effective enforcement and sanctions regime.

The International Fire Safety Standards Coalition (formed July 2018) may well play a role in the dialogue of reform moving forwards. There is certainly enthusiasm for further resources being made available for enforcement purposes.