A warning from CQC – ensure your fire safety measures have not been compromised

25th August 2020

On 7 August 2020, CQC sent out its regular COVID-19 update email to adult social care providers. One of the topics covered in the email bulletin was ‘making sure your building is safe from fire’. The email stated that, “Due to the ongoing coronavirus risks, measures have been put in place in many care homes to help restrict contact with surfaces. For example, fire doors being held in the open position to allow for passing through without touching door handles. However, some of these measures may mean fire safety measures are compromised.” CQC’s email acts as a good reminder to providers to review fire safety measures in their services and ensure that they are not being compromised which could lead to enforcement action being taken.

In its email, CQC encouraged providers to review fire risk assessments to ensure that the following key areas are considered:

  • A review of emergency evacuation procedures, including a staff to patient ratio assessment
  • Regular fire drill and fire safety training to take account of any changes to procedures, layouts to the building or vulnerability of people using services
  • Closing fire doors when not in use, or using an approved door holding device linked to the fire alarm system if it needs to be held in an open position
  • Testing and maintenance of fire safety devices, such as fire alarms, emergency lighting and sprinklers.

What else do providers need to know about fire safety and the CQC?

The CQC takes the issue of fire safety extremely seriously, as it should do. The CQC is able to use a range of civil and criminal sanctions to prosecute providers if they are in breach of regulations. Under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the “Regulations”), providers must ensure that premises used by the provider ‘are safe to use for their intended purpose and are used in a safe way’.

The intention of Regulation 12 is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. The CQC can prosecute for a breach of Regulation 12 or a breach of part of Regulation 12 if a failure to meet the regulation results in avoidable harm to a person using the service or if a person using the service is exposed to significant risk of harm. Such matters can arise from fire safety risks if providers do not take steps to identify and minimise them.

We previously assisted a client to draft representations to a CQC Notice of Proposal (“NOP”) which sought to vary conditions to its registration. The proposed variation would have resulted in the removal of the service from the authorised locations which was essentially the equivalent of a proposal to cancel the location’s registration. One of the issues identified in the NOP was in relation to fire safety measures. The NOP stated that the provider had “not ensured the safety of service users and others in the event of an emergency evacuation of the building… because your personal emergency evacuation (PEEPs) folder was not accurate.” It also stated that the provider had ‘failed to ensure the safety of people and others in relation to fire safety procedures” because although the provider’s fire drills raised issues, the provider “had not developed an action plan from these drills to ensure actions were taken in the future to ensure fire safety.’ The CQC maintained that this was a breach of Regulation 12 of the Regulations.

In representations to the NOP, we explained that our client had taken a number of steps to improve fire safety procedures in the service. Personal Emergency Evacuation Plans (“PEEPs”) documentation had been reviewed and updated and was kept on all floors of the building as well as an individual PEEPs being kept in each service user’s bedroom. We also explained that fire drills at the service had improved, with them happening more regularly and with our client’s fire procedure being followed appropriately. We provided evidence to the CQC that staff had also received appropriate fire safety training including relevant refresher training. This helped to assure the CQC that the service was compliant with the regulations. Such action by the CQC is serious and can result in businesses being closed down and providers, and possibly individuals, being prosecuted. No harm need to have actually occurred – just the risk of it.
Practical steps providers can take to reduce risks

The fact that the CQC has specifically referred to fire safety measures in its 7 August 2020 COVID-19 update bulletin, indicates that this will likely be an area of focus during upcoming CQC inspections. It is therefore a good time for providers to review fire safety risks and take appropriate action to mitigate against the risks. Examples include reviewing individual service users’ PEEPs which set out how individuals are to be assisted to evacuate the premises in the event of an emergency. PEEPs should set out what a service user’s personal evacuation procedure involves, including any methods of assistance required such as transfer procedures and refer to any necessary equipment.

Under Regulation 15 of the Regulations, providers must ensure that premises are suitable for the purpose for which they are being used and properly maintained. Regular visual checks of the service is a good way to identify any issues. Visual checks of the building should include (but are not limited to) ensuring that fire exits are clear from obstructions, fire doors have self-closing devices and have not been propped open and also that fire signage is visible.

In the CQC’s 7 August 2020 email, the CQC referred to a ‘staff to patient ratio assessment’ as an area for providers to consider. The intention of Regulation 18 is to ensure that providers deploy enough qualified, competent and experienced staff to enable them to meet all the other regulatory requirements. The CQC will consider if staffing levels are regularly assessed to ensure they are sufficient to meet people’s individual needs. The CQC will also look at the arrangements in place for making sure that staffing levels have the right mix of skills, competencies, experience and knowledge, to meet people’s needs. If there are any service users who require 1:1 care and extra assistance from staff in the event of an emergency, the CQC will want to see that a provider has factored this into their staffing levels.

During the height of the COVID-19 pandemic it has been difficult for training to take place as normal but now that things are returning to a ‘new normal’ providers should ensure that staff are up to date with relevant fire safety training. Staff need to receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out their duties and manage fire safety issues. If staff have not received appropriate training, the CQC could rely on this to determine a breach of Regulation 18 and use it to bolster its argument that enforcement action needs to be taken against the provider.

The organisation Skills for Care, produced advice for providers on training during the pandemic stating that “training that remains a priority during this period to ensure there is a skilled and competent workforce”. Skills for Care encourages providers to use digital solutions to deliver and access training as far as is practical and if digital solutions are not practical, they encourage organisations to carry out a thorough risk assessment to ensure the safety of everyone involved.

If providers identify any issues during fire drills such as people not leaving the building in sufficient time, staff not following PEEPs appropriately or blocked fire exits, this needs to be addressed urgently.


Providers should ensure that proper risk assessments have been carried out in relation to fire safety and that they are kept under review when situations change. Providers should also ensure that individual PEEPs are regularly reviewed and updated. If the CQC carry out an inspection and want to see what systems and processes are in place for fire safety, it is important to have clear records and be able to show how risks have been identified, mitigated against and what action has been taken by a service to address risks as well as evidence to show that risks are kept under regular review. The CQC will also want to see that staff training is up to date.

If you require any assistance or advice in relation to CQC inspections that identify issues with fire safety measures, or if CQC is taking enforcement action against you using civil or criminal sanctions to prosecute, our specialist solicitors can help.