Action required (Please tick) If you answered YES, record Action Points at STEP 4

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RECORD OF FIRE SAFETY RISK ASSESSMENT Building Name & Use: Address: Postcode: Name of person(s) with fire safety duties: Name and contact details of assessor: Date of Assessment: 6 th February 2011 Laurel Care Home, 87 David Street, Belfast. BT5 1XN Care Home with sleeping accommodation for up to 40 residents Mr & Mrs R Smyth Mr G Prophet, Fire Safety Advisor, 25 Toby St, Belfast, BT16 2QQ Assessor signature: STEP 1 IDENTIFY FIRE HAZARDS Refer to Part One of the relevant Fire Safety Risk Assessment guide (see list on back page) Sources of ignition, eg, electrical fittings, smoking, heating, open flames Normal range of electrical appliances for a care home environment. This includes appliances belonging to the Care Home and to the residents. Washing, drying and ironing appliances in laundry room. No evidence of misuse or wear and tear evident. A no smoking policy is in place in accordance with current legislation. A designated smoking area is provided outside for both staff and residents, although signage and disposal facilities are inadequate. Staff retain any smoking materials belonging to residents. The premises are provided with a gas-fired heating system, maintained under contract. The use of candles is prohibited but scented candles were evident in a number of rooms, a firmer control of this item will be required. Cooking facilities are the only other evidence of a naked flame. Sources of fuel, eg, furniture, textiles and fabrics If you answered, record Action Points at STEP 4 A normal provision of furniture throughout the premises which meets the required standards for the Care Home environment. Sources of oxygen, eg, ventilation If you answered, record Action Points at STEP 4 Normal ventilation through windows and doors. No residents require oxygen therapy. Risk assessment should be reviewed if oxygen is used in the premises. If you answered, record Action Points at STEP 4 1 of 14

STEP 2 IDENTIFY PEOPLE AT RISK Refer to Part One of the relevant Fire Safety Risk Assessment guide List all persons potentially at risk from fire, including employees, tenants, visitors and contractors At the time of assessment, the Care Home had 37 long stay residents with different levels of need. There are 10 members of staff during the day and 3 at night. Each resident is accommodated in a single occupancy bedroom. Most residents suffer from mental health problems and are heavily reliant on staff supervision. Residents are vulnerable to fire as a result of their age, capabilities, needs and in some cases lack of mobility. Visitors to the Care Home may be relatives, friends, professionals (e.g. Social workers, GPs, hairdressers, etc), in many cases they will have a familiarity with the building, others will not. Permanent employees are familiar with the building layout, however agency workers which are frequently used do not. Occasionally contractors will be working on the premises. At the time of assessment there were no young persons under the age of 18 years employed. If you answered, record Action Points at STEP 4 STEP 3 EVALUATE, REMOVE, REDUCE AND PROTECT FROM RISK Refer to Part One of the relevant Fire Safety Risk Assessment guide Likelihood of a fire starting The likelihood for a fire starting is normal for this type of occupancy, considering the fuel load, ignition sources and people present. The potential for deliberate fire setting is increased as external waste containers, although sited well away from the main building, were found to be overflowing at time of assessment and were not fitted with a suitable lid or cover. If you answered, record Action Points at STEP 4 Evaluate the risk to people Due to the dependency of residents and the assessment of existing fire safety standards measures, any incidence of fire would put residents at significant risk, particularly at night when staffing levels are reduced. The controlled efficient evacuation of elderly, confused, disabled or slow moving residents, particularly with limited numbers of staff, many of whom have never received sufficient training on fire evacuation procedures, would prove difficult to implement. Any failure by staff to implement the correct emergency procedures and in particular the appropriate horizontal phased evacuation strategy, could have major detrimental repercussions for all concerned. If you answered, record Action Points at STEP 4 2 of 14

STEP 4 RECORD, PLAN, INFORM, INSTRUCT AND TRAIN Refer to Part One of the relevant Fire Safety Risk Assessment guide Fire Safety policy (further guidance on Fire Safety Policy in Part Two of guide) A fire safety policy has been established, however employees were unclear what the policy entailed and who had overall responsibility at management level for dealing with fire issues. Emergency fire action plan If you answered, record Action Points at STEP 4 An emergency fire action plan, identifying a phased horizontal evacuation strategy was generally adequate, however: The plan/procedures were not regularly tested and some staff had never participated in a fire drill. No fire drill has ever been undertaken to confirm that the emergency plan/procedures could be successfully implemented during periods of minimum personnel levels and highest risk i.e. overnight periods. Agency staff have not been advised of the fire emergency plan and procedures. Some employees were unaware of their specific roles/duties in relation to fire. Fire safety information and training If you answered, record Action Points at STEP 4 Some deficiencies in staff training were evident in respect of: Use of fire extinguishers. Emergency procedure for fire drills. Some staff, especially agency staff, unaware of the reason for and use of manual overrides (green boxes) on doors fitted with electronic operated locks. A number of Fire Action Notices missing from staff areas. If you answered, record Action Points at STEP 4 3 of 14

STEP 4 RECORD, PLAN, INFORM, INSTRUCT AND TRAIN (continued) Refer to Part One of the relevant Fire Safety Risk Assessment guide Fire drills No fire drills take place. If you answered, record Action Points at STEP 4 Maintenance of safety measures (For further guidance see Appendix A of relevant Risk Assessment guide) The fire alarm was being tested, however, it was being done sporadically rather than on a weekly basis. The emergency lighting was not being tested. First aid fire fighting equipment had not been maintained within the previous 12 month period. Recording information and keeping records If you answered, record Action Points at STEP 4 No suitable records of maintenance and testing of fire safety measures were kept on the premises. If you answered, record Action Points at STEP 4 4 of 14

FURTHER DETAILS ON FIRE RISKS AND PREVENTATIVE MEASURES Refer to Part Two, Section One of the relevant Fire Risk Assessment guide Housekeeping and Storage- Materials and Substances Generally reasonable standard maintained, however at time of inspection it was noted that several bags of bedding were left on landings inside fire escape staircases, this had been following a bed change a number of hours earlier. Office areas generally tidy, however waste bins were quite full of combustible waste. The roof space was partially floored and being used for the mixed storage of residents personal items in cardboard boxes, consumable stock including large quantities of absorbent pads, aerosol sprays and cleaning materials, some of which are combustible or flammable and would contribute to fire spread. Some boxes and their contents had fallen over. Equipment, Machinery and Electrical If you answered, record Action Points at STEP 4 In the laundry room on ground floor, evidence that dryer filters not being cleaned regularly. Some combustible items being stored in electrical switch room. There was evidence of inadequate cleaning of extraction equipment in kitchen, obvious build up of grease and fat deposits. Hazards in Escape routes If you answered, record Action Points at STEP 4 Upholstered furniture located in fire escape staircase at reception area. Fire exit door at first floor level only capable of being unlocked by a key. Some fire doors are being wedged open. If you answered, record Action Points at STEP 4 5 of 14

FURTHER DETAILS ON FIRE RISKS AND PREVENTATIVE MEASURES Refer to Part Two, Section One of the relevant Fire Risk Assessment guide Restricting the spread of fire and smoke The premises are compartmented with fire resisting construction to staircases, bedrooms and corridor escape routes. Premises are generally satisfactory although it was noted, following recent refurbishment works, that holes for the passage of cables and pipe work through fire resisting walls and other protected routes serving bedrooms had not been fire stopped. The building is constructed in accordance with current building standards and is considered satisfactory and it is therefore assumed cavity barriers have been fitted. The internal surface finishes are emulsion paint to walls, however polystyrene tiles were noted on ceiling of upper corridor fire escape route. Deliberate fire setting If you answered, record Action Points at STEP 4 A timber hut sited close to external wall gives the potential for fire spread to the main building through a window. If you answered, record Action Points at STEP 4 FURTHER DETAILS ON FIRE DETECTION AND WARNING SYSTEMS Refer to Part Two, Section Two of the relevant Fire Risk Assessment guide System type There is an electrical fire warning system. Manual call points are sited next to exit doors. The system incorporates automatic fire detectors, smoke detectors in circulation areas and heat detectors in the bedrooms. There is no detection in roof space area. If you answered, record Action Points at STEP 4 6 of 14

FURTHER DETAILS ON FIRE FIGHTING EQUIPMENT AND FACILITIES Refer to Part Two, Section Three of the relevant Fire Risk Assessment guide Fire Fighting equipment for use by persons There is an adequate number and range of fire extinguishers for the occupancy type. Some of the extinguishers require to be wall mounted or placed on purpose designed stands. Consider training some staff to fire warden standard. If you answered, record Action Points at STEP 4 FURTHER DETAILS ON MEANS OF ESCAPE Refer to Part Two, Section Four of the relevant Fire Risk Assessment guide Escape routes There is adequate provision of fire doors throughout the building. The number and location of fire exits is also sufficient. No travel distances exceed the required guidelines. In general escape routes are kept clear and free from obstruction. If you answered, record Action Points at STEP 4 7 of 14

FURTHER DETAILS ON EMERGENCY ESCAPE PLAN Refer to Part Two, Section Five of the relevant Fire Risk Assessment guide Escape route lighting The normal lighting and emergency lighting is satisfactory. Testing and maintenance is required. If you answered, record Action Points at STEP 4 FURTHER DETAILS ON SIGNS AND TICES Refer to Part Two, Section Six of the relevant Fire Risk Assessment guide Signs and notices Some escape routes are not clearly indicated. During the assessment it was evident of the need for some fire exit directional signage. If you answered, record Action Points at STEP 4 8 of 14

FURTHER DETAILS ON RECORDING, PLANNING, INFORMING, INSTRUCTIONS AND TRAINING Refer to Part Two, Section Seven of the relevant Fire Risk Assessment guide No fire evacuation procedures were available to both visitors and contractors. No procedures in place for the periodic checking and reporting of defects in relation to escape routes, extinguishers, fire doors, etc. Keep records of any false alarms in log book. Have any relevant documentation available for inspection by enforcing authority. If you answered, record Action Points at STEP 4 9 of 14

The assessor completing the following section should prioritise remedial measures, based on the level of risk. Priority ratings and suggested timescales: Low (L) 3 6 months Medium (M) Up to 3 months (H) As soon as possible STEP 4 ACTION POINTS Priority Person responsible Completion date Provide No Smoking signs. Review fire exit directional signage. Fire Action notice signage required. Notify all staff that candles are prohibited in residents rooms. Establish a routine for cleaning filters from tumble dryer and cooking extraction equipment. Mrs Smyth Remove polystyrene tiles and replace with suitable wall covering or painted finish. Medium May 2011 Survey premises and surrounding grounds and implement any measures to reduce likelihood of deliberate fire setting. Medium May 2011 External waste containers to have suitable lids and consider waste reduction. Low Aug 2011 Review fire safety policy. Inform employees of all relevant aspects of the policy. Identify person with overall management responsibility for fire issues. Mrs Smyth Note: Please print additional sheet if required 10 of 14

The assessor completing the following section should prioritise remedial measures, based on the level of risk. Priority ratings and suggested timescales: Low (L) 3 6 months Medium (M) Up to 3 months (H) As soon as possible STEP 4 ACTION POINTS Priority Person responsible Completion date Review staff training & inform staff of fire action plan. Confirm the suitability by implementing fire drills at times of low staffing levels to test roles & responsibilities. Mrs Smyth Prohibit the use of wedges to hold doors designed to be self closing and fire resisting. If necessary consider use of approved hold open devices. Ensure appropriate employees are trained in the use of fire extinguishers. Medium May 2011 Inform staff on the use of manual overrides for locks on doors. Change locking mechanism on 1 st floor fire exit door. Agency staff to be given sufficient level of training on induction. Fire safety brief to be made available to both visitors and contractors, held at reception. Mrs Smyth A suitable programme of testing and maintenance in respect to fire safety measures should be implemented. Information to be kept in Fire Safety Log book. Note: Please print additional sheet if required 11 of 14

The assessor completing the following section should prioritise remedial measures, based on the level of risk. Priority ratings and suggested timescales: Low (L) 3 6 months Medium (M) Up to 3 months (H) As soon as possible STEP 4 ACTION POINTS Priority Person responsible Completion date Inform staff that laundry bags on fire escape stairways should be removed as soon as possible. Waste bins to be emptied once a day. Mrs Smyth Remove storage from roof space area or consider construction of suitable fire rated storage area. Remove storage from electrical switch room. Infill all openings in fire resistant walls with suitable fire resistant material. Provide smoke detection to roof space. Medium May 2011 Re-site timber hut at least 3 metres from building. Remove upholstered furniture from reception fire exit staircase. Medium May 2011 Mount fire extinguishers on walls or provide suitable stands. Low Aug 2011 Consider training member of staff to Fire Warden standard. Note: Please print additional sheet if required 12 of 14

Review the fire risk assessment if there is a reason to suspect it is no longer valid or if there has been a significant change in the matters to which it relates Reference Part One of the relevant sector specific, fire safety risk assessment guide STEP 5 ASSESSMENT REVIEW Review date February 2012 Review by Reason for review: Annual review. Outcomes of review 13 of 14

FIRE SAFETY RISK ASSESSMENT GUIDES The following premises guides are available from Northern Ireland Fire & Rescue website www.nifrs.org. Follow the Make sure you re Fire Safe link and go to Guidance Documents. These can be downloaded from the Communities and Local Government section. 1 Offices and Shops; 2 Factories and Warehouses; 3 Sleeping Accommodation; 4 Residential Care Premises; 5 Educational Premises; 6 Small and Medium Places of Assembly; 7 Large Places of Assembly; 8 Theatres, Cinemas and Similar Premises; 9 Open Air Events and Venues; 10 Healthcare Premises; 11 Transport Premises and Facilities; 12 Animal Premises and Stables; 13 Means of Escape for Disabled People (Supplementary Code); and 14 Reducing the Number of False Alarms from Detection and Alarm Systems. Adapted from original materials created by the Scottish Centre for Healthy Working Lives and the Scottish Fire and Rescue Services 14 of 14