Fire safety policy (Fire Safety Order 2005)

1. What the regulation says

the person who has control of the premises (as occupier or otherwise) in connection with the carrying on by him of a trade, business or other undertaking.

The responsible person must (a) take such general fire precautions as will ensure, so far as is reasonably practicable, the safety of any of his employees; and (b) in relation to relevant persons who are not his employees, take such general fire precautions as may reasonably be required in the circumstances of the case to ensure that the premises are safe.

The responsible person must make a suitable and sufficient assessment of the risks to which relevant persons are exposed for the purpose of identifying the general fire precautions he needs to take to comply with the requirements and prohibitions imposed on him by or under this Order.

Any assessment made under paragraph (1) must be reviewed by the responsible person regularly so as to keep it up to date and particularly if (a) there is reason to suspect that it is no longer valid; or (b) there has been a significant change in the matters to which it relates including when the premises, special, technical and organisational measures, or organisation of the work undergo significant changes, extensions, or conversions.

As soon as practicable after the assessment is made or reviewed, the responsible person must make a record of the assessment or review, which must in particular include the information prescribed by paragraph (7).

The full text of the Order is at https://www.legislation.gov.uk/uksi/2005/1541/contents. Where this policy and the Order diverge, the Order wins.

2. Plain British summary

The Regulatory Reform (Fire Safety) Order 2005 places fire safety duties on the Responsible Person for any non-domestic premises in England and Wales. For most ISC providers, the Responsible Person is the employer where the premises are under their control. The load-bearing duties are: take such general fire precautions as will ensure the safety of employees and other relevant persons (Article 8); conduct a suitable and sufficient Fire Risk Assessment to identify those precautions (Article 9); record the FRA and review it regularly, particularly when there is reason to suspect it is no longer valid or when there has been a significant change in the premises, fire safety measures, or work organisation (Article 9(3) and 9(6)); plan and implement fire safety arrangements proportionate to the assessed risks (Article 11); and ensure staff receive adequate fire safety training (Article 21). In healthcare premises, an additional operational concern is the choice between simultaneous-evacuation and progressive-horizontal (stay-put-and-relocate) strategies; the choice depends on the premises' compartmentation, building design, and patient population, and is a matter for the FRA to address.

3. Scope

This policy applies to all employees, contractors, agency workers, and visitors at every premises under the control of . It covers every clinical and non-clinical area, every shared building service (electrical, gas, kitchen, laundry, plant rooms), every fire-detection and fire-suppression system installed, every emergency exit and escape route, and every evacuation arrangement (simultaneous, progressive horizontal, stay-put) the Fire Risk Assessment specifies.

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

• Registered Manager / Responsible Person: the "responsible person" under the Order for the premises (where the employer has control). Accountable for the Fire Risk Assessment, the fire safety arrangements, fire safety training, and the testing-and-maintenance cycle.
• Nominated Individual: holds provider-side accountability for the Order across all premises.
• Fire Safety Lead (named individual; in small services often the Registered Manager): the day-to-day fire-safety authority. Coordinates the FRA review cycle, the testing-and-maintenance schedule, the evacuation drill programme, and the escape-route inspections.
• Fire Wardens (named individuals per premises; in small services the role rotates among trained staff): the on-the-day evacuation leaders. Sweep designated zones during an alarm; account for service users, visitors, and staff at the assembly point; brief the Fire and Rescue Service on arrival.
• All staff: know the evacuation procedure for their work area, recognise the alarm sound, complete fire safety training, do not block escape routes or wedge fire doors.

(Tenant updates the named role-holders.)

5. Procedure

The Fire Safety Order procedure operationalises the Responsible Person duties under Articles 8 through 22.

1. Fire Risk Assessment. A suitable and sufficient FRA is in place for every premises. The FRA is produced or reviewed by a competent fire risk assessor (an external specialist or a trained internal assessor with relevant qualification). The FRA identifies hazards, who is at risk, the existing fire safety arrangements, and the additional precautions needed.
2. FRA review cycle. The FRA is reviewed regularly per Article 9(3); the cycle is annually as a minimum, immediately on any significant change to the premises, the work, or the population at risk. The reviewed FRA is dated, the reviewer is named, and the document is held with the premises records.
3. Evacuation strategy. The FRA specifies the evacuation strategy for each premises: simultaneous (everyone out at the alarm), progressive horizontal (move to an adjacent fire compartment then onward as required), or stay-put-and-relocate (refuge points used). For healthcare premises with patients who cannot be quickly evacuated, the strategy depends on building compartmentation and patient population; this is a clinical-and-fire judgement to be made in the FRA.
4. Fire safety arrangements. Arrangements are planned and implemented per Article 11 proportionate to the FRA's risks: fire-detection and alarm systems, escape lighting, signage, emergency exit doors, fire doors (kept closed unless held open by linked devices), portable fire extinguishers, automatic fire-suppression where the FRA requires.
5. Testing and maintenance. Fire-detection systems are tested weekly (call-point activation rotation) and serviced annually by a competent contractor (BS 5839). Escape lighting is tested monthly and serviced annually (BS 5266). Fire extinguishers are inspected monthly by the Fire Safety Lead and serviced annually by a competent contractor. Fire doors are inspected monthly. The maintenance schedule is held in the premises maintenance register.
6. Evacuation drills. Each premises holds a documented evacuation drill at least annually (more often for premises with sleeping accommodation). The drill is observed by the Fire Safety Lead, the time-to-clear is recorded, any failures are captured as improvement actions.
7. Personal Emergency Evacuation Plans (PEEPs). Where any individual service user, employee, or regular visitor has a disability or condition that means the standard evacuation procedure does not work for them, a PEEP is produced and recorded against that person. PEEPs are reviewed annually and on any change of circumstance.
8. Training. All staff receive fire safety training as detailed in Section 6. Fire wardens receive additional training. New staff complete fire safety training as part of induction before unsupervised work begins.
9. Incident reporting. Any actual fire incident, false alarm, or fire-safety near miss is logged in the platform's incident reporting register. Fire incidents resulting in death or serious injury also meet RIDDOR and CQC Reg 18 (Registration Regulations 2009) thresholds.
10. Liaison with the Fire and Rescue Service. The Responsible Person cooperates with the local Fire and Rescue Service. Any FRS audit visit is recorded with the date, the officer, the findings, and any enforcement notice. Enforcement notices are addressed within the timescales they specify.

6. Training requirement

• All staff complete basic fire safety awareness training at induction (before unsupervised work begins) and annually.
• Fire wardens complete fire warden training at appointment and refresher every two years.
• The Fire Safety Lead completes role-specific training at appointment and refresher every two years.
• The competent fire risk assessor (if internal) holds a recognised fire safety qualification and refreshes per the qualification's CPD requirements.

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the Fire Safety Lead:

• Weekly fire-detection test: rotating call-point activation; result recorded.
• Monthly inspection round: escape lighting, fire doors, portable extinguishers, signage, escape routes (kept clear), fire-door closers, refuge points; result recorded.
• Annual servicing: fire-detection system, escape lighting, fire extinguishers, by competent contractors; certificates filed with the premises records.
• Annual evacuation drill: observed, timed, learning captured.
• Annual FRA review: the FRA itself reviewed; any significant change triggers an interim review.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Fire safety records (the current FRA, every previous FRA version, weekly and monthly inspection logs, annual servicing certificates, evacuation drill records, PEEPs, training records, incident records, FRS correspondence) are held for a minimum of 6 years from the date of the record. The FRA itself is retained for the duration the premises is under the Responsible Person's control plus 6 years after that, in case enforcement action references a past assessment. PEEPs are retained for the duration of the person's engagement with the service plus the standard retention period.

Insurance and litigation considerations may extend the retention period; some providers retain fire records for 12 years aligned to the limitation period for personal-injury claims arising from premises.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

• Premises and Equipment Policy (hscra-reg-15-premises-and-equipment)
• Health and Safety Reporting (RIDDOR) Policy (riddor-health-and-safety-reporting)
• Safe Care and Treatment Policy (hscra-reg-12-safe-care-and-treatment)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.