The LFB plans to conduct a regulatory audit of the premises, issue a clarification of LFB policy on vetting of fire safety audits, conduct a full review of training material for vulnerable sleeping risk premises and develop refreshed CPD, apply the new national scheme for third-party accreditation of fire safety inspecting officers, review guidance on portable electric fan heaters, highlight the issue to housing providers, and continue to press for guidance on fitting of digital keypads. (AI summary)
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REGULATION 28 PREVENTION OF FUTURE DEATH REPORT (1) REF: 108578 I am writing in response to your report dated 26 April 2022 (under the above reference) concerning the death of Ashlie Clare Liana TIMMS, which was initially sent to Deputy Assistant Commissioner Stephen Norman who gave evidence into the inquest. In your report you noted six areas of concern which were:
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm.
2. Fire alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters.
5. No clear guidance exists regarding the fitting of digital keypads on doors in specialist housing.
6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. It may be helpful to note at the outset, that for matters of concern numbered 4, 5 and 6, the Secretary of State for the Home Office is under a statutory duty in Article 50 of the Regulatory Reform (Fire Safety) Order 2005 (the FSO) to “…ensure that such guidance as he considers appropriate, is available to assist responsible persons in the discharge of their duties…”. Insofar as the matters of concern relate to parts of premises to which the FSO applies, it may be appropriate for these concerns to be drawn to the attention of Home Office ministers. My understanding is that the Home Office are currently engaged in a programme of refreshing national fire safety guidance documents that are used by both responsible persons and the authorities enforcing it. Similarly, the Secretary of State for the Department for Levelling Up, Housing and Communities has responsibility for the Housing, Health and Safety Rating System enforced by local authorities and which is applicable to the private domestic areas of many residential properties (where the FSO does The London Fire Commissioner is the fire and rescue authority for London
Date: 20 June 2022
not apply). The Secretary of State has a duty to provide guidance on the assessment of hazards and enforcement against them in section 9 of the Housing Act 2004 and also provides other guidance for landlords and property-related professionals. There is a need for all guidance on these matters to be co-ordinated, clear and readily available across all reasonable sources. Consequently, I would suggest that your concerns in this regard are also raised directly with the relevant Secretaries of State. I have addressed each of the matters of concern below:
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm. This raises a concern that premises management is not compliant with duties under the FSO, in particular the duty in Article 15 concerning appropriate procedures to be followed in the event of serious and imminent danger to relevant persons. The FSO is a self-compliance regime with the duty for compliance placed firmly with the responsible person. As the London Fire Commissioner, I have a duty to enforce those regulations. In enforcing the FSO my officers must act in accordance with the requirements of the statutory Regulators Code. LFB Fire Safety Inspecting Officers plan to attend the premises shortly after the end of the 56 day reply period to conduct a regulatory audit under the FSO. This will consider whether there is compliance with the FSO including Article 15.
2. Fire alarms in three units operated by Sequence Care Group remain non-compliant with the 2013 British Standard guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated. Regulators cannot directly enforce the recommendations of a British Standard unless it is cited as a required standard in relevant legislation or unless the arrangements actually in place can be shown to create a “risk gap” from the level expected by that standard. I understand the suggestion here was that the alarm did not include a link to an ARC because the premises had 24/7 staffing in place. LFB might consider this to be non-compliance with Article 13 of the FSO, although this would have to be considered in the light of the circumstances of an individual premises including the arrangements for staff training and testing of the arrangement. It would then be raised with the responsible person as part of any follow up to the regulatory audit. Making the recommendations of at least some British Standards directly enforceable is a matter that has been raised by other Coroners through regulation 28 reports with the relevant Secretaries of State, with support of the fire service. I would urge you to join them in to doing so.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete. I would firstly refer you to the statement of DAC dated 8 April 2022 and his live evidence to the inquest on 11 April 2022. In the year before the death of Ashleigh Timms, LFB had changed its policy on the vetting/review of fire safety regulatory audits by managers so as to include all audits of sleeping and vulnerable
sleeping accommodation regardless of the audit outcome. We have now undertaken a review of that element of policy and concluded that due to the ordering of paragraphs in the policy document a potential degree of ambiguity may have remained. That drafting has been addressed to place the matter beyond doubt and this has been promulgated to all staff working in the technical fire safety function. We have also amended our audit form to ensure improved justifications are stated for the overall scoring of an audit and for each article. This should better ensure there are records setting out exactly why the FSIO has deemed it to have been or complied with (or not). Over the course of the past two years LFB’s Central Regulatory Enforcement Group have been conducting bespoke training for regulatory fire safety team leaders on the management vetting of their team’s audit forms and Enforcement Notices to increase team leaders’ knowledge and skills. LFB has now brought in additional resources to assist with that and develop and roll out a new training package for all staff involved in the management vetting process. We expect to complete this over the course of the next six to twelve months. Deputy Assistant Commissioner Steve Norman drew your attention to work undertaken to educate staff on the risk arising in specialised housing and to our work running a series of external seminars for the managers of care homes. LFB’s Fire Prevention and Protection Department (P&P) are currently developing a new training needs analysis for LFB’s inspecting officers. Over the next six months P&P will conduct a full review of the training and continuous professional development (CPD) material used for all forms of vulnerable sleeping risk premises including care homes, extra care schemes and sheltered housing and supported living schemes. From this, over the next twelve months we will develop and roll out refreshed CPD covering the specific risks arising for these premises types. That CPD will be mandatory for all staff involved in the audit of these premises types and will form part of mandatory refresher training through our Development and Maintenance of Operational Professionalism (DaMOP) framework. LFB is also committed to applying the new national scheme of third-party accreditation of the competency of fire safety inspecting officers whose work involves the audit or provision of advice to higher risk premises. All such staff have achieved or are working towards an NVQ level 4 Diploma qualification after which they will be assessed though a new scheme operated by the Institution of Fire Engineers in conjunction with the Engineering Council. Achieving this level of accreditation for all Fire Safety Inspectors will take some time, potentially four to five years as there is currently a lack of approved assessors across the country. We expect the first tranche of Inspectors to be assessed over the coming 18 months.
4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters.
Although there is some guidance contained in government approved and National Fire Chief Council guidance, we believe this is a matter that should be expanded on as part of the Government review of guidance to the public.
From the London Fire Brigade perspective, use of portable heaters forms part of the considerations under our home fire safety visits and the guidance documents we issue for fire safety in the home for example https://www.london-fire.gov.uk/safety/the-home/portable-heaters-gas-fires-and-open- fires/
We are currently reviewing our own guidance and I have instructed staff to include this issue in that review over the course of 2022.
We also operate a number of primary authority partnerships with housing providers and work with the G15 group of providers. Now that the inquest findings are available officers will highlight the issue to those we work with. However, you will recognise that under existing terms of lease or tenancy, the options for them to act in relation to their tenants may be limited and it is not something that my officers have a power to enforce.
5. No clear guidance exists regarding the fitting of digital keypads on doors in specialist housing.
Although there is some guidance contained in government approved and National Fire Chief Council guidance, I believe this is a matter that should be expanded on as part of the Government review of guidance to the public. However, the forms of locking devices used on the exit from a flat as a private dwelling is not something that falls to be regulated under the FSO. Therefore, LFB officers cannot enforce against it. This issue does arise from time to time in material and guidance produced in respect of ‘secure by design’. We will continue to press for guidance in that regard which does not adversely, or potentially adversely, inhibit escape from domestic premises in case of a fire emergency.
6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. The ethos of the FSO is one of risk-based fire safety preventative and protective measures. Under Government guidance that does mean that it is not a prescriptive regime. Alternative means can be used to demonstrate compliance rather than adherence to a British Standard. As an enforcing authority we use British Standards as the benchmarks of good practice. However, we cannot necessarily enforce them unless a demonstrable risk arises from failing to comply with them. If that were to be the case, then we can and will continue to direct that the appropriate British Standard is followed. However, that cannot be done if alternative means to the recommendations of the British Standard (or other guidance) have been used and are found, on the day of inspection, to apparently be providing an equivalent level of safety. In the latter circumstances an enforceable level of risk would not have been identified and so a direction could not be given under article 30 of the RRFSO. The issue appears to be a lack of a direct enforcement mechanism for British Standards. That is a matter my officers have previously raised through the coronial system and with government. If a specific requirement is to be enforceable it will require legislative change. We will continue to advocate for this in appropriate cases as part of our ongoing work with government, other regulators and the sector itself. To summarise, along with the action already taken, LFB intends the following further actions:
1. Officers plan to attend the premises shortly after the end of the 56 day reply period to conduct a regulatory audit under the FSO.
2. A clarification of LFB policy expanding the requirement for vetting/review of fire safety regulatory audits by managers is to be issued to officers in the next few weeks.
3. Over the coming six months LFB will conduct a full review of the training and continuous professional development material used for all forms of vulnerable sleeping risk premises
including care homes, extra care schemes and sheltered housing and supported living schemes.
4. From this work in point 3, over the course of the next twelve months LFB will develop and roll out refreshed CPD covering the specific risks arising for these premises types.
5. LFB is committed to applying the new national scheme of third-party accreditation of the competency of fire safety inspecting officers whose work involves the audit or provision of advice to higher risk premises. We expect the first tranche of Inspectors to be subject to assessment over the coming 18 months.
6. Over the course of 2022 we will review our own guidance offering concerning portable electric fan heaters in premises such as these.
7. We operate a number of primary authority partnerships with housing providers and work with the G15 group of providers. LFB officers will highlight the issue of the use of high-risk electrical devices such as portable electric fan heaters to those providers we work with.
8. We will continue to press for guidance on fitting of digital keypads on doors in specialist housing that will not adversely, or potentially adversely, inhibit escape from domestic premises in case of a fire emergency. I hope that this satisfactorily explains the actions that have been taken and those which we will continue to take to address the concerns raised in your letter.