ESSEX COUNTY
FIRE & RESCUE SERVICE
Fire Safety Policy Directive
REGULATORY REFORM (FIRE SAFETY) ORDER 2005
AUDIT PROCEDURES
1
Approval
Prepared and
Approved By:
Signature:
Date:
Reviewed By:
Signature:
Date:
2
Abstract:
Information and guidance for inspectors on The Regulatory Reform (Fire Safety) Order
2005 and the associated procedures.
Contents:
Part 1: Regulatory Reform (Fire Safety Order) 2005 Procedures
3
Part 2: The Workplace Fire Safety Audit
8
Part 3: Fire Safety Audit and Data Gathering Form Guidance Note
13
Part 4: Enforcement Verification Using the Enforcement Management Model
16
Part 5: Tables Flowcharts and Guidance Notes
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PART 1 - REGULATORY REFORM (FIRE SAFETY) ORDER 2005 PROCEDURES
1.
2.
INTRODUCTION
1.1
The Regulatory Reform (Fire Safety) Order 2005 “The Order” introduced in 2006
replaces the two major pieces of fire safety legislation, the Fire Precautions Act 1971
and the Fire Precautions (Workplace) Regulations 1997 as amended. The Order also
consolidates the fire safety provisions of other legislation under one simplified set of
goal based requirements.
1.2
The Order builds on the 1997 Regulations in that it applies not only to persons at work
but to all persons lawfully on the premises and those not on the premises but in its
vicinity who may be affected by a fire on the premises. As with the 1997 Regulations,
risk assessment is used as the basis for compliance and the responsible person, in the
circumstances defined by the Order, is held liable in the case of any breach.
1.3
The Order applies to all premises except those listed in Part 1 Article 6(1) (a)-(g) 6(2).
1.4
The Fire and Rescue Authority has responsibility for the enforcement of the provisions
of “The Order” in premises within its area subject to the exceptions detailed in Article
25(b)-(e) using inspectors appointed under Article 26(1).
DEFINITIONS
The main definitions used in this directive are listed below, the full list can be found by
referring to Part 1 Article 2 of The Order.
2.1
“relevant person” means;
(a)
any person (including any responsible person) who is or may be lawfully on the
premises. And
(b)
persons in the immediate vicinity of the premises who are at risk from a fire on
the premises.
But does not include a fire fighter carrying out his/her duties in relation to the functions
of a fire and rescue authority insofar as they relate to fire-fighting, road traffic accidents
and other emergencies.
2.2
2.3
“premises” includes any place and, in particular includes;
(a)
any workplace;
(b)
any vehicle, vessel, aircraft or hovercraft
(c)
any installation on land (including the foreshore and other land intermittently
covered by water), and any other installation (whether floating, or resting on the
seabed or the subsoil thereof, or resting on other land covered with water or
the subsoil thereof); and(d) any tent or movable structure.
Responsible Person
The process of enforcement can only be taken forward by dealing with the responsible
person and in this respect “responsible person” means;
(a)
in relation to a workplace the employer, if the workplace is to any extent under
his/her control;
(b)
in relation to any premises other than a workplace
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(i)
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 (for profit or not); or
(ii)
the owner, where the person in control of the premises does not have control in
connection with the carrying on by that person of a trade, business or other
undertaking.
Inspectors will need to use their powers to identify the responsible person(s) in respect
of premises. In premises constituting a workplace, this would normally be the
employer, but enquiries about responsibility can be made of the following:
(a)
The employer,
(b)
The general manager,
(c)
The health and safety manager,
(d)
A nominated agent of the employer or other person having control,
(e)
The owner in respect of matters outside the employer’s control.
Note: Those individuals at (b), (c) and (d) should only be dealt with in the absence of the employer,
and where responsibility for fire safety forms part of their contractual duties. The owner in (e)
can be dealt with once it is established that certain parts of the workplace (generally common
parts) are outside the employer’s control.
3.
2.4
In the case of premises in multiple occupation, the employer is under an obligation to
comply with the Order, insofar as his/her control extends. Where a person other than
the employer exercises control (such as in the common parts of multi-occupied
premises) legal responsibility rests on such persons. The inspector must use his/her
powers under the Order to ascertain control, and therefore an obligation to comply with
the Order. In some cases an informal approach to the employer may prove to be the
most appropriate. However, where there is no transparency, investigation may require
the examination of documents, such as leases and contracts under the powers in
Article 27.
2.5
“workplace” means any premises or part of premises, not being domestic premises,
used for the purposes of an employer’s undertaking and which are made available to
an employee of the employer as a place of work and includes;
(a)
any place within the premises to which such employee has access while at
work, and
(b)
any room, lobby, corridor, staircase, road, or other place;
(i)
used as a means of access to or exit from that place of work; or
(ii)
where facilities are provided for use in connection with that place of work, other
than a public road.
RISK BASED INSPECTION PROGRAMME
3.1
The development and management of a Risk Based Inspection Programme will
provide important data to assist in the development and evaluation of the Service’s
Integrated Risk Management Plan (IRMP). This will enable The Service to fulfil its
duty to manage the fire risk in the community.
3.2
The final decision on the level of enforcement to be taken following an inspection and
assessment of risk in any premises will embody the principles, expectations and
methodology of the Enforcement Management Model (EMM) produced by the Health
and Safety Executive (HSE), which is considered national best practice.
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3.3
The use of the EMM will allow inspectors to make consistent and fair enforcement
decisions based on clear guidelines, which will be robust if challenged, and auditable
when required. (See Part 4)
3.4
There are three principle areas that will enable the fire and rescue service to manage
the fire risk in the community. These are:



3.5
4.
Fire Prevention
Fire Protection
Fire Response
The integrated approach recognises that activity in one or more of these areas has the
potential to reduce the risk in the community. However in situations where it may not
always be possible to reduce the risk to an acceptable level using Statutory or
Community Fire Safety initiatives, the information gathered will be used to provide an
appropriate level of fire cover.
DETERMINING THE RISK LEVEL
4.1
The Risk Based Inspection Programme forms part of the Service’s overall integrated
approach to management by prioritising the inspection of premises. It will initially be
necessary to determine the level of risk in the premises in question. This will be
determined by the carrying out of an on-site or remote audit, which will, on completion
apply a risk level. The risk to individual persons will be of concern to inspectors
carrying out the audit, and it will be the potential for the loss of life or serious injury
based on the fire frequency national statistics for buildings taken from FDR data that
will have a major influence on the level of risk determined.
4.2
Whilst the risk to the employees and other persons that may be present is the prime
influence. An assessment of the risk in the premises and its inclusion in the inspection
programme can be made for a number of other purposes, such as:





Property/business loss
Loss of heritage
Loss to the community
Environmental damage
Fire fighting operations
The findings of the audit process and any risk level applied to a premises, to be
stored within the Fire Safety Data Base, will be influenced not only by life safety
considerations but also the potential loss or risk to the community, at a local or national
level.
4.3
When determining the risk presented by a particular premises the following factors will
be considered. The following list is not exhaustive each must be assessed on an
individual basis using all relevant factors:











Type
Type of structure
Use
Nature of occupants
Furniture, fittings and surface finishes
Processes undertaken/materials stored
Potential sources of fire (accidental or deliberate)
Potential fire spread internal and external
Structural fire protection
Compliance with parts B1-B5 of Approved Document B
Fire precautions provided
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






Standard of fire safety management
Location
Access
Water supplies
Operational needs
Safety of fire-fighters
Environmental impact of any fire
4.4
When considering these factors it will also be necessary to utilise information from
current fire fighting practice, at a national and local level. Current fire intelligence and
a review of the historical experience of the premises will be taken into account before a
final determination of risk level can be made.
4.5
Professional judgement will be required as part of the overall process, to determine the
life and relative risk each building has. Relative risk is when comparisons are made
between different types of buildings. From data collected a determination can be
made as to the risk of a fire occurring and the risk to persons e.g. a low risk hospital
may have a risk rating of 5, the same as a very high-risk office. In the case of the
hospital the inspector needs only to document the inspection. However in the case of
the office, the inspector when faced with conditions that present a high risk will need to
take immediate enforcement action.
4.6
An initial estimation of the levels of risk, for most occupancy types, can be undertaken
according to variations in the following:



4.7
The provision of active and/or passive fire safety systems,
the level of fire safety management provided, or
the size of the premises.
Using the provision of active and/or passive fire safety systems that would normally be
expected in any particular occupancy type as the “bench mark” then the level of risk
could be varied as follows:





Severe under provision
Under provision
Normal provision
Over provision
Significant over provision
Very High Risk
High Risk
Medium Risk
Low Risk
Very Low Risk
The same approach would apply to the level of fire safety management provided or the size of
the workplace.
4.8
As increasingly sophisticated community risk models are developed to support IRMP,
the audit process for a premises must be compatible across all areas of fire and
rescue service activity, particularly a correlation between the levels of risk for a Fire
Safety Inspection Programme and the Fire Cover Review process.
4.9
In order to demonstrate that the Fire and Rescue Authority is meeting its legislative
responsibilities it is critical that at every stage the processes by which the levels of risk
and the resulting inspection activity have been determined are reasonable, are
recorded, transparent and auditable.
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5.
ASSESSMENT OF RISK
5.1
The responsible person should assess the risk from fire in the premises (either as part
of a general review of health and safety risks or as a specific exercise). The following
checks should be included;





5.2
6.
That a fire can be detected in a reasonable time and that relevant persons can
be warned,
That relevant persons who may be in the premises can get out safely,
That reasonable fire-fighting equipment is provided,
That relevant persons in the premises know what to do if there is a fire,
That all fire safety equipment is checked and maintained at the required time
periods, and to a satisfactory standard.
Where a responsible person employs 5 or more people (whether or not they are at
work in the premises at any one time, or at separate premises), he/she must keep a
written record of the risk assessment in respect of each premises. The record should
include all the identified significant findings and the measures taken to deal with them.
The requirement for a written record depends on the number of people employed, not
where they work.
THE AUDIT PROCESS
6.1
The process for carrying out the fire safety inspection of premises is determined by the
level of risk presented by those premises regardless of what other legislation might
apply to them. The principle of audit will form the basis of the inspections. (see Part
2).
6.2
The process of inspecting premises, assessing risks and making enforcement
decisions where appropriate will embody the principles, expectations and methodology
of the EMM produced by the HSE, which is considered national best practice.
6.3
Whilst the tables in Part 5 give general guidance on determining the level of risk for a
premises, that level can be varied according to local circumstances such as:





Historical information on the workplace concerned,
A visit to a premises under Fire and Rescue Services Act 2004,
Reports on fires attended,
Local trends or socio-economic factors,
Fire risk assessments by or on behalf of responsible persons or other bodies
such as HSE, local authorities and Environment Agency.
6.4
Table 1 Is the Relative Risk Level Matrix and is used to determine the premises risk
level. It will be noted that the types of premises are in line with those used in the
ODPM’s model, “Fire Services Emergency Cover” toolkit (FSEC).
6.5
The Relative Risk Level Matrix may be used to assist with the prioritising of inspections
as determined by fire safety management. Premises having a higher risk value should
be prioritised for inspection over and above the lower risk ones, however continued
sampling of lower risk premises should be carried out at the discretion of fire safety
management when considering the resources available to complete the time based
inspections.
6.6
The numerical values 8 to 2 provided in the relative life risk score of the matrix
represent levels of risk and are a guide to overall priorities for inspection. They
cannot be used to dictate the enforcement action to be taken. Whatever the score of a
workplace, a Very High or High Risk will warrant some form of action to reduce the
risk.
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PART 2 - THE PREMISES FIRE SAFETY AUDIT
1.
INTRODUCTION
This part sets out an audit-based approach to carrying out a fire safety inspection at a
premises (the fire safety audit). The fire safety audit provides inspectors with a risk-based
methodology that supports the enforcement principles embodied in The Regulatory Reform
(Fire Safety) Order 2005 and the EMM.
There are two types of audit that inspectors will use: The remote audit - On first allocation of a file, inspectors will carry out a remote audit of the
premises using any information that is available and apply an initial risk level using the
Relative Risk Level Matrix Table 1. This initial risk level will generally be equivalent to a
medium risk values for the relevant premises use group column.
The premises fire safety audit - This audit of premises will be carried out using the Fire
Safety Audit and Data Gathering Form. The results of the premises audit will determine the
risk level. The inspector will need to consider fire intelligence data concerning external
2.
AUDIT PRINCIPLES
The following paragraphs are provided to give guidance on audit principles to those
inspectors who may be unfamiliar with this type of inspection. Instruction on the carrying out
of a fire safety audit can be found in the following sections of this Part.
2.1
The process of audit is designed to allow the inspector to determine if the process or
procedure, subject to the audit, is in practice a true reflection of theory. It is the
system, process or procedure that is subject to audit and not the people in or around
the premises. For example, the audit of staff training procedures will look at the
sequence of events detailed in writing, being performed in reality. If the procedure
states that ‘all staff will receive comprehensive fire safety training on a quarterly basis’,
the inspector will expect to see evidence that this is true. The efficiency with which the
task is completed may be of relevance but is not what the inspector is looking for.
Only if the task is not carried out will reasons be looked for.
2.2
The fire safety inspector will start by looking at a system and frequency for review, to
ensure it is actually in place. Following this each element of the system will then be
checked, including the review process.
The important factors to be considered are:






3.
Establish that a system exists (policy or procedure),
Check each element (hazard identification, risk assessment, control measures,
review),
Only check samples (select particular components of each element),
Check by observation and communication (look and listen for evidence, talk to
persons),
Identify deficiencies (in the areas selected for audit),
Address deficiencies.
THE FIRE SAFETY AUDIT
A fire safety audit is, as its title implies, an inspection that uses the principles of audit as its
base, but not as its sole methodology. The process of auditing a workplace, assessing risks
and making enforcement decisions will embody the principles, expectations and methodology
of the (EMM).
3.1
To assist inspectors to complete a fire safety audit, a form is provided (Fire Safety
Audit/Data Gathering Form) with guidance notes and step by step instructions (Tables
11 and 12) in Part 5. The form will be used on every occasion a fire safety audit is
carried out to ensure a consistent approach and provide a contemporaneous record for
future reference.
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4.
3.2
The Regulatory Reform (Fire Safety) Order 2005 is founded upon the unequivocal
responsibility of the responsible person to assess and mitigate the risk to those
relevant persons who could be affected by fire. It is not appropriate for the Fire and
Rescue Authority to provide a prescriptive solution as the sole means of addressing
deficiencies, except where communications have broken down and formal methods
are necessary.
3.3
It is important for inspectors to recognise that any enforcement action taken must be
first verified against the EMM. This is achieved by using Tables 4 to 10 in Part 5. Any
enforcement action must be detailed enough for the responsible person to act upon,
and it must make clear the required objective.
CONDUCTING THE AUDIT
4.1
Prior to the Inspection
4.1.1
Time must be taken to prepare for the audit. If the premises are known, then
careful research of the premise history should be undertaken. Particular
attention must be given to all factors that will affect the overall risk rating of the
premises, these will include not only life risks but also those to facilitate IRMP,
compliance with parts B1-B5 of the current Building Regulations, fire-fighter
safety and the effect of any fire in the premises or the environment.
4.1.2
Unless an immediate inspection is required because a serious risk has come to
light, the occupier should be contacted by telephone and an appointment made
giving where possible at least 5 weeks notice. The occupier will be referred to
the relevant guidance document and informed of the nature and duration of the
audit in addition to the documentation that the inspector will require to examine.
The appointment will be confirmed in writing. A note of the telephone number
of the contact is to be made and left on the premises file and the inspectors
desk diary.
Note: Where an appointment cannot be kept, for whatever reason, the occupier will
be informed by either the inspector or a third party where this is not possible.
4.1.3
4.2
In circumstances where an occupier refuses an inspector entry or becomes
abusive or aggressive, inspectors will confirm their powers under the relevant
legislation as described in the Authorised Inspector Warrant. Where the
occupier continues to be obstructive the audit will be terminated, and the
occupier informed that if the obstruction continues they could face prosecution.
A contemporaneous note is to be made of all events and actions in the
notebook and a note placed on the premises file. A contemporaneous note is
to be made on every occasion a visit is made to premises in connection with
carrying out the duties of a fire safety inspector.
Responsible Person
The inspectors initial objective is to identify the responsible person(s) In multi-occupied
premises the first point of contact should normally be the building manager (owner
and/or agent) who will normally have responsibility for the building overall, and in
particular the common parts and common fire safety systems.
An individual responsible person’s responsibility for safety in a premises extends
beyond the part(s) of the premises they occupy to a place of ultimate safety. This will
include (as a minimum) some responsibility for the common parts.
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In multi-occupied premises responsible persons have a responsibility to co-operate
with each other and any other person who has control overall of the premises to
ensure adequate fire safety measures are in place. This process will inevitably require
action by the owner, as a person having control (and responsibility).
It is not acceptable for an individual responsible person in a multi-occupied premises to
simply tolerate inadequacies in the common parts of the premises on the basis that a
third party has principal control.
4.3
Employers Fire Safety Management Plan (or equivalent)
Every responsible person shall make arrangements as appropriate, having regard to
the nature of their activities and the size of their undertaking, for the effective planning,
organisation, control, monitoring and review of the preventive and protective
measures. (Preventative and protective measures mean the measures identified in
the risk assessment the responsible person needs to make to comply with the
requirements and prohibitions imposed upon him/her by or under the relevant statutory
provisions, this shall be recorded where 5 or more employees are employed). In order
to develop and maintain the safety of the building and that of employees and other
relevant persons, the building management team should have formulated and
documented a fire safety strategy.
This strategy may include a fire safety manual in which technical specifications for all
aspects of the workplace are included i.e.

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

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


A fire safety policy statement appropriate to the building configuration,
location, occupation and use. The fire safety policy statement should include
general safety issues related to the use of the building and the aims and
objectives of the proposed management system and its methodology,
Fire safety specification for the premises including plans where appropriate,
Safety management structure,
Continuing controls and audit procedures,
Actions to be taken in a fire emergency,
Fire drills,
Housekeeping,
Planned maintenance procedures,
Staff training,
Security,
Record Keeping.
In order to maintain the effectiveness of the fire safety strategy, it will be essential that
regular and effective testing and maintenance procedures are conducted and evidence
of this is documented.
4.4
Risk Assessment
The premises fire safety audit should commence with an examination of the fire safety
risk assessment and emergency plan. These documents underpin the rationale for the
fire safety strategies within the premises. The inspector must use professional
judgement to form an initial view regarding the safety case presented and decide to
what extent these matters will require verification.
Past experience has shown that there are a considerable number of responsible
persons who are unaware of their responsibilities to carry out a risk assessment.
However, even where there is no risk assessment available most responsible persons
do have a general, if incomplete or imprecise, understanding of their responsibilities for
fire safety in the workplace. In many cases they may have taken some action to meet
these obligations. In the absence of a written fire risk assessment, the inspector must
establish what, if any, control measures are in place. This will form the starting
point for the audit. This process will enable the inspector to gauge the extent of the
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responsible persons understanding of their responsibilities and provide an opportunity
to educate and inform. Understanding and acceptance of responsibility should be
seen as one of the primary purposes of the fire safety audit.
4.5
Emergency Plan
The responsible person should ensure that:




relevant persons on the premises know what to do if there is a fire,
the premises can be safely evacuated,
there is a written plan where five or more people are employed, and
the written plan is available for inspection by the fire and rescue authority.
In drawing up the emergency plan, the employer should take the results of their risk
assessment into account. If the premises is in a building, which is shared with other
employers or occupiers, the emergency plan should be drawn up in consultation with
those employers and the owner(s) or other people who have any control over any part
of the building.
4.6
Documentation
A range of documentation will support any effective management system. The
inspector will inspect available documents to obtain evidence that effective systems
are in place.
In addition to the written risk assessment this evidence should include the emergency
plan, service records, staff training records, fire drill records and the company policies
and procedures relating to fire.
The inspection of documents need not be exhaustive; the inspector should record
those documents seen, including the date of each document. The aim is to establish
the current position, raise management awareness and assist in forming a view about
how detailed the physical inspection of the workplace will need to be.
4.7
Verification of Standards
Verification is completed by a physical inspection of some or all of the premises to
check compliance with the Regulations. The extent of the verification will depend upon
a number of factors but must always include the risk critical constituent and may
include a sample constituent.
4.8.
Risk Critical Constituent (Those elements most important to the safety of
persons in or around the building in the event of fire)
The fire safety audit will include a physical inspection of at least one of the following
parts of the building.





Common parts and fire safety systems of multi-occupied premises,
Final exits,
Protected/external staircases,
External routes,
Areas licensed for public entertainment.
Note: Where major deficiencies are found in the sampled risk critical elements a full
inspection of all risk critical elements is to be made.
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4.9.
Sample Constituent
The selection of the sample constituent will follow when the risk critical constituent has
taken place. By this stage the inspector will have enough information to form a
comprehensive view regarding the standard of the workplace and must now exercise
professional judgement to decide the extent of the additional sample constituent to be
inspected. When making this decision inspectors should include the areas that appear
to present the greatest risk. In a single occupied building no further verification may be
necessary. When considering the sample to be inspected, inspectors should take into
account any relevant history on the premises file. Particular account should be taken
of records that indicate a higher level of risk in a certain area of the premises. Where
areas of high fire risk are noted during the risk critical constituent the inspector may
wish to include these in the sample constituent e.g. industrial kitchen, spray booth,
highly flammable store, vulnerable occupants etc. A multi-storey single occupied
premises, where the risk profile is uniform, the recommended approach is to randomly
sample enough floors to satisfy the professional judgement of the inspector. In multioccupied buildings a different approach is required. The premises not the building is
the significant area under the Regulatory Reform (Fire Safety) Order 2005. Multioccupied buildings will contain a number of individual premises, and as such a number
of responsible people. When carrying out a verification inspection, an audit of the
premises or areas with the highest risk should be sampled but all individual premises
are to be visited in order to assess, educate and inform the responsible persons. Part
A of the form will be completed for each occupier. If in the professional judgement of
the inspector, there remain areas of concern following the sampling and verification
process, a full top to bottom inspection should be carried out.
4.10
Risk Level
As part of the fire safety audit process the inspector will be required to calculate the life
risk score for the premises as required on Part C for Building and occupants and
Management and other issues. To determine the relative risk level for the premises it
is necessary to use the equation shown on Table 13 however, the calculation will
normally be carried out with the aid of the Risk Level Calculator or an alternative. This
rating will be used to determine the frequency of future fire safety audits.
4.11
Educating and Informing
Educating and informing responsible persons and others about their duties under the
Regulations is a fundamental part of the enforcement regime of the Fire and Rescue
Service. The Regulatory Reform (Fire Safety) Order 2005 requires specified
individuals, (responsible persons) to take responsibility for providing, applying and
maintaining their own fire safety solutions.
In the context of the Order, educating and informing serves two purposes:


5.
To provide an initial level of enforcement activity where a premises gives no
immediate cause for concern but no risk assessment has been completed.
To provide an efficient method for dealing with a predictable need, i.e. lack of
knowledge concerning responsibilities under the Order.
AFTER THE AUDIT
5.1
When the audit has been completed, the Compliance Level from the form will be
compared with Table 4 Initial Enforcement Expectations, which will offer the range
of enforcement options to be considered. It must be ensured that a full and detailed
contemporaneous note of the audit has been taken.
5.2
A meeting with the responsible person is to be held where possible, to discuss the
areas of non-compliance, and the possible enforcement options available.
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6.
5.3
The inspector will, on return to the fire safety base, verify the level of enforcement
indicated using Tables 4 to 10 in Part 5 and if required arrange for a management
review to be carried out.
5.4
Just as important as enforcement action, encouragement should also be given for
compliance. If appropriate, observations should also be made to encourage the
process of continual improvement.
5.5
The inspector should use the completed form as the basis to prepare additional reports
or considering the appropriate enforcement action. When all work on the file is
completed the form shall be retained on the file for future reference and quality
assurance purposes. A copy of Part A shall be forwarded to Fire Safety
Administration for retention.
RISK BASED - INSPECTIONS
6.1
A system of risk based inspections will be developed in accordance with service policy.
6.2
Fire safety audits are carried out under The Regulatory Reform (Fire Safety) Order
2005 and will form the primary inspection. Any deficiencies will be dealt with in
accordance with service policy.
6.3
Any deficiencies identified, which contravene other legislation, will be dealt with using
a separate job card using the reason code appropriate for the legislation involved.
This will form the secondary inspection.
6.4
Ad hoc fire safety audits
There may be occasions when Fire Safety Management wishes to scrutinise the
system to select a particular premises group with a specified risk rating.
Administration will then create individual job cards and issue to selected fire safety
inspectors as appropriate.
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PART 3 - FIRE SAFETY AUDIT AND DATA GATHERING FORM
GUIDANCE NOTES
1.
INTRODUCTION
The purpose of these notes is to explain the use of the Fire Safety Audit and Data Gathering
Form. The form is a three part form used not only for the audit of fire safety provisions within
a premises but also as a vehicle for the collection of operational data required for inclusion in
the Integrated Risk Management Plan (IRMP).
1.1
Fire safety inspectors will complete parts A, B & C of the form when carrying out a fire
safety audit of a single occupancy, and for the common areas of multi occupied
premises. In the case of multi occupied premises, Part B may be used on selected
occupiers identified through the professional judgement of the inspector. Parts A & C
however must be completed for each occupier. The judgement when to use Part B is
to be made when gathering the information for Parts A & C or from reviewing historic
information, or both.
1.2
Following the expiry of an enforcement notice, a reinspection will be made and an
additional Parts B & C will be completed by the inspector to confirm that the
requirements of the enforcement notice have been complied with and to re-affirm
and/or amend the risk rating.
1.3
The purpose of the audit is to ensure a responsible person is in compliance with the
Order. As an auditor, it is better to think of yourself as someone who can help a
responsible person, rather than someone who is looking for faults.
1.4
The Fire Safety Audit process embodies the expectations and principles of the EMM
considered to be national best practice.
1.5
The fire safety audit and data gathering process fulfils the following functions:




1.6
2.
To produce a relative life risk level.
To identify the level of compliance of a premises and thus the level of
enforcement where appropriate.
To determine whether a follow up inspection is needed.
To determine the level of intervention as part of the IRMP.
It should be noted that whilst the information gathered as part of the IRMP process will
affect the overall risk profile of a given premises it will have no effect on the
compliance level and thus the level of enforcement applied.
COMPLETING THE FORM
2.1
Parts A, B & C including a sample of the risk critical elements of the form are
mandatory and will be completed on every occasion. The inspector will use
professional judgement to decide which, if any, of the non mandatory elements of the
form will be completed during the sample constituent of the audit.
2.2
To assist FRS’s to identify which data fields need to be migrated to either different
databases or other parts of the audit form, colour has been used. The migration of
data may be made either electronically or manually. It is not expected a colour version
of the Fire safety audit form to be used by a FSI when conducting the actual audit of
the premises. Part A of the form gathers information for the fire safety database
(highlighted in green) and information for use with FSEC (framed in blue). Those
items highlighted in red are either migrated from part B or taken forward to part C of
the form. For the avoidance of doubt a description of the more complex items is
included in Table 12.
15
2.3
Part B of the form gathers information to support the fire safety audit. This part is
divided into eleven areas headed; management, maintenance of provisions, means of
escape, alterations notice, fire warning arrangements, information to employers and
employees, general duties of employees at work, fire-fighters switches for luminous
discharge tubes, maintenance of measures provided for protection of fire-fighters,
management and other issues and building and occupant features. Each mandatory
question should be considered and a score allocated.
2.4
Part C Allows the relative risk level to be calculated.
2.5
Each of the first nine elements of the form is divided into four areas.




The matter to be assessed,
Areas of considerations,
Deficiencies,
Compliance level for the section.
2.6
The Deficiencies area is provided for the inspector to make any notes regarding
deficiencies identified during the audit and will form a note which may be used as the
basis for any enforcement procedure which may follow. Items identified in this section
will be used also for inclusion in a report or discussion with the responsible person on
completion of the audit. It will however, still be necessary for the inspector to make a
full and detailed contemporaneous note for use in any subsequent court proceedings.
2.7
If it is decided to use non-mandatory sections the inspector shall ensure that the
question at the head of each of these sections of the form is answered as accurately
as possible. This will be achieved by verification, either verbally, physically or by
examination of documents.
2.8
The inspector must exercise professional judgement to decide the level of compliance
in any given section during the audit, based on certain areas for consideration. The list
of Areas of considerations for each section is not exhaustive, and is intended as an
aid for the inspector when considering the compliance level.
2.9
There may be further items that the inspector will wish to take into consideration when
making a determination of the compliance level in a particular section. Each section of
the form used will be given a numerical value of 1, 3 or 5. Some elements score 0 for
sections which are non-applicable to the type of premises being audited.
0 = N/A
1 = Fully compliant
3 = Partially compliant
5 = Non compliant
The level of compliance for each relevant section is indicated by placing a tick in the
appropriate box in the compliance level area at the end of that section.
2.10
The awarded numeric values from each section audited are added together and
divided by the same number of sections.
Note: Mandatory sections which are considered not to be applicable are to be
discounted from the dividing total for sections.
The result of this process will give the compliance level score. This compliance level
score will be subjected to the EMM process and will form the basis for the enforcement
activity. This compliance level score is then used to determine a Fire Safety
Management Score. In the case of Part B not being completed the description,
“Average for the occupancy” Score 0 is to be selected from the Fire Safety
Management Section in Part C.
16
2.11
The totals from each column in Part C are entered in the relevant sub total box at the
foot of each column and the sum of these is entered into the, “Life Risk Score” box.
The relative life risk score is obtained using the formula in Table 13. The calculation
takes into account the frequencies of fires in buildings taken from FDR data. A Risk
Level Calculator is available to simplify the process
2.12
Correct and accurate completion of the form will enable the inspector to better assess
the risk for the premises and decide the level of enforcement applicable (if any) when
the audit is complete. In general, any non-compliance will be addressed through the
appropriate enforcement strategy.
2.13
Each inspector will adopt his or her own style when conducting an audit. However the
form and its methodology shall be used on every occasion a fire safety audit is carried
out to ensure a consistent approach across the service.
Note: Part A of the form shall be used for each occupier in a multi-occupied building.
2.14
Tables 11 and 12 will assist the inspector when completing the form.
17
PART 4 - ENFORCEMENT VERIFICATION
USING THE ENFORCEMENT MANAGEMENT MODEL
1.
INTRODUCTION
The process of inspecting workplaces, assessing risks and making enforcement decisions
where appropriate will embody the principles, expectations and methodology of the
Enforcement Management Model (EMM) produced by the Health and Safety Executive (HSE),
which is considered national best practice.
The use of the EMM will allow inspectors to make consistent and fair enforcement decisions
based on clear guidelines, which will be robust if challenged, and auditable.
2.
PRINCIPLE OBJECTIVES
Once an Initial Enforcement Expectation (IEE) has been reached from Table 4 in Part 5 it
will be necessary to apply two tests to arrive at a final decision. The tests will involve a series
of questions relating in the first instance to the responsible person, which will allow the
enforcement decision to be verified or modified. Finally that enforcement decision will be set
against a number of strategic factors to either confirm the decision or establish the need for a
management review.
3.
4.
RESPONSIBLE PERSON FACTORS
3.1
Responsible person factors are, on the whole, specific to the responsible person and
their activities and usually confirm the IEE or alter the enforcement level up or down by
one level, e.g. from a prohibition notice to prosecution, or from an enforcement notice
to notification of fire safety deficiencies.
3.2
Table 5 Responsible Person Factors in Part 5 lists a series of factors relevant to the
responsible person that may influence the enforcement decision. The way these
elements are applied to the IEE is represented in Tables 6 to 8. The elements in each
flowchart vary because different enforcement expectations have different factors
influencing them.
3.3
Where the IEE indicates the issue of a prohibition notice, the inspector will go through
the process described in Table 6 to determine if a prosecution should be considered in
addition to a prohibition notice.
3.4
Where the IEE indicates the issue of an enforcement notice the procedure detailed in
Table 7 should be followed. This would allow either consideration of prosecution or
the more informal notification of fire safety deficiencies form.
3.5
Where the IEE indicates the issue of a notification of fire safety deficiencies the
procedure detailed in Table 8 should be followed. This would allow either
consideration of the more informal notification of fire safety deficiencies form or the
serving of an enforcement notice.
STRATEGIC FACTORS
4.1
There are a range of strategic factors (see Table 9) that may impact on the final
enforcement decision. Inspectors have to ensure that public interest and vulnerable
groups (e.g. children, patients, and the elderly) are considered, and that the broader
socio-political impact of the enforcement action is taken into account. Strategic factors
qualify the decision; they do not determine it.
4.2
There are competing demands on the finite resources of the Fire and Rescue
Authority, and a balance has to be achieved based upon risk, potential outcomes and
public expectations.
18
4.3
When considering public interest, inspectors and Fire Safety Management will have
to satisfy themselves that the proposed action will produce a net benefit to the wider
community in terms of reducing risk, and in the costs of pursuing a particular course of
action.
4.4
Public interest is a difficult issue to assess. Inspectors must ask themselves: What
would a reasonable person expect from the Fire and Rescue Authority in the
circumstances? A further test is whether the particular decision could be justified if
challenged in law.
4.5
Certain issues may have a significant bearing on public expectation, for example fatal
fires involving vulnerable groups such as children or the elderly or customers of leisure
centre activities. While public expectation must be carefully considered, it should not
determine the action taken. The public will not have all the facts in any particular case,
or the training, experience or organisational support that the inspector can draw upon
when making decisions.
4.6
The process of applying the strategic factors is illustrated in Table 9. The proposed
enforcement actions are tested against the strategic factors – see Table 10. The flow
chart leads to a confirmed enforcement action that should be subject to a management
review where it does not address all the strategic factors or accord with the
enforcement policy.
4.7
There is no ranking of importance implied in the progression through the factors.
However, the final question must be does the proposed action meet the principles and
expectations of the Fire and Rescue Authority?
19
PART 5 - TABLES FLOWCHARTS AND GUIDANCE NOTES
The following list of tables and guidance notes are referred to in Parts 1 to 4 of this directive.
Table 1
Relative Risk Level Matrix
Table 2
Floor Area Sizes by Occupancy Type
Table 3
Valuation Officer Codes
Table 4
Initial Enforcement Expectations
Table 5
Responsible Person Factors
Table 6
Responsible Person Factors Flow Chart
(Initial Enforcement Expectation – Prohibition Notice)
Table 7
Responsible Person Factors Flow Chart
(Initial Enforcement Expectation – Enforcement Notice)
Table 8
Responsible Person Factors Flow Chart
(Initial Enforcement Expectation – Notification of deficiencies)
Table 9
Strategic Factors
Table 10
Strategic Factors Flow Chart
Table 11
Fire Safety Audit and Data Gathering Form – Aide-memoire
Table 12
Fire Safety Audit and Data Gathering Form – Additional Notes
Table 13
Calculating The Relative Risk Rating
20
VH
H
H
M
M
M
L
L
VL
21
VH
H
H
H
M
M
M
L
L
VL
VH
H
H
H
M
M
M
L
L
VL
VH
H
H
M
M
M
L
L
L
VL
M
VH
H
H
M
M
M
L
L
L
VL
N
VH
H
H
H
M
M
L
L
L
VL
P
VH
H
H
H
M
M
M
L
L
VL
R
S
T
VH
H
H
M
M
M
L
L
L
VL
VH
H
H
M
M
M
M
L
L
VL
VH
H
H
M
M
M
M
L
L
VL
Factory or
Warehouse
Other Premises
Open to Public
L
Shop
K
Other workplace
VH
H
H
M
M
M
M
L
L
VL
J
Office
VH
H
H
H
M
M
M
L
L
VL
VH
H
H
H
M
M
M
L
L
VL
H
School
VH
H
H
H
M
M
M
L
L
L
VL
G
Licensed Premises
VH
H
H
H
M
M
M
M
L
L
VL
F
Public Building
VH
H
H
M
M
M
L
L
L
VL
VH
H
H
M
M
M
L
L
VL
E
Further Education
D
Other Sleeping
Accommodation
C
House Converted
to Flat
B
Hotel
A
Hostel
HMO Tenement
Purpose Built Flats
=>4 Storeys
Care Home
FSEC Group
Relative
Risk Rating
8
7.75
7.5
7.25
7
6.75
6.5
6.25
6
5.75
5.5
5.25
5
4.75
4.5
4.25
4
3.75
3.5
3.25
3
2.75
2.5
2.25
2
Hospital
Premises Use
Group
Table 1: RELATIVE RISK LEVEL MATRIX
Table 2: FLOOR AREA SIZES BY OCCUPANCY TYPE
FSEC Group
Extremely
Small
-5
< 500
Hospitals
Care Homes
< 200
Houses in Multiple
Occupation
Purpose Built Flats
< 1400
Hostels
< 123
Hotels
< 201
Houses Converted
to Flats
Other Sleeping
Accommodation
Further Education
< 251
Public Buildings
< 101
Licensed Premises
< 151
Schools
< 201
Shops
< 61
Other Premises
Open to the Public
Factories and
Warehouses
Offices
< 101
Other Workplaces
< 51
< 30
< 51
< 331
< 101
< 100
Very
Small
Small
M2
Medium
Large
Very
Large
-3
-2
0
2
3
500 to
651 to 2001 to 10001 to 50001 to
650
2000
10000
50000
100000
200 to
351 to
641 to 1501 to
2501 to
350
640
1500
2500
4500
30 to 80 81 to 300 301 to
701 to
2301 to
700
2300
20000
1400 to 3001 to 5001 to 8301 to 10301 to
3000
5000
8300
10300
12600
123 to
221 to
351 to
751 to
1901 to
220
350
750
1900
4000
201 to
351 to
651 to 1301 to
3601 to
350
650
1300
3600
9500
251 to
301 to
401 to
501 to
601 to
300
400
500
600
1000
51 to 90 91 to 140 141 to
361 to
1501 to
360
1500
4200
331 to
561 to 2001 to 6001 to 15001 to
560
2000
6000
15000
32000
101 to
201 to
351 to
951 to
2701 to
200
350
950
2700
7500
151 to
251 to
401 to
701 to
1201 to
250
400
700
1200
2300
201 to
401 to 1001 to 2501 to
6001 to
400
1000
2500
6000
13000
61 to 130 131 to
201 to
501 to
1401 to
200
500
1400
6000
101 to
176 to
301 to 1001 to
3301 to
175
300
1000
3300
8000
101 to
261 to
716 to 2401 to
7001 to
260
715
2400
7000
15000
100 to
201 to
401 to 1001 to
2701 to
200
400
1000
2700
9400
51 to 100 101 to
301 to
601 to 701 to 800
300
600
700
22
Extremely
Large
5
> 100000
> 4500
> 20000
> 12600
> 4000
> 9500
> 1000
> 4200
> 32000
> 7500
> 2300
> 13000
> 6000
> 8000
> 15000
> 9400
> 800
Table 3: VALUATION OFFICER CODES
PRIMARY DESCRIPTION
Residential (Dwellings)
Single Private Dwelling
Self-Catering Holiday Unit
Flats Or Maisonettes Up To 3 Floors Purpose Built
Flats Or Maisonettes 4 Floors And Over Purpose Built
Time Share Complex
Houses Converted To Flats Up To2 Floors
Houses Converted To Flats 3 Floors And Over
Hostel
HMO (Purpose Built Flatlets)
HMO (Converted to Flatlets)
HMO (Other)
Camping Site
Caravan Park
Chalet Park
Caravan And Chalet Park
Gypsy Caravan Site
Residential (Institutional)
Hospital
Hospital (Private)
(Care) Home For Older People (Over 65)
(Care) Home For Adult Placements
(Care) Home For Adults Aged 18-65
Adult Placement Schemes
Domiciliary Care
Children’s Homes
Adoption Homes
Residential Family Centres
Foster Homes
Boarding Schools
Halls of Residence
Accommodation For Students Under 18 By Further Education Colleges
Childminders (Nursery and Sleeping)
Police Station (With Cells)
Prison (With Cells)
Hotel
Guest House (Up to 6 Guests)
Motel
Holiday Centre/Hotel (FPA Cert)
Holiday Centre/Licensed (FPA Cert)
Holiday Centre/Other Sleeping Accommodation (FPA Cert)
Fire Station (With Sleeping Accom)
Ambulance Station (With Sleeping Accom)
Royal Palaces, Other Crown With Sleeping Accommodation
Offices
Office (FPA Cert)
Office (Non Cert)
Computer Centre (FPA Cert)
Computer Centre (Non Cert)
Offices (Local Govt)/Open to the Public (FPA Cert)
23
VO Code
R1
CH1
R2
R3
CC7
R4
R5
MR
R6
R7
R8
CC
CC1
CC5
CC6
CC8
MH2
MH3
MR1
MR2
MR3
MR4
MR5
MR6
MR7
MR8
MR9
MR10
MR11
MR12
MR13
MP
MP2
CH
CH2
CH3
CC2
CC2
CC2
MS1
MS2
TX
CO
CO
CO1
CO1
ML
Offices (Local Govt)/Open to The Public (Non Cert)
Offices (Local Govt)/Not Open to the Public (FPA Cert)
Offices (Local Govt)/Not Open to the Public (Non Cert)
Forces Careers Office (FPA Cert)
Forces Careers Office (Non Cert)
Police Station (No Cells) (FPA Cert)
Police Station (No Cells) (Non Cert)
Bank (FPA Cert)
Bank (Non Cert)
Shops And Commercial
Shop Not Listed Below (FPA Cert)
Shop Not Listed Below (Non Cert)
Shop Not Listed Below (Other)
Petrol Filling Station
Car Showroom (FPA Cert)
Car Showroom (Non Cert)
Market (Indoor) (FPA Cert)
Market (Indoor) (Non Cert)
Licensed – Restaurant (FPA Cert)
Licensed – Restaurant (Non Cert)
Unlicensed- Restaurant (FPA Cert)
Unlicensed- Restaurant (Non Cert)
Licensed – Café (FPA Cert)
Licensed – Café (Non Cert)
Unlicensed –Café (FPA Cert)
Unlicensed –Café (Non Cert)
Food Court (FPA Cert)
Food Court (Non Cert)
Betting Shop (FPA Cert)
Betting Shop (Non Cert)
Hairdressing Salon (FPA Cert)
Hairdressing Salon (Non Cert)
Kiosk/Shop (FPA Cert)
Kiosk/Shop (Non Cert)
Kiosk/Office (FPA Cert)
Kiosk/Office (Non Cert)
Laundrette (FPA Cert)
Laundrette (Non Cert)
Post Office (FPA Cert)
Post Office (Non Cert)
Showroom (FPA Cert)
Showroom (Non Cert)
Hypermarket (FPA Cert)
Hypermarket (Non Cert)
Superstore (FPA Cert)
Superstore (Non Cert)
Shopping Centre (FPA Cert)
Assembly & Recreation
Public House
Wine Bar
Club (Social) (Licensed)
Club Social) (Unlicensed)
Club House (Licensed)
24
ML
ML1
ML1
TD1
TD1
MP
MP
CS1
CS1
CS
CS
CS
CG
CG3
CG3
CM1
CM1
CR
CR
CR3
CR3
CR1
CR1
CR4
CR4
CR2
CR2
CS2
CS2
CS3
CS3
CS4
CS4
CS41
CS41
CS5
CS5
CS6
CS6
CS7
CS7
CS8
CS8
CS9
CS9
CS
CL
CL1
CL2
CL21
LC1
Club House (Unlicensed)
Cinema
Bingo Hall/Licensed
Bingo Hall/Non Licensed
Theatre
Night Club
Casino
School
School (Private)
Day Nursery
College (Public)
College (Private)
University
Other Education, Training And Cult.
Library (FPA Cert)
Library (Non Cert)
Museum
Community Centre
Leisure Centre
Hall
Sports Centre
Stadium
Sports Ground (Designated Sports Ground)
Sports Ground (Non Designated)
Sports Ground (Regulated Stands)
Sports Ground (Non Regulated)
Football Ground (Non Designated)
Swimming Pool
Tennis Centre
Amusement Arcade
Crematorium (FPA Cert)
Crematorium (Non Cert)
Place Of Worship
Surgery (Doctors, Dentists Or Vets)
Health Centre
Law Court (FPA Cert)
Law Court (Non Cert)
Bus Station (FPA Cert)
Bus Station (Non Cert)
Auxiliary Defence Establishment
Railway Station (FPA Cert)
Railway Station (Non Cert)
Sub-Surface Railway Station (FPA Cert)
Sub-Surface Railway Station (Non Cert)
Airport Or Ferry Terminal (FPA Cert)
Airport Or Ferry Terminal (Non Cert)
LC11
LT
LT2
LT2
LT3
PL1
PL2
EL
EP
EN1
EL1
EP1
EU
EX
EM
EM
EM1
LC
LC2
LC3
LI
LI1
LS
LS11
LS12
LS13
LS5
LS6
LS7
LT1
MC1
MC1
AR2
MH
MH1
MP1
MP1
NT
NT
TD2
AR3
AR3
AR4
AR4
AR5
AR5
Industrial
Vehicle Repair (FPA Cert)
Vehicle Repair (Non Cert)
Garage (FPA Cert)
Garage (Non Cert)
Factory (FPA Cert)
Factory (Non Cert)
CG1
CG1
CG2
CG2
IF
IF
25
Mill (FPA Cert)
Mill (Non Cert)
Works (FPA Cert)
Works (Non Cert)
Workshop (FPA Cert)
Workshop (Non Cert)
Brickworks (Structures Only) (FPA Cert)
Brickworks (Structures Only) (Non Cert)
Concrete Batching Plant (Structures Only) (FPA Cert)
Concrete Batching Plant (Structures Only) (Non Cert)
Other Industrial Mineral (Structures Only) (FPA Cert)
Other Industrial Mineral (Structures Only) (Non Cert)
Industrial Miscellaneous (Structures Only) (FPA Cert)
Industrial Miscellaneous (Structures Only) (Non Cert)
Sewage Treatment Works Structure) (FPA Cert)
Sewage Treatment Works Structure) (Non Cert)
IF1
IF1
IF2
IF2
IF3
IF3
IM2
IM2
IM3
IM3
IMX
IMX
IX
IX
NW
NW
Storage & Other Non-Residential
Retail Warehouse (FPA Cert)
Retail Warehouse (Non Cert)
Warehouse (Unknown Use)
Storage Depot/Factory Or Warehouse
Storage Depot/Other Workplace
Store (Unknown Use)
Explosive Or Highly Flammables Store (E28a)
Explosive Or Highly Flammables Store (E29)
Explosive Or Highly Flammables Store (E29a)
Public Car Park (Covered Or Multi Storey)
Private Car Park (Covered Or Multi Storey)
Other Commercial Premises (Unknown Use)
Business Unit (Unknown Use)
Laboratories/Research Establishment
Animal Boarding Or Breeding Establishment
Fire Station ( No Sleeping Accom) (FPA Cert)
Fire Station ( No Sleeping Accom) (Non Cert)
Ambulance Station (No Sleeping Accom) (FPA Cert)
Ambulance Station (No Sleeping Accom) (Non Cert)
Railway Premises (Not Stations) (FPA Cert)
Railway Premises (Not Stations) (Non Cert)
Vacant Or Unoccupied Premises
Outdoor Workplace/Event
Market (Outdoor)/Public Or Trade
Storage Land/Used By Public Or Trade
Dock Hereditament
Electricity Hereditament
Quarry
Tipping Site/Public Or Trade
Spoil Heap Workings
Golf Course
Marina
Amusement Park
Other Leisure
Cemetery
Mooring
26
CS10
CS10
CW
CW2
CW2
CW3
S1
S2
S3
CP
CP2
CX
IF4
OC1
OC2
MS1
MS1
MS2
MS2
OC3
OC3
OC4
CM
CW1
FD
FE
IM
IM4
IM5
LS2
LS3
LT4
LX
MC
NT1
Wharf
Mine
Road Haulage
Transport System Tunnel Or Bridge etc
Outdoor Public Event
Remaining Valuation Codes
Advertising Right
Advertising Station
Caravan And Pitch
Caravan Pitch
Car Parking Space
Peat Fields (Structures Only)
Beach Hut
Sporting Right
Playing Field
Communication Station
Public Telephone Kiosk
Other Communication
Other Miscellaneous
Other Non-Formula
NT3
IM1
CG4
OW1
OP1
CA
CA1
CC3
CC4
CP1
IM6
LH1
LS1
LS4
MT1
MT2
MTX
MX
NX
27
Table 4: INITIAL ENFORCEMENT EXPECTATIONS
Note - Prohibition/Prosecution may be considered regardless of the premises overall compliance
level
Compliance
Level
Compliance
Level 5
Description
Enforcement
Expectation
resulting in deficiencies so serious as to pose a serious risk to Prohibition
persons in case of fire
FOLLOW UP AUDIT ALWAYS REQUIRED
Generally workplace risk rating very high/high
require structural alterations
Compliance
Level 4
Compliance
Level 3
Poor management with numerous serious contravention’s of
fire safety legislation.
Disregard for fire safety issues with bad housekeeping and no
risk assessment or records of training or testing.
Following a fire where greater emphasis is required to
address deficiencies
History of previous enforcement or informal action
FOLLOW UP AUDIT ALWAYS REQUIRED
Enforcement
Notice
Generally workplace risk rating medium
Numerous less serious deficiencies possibly with history of
other minor issues
Poor management evident and inspector has lack of
confidence that matters will be adequately addressed
Enforcement
Notice
Consider referral to CFS if appropriate
FOLLOW UP AUDIT ALWAYS REQUIRED
Compliance
Level 2
Several less serious deficiencies but without a previous
history. Inspector has confidence in the overall management
of the workplace that matters will be adequately addressed.
Notification of
Fire Safety
Deficiencies
Notification of
Fire Safety
Deficiencies
FOLLOW UP AUDIT NOT NORMALLY REQUIRED
Compliance
Level 1
Generally workplace risk rating low/very low or those premises
in multi-occupied buildings not selected for a sample audit
Possibly no Risk Assessment carried out/recorded but
building generally satisfactory in all other respects
Only very few less serious deficiencies. Approach to include
verbal advice/agreement and information (inspector to record
any advice given)
Only very low level deficiencies. Approach to include verbal
advice/agreement and information (inspector to record any
advice given)
Any situation where workplaces comply with the order but
where additional measures would reduce the risk category
Consider referral to CFS if appropriate.
NO FOLLOW UP REQUIRED
28
Notification of
Fire Safety
Deficiencies
Educate &
Inform
Table 5: RESPONSIBLE PERSON FACTORS
Descriptor
Definition
Does the responsible person have a history of relevant enforcement action being taken?
Yes
Enforcement action has been taken against the responsible person on the
same or similar issues, by notices, prosecutions or informal action.
No
No enforcement action against the responsible person has been issued on the
same or similar matters
Is there a history of operational incidents at the premises?
Yes
There is a history of operational incidents at the premises (e.g. fires, false
alarms, and spillages etc.)
No
There is no history of related incidents at the premises e.g. fires, false alarms,
and spillages etc. or reports of incidents from other agencies
What is the intention of the responsible person in non-compliance?
Deliberate
Responsible person is deliberately avoiding minimum legal requirements for
economic
commercial gain
advantage sought
No economic
Failure to comply is not commercially motivated
advantage sought
What is the level of perceived harm?
Serious
A risk so serious as to endanger life may occur as a result of the matter under
consideration
Not serious
There is little or no risk of serious harm
What is the cause of perceived/actual harm?
Deliberate
The responsible person knowingly carries out or permits actions that create a
risk so serious as to endanger life.
Omission
The responsible person carries out or permits actions in ignorance of safety
legislation that creates a risk so serious as to endanger life.
What is the inspection history of the responsible person?
Poor
The responsible person has an inspection history of significant problems,
copious advice and poor inspection ratings
Average
The responsible person has an inspection history of nominal or piecemeal
problems, where non-compliance has been related to new/or obscure duties,
rating history is in the average range
Good
The responsible person has a general inspection history of good compliance,
effective response to advice, consistently high standards and low inspection
rating
What is the standard of general conditions?
Poor
There is a general failure of compliance across a range of issues, including
those related to the activity being considered through the EMM
Reasonable
The majority of issues are adequately addressed, with only minor omissions
Good general
Full compliance across the whole range of indicators with no notable omissions
compliance
What is the attitude of the responsible person?
Hostile/
The responsible person is actively antagonistic, or generally uninterested in fire
indifferent
safety. Impossible to establish an effective relationship
Reasonable
The responsible person is generally open to discussion and reasoned
persuasion and effective communication can be established
Positive
The responsible person is generally enthusiastic and proactive towards fire
safety, actively seeking advice and pursuing solutions
29
Table 6: RESPONSIBLE PERSON FACTORS FLOW CHART
INITIAL ENFORCEMENT EXPECTATION - PROHIBITION NOTICE
PROHIBITION NOTICE
Previous relevant documented
enforcement?
Yes
No
Relevant incident history?
Yes
No
Deliberate economic
advantage sought
Intention of responsible person?
No economic advantage sought
Cause of Perceived/Actual Harm?
Deliberate
Omission
Inspection history?
Poor
Average
Standard of general Conditions?
Poor
Standard of general
Conditions?
Reasonable
PROHIBITION
NOTICE
CONSIDER
PROSECUTION
AND
30
Poor
Table 7: RESPONSIBLE PERSON FACTORS FLOW CHART
INITIAL ENFORCEMENT EXPECTATION - ENFORCEMENT NOTICE
ENFORCEMENT
NOTICE
Previous relevant
documented enforcement?
Yes
No
Relevant incident history?
Yes
No
Deliberate economic
Advantage sought
Intention of responsible person?
No economic advantage sought
Level of perceived harm?
Serious
Not serious
Good
Inspection history?
Poor
Average
Good
Standard of general Conditions?
Poor
Standard of general
conditions?
Reasonable
Standards of
general Conditions?
Good
Attitude of Responsible Person?
Poor
Attitude of
Responsible person?
Poor
And
CONSIDER
PROSECUTION
ENFORCEMENT
NOTICE
And
Good
ACTION PLAN
31
Table 8: RESPONSIBLE PERSON FACTORS FLOW CHART
INITIAL ENFORCEMENT EXPECTATION – NOTIFICATION OF DEFICIENCIES
NOTIFICATION OF
DEFICIENCIES
Previous relevant
enforcement?
Yes
No
Relevant incident history?
Yes
No
Deliberate economic
advantage sought
Intention of responsible person?
No economic advantage sought
Good
Inspection history?
Poor
Average
Standard of general conditions?
Standard of general conditions?
Poor
Reasonable
Reasonable
Good
Attitude of responsible
person?
Attitude of responsible
person?
Reasonable
Hostile/
Indiffernt
Standard of general
conditions?
Poor
Attitude of responsible
person?
Hostile/
Indiffernt
Positive
ENFORCEMENT
NOTICE
NOTIFICATION OF DEFICIENCIES
32
Table 9: STRATEGIC FACTORS
Does the action coincide with the Public Interest?
Yes
The action results in a net benefit to the wider community in terms of targeting
resources on risk and meeting public expectations of the fire authority
No
The action results in a net disadvantage to the wider community in terms of
addressing risk, targeting resources on risk and failing to meet public
expectations of the fire authority
Are vulnerable groups protected?
Yes
The action results in control of risk to vulnerable groups
No
The action does not result in control of risk to vulnerable groups
What is the long-term impact of the action?
Sustained
The action is sufficient to achieve sustained compliance across the range of risks
Compliance
associated with the premises
No long-term
The action is insufficient to secure sustained improvements and that problems
impact
may be expected at subsequent visits
What is the effect of the action on other responsible persons?
Positive
Other responsible persons in the same industry, geographical location or wider
effect
business community are deterred from committing similar offences or
encouraged to adopt a more favourable view of fire safety requirements. The
action taken broadcasts a positive message about fire safety
Negative
The course of action undermines both positive responsible persons perception of
effect
the fire authority and the wider appreciation of the standard of fire safety required
What is the initial impact of the action?
Benchmark
The action secures compliance with the relevant benchmark
achiever
Incomplete
The action does not secure full compliance with the benchmark
compliance with
the benchmark
What is the functional impact of the action?
Acceptable
There is a net benefit to the employees and others who might be affected.
NB -Risk is the overriding concern, and that the wider impact may be a qualifying
issue, but is not definitive. E.g. Where the strict application of the law would
result in the closure of the premises or unemployment, then all of the
ramifications of the action are to be taken into account. The net benefit of the
enforcement action in this situation is for the inspector to judge
Unacceptable
There is a net disadvantage to employees and others who might be affected,
from the action taken.
NB - Risk is the overriding concern, and that the wider impact may be a
qualifying issue, but is not definitive.
Have the principles and expectations of the enforcement policy been met?
Yes
The policy has been followed
No
The policy has not been followed
33
Table 10: STRATEGIC FACTORS FLOW CHART
Does the action coincide with
The public interest?
No
Yes
Are vulnerable groups protected?
No
Yes
No long term
impact
What is long-term impact of action?
Sustained compliance
What is the effect of the action on other
responsible persons?
Negative
Positive
Benchmark
incomplete
What is the initial effect of the action?
Benchmark achieved
What is the functional impact of the
action?
Unacceptable
Acceptable
Have the principles and expectations of
the enforcement policy been met?
No
Yes
ACTION CONFIRMED
MANAGEMENT REVIEW OF ACTION
34
Table 11: FIRE SAFETY AUDIT AND DATA GATHERING FORM
AIDE-MEMOIRE
COMPLETING THE FORM
The following parts of the form are mandatory and shall be completed on every occasion, with the
exception to Multi Occupied premises where Part B will only be required on selected premises:


Part A
Part B
o
o
o
o

Management, all parts
Maintenance of Provisions, all parts
Means of escape - a sample of the Risk Critical components
Alterations notice
Part C
STEPS
1.
Complete the details in all parts of Section A & C of the form.
2.
Carry out on site assessment of the premises
3.
Complete Part B mandatory sections and a sample of the risk critical components in the
means of escape section, other sections of the form will be completed at the discretion of the
inspector. In the case of MO buildings part B is only necessary for selected premises.
4.
Enter the Compliance Level for each section used by placing a tick in the relevant box (1-35) at the end of each section or part. Some sections are non-applicable and will receive a
score of 0.
5.
A the end of part B determine the Compliance Level for the premises, this is carried out by
placing the relevant numbers in the boxes and using the following calculation:
TOTAL POINTS ÷ NUMBER OF SECTIONS USED = COMPLIANCE LEVEL
(<.5 round down, = or > .5 round up)
6.
Circle the Compliance Level for the premises in the Results of Audit section. In part C
select the appropriate score (1-5) as set against the compliance level score in the element,
“Fire safety management (Compliance level score -2 to 2).
7.
Complete Part C, “Management and Other Issues” and “Building and Occupant Features”
sections and total up the two sub totals A & B. Add the two sub totals to determine the life risk
score.
8.
By using the life risk score it is possible to determine the Relative Risk Level VL to VH by
using the equation shown on Table 13. A simpler alternative is to use the Risk Level
Calculator or similar software.
9.
Determine the expected level of enforcement by applying the Compliance Level (1 - 5) to
Table 4: Initial Enforcement Expectations.
10.
In the case of compliance level 3 and above, apply the Responsible Person and Strategic
Factors using Tables 5, 6, 7, 8, 9 & 10 to verify the indicated enforcement action.
35
11.
Where the indicated enforcement requires a management review, the Fire Safety Manager will
be required to sign the form in addition to the inspector.
12.
Compile any reports and Notices as necessary. Complete the Job Card with new Risk Rating
and date of next inspection if required. Return file to Fire Safety Administration for
processing.
36
Table 12: FIRE SAFETY AUDIT AND DATA GATHERING FORM
ADDITIONAL NOTES
Occupancy type - To complete details in this item the list Valuation Officer Codes should be consulted
and the relevant details from this list entered on the form.
Description of Occupants – The information required is whether the predominant type of occupant is
more or less vulnerable than the type of person most commonly found in the type of premises being
assessed. For example:
In an ordinary care home you would expect a normal mix of ambulant and non-ambulant elderly
residents who would be of “average mobility for this type of occupancy”. However if the majority of
residents were bedridden, the occupants would be “Un-typically vulnerable”.
In an ordinary school you would expect a normal mix of ambulant and non-ambulant children.
However if it was a school for the blind the occupants could be considered “Untypically vulnerable”. If
it was a school for gymnasts the occupants could be considered “atypically mobile”.
Sole supplier – If the building being assessed is a commercial or public sector building which
provides a high value or unique service, it should be identified in this section. Examples include
manufacture of specific items in the UK or perhaps the treatment of a particular disease available only
at certain hospitals.
Exceptional Value – Properties with a value of close to or exceeding £100,000,000 should be
included in this section. This approximates to the rebuilding and restocking of a large shopping
precinct
Heritage Risk – Details should be provided in this section if the building being assessed is of national
or international significance. There are no hard and fast rules but if the building is listed on the
National Monuments Record it could be considered a heritage risk. The National Monuments Record
is maintained by English Heritage and can be viewed on their website (Error! Bookmark not
defined.).
Community Loss – This question aims to identify buildings, which if involved fire could result in
significant consequential loss to the local community. The building may be occupied by a large
employer, if the business was unable to operate or even close many people would be affected
(unemployed).
To qualify, the loss of the building/business must represent more than an inconvenience, the number
of persons affected (unemployed) should be at least 100. Consideration should also be given to the
likelihood of people being able to find alternative employment in the area. The destruction of a local
school will be disruptive but alternative arrangements to educate pupils can normally be put in place
quite quickly.
Property Loss - The potential for loss due to an uncontrolled fire in the building of origin and the
potential for loss due to fire spread from the building of origin to surrounding buildings assuming no
intervention of any kind.
e.g. The potential for an uncontrolled fire in a heavily built up urban area spreading beyond the
building of origin to the surrounding buildings and streets.
37
Table 13: CALCULATING THE RELATIVE RISK LEVEL
The life risk score for the premises is a useful comparator for premises of the same occupancy type.
However, to get a relative risk, which allows comparison between different occupancy types as well
as different premises, the fire frequency of each occupancy type is needed.
Fig. 1 gives the fire frequencies (calculated from fdr1 figures and adjusted for occupied and
unoccupied hours) for different occupancy types
Occupancy
FSEC Group Number of fires per annum per 1,000,000
premises
Hospitals
A
357
Care Homes
B
83
Houses of Multiple Occupation (HMO)
C
Tenement
111
High Rise Flats
D
Purpose Built Flats >=4 storeys
111
Hostels
E
39
Hotels
F
29
Houses converted to flats
G
111
Other Sleeping Accommodation
H
31
Further Education
J
8
Public buildings
K
8
Licensed premises
L
11
Schools
M
10
Shops
N
50
Other premises open to the public
P
8
Factories and Warehouses
R
4
Offices
S
3
Other workplaces
T
4
Fig. 1: Annual fire frequencies
The relative risk rating of different premises can be calculated by multiplying the life risk score for the
premises by the fire frequency for the occupancy.
So for a care home with a life risk score of 10, the relative risk rating would be 0.000083 x 10 =
0.00083, whilst the relative risk for an office with a life risk of 10 would be 0.000003 x 10 = 0.00003
and finally the relative risk in an office with a life risk score of -10 would be 0.000003  10 =
0.0000003.
Negative life risk scores are more difficult to handle because they should reduce the fire frequency by
the factor of their size, but this can’t be a handled as a straight division because we need to take
account of the magnitude as well as the sign.
To make these number more manageable and to ensure that negative life risk scores are reflected
correctly, we take log10 of the fire frequency and the life risk score, and add them together and add 3
(simply to ensure positive values).
-
for a care home with a life risk score of 10,
3 + log10(10) + log10(0.000083) = 5.92
-
for an office with a life risk score of 10,
3 + log10(10) + log10(0.000003) = 4.48
-
for an office with a life risk score of -10
38
3 - log10(10) + log10(0.000003) = 2.48
The generic expression is:
IF(abs(Life risk score>=1),(LOG10(life risk score*(Fire
frequency/1000000)*1000000000)),(LOG10((fire frequency/1000000)*1000000000/-life risk score)))
These calculations are the basis for the relative risk levels in FSEC and those provided in table 1of
IRMP Guidance note 4 (although guidance note 4 is based on older fire frequencies and therefore
needs updating to be in line with those shown in this note) A Risk Level Calculator spreadsheet is
available which contains these calculations
39