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Fire Safety Policy Directive

REGULATORY REFORM (FIRE SAFETY) ORDER 2005 AUDIT PROCEDURES

ESSEX COUNTY

FIRE & RESCUE SERVICE

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Approval

Prepared and Approved By: Signature: Date: Reviewed By: Signature: Date:

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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 17

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PART 1 - REGULATORY REFORM (FIRE SAFETY) ORDER 2005 PROCEDURES

1. 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).

2. 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 “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.

2.3 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.

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.

3. 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:

Fire Prevention

Fire Protection

Fire Response

3.5 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.

4. 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:

The provision of active and/or passive fire safety systems,

the level of fire safety management provided, or

the size of the premises. 4.7 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 Very High Risk

Under provision High Risk

Normal provision Medium Risk

Over provision Low Risk

Significant over provision 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;

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.

5.2 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.

6. 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:

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. 3. 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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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.

4. 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 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.

4.2 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.

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 multi-occupied buildings a different approach is required. The premises not the building is the significant area under the Regulatory Reform (Fire Safety) Order 2005. Multi-occupied 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:

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.

5. 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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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.

6. 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:

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.

1.6 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.

2. 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.

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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.

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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.

18

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. 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.

4. 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.

19

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?

20

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

21

Table 1: RELATIVE RISK LEVEL MATRIX

Pre

mis

es U

se

Gro

up

Hospital

Care

Ho

me

HM

O T

en

em

ent

Purp

ose

Bu

ilt F

lats

=>

4 S

tore

ys

Hoste

l

Hote

l

House C

onvert

ed

to F

lat

Oth

er

Sle

epin

g

Accom

mo

datio

n

Furt

her

Education

Pub

lic B

uild

ing

Lic

ense

d P

rem

ises

Schoo

l

Sho

p

Oth

er

Pre

mis

es

Open t

o P

ublic

Facto

ry o

r

Ware

house

Offic

e

Oth

er

work

pla

ce

FSEC Group A B C D E F G H J K L M N P R S T

Relative Risk Rating

8

7.75

7.5

7.25

7

6.75

6.5 VH

6.25 H VH VH VH

6 H VH H H H

5.75 M H H H VH H VH

5.5 M H H H H VH H VH H

5.25 M M M M H H M H H

5 L M M M H H M H VH VH VH VH H VH

4.75 L M M M M M M M H H H H M H

4.5 VL L M L M M L M H H H H M H VH VH VH

4.25 L L L M M L M H H M M L H H H H

4 L L L L M VL L M M M M L M H H H

3.75 VL VL VL L L L M M M M L M M M M

3.5 VL L VL M M L L VL M M M M

3.25 VL L L L L L M M M

3 L L L L L L M M

2.75 VL VL VL VL VL L L L

2.5 L L L

2.25 VL VL VL

2

22

Table 2: FLOOR AREA SIZES BY OCCUPANCY TYPE

M2

FSEC Group

Extremely Small

Very Small

Small Medium Large Very Large

Extremely Large

-5 -3 -2 0 2 3 5

Hospitals < 500 500 to

650 651 to 2000

2001 to 10000

10001 to 50000

50001 to 100000

> 100000

Care Homes < 200 200 to 350

351 to 640

641 to 1500

1501 to 2500

2501 to 4500

> 4500

Houses in Multiple Occupation

< 30 30 to 80 81 to 300 301 to 700

701 to 2300

2301 to 20000

> 20000

Purpose Built Flats < 1400 1400 to 3000

3001 to 5000

5001 to 8300

8301 to 10300

10301 to 12600

> 12600

Hostels < 123 123 to 220

221 to 350

351 to 750

751 to 1900

1901 to 4000

> 4000

Hotels < 201 201 to 350

351 to 650

651 to 1300

1301 to 3600

3601 to 9500

> 9500

Houses Converted to Flats

< 251 251 to 300

301 to 400

401 to 500

501 to 600

601 to 1000

> 1000

Other Sleeping Accommodation

< 51 51 to 90 91 to 140 141 to 360

361 to 1500

1501 to 4200

> 4200

Further Education < 331 331 to 560

561 to 2000

2001 to 6000

6001 to 15000

15001 to 32000

> 32000

Public Buildings < 101 101 to 200

201 to 350

351 to 950

951 to 2700

2701 to 7500

> 7500

Licensed Premises < 151 151 to 250

251 to 400

401 to 700

701 to 1200

1201 to 2300

> 2300

Schools < 201 201 to 400

401 to 1000

1001 to 2500

2501 to 6000

6001 to 13000

> 13000

Shops < 61 61 to 130 131 to 200

201 to 500

501 to 1400

1401 to 6000

> 6000

Other Premises Open to the Public

< 101 101 to 175

176 to 300

301 to 1000

1001 to 3300

3301 to 8000

> 8000

Factories and Warehouses

< 101 101 to 260

261 to 715

716 to 2400

2401 to 7000

7001 to 15000

> 15000

Offices < 100 100 to 200

201 to 400

401 to 1000

1001 to 2700

2701 to 9400

> 9400

Other Workplaces < 51 51 to 100 101 to 300

301 to 600

601 to 700

701 to 800 > 800

23

Table 3: VALUATION OFFICER CODES

PRIMARY DESCRIPTION VO Code Residential (Dwellings) Single Private Dwelling R1 Self-Catering Holiday Unit CH1 Flats Or Maisonettes Up To 3 Floors Purpose Built R2 Flats Or Maisonettes 4 Floors And Over Purpose Built R3 Time Share Complex CC7 Houses Converted To Flats Up To2 Floors R4 Houses Converted To Flats 3 Floors And Over R5 Hostel MR HMO (Purpose Built Flatlets) R6 HMO (Converted to Flatlets) R7 HMO (Other) R8 Camping Site CC Caravan Park CC1 Chalet Park CC5 Caravan And Chalet Park CC6 Gypsy Caravan Site CC8 Residential (Institutional) Hospital MH2 Hospital (Private) MH3 (Care) Home For Older People (Over 65) MR1 (Care) Home For Adult Placements MR2 (Care) Home For Adults Aged 18-65 MR3 Adult Placement Schemes MR4 Domiciliary Care MR5 Children’s Homes MR6 Adoption Homes MR7 Residential Family Centres MR8 Foster Homes MR9 Boarding Schools MR10 Halls of Residence MR11 Accommodation For Students Under 18 By Further Education Colleges MR12 Childminders (Nursery and Sleeping) MR13 Police Station (With Cells) MP Prison (With Cells) MP2 Hotel CH Guest House (Up to 6 Guests) CH2 Motel CH3 Holiday Centre/Hotel (FPA Cert) CC2 Holiday Centre/Licensed (FPA Cert) CC2 Holiday Centre/Other Sleeping Accommodation (FPA Cert) CC2 Fire Station (With Sleeping Accom) MS1 Ambulance Station (With Sleeping Accom) MS2 Royal Palaces, Other Crown With Sleeping Accommodation TX Offices Office (FPA Cert) CO Office (Non Cert) CO Computer Centre (FPA Cert) CO1 Computer Centre (Non Cert) CO1 Offices (Local Govt)/Open to the Public (FPA Cert) ML

24

Offices (Local Govt)/Open to The Public (Non Cert) ML Offices (Local Govt)/Not Open to the Public (FPA Cert) ML1 Offices (Local Govt)/Not Open to the Public (Non Cert) ML1 Forces Careers Office (FPA Cert) TD1 Forces Careers Office (Non Cert) TD1 Police Station (No Cells) (FPA Cert) MP Police Station (No Cells) (Non Cert) MP Bank (FPA Cert) CS1 Bank (Non Cert) CS1 Shops And Commercial Shop Not Listed Below (FPA Cert) CS Shop Not Listed Below (Non Cert) CS Shop Not Listed Below (Other) CS Petrol Filling Station CG Car Showroom (FPA Cert) CG3 Car Showroom (Non Cert) CG3 Market (Indoor) (FPA Cert) CM1 Market (Indoor) (Non Cert) CM1 Licensed – Restaurant (FPA Cert) CR Licensed – Restaurant (Non Cert) CR Unlicensed- Restaurant (FPA Cert) CR3 Unlicensed- Restaurant (Non Cert) CR3 Licensed – Café (FPA Cert) CR1 Licensed – Café (Non Cert) CR1 Unlicensed –Café (FPA Cert) CR4 Unlicensed –Café (Non Cert) CR4 Food Court (FPA Cert) CR2 Food Court (Non Cert) CR2 Betting Shop (FPA Cert) CS2 Betting Shop (Non Cert) CS2 Hairdressing Salon (FPA Cert) CS3 Hairdressing Salon (Non Cert) CS3 Kiosk/Shop (FPA Cert) CS4 Kiosk/Shop (Non Cert) CS4 Kiosk/Office (FPA Cert) CS41 Kiosk/Office (Non Cert) CS41 Laundrette (FPA Cert) CS5 Laundrette (Non Cert) CS5 Post Office (FPA Cert) CS6 Post Office (Non Cert) CS6 Showroom (FPA Cert) CS7 Showroom (Non Cert) CS7 Hypermarket (FPA Cert) CS8 Hypermarket (Non Cert) CS8 Superstore (FPA Cert) CS9 Superstore (Non Cert) CS9 Shopping Centre (FPA Cert) CS Assembly & Recreation Public House CL Wine Bar CL1 Club (Social) (Licensed) CL2 Club Social) (Unlicensed) CL21 Club House (Licensed) LC1

25

Club House (Unlicensed) LC11 Cinema LT Bingo Hall/Licensed LT2 Bingo Hall/Non Licensed LT2 Theatre LT3 Night Club PL1 Casino PL2 School EL School (Private) EP Day Nursery EN1 College (Public) EL1 College (Private) EP1 University EU Other Education, Training And Cult. EX Library (FPA Cert) EM Library (Non Cert) EM Museum EM1 Community Centre LC Leisure Centre LC2 Hall LC3 Sports Centre LI Stadium LI1 Sports Ground (Designated Sports Ground) LS Sports Ground (Non Designated) LS11 Sports Ground (Regulated Stands) LS12 Sports Ground (Non Regulated) LS13 Football Ground (Non Designated) LS5 Swimming Pool LS6 Tennis Centre LS7 Amusement Arcade LT1 Crematorium (FPA Cert) MC1 Crematorium (Non Cert) MC1 Place Of Worship AR2 Surgery (Doctors, Dentists Or Vets) MH Health Centre MH1 Law Court (FPA Cert) MP1 Law Court (Non Cert) MP1 Bus Station (FPA Cert) NT Bus Station (Non Cert) NT Auxiliary Defence Establishment TD2 Railway Station (FPA Cert) AR3 Railway Station (Non Cert) AR3 Sub-Surface Railway Station (FPA Cert) AR4 Sub-Surface Railway Station (Non Cert) AR4 Airport Or Ferry Terminal (FPA Cert) AR5 Airport Or Ferry Terminal (Non Cert) AR5

Industrial

Vehicle Repair (FPA Cert) CG1 Vehicle Repair (Non Cert) CG1 Garage (FPA Cert) CG2 Garage (Non Cert) CG2 Factory (FPA Cert) IF Factory (Non Cert) IF

26

Mill (FPA Cert) IF1 Mill (Non Cert) IF1 Works (FPA Cert) IF2 Works (Non Cert) IF2 Workshop (FPA Cert) IF3 Workshop (Non Cert) IF3 Brickworks (Structures Only) (FPA Cert) IM2 Brickworks (Structures Only) (Non Cert) IM2 Concrete Batching Plant (Structures Only) (FPA Cert) IM3 Concrete Batching Plant (Structures Only) (Non Cert) IM3 Other Industrial Mineral (Structures Only) (FPA Cert) IMX Other Industrial Mineral (Structures Only) (Non Cert) IMX Industrial Miscellaneous (Structures Only) (FPA Cert) IX Industrial Miscellaneous (Structures Only) (Non Cert) IX Sewage Treatment Works Structure) (FPA Cert) NW Sewage Treatment Works Structure) (Non Cert) NW

Storage & Other Non-Residential

Retail Warehouse (FPA Cert) CS10 Retail Warehouse (Non Cert) CS10 Warehouse (Unknown Use) CW Storage Depot/Factory Or Warehouse CW2 Storage Depot/Other Workplace CW2 Store (Unknown Use) CW3 Explosive Or Highly Flammables Store (E28a) S1 Explosive Or Highly Flammables Store (E29) S2 Explosive Or Highly Flammables Store (E29a) S3 Public Car Park (Covered Or Multi Storey) CP Private Car Park (Covered Or Multi Storey) CP2 Other Commercial Premises (Unknown Use) CX Business Unit (Unknown Use) IF4 Laboratories/Research Establishment OC1 Animal Boarding Or Breeding Establishment OC2 Fire Station ( No Sleeping Accom) (FPA Cert) MS1 Fire Station ( No Sleeping Accom) (Non Cert) MS1 Ambulance Station (No Sleeping Accom) (FPA Cert) MS2 Ambulance Station (No Sleeping Accom) (Non Cert) MS2 Railway Premises (Not Stations) (FPA Cert) OC3 Railway Premises (Not Stations) (Non Cert) OC3 Vacant Or Unoccupied Premises OC4 Outdoor Workplace/Event Market (Outdoor)/Public Or Trade CM Storage Land/Used By Public Or Trade CW1 Dock Hereditament FD Electricity Hereditament FE Quarry IM Tipping Site/Public Or Trade IM4 Spoil Heap Workings IM5 Golf Course LS2 Marina LS3 Amusement Park LT4 Other Leisure LX Cemetery MC Mooring NT1

27

Wharf NT3 Mine IM1 Road Haulage CG4 Transport System Tunnel Or Bridge etc OW1 Outdoor Public Event OP1 Remaining Valuation Codes Advertising Right CA Advertising Station CA1 Caravan And Pitch CC3 Caravan Pitch CC4 Car Parking Space CP1 Peat Fields (Structures Only) IM6 Beach Hut LH1 Sporting Right LS1 Playing Field LS4 Communication Station MT1 Public Telephone Kiosk MT2 Other Communication MTX Other Miscellaneous MX Other Non-Formula NX

28

Table 4: INITIAL ENFORCEMENT EXPECTATIONS

Note - Prohibition/Prosecution may be considered regardless of the premises overall compliance

level

Compliance Level Description

Enforcement Expectation

Compliance Level 5

resulting in deficiencies so serious as to pose a serious risk to persons in case of fire

FOLLOW UP AUDIT ALWAYS REQUIRED

Prohibition

Compliance Level 4

Generally workplace risk rating very high/high

require structural alterations

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

Compliance Level 3

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

Consider referral to CFS if appropriate FOLLOW UP AUDIT ALWAYS REQUIRED

Enforcement Notice Notification of Fire Safety Deficiencies

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.

FOLLOW UP AUDIT NOT NORMALLY REQUIRED

Notification of Fire Safety Deficiencies

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

Notification of Fire Safety Deficiencies Educate & Inform

29

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 economic advantage sought

Responsible person is deliberately avoiding minimum legal requirements for commercial gain

No economic advantage sought

Failure to comply is not commercially motivated

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 compliance

Full compliance across the whole range of indicators with no notable omissions

What is the attitude of the responsible person?

Hostile/ indifferent

The responsible person is actively antagonistic, or generally uninterested in fire 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

30

Table 6: RESPONSIBLE PERSON FACTORS FLOW CHART

INITIAL ENFORCEMENT EXPECTATION - PROHIBITION NOTICE

PROHIBITION NOTICE

Yes

No

Previous relevant documented

enforcement?

Relevant incident history? Yes

No

Intention of responsible person?Deliberate economic

advantage sought

No economic advantage sought

Cause of Perceived/Actual Harm? Deliberate

Omission

Inspection history? Poor

Average

Standard of general Conditions? Poor

ReasonableStandard of general

Conditions?

PROHIBITION

NOTICEAND

CONSIDER

PROSECUTION

Poor

31

Table 7: RESPONSIBLE PERSON FACTORS FLOW CHART INITIAL ENFORCEMENT EXPECTATION - ENFORCEMENT NOTICE

ENFORCEMENT

NOTICE

Previous relevant

documented enforcement?

No

Relevant incident history?

Intention of responsible person?

No economic advantage sought

Level of perceived harm?

Not serious

Inspection history?

Average

Standard of general Conditions?

Reasonable

Attitude of Responsible Person?

No

Poor

Yes

Yes

Deliberate economic

Advantage sought

Serious

Poor

Standards of

general Conditions?

Poor

AndCONSIDER

PROSECUTION

Attitude of

Responsible person?

Good ACTION PLANENFORCEMENT

NOTICEAnd

Poor

Good

Standard of general

conditions?

Good

Good

32

Table 8: RESPONSIBLE PERSON FACTORS FLOW CHART

INITIAL ENFORCEMENT EXPECTATION – NOTIFICATION OF DEFICIENCIES

NOTIFICATION OF

DEFICIENCIES

Previous relevant

enforcement?

No

Relevant incident history?

Intention of responsible person?

No economic advantage sought

Inspection history?

Average

Standard of general conditions?

Reasonable

No

Yes

Yes

Deliberate economic

advantage sought

Poor

Poor

Good

Attitude of responsible

person?

Reasonable

Standard of general conditions?

ReasonableStandard of general

conditions?

Hostile/

IndifferntPoor

Good

Attitude of responsible

person?

Attitude of responsible

person?

Hostile/

IndifferntPositive

NOTIFICATION OF DEFICIENCIESENFORCEMENT

NOTICE

33

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 Compliance

The action is sufficient to achieve sustained compliance across the range of risks associated with the premises

No long-term impact

The action is insufficient to secure sustained improvements and that problems may be expected at subsequent visits

What is the effect of the action on other responsible persons?

Positive effect

Other responsible persons in the same industry, geographical location or wider 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 effect

The course of action undermines both positive responsible persons perception of the fire authority and the wider appreciation of the standard of fire safety required

What is the initial impact of the action?

Benchmark achiever

The action secures compliance with the relevant benchmark

Incomplete compliance with the benchmark

The action does not secure full 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

34

Table 10: STRATEGIC FACTORS FLOW CHART

Does the action coincide with

The public interest?

Yes

Are vulnerable groups protected?

Yes

What is long-term impact of action?

Sustained compliance

What is the effect of the action on other

responsible persons?

Positive

What is the initial effect of the action?

Benchmark achieved

What is the functional impact of the

action?

Acceptable

Have the principles and expectations of

the enforcement policy been met?

Yes

ACTION CONFIRMED

No

No

No long term

impact

Negative

Benchmark

incomplete

Unacceptable

No

MANAGEMENT REVIEW OF ACTION

35

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 Management, all parts o Maintenance of Provisions, all parts o Means of escape - a sample of the Risk Critical components o 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 (1-3-

5) 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.

36

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.

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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.

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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) Tenement

C 111

High Rise Flats Purpose Built Flats >=4 storeys

D 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

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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