Sample policy · Fire Safety

Fire safety policy template

Statutory anchor: Regulatory Reform (Fire Safety) Order 2005 (SI 2005/1541). The same fire-safety duties engage Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). · primary source

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Verivius pack version v1, 2026-06-10

1. What the regulation says

The primary fire-safety duties sit in the Regulatory Reform (Fire Safety) Order 2005, from which the verbatim text below is drawn. The same fire-safety duties also engage Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

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

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

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responsible person regularly so as to keep it up to date and particularly if (a) there is reason to suspect that it is no longer valid; or (b) there has been a significant change in the matters to which it relates including when the premises, special, technical and organisational measures, or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

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

The full text of the Order is at https://www.legislation.gov.uk/uksi/2005/1541/contents, and the engaged CQC regulations are at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/15. Where this policy and the live source diverge, the live source wins.

2. Plain-English summary

The Regulatory Reform (Fire Safety) Order 2005 places fire safety duties on the Responsible Person for any non-domestic premises in England and Wales. For most ISC providers, the Responsible Person is the employer where the premises are under their control. The load-bearing duties are: take such general fire precautions as will ensure the safety of employees and other relevant persons (Article 8); conduct a suitable and sufficient Fire Risk Assessment to identify those precautions (Article 9); record the FRA and review it regularly, particularly when there is reason to suspect it is no longer valid or when there has been a significant change in the premises, fire safety measures, or work organisation (Article 9(3) and 9(6)); plan and implement fire safety arrangements proportionate to the assessed risks (Article 11); and ensure staff receive adequate fire safety training (Article 21). In healthcare premises, an additional operational concern is the choice between simultaneous-evacuation and progressive-horizontal (stay-put-and-relocate) strategies; the choice depends on the premises' compartmentation, building design, and patient population, and is a matter for the FRA to address. Since 1 October 2023, Section 156 of the Building Safety Act 2022 has amended the Fire Safety Order so that all Responsible Persons must record the fire risk assessment in full, record their fire safety arrangements, and cooperate and share relevant fire safety information where duties overlap; the former "five or more employees" recording limitation no longer applies.

Under the engaged CQC regulations, care and treatment must be provided in a safe way: this means assessing the risks to people's health and safety, doing all that is reasonably practicable to mitigate those risks, and ensuring that the premises are safe to use for their intended purpose and used in a safe way. Regulation 15 requires premises and equipment to be clean, secure, suitable, properly used, properly maintained and appropriately located. Fire safety is one of the clearest ways a service evidences these duties for its premises.

3. Scope

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

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

(Tenant updates the named role-holders.)

5. Procedure

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

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

6. Training requirement

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

7. Audit

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

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

8. Record-keeping

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

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

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

9. Related policies in this pack

10. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

11. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

12. Document control

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names the Fire Safety Lead and Fire Warden roles. Section 5 expanded to a 10-step procedure covering FRA, review cycle, evacuation strategy, arrangements, testing and maintenance per BS 5839/BS 5266, evacuation drills, PEEPs, training, incident reporting, FRS liaison. Section 6 names training tiers. Section 7 names the five audit cadences (weekly to annual). Section 8 names the 6-year minimum retention and the 12-year-aligned-to-limitation-period option.
v1 (pack) 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Added the verbatim "What the regulation says" blockquotes from the engaged CQC Regulations 12 and 15, the Plain-English summary, Sources and further reading, and When to seek further advice. The original Scope, Roles, Procedure, Training, Audit, Record-keeping and Related-policies sections are preserved unchanged.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Fire is the premises risk where the people you care for are also the reason evacuation is hard. Someone sedated, bed-bound, living with dementia or dependent on piped oxygen cannot simply walk out when the alarm sounds, and a strategy that would keep a fully mobile office safe can be fatal in a care setting. That is why the evacuation strategy has to be matched to the building's compartmentation and to the actual dependency of the people in it, and why a Personal Emergency Evacuation Plan has to track a person's changing condition rather than sit frozen at the date they were admitted. Progressive horizontal evacuation only works if the compartment it moves people into still holds, which is exactly what an extension, a knocked-through wall or a wedged fire door quietly undoes. The evidence trail matters for what it buys on the night: a Fire Risk Assessment that has seen the building as it is now, a maintenance register with no gaps, and a drill someone actually watched and learned from are the difference between staff who know who they are moving and how, and a night shift improvising in smoke with the wrong number of hands. When the assessment is stale or the corridor is stacked with equipment, the person who pays is the one who could not get themselves out. What an inspector sees is downstream of that.

  1. The Fire Risk Assessment is current and recorded in full, dated with the reviewer named, reviewed at least annually and immediately on any significant change to the premises, work or population, so the precautions match the building as it stands today. An assessment years out of date, or a significant building change with no interim review, leaves the night shift working to a plan for a building that no longer exists.

    Strong evidence: The current dated Fire Risk Assessment (FRA) held with the premises records, plus the annual FRA review and any interim review triggered by a significant change (Procedure steps 1, 2; Audit).

    Weak evidence: A Fire Risk Assessment that is a one-page tick sheet naming no competent assessor, or a full assessment that predates the extension, the reconfigured unit or the shift to more dependent people now admitted. The statutory trigger is a significant change to the premises, the work or the population, so the real danger is a building that has changed and an assessment that has not; the annual cycle is the service's own standard, not the legal test. A partial or unrecorded assessment is a gap in its own right, now that the recording duty applies whatever the staff headcount.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Regulatory Reform (Fire Safety) Order 2005, art 9(1) and 9(3)(b), with the recording duty in art 9(6)-(7) as amended by Building Safety Act 2022 s.156

  2. The testing-and-maintenance cycle actually ran at its stated frequency, rather than only being scheduled, with no gap in the weekly detection test and no lapsed annual service certificate.

    Strong evidence: The premises maintenance register (weekly detection test, monthly escape-lighting, fire-door and extinguisher inspections) and the annual servicing certificates filed with the premises records (Procedure step 5; Audit).

    Weak evidence: A maintenance schedule that lists the weekly detection test against a register with month-long gaps, initials with no dates, or a run of identical ticks entered in one sitting. An annual service certificate that expired months ago, or escape lighting and extinguishers with no monthly evidence at all, show a cycle that was planned but never actually run. Testing the wrong thing counts too: a weekly test that hits the same call point every week leaves most of the building unproven.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The evacuation strategy the Fire Risk Assessment specifies matches the building's compartmentation and its patient population, and it is tested, with the drill observed, timed and its failures turned into improvement actions, not a strategy assumed on paper for people it cannot move safely.

    Strong evidence: The FRA's evacuation-strategy section and the annual evacuation drill record showing time-to-clear and failures logged as improvement actions (Procedure steps 3, 6; Audit).

    Weak evidence: A drill record that logs only the date and a tick, with no note of what went wrong and nothing carried into the improvement actions. A strategy that assumes progressive horizontal evacuation into a compartment that no longer holds after an extension or a knocked-through wall, or that assumes everyone leaves at the alarm when some people cannot be moved without two staff and a piece of equipment, repeated on the same paper year after year with no failure ever turned into a change.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Regulatory Reform (Fire Safety) Order 2005, art 15(1)(a), read with art 9(1) and art 14

  4. Anyone who cannot use the standard evacuation has a current Personal Emergency Evacuation Plan recorded against them, reviewed annually and on any change of circumstance, not a plan that predates a change in their condition.

    Strong evidence: The Personal Emergency Evacuation Plan (PEEP) recorded against the individual and its annual and on-change review (Procedure step 7; Record-keeping).

    Weak evidence: A generic evacuation note that could apply to anyone, rather than a Personal Emergency Evacuation Plan naming the person, their specific mobility, cognitive or sensory need, and who moves them and how. A plan dated before the stroke, the new wheelchair or the move to bed-based care is a plan for a person who no longer exists, and someone who cannot self-evacuate with nothing recorded against them at all is the sharpest gap on the floor.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Fire doors and escape routes are kept clear and closed in practice, verified on the day by walking the route during the monthly inspection round rather than asserted in the policy, so a wedged fire door or a blocked escape route is found and cleared before someone needs that exit.

    Strong evidence: The monthly inspection round record covering escape lighting, fire doors and closers, extinguishers, signage, escape routes kept clear and refuge points (Procedure step 4; Audit).

    Weak evidence: The policy asserts routes are kept clear while the corridor holds stacked equipment, a fire door is wedged with a bin or propped by a chair, and a final exit is locked or blocked on the day. A monthly inspection round signed off as all clear that the walk-round immediately contradicts is the tell that the record was completed at a desk rather than on the floor.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Regulatory Reform (Fire Safety) Order 2005, art 14(2)(a) and art 17(1)

  6. A real fire, serious false alarm or fire-safety near miss is logged in the incident register and, where it results in death or serious injury, tested against two separate duties: the threshold for a report under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) to the Health and Safety Executive, and, independently, the threshold for a statutory notification to CQC under the Care Quality Commission (Registration) Regulations 2009. One does not discharge the other, and logging it locally discharges neither.

    Strong evidence: The incident-register entry and the spawned RIDDOR report and CQC notification where the death or serious-injury threshold is met (Procedure step 9).

    Weak evidence: A fire or serious false alarm logged in the local incident book and closed there, with no report under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) to the Health and Safety Executive where someone was killed or suffered a reportable injury, and no separate Care Quality Commission (CQC) statutory notification where that threshold is met. Two further tells: a fire that injured nobody but suspended normal work, dismissed as unreportable when the RIDDOR dangerous-occurrence route may still apply; and a near miss such as a detector found dead only during a real alarm, recorded nowhere, so the event never spawned the duties it should have.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    RIDDOR 2013 reg 4, reg 5 and reg 7 with Schedule 2 (fire as a dangerous occurrence); Care Quality Commission (Registration) Regulations 2009, regs 16 and 18

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Last verified 20 July 2026

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Last reviewed 10 June 2026