Rosepark FAI

[Marek]

As a Fire Consultant and Training provider specialising in Residential Care I have been following the Fatal Accident Inquiry into the Rosepark Care Home Fire with interest.
http://www.heraldscotland.com/news/crime-courts/search-7.1010  (If you google 'Rosepark Fire Scottish Herald' - when on Herald site search 'Rosepark' for all reports on the FAI)Some of the issues that have arose are of no surprise, i.e. the doors to resident bedrooms being open, self closers removed, staff training - in particular lack of fire drills,  It is also interesting to note some of the witnessess who have provided evidence have had no involvement with the premises for a number of years prior to the fatal fire - a reminder that we are all accountable when offering advice or service in our professional roles.

There are 2 points I would like to raise:
1) Strathclyde Fire & Rescue had not inspected Rosepark since it opened in 1992 up and until the Fatal Fire in 2004. The then SFSO told the FAI that 'a routine inspection had not been carried out because they had not been invited by the owners or ever advised of any problems' The former Firemaster stated 'that despite SF&R having an obligation under the Fire Precautions (Workplace) Regulations 1997 it was not in a habit of officers to arrange inspections' In addition he told the FAI that a breakdown in communication between SF&R and the Care Commission meant that neither body conducted a fire safety check at the care home - each being under the assumption that the other was responsible for fire safety in residential care homes.
Comment
This suggests that SF&R had no reinspection programmes for care homes or other life risk premises; the Brigades I served in used to inspect high life risk every year, in the case of care homes copies of the inspection reports were sent to the registration authority.
The RRO has resulted in F&R carrying out fire safety audits on a risk based approach to check that the 'Responsible Person' has complied with their duties under the Order. I am aware of a number of care homes, in different fire authority areas, that have not have a visit or inspection since 2005. The number of Enforcement Notices and Prosecutions being undertaken suggests that standards are not being met or maintained; I have advised some of the care home owners (where I have not carried out the FRA) that the fire safety provisions in their premises do not meet those as recommended within the FRA guide for RCP's.
Question
Should F&R carry out more frequent inspections of Life Risk premises?
If Hampshire F&R had not carried out an inspection of Kitnocks House and served an Enforcement Notice.  we could be discussing another Rosepark as a fire occurred the following year resulting in one fatality.
www.hantsfire.gov.uk/776-809578.doc
http://www.carehome.co.uk/news/article.cfm/id/1546506/william-woodford-died-after-television-fire-at-kitnocks-house

2) It was estimated that there was a 8-10 minute delay in calling the F&R service, following advice given by SF&R following their attendance at a false alarm. The SFSO stated that their officers would not have given such advice and would have made it clear to staff to call the fire brigade everytime without delay.
Comment
As I understand, to assist with the reduction of call outs to AFD's, the F&R service have promoted the checking of fire zones first, unless there is a known or suspicion of fire. Staffing levels, time of day. occupancy, size of property and outcome of the FRA may determine that F&R is called immediately.
In practice most care homes, when staffing levels permit, send staff to check the fire zone first rather than calling out the F&R everytime the fire alarm activates. I have asked a number of fire officers on their views and if following the Rosepark FAI they would now recommend that 999 is called straight away - I have not had a definitive answer.
I follow a risk based approach, nature of occupancy, size and complexity of the building, staffing levels  and training etc.
I also work on the principle of sending 3 to check the zone, 1 to return leaving 2 to deal with any situation, this means that there must be at least 4 on duty, so when there is less than 4 the F&R are called immediately
Question
It would be interesting to know what your views are on this; in the light of Rosepark should the F&R be called immediately the fire alarm sounds irrespective of tiemof day, staff levels etc?

[JWatts]

Not sure whether it's just me your first link doesn't work for?

[kurnal]

I also work on the principle of sending 3 to check the zone, 1 to return leaving 2 to deal with any situation, this means that there must be at least 4 on duty, so when there is less than 4 the F&R are called immediately
Question
It would be interesting to know what your views are on this; in the light of Rosepark should the F&R be called immediately the fire alarm sounds irrespective of tiemof day, staff levels etc?

I follow a similar approach but where possible would recommend 2 to investigate, 1 to remain at the panel and maintain radio communication between them at all times.

I think it entirely valid to go and check for signs of fire before calling the Brigade. And to ensure the call is made immediately if there are any signs at all.

[Chris Houston]

I the Fire and Rescue Services standard request (if there is such a thing) was to investigate if there is a fire before calling them and that the initiatives to reduce unwanted fire calls had these very recommendations.  I'm thinking of the CFOA/London Fire Brigade initiative.

[Midland Retty]

I think it is reasonable to expect staff to investigate the cause of an alarm before calling the fire service.

If there is a genuine fire then one member of staff should be tasked to call the fire service, and get ready to meet and greet the crews on arrival, whilst the remainder of the staff should instigate horizontal evacuation.

Clearly at night this can be an issue, particular in larger care homes employing only two members of staff.
 
There has been much debate about staffing levels in the past, and prior to the Reg Reform (FS) Order (not sure how this plays out in the Scottish legislation) the fire service could not really comment on the number of staff.

The answer is it depends, it all depends on the amount of staff available, the number and mobility of the service users and of course pounds shillings and pence.

[Indiana]

I also think that it would be reasonable to check if there is a fire before calling the Fire Brigade out. After all, the evacuation of the premises should already be taking place and not be delayed. This evacuation is independent of whether the Fire Brigade are coming or not.

[Username]

We have four care homes, along with sheltered housing for the elderly in four retirement villages. There are staff on duty 24hrs and night staffing levels are fairly adequate.

The Fire Servive are automatically called to every alarm via a monitoring station. Once we have investigated we update the FRS via a follow-up call so that if it is a false alarm they have the option of turning back.

[nearlythere]

Check for Fire - Call Fire Service, or Call Fire Service - Check for Fire?
Both are problematic.
I go for the latter unless there is an issue with false alarms with good intent.
A real "damned if you do - damned if you don't" situation.

[noexpert]

In relation to the fire you linked to near Southampton, I noted that the newspaper article was along the lines of "the door closed, trapping the occupant in the bedroom with toxic fumes and fire" - blaming the door for the fatality. Maybe it's better to think that because the door closed, the fire spread was prevented...

I work in Ireland, where door closers on bedrooms in nursing homes are a hot topic in our area, and aren't present in some homes. Our view would be that door closers are a good thing - is that something that is a risk-assessed issue in England and Wales, or are door closers required by code?

In relation to the calling issue - I don't think we have as big a problem with false alarms as that, and our advice would be to get the fire brigade out as soon as possible. I can see the catch-22 other posters have referred to though, and if we were to get many false alarms there'd be a change in approach.

Oh, and hi all, this is my first post, I'm officially not a lurker now?

[nearlythere]

I work in Ireland, where door closers on bedrooms in nursing homes are a hot topic in our area, and aren't present in some homes. Our view would be that door closers are a good thing - is that something that is a risk-assessed issue in England and Wales, or are door closers required by code?

Welcome noexpert.
By trying to address one problem you can create another.
Elderly persons, particularily those with reduced mobilty and using zimmer frames can have trouble with self closing doors, and they can be quite hazardous. Fire safety is very important but so is quality of life.
There was a relaxation in the provision of self closers on bedroom doors provided compartmentation was provided. This, in addition to hold open devices on corridor doors, was considered to be a reasonable compromise by F&R Sevices and also allowed premises to reflect a more homely environment rather than a place of incarceration for the elderly.

[Midland Retty]

Hi Noexpert , welcome to the forums, you're definately not a lurker anymore.

With regard to self closers on doors... In simple terms the aim is to ensure that all fire doors are in the closed position when a fire occurs.

This can be achieved through several means ranging from normal positive self closing mechanisms to automatic hold open devices linked to the fire alarm which release, and thus close the fire door, on activation of the fire alarm. You could also have a system where staff are tasked to close certain fire doors too, so long is was well managed.

Previous guidance documents in England and Wales used to allow fire doors to be fitted without self closers in care homes depending on the amount of bedrooms within a fire compartment.

We're now in the days of risk assessment which allows some flexibility, and suits the desire to provide a homely environment for service users.

The government guides applicable to england and wales do from memory advocate the installation of self closing mechanisms on fire doors, but they are just guides, and so long as there is a method of ensuring doors can be closed upon activation of the fire alam, then this would demonstrate compliance with current legislation.

[kurnal]

We could spend ages arguing this minor topic- really theres a much bigger one hiding behind it.
What is the emergency plan for the building, are ALL staff well trained in it, do they understand it and do they practice it regularly?
If you look at the fires that have occurred in the past and the outcome of subsequent enquiries, it is these issues- training , understanding and drills - that have made the difference between life and death.

[Clevelandfire 3]

Be careful there . Self closers  and fire doors arent a minor topic. But I agree that they are just part of the bigger puzzle and that staff training is key especially in the care industry where staff turnover is high. Often migrant workers are employed and english isnt their first language . That can present communication barriers.

[kurnal]

Sorry C3 I was referring to the issue of "Check for Fire - Call Fire Service, or Call Fire Service - Check for Fire?" but did not make that clear.

[Chris Houston]

I also think that it would be reasonable to check if there is a fire before calling the Fire Brigade out. After all, the evacuation of the premises should already be taking place and not be delayed. This evacuation is independent of whether the Fire Brigade are coming or not.

Yes.  Good point.

Although I wonder if in reality all staff are needed for evacuation in a care home and if that leaves anyone able to check.  Many might have quite low numbers on at night.