The place of PEEPs

As part of Ventro’s latest fire safety webinar, Elspeth Grant examined the current status of PEEPs and their importance in healthcare settings

There is a common perception that recently we are being hit by new fire safety regulations and laws almost on a monthly basis. However, how much has really changed and where do Personal Emergency Evacuation Plans (PEEPs) fit in?

The Regulatory Reform (Fire Safety) Order (FSO) has been on the statute books since 2006 and there have only been very small changes to it since its release. From the outset it has been a legal requirement that everyone has to be able to leave a building in the event of a fire, that there has to be appropriate procedures for this, with fire safety drills taking place, and that a sufficient number of competent people to implement those procedures must be nominated. One of the key points to note is that there are no exclusions for disabled or temporarily impaired people from those legal requirements.

Further to this, Home Office guidance as it stands reinforces these legal requirements such that any evacuation plan should not rely upon the intervention of the fire and rescue services to be successful. In sleeping accommodation and residential care premises, once a fire has started, everyone in the premises should be able to escape to a place of total safety outside the building.

Whilst the legislation has changed little since coming into law, in recent months there have been a number of prosecutions that provide us with lessons as to how the authorities are approaching fire safety and evacuation failings.

Cheshire Fire and Rescue Service has started a prosecution of six companies following a fire at Beechmere Retirement Village in 2019 where the building was completely destroyed. It is interesting to note that these prosecutions are going ahead despite there being no injuries or fatalities because it is alleged that there was a failure to establish and give effect to appropriate evacuation procedures, including safety drills.

Whilst this legal action is ongoing and we have yet to see whether it will come to court, in July 2024 two care home directors were prosecuted over fire safety failings in their buildings and were fined £124,455 and received criminal records. The enforcement notices that preceded this prosecution stated that the fire risk assessment needed to adequately address the needs of all people, including disabled people.

The judgment on these convictions said, “the number of vulnerable residents placed at risk due to the defective fire doors and lack of detection alarms raised the level of harm to a higher level”, with the judge adding that “the owner should have taken the time to understand published regulations and guidance when providing this type of service”. These cases show the level to which responsible persons must engage with all regulations and guidance, including that around evacuation planning.

Producing a PEEP

Too often there is confusion over what must be produced to meet the requirements. To begin with, there is a clear difference between a Person-Centred Fire Risk Assessment (PCFRA) and a PEEP. A PCFRA is about protecting individuals from fire and preventing it occurring in the first place. It is not an evacuation plan to total safety, which is what the law requires.

A PCFRA certainly has its place in a healthcare environment, as they address things like oxygen cylinders, air mattresses, and storage of incontinence pads whose flammability can exacerbate a fire.

A PEEP, on the other hand, is a document with a plan of action agreed with residents that have mobility impairment or reduced capacity to self-evacuate the building. There must be a plan to evacuate them to a place of total safety, irrespective of whether a person can evacuate vertically, or whether there is a ‘stay put’ policy for the building. It is still a legal requirement to have a plan to get everybody out of the building if necessary. It is also worth remembering that having to go through an emergency rescue process can be a brutal experience, particularly for frail, elderly, or even young people with complex conditions. If the individual’s specific needs have not been thought about, then these conditions and impairments are likely to be exacerbated during an evacuation.

Mental health and any neurodiversity, such as symptoms of dementia, must also be considered when you approach evacuation planning, and it should be remembered that it is very much a personal emergency evacuation plan. The needs of that individual, what their capabilities are, what the challenges are, must be taken into account when devising an emergency plan. Another key part of creating the PEEP is testing the plan and helping the individual understand what they need to do, because one of the issues with any neurodiversity is that a neurodiverse person may feel the need to hide in an emergency rather than evacuate or try to re-enter the building, as they may not recognise any danger. An awareness of the potential impact of neurodiversity and mental health is a key consideration when creating a PEEP, particularly in a hospital or care home environment.

I advise everyone to go back and read the Enforcements and the sanctions for non-compliance document  published by the government in February 2024, which makes it very clear about the personal responsibilities of managers and directors. When going through the PEEPs process, make sure that you fully document it as this will provide an appropriate and useful audit trail.

There is a view taken by some that only employees can provide assistance, and in a care home environment this will probably be the case. In any other environment we suggest avoiding using employees to assist in evacuations wherever possible because of the Management of Health and Safety at Work Regulations 1999. These regulations require a full risk assessment be completed to ensure that the employee is not put in danger if the planned PEEP involves an employee. Alongside this, it would be very unwise to put in a contract to expect an employee to stay in a burning building to help a disabled person, even if they are part of a waking watch or the building’s concierge team.

Returning to care homes, if an employee is used to provide assistance, they must be given the time and the means to properly fulfil these functions. They must also be competent and have had sufficient training, experience, and knowledge to assist them in undertaking the preventative and protective measures required.

PEEPs in the new regime

The new Building Safety Regulator (BSR) has the authority to regulate care homes and hospitals during their design and construction phases, although not during the occupation phase. The BSR is a statutory consultee for relevant buildings and review applications submitted to planning authorities. The BSR has made it very clear that it wants fire safety fire engineering to be embedded from day one of any project, as all too often fire engineering or fire safety comes into play at too late a stage.

Being a part of the Health and Safety Executive (HSE) it should also be expected that the BSR will be just as meticulous about legislation, regulations, and guidance and the enforcement thereof. For example, Building Regulations ‘Approved Document B Volume 2: means of escape’ has been in effect since 2010, and was amended in 2019 to include the requirement that all people can escape to a place of safety without external assistance. This requirement is very specific and I would suggest that under the new regime, those not complying with this requirement are going to find themselves under the enforcement spotlight.

Once the construction phase has finished, but before a new building can be occupied it must be issued with a completion certificate from the BSR. We must therefore expect the BSR to look for detailed evidence that demonstrates a building was constructed according to the approved plans and changes, and that it meets all building regulations. This includes those regulations concerning means of escape, and particularly the evacuation of disabled people. It is therefore imperative that these considerations need to be embedded in a project from day one.

By developing strategies for individual PEEPs and accessing tools to ensure both plans and staff meet the legal requirements, responsible persons can ensure not only the safety of all building residents, but also that they themselves remain legally compliant. If a responsible person or an organisation decide to have insufficient or inadequately trained staff in place to carry out an evacuation, then they risk a subsequent prosecution. We are now entering a very different regulatory and enforcement environment and I would suggest that the risks in not complying with the requirements to have suitable PEEPs in place are now considerably higher.

For more information on the training available via Triple A Solutions, visit their website here

You can access the full Healthcare webinar from Ventro Fire Compliance and find out details of the rest of their Fire Safety Webinar programme here.

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Elspeth Grant is the CEO of Triple A Solutions