Primary legislation and enforcement – audit and inspection process


The aims of the Warwickshire Fire and Rescue Service (WFRS) audit and inspection process are to reduce the risk and impact of fire on the community, safeguarding our fire-fighters, heritage and environment, reducing injuries and the loss of life and reducing commercial, economic and social costs. Consequently our statutory duty to enforce fire safety law and promote fire safety will be based on risk, providing our community with value for money.

Premises managed by public, commercial or voluntary organisations, which present the highest risk, will be audited and inspected on a more frequent basis.

Premises considered to be lower risk will be audited primarily in response to complaints, following incidents or on a random basis, to verify their lower risk classification and to confirm that the responsible person(s) are complying with the requirements of fire safety law.

WFRS have adopted the general audit procedures developed through the Chief Fire Officers’ Association (CFOA) in partnership with the Department of Communities and Local Government (CLG). These procedures will enable delivery of a risk based audit and inspection programme, aligned to the Government’s current Integrated Risk Management Planning Guidance Notes and the Fire and Rescue Service National Framework guidance.

Audit, inspection and enforcement activities will be carried out in accordance with the Enforcement Concordat and will embody the principles, expectations and methodology of the Enforcement Management Model (EMM), which is produced by the Health and Safety Executive (HSE) and is considered to be national best practice; our policies will comply with the requirements of the Government’s Regulators’ Code.

With regard to the adequacy of fire safety provisions, national guidance will be used, primarily the fire risk assessment guidance documents issued by HM Government, to judge the adequacy of fire safety arrangements in premises. We will also recognise other fire risk assessment methods that are equally valid.
Adherence to relevant British Standards and particular standards produced by other bodies will generally indicate that the responsible person has done enough to comply with the law. However, the outcome of the fire risk assessment process may indicate that compliance with fire safety law may be achieved by an alternative method.

WFRS will provide fire safety education, information and advice, where appropriate, but will not undertake fire risk assessments.

Over time, the collection of data and the audit and inspection process will bring about a reduction in community risk and enable the Fire and Rescue Authority’s IRMP to be further refined.

The audit and inspection will be open, transparent, fair and audit-able. The requirement to comply with fire safety law rests firmly with the ‘responsible person,’ not the Fire and Rescue Authority.

Except in cases of extreme non-compliance or where relevant people have been put at serious and probable risk, we will seek to work with the ‘responsible person’ to assist them to meet their obligations under the Regulatory Reform (Fire Safety) Order 2005 (FSO).

Risk based inspection programme

The development and management of a Risk Based Inspection Programme provides important data to assist in the development and evaluation of the Service’s Integrated Risk Management Plan (IRMP). This enables the Service to fulfil its duty to manage the fire risk in the community.

There are three principle areas that will enable the Fire and Rescue Authority to manage the fire risk in the community. These are:

  • Fire Prevention
  • Fire Protection
  • Fire Intervention.

This integrated approach recognises that activity in one or more of these areas has the potential to reduce the risk in the community. However, in situations where it may not always be possible to reduce the risk to an acceptable level using Statutory or Community Fire Safety initiatives, the information gathered will be used to provide an appropriate level of fire cover.

Determining the level of risk

The Risk Based Inspection Programme forms part of the Service’s overall integrated approach to management by prioritising the inspection of premises. To achieve this, the level of compliance with the FSO within a premises is determined by the carrying out of an on-site audit which will, on completion, apply a risk rating which not only reflects the compliance with the FSO, but also the potential for the loss of life or serious injury linked to occupancy type.

Where premises have a very high heritage value, community value or unique services value or where excessive environmental damage or fire-fighting difficulties would be present in fire, the initial risk rating is re-assessed on an individual case by case basis and may be adjusted to acknowledge this fact, both at a local and national level.

The audit process

The process for carrying out a fire safety audit of premises is determined by the level of risk presented by those premises, regardless of what other legislation might apply to them.

Audits will be carried out on all known premises following a pre-determined inspection programme, based on the overall risk score that has been allocated.

In addition to this, audits will also be carried out following:

  • Receipt of selected Building Regulations Completion Certificates/Final Notices
  • Notification of a serious fire incident
  • Notification from Operational Personnel of a serious risk to persons due to the lack of fire protection measures within a premises, and
  • An application for a new licence under other statutory regulations or acts of parliament.

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 enforcement activity have been determined are reasonable, recorded, transparent and auditable.

The fire safety audit methodology

All hospitals, care homes, hostels, boarding schools, night clubs and hotels will be included in the programmed audit process where they have been judged to have an overall risk score that indicates poor compliance.

All other types of premises will be audited based on societal risk or locally identified specific risk. This will include a minimum yearly audit of 10% of Schools and Further Education Establishments, 10% of Shops and Retail Premises, 5% of Offices, 3% of Factories and Warehouses, and 3% of Licenced Premises, from known premises with a risk score that indicates poor compliance.

All premises, other than those indicated in the first paragraph above, will initially be subject to a pre-inspection information gathering process prior to any audit taking place, allowing an indication of compliance with the FSO to be obtained and thereby allowing a determination as to whether a full audit is required, subject to the minimum yearly audit targets being met from the second paragraph above.

Where no audit has been carried out and little or no information is known the overall risk score will be set to poor compliance.

Premises with a risk score that indicates average compliance or better will be audited by sample only, taking into account available Service resources.

This inspection methodology allows the resources of the Service to be directed at those areas of highest need and to ensure enforcement is proportional to the risk to the public at large.

The results of the premises audit will be used to determine the final risk score and therefore the next scheduled audit, if required.

Audit principles

The audit process is designed to allow the inspector to determine if the process and procedures, 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 of this.

The efficiency with which the task is completed may be of relevance, but is not primarily what the inspector is looking for. Only if the task is not carried out will reasons be looked for.

The 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 audited, including the review process.

The important factors to be considered are:

  • Establish that a system exists (management policy or procedure)
  • Check each element (hazard identification, risk assessment, control measures, review)
  • Only check samples (select particular components of each element)
  • Check by observation and communication (look and listen for evidence, talk to persons)
  • Identify deficiencies (in the areas selected for audit).
  • Address deficiencies.

The fire safety audit

A fire safety audit is, as its title implies, an inspection that uses the principles of audit as its base, but not as its sole methodology. The process of auditing a premises, assessing risks and making enforcement decisions, will embody the principles, expectations and methodology of the EMM which will allow inspectors to make consistent and fair enforcement decisions based on clear guidelines, which will be robust if challenged, and auditable when required.

The FSO 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.

Any enforcement action taken must be first verified against the EMM, it must be detailed enough for the responsible person to act upon and it must make the required objective clear.

In multi-occupied buildings, responsible persons have a responsibility to co-operate and co-ordinate with each other to ensure that adequate fire safety measures are in place. It is not acceptable for an individual responsible person in multi-occupied buildings to simply tolerate inadequacies in the common parts of the building on the basis that a third party has principal control.

Fire risk assessment

The premises fire safety audit should commence with an examination of the fire risk assessment and emergency action plan. These documents underpin the rationale for the fire safety strategies within the premises. The inspector must use their professional competence to form an initial view regarding the safety case presented and decide to what extent these matters will require verification.

In the absence of a written fire risk assessment, the inspector must establish what, if any, control measures are in place.

This process will enable the inspector to gauge the extent of the 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.

Documentation

A range of documentation will support any effective management system. The inspector will examine available documents to obtain evidence that effective systems are in place.

In addition to the written fire risk assessment, this evidence should include the emergency plan, test and maintenance 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 aim is to establish the current position, raise management awareness and assist in forming a view about how detailed the physical inspection of the premises will need to be.

Verification is completed by a physical inspection of some or all of the premises.

When the audit has been completed, a meeting with the responsible person should be held, where possible, to discuss the areas of non-compliance and the possible enforcement options available. Encouragement should be given for compliance, if appropriate, and observations should also be made to encourage the process of continual improvement.

Educating and informing responsible persons and others about their duties under the FSO is a fundamental part of the enforcement regime of the Fire and Rescue Service.

The Inspector should, where appropriate, effectively consult with the responsible person to minimise the costs of compliance for the business by ensuring that any action eventually taken is proportionate to the risks. Therefore, it is suggested that, unless immediate formal enforcement action is required, inspectors should provide an opportunity to discuss the circumstances of each case and, if possible, resolve points of difference; one method is the use of an action plan.

The aim of an action plan is to focus attention on any identified risk and to specify what preventive and protective measures are necessary to either reduce the risk to an acceptable level or eliminate the risk.

Where an action plan exists, or is proposed, the relationship between the inspector and the responsible person should be viewed as a partnership. As part of this partnership both sides agree the findings of the fire risk assessment and the projected time scale for implementation and completion of the measures identified in the action plan. These will need to be placed in order of priority for completion and may include interim measures prior to long term or permanent measures being implemented.

The responsible person must understand that by prioritising and implementing the agreed measures, they are taking steps to remedy their failures in the provisions for fire safety matters for employees and other persons who may resort to the premises, as required by the fire safety legislation.

If the measures identified in the action plan are not completed within the agreed time, the inspector may either, depending on the situation and risk, re-negotiate and agree a revised time scale or issue an enforcement notice.

Principle objectives

Following the completion of an audit, the inspector will verify the level of enforcement; professional competency will be required as part of the overall process of enforcement.

Once an Initial Enforcement Expectation (IEE) has been reached 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 that 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.

The process leads to a confirmed enforcement action that may be subject to a management review where it does not address all the strategic factors or accord with the enforcement policy.

Feedback

All feedback is welcomed and is important to allow us to monitor and improve our services. Following the completion of an audit, the inspector will issue a postcard inviting comment by way of a short survey.

Primary legislation and enforcement – audit and inspection process was last updated on April 18, 2016.


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