Corporate report

Crown Premises Fire Safety Inspectorate: annual report 2018 to 2019 (accessible version)

Published 24 June 2020

June 2020

Introduction by the Chief Inspector, Peter Holland CBE QFSM FIFireE (Life)

I am pleased to present my Annual Report on the work of the Crown Premises Fire Safety Inspectorate (CPFSI) during the period April 2018 to March 2019.

My team’s role on behalf of the Government is to ensure that levels of compliance with the Regulatory Reform (Fire Safety) Order 2005 (FSO) is high in Crown Premises and that both employees and members of the public are always kept safe from the risk of fire.

The tragic Grenfell Tower fire in June 2017 undoubtedly and rightly helped to raise awareness of the importance of fire safety. It is a well-known fact that in the immediate aftermath of seeing tragedies people do react positively from a safety perspective. Sadly, their memories are under normal circumstances far too short. However, this horrific incident has rightly raised awareness over a much longer period. I am therefore pleased to say I have noticed a marked improvement in fire safety awareness particularly in government occupied buildings. This has not meant that we have been complacent, and the inspection programme has continued to be proactive and targeted on the highest risk premises.

It was a challenging year as we carried one Inspector vacancy for most of the period with the result that we didn’t carry out as many inspections as I had planned. However, our risk- based inspection programme meant that we focussed on those premises with the highest risk. Prisons and other custodial secure premises are, and continue to be, by far the highest risk from a fire safety perspective.^{[footnote 1]}

This is to some extent inevitable given the nature of the institutions. I don’t therefore underestimate the scale of the challenge to raise the fire protection standards to a satisfactory level given the age profile of the prisons in England. Most of the prison estate was originally built to much lower fire safety standards and before the FSO applied to prisons. I have had regular meetings at the highest level in HM Prison & Probation Service (HMPPS) and my team of Inspectors have met more frequently with HMPPS’s senior fire adviser. When writing this report HMPPS had secured additional funding for 2020/21 to generally improve fire safety and specifically to address the current shortfall in automatic fire detection in cells.^{[footnote 2]} Between 2017/18 and 2018/19 there was an overall reduction in the number of fires in prisons, but we have not seen falls in the numbers of staff and prisoners who are injured. ^{[footnote 3]} There is evidence that the continuing rate of injuries may be due to drug use and perversely the smoking ban which has resulted in prisoners using increasingly innovative methods for ignition sources.

We have been working closely with HMPPS and the Ministry of Justice (MoJ) to drive down the fire risk where it is reasonably possible. Whilst it is clear that HMPPS have taken steps to improve fire safety, even more concerted action is necessary. After full audits were carried out in nine prisons, all but two of them had serious enough deficiencies to require formal action, and we served one Prohibition Notice at one establishment and one Enforcement Notice at another. In the other five serious cases the respective Governors had to produce 28-day action plans to address the non-compliance with the FSO identified by our inspections. This area of our work will continue to be a high priority in coming years.

I am fortunate enough to have a highly skilled and experienced Team Leader who is widely respected both by stakeholders and the other Inspectors. I have also been pleased to retain the expertise within the team by changing the employment model to move them onto permanent contracts. This is ensuring there is long term commitment to improving fire safety compliance in Crown Premises as they are no longer on fixed short-term secondments. This has also reduced the training demand as the team are all experienced Inspectors.

We have also started the development of a long overdue new management information system (MIS) for the team. ‘Themis’ as it will be known will improve our assessment of fire risk as it will be dynamic, providing up to date information. It will also improve our ability to capture more accurate fire safety management data and to deploy our Inspectors even more effectively.

I would like to take this opportunity to thank the team for their hard work and dedication.

Peter Holland

1. Context and role of the Crown Premises Fire Safety Inspectorate

1.1 The Home Office has policy responsibility for the Regulatory Reform (Fire Safety) Order 2005 (FSO) which applies to all premises, save for those expressly excluded, such as domestic premises. In multi-occupied residential buildings, the FSO applies to the parts of the building that are used in common, but not individual homes.^{[footnote 4]} Local fire and rescue authorities are the enforcing authority for the majority of premises to which the FSO applies. The Fire and Rescue National Framework for England requires fire and rescue authorities to have a risk based inspection programme and management strategy in place to ensure compliance with the FSO in their area.

1.2 The Crown Premises Fire Safety Inspectorate (CPFSI), based in the Home Office, is the regulatory body which ensures compliance with the FSO in government buildings, Parliament, Royal Palaces and premises owned by or in right of the Crown. The Inspectorate responsible for compliance with the FSO in over 10,000 Crown Premises made up of over 16,000 buildings - many premises or sites comprise multiple buildings. Ministry of Defence premises have their own fire safety inspectors within their Defence Safety Authority.

1.3 The budget for CPFSI for the period of this report was £760,000. The team consisted of 7 Inspectors, a Team Leader and a Chief Inspector. The Inspectors and Team Leader are contracted home workers and their work takes them all around England. Fire safety is a devolved matter in Scotland, Wales and Northern Ireland so they have their own arrangements. Although based in the Home Office, the Inspectors work independently with no interference in the way they carry out their inspections and write their reports, other than for normal management supervision.

1.4 The inspection regime is based on risk of fire and injury, with the highest risk premises being prisons and other custodial secure premises. Inspectors liaise with a variety of stakeholders, including fire and rescue services, other enforcing authorities and statutory bodies, to promote consistency, share advice and guidance as well as identifying and highlighting increased risk. This includes providing advice on proposed building work in Crown Premises in order to ensure compliance with the Building Regulations in relation to fire safety.

1.5 The inspection process for prisons is both lengthy (involving four inspectors for two days) and complex in comparison with other inspections. This is in part because there are numerous buildings to inspect and because personal safety for Inspectors must take equal priority with efficient working but it also reflects the complexity of the fire risk and control measures in prisons where neither the staff nor the prisoners can escape from fire as easily as in normal premises, and demands a more detailed and rigorous approach in comparison to other Crown premises.

1.6 When initial advice and suggested actions are not put in place following our inspections, urgently where necessary, we take appropriate enforcement action in accordance with our Enforcement Policy and follow the principles of good enforcement set out in the Regulators Code. Crown Immunity from prosecution exists for Crown bodies in accordance with Section 49 of the FSO, but CPFSI has full statutory enforcement powers in relation to non-Crown bodies working in or on Crown premises.

2. The scale of the issue: the number of fires in Crown Premises

2.1 Data sources:

The Home Office Incident Recording System (IRS)^{[footnote 5]} allows FRSs to complete an online incident form for every emergency incident attended, be it a fire, a false alarm or a non-fire incident (also known as a Special Service).

2.2 Fire statistics in prisons are collected by HMPPS prison staff using an online system. These statistics include all fires in prisons, that is both those attended by FRSs and fires that are deemed to be small and under the full control of prison staff so no call is then made to the FRS. IRS and HMPPS statistics are not, therefore, directly comparable.

2.3 The rate of fires in prisons compared with that in other buildings is very high. Using data from the IRS, for the combined years ending September 2012 to September 2018 there were 5,021 fires for every 1,000 prison buildings, compared with the next highest category, hospitals, where it was 263 per 1,000 and Sheltered Housing where it was 163 per 1,000 buildings.^{[footnote 6]}

2.4 Using HMPPS fire statistics^{[footnote 7]} there were 1,055 prison fires in 2018/19 (down 13% from 1,210 in 2017/18). Only a very small number of fires (IRS statistics) happened in other Crown Premises - 12 (2017/18) and 10 (2018/19).

2.5 It should be noted that the proportion of deliberate to accidental fires in Crown premises is very different to that in other occupancies. IRS statistics for 2018/19 show that 24 per cent of non-dwelling fires and 91 per cent of fires in prisons and young offender units attended by FRSs were deliberate.^{[footnote 8]}

2.6 Deliberate fires in prisons are driven by a range of factors – such as status, regime challenge, self-harming - which are largely exclusive to the prison environment and population. In parallel, the proportion of injuries is far higher for fires which are started in a cell from which the occupant cannot self-evacuate to protect themselves. The reduction in the number of fires in prisons over the last year has not resulted in a consequent fall in prison fire injuries. In fact, the numbers of staff and prisoners who are injured as a result of fires have slightly increased from 52 to 61 in the corresponding period, including one fatality, although these numbers are relatively low and so prone to fluctuation. ^{[footnote 9]}

Figure 1: Fires and injuries in Crown Premises, England, 2017/18 and 2018/19

	2017/2018	2018/2019
Prison fires	1210	1055
Prison fire injuries	57	61
Other Crown Premises fires	12	10
Other Crown Premises injuries	0	1

3. Report on inspection activity during the year

3.1 Between April 2018 and March 2019 there were seven Inspectors, a Team Leader and a Chief Inspector. In addition, one Inspector vacancy was carried for most of the year and a further Inspector was seconded to the replacement Management Information System (MIS) project. The new MIS ‘Themis’ will provide high quality data for improved risk-based inspection planning and provide valuable streamlining of work effort, so will enable the team to carry out more inspections with even better anticipation of the fire risk present in each premises. A useful addition will be the ability to record the performance of contractors on fire safety matters across England.

3.2 Despite running with a vacancy, the team still carried out 178 inspection visits overall during the year. Information on these inspections is recorded by the inspectors using a manual spreadsheet and quality assured internally by the Team Leader. The visits involved a range of premises from normal risk to very high-risk buildings, consisting of inspections, investigations, follow ups and short audits. More staff time was necessarily spent on prison inspections than on other premises as they are larger more complex sites. Eighty-five per cent of these inspections were driven by the pre-scheduled risk-based inspection programme. Some planned inspections had to be delayed because of investigating the effectiveness of fire safety measures following incidents in prisons.

3.3 There were 72 prison inspections which included full audits, short audits, follow up visits to check progress on non-compliances and fire investigations. The breakdown was as follows:

• 9 full audits
• 11 follow up visits
• 24 short audits
• 28 post fire investigations

Figure 2: Total number of inspections in prisons, England, 2018/19

Type of inspection	Number
Full audits	9
Follow up visits	11
Short audits	24
Post fire investigations	28

3.4 Fires started deliberately in cells were the largest single cause of fires in prison. Where injuries resulted from those fires, the main contributing factor beyond the ignition itself lay in the extent of delays in detecting these fires. This reflects the lack of in-cell automatic fire detection in much of the prison estate. Following meetings with the CEO of HMPPS to try to resolve this problem, it was agreed that an interim solution of installing domestic smoke detectors either in the cell or immediately outside and above the cell door would provide an acceptable short-term solution. It is proving a major challenge for prison staff to manage tampering with and vandalism to the domestic smoke detectors. In the longer term it remains imperative that automatic fire detection is installed in every cell to ensure that prison staff are rapidly alerted to fires, however caused. HMPPS must appropriately prioritise their investment and maintenance programme to ensure this work is completed as rapidly as possible. This may require additional capital spend. ^{[footnote 10]}

3.5 The key elements of protection in the event of cell fires are fire detection, fire- fighting equipment, Respiratory Protective Equipment, staff instructions and training and smoke control. After cell fire detection the next most serious risk in prisons related to the inadequacy of smoke control systems where these are needed to protect both staff and prisoners from the effects of smoke spread. However, this risk was primarily concentrated at a few prisons.

3.6 Finally, the inspection programme identified concerns around inadequate emergency lighting and fire-fighting equipment for staff when dealing with cell fires. In all cases of non-compliance either Action Plan notices or Enforcement Notices were served on the relevant Governors.

3.7 Across other types of Crown Premises, the most serious risks were visible as a general lack of preparedness to deal with fire situations. This was the result of inadequate staff training together with not using fire drills to test the emergency procedures and identify and address shortfalls. Disturbingly, some of our inspections also found evidence that people would not always be able to escape from a fire quickly and safely, often due to inappropriate security fastenings on doors and the poor state of fire-resisting structure and fittings, including fire doors. In all of these cases of non-compliance the responsible persons received formal notification via Enforcement Notices of what they needed to do to comply with the FSO.

3.8 Across the whole Crown sector, those risks had clear and repeating links with specific failures of fire safety management, principally poor day-to-day management of fire safety, poor fire risk assessments and fire risk assessment action plans which would not achieve the level of safety required for compliance even if implemented. Alongside this, we commonly discovered inadequate arrangements to act as an effective client when monitoring the performance of the facilities’ management providers who maintain the fire safety measures.

3.9 There were 106 inspections of other Crown Premises which included full audits and follow up visits to check progress on non-compliances. The breakdown was as follows:

• 95 full audits
• 11 follow up visits

Figure 3: Type of inspections of other Crown Premises, England, 2018/19

Type of inspection	Number
Full audits	95
Follow up visits	11

4. Compliance/non compliance

Table 1: Details of Informal and Formal Notifications

Informal Notifications
Minor non compliance	There are issued if the enforcing authority has identified minor deficiencies in the fire safety measures or management of fire safety and takes the view that the responsible person can resolve the deficiencies without further intervention.
Action Plan	There are issued if the enforcing authority has identified significant deficiencies in the fire safety measures or management of fire safety and takes the view that the responsible person can resolve the deficiencies with the oversight of the enforcing authority.

Formal Notifications
Enforcement notices (Article 30 of FSO)	These are served if the enforcing authority is of the opinion that the responsible person has failed to comply with any provision of the FSO or of any regulations made under it.
Prohibition Notices (Article 31 of FSO)	These are served on the responsible person or any other person, if the enforcing authority is of the opinion that use of premises involves or will involve a risk to relevant persons so serious that use of the premises ought to be prohibited or restricted.

4.1 Results from the nine full audits of prisons resulted in:

• one being served with a Prohibition Notice
• one being served with two Enforcement Notices
• five were required to produce an action plan within 28 days
• two were notified of minor non-compliance with fire safety standards

4.2 Action plan notices are used to direct the responsible person to set out an acceptable plan for rectifying the issues which had been identified during the inspection. The inspection data shows that regardless of whether prison inspections were planned or unplanned, none of them met the required ‘satisfactory’ standard.

4.3 In other Crown Premises, of the 95 full audits carried out:

• two Enforcement Notices were served (on one Court building)
• 28 were required to produce action plans within 28 days
• 51 had minor non-compliance issues to address
• 15 were found to be satisfactory

Figure 4 Initial outcomes following inspection, England, 2018/19

	Other Crown Premises	Prisons
Minor non compliance	51	2
Action plan	28	5
Satisfactory	15	0
Enforcement notice	2	2
Prohibition notice	0	1

4.4 Another follow-up inspection was carried out several weeks (and in some cases months) later. Of those prisons which had to respond to formal enforcement action only one achieved a satisfactory standard, five had minor deficiencies and five were required to urgently produce an effective action plan. One Enforcement Notice remained in force. ^{[footnote 11]}

4.5 In other Crown Premises only a small number of follow up visits (11) were undertaken due to the relatively low risk of fire found at the majority of premises. Of these 11 instances, three had minor deficiencies and eight were deemed satisfactory as a result of our action.

Figure 5 Outcomes after follow-up inspections, England, 2018/19

	Other Crown Premises	Prisons
Minor non compliance	3	5
Action plan	0	5
Satisfactory	8	1
Enforcement	0	1

4.6 HMPPS need to ensure that the officers making up the collective ‘Responsible Person’ under the FSO are appropriately accountable for meeting their statutory responsibilities. We have noted that the Governor in charge of a prison doesn’t always have the full control required to be able to act as the sole Responsible Person under the FSO, as they do not have the financial authority to take all necessary steps for compliance where major expenditure is required.

5. Summary of overall picture

5.1 Overall the risk from fire is generally low in the majority of Crown Premises but remains concentrated in the prison estate. The data masks some improvements in fire safety management in the custodial sector which create a significant expectation that fire risk will be better controlled once the stability of prisons is reasserted.

5.2 The smoking ban in prisons has, somewhat surprisingly, negatively altered the nature of fire risk. Whilst opportunistic fire-setting has reduced, we have seen an increase in serious non-deliberate fire injuries linked with substance abuse. The repeating nature of those incidents has raised a fresh challenge for prisons in their duty to safeguard those in custody.

5.3 There is a lack of automatic fire detection in every cell which would ensure a rapid alert to prison staff in all prisons. ^{[footnote 12]}

5.4 In the remainder of the Crown sector, improvements are generally localised and linked to effective action by an individual or group, rather than to more general improvements by a department.

6. Plans going forward: 2019/20 and beyond

6.1 Introduction of new Management Information System (THEMIS):

As at the 31 March 2019 the replacement Management Information System (MIS) named ‘Themis’ was being finalised. Management information was hugely time consuming to extract from the existing DataViewer MIS. During 2019/20 Themis was introduced providing a dynamic risk assessment tool enabling Inspectors to be deployed to premises with the highest risk. ^{[footnote 13]}

6.2 Increase in capacity of team:

As recommended by the National Fire Chiefs Council (NFCC), following a review in 2018, the team of inspectors needed to be increased by 6 to meet the targets for inspections of higher risk premises. The 2019/20 revenue budget had an extra £241,000 built into it to fill these new posts. This has provided funding for five extra inspectors as well as business and policy support to the Chief Inspector and the team. It is hoped that funding for the other additional post will be provided in either 2020/21 or the following year. ^{[footnote 14]}

6.3 Increase in inspections of high- risk premises:

Given the increase in team capacity, additional inspections of high-risk premises will take place. However, recruitment, subsequent induction and training time mean that this is only likely to be reflected in the number of inspections in 2020/21. A keen focus will be made to ensure targeting of the highest risk premises, predominantly prisons, will continue to take place to reduce risk and increase compliance as much as is reasonably possible.

6.4 Clearer Governance and accountability:

During the year a working protocol will be drawn up and signed between the Chief Inspector, the Home Office Crime, Policing and Fire Group Director General and the Director of Fire and Resilience to ensure that the Inspectorate’s independence as a Regulator is made transparent.

1. https://www.gov.uk/government/statistics/detailed-analysis-of-fires-attended-by-fire-and-rescue-services-england-april-2018-to-march-2019 Home Office FRS statistics for 2018/19: The highest rates of fire per 1,000 buildings per year were seen in; prisons with 5,021, hospitals with 263, and supported/sheltered housing with 158 ↩

2. https://www.gov.uk/government/news/prisons-receive-156-million-maintenance-boost ↩

3. HMPPS internal Fire Incident Report data - unpublished ↩

4. The Fire Safety Bill will clarify how the FSO applies to certain parts of domestic premises (flat front doors and cladding) ↩

5. https://www.gov.uk/government/publications/data-protection-and-privacy-notices/fire-and-rescue-service-incident-recording-system-privacy-information-notice ↩

6. From Table 3 in https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/831136/detailed-analysis-fires-attended-fire-rescue-england-1819-hosb1919.pdf ↩

7. HMPPS Fire Incident Reporting System data – unpublished. ↩

8. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/823705/other-building-fires-dataset-aug19.ods ↩

9. Precautionary check-ups are not included in these figures ↩

10. The foreword to this document makes additional references to the MoJ planned investment in prison fire safety measures. ↩

11. Please note that four of the follow up visits related to full audits undertaken late in the previous financial year 2017/18 ↩

12. The foreword to this document makes additional references to the MoJ planned investment in prison fire safety measures including automatic fire detection ↩

13. It has long been recognised that focussing efforts on the very highest risk premises will improve outcomes at a much faster rate. Those outcomes are fewer fire-related fatalities and injuries as well as a lower incidence of fire and improved compliance with Crown Premises statutory fire safety obligations under the FSO. ↩

14. 5 new Inspectors were subsequently appointed in 2019 ↩