Risk assessment

Fire Safety Risk Assessment

A comprehensive, sector-specific fire safety risk assessment for private healthcare providers, structured to evidence compliance with the Regulatory Reform (Fire Safety) Order 2005, the Fire Safety Act 2021, and the CQC single assessment framework.

For Private Healthcare ClinicRef BS-PH-RA-002See a sample (PDF) →
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  • Instant download after checkout
  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This risk assessment is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Scope and purpose
  • 2. Legal and regulatory framework
  • 3. Risk assessment methodology
  • 4. Hazards, controls and risk rating
  • 5. Action plan
  • 6. Monitoring and review
  • 7. Disclaimer

Legislation & standards it maps to

  • Regulatory Reform (Fire Safety) Order 2005 (as amended)
  • Fire Safety Act 2021
  • Fire Safety (England) Regulations 2022
  • Building Safety Act 2022
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment), Regulation 15 (Premises and equipment), Regulation 17 (Good governance) and Regulation 18 (Staffing)
  • Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999
  • Health Technical Memorandum HTM 05-02 (Firecode) and Health Technical Memorandum HTM 05-03 (Operational provisions)
  • BS 9999:2017 (Code of practice for fire safety in the design, management and use of buildings) and BS 5839-1:2017 (Fire detection and fire alarm systems for buildings)

Who it applies to

All premises, staff, service users, visitors and contractors of [Organisation Name], including inpatient wards, clinical treatment areas, theatres, recovery and day-case units, plant rooms, and ancillary spaces.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Accountable Person
The person or organisation legally responsible for the safety of a higher-risk or multi-occupied building, including its structure and common parts.
Alcohol-based hand rub
A fast-drying hand sanitiser containing alcohol; it kills germs but is flammable and must be kept away from ignition sources.
Anaesthesia
Medication used to prevent pain during surgery or procedures, which can leave a patient unconscious or unable to move and so unable to evacuate unaided.
Area valve service unit
A wall-mounted box of valves that lets staff shut off the medical gas supply to a particular area in an emergency.
Arson
The criminal act of deliberately setting fire to property.
Automatic fire detection
Devices such as smoke and heat detectors that sense a fire and trigger the alarm without anyone having to raise it.
Biomedical engineering
The team responsible for maintaining, testing and repairing medical equipment so it stays safe to use.
British Approvals for Fire Equipment (BAFE)
An independent body that registers and certifies competent fire safety companies and assessors against recognised schemes.
BS 5839-1:2017
The British Standard setting out how fire detection and alarm systems should be designed, installed and maintained in buildings.
BS 7671 (IET Wiring Regulations)
The British Standard for the safe design and installation of electrical wiring in buildings.
BS 9999:2017
The British Standard giving guidance on fire safety in the design, management and use of buildings.
Building Safety Act 2022
A law that strengthened the safety regime for higher-risk buildings, such as those over 18 metres or seven storeys tall.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Cause-and-effect matrix
A plan that defines exactly what the fire system should do (for example which doors release or alarms sound) when a particular detector activates.
Closed-circuit television (CCTV)
A video camera and recording system used to monitor a site for security and safety.
Cold smoke seals
Strips fitted around a fire door that stop cool smoke passing through the gaps before a fire takes hold.
Compartmentation
Dividing a building into fire-resisting sections so that fire and smoke are contained and cannot spread quickly.
Competent person
Someone with the training, experience and knowledge needed to carry out a task safely and correctly.
Controlled drug
A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
Corporate risk register
A central record of the most significant risks an organisation faces, together with the actions being taken to manage them.
Day-case unit
An area where patients have a procedure and go home the same day rather than staying overnight.
Duty to cooperate and coordinate
The legal requirement for parties sharing a building to work together so that fire safety arrangements join up.
Emollient
A moisturising skin cream or ointment; some paraffin-based types can make fabric catch fire more easily.
FD30 / FD60
Ratings for fire doors, meaning the door can resist fire for 30 or 60 minutes.
Fire and rescue authority
The local fire service, which both responds to fires and enforces fire safety law.
Fire-resisting subdivision
Walls, floors and doors built to hold back fire and smoke for a set period and so create protected sections within a building.
Fire risk assessor
A suitably qualified person who examines premises to identify fire hazards and judge whether the precautions are adequate.
Fire Safety Act 2021
A law that made clear the Fire Safety Order also covers a building's structure, external walls and flat entrance doors.
Fire Safety (England) Regulations 2022
Rules placing specific fire safety duties on responsible persons in certain multi-occupied residential buildings.
Fire-stopping
Sealing the gaps where pipes and cables pass through walls and floors so that fire and smoke cannot travel through them.
Firecode
The set of healthcare-specific fire safety guidance documents, of which Health Technical Memorandum HTM 05-02 is the main design guide.
Golden thread
An accurate, up-to-date set of building safety information kept and shared throughout a building's life under the Building Safety Act 2022.
Health and Safety at Work etc. Act 1974
The main law setting out employers' general duties to protect the health and safety of staff and others.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that providers of regulated care must meet, enforced by the Care Quality Commission.
Health Technical Memorandum (HTM)
Official technical guidance on the design, installation and operation of healthcare buildings and systems; HTM 02-01 covers medical gases and HTM 05-02 and HTM 05-03 cover fire safety.
Hierarchy of control
A ranked approach to managing risk, preferring to remove a hazard first and using protective equipment only as a last resort.
Higher-risk building
Under the Building Safety Act 2022, a building that is especially tall or otherwise high-risk and so subject to stricter safety rules.
Hot works
Work that produces heat, sparks or flame, such as welding, cutting or soldering, which can start a fire.
Institute of Fire Safety Managers (IFSM)
A professional membership body for people who manage fire safety, which maintains a register of competent practitioners.
Institution of Fire Engineers (IFE)
A professional body for fire engineers that sets standards and maintains a register of qualified fire risk assessors.
Intumescent strip
A strip fitted to a fire door that swells in heat to seal the gap and block the spread of fire and smoke.
L1 system
The highest category of automatic fire detection under BS 5839-1, giving detection throughout all areas of a building for the earliest warning.
Life safety
Measures whose primary aim is to protect people's lives, as distinct from protecting the building or property.
Lithium-ion battery
A rechargeable battery used in many devices that can overheat and catch fire if damaged or charged incorrectly.
Management of Health and Safety at Work Regulations 1999
Regulations requiring employers to assess and manage risks to the health and safety of staff and others.
Medical gas pipeline system (MGPS)
The fixed network of pipes that delivers oxygen and other medical gases to clinical areas.
Medicines and Healthcare products Regulatory Agency (MHRA)
The body that regulates medicines and medical devices in the United Kingdom and issues safety guidance.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Nominated Individual
The senior person responsible to the regulator for supervising how a service is provided.
PAS 79-2:2020
A published methodology setting out a structured way to carry out and record a fire risk assessment for healthcare premises.
Passive fire protection
Built-in fire safety features such as fire-resisting walls, doors and fire-stopping that work without any action being taken.
Personal Emergency Evacuation Plan (PEEP)
An individual plan setting out how a person who cannot get out unaided will be helped to safety in a fire.
Phased evacuation
Evacuating a building in stages, area by area, rather than everyone leaving at once.
Piped medical gases
Gases such as oxygen delivered to clinical areas through fixed pipework rather than from portable cylinders.
Portable appliance testing
The routine inspection and testing of plug-in electrical equipment to check it is safe to use.
Progressive horizontal evacuation
A strategy of moving people sideways into an adjoining fire-safe compartment on the same floor, used where vertical escape is difficult.
Provider Information Return
Information a registered provider submits to the Care Quality Commission to show how it is meeting standards.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Regulatory Reform (Fire Safety) Order 2005
The main fire safety law for non-domestic premises in England and Wales, placing duties on the Responsible Person.
Residual current device (RCD)
A safety device that quickly cuts off the electricity supply if it detects a fault, helping to prevent fire and electric shock.
Residual risk
The level of risk that remains once existing control measures have been taken into account.
Responsible Person
The person who, under the Fire Safety Order, holds the legal duty for fire safety in a set of premises, usually the employer or person in control.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Risk matrix
A grid that scores a risk by combining how likely it is with how serious the outcome would be.
Sedation
Medication that makes a patient calm or drowsy, which can reduce their ability to react or escape in an emergency.
Service user
A person who receives care or treatment from the service; also called a patient or client.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
So far as is reasonably practicable
A legal test meaning a risk must be reduced unless the time, trouble or cost would be grossly disproportionate to the benefit.
Statement of Purpose
A required document describing who a service is, what it does and where, shared with the regulator.
Sub-compartment
A smaller fire-resisting division within a compartment, giving an extra place of relative safety during evacuation.
United Kingdom Accreditation Service (UKAS)
The national body that checks and accredits certification and inspection schemes so they can be trusted.
Waking watch
Trained staff who patrol a building continuously to detect fire and raise the alarm when other fire precautions are inadequate.
Wayfinding signage
Signs that help people find their way around a building, including the routes to fire exits.

How it works

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  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

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