Fire safety in a standard commercial building is ultimately a question of how quickly people can get out. In a care home, that question cannot be answered without first asking who those people are, what they can do unaided, what they cannot do at all, and how many staff are available at any given hour of the day or night to bridge the gap. It is a fundamentally different problem — and the law treats it as such.

The government's statutory guidance specifically identifies residential care premises as one of the highest-risk categories for fire safety, sitting alongside sleeping accommodation and high-rise residential buildings. The London Fire Brigade has recorded that around one third of people who die in fires in London are receiving care services. The evacuation challenge is not incidental to fire safety in this sector. It is central to it.

Why Evacuation in Care Settings Is Categorically Different

In most buildings, the fire risk assessment addresses the means of escape and assumes that occupants — given adequate warning — can use those means. In a care home, that assumption cannot be made for the majority of residents. The responsible person must instead ask, for each resident individually, what their actual evacuation capability is, and what mitigating measures are required to bridge the gap between that capability and a safe outcome.

The factors that complicate evacuation in care settings include several that do not appear in any other premises type.

Mobility impairment

Many residents cannot walk unaided or use stairs at all Non-ambulant residents — those confined to wheelchairs, beds or hoists — require physical assistance to move. That assistance takes time, requires trained staff and appropriate equipment, and cannot be improvised in a smoke-filled corridor at 3am. The fire risk assessment must specify, for each non-ambulant resident, how they will be moved, by whom, using what equipment, and along which route. A PEEP that says "staff will assist" without specifying the detail is not adequate.

Cognitive impairment

Residents with dementia may not respond to an alarm or may resist evacuation A fire alarm is not a reliable prompt for a resident who does not understand what it means, who may be frightened by the noise, or who may become distressed and resistant when staff attempt to move them. For residents with advanced dementia, evacuation may require physical care that takes considerably longer than standard evacuation planning assumes. Staff must be trained for this specifically — it is not a situation that standard fire marshal training covers.

Oxygen and medical equipment

Residents on oxygen therapy or connected to medical equipment present additional fire and evacuation risks Oxygen dramatically accelerates combustion. A resident using supplemental oxygen who is also using emollient skin creams — common in care settings — faces a heightened ignition risk that must be specifically assessed. The BUPA Manley Court case, in which a resident died after a fire involving emollient creams, turned precisely on whether the risk assessment had identified and addressed this combination of factors. It had not. The prosecution followed.

Night staffing levels

The staffing available at night may be a fraction of the daytime complement Evacuation plans that are feasible with full daytime staffing may be entirely undeliverable at 2am with a skeleton crew. The fire risk assessment must be based on the worst-case staffing scenario, not the best. This is one of the most consistently overlooked failures in care home fire risk assessments — and one of the first things a fire safety auditor will examine.

Progressive horizontal evacuation

Most care homes use progressive horizontal evacuation rather than full simultaneous evacuation Because full simultaneous evacuation of a care home is often impractical, most care homes operate a progressive horizontal evacuation strategy — moving residents away from the fire compartment into adjacent fire-resistant areas, rather than out of the building entirely. This strategy is only viable if compartmentation is intact, fire doors are working, and staff know exactly what to do and in what sequence. The fire risk assessment, the staff training programme, and the evacuation drills must all reflect the actual strategy in use.

Personal Emergency Evacuation Plans: The Legal Position

Personal Emergency Evacuation Plans — PEEPs — are individual evacuation plans for residents whose ability to self-evacuate is compromised. In a care home, that means virtually every resident. The requirement to have PEEPs in place is not new: it has been implicit in the fire risk assessment duty under the Regulatory Reform (Fire Safety) Order 2005 for two decades. What is changing is the regulatory environment around them.

From 2 March 2025, all newly constructed care homes in England must be fitted with automatic sprinkler systems regardless of height or size — a direct acknowledgement that in buildings where evacuation is slow and complex, suppression systems provide a critical additional layer of protection. BS 9991:2024, the updated fire safety standard for residential buildings, has extended its scope specifically to include residential care homes and sets specific provisions for the management of fire safety for vulnerable residents.

For existing care homes, the responsible person's duty to have suitable PEEPs in place for all residents whose evacuation capability is compromised is enforceable now — under the existing Fire Safety Order. It does not require new legislation to trigger prosecution. As the cases below illustrate, enforcement authorities have been using the existing framework to prosecute care providers whose evacuation arrangements are inadequate.

A PEEP that exists on paper but has never been rehearsed, that was written for a resident whose condition has since changed, or that assumes staffing levels unavailable at night, is not a PEEP. It is a document. The courts have shown they understand the difference.

What the Courts Have Done

Knutsford, Cheshire, 2013 — Rangemore Nursing Home

A fire broke out at the Rangemore Nursing Home in Knutsford in October 2010 and six people had to be rescued from the first floor. A subsequent investigation found a number of fire safety breaches. Richard Dickinson, the former owner of the home, was sentenced at Chester Crown Court in December 2013 to 12 months' imprisonment, suspended for two years, and 200 hours of community work, for three offences under the Fire Safety Order.

The sentencing judge praised the fire service's actions in averting what could have been a major tragedy and stressed that those running premises for vulnerable people must scrupulously adhere to fire safety regulations. This case was brought in the courts serving Fletcher Risk's own operating area — and the failings it identified are not unusual.

East Sussex, 2024 — Care Pro (Southeast) Limited

Two directors of Care Pro (Southeast) Limited — Thuraisamy Ravichandran and Radha Ravichandran — were fined nearly £125,000 at Brighton Magistrates Court in July 2024 after pleading guilty to 12 fire safety offences across four premises. East Sussex Fire and Rescue Service described it as one of the most serious cases they had ever prosecuted. Defective fire doors and inadequate detection and alarm systems were among the failings cited, alongside risks to vulnerable residents.

The enforcement manager said after sentencing: "Owners and those responsible for any premises where the fire service find fire safety contraventions are reminded of the potential consequences, including unlimited fines and potential custodial sentences."

Cardiff, 2020 — Hillcroft Residential Care Home

Farrington Care Homes, responsible for the Hillcroft Residential Care Home in Cardiff, was fined £432,944 — later reduced to £300,000 on appeal — following a prosecution brought by South Wales Fire and Rescue Service. The failings had been identified through multiple inspections dating back to 2011. Extensions were granted repeatedly to allow the company to rectify the issues. They were not rectified.

In sentencing, District Judge Khan said: "This is firmly in the category of high culpability… these are the most vulnerable members of our society… each of them was put at risk… there was a risk of a large scale tragedy." The offences included an inadequate fire risk assessment, blocked escape routes, insufficient smoke alarms, deficient emergency lighting, failure to conduct evacuation drills, and substandard fire safety management.

The Specific Risks the Fire Risk Assessment Must Address

A fire risk assessment for a care home must go beyond the standard template. The responsible person — typically the registered manager or care provider as employer — must ensure the assessment specifically addresses the following.

Individual resident assessment

Every resident whose evacuation capability is compromised must have an individual PEEP This includes residents with mobility impairments, cognitive impairments, sensory impairments, or medical conditions that affect their response to an emergency. PEEPs must be reviewed whenever a resident's condition changes and at least annually. They must be realistic — specifying who will assist, with what equipment, via which route, and in what sequence — and they must be tested in drills.

Emollient creams and oxygen

The combination of emollient creams and smoking or open flame is a specific and well-documented risk Emollient skin creams — used widely in care settings for pressure sore prevention and skin conditions — can accumulate on clothing and bedding and become highly flammable. Where residents use these products and also smoke, or where there is any risk of ignition source near bedding or clothing, the risk assessment must address this combination specifically. The BUPA Manley Court prosecution turned on precisely this failure.

Night-time staffing

The evacuation plan must be deliverable with night-time staffing levels If the evacuation plan requires five members of staff to move non-ambulant residents simultaneously, and the night-time rota has two, the plan is not viable. The fire risk assessment must model the worst-case scenario and the evacuation strategy must be designed around it — not around the best-case staffing complement.

Compartmentation and fire doors

Progressive horizontal evacuation depends entirely on compartmentation working as designed The strategy of moving residents to an adjacent compartment rather than out of the building only works if the fire-resistant walls, floors and — critically — fire doors between those compartments are intact and functioning. A fire door that is wedged open, damaged or missing its smoke seals provides no protection. Regular fire door inspections are not optional in a progressive horizontal evacuation building — they are the structural basis on which the entire strategy depends.

Staff training and drills

Evacuation procedures must be rehearsed, not just documented Staff must know what to do when the alarm sounds — not in general, but in specific detail: which residents need assistance, in what order, via which routes, and with what equipment. That knowledge comes from training and from regular, realistic drills. The Hillcroft case included failure to conduct appropriate evacuation drills as one of its offences. Training records and drill records must be maintained. High staff turnover — common in the care sector — makes regular refresher training more important, not less. Our fire safety training programmes can be tailored specifically to care environments.

What Has Changed Recently

2025 brought two significant regulatory developments for the care sector. The mandatory sprinkler requirement for new care homes from 2 March 2025 reflects a direct policy response to the recognised difficulties of evacuating vulnerable residents — suppression buys the time that manual evacuation requires. BS 9991:2024 has extended its scope to include residential care homes with specific provisions for vulnerable residents, setting a clearer framework for what fire safety design and management in this setting should look like.

For existing care homes, neither of these changes alters the fundamental obligation that has existed since 2005: carry out a suitable and sufficient fire risk assessment, implement what it finds, and maintain the measures it identifies. What the recent changes signal is that regulatory scrutiny of this sector is increasing — and the tolerance for the kind of long-running, repeatedly warned, repeatedly unaddressed failures seen in the Hillcroft case is diminishing.

We carry out fire risk assessments, fire door inspections and fire safety training for care homes and healthcare premises across Chester, the North West and North Wales. If you manage a care home or healthcare premises and are not confident that your current fire risk assessment adequately addresses evacuation of vulnerable residents, get in touch.

Does your care home's fire risk assessment properly address evacuation?

We carry out specialist fire risk assessments for care homes and healthcare premises across Chester, the North West and North Wales — covering resident-specific PEEPs, night-time staffing scenarios, compartmentation and staff training.

Disclaimer: This article is intended as general guidance only and does not constitute legal advice. Case details are drawn from publicly available court records, fire service press releases and industry publications. The legal position described reflects the law as it applies in England and Wales. Responsible persons should seek professional fire safety and legal advice tailored to their specific premises and circumstances. Fletcher Risk Management is not a law firm and accepts no liability for actions taken or not taken on the basis of this article. Fletcher Risk Management is based in Chester and provides fire risk assessments, fire door inspections and fire safety training across the North West and North Wales. © Fletcher Risk Management Ltd, April 2026.