HOUSING MANAGEMENT ADVISORY BOARD – 21st AUGUST 2013

Report of the Interim Head of Landlord Services

ITEM 6 FIRE SAFETY REPORT Purpose of Report To advise HMAB of the actions being taken and monitoring systems in place to ensure the safety of our residents in their homes ACTION REQUESTED Board are requested to note and comment on this report BACKGROUND The Regulatory Reform (Fire Safety) Order 2005 places a duty on Landlords and Employees to ensure the safety of its employees and residents in the workplace and home. In June 2012 Charnwood Neighbourhood Housing (CNH), commissioned Chubb to carry out Fire Risk Assessments (FRA’s) in the communal areas of all premises and offices so it could identify actions required to ensure the safety of residents and employees. When the transfer of the service back to the Council took place on 1st November 2012, these had not been completed. Fire Risk Assessments were completed in January 2013 and over 1000 actions identified to ensure safety in the home and workplace. These included

• Fitting of Fire Resistant Doors in communal areas of blocks of flats, including residents own front doors

• Fitting of intumescent strips and seals to doors • Fitting of Emergency Lighting systems to communal staircases • Removal of combustible material in communal areas and staircases

Since the transfer of the landlord service to the Council, the following actions have been completed.

• Completed the inspection of all communal areas and offices and obtained an updated FRA

• Set up a monitoring system to show the number of fires in CBC properties. In 2012/13 there were seven fires with two fatalities.

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• Put in place a system of servicing and evidencing Smoke Detectors in residents homes, and a policy to ensure every home had at least one Smoke Detector.

• We requested Internal Audit to investigate the policy and processes in the first quarter of 2013/14 to give assurance that suitable processes were in place and to help identify any gaps.

• Set up a monthly monitoring report to show progress in carrying out FRAs and the actions recommended

• Included within the housing capital budget for the year, £248,000 to install Emergency Lighting systems and £224,000 to renew outdated Fire Alarms

• Carry out a fire Home safety check with all new tenants • Met with the Leicestershire Fire and Rescue Service (LFRS) twice and agreed

a joint training session for colleagues in October, and safety visits during October to December by LFRS to a small number of schemes

• Included articles in our Tenants Newsletter on Home Fire Safety written by LFRS

CURRENT POSITION There was a small fire in the communal area of our scheme at School Street Syston in June 2013 and as a result Leicestershire Fire Rescue Service served an Enforcement Notice upon us (copy attached). The main actions in the notice were:

• Installation of Emergency Lighting to the communal areas • Update the old CNH Fire Policy and process • Remove combustible material from the communal areas and staircase • Fitting of Fire Doors

The majority of the actions in the notice have been completed, and an extension of time requested for the remainder. An joint inspection of the scheme with the LFRS took place on 31st July and provided evidence of all the actions completed so far; we are still awaiting their response Internal Audit have produced a draft report on the policy and processes, which identifies a number of gaps and therefore gives only Limited Assurance at this stage that we are compliant or following best practice to ensure the safety of our residents. The final version of the report is yet to be agreed, although a copy of the latest draft is attached which includes the action plans to meet the requirements that are outlined in the report.

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A contract has been agreed with Chubb to install 238 new Emergency lighting systems and 12 Fire Alarms by 30th December 2013. We have agreed to install a second Smoke Detector in every house as per current Building regulations during 2013/14. A monthly monitoring report is now in place at Landlord Services Senior Management Team to show progress in completing actions identified in the FRAs. This report will be included in future Performance Reports to the Board.

Officer to contact: Jim Preston

jim.preston@charnwood.gov.uk 01509 634669

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Internal Audit Services

Residential Fire Safety

Draft Internal Audit Report

ASSURANCE RATING - LIMITED

CORPORATE SIGNIFICANCE - HIGH

July 2013

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Contents: Page No

1. Introduction

1.1 Background 3 1.2 Scope 3 1.3 Audit Approach 3 1.4 Acknowledgements

2. Executive Summary

2.1 Overview 5 2.2 Key Findings 5

3. Action Plan 7

4. Detailed Findings 16

Circulation:

Officer

Terms of Reference

Draft Report

Final Report

Eileen Mallon; Director of Housing, Planning & Regeneration & Regulatory Services

Jim Preston; Interim Assistant Director of Property & Investment

Lesley Walker; Housing Services Manager

Craig Denholm; Health, Safety & Environment Manager (Housing)

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1. Introduction 1.1 Background

The Council owns approximately 5845 residential properties and there are approximately 220 communal areas such as stairwells and lounges, which are subject to a Fire Risk Assessment under the Regulatory Reform Fire Safety Order 2005. This requires the identification of the potential risks, the people at risk, the remedial action that should be carried out and the party responsible for undertaking remedial action. It also requires a system of monitoring to be in place to ensure the recommendations have been implemented within an agreed timescale.

1.2 Scope The interim Head of Landlord Services requested Internal Audit to

provide assurance to management that the key risks to the Council achieving its objectives have been identified and are being effectively managed.

To ensure that there are appropriate risk management procedures in place our review will focus on the following, ensuring that:

• There is an established policy and process for undertaking risk

assessments in residential accommodation owned by the authority; • Risks identified are individually rated and mitigating actions

recommended are followed up to ensure they have been implemented;

• There are satisfactory procedures in place for the inspection, testing and maintenance of fire safety systems and equipment;

• Fire Safety is actively promoted to residents. • Ascertain the effectiveness of fire safety checks undertaken in

communal areas of residential accommodation 1.3 Approach

• Undertake interviews with relevant officers, to ascertain the procedures in place for identifying and managing risk;

• evaluate whether the procedures in place provide for an adequate and effective level of control;

• test, where appropriate, that the controls identified are operating in practice;

• issue a draft audit report for management’s consideration; agree with management a final version of the report and, where necessary, an improvement action plan.

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1.4 Acknowledgements We would like to thank all members of staff for their assistance and co- operation during the course of this review.

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2 Executive Summary

2.1 Overview

ASSURANCE RATING - LIMITED

CORPORATE SIGNIFICANCE - HIGH

Assurance Internal Audit can only give limited assurance to those charged with governance, as there are significant weaknesses in the internal control environment within the areas reviewed and we have made several recommendations in the action plan to address these. Corporate Significance We have classed this audit as being of high corporate significance due to the following reasons:

• General risk of loss is greater than £100,000; • The risk of reputational damage is high; • There is a significant health and safety risk; • Failures in this area may have severe consequences for

customers. 2.2 Key Findings The main weaknesses that we identified were as follows:

• The policies and procedures in relation to fire safety were devised for Charnwood Neighbourhood Housing and are therefore now out of date as this function has been brought back in house. It also fails to identify the key tasks to be performed by officers.

• Procedures for addressing fire safety were being developed, but

agreed tasks were not formally assigned to designated officers with set completion deadlines, although, during the audit, one action plan had been devised.

• Data integrity issues were identified in the list of properties that

require a Fire Risk assessment. There was no planning before the assessment was carried out in order to establish what to check. The Fire Risk Assessments are carried out by Chubb but there is no formal Service Level Agreement or contract in place.

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• There were significant delays in allocating remedial actions recommended from the Fire Risk Assessment to officers in the authority and there were long delays in implementing the recommendations.

However, we are pleased to report that the procedures in place incorporate the following examples of good practice:

• Home Fire Safety checks will be provided to all new council tenants and those tenants who are identified as being a greater fire risk, although this is not yet documented in policies or procedures.

• The Fire Risk Assessments that are carried out by Chubb rate

the risks on the basis of the likelihood and impact. It also identifies the relevant people that would be affected by fire in accordance with the Regulatory Reform Fire Safety Order. The recommended remedial actions that arise from the assessments are stored on a central database which can be accessed by the authority in order for the tasks to be allocated to officers. It is also possible to obtain a report showing which recommendations are outstanding.

• A new fire safety checklist has been devised for the regular

inspection of communal areas, in order to identify potential hazards. However, this is yet to form part of a formal procedure.

• Records are maintained that show when key safety tests have

been carried out in properties, such as gas safety and smoke detector tests, however fire alarm testing and fire drills have been overlooked from this. The prospect of utilising the authority’s asset management system to record all this data should be explored.

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3. Action Plan

Observation Risk Recommendation Priority Response/Agreed Action

Officer Responsible

Action Date

1. The policies and procedures in place that address fire safety refer to Charnwood Neighbourhood Housing, and therefore the key roles and responsibilities of officers are not identified.

There is no accountability for undertaking mitigating actions in relation to fire safety. Officers are unaware of what duties they are required to perform.

A formal policy and procedure document should be devised outlining key roles and responsibilities in relation to fire safety. The policy document should include:

• The need to undertake fire safety checks in communal areas on a regular basis

• The need to undertake home fire safety checks for new tenants and tenants that pose a greater fire safety risk to the authority.

• The need to

H This has been brought up to date and presented to the LFRS on 31st July, and includes the points stated.

CG 1 August 2013

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include an agenda item on fire safety at monthly SMT meetings, which includes discussion of performance

2. The SMT meetings act as a forum and a central point of communication for fire safety, however, agreed tasks to be undertaken by officers are not being recorded.

There is no accountability for tasks that are to be completed and formal deadlines are not set.

Agreed actions to be undertaken relating to fire safety should be formally documented on an action plan. This should identify the officers responsible for completing tasks and the target completion dates. Audit did however see the first such action plan that was devised on 21 June 2013. The one-to-one progress meetings that the Head of Landlord Services has with the Strategic Director, should also be used as a forum to discuss and monitor

H The Compliance Team now control the FRA process The Action Plan devised with LFRS will be monitored until completion as will the actions agreed at SMT Fire safety is already discussed at a high level with the Head of Service at their weekly meetings, including the monitoring statistics, but more attention needs to be paid to progress and control. This will happen at the

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progress of the action plan. Fire Safety should form a part of the agenda item in the monthly SMT meeting. Agreed actions should be documented in minutes of the meetings or on action plans, which should identify the officers that have been tasked with responsibilities and the target completion date. It should be noted however, that the first action plan internal audit have seen was that devised on 21 June 2013 which was during the audit.

SMT and at future 1-1 meetings with the Compliance Manager and the Repairs and Investment manage

3. The authority does not have an accurate record of which properties are subject to a Fire Risk Assessment under the Regulatory

Fire Risk Assessments may not be carried out as required under the order and there is non-compliance with

There should be a reconciliation between the details of the properties that require Fire Risk Assessment on Chubb’s database and Housing Services’ list.

H Agreed, this is underway, but this had been done at the original instruction for Chubb, subsequent Audits identified incorrect data, and we have now identified a

Business Support Team Manager, Housing Operations and Business Support

30 September 2013

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Reform Fire Safety Order 2005. Chubb are used to carry out the Fire Risk Assessment and there is a mismatch between the sites that require assessing on the authority’s list and on Chubb’s database. Housing Services are also unaware of where exactly all communal areas are located.

legislation due to data integrity.

The authority’s asset management system may be able to record where exactly the communal areas are and when they require assessing and Housing Services should liaise with the system administrators in order to establish if this functionality can be utilised.

large number of potential discrepancies which will require site visits to resolve Agreed but we are presently looking at the transfer of Stock condition data onto QL. This project will continue, we will look at identifying communal areas afterwards

4. The Auditor observed a Fire Risk Assessment being carried out by the Chubb. This established that the specific areas that require assessing are not identified:

Fire Risk Assessments may not be carried out where they are required resulting in non-compliance with legislation.

There should be liaison with the wardens and the housing officers in order to establish exactly where the communal areas are prior to undertaking a Fire Risk Assessment. Details of all communal areas should be recorded on QL or otherwise.

L Agreed, this is underway, but this had been done at the original instruction for Chubb, subsequent Audits identified incorrect data, and we have now identified a large number of potential discrepancies which will require site visits

Business Support Team Manager, Housing Operations and Business Support/VB

30 December 2013

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• the contractor was not provided of the details of where the assessments had to be carried out .

• A warden that happened to be passing by the site being inspected informed the contractor of a communal lounge that needed inspecting.

to resolve. Once all the communal areas have been identified, we will look into trying to record this on Q, however, this cannot be prioritised at present..

5. The observation of a Fire Risk Assessment identified that arrangements had not been made to allow the contractor access to all areas that

The risk assessment is not being carried thoroughly

There should be liaison between those responsible for undertaking Fire Risk Assessments, and housing officers or wardens in order to arrange for all access into communal areas.

L Agreed. This is a simple instruction that FRAs are taking place, which was not communicated previously. Compliance Manager to ensure relevant colleagues are

Compliance Team Leader, Planned Support

1 August 2013

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need assessing. There were several locked electricity meter boxes that could be accessed with the standard triangular key used for all electricity meter boxes, but this had not been made available to the contractor.

notified when FRAs are to take place.

6. There is currently no contract or Service Level Agreement in place with Chubb, who are used to carry out the Fire Risk Assessments. The auditor was informed that Chubb are compliant with the British Standard on Fire Risk Assessments (Publically

There are no set standards to which Chubb are expected to perform to.

A service Level Agreement / contract should be implemented for Chubb to undertake Fire Risk Assessments and this agreement should be subject to regular review. It should also specify that Chubb must be compliant with the requirements of PAS79.

L Chubb were chosen because they are one of the UKs leading companies in fire safety and no FRAs existed in June 2013 for the stock. They also allowed access to their database for us to manage the process. During 2015 a tender will take place to appoint a new contractor to carry out FRAs

30 December 2013

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Available Specification 79 -PAS79). However, this has not been verified 7. Once the Fire Risk Assessments are completed; the recommended remedial actions have to be allocated to an officer within the authority. However, out of the 981 recommendations made since July 2012, • 439 due to have

been completed by January 2013 but were not marked as completed;

• 19 very high risk

Value for money is not being obtained from the work being undertaken by Chubb as the recommendations that they are making are not being implemented. Consequently; the level of risk that the authority is exposed to is not being reduced.

Remedial actions recommended by Chubb should be allocated to officers promptly and active steps should be taken in order to reduce the number of outstanding actions left from the Fire Risk Assessments.

H Agreed. This is underway, statistics will be available in the monthly KPI monitoring report

Business Support Team Manager, Housing Operations and Business Support

1 August 2013

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recommendations due to have been completed by March 2013 had not been allocated to officers.

8. The auditor was informed that fire incidents were not being notified promptly to the authority

Urgent actions required such as the immediate rehousing of residents may not be achieved.

Housing services should liaise with the Leicestershire Fire and Rescue Service in order to establish how to improve the procedure of the authority being notified of fires in its properties.

L This has already been done on 2 occasions, in March 2013 and in July 2013 with meetings between the Head of Service and Senior fire Officers from LFRS. Our stock lists and emergency telephone contacts have been given on 2 occasions. Progress will be monitored.

Assistant Director of Property and Investment, Investment and Regeneration

Ongoing

9. The Compliance Team Leader maintains records of when various safety inspections are due and when they have been carried out, however, this does

Routine testing will be overlooked.

Details of when fire drills and electricity testing was carried out for all properties should be maintained.

M Agreed, it is in the sheltered schemes and offices, it needs to be on a central database

Business Support Team Manager, Housing Operations and Business Support

1 October 2013

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not include electricity testing, and fire drills. This issue was further highlighted when the auditor attended a Fire Risk Assessment and identified that the safety certificate of an electricity fuse box was nine years out of date.

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4. Detailed Findings 4.1 Policies and procedures The responsibility for providing housing services transferred from Charnwood Neighbourhood Housing Ltd; a fully owned subsidiary of Charnwood Borough Council back to the authority directly in November 2012. As a result of this, Landlord Services are in a period of transition, which has meant that several senior positions are now being covered by interim staff; All the previous policies and procedures relating to fire safety are now out of date, particularly as the roles tasked with the responsibilities no longer exist, such as the CEO of the company. Hence there is currently no formal structure chart for fire safety and roles and responsibilities are not identified. The SMT meetings act as a central point of communication for fire safety, but the actions to be taken that have been agreed at the meetings are not being documented and formally allocated to individual officers, with agreed deadlines. However, Internal Audit do acknowledge that Landlord Services have recently started to record this as of 21 June 2013 in the form of an action plan. Details of some of the issues that have not been documented include the following:

• The Compliance Team Leader having been tasked with the responsibility of managing a program to implement emergency lighting in communal areas

• Home Fire Safety Checks to be carried out for new tenants and tenants who may pose a greater risk in relation to fire safety

• New tasks that are to be performed by Compliance Team Leader as a result of the Health, Safety and Environment Manager leaving the authority, i.e. allocating remedial action recommended on Fire Risk Assessments to officers within the authority.

4.2 Accuracy of records to show where Fire Risk Assessments are required Properties that require a Fire Risk Assessment under the Regulatory Reform Fire Safety Order 2005 include those with communal areas, such as stairwells and sheltered accommodation. The details of the housing stock held by the authority is recorded on the QL Asset Management System and this was used to determine which properties are subject to a Fire Risk Assessment. These sites are recorded on a separate spreadsheet which also shows the dates of when Fire Risk Assessments were carried out and when they are next due. Chubb are used as a contractor for undertaking the Fire Risk Assessment and their findings are recorded on their database which is accessible by Landlord Services. A comparison was made between the authority’s list of sites that require assessing and the sites listed on Chubb’s database and there was a significant mismatch:

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Number of sites on the authority’s list that require a Fire Risk Assessment 74Number of sites on the authority’s list that are on the Chubb System 7Sites missing from Chubb System: Freehold Street Leicester Road North Street Burns Road St. Peters Court Durham Road ST Michaels Court

Number of Sites on Chubb Database 66Number of sites on Chubb that are not on the authority’s that require a Fire Risk Assessment 10Sites on the Chubb database that are not on the authority’s list that require a Fire Risk Assessment 1 - 6 Cordell Road 15-19 Factory Street 194-204 Park Road 21&23 Sharpley Road 30&32 Hermitage Road 43-49 Wordsworth Road 7-11 Cordell Road Castle Hill Court Humphrey Babington House Ling Road

The auditor observed a Fire Risk Assessment being undertaken by Chubb at Harlech Close and identified the following issues:

• The contractor undertaking the risk assessment was not provided with details of which communal areas required assessing. Instead, he was accompanied by the Health, Safety and Environment Manager, who pointed out the properties to inspect.

• The electricity meter boxes in the communal stairwells could not be assessed as the majority were locked. They all required the same standard triangular key used for all electricity meter boxes, but this had not been made available to the contractor.

• When a warden arrived at the site being inspected, she was asked if there were any other communal areas at that site, at which point the Health, Safety and Environment Manager became aware of a communal lounge on Durham Close that needed inspecting. The assessment here identified that there was a fuse box with a 9 year out

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of date Electricity Safety Certificate, and fire extinguishers which were one month past their service date.

This established that there is no central list of all communal areas that are subject to a Fire Risk Assessment. The System Administrator for QL stated that QL could be utilised to show which properties have communal areas and thus, when risk assessments should be carried out. 4.3 Contract with Chubb to undertake Fire Risk Assessments There is currently no Service Level Agreement or contract in place for Chubb to undertake the Fire Risk Assessments. The previous Service Level Agreement was with Charnwood Neighbourhood housing Ltd and listed the Fire Risk Assessments that were to be undertaken up to January 2013. The auditor was informed by the Health, Safety and Environment Manager that Chubb are compliant with ‘PAS79’ which is the British Standard for Fire Risk Assessments, however, we were unable to verify this. 4.4 Implementation of recommended remedial action stated on Fire Risk Assessment reports. Once a Fire Risk Assessment has been completed by the contractor, the Health, Safety and Environment Manager receives an email informing him of this. He then needs to access the Chubb database in order to allocate the recommended remedial actions to officers within the authority. A data extract of recommended actions from the Chubb database identified that there had been 981 remedial actions required since July 2012.However, we found occasions where actions were not being allocated to officers in the authority and several actions had not been completed by the target date. As an example, there were 439 recommendations where the target completion dates were prior to 2013 and these had not yet been completed, and 19 Very high risk recommendations which were to have been completed by March 2013 had not been allocated to officers. 4.5 Monthly performance reports A monthly performance report has been devised by the Health, Safety and Environment Manager, which includes:

• the number of risk assessments that are due to be carried out and the number that have been carried out,

• the number of recommendations from Risk Assessments that have been implemented and the number that are overdue,

• the number of smoke detector tests that have been undertaken and the number that are now due

However, in order to add value and substance to the performance report; there needs to be a narrative explaining what the charts are showing. The monthly performance report should also be discussed in the one-to one-progress meetings between the Head of Landlord Services and the Strategic Director, so that any issues identified here can be resolved. This performance report should also be included in the policies and procedures.

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4.6 Planned monthly fire safety checks in communal areas A checklist for assessing fire safety in communal areas has been devised by the Health, Safety and Environment Manager. These checks are to be carried out on a regular basis by wardens and housing officers for properties within their remit, however, there are no procedures in place in order to centrally manage and enforce compliance with this requirement. 4.7 Process of notification of fire incidents to the authority The auditor was informed by Landlord Services that there are often delays in the authority being notified by Leicestershire Fire and Rescue Service of fires that occur in its properties. The delay is usually no more than a few days, although, a new commander has been appointed for Charnwood Borough and the authority should continue dialogue with Leicestershire Fire and Rescue Service in order to improve the notification procedure so that any immediate issues such as re-housing can be considered promptly. 4.8 Routine Maintenance The Compliance Team Leader maintains a spreadsheet showing which safety inspections and tests that are required in properties owned by the authority. These include;

• Fire Extinguishers and Fire Blankets • Smoke Detectors • Fire Alarms. • Gas safety certificates

However, details of when fire drills were carried out and electrical safety certificates appear to have been overlooked. Our discussions with the database administrator for the authority’s QL asset management system established that it is possible to put all this information on QL system. However, there needs to be dialogue with those in the Landlord Services.

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