Adam Bannister

Editor, IFSEC Global

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Adam Bannister is editor of IFSEC Global. A former managing editor at Dynamis Online Media Group, he has been at the helm of the UK's leading fire and security publication since 2014.
February 11, 2015

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Rosepark Care Home Tragedy: Have the Lessons Been Learned?

rosepark fire

A fire that broke out in a residential home in Cheshunt, Hertfordshire, killed two women, aged 91 and 89.

Firefighters called to the blaze at Newgrange residential home, managed to rescue 33 people after flames engulfed the upper floors of the building on Saturday 8 April 2017.

Three other residents are in hospital in a serious condition, according to Hertfordshire Police.

Emergency services are continuing to investigate how the fire at the 38-bed facility in Cadmore Lane was started.

Hertfordshire County Council said in a statement:

“Firefighters were faced with an extremely fierce fire, well-established in the first floor and the roof of the building, which has since collapsed.”

Thirty-three residents were rescued and the firefighters worked closely with police and ambulance colleagues to evacuate them to a nearby emergency reception centre.

It’s one of the worst care home fires since the blaze that killed 14 elderly residents at Rosepark Care Home in Uddingston, South Lanarkshire in 2004. It’s still too early to know if, and what, deficiencies in fire safety might have contributed to the latest tragedy, but the damning 2011 inquiry into the Rosepark fire concluded:

“The management of fire safety at Rosepark was systematically and seriously defective. The deficiencies in the management of fire safety at Rosepark contributed to the deaths.

“Management did not have a proper appreciation of its role and responsibilities in relation to issues of fire safety.”

That blaze began on 31 January 2004 because of an earth fault in a cable passing through an electrical distribution board inside a cupboard.

Two prosecutions of the home’s owners, Thomas and Anne Balmer and their son Alan, for alleged safety breaches were dismissed in 2007 and 2008.

Leading the 141-day probe into the tragedy Sheriff principal Brian Lockhart identified the following failings on the care home’s part:

  • “Some or all” of the deaths could have been prevented if the home had a “suitable and sufficient” fire-safety plan
  • “Inadequate arrangements” were made for calling the fire brigade. The care home’s procedures dictated that a member of staff find the source of the blaze before dialling 999. Staff waited nine minutes before contacting the fire service
  • A “critical failing” to identify high-risk residents or consider contingency plans in the “worst-case scenario” of a fire beginning at night
  • “Limited attention” paid to evacuation procedure (particularly egregious given the mobility issues of residents). Too many people were housed in one corridor to evacuate effectively. The electrical distribution board sat alongside flammable materials in a cupboard that opened to a “critical escape route
  • Staff not given adequate fire-safety training
  • A lack of fire dampeners
  • The risk assessment was “obtained in good faith” but contained a “serious error”

Although the fire brigade went to the wrong entrance, extending the delay by a further four minutes, they “did everything in good faith and with dedication and heroism,” said Sheriff Lockhart.

Rosepark should have been assigned a special risk category by the fire service, however, with the local station visiting annually and becoming familiar with its layout.

The local health board’s inspection failures – like failing to spotlight the leaving open of residents’ bedroom doors at night – also “contributed to the deaths”.

Sheriff Lockhart did note “very substantial developments which have taken place in respect of fire safety since the Rosepark fire.”

Four years on and not everyone believes improvements are yet – let alone then – adequate.

England & Wales versus Scotland

“While Scotland has clearly responded well to the Rosepark fire by requiring that all new care homes are provided with sprinkler systems, England has behaved as if the Rosepark care home was located in Papua New Guinea and the fire there had no relevance to the safety of some of the most vulnerable people in the country,” says Dave Sibert, an IRMP advisor at the Fire Brigades’ Union.

“There has been piecemeal implementation of some measures, but there was no coherent common response by government, fire and rescue services or the wider fire sector.”

Management – not buildings – the problem

Nick Coombe, who provides fire-safety management support, audit and performance at the London Fire Brigade, believes much of the care home industry has, by contrast, heeded the lessons. “It’s difficult to say. I think they have improved. I definitely think it was a wake-up call for a number of care homes.

“I think the issue with care homes is the change of care providers and management they go through rather than anything physically wrong with the building or the physical fire precautions in there. I think most care homes probably do have adequate fire-safety measures.

“Rosepark did – it was the management of them that was the issue. When we inspect care homes we rarely turn up to find there’s no fire alarm or fire doors etc; it’s how they’re managing and dealing with it.”

Cuts

Financial constraints, he says, have an adverse effect.

“Care homes have suffered the austerity cuts that we are all  going  through and they’re trying to do more for less – like with staff ratios,” says Coombe. “That’s what we focus on more than the physical bits: the management part and evacuation strategy.

“If there is a fire, what’s their evacuation plan and can it physically work? Some care homes say ‘well, we’ll move this person and then that person  and you say ‘hang on, do you know how long that’s going to physically take you and have you got the enough  staff to do it quickly and safely ?’

“Do you need more staff? Better compartmentation or  the answer in some cases is sprinklers? It’s a balance.

“I would say that the industry learned some lessons but it’s an ever-expanding sector. The sector is moving aware from traditional ‘institutional like’ care homes   to more ‘user-friendly’ care packages to cope with the growing ageing population.

“However , they’re looking to save money like everyone else and sometimes safety gets cut – and that’s what we’re their for – the fire and rescue service – to make sure they maintain at least the legal minimum standards.”

PAS 7

Ben Bradford is the founder and MD of fire-safety engineering firm BB7.

“An adequate system of fire safety management is neither an unrealistic level of excellence nor a complete disregard for the minimum requirements of legislation,” he says. “Put simply it should be the acceptable norm.

“However, we know the reality is that there are many organisations who to not maintain an adequate system of fire safety management, and some that would be well advised to implement an enhanced system of fire safety management.”

Bradford was instrumental in writing PAS 7: Fire Risk Management Systems Specification 2013, a fire-risk strategy from the British Standards Institution that he believes makes a helpful contribution to preventing further tragedies.

“The review panel considering changes to BS 9999 are currently considering proposed changes to section 4 of this standard in light of the publication of PAS 7 and the latest insights gained auditing against it.”

‘Swiss cheese model’

Sibert, however, believes that the failings from Rosepark encompassed more than just fire-risk management.

“The Rosepark fire was a classic case of the ‘Swiss Cheese Model’ of system failure where the holes lined up in every layer of protection from the construction of the building to the attendance of the fire service,” he says.

“For me it shows up the importance of providing a robust multi-layered approach to fire safety and the importance of testing all those layers because even the most robust looking system can develop holes over time.”

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5 Comments on "Rosepark Care Home Tragedy: Have the Lessons Been Learned?"

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InTheTopOne
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So let’s summarize… inadequate training, inadequate fire-fighting equipment, inadequate staffing levels, inadequate fire evacuation procedures, inadequate fire-fighting procedures, inadequate risk assessment, possibly inadequate staff competence, but we’ll give them the benefit of the doubt…

What did they actually get right?

At least we can now see for ourselves what life in a care home actually means; safety on a shoe-string budget. 

Would you let your aged parents live there????

wma46
Guest
InTheTopOne Hindsight is 20:20 and some of these issues were flawed however the article has taken some of the findings out of context. For instance the staff had already investigated and found no fire as the fire panel wrongly identified the location of the fire alarm. This was the second time the alarm had tripped that day and therefore the thought was a faulty alarm hence 9 minutes to phone Fire Service. That is not the staffs fault and a lot of the other issue resulted from this mistake which was inherent in the building before occupation took place. Including… Read more »
InTheTopOne
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So it’s nobody’s fault (!)  It’s just one of those things that couldn’t have been avoided…these things happen… no-one’s to blame… they were old people anyway and they’ve had a good run… let’s gloss over it and pretend that it didn’t actually occur in the first place… They way you callously trivialize the events at Rosepark just goes to show the depths to which this country has plummeted. These people were loved ones, relatives, Mums, Dads, grandparents. Why don’t you tell their relations that nobody’s to blame? Suppose, God forbid, it had been your parents who perished in the flames.… Read more »
wma46
Guest
InTheTopOne I beg your pardon casually trivalise I did not. Please re read my comments. just because someone can reason and read the evidence does not mean its been trivialised but I believe you have not read all the documents. Please do your homework I questioned the article biasness which was skewed. For instance I agree some of the systems were flawed first line then my main concern the biasness and the good things that came out of it smoke control and staffing levels at the end. How has that trivialised anything. I believe that is you who has plummeted… Read more »
Adam Bannister
Guest

wma46 InTheTopOne Hi both. I’m the editor of IFSEC Global. Thanks for your interesting, insightful comments on this story. Would you be interesting in commenting again – this time within another article about the subject?