HERTFORDSHIRE FIRE & RESCUE SERVICE Fire Protection Postal Point MU103 Elmhurst Residential Care Home Mundells Windhill AL7 1FT Bishops Stortford CM23 2NF Telephone : 01707 292310 Fax : 01707 292588 FAO Donna Mason, Manager E mail : administration.cfs@.gov.uk Your ref : 003189/JWV My ref : Z01/1 Date : 21st March 2014

Dear Sec 40 (2) ,

THE REGULATORY REFORM (FIRE SAFETY) ORDER 2005 Elmhurst Windhill, Bishops Stortford, Hertfordshire, CM23 2NF

With reference to the fire safety audit and inspection of the above premises on 21st March 2014; I confirm that the premises will be considered satisfactory when the detailed verbal advice listed below given on site to yourself, has been carried out:-

1. It appears that the fire alarm and emergency lights testing, which was previously carried out weekly and monthly respectively, as required, has lapsed since the end of January 2014. Please ensure that the frequency of these tests is reinstated as required;

2. It is essential that fire drills are carried out at least annually and should include as many residents as possible. We discussed carrying out a drill each quarter with a different unit by using progressive horizontal evacuation. Any resident not able to take part should be replaced with a member of staff in role play. This would highlight any weaknesses that you may come across.

3. We discussed the storage and charging of hoists. The present practice of them being charged and stored within the corridor must cease immediately. These are protected means of escape corridors and should remain sterile at all times. If these need to be charged then they should be charged in a storage area suitable for that purpose i.e. enclosed within a construction capable of achieving a minimum of 30 mins fire resistance.

4. We also discussed the sensory areas. These cannot be allowed, again, as in Item 3, these areas form part of the protected means of escape and therefore ALL combustibles must be removed, including all electric appliances ie radios, air fresheners etc. If the sensory areas are required then we are open to the discussion of alternative methods which would allow this type of therapy to progress.

5. As discussed please check all cushions comply with the required British Standard for flammability requirements.

No further audit or inspection will be carried out at this stage.

It will still be necessary to review your fire risk assessment regularly (recommended to be at least once a year) and on the occasion of any of the following:-

(a) There is reason to suspect that it is no longer valid, or,

(b) There has been a significant change to the matters to which it relates.

Where as a result of any such review, changes to the assessment are required, the responsible person concerned shall make them.

I would like to take this opportunity of thanking you for your kind hospitality and to say that it is a pleasure to work with someone such as yourself who takes their responsibilities with regards to fire safety and the health and welfare of the service users as a priority second to none. It is also pleasing to hear the residents lovely praising comments about the care they receive and from the staff they get it from. Well done to you all.

If you have any enquiries regarding the content of this letter, you should direct them to the inspector named below.

Yours faithfully,

Sec 40 (2) Fire Protection Officer

CC Quantum Care Ltd 4 Silver Court Watchmead Welwyn Garden City AL7 1TS

FAO Sec 40 (2) , Health, Safety & Risk Manager

Quantum Care Ltd 4 Silver Court Watchmead Welwyn Garden City AL7 1TS

FAO Sec 40 (2) , Health, Safety & Risk Manager

HERTFORDSHIRE FIRE & RESCUE SERVICE Elmhurst Fire Protection Windhill Postal Point CH0331, Room 346, Bishops Stortford Old Block, County Hall, . Hertfordshire SG13 8DQ. CM23 2NF Telephone : 01707 292310 FAO – Beverly Chapel E mail : [email protected] My ref : INU/011750/GAH Date : 30 May 2019

Dear Madam,

LETTER OF FIRE SAFETY MATTERS

Elmhurst , Windhill, Bishops Stortford, Hertfordshire, CM23 2NF.

We visited your premises on 30th May 2019, and evaluated the fire safety provided. This Authority is pleased to advise you that you showed adequate fire safety provision. However, we are of the opinion that you can improve that safety. The attached schedule sets out our suggested improvements. There is no time limit associated with this letter. We do not intend to return in connection with this visit.

Please note that further inspections may be carried out by this Authority at a future date.

Have Your Say

You can clarify or challenge the works identified in the schedule attached. You can also comment on your experience of this authority’s regulation of you and you will find this information by using the web link listed below.

http://www.hertfordshire.gov.uk/your-community/havesay/commentcomplain/

Fire Safety Management

The schedule sets out what you need to do to improve fire safety. Taking this advice will help you sustain those improvements.

Alternative Solutions

You might want to use a different solution to meet the outcome(s) stated in the schedule. An alternative approach might enable you to make improvements that better meet your needs. This authority will be happy to discuss your ideas and suggestions.

Further Recommendations

None

Yours faithfully,

Sec 40 (2) Fire Safety Inspector

HERTFORDSHIRE FIRE AND RESCUE SERVICE File Ref: INU/011750/GAH

SCHEDULE OF WORK

Name and Address of Premises:

Elmhurst, Windhill, Bishops Stortford, Hertfordshire, CM23 2NF.

Inspector: Date of Inspection:

Gavin Hill 30/05/2019

Specification of Work Required

Responsibility for rectifying the failures listed below and the means by which this is done rests with the responsible person who has control over the premises. To assist you in this process, we detail below what we would consider to be minimum requirements for achieving compliance with the legislation. Should you choose to seek compliance by other means, you should consult with us prior to embarking on any works so that agreement can be sought as to whether your proposals would fully meet the requirement of the legislation.

Article 11- Fire safety arrangements

1. At the time of the inspection it was noted that although a fire drills have been taking placed and logged, an evacuation drill to ascertain the time taken to clear a compartment in the worst case scenario has not taken place.

Evacuation drills are important for the management to gauge the suitability of the current evacuation policies. An evacuation drill of the biggest compartment will need to take place using the night time staffing levels. Once this is completed an assessment of the time will need to take place to ensure that it is acceptable. If it is considered to be unacceptable then measures will need to be put in place in order to bring the time down to guidance levels.

Article 14 – Emergency routes and exits

2. At the time of inspection it was noted that the emergency escape signage was confusing and in some places lacking.

Whilst we understand that the premises is the residents home and you may not want to institutionalize the building it is important that there is no hesitation from anyone on the premises when it comes to evacuation. Therefore a review of your escape signage throughout the premise will need to take place and additional signs installed where required.

3. It was noted that several of the fire doors did not close fully against their stops.

A review of all fire doors will need to take place in order to ensure that they all close fully against their stops from any position within the timeframe of 25 seconds. Underneath the fire door, a gap of 8mm is traditionally acceptable; although for fire doors that are required to limit spread of cold smoke only 3 mm is permissible with a threshold seal (cold smoke seal) to be fitted if the gap is bigger.

4. It was noted that some of the store room doors which had signage indicating that they should be kept locked where not being locked when not in use.

It is good practice to ensure that all store rooms that are not in use are kept locked in order to ensure that contents are controlled by the management team. If a door has signage indicating that it is required to be kept in the locked position all efforts are to be made to ensure that this is done.

Notes to this Schedule:

The government guidance most suitable to your premises is “Residential Care Premises” which can be found at https://www.gov.uk/government/collections/fire-safety-law-and-guidance- documents-for-business

Before you make certain changes to the premises, you may have to apply for approval from statutory bodies and/or others having interest in them. If you have doubt about the need for approval, you should ask the relevant body. For example, you may have to apply for approval from a Building Control Body to make ‘material alterations’. You might also need to apply for the property owners’ permission or for ‘listed building consent’, among others.