Introduction

In residential healthcare settings across Ireland, the safety of residents during a fire emergency is of paramount importance. Nursing homes, disability services, and other designated centres accommodate individuals with varying degrees of mobility impairment, cognitive decline, and complex health conditions — populations for whom a standard, one-size-fits-all evacuation procedure is wholly inadequate and potentially dangerous.

Effective fire safety in these environments demands a bespoke approach — one that meticulously accounts for each resident's unique needs through Personal Emergency Evacuation Plans (PEEPs), clear evacuation prioritisation strategies, a structured dependency classification system, and well-rehearsed staff responses. Without these elements, the risk to life during a fire incident is significantly elevated.

This article sets out the key principles, regulatory obligations, and practical measures that registered providers of designated centres in Ireland must have in place. It draws on the HIQA Fire Safety Handbook, HIQA Regulation 28, and the broader Irish legislative framework to provide authoritative, actionable guidance for providers, managers, and fire safety professionals.

Why Tailored Evacuation Plans Are Essential

Residents in designated centres are particularly vulnerable to the effects of fire. Impaired mobility, cognitive disabilities, frailty, reliance on specialist equipment, and the effects of medication all compound the risk during an emergency. HIQA inspection data consistently highlights that providers who lack robust fire safety management systems present a heightened risk of harm to the people in their care.

Unlike commercial or office buildings, where occupants can largely self-evacuate, healthcare facilities require a defend-in-place strategy supported by progressive horizontal evacuation. This method moves residents laterally — compartment to compartment — rather than vertically, reducing the physical and clinical risks associated with moving highly dependent individuals down staircases or out of the building entirely during an alarm activation.

Experience from fire incidents in other jurisdictions demonstrates that where good fire safety management policies, effective structural fire precautions, and comprehensive staff training are in place, the risk of serious harm to residents is dramatically reduced. Tailored evacuation planning is not merely best practice — it is a legal and regulatory obligation for every registered provider of a designated centre in Ireland.

HIQA Fire Safety Handbook: Four Key Themes

The HIQA Fire Safety Handbook — the principal guidance document for registered providers and staff in designated centres — identifies four intrinsically linked themes that are central to achieving and maintaining fire safety. These themes provide a framework for self-assessment, continuous improvement, and HIQA compliance inspections.

1. Governance and Management

The registered provider must have a robust fire safety programme with clear lines of oversight, accountability, and adequate resources. This includes documented fire safety policies, a designated person with responsibility for fire safety, a programme of regular audits, and evidence that fire safety is embedded into the governance structures of the organisation — not treated as a peripheral concern.

2. Risk Management

Providers must actively identify, assess, and mitigate fire risks across the premises. This encompasses the physical environment — such as compartmentation integrity, fire door condition, and the presence of ignition sources — as well as operational risks arising from staff practices, resident behaviours, and care routines. A current, professionally conducted fire risk assessment is the cornerstone of effective risk management.

3. Diverse Care Needs

Fire safety planning must reflect the actual care needs of the residents in the centre. This theme acknowledges that no two residents are the same — evacuation plans, staffing levels, bedroom locations, and assistance requirements must all be calibrated to the specific dependency profile of each individual. The handbook emphasises that providers must regularly reassess these needs as residents' conditions change over time.

4. Staff Knowledge and Competency

All staff — regardless of role — must understand fire emergency procedures, know evacuation routes, and be competent in assisting residents with varying dependency levels. Regular CPD-certified fire warden training, compartment evacuation drills, and documented competency records are essential. HIQA inspectors will assess whether staff can demonstrate, in practice, what to do when a fire alarm activates.

Resident Dependency Categories

A fundamental component of evacuation prioritisation is a clear, consistent system for classifying the dependency level of each resident. Three categories are used in practice across Irish designated centres, each associated with a colour code that enables rapid identification and appropriate staff response during an emergency.

Independent (Green)

A resident classified as Independent is capable of self-evacuating without staff assistance when the fire alarm activates. They understand the alarm, can follow evacuation routes, and can move to a place of safety under their own volition. Residents in this category still require clear information about procedures and routes, but do not need dedicated evacuation support from a member of staff.

Characteristics of an Independent (Green) resident include:

Can self-evacuate when the fire alarm sounds
Understands evacuation instructions and routes
Mobile without assistive devices or with personal mobility aids they can use independently
No cognitive impairment affecting emergency comprehension

Dependent (Amber)

A Dependent resident requires the assistance of one or more members of staff to evacuate safely. They may have limited mobility, require verbal prompting due to cognitive impairment, or need assistance navigating the evacuation route. These residents can be moved — with assistance — to an adjacent fire compartment or to a place of safety, but cannot be left to evacuate unaided.

Characteristics of a Dependent (Amber) resident include:

Requires physical or verbal assistance to evacuate
May use a wheelchair, walking frame, or other assistive device requiring staff guidance
May have mild-to-moderate cognitive impairment affecting ability to respond to alarms
Can be transferred to a place of relative safety within the building with assistance

Very High Dependency (Red)

A Very High Dependency resident is bedbound, requires specialist lifting equipment, or has clinical needs so complex that their evacuation presents significant logistical and clinical challenges. These residents require the most detailed individual planning, the greatest staff resource allocation, and the most thorough consideration of bedroom placement and compartmentation design.

Characteristics of a Very High Dependency (Red) resident include:

Bedbound or unable to weight-bear
Reliant on specialist moving and handling equipment (e.g., evacuation mattresses, hoist systems)
Has complex clinical needs (e.g., oxygen dependency, ventilator use, catheterisation) that complicate movement
Requires multiple staff members and coordinated procedures to move safely
Their PEEP must specify clinical protocols and equipment required during evacuation

Personal Emergency Evacuation Plans (PEEPs)

A Personal Emergency Evacuation Plan (PEEP) is an individualised, documented plan that sets out precisely how a specific resident will be evacuated or assisted to a place of safety in the event of a fire. Every resident who cannot self-evacuate — that is, every Dependent (Amber) or Very High Dependency (Red) resident — must have a current, accessible, and regularly reviewed PEEP.

Under HIQA Regulation 28 and the Care and Welfare of Residents in Designated Centres for Older People Regulations 2013, providers are obligated to ensure that evacuation procedures account for the individual needs of all residents. PEEPs are the primary mechanism through which this obligation is met.

The Six-Step PEEP Process

Developing an effective PEEP is a structured process that must be completed for each eligible resident on admission and reviewed regularly as their condition changes. The following six-step framework reflects established best practice:

Assessment of Evacuation Needs — Evaluate the resident's mobility, cognitive function, clinical dependencies, communication needs, and any specialist equipment required for safe movement.
Classification and Colour Coding — Assign the appropriate dependency category (Independent/Green, Dependent/Amber, or Very High Dependency/Red) and ensure this is reflected in the visual identification system.
Evacuation Route and Strategy — Document the specific evacuation route(s) to be used, the destination compartment or place of safety, and the sequence of actions required, including door management and any intermediate safe points.
Staff Roles and Responsibilities — Identify by role (not solely by name, to account for shift changes) which staff members are responsible for assisting the resident, and the number of staff required at any given time of day, including night shifts.
Equipment Requirements — Specify any evacuation aids, mattresses, wheelchairs, or clinical equipment required, and confirm their storage location, maintenance status, and accessibility during an emergency.
Review and Drill — Review the PEEP whenever the resident's condition changes materially, at a minimum of annually, and incorporate PEEP procedures into compartment evacuation drills so that staff are practised and confident in executing the plan.

PEEPs must be stored accessibly — typically at the nurses' station or within the resident's file — and must be immediately available to all staff, including agency and temporary staff who may be less familiar with individual residents' needs. They should never be locked away or inaccessible during an emergency.

Visual Identification Systems

A practical and widely adopted tool for supporting rapid evacuation decision-making is a colour-coded visual identification system. This system uses door markers — typically coloured cards, tags, or discs — placed on or adjacent to each resident's bedroom door to communicate their dependency category at a glance.

The colour coding aligns directly with the three dependency categories:

Green — Independent: self-evacuation, no staff assistance required
Amber — Dependent: requires one or more staff to assist with evacuation
Red — Very High Dependency: requires significant staff resources, specialist equipment, and specific clinical procedures

This system is particularly valuable during night shifts, when staffing levels are lower, or when agency staff are on duty. A member of staff conducting a compartment sweep can instantly identify which rooms require prioritised attention without needing to consult documentation in the moment. Door markers must be updated promptly when a resident's dependency status changes — this is a clinical and fire safety governance responsibility.

The visual identification system should be integrated with the wider evacuation management system used in the centre. Phoenix STS's TagEvac system complements the colour-coded approach by providing fire wardens with a mechanical zone-clearing mechanism that works without electronics, batteries, or network dependency — an important consideration in healthcare environments where power continuity during an emergency cannot always be guaranteed.

Bedroom Allocation Considerations

Bedroom placement is a critical but often overlooked element of evacuation planning. Where a resident is accommodated within the building has a direct bearing on the speed, safety, and feasibility of their evacuation in an emergency. Providers must give careful consideration to the following principles when allocating bedroom locations:

Very High Dependency (Red) residents should ideally be accommodated on the ground floor or in compartments that adjoin a place of safe refuge or have a short, direct route to an exit — minimising the distance staff must travel with specialist equipment during an evacuation.
Bedroom location must account for night-time staffing ratios — if the number of Very High Dependency residents on a floor or in a compartment exceeds what can be safely evacuated by the staff on duty at night, this represents an unacceptable risk that must be addressed through either relocation, staffing review, or structural mitigation.
Compartmentation boundaries must be respected — bedroom locations should be planned so that progressive horizontal evacuation can be achieved within the time parameters demonstrated by fire drills, and in accordance with the compartment sizes specified in Technical Guidance Document B (TGD B) 2024 Reprinted Edition (January 2026).
Bedroom allocation must be a dynamic process — as residents' conditions change, their bedroom location should be reviewed in conjunction with their PEEP to ensure continued appropriateness.

Implementation Measures

Effective evacuation planning does not exist in isolation — it must be underpinned by a suite of physical, technical, and procedural fire safety measures working in concert. The following are the key implementation elements required in every designated healthcare centre.

Fire Detection and Alarm Systems

A compliant automatic fire detection and alarm system is the first line of defence. Systems must be designed, installed, and maintained in accordance with IS 3218 (the Irish standard for fire detection and alarm systems in buildings) and must provide adequate coverage of all areas of the premises, including circulation spaces, bedrooms, and utility areas. Early warning is especially critical in healthcare settings, as the time required to prepare and move very high dependency residents is significantly longer than in ambulant populations.

Escape Routes and Emergency Lighting

All escape routes must be maintained clear of obstructions at all times and must be of sufficient width to accommodate evacuation equipment such as mattresses and wheelchairs. Emergency lighting — compliant with IS 3217 — must provide adequate illumination along all escape routes and in all high-risk areas to enable safe evacuation when mains power fails. Escape route signage must comply with the relevant Irish standards and be visible from all parts of the route.

Compartmentation

In a defend-in-place strategy, the integrity of fire compartments is paramount. Walls, floors, ceilings, and all penetrations must maintain their specified fire resistance rating. Any breach — a damaged wall, an unsealed service penetration, or a propped open fire door — undermines the strategy entirely and can render a progressive horizontal evacuation plan unsafe. Providers must conduct and document regular compartmentation surveys and remediate defects without delay.

Fire Doors

Fire doors are arguably the most critical passive fire protection element in a healthcare building. They contain fire and smoke, protecting residents in adjacent compartments during progressive horizontal evacuation. All fire doors must be subject to a formal, documented inspection programme — checking door leaf condition, frame integrity, cold smoke seals, intumescent seals, self-closing devices, and ironmongery. Defective fire doors must be repaired or replaced as a priority. Staff must never prop fire doors open using unauthorised means.

Staff Training and Fire Drills

All staff must receive fire safety induction training on commencement and regular refresher training thereafter. CPD-certified fire warden training — covering alarm response, sweep procedures, evacuation techniques, fire door management, and the use of fire fighting equipment — should be provided to all designated fire wardens. Compartment evacuation drills must be conducted at least twice per year across all shifts (including nights), with outcomes recorded and used to drive continuous improvement in evacuation procedures.

Legislative Framework

Fire safety in Irish designated healthcare centres is governed by an interlocking framework of legislation, regulations, and technical guidance. Providers must demonstrate compliance with all applicable instruments.

HIQA Regulation 28 — Fire Precautions

HIQA Regulation 28 is the primary regulatory instrument governing fire safety in designated centres registered with HIQA. It requires registered providers to take adequate precautions against fire, provide suitable fire fighting equipment, ensure adequate means of escape with emergency lighting, maintain all fire equipment, and ensure staff are trained in fire prevention and emergency procedures. It also requires fire safety management, fire drills at suitable intervals, and the maintenance of records of drills, equipment tests, and defects. Compliance with Regulation 28 is assessed by HIQA inspectors and non-compliance can result in regulatory action.

HIQA Fire Safety Handbook

The HIQA Fire Safety Handbook — A Guide for Registered Providers and Staff provides detailed practical guidance on how to comply with Regulation 28 across the four key themes of Governance, Risk Management, Diverse Care Needs, and Staff Knowledge. Providers should treat this handbook as the authoritative operational guide for fire safety management in their centre. The handbook is published by HIQA and should be consulted alongside the relevant regulations.

Fire Services Act 1981 and 2003

The Fire Services Act 1981 (as amended by the Fire Services Act 2003) places a general duty on those who have control of premises to take all reasonable measures to guard against the outbreak of fire, to ensure the safety of persons on the premises in the event of fire, and to prevent the spread of fire. Section 18 of the Act establishes the general obligation to ensure fire safety. The Act also provides local authority fire services with powers to issue fire safety notices (Section 20) and carry out inspections (Section 22).

Care and Welfare of Residents in Designated Centres for Older People Regulations 2013 and 2016

The Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (S.I. No. 415 of 2013), as amended, set out the detailed obligations of registered providers in relation to the care, welfare, and safety of residents. Regulation 28 within this instrument specifically addresses fire precautions and requires providers to ensure arrangements are in place for detecting, containing and extinguishing fires; giving warning; calling the fire service; and evacuating residents safely. The 2016 amending regulations updated and refined a number of the requirements applicable to registered providers.

Safety, Health and Welfare at Work Act 2005

The Safety, Health and Welfare at Work Act 2005 places a statutory duty on employers to ensure the safety, health, and welfare of employees so far as reasonably practicable. In the context of fire safety, this requires employers to prepare and revise emergency plans and procedures, appoint competent persons to implement those procedures, provide training and information to employees, and identify and assess emergency risks. The Act applies to all healthcare employers and complements the specific obligations under HIQA regulations.

Technical Guidance Document B (TGD B) — 2024 Reprinted Edition (January 2026)

Technical Guidance Document B (TGD B) — published under the Building Regulations 1997 — provides technical guidance on how to satisfy the fire safety requirements of Part B of the Second Schedule to the Building Regulations in Ireland. The current version is the 2024 Reprinted Edition, published January 2026. It addresses means of escape, internal fire spread (linings and structure), external fire spread, access for fire service operations, and compartmentation requirements. For healthcare buildings — classified as Occupancy Purpose Group 6 (Residential Care) under TGD B — specific provisions apply regarding compartment sizes, corridor widths, and fire resistance periods for structural elements.

Frequently Asked Questions

What is the difference between defend-in-place and progressive horizontal evacuation?

Defend-in-place is an overarching strategy whereby residents remain within the protected building rather than being immediately evacuated outside. Progressive horizontal evacuation is the tactical method used to implement it — moving residents laterally from a fire-affected compartment into an adjacent fire-resisting compartment, keeping them within the protected envelope of the building and away from the fire source. Full external evacuation is only undertaken as a last resort, or as directed by the fire service.

How often must PEEPs be reviewed?

PEEPs should be reviewed at a minimum of annually, and immediately whenever a resident's condition changes materially — for example, following a fall, a significant deterioration in mobility, a new diagnosis, or a change in the specialist equipment they require. They should also be reviewed following each evacuation drill if the drill revealed any deficiencies in the plan.

Are PEEPs a regulatory requirement in Ireland?

Yes. While the term 'PEEP' is not explicitly used in every piece of legislation, the requirement to have documented, individual evacuation procedures for residents who cannot self-evacuate is firmly embedded in HIQA Regulation 28, the Care and Welfare Regulations 2013, and the HIQA Fire Safety Handbook. HIQA inspectors specifically assess whether individual evacuation needs are documented and whether staff can demonstrate knowledge of them.

How many compartment fire drills are required per year?

HIQA Regulation 28 requires fire drills to be conducted at suitable intervals. In practice, HIQA expects drills to be carried out on each shift (including night shifts) and for all compartments to be tested. A minimum of four drills per year is widely considered the baseline — however, providers with complex dependency profiles or recent regulatory concerns should conduct drills more frequently. All drills must be recorded, and the records must be available for inspection.

What is TagEvac and how does it help with healthcare evacuation?

TagEvac is a mechanical sweep evacuation system used by fire wardens to manage zone clearance during an emergency. Fire wardens systematically check every room within their designated zone and remove a uniquely coded tag once the zone is confirmed clear. Tags are brought to a central Emergency Master Control Board at the assembly point — missing tags instantly indicate which zones still require attention. TagEvac requires no electronics, batteries, software, or network connection, making it highly reliable in healthcare environments where power disruption is a real contingency.

Does TGD B apply to existing healthcare buildings or only new builds?

Technical Guidance Document B is primarily a building regulations document applicable to new construction and material alterations. However, its principles — particularly regarding compartmentation, means of escape, and fire resistance — are directly relevant to assessing the adequacy of existing buildings and to any refurbishment or extension works. Fire risk assessors and fire safety engineers routinely use TGD B as a benchmark when evaluating existing designated centres.

What happens if a fire risk assessment identifies serious deficiencies?

Where a fire risk assessment identifies serious deficiencies — such as compromised compartmentation, inadequate staffing for night-time evacuation, or the absence of PEEPs — these must be addressed as a priority. The provider must develop a prioritised action plan with assigned responsibilities and timescales. Where the deficiencies present an immediate risk to life, interim measures must be implemented while permanent remediation is arranged. Failure to act on identified deficiencies is a significant regulatory and legal risk under both HIQA regulations and the Fire Services Acts.

Can agency staff use the visual identification and PEEP system effectively?

The colour-coded door marker system is specifically designed to be intuitive and self-explanatory, reducing the knowledge burden on agency and temporary staff who may be unfamiliar with individual residents. However, the visual system is a supplement to — not a replacement for — a proper fire safety induction for all agency staff before they commence their shift. Providers should have a brief, standardised fire safety induction protocol that covers evacuation procedures, dependency categories, PEEP locations, and fire warden contact for all agency personnel.

How Phoenix STS Can Help

Phoenix STS is a specialist fire safety consultancy serving healthcare providers across Ireland. Our team of BEng-qualified fire engineers and NFRAR Advanced-registered fire risk assessors provides comprehensive, HIQA-aligned fire safety services — from evacuation planning and PEEPs to fire risk assessments, fire warden training, and TagEvac installation.

Whether you are preparing for a HIQA inspection, responding to an inspection report, or proactively strengthening your fire safety management system, we can provide the expertise and practical support you need.

To discuss your requirements, contact us today:

Enquire Now
Phone: 043 334 9611

Related Services

Disclaimer

The information contained in this article is provided for general guidance purposes only and does not constitute professional fire safety advice. Whilst every effort has been made to ensure accuracy and currency at the time of publication, legislation, regulations, and technical guidance documents are subject to change. Readers should not rely solely on the content of this article when making decisions about fire safety compliance and should seek independent professional advice appropriate to their specific circumstances. Phoenix STS accepts no liability for any loss or damage arising from reliance on the information contained herein. All fire safety measures should be implemented under the guidance of a suitably qualified and registered fire safety professional.