Fire safety in nursing homes is not simply a technical matter of alarms and extinguishers. It is, fundamentally, a matter of protecting some of the most vulnerable people in Irish society — persons who may have limited mobility, cognitive impairment, sensory loss, or complete dependence on staff for their evacuation in an emergency.

HIQA Regulation 28 sets out the fire safety requirements for designated centres for older people. Non-compliance is one of the most frequently cited issues in HIQA inspection reports, and it can lead to regulatory action up to and including conditions on registration or refusal to register.

This guide explains what Regulation 28 requires, the legislation underpinning it, common non-compliance findings, and how nursing home operators can build and maintain a robust fire safety management system.

The Legislative Framework

Health Act 2007

The Health Act 2007 established the Health Information and Quality Authority (HIQA) and gave it the power to set standards for and regulate residential services for older people, people with disabilities, and children. Part 8 of the Act provides for the registration and inspection of designated centres.

S.I. 415/2013 as Amended by S.I. 1/2025

The **Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (S.I. No. 415 of 2013)**, commonly referred to as the "2013 Regulations," set out the detailed requirements for the operation of nursing homes and other designated centres for older people. These regulations have been amended by **S.I. No. 1 of 2025**, which updated certain provisions to reflect evolving standards of care and safety.

**Regulation 28** of S.I. 415/2013 deals specifically with fire precautions. It imposes obligations on the registered provider (the person or organisation registered with HIQA to operate the centre) to ensure adequate fire safety arrangements are in place.

What Does Regulation 28 Require?

Regulation 28 is concise in its statutory text but far-reaching in its practical implications. It requires the registered provider to ensure, by means of fire safety management and fire precautions, that:

1. Persons in the designated centre are protected from the risk of fire 2. Adequate arrangements are in place for detecting, containing, and extinguishing fires 3. Adequate arrangements are in place for giving warning of fires 4. Adequate arrangements are in place for the evacuation, including the safe placement, of residents and staff in the event of fire 5. Adequate arrangements are in place for the maintenance of all fire equipment, including fire alarm systems, emergency lighting, fire-fighting equipment, and fire doors 6. Adequate arrangements are in place for reviewing fire precautions 7. Adequate means of escape are provided and maintained 8. Staff receive suitable training in fire prevention and emergency procedures 9. Fire safety records are maintained 10. There are adequate arrangements for the safe evacuation of residents, having regard to the needs of the residents

The phrase "adequate arrangements" carries significant weight. What is adequate depends on the specific characteristics of the centre — its size, layout, construction, the number and dependency levels of residents, staffing levels, and the inherent fire risks present. There is no one-size-fits-all answer.

Fire Risk Assessment in Nursing Homes

A current, comprehensive fire risk assessment is the cornerstone of Regulation 28 compliance. Without it, you cannot demonstrate that your fire safety measures are adequate because you have not systematically identified and evaluated your risks.

The fire risk assessment for a nursing home must be carried out by a competent person following a recognised methodology, typically **PAS 79-1:2020**. It must take account of the specific risks associated with residential care, including:

Sleep Risk

Residents are present 24 hours a day, including during the night when staffing levels are typically reduced. Sleeping occupants have delayed awareness of fire and require more time to respond.

Mobility and Cognitive Impairment

Many residents have limited mobility, use wheelchairs, or are bed-bound. Others may have dementia, confusion, or other cognitive conditions that affect their ability to understand and respond to an emergency. The fire risk assessment must account for the evacuation needs of every resident.

Progressive Horizontal Evacuation

Most nursing homes in Ireland are designed around the principle of progressive horizontal evacuation (PHE) — moving residents horizontally to an adjacent fire compartment rather than down stairways. The fire risk assessment must verify that:

- Fire compartmentation is adequate and intact (compartment walls, fire doors, fire-stopping penetrations) - Each compartment can accommodate the residents from an adjacent compartment - Staff are trained in PHE procedures - Equipment (evacuation sheets, ski pads, wheelchairs) is available and maintained

Building Fabric and Fire Compartmentation

The condition of fire compartmentation is a critical concern in nursing homes, particularly in older buildings or premises that have undergone extensions and refurbishments over time. The fire risk assessment should examine:

- Fire-resisting walls and floors - Fire doors (condition, self-closing devices, seals, gaps) - Fire-stopping at service penetrations (pipes, cables, ducts passing through compartment walls and floors) - Cavity barriers - Roof-space compartmentation

Breaches in compartmentation are among the most common and most serious non-compliances found in nursing homes.

Fire Detection and Alarm Systems

The fire alarm system must comply with **IS 3218:2024**. For nursing homes, the system is typically Category L1 (detection throughout) with a staff alarm arrangement. The fire risk assessment should evaluate:

- Detection coverage and suitability of detector types - Alarm zoning and the ability to identify the location of a fire quickly - Alarm signalling (staff alarm vs. general evacuation) - False alarm management - Monitoring arrangements - Maintenance and testing records

Emergency Lighting

Emergency lighting must comply with **IS 3217:2023** and provide adequate illumination of escape routes and critical areas in the event of mains power failure. The fire risk assessment should verify coverage, condition, and testing records.

Fire-Fighting Equipment

Portable fire-fighting equipment (extinguishers, fire blankets) must be appropriate to the risks, correctly sited, and maintained. Staff must be trained in their use.

Fire Safety Management

Regulation 28 is not satisfied by hardware alone. A compliant fire safety management system includes:

Fire Safety Policy

A documented fire safety policy, endorsed by senior management, setting out the centre's commitment to fire safety and the organisational arrangements for delivering it.

Fire Safety Procedures

Written procedures for:

- Action on discovering a fire - Action on hearing the fire alarm - Evacuation procedures (daytime and night-time), including progressive horizontal evacuation - Procedures for residents who refuse to evacuate or who are receiving end-of-life care - Calling the fire service - Meeting the fire service on arrival - Post-incident procedures

Personal Emergency Evacuation Plans (PEEPs)

Every resident must have a Personal Emergency Evacuation Plan that documents their specific evacuation needs, the level of assistance required, the equipment needed, and the evacuation route from their room to a place of safety. PEEPs must be reviewed regularly and updated when a resident's condition changes.

Fire Drills

Regular fire drills must be conducted to test evacuation procedures and staff competence. Best practice in nursing homes includes:

- At least two fire drills per year (many providers conduct them quarterly) - At least one drill simulating night-time conditions (reduced staffing) - Drills that test progressive horizontal evacuation, not just full building evacuation - Documented records of each drill, including date, time, scenario, staff involved, observations, and corrective actions

Fire Safety Training

All staff must receive fire safety training upon induction and at regular intervals thereafter (at least annually). Training should cover:

- Fire prevention - Action on discovering a fire or hearing the alarm - Evacuation procedures, including the use of evacuation equipment - Operation of fire-fighting equipment - The specific needs of residents (PEEPs) - Compartmentation awareness — keeping fire doors closed, reporting defects

Training records must be maintained and available for inspection.

Fire Safety Records

Regulation 28 requires the maintenance of fire safety records. These include:

- Fire alarm testing records (weekly tests and six-monthly servicing) - Emergency lighting testing records (monthly function tests and annual full-duration tests) - Fire extinguisher maintenance records - Fire door inspection records - Fire drill records - Fire safety training records - Fire risk assessment reports and action plans - Records of any fire incidents or near misses - Maintenance records for all fire safety systems and equipment

Common Non-Compliance Findings

Analysis of HIQA inspection reports reveals recurring themes in Regulation 28 non-compliance. The most common findings include:

Compartmentation Deficiencies

- Fire doors propped open (without appropriate automatic release mechanisms linked to the fire alarm) - Damaged fire doors, missing intumescent seals, failed self-closing devices - Unprotected service penetrations through compartment walls - Gaps above suspended ceilings where compartment walls do not extend to the structural soffit

Inadequate Fire Risk Assessment

- No fire risk assessment in place - Fire risk assessment carried out by an unqualified person - Fire risk assessment that is out of date and has not been reviewed - Action plan items not addressed within recommended timeframes

Training Deficiencies

- Staff who have not received fire safety training - No evidence of training for agency or temporary staff - Training that does not cover the specific evacuation needs of residents - No fire drills conducted, or drills that do not simulate realistic scenarios

Documentation Gaps

- Missing or incomplete fire safety records - Weekly fire alarm tests not recorded - Emergency lighting tests not recorded - No Personal Emergency Evacuation Plans for residents

Means of Escape

- Escape routes obstructed by furniture, equipment, or stored items - External escape routes not maintained (overgrown, poorly lit, uneven surfaces) - Locked or restricted final exit doors

Equipment and Systems

- Fire alarm system not maintained to IS 3218:2024 - Emergency lighting not compliant with IS 3217:2023 - Fire extinguishers overdue for servicing - Evacuation equipment (ski pads, evacuation sheets) not available or not tested

The HIQA Inspection Process

HIQA conducts both announced and unannounced inspections of designated centres. Regulation 28 is assessed during most inspections. The process typically involves:

1. **Documentation review**: The inspector examines fire safety records, the fire risk assessment, training records, fire drill records, PEEPs, and maintenance records.

2. **Physical inspection**: The inspector walks the premises, checking fire doors, escape routes, fire alarm panels, emergency lighting, fire-fighting equipment, compartmentation, signage, and housekeeping.

3. **Staff interviews**: The inspector may ask staff about their fire safety training, their knowledge of evacuation procedures, and what they would do in the event of a fire.

4. **Resident-focused assessment**: The inspector considers whether fire safety arrangements are adequate for the specific residents in the centre, including those with high dependency needs.

Following the inspection, HIQA issues a report that is published on its website. Non-compliances are categorised as:

- **Compliant**: The centre meets the requirements of the regulation - **Substantially compliant**: The centre largely meets the requirements, but minor issues have been identified - **Not compliant**: The centre does not meet the requirements, with the non-compliance classified as either: - **Orange** (moderate risk): Issues that need to be addressed but do not pose an immediate threat - **Red** (high risk): Serious issues posing an immediate or significant risk to residents

A pattern of non-compliance, or a failure to address identified non-compliances, can lead to conditions being attached to the centre's registration, or ultimately to refusal to renew registration.

Preparing for a HIQA Inspection

Preparation for a HIQA inspection should not be a last-minute scramble. The most effective approach is to maintain continuous compliance — so that when an inspector arrives, whether announced or unannounced, the centre is always ready.

Key steps include:

- **Maintain a current fire risk assessment** carried out by a competent, qualified fire risk assessor, with all action plan items tracked to completion - **Ensure all fire safety systems are maintained** and that records are complete and accessible - **Conduct regular fire drills** and document them thoroughly - **Keep all staff training up to date** with records readily available - **Review PEEPs regularly** and update them when residents' needs change - **Carry out monthly internal fire safety checks** covering fire doors, escape routes, compartmentation, and equipment - **Address any identified issues promptly** and document the corrective actions taken

Phoenix STS — Specialist Fire Safety for Nursing Homes

[Phoenix STS](/nursing-home-fire-safety-compliance) is a specialist provider of fire safety services to the nursing home and healthcare sector in Ireland. We currently work with over 85 nursing homes across the country, providing:

- **Fire risk assessment** to PAS 79-1:2020, specific to HIQA-regulated premises - **IS 3218:2024 fire alarm audits** to verify system compliance - **Fire safety management consultancy**, including policy development, procedure writing, and PEEP templates - **Fire safety training** for all staff, including evacuation procedures and equipment use - **Fire door surveys** and compartmentation assessments - **Pre-inspection readiness reviews** to identify and address gaps before HIQA visits

Our fire engineers hold BEng-level qualifications and are registered on the National Fire Risk Assessment Register (NFRAR). We understand the unique challenges of protecting vulnerable residents and work with nursing home operators to build practical, sustainable fire safety management systems that satisfy both the letter and the spirit of Regulation 28.

S.I. 1/2025 — What Changed

The Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) (Amendment) Regulations 2025 (S.I. 1/2025) came into operation on 31 March 2025, introducing significant amendments to S.I. 415/2013.

Key changes include new requirements for the person in charge, including a minimum of three years' experience in nursing management and a limit of responsibility for a maximum of two designated centres. Visiting requirements were strengthened. Infection prevention and control provisions were expanded — where infection control measures affect fire safety arrangements (additional doors, changes to ventilation, storage of PPE), these interactions must be addressed in the fire risk assessment. The risk management policy requirement was expanded to address a broader range of operational risks, with fire risk featuring prominently. Resident rights provisions were strengthened, including the right to be consulted about matters affecting their safety and welfare.

The Role of the Person in Charge

Under the amended regulations, the person in charge holds specific fire safety responsibilities. They must ensure fire drills are conducted regularly, at intervals that ensure all staff — including night staff, part-time staff, and agency staff — have participated within a reasonable period. Drills should simulate realistic scenarios, including night-time evacuations with reduced staffing.

They must ensure fire safety training is provided to all staff upon induction and refreshed at regular intervals. Training must cover firefighting equipment, fire alarm activation, evacuation procedures including progressive horizontal evacuation, evacuation equipment use, and the particular needs of residents with reduced mobility or cognitive impairment.

They must ensure records are maintained of all fire safety activities. Critically, any fire safety deficiencies identified — whether through fire drills, fire risk assessments, HIQA inspections, or staff observations — must be reported to the registered provider and addressed promptly.

Night-Time Fire Safety

Night-time presents the highest-risk window for a serious fire incident in nursing homes. The combination of reduced staffing levels, sleeping residents, delayed detection and response times, and the vulnerability of the resident population demands specific attention.

The fire risk assessment must specifically address night-time scenarios, including whether the fire detection and alarm system provides adequate coverage and sound levels during sleeping hours. IS 3218:2024 specifies a minimum of 75 dB(A) at the bedhead in residential institutional sleeping areas.

Staffing levels during night hours must be sufficient to implement the evacuation strategy. In most nursing homes based on progressive horizontal evacuation, the fire risk assessment should evaluate whether night staff can complete compartment transfer within the time afforded by fire-resisting construction.

Staff on night duty must be specifically trained in night-time evacuation procedures, know the location of all evacuation equipment, and know how to operate the fire alarm panel and contact the fire service. Night-time fire drills should be conducted periodically to test effectiveness under realistic conditions.

Working with Your Fire Safety Consultant

Share all building plans and documentation. Provide up-to-date floor plans, the fire safety certificate, details of the fire detection and alarm system including its IS 3218:2024 category, emergency lighting plans, and compartmentation drawings.

Disclose previous HIQA findings. Share inspection reports and action plans so the consultant can verify previous issues have been resolved and identify recurring themes.

Allow access to all areas. The fire risk assessment must cover the entire premises including roof voids, plant rooms, storage areas, kitchens, laundry rooms, and external structures.

Involve the person in charge. Their direct involvement ensures the assessment reflects the operational reality of the centre.

Implement action plan items promptly. Delayed implementation leaves residents at risk and can result in adverse HIQA findings. Maintain documented records of all actions taken, as evidence of proactive management is viewed positively by HIQA inspectors.

Frequently Asked Questions

**Q: What is HIQA Regulation 28?** A: Regulation 28 of S.I. 415/2013 (as amended by S.I. 1/2025) requires registered providers of designated centres for older people to ensure adequate fire safety arrangements, including detection, alarm, evacuation, maintenance, training, and record-keeping.

**Q: Does every nursing home need a fire risk assessment?** A: Yes. A current, comprehensive fire risk assessment carried out by a competent person is essential to demonstrating Regulation 28 compliance. It is the foundation upon which all other fire safety arrangements are built.

**Q: How often should a nursing home's fire risk assessment be reviewed?** A: At least annually, and immediately following any significant change (building works, change in resident profile, fire incident, HIQA findings). Given the vulnerability of residents, more frequent review may be appropriate.

**Q: What happens if my nursing home is found non-compliant with Regulation 28?** A: HIQA will record the non-compliance in its inspection report (published online). Depending on severity, it may be classified as moderate (orange) or high (red) risk. Persistent or serious non-compliance can lead to conditions on registration or refusal to renew registration.

**Q: What fire alarm standard applies to nursing homes in Ireland?** A: IS 3218:2024 is the applicable Irish standard for fire detection and alarm systems. Nursing homes typically require a Category L1 system with staff alarm arrangements. The system must be designed, installed, and maintained in accordance with IS 3218:2024.

**Q: What is progressive horizontal evacuation?** A: Progressive horizontal evacuation (PHE) is the primary evacuation strategy in most nursing homes. It involves moving residents horizontally from the fire-affected compartment to an adjacent safe compartment on the same level, rather than evacuating down stairways. This requires adequate compartmentation, trained staff, and appropriate evacuation equipment.

**Q: What training do nursing home staff need for fire safety?** A: All staff must receive fire safety training on induction and at least annually thereafter. Training must cover fire prevention, alarm response, evacuation procedures (including use of equipment such as ski pads and evacuation sheets), and the specific needs of residents. Records must be maintained.

**Q: Can Phoenix STS help prepare for a HIQA inspection?** A: Yes. Phoenix STS provides pre-inspection readiness reviews, fire risk assessments, IS 3218 audits, training, and ongoing fire safety management consultancy for nursing homes. We work with over 85 nursing homes nationwide. Contact us on 043 334 9611 or visit [phoenixsts.ie/contact-us](/contact-us).

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**Contact Phoenix STS** to discuss fire safety compliance for your nursing home. Call us on **043 334 9611** or visit [phoenixsts.ie/contact-us](/contact-us).