(HTM 05-03 Part K – Healthcare Standard) 

Our Primary Fire Risk Assessments are delivered fully in line with HTM 05-03: Firecode – Part K—the NHS benchmark for fire risk assessment in healthcare buildings. They are undertaken by at least one chartered person with a minimum of five years healthcare experience.   

This is a Fire Risk Assessment specifically designed for hospitals and not adapted from other sectors.

It recognises the realities of healthcare environments:
patients who are asleep, dependent, very high dependency, or reliant on staff to move them. Fire safety here is about containment, protection and progressive horizontal evacuation, not simply getting people outside. 

An HTM 05-03 Part K Primary FRA is not generic and not tick-box. 

It is a structured, evidence-led assessment that tests whether the building’s core fire safety measures are: 

  • present, 
  • effective, and 
  • appropriate for the level of clinical risk and patient dependency. 

Where assurance can be given, it is evidenced. Where it cannot, that is clearly stated. 

 

Why the Primary FRA Matters 

The Primary Fire Risk Assessment gives the Responsible Person and Trust Board a clear, defensible view of baseline fire safety performance of the entire building, focused on what actually protects patients. 

Specifically, it is used to: 

  • Confirm that general fire precautions meet HTM Firecode principles 
  • Check that evacuation and protection arrangements work for the occupants at risk 
  • Identify gaps that require secondary or technical assessment 
  • Produce a prioritised, risk-based action plan, aligned to patient dependency and consequence 

HTM 05-03 Part K is explicit: assurance by assumption is not acceptable. 

If access is limited, records are incomplete, or construction cannot be verified, this is recorded transparently and actions are raised. No false comfort. No unjustified sign-off. 

 

Evidence First. Always. 

Primary FRAs are predominantly visual and evidence-based, supported by: 

  • fire drawings and compartmentation layouts 
  • certification and test records 
  • system documentation 
  • on-site verification where reasonably accessible 

Where evidence is missing, that gap is treated as a finding, not ignored. 

 

Escalation and Risk Control 

Where the Primary FRA identifies uncertainty or elevated risk, particularly relating to: 

  • compartmentation integrity 
  • evacuation capability 
  • staffing-dependent procedures 
  • very high dependency or sleeping occupants 

we set out a clear escalation route, which may include: 

  • intrusive surveys or a fire strategy review 
  • immediate interim mitigation where patient safety could be affected 

This ensures risks are managed early, proportionately and transparently, in line with NHS governance expectations.  

 

Why BAFE SP205 (UKAS-Accredited) Matters 

We are UKAS-accredited to BAFE SP205, the recognised third-party certification scheme for fire risk assessment organisations. 

In healthcare, this matters. 

It provides a level of independent assurance that: 

  • our assessors are competent, qualified and experienced in complex buildings 
  • our methodology aligns with current legislation, HTMs and British Standards 
  • our work is subject to routine external audit and technical oversight 
  • our conclusions are defensible under regulatory, enforcement and Board scrutiny 

For NHS Trusts, BAFE SP205 supports compliance with: 

  • HTM 05-01 governance requirements 
  • the Premises Assurance Model (PAM) 
  • the duty to appoint competent persons under the Regulatory Reform (Fire Safety) Order 2005  

 

Assurance for Healthcare Environments 

Our Primary Fire Risk Assessments are written to support: 

  • patient safety 
  • operational decision-making 
  • Board-level assurance 

They are clear, proportionate and focused on what matters most, keeping vulnerable people safe in complex healthcare buildings.