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Fire Safety Gap Analysis
GAP ANALYSIS Summary Appendix A
Cathy Day Interim Head of OHSW
Preventive and protective
measures identified and in place
The Council has delegated responsibility for managing fire safety to
Property and Facilities Managers. They source and manage
contracted Fire Risk Assessments, fire protection measures, fire
prevention measures, fire safety training, fire drills, fire evacuation
and fire alarms.
The Occupational Health, Safety & Wellbeing team (OHSW)
provide advice upon request and produce the Fire Safety Policy
although this policy is currently in need of updating.
Practice in respect of fire safety would appear to vary across each
property. A view as to whether these practices are suitable and
sufficient or not would be identified via the audit programme and
regular inspections.
The Fire Safety Policy should be updated and simplified to
provide useful support to Property Managers and enable a
more consistent approach to fire safety across the Council.
A cross matrix audit of fire safety across the Council would be
useful in identifying where there might be inconsistencies or
non-conformities so that these can be addressed.
A simple fire safety inspection template could be introduced to
ensure greater awareness of local conditions, improve
consistency and fire safety culture.
The Council could consider the appointment of a dedicated in-
house Fire Safety Adviser to carry out fire risk assessments,
provide specialist advice and monitor fire safety actions.
Asbestos management has been delegated to the Property
Managers who are required to maintain an Asbestos Register and
provide an asbestos induction to contractors working in areas
where asbestos is known or suspected to be.
The Asbestos policy needs to be updated to reflect the change
in legislation in 2014. It also needs to identify the measures
that the Council wants all Property Managers to take in order to
ensure good practice in respect of this high risk hazard.
A cross matrix audit of asbestos management would be
beneficial to help identify areas of further focus and
An overview of asbestos registers and contractor inductions
would be useful in providing assurance to the Council.
Legionella management has been delegated to the Property
Managers who generally contract out the measuring and monitoring
The Legionella policy needs updating.
Council wide procedures for the management of water systems
would be useful in ensuring consistency, legal compliance and
good practice, thus reducing risk to the Council.
There is currently no Construction and Demolition Policy to reflect
the new legislation in 2015.
Practice across the Council is very varied especially in relation to
the application of the new regulations
Produce a relevant Construction and Demolition Policy
Work with Property Managers to produce and provide ‘good
practice’ processes and procedures
Provide suitable training for Property Managers to improve
consistency and application of legislation.
Work with Property Managers to produce and provide simple
checklists for those working within construction and
Lone working and personal safety is managed autonomously by
each directorate with some areas of good and not so good practice
Carry out a cross matrix audit of lone working and personal
safety to identify the risk, determine what processes,
procedures and policy need to be implemented and which if
any pragmatic solution needs to be put in place.
Equipment identified and well
The Council has an asset register although it’s not clear how
comprehensive this is and whether it includes all equipment or
Identify or implement a single Asset Register for all Council
assets to include condition and maintenance records.
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