5 Essential CQC Checks Every Practice Manager Must Pass
GP surgery fire safety is no longer treated as a tick box exercise by the Care Quality Commission. CQC inspections now include explicit fire safety checks, and a non-compliant surgery can have its rating downgraded with knock-on effects for patient list growth, partner reputation, and in the case of NHS contracts, future funding.
After working with GP surgeries, dental practices, and clinics across Lancashire, Greater Manchester, and Yorkshire for over 40 years, the gaps we find are consistent. Practice managers know the clinical side of CQC inside out. The GP surgery fire safety side often falls down the priority list until inspection week.
This guide walks through the five fire safety checks every CQC inspector either runs through directly or asks about during their visit. These aren’t obscure technicalities. They’re the basics, and most surgeries fail on at least one of them.
Why CQC Now Takes GP Surgery Fire Safety Seriously
Fire safety used to sit at the edge of CQC inspections acknowledged, not always probed. That changed after Grenfell and the subsequent strengthening of the Regulatory Reform (Fire Safety) Order 2005, which placed direct personal liability on the “responsible person” for each premises.
For a GP surgery, the responsible person is usually a partner or the practice manager. That means individual liability for fire safety failures, on top of any operational consequences for the practice. CQC inspectors are now trained to look for the documentary trail that proves the responsible person has discharged their duties and the absence of that trail is what gets surgeries marked down.
The good news is that GP surgery fire safety is one of the most solvable elements of CQC compliance. Unlike clinical governance, which has hundreds of moving parts, fire safety is a finite checklist. Get the five elements below right, and you can walk into your next inspection knowing this part of the assessment is sealed.
1. Current Fire Risk Assessment
Your fire risk assessment must be from within the last 12 months. It must be signed off by a competent person. And critically, it must reflect the building as it actually is today not the building as it was when the assessment was first commissioned three years ago.
This is where most surgeries fail. Building modifications, new partitions, removed walls, additional consulting rooms, new IT installations these all affect fire safety risk. If your fire risk assessment doesn’t reflect those changes, CQC will mark you down.
Quick test: pull out your current fire risk assessment. Does it mention every room in the surgery as it exists today? If not, it’s out of date regardless of when it was signed.
It’s worth noting that “competent person” has a specific meaning. The Health and Safety Executive defines competence as the right combination of training, experience, knowledge, and other qualities. For most GP surgeries, this means engaging a third-party assessor with healthcare experience not a member of staff who attended a one-day course. CQC inspectors increasingly ask who signed the assessment, and a fire risk assessment signed by an uncertified internal person will not pass scrutiny.
2. Appropriate Fire Detection for GP Surgery Fire Safety Standards
Most GP surgeries need L3 fire detection coverage as a minimum, under BS 5839-1. L3 covers all escape routes plus all rooms adjoining escape routes which in a surgery means most consulting rooms, treatment rooms, the dispensary, and any storage spaces along corridors.
Surgeries we audit often have L4 or even L5 detection which only covers escape routes themselves, not adjoining rooms. This was acceptable design practice 15 years ago. It’s not acceptable today, and a CQC inspector who knows what to look for will flag it.
The technical detail matters because retrofitting from L4 to L3 isn’t a small job. If your surgery has anything other than L3 coverage, you need a quotation for upgrade work before your next inspection, even if you don’t commission it immediately. A documented upgrade plan in progress is materially different to no plan at all and inspectors will treat them differently.
Beyond detection category, the system itself must be serviced twice a year by a BAFE accredited fire alarm contractor. Annual service alone is not enough for commercial premises and will trigger a finding. The two service visits should be approximately six months apart, both documented, both signed off.
3. Disability Provisions for Patients and Staff
Evacuation planning for patients with reduced mobility, visual impairments, or hearing impairments is the single most overlooked element in GP surgery fire safety. Most surgeries miss this entirely.
CQC inspectors increasingly ask: “What’s your evacuation plan if there’s a patient in a wheelchair in consulting room 3 when the alarm goes off?” If the answer is “we’d call the fire brigade,” that’s a failure.
Real plans include:
- Personal Emergency Evacuation Plans (PEEPs) for regular patients with mobility needs
- Refuge points marked in the building with appropriate signage
- Visual alarm devices for patients with hearing impairments
- Properly maintained emergency lighting along all escape routes that’s tested monthly
- Trained staff who know exactly who is responsible for assisting whom
This isn’t expensive to put in place. It is, however, time-consuming to design properly. Surgeries that wait until the week before inspection to address this almost always get marked down.
One detail worth flagging: under the Equality Act 2010, surgeries have an additional duty to make reasonable adjustments for disabled patients. Evacuation planning is part of that duty, which means a failure here can attract scrutiny from beyond CQC. Solicitors acting for disabled patients have begun citing PEEP failures in complaints, and at least one surgery in Greater Manchester has settled a case on exactly this basis.
4. Staff Fire Warden Training
Fire wardens must be documented. Training must be refreshed annually. Named individuals must be on every shift covered by the surgery’s opening hours.
This is particularly difficult for surgeries with high staff turnover. The fire warden who was trained in March may have left by November. If the training record is more than 12 months old, or if you can’t name the on-duty fire warden right now, CQC will flag it.
Practical fix: keep a running log of fire warden training, refresh annually, and ensure at least two fire wardens are on shift during every opening hour. For surgeries running extended hours, this often means designating four to six trained wardens to cover overlapping shifts.
Training itself doesn’t need to be expensive or elaborate. A two-hour online course followed by an in-person familiarisation walk through the premises is typically sufficient for non-complex sites. Where the building has multiple storeys, basement areas, or significant numbers of vulnerable patients, in-person specialist training is warranted.
The documentation matters as much as the training. Keep a single signed log showing date of training, name of warden, name of trainer, and renewal date. CQC inspectors don’t take “we definitely did the training” at face value.
5. Fire Drills and Documentation
Minimum one fire drill per year. Logged with the date, time, evacuation time, attendance count, and lessons learned. Some surgeries we audit haven’t run a drill in 18 months. Some haven’t logged a drill in years.
Drills don’t need to be elaborate. A 15-minute exercise once a year, properly documented, satisfies the requirement. The discipline isn’t the drill itself — it’s the documentation that proves it happened.
If your last documented drill is older than 12 months, you have a compliance gap right now.
Beyond the annual drill, surgeries with high-risk profiles practices treating vulnerable patients, premises with limited escape routes, multi-storey buildings — should run drills more frequently. Twice yearly is a reasonable cadence. Drills should be varied: one with full patient evacuation simulation, one focused on staff-only response, one timed against a stopwatch to measure improvement.
After each drill, capture three things in writing: how long evacuation took, what went wrong, and what will be done differently next time. That last point is what separates a meaningful drill from a tick box exercise and inspectors can tell the difference within thirty seconds of reading the log.
The Cost of Failing on GP Surgery Fire Safety
CQC ratings have material consequences. A surgery downgraded from “Good” to “Requires Improvement” on fire safety grounds typically faces:
- Higher insurance premiums at next renewal
- Restricted ability to take on new patients in some commissioning arrangements
- Mandatory re-inspection within six months, at the surgery’s operational cost
- Public visibility of the rating on the CQC website, affecting patient choice
- Personal liability exposure for the named responsible person
A surgery downgraded to “Inadequate” on fire safety grounds can face special measures, which limits the practice’s ability to operate normally and can ultimately threaten the NHS contract. None of this is theoretical these are documented outcomes for surgeries who failed to address basic fire safety compliance.
The cost of preventing this is small. A competent fire risk assessment, an L3-compliant alarm system, proper warden training, and a documented drill schedule together cost less than a single month of locum cover. The asymmetry is what makes this issue so frustrating: small investment, large protection.
How Compliant Surgeries Stay Ahead of GP Surgery Fire Safety Requirements
The surgeries that handle CQC inspections smoothly do four things differently:
- Treat GP surgery fire safety as a quarterly operational rhythm, not an annual scramble. Quarterly review meetings catch problems early.
- Maintain a single folder – physical or digital with every fire safety document in one place. Risk assessment, service certificates, drill logs, warden training records, PEEPs.
- Refresh fire risk assessments whenever the building changes, not annually by default. A new consulting room or partition triggers a fresh assessment immediately.
- Use a single accredited provider for all fire safety work so documentation is consistent. Mixing providers creates documentation gaps, and gaps are what CQC penalises.
Full Circuit works with GP surgeries, dental practices, and clinics across Lancashire, Greater Manchester, and Yorkshire on exactly this kind of operational fire safety. SSAIB certified, BAFE accredited, with healthcare-specific experience built up over 40 years.
Frequently Asked Questions on GP Surgery Fire Safety
How often should a GP surgery fire risk assessment be reviewed?
Annually as a minimum, but immediately whenever the building changes, the staffing structure changes, or there’s been an incident. The Health and Safety Executive’s guidance is explicit on this.
What fire detection grade does a GP surgery need?
L3 as a minimum under BS 5839-1, which covers escape routes and rooms adjoining escape routes. Some surgeries with higher patient acuity or vulnerable patient profiles require L1 (full coverage). L4 and L5 are not adequate for modern primary care premises.
Are fire wardens legally required in a GP surgery?
Yes. Under the Regulatory Reform (Fire Safety) Order 2005, the responsible person must ensure adequate staff training and named individuals capable of leading evacuation. In practice, this means trained fire wardens covering every operational shift.
What does CQC look at first during a fire safety inspection?
Documentation. Specifically: the current fire risk assessment, recent service certificates for the fire alarm and emergency lighting, drill logs, and warden training records. If the documentation is missing or out of date, the inspector will assume the underlying practice is also non-compliant.
Can one provider handle all our GP surgery fire safety needs?
Yes and it’s the most efficient way to maintain consistent documentation. Full Circuit Fire & Security provides fire alarm servicing, fire risk assessments, emergency lighting, fire extinguishers, and disability provision audits under one contract.
Book Your Free GP Surgery Fire Safety Walkthrough
We offer practice managers a free fire safety walkthrough designed around what CQC inspectors actually check. 90 minutes on-site, written report you can keep on file for inspection.
Read more about our fire risk assessment services or service and maintenance offering for healthcare premises across the North West.
Call 01254 956 655, email quotes@fullcircuit.uk, or book a free quote online to arrange your walkthrough.
Full Circuit Fire & Security has been protecting healthcare premises across the North West since 1981. SSAIB Certified. BAFE Accredited. In-house engineers.