Capital Development Guideline

Capital Development Guideline7.5 Fire Risk Management in Congregate Care FacilitiesCapital Management Branch September 2001

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Capital DevelopmentGuideline7.5 Fire Risk Management inCongregate Care Facilities

Capital Management Branch

September 2001

7.5 Fire Risk Management in Congregate Care Facilities, Edition 2 © State of Victoria, September 2001

Acknowledgments(c) Copyright State of Victoria 2001.

Published by the Capital Management Branch, Resources Division, Victorian Government Departmentof Human Services.

Design and production by Human Services Corporate Communications Unit

Prepared by Warrington Fire Research Aust. Pty Ltd.

Edition 2This publication is available at Department of Human Services Intranet address:

http://intranet_1/capital/contects.htm

ValidityThis guideline will be revised on an as-needs basis. The reader should check the status of thedocument prior to implementing any requirements.

The copyright in this guideline is owned by the State of Victoria. Photocopying or other reproductionof this material without permission is prohibited. All other rights reserved.

DisclaimerCompliance with this guideline alone should not be considered as automatically satisfying thebuilding regulations or occupational health and safety obligations of a building owner or operator, noras satisfying applicable legislation.

No liability will be accepted for any loss or injury occurring in relation to the use of this document forany purpose.

It is the responsibility of the fire safety engineer undertaking the consultancy works and the relevantbuilding surveyor to formulate a fire safety strategy that would satisfy the nominated Department ofHuman Services’ objectives and relevant statutory requirements.

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Contents

1. Introduction 1

2. Fire Risk Management Objectives 3

3. Definitions 5

4. Implementation 7

5. Fire Safety Measures and Mandatory Precautions with Prescribed Minimum Standards 9

6. Fire Safety Measures and Precautions To Be Derived and Verified by a Fire Risk Assessment 13

7. Interim Measures 19

8. Prioritisation 21

Bibliography 23

Appendix 1: Client Capabilities 25

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iv 7.5 Fire Risk Management in Congregate Care Facilities, Edition 2 © State of Victoria, September 2001

1. Introduction

1.1 This document provides guidance for firerisk management requirements for congregatecare facilities owned or operated by theDepartment of Human Services or byDepartment-funded agencies.

1.2 For the purposes of this guideline, acongregate care facility has been defined as: Abuilding or part thereof that does not form partof a hospital, subject to Note 1, and normallyaccommodates more than six people requiring24-hour care or is greater than 350m2.

Note 1:

If a hospital or major part of a hospital ispredominantly used for the 24-houraccommodation of the aged or those withmental illness or intellectual disabilities theparts providing these services should be treatedas congregate care facilities.

1.3 The models of care and support covered bythis guideline include:• Accommodation for the aged

• Nursing homes• Geriatric facilities.

• Accommodation for people with disabilities• Training centres providing 24-hour care• Nursing homes• Shared support accommodation• Community residential units.

• Mental Health Facilities• Community care units• Secure extended care units• Psychiatric units.

1.4 This guideline will be undergoing continuedreview and development to take account of theintroduction of revised building regulations andbuilding classification systems.

1.5 The adequacy of the fire safety system ateach facility is to be assessed using theDepartment of Human Services CapitalDevelopment Guideline 7.2 Fire Risk ManagementEngineering Guidelines.

1.6 This guideline forms part of a series ofdocuments presenting consistent fire riskmanagement principles for facilities where theDepartment of Human Services owns or leases orwhere the Department is the purchasing agency.The format of the series of guidelines is shown infigure 1.

1.7 The Fire Risk Management Guidelines havebeen provided as a general indication of theDepartment of Human Services expectations forfire risk management in buildings owned oroccupied by the Department of Human Servicesor Department-funded agencies. The guidelinesenable appropriately qualified professionaladvisers, such as registered fire safety engineersand building surveyors, to assess fire risk,recommend steps to minimise fire risk, andassess and report on acceptable standards of firesafety, in specific settings.

The use of the guidelines is subject to thefollowing:a) The guidelines do not constitute specific fire

safety advice and are provided for assistancein determining appropriate fire safetymeasures. It is up to individuals acting withappropriate professional advice to determinetheir application to particular situations.

b) Each guideline should be used for purposesonly within the range set out in the ‘Scope’ or‘Introduction’ section at the start of eachdocument.

c) In addition to the fire safety requirements andstandards in the guidelines, owners andoperators of facilities may be subject tovarious statutory, common law andcontractual obligations. They should seekspecific legal advice on the existence andscope of these obligations.

1.8 The Department of Human Services makesno representation that the guidelines are suitablefor any particular situation, and accepts noresponsibility for any loss or damage arising outof any decision to apply the guidelines to anyparticular situation.


2 7.5 Fire Risk Management in Congregate Care Facilities, Edition 2 © State of Victoria, September 2001

Figure 1: Department of Human Services Fire Risk Management Guidelines

CDG 7.1 Fire Risk Management Policy and Procedures

Fire Risk Management Guidelines for Specific Occupancy Types

Fire and Emergency Response Procedures andTraining Framework

CDG 7.2 Fire Risk Management EngineeringGuidelines

Fire Statistics forResidential Properties

Fire Statistics forHealth Care Facilities

CDG 7.3Secure

Facilities

CDG 7.4Supported

Community-Based Houses

CDG 7.5Congregate

Care Facilities

CDG 7.6Hospitals

CDG 7.7Community-Based Houses

CDG 7.8Single

Dwellings

CDG 7.9Multi-storey

housing

CDG 7.10BoardingHouses


2.3 The Department of Human Servicesconsiders fire prevention and fire safety(emergency) management should form anintegral part of any fire risk managementstrategy and since these are not adequatelyaddressed in the BCA 1996, this documentincludes additional guidance.

2.4 The individual performance requirementsspecified in the BCA 1996 must be satisfied, orequivalency with deemed-to-satisfy solutions inthe BCA 1996 be demonstrated.

2.5 To aid interpretation of these statutoryrequirements, the objectives and functionalstatements presented in the various parts of theBCA 1996 (Class 2 to Class 9 buildings) havebeen consolidated and are listed below.

BCA Objectives• Safeguard people from illness or injury due to

fire in a building.• Facilitate the activities of emergency services

personnel in the event of a fire.• Protect other buildings and property from

physical damage due to collapse or firespread.

• Maintain fire protection equipment to satisfythe above objectives.

BCA Functional Statements• A building is to be constructed to maintain

structural stability during a fire to:• Allow occupants time to evacuate safely.• Allow for fire brigade intervention.• Avoid damage to other property.

• A building is to be provided with safeguardsto prevent fire spread:• To Sole Occupancy Units providing

sleeping accommodation in Class 2, 3 or 4buildings.

• To adjoining fire compartments.• Between buildings.• So occupants have time to evacuate safely

without being overcome by the effects of fire.• To allow fire brigade intervention

2. Fire Risk Management Objectives

2.1 The Department of Human Services fire riskmanagement objectives comprise the following:

Primary Objectives• To safeguard people from illness or injury due

to a fire in a building.• To comply with building regulations and

other appropriate legislation.

In order to identify provisions necessary to satisfythe objective of safeguarding people, theDepartment of Human Services requires a firesafety audit and risk assessment. This must beundertaken by an appropriately qualified firesafety engineer to determine fire hazards andreasonable practicable precautions to address thehazards. References shall be made to CapitalDevelopment Guidelines (CDGs) 7.1 and 7.2 toidentify the frequency and depth of fire safetyaudits and fire risk assessment and the appropriatequalifications required for fire safety engineers.

Secondary Objectives• Maintain services to the local community.• Continue operation (minimise business

interruption).• Protect assets.• Enhance public image and satisfy moral

obligations.

A judgement is required as to the relativeimportance of a facility or part thereof, in orderto ascertain if there is a need for additionalprecautions to satisfy these secondary objectives.The facility management in consultation with theDepartment of Human Services will normallymake this judgement.

2.2 The objectives, functional statements andperformance requirements of the Building Codeof Australia 1996 (BCA 1996), supplemented bythe Building Regulations 1994 and otherappropriate legislation referred to in CDG 7.1,have been adopted by the Department of HumanServices as the benchmark for fire riskmanagement in facilities it owns or occupies.However, each facility will normally require auniquely tailored fire safety strategy andvariations will be expected between facilities.

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2.6 In many types of facility it must beacknowledged that the buildings are clients’homes and it is desirable to minimise theperception of an institution.

2.7 The Building Regulations in the 1 August1997 amendment prescribes automatic sprinklerprotection for existing buildings classified in thisguideline to be congregate care facilities.

Reference to Acts, Regulations,Codes and Standards andGuidelines2.8 Throughout this document reference to anyAct, regulation, code, standard and guidelineshall be taken as referring to the current versionas amended at the time of use.


3. Definitions

Congregate Care FacilityA ‘residential care building or group of buildings’,as defined in the Building Regulations, with 24-hour on-site support or care staff, and having afloor area greater than 350m2 or accommodatingmore than six residents where 10% or morerequire significant (or physical) assistance toevacuate the building during an emergency.

Community-Based HousesHouse of a typical domestic type construction andlayout with a total floor area up to 350m_ with 24-hour staff accommodating no more than 12 personsof which not more than one requires assistance toevacuate the building during an emergency.

FacilityA facility is a building or group of buildings thatis ‘staffed’ but excludes single dwellings,community-based houses and supportedcommunity-based houses.

Fire Risk AssessmentIn the context of these guidelines, a fire riskassessment is one or more, normally acombination, of:• a qualitative fire risk assessment• a quantitative fire risk assessment• a regulatory assessment

Depending on the particular application.

Fire Safety AuditA site inspection and document review tocharacterise the building contents, the fire safetyprovisions, people and the environment, to thedegree necessary to undertake a fire riskassessment and to identify severe fire hazardsrequiring interim fire precautions.

Fire Safety EngineerAn engineer, who is registered under the categoryof engineer, Class of Fire Safety Engineer by theVictorian Building Control Commission and hasappropriate experience in conducting fire safetyaudits and risk assessments.

Fire Safety PlanA document that defines the fire safety strategyfor a facility in terms of the required levels ofperformance, design parameters andmaintenance requirements for each physical orhuman measure/factor.

Fire Safety StrategyA combination of physical and humanmeasures/factors including maintenance andmanagement systems that have been specified toachieve nominated fire risk managementobjectives.

Human Factors (Measures orPrecautions) Occupant characteristics, management practices,emergency control organisation, training and thelike that may impact on fire safety. Humanmeasures or precautions typically relate tofacilities/building management issues.

Non-Combustible

Not deemed combustible by the BCA or whentested to AS1530.1 - combustibility tests formaterials.

Physical Factors (Measures orPrecautions) Fire protection equipment, lining materials,architectural layout, egress provisions and thelike that may impact on fire safety. Physicalmeasures or precautions generally relate tocapital works.

Practical (practicable) Practical (practicable) having regard to:(a) The severity of the hazard or risk in question.(b) The state of knowledge about the hazard or

risk and any ways of removing or mitigatingthat hazard or risk.

(c) The availability and suitability of ways toremove or mitigate that hazard or risk.

(d)The cost of removing or mitigating thathazard or risk.


Relevant Building SurveyorThe building surveyor appointed to the project.The relevant building surveyor shall haveobtained at least a graduate certificate related toperformance-based building and fire codes andshall be registered by the Building ControlCommission under the class of BuildingSurveyor and in addition under the 1997Amendment to the Building Regulations 1994 toassess performance-based submissions.

Relevant Fire Safety EngineerThe fire safety engineer appointed to the project.

Risk AssessmentAn assessment of the potential for the realisationof an unwanted event, which is a function of thehazard, its probability and consequences. Seealso Fire Risk Assessment.

Single DwellingA detached house or one or more attacheddwellings, each being a building separated by afire-resisting wall, and housing a family unit.

Sole Occupancy Unit (SOU) The BCA 1996 definition of a sole occupancy unitis a room or other part of a building foroccupation by one or joint owner, lessee, tenantor other occupier to the exclusion of any otherowner, lessee, tenant or other occupier.

Supported Community-BasedHousesHouses of a typical domestic type constructionand layout, which may be on separate sites orgrouped together on one site with 24-hour on-sitesupport or care staff and having a floor area notgreater than 350m2 and accommodating no morethan six residents and where any of the residentsrequire significant (or physical) assistance toevacuate the building during an emergency.


4.1 The occupancy characteristics and buildingtypes vary considerably for congregate carefacilities. A fire safety audit and risk assessmentshould therefore be performed in accordancewith the Department of Human Services CDG 7.2Fire Risk Management Engineering Guidelines.

4.2 The fire safety measures and precautionsmust be compatible with the building use andoccupant characteristics. A general discussion ofoccupancy characteristics for typical congregatecare facilities is provided in Appendix 1 of thisguideline.

4.3 Reference shall be made to CDG 7.2 for theimplementation process.

4. Implementation



5. Fire Safety Measures and Mandatory Precautionswith Prescribed Minimum Standards

assessment. The need and required performancefor the precautions/measures are to be derivedfrom the risk assessment and/or regulatoryassessment.• Precautions and measures required to address

hazards not adequately addressed bymandatory requirements.

These apply to facilities where the need for themandatory requirements to be supplemented hasbeen clearly demonstrated by the fire riskassessment in order to satisfy the fire safetyobjectives of the Department of Human Services.

5.2 Table 1 provides a summary of the firesafety precautions and measures that areapplicable to congregate care facilities. The listis not necessarily exhaustive.


General5.1 In the context of the Fire Risk ManagementGuidelines, fire safety precautions can beallocated to the following three categories:• Mandatory with prescribed minimum

standards.These apply to measures and precautions whichmust be installed and for which minimum designstandards are specified in the guidelines. Theminimum standards may be exceeded if the needis demonstrated in the risk assessment and/orregulatory assessment.• Consideration mandatory with requirements

to be derived from the fire risk assessment. These apply to measures and precautions thatmust be specifically considered in the fire risk

Table 1: Summary of Fire Precautions and Measures

Fire Safety Provision Category Specific Requirements and Recommendations

Automatic Smoke Detection Mandatory Minimum Standards specified in sections 5.5-5.10*

Automatic Fire Sprinklers Mandatory Minimum Standards specified in sections 5.11-5.12*

Appliance Safety Mandatory Minimum Standards specified in sections 5.13-5.17*

Special Provisions (e.g. self- Consideration Mandatory Requirements derived from risk assessment.harm risk minimisation) Refer to section 6.56 for guidance

Automatic Warning and Consideration Mandatory Requirements derived from risk assessment.Communication System Refer to sections 6.3-6.8 for guidance

Construction Requirements Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.9-6.14 for guidance

Manual Fire Fighting Equipment Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.15-6.18 for guidance

Provision for Escape Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.19- 6.24 for guidance

Emergency Lighting Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.25-6.27 for guidance

Emergency Exit Signage Consideration Mandatory Requirements derived from risk assessment.Refer to section 6.28 for guidance

Manual Call Points Consideration Mandatory Requirements derived from risk assessment.Refer to section 6.29 for guidance

Electrical Protection Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.30-6.32 for guidance

Fire Safety Provision Category Specific Requirements and Recommendations

Precautions for Ducted Systems Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.33-6.35 for guidance

Active Smoke Control Systems Need to be clearly Requirements derived from risk assessment.demonstrated by Refer to section 6.36 for guidancequantitative risk assessment

Fire Prevention / Management Consideration Mandatory Requirements derived from risk assessment.Refer to sections 6.37-6.43 for guidance

Emergency Control Organisation Consideration Mandatory Requirements derived from risk assessment in consultationwith facility management.Refer to Fire and Emergency Response procedures and Training Framework

Fire Emergency Procedures Consideration Mandatory Requirements derived from risk assessment and Fire and and Training Emergency Response Procedures and Training Framework

guideline.Refer to sections 6.44-6.48 for guidance

Fire Orders and Evacuation Plans Consideration Mandatory Requirements derived from risk assessment.Refer to section 6.49 for guidance

Record Keeping and Documentation Mandatory Minimum Standards specified in sections 5.18-5.20 and CDG 7.1 *

Maintenance Mandatory Minimum Standards specified in sections 5.21-5.22 and CDG 7.1 *

Resident Capability and Consideration Mandatory Requirements derived from risk assessment.Case Management Refer to sections 6.50-6.55 for guidance

Other Need to be demonstrated Requirements derived from risk assessment.by risk assessment

*Higher Standards may be prescribed based on risk assessment findings

5.3 Examples of requirements that may bederived and verified by the fire risk assessmentare given in section 6.

5.4 The mandatory measures and precautionswith prescribed minimum standards aredescribed in more detail in the remainder of thissection. These fire safety precautions shall beimplemented in all facilities in addition to anyother findings of a fire safety audit and riskassessment. These prescribed requirementsreflect the importance that the Department ofHuman Services attaches to the provision of areliable smoke detection system as a fundamentalpart of its fire risk management strategy.


Smoke DetectionGeneral5.5 All buildings used to provide sleepingfacilities for residents must be provided with asmoke detection system throughout, complyinggenerally with AS3786/AS1670.6 or AS1670.1 tothe satisfaction of the fire safety engineer and therelevant building surveyor.

5.6 Minor variations from AS1670.1 and thefollowing requirements may be necessary toaddress the risk of vandalism. Under suchcircumstances, the performance of the alternativesystem must be quantified by the fire safety

engineer and taken into account in their analysis.A typical variation may include the provision ofa very early detection system with samplingpoints in return air ducting. Such systems shallbe designed so that they continue to operateunder all conditions including shut down of theheating/cooling systems.

5.7 Smoke detectors or smoke alarms must beinstalled throughout the building, except in areassuch as kitchens and bathrooms which may besubject to spurious alarms. In these areas thesmoke detectors/alarms may be replaced withheat detectors as permitted by the appropriatestandards.

New Facilities5.8 For all new facilities the fire detectionsystem shall comply fully with the currentedition of AS1670.1 together with an appropriateoccupant warning system. Refer to sections 6.3-6.8 of this guideline for further information.

5.9 For medium or large facilities (more than 20residents), consideration shall be given to theuse of an addressable smoke detection system.Consideration shall be given to the provision ofphotoelectric type smoke detectors in client areasand alternate photoelectric and ionisationdetectors in corridors, hallways, passagewaysand the like.

Existing Facilities5.10 Existing smoke detection systems may beretained if the installation complies fully with thecurrent edition of AS1670.1, or AS3786/AS1670.6and Building Control Commission Practice Note27 (November 1996) subject to the followingrequirement. Smoke detectors or smoke alarmsmust be fitted throughout except in areas such askitchens and bathrooms where smoke detectorsor smoke alarms may cause spurious alarms. Inthese areas they must be replaced with heatdetectors or heat alarms as appropriate.

Automatic Fire Sprinklers System5.11 In order to comply with the BuildingRegulations, automatic fire sprinkler protectionmust be provided throughout all existingresidential buildings prior to 1 August 2002.

Automatic sprinkler protection must, therefore,be implemented as part of a major fire safetyupgrade to any congregate care residentialbuilding expected to be in use beyond 2002.

5.12 The fire sprinkler system must be installedand certified as being designed in accordancewith AS2118.4 or equivalent and must includeresidential/fast response sprinkler heads.

Mandatory Appliance Safety5.13 No gas or electric cookers or portableheating appliances are permitted within internalstairways or corridors. Where operation of anautomatic fire sprinkler system or otherautomatic fire suppression system mayextinguish an appliance flame, the applianceshall be fitted with

(a) a flameguard systemor(b) a system which will shut off the gas supply

and cause lockout, when an extinguishingsystem operates.

5.14 Individual heaters, where provided, shall befixed in position and should be constructed,installed and guarded in accordance withappropriate Australian Standards, the BCA 1996,manufacturer’s instructions and other relevantActs and regulations.

5.15 It is strongly recommended that portableheating appliances should not be used or storedin congregate care facilities. If it is not practicableto used fixed heaters, appropriate portableheaters such as oil filled column heaters must beused.

5.16 All heating appliances shall be regularlycleaned, tested and maintained within thetimeframes specified by the manufacturer orappropriate standards.

5.17 Electrical, heating and other equipment thatappears faulty may present a risk of ignition orfire hazard and shall be withdrawn from serviceuntil repaired by an appropriately qualifiedperson or replaced.



Record Keeping andDocumentation5.18 The relevant fire safety engineer shallprepare a fire safety plan. This plan shall definethe fire safety strategy for the facility includingnominating the required performance of all fireprotection systems present. The plan shall alsospecify requirements for the Fire Emergency andEvacuation Procedures and Training, on which thestrategy is based, together with maintenancerequirements and inspection procedures.

5.19 Contact numbers for after hours, emergencyand fire safety engineer may be included.

5.20 Records must be kept of:• All fire safety installations including

schematics and as built drawings of all the fireprotection systems.

• Evacuation and training exercises.• Fire incidents and alarms.• Maintenance and testing undertaken.• Inspection and checks carried out by staff.• Details of fire safety issues reported (for

example, blocked exits or faulty fire protectionequipment) actions required and evidence thatactions have been completed satisfactorily.

• Essential services records/reports.• Other information required by CDG 7.1 the

Fire and Emergency Response Procedures andTraining Framework and the fire riskassessment.

It is the responsibility of relevant seniormanagement to ensure appropriate recordkeeping and documentation occurs.

System Maintenance5.21 All fire protection systems, measures andassociated building services shall be maintainedas defined in the fire safety plan prepared by thefire safety engineer and Part 11 of the BuildingRegulations as required by CDG 7.1. They shouldbe regularly checked on the basis defined by thefire safety engineer to ensure they continue tosatisfy the required performance levels and arebeing regularly maintained in accordance with

the appropriate Australian Standards and theBuilding Regulations as a minimum.Maintenance contracts shall be in place,supplemented by staff checks on a regular basis.

Note:

Where maintenance contracts are renewed,measures shall be in place to ensure theminimum test/maintenance frequencies for asystem to continue to satisfy the requirementsof the fire safety plan.

5.22 In the detailed design of fire safetyequipment, consideration must be given to thelife cycle costs of the system and methods ofreducing the costs of testing and maintenance by,for example, the incorporation of remotemonitoring/test function. Testing of complexsystems (such as zone pressurisation systems)against the nominated levels of performanceshall be regularly undertaken.

6. Fire Safety Measures and Precautions to beDerived and Verified by a Fire Risk Assessment


General6.1 The following fire safety measures andprecautions must be considered by the relevantfire safety engineer and building surveyor inderiving a fire safety strategy that satisfies theperformance requirements of the BCA 1996 andother objectives prescribed in these guidelines.The BCA 1996 deemed-to-satisfy solutions maybe used as the initial basis of a fire riskmanagement strategy, but it is expected that theywill require modification to satisfy theDepartment of Human Services objectives andprovide cost-effective solutions. Examples oftypical design solutions for each fire safetymeasure or precaution are given for illustrativepurposes only. This section should not beconstrued as implying a benchmark.

6.2 It should be noted that the final solutionwill vary from one facility to another, beingtailored to the specific circumstances, andreflecting the uniqueness of each facility. Thefollowing items cannot therefore be consideredinclusive of all fire safety measures andprecautions that should be considered.

Building Occupant WarningSystems6.3 The building warning system shall providea warning for staff (and clients as appropriate)and provide an audible alarm, together with avisual alarm system, where appropriate,throughout the building.

6.4 The A-weighted sound pressure level for anaudible alarm should (except for the relaxationsfollowing):• Exceed the nosiest background by at least

15dBA.and• Not be less than 65dBA.and• Not be more than 105dBA.

Note:

It is preferable for the maximum sound pressurelevel not to exceed 95dBA in occupied areas.

6.5 In client areas the audible alarm may beadjusted in volume and content to minimisetrauma, consistent with the type and condition ofclients. Under such circumstances, means mustbe provided for staff members to be alerted andidentify the location of the alarm.

6.6 If the audible alarm is intended to arousesleeping occupants, the sound pressure levelsshall not be less than 75dBA when measured atthe pillow position.

6.7 For large facilities with more than 32 clients,the detection and alarm system shall provide ameans for readily identifying the position of theactivated fire detection device(s). This will enablestaff to respond in a timely manner and must becompatible with the mode of operation of thefacility and its emergency procedures.

For example, the Fire Indicator Panel and mimicpanels could be used to identify the location ofthe activated device, with the information beingreplicated on electronic pagers carried by staff.

6.8 Means shall also be provided for publicannouncement and/or two-way communicationbetween staff.

Construction Requirements6.9 The building shall have structural membersand separating elements that will maintainstructural stability and prevent fire spread duringa fire to the degree necessary to satisfy therelevant objectives stated in section2.1 of thisguideline and the performance requirements ofthe BCA 1996.

6.10 This may require predicting the likely fireseverity and calculating the ability of themembers to withstand exposure to the fire.

6.11 Stairs and shafts connecting two or morelevels shall be enclosed in construction havingappropriate resistance to fire and smoke spreadto the degree necessary to satisfy the relevantobjectives of the BCA 1996.

6.12 For large facilities housing more than 32residents or exceeding 500m2, consideration shall


be given to the provision of smoke and fireseparation to form zones, nominally equal to orless than 500m2 and housing not more than 12residents, for example, with self-closing doors.The doors may be held open by automatic hold-open devices which automatically release thedoors upon any one of the following events: afire alarm, power failure to the hold-open deviceor by activation of a button located close to thedoor set.

Note:

The Department of Human Services expectssome levels of redundancy within the total firesafety system. For example, in a buildingprotected by automatic sprinklers, theconsequences of fires that are too small toactivate a sprinkler head or are shielded fromthe water discharge need consideration. Totalfailure of the sprinkler system also requiresconsideration. Thus some degree of smoke andfire compartmentation is required to beretained, even if a sprinkler system is provided.

6.13 For new buildings, consideration should begiven to requiring wall and ceiling linings to benon-combustible or to meet the typical BCAdeemed-to-satisfy requirements for appliedfinishes when tested in accordance with AS1530.3as summarised below.

In public corridorsCeiling and walls:Spread of flame index 0Smoke development index 5

In other areas:Ceiling: Spread of flame index 0Smoke development index 3

Walls:

Spread of flame index 0

Smoke development index 5

The above requirements do not apply to skirtingsup to 150mm high.

For existing buildings, variations from theindices above must be considered as part of thefire engineering analysis.

6.14 For new buildings and buildings beingrefurbished where carpets are being replaced aspart of the refurbishment, consideration shouldbe given to selecting a carpet with lowflammability, flame spread and smokeproduction characteristics.

Note:

Control of lining materials is consistent withthe Department of Human Services policy offire prevention.

Manual Fire Suppression6.15 The following are examples of manual firefighting equipment which should be consideredon a case by case basis, with the finalrequirements being derived by the relevant firesafety engineer in consultation with the buildingsurveyor and the fire authorities, as appropriate.

• If fire hydrants are provided, they shall beinstalled in accordance with AS2491.1 andlocal Fire Brigade requirements unlessappropriate dispensations are obtained fromthe fire brigade

• If fire hose reels are provided, no point on afloor shall be more than 36m from a fire hosereel. Fire hose reels shall be certified asmeeting AS1221 and shall be installed andcertified as installed to AS2441.

• If portable fire extinguishers are provided,they shall be appropriately positioned andselected to address the likely types of fire buthaving regard for potential side effects (forexample, powder extinguishers initiatingasthma attacks or causing damage toelectronic equipment).

6.16 Portable fire extinguishers shall be certifiedas meeting the requirements of the appropriateAustralian Standard and AS1841.5, and shall beinstalled in accordance with AS2444. A record ofthe installation of portable fire extinguishersshall be provided in accordance with AS1851.1.


Note:

It is preferable for kitchen and lounge areas tobe separated from the exit routes and frombedrooms by walls having appropriateresistance to smoke and fire spread.

Door Operation6.23 All doors on the escape path should bereadily opened by a single-handed single actionwithout a key from the side that faces a personexiting the building. Where security measuresconflict with these requirements, electric strikesor similar devices shall be considered to facilitatea timely evacuation path.

6.24 Security provisions should be specificallyexamined by the relevant fire safety engineer toensure that fire safety is adequately addressed,while also addressing the safety of the generalcommunity, staff and occupants.

Emergency Lighting6.25 Emergency lighting should be provided inevery:• Passageway, corridor, hallway and the like

that is part of the path of travel to adesignated exit(s).

• Stair.• Room to which clients have access with a floor

area of more than 120m2.

6.26 Emergency lighting shall also be provided:• To a fire control area and/or staff area from

which public address announcements aremade, client lists are maintained and theposition of the fire can be identified (by, forexample, a mimic panel).

• Where manual call points are provided.• Any other locations deemed necessary by the

relevant fire safety engineer or buildingsurveyor.

6.27 The emergency lighting should comply withAS2293 and section E4.4 of the BCA 1996 asappropriate.

6.17 Appropriate signage should be provided.

6.18 Should the client characteristics be such thatmisuse of portable extinguishes or hose reels islikely, then they may be secured or stored insecure locations with means for them to bereadily available in a fire emergency.

It may be appropriate to site extinguishers at staffwork stations, in addition to siting them adjacentto specific fire hazards such as electricalswitchboards.

Provision for Evacuation6.19 For new buildings there should be at leasttwo exits from each storey occupied by clients.The entrance to a client’s room/suite should be amaximum of 6m from an exit or from a point inwhich travel in two directions is possible. Nopoint on any floor should be more than 12m froman exit or from a point in which travel in twodirections is possible.

6.20 Exits should be distributed as uniformly aspracticable within or around the storey served, orin positions where unobstructed access to at leasttwo exits is readily available. Exits must be notless than 9m apart and not more than 45m apart.

6.21 The width of the exits, except for internaldoorways, should be at least 1.25m or that whichis prescribed by the BCA 1996 section D1.6,whichever is the greater where practicable. Thedischarge from the exits shall not be obstructedand shall generally comply with therequirements of section D1.10 of the BCA 1996 ifappropriate.

6.22 For some facilities, such as aged care andthose housing the mentally ill, it may beappropriate to consider the provision of secureexternal areas to act as an open place in order tomaintain the safety of the residents andcommunity without unnecessarily compromisingfire safety. Such an area should allow occupantsto evacuate to a safe distance having regard forthe potential for exposure to radiant and/orconvective heat, smoke and toxic gases.

inspections, taking account of the age and state ofthe existing wiring, and nominate any urgentworks required to address any hazards. Theseurgent works shall be undertaken as soon aspracticable.

Ducted Heating Ventilation and AirConditioning Systems6.33 Ducted heating ventilation and airconditioning systems can facilitate smoke andfire spread through a facility. It is recommendedthat if the use of ducted heating/cooling systemsis needed, then the following precautions shall beconsidered:• Fitting combinations of fire and smoke

dampers within the ducting.• Controlling the flame spread characteristics of

the ducting.• Adequate fire prevention measures at the heat

source, for example, reliable thermal cut-outs.• Automatic shut down of the system upon

activation of a fire alarm and if a gas supply isused it shall also be automatically cut off.

• Early suppression by automatic sprinklers.• Locating the heat source outside the building.

6.34 It should be noted that AS2118.4 requiressprinkler protection of the roof space if itcontains combustible materials such ascombustible flexible ducting.

6.35 All heating appliances shall be regularlycleaned and maintained.

Smoke Control6.36 Where demonstrated to be necessary by thefire risk assessment, active smoke control orsmoke venting measures should be implemented.Account should be taken of the reliability of anyproposed systems.

Fire Prevention and FireManagement6.37 The Department of Human Services has apolicy of smoke-free workplaces that should beenforced.


Exit Signs6.28 Illuminated exit signs above doors and exitdirection signs to direct staff and clients to exitsshould be provided so that they are clearlyvisible to persons approaching an exit from anypoint in a corridor. The mounting location of theexit signs should take into account theirperformance in an expected smoky environment.Exit signs and exit direction signs must complywith AS2293.1, and sections E4.5 and E4.8 of theBCA 1996.

Manual Call Points (MCPs)6.29 MCPs should be provided so that no pointis more than 30m from a call point, unless theclient characteristics are such that deliberate falsealarms could be raised. In such a case, the MCPsshall be positioned in each staff area, forexample, staff work station. Activation of anMCP should operate the fire alarm and, whereappropriate, alert the fire brigade.

Electrical Protection6.30 Earth leakage current protection employingresidual current devices should be installed to allelectrical switchboards or general power outletswhere reasonably practical in accordance withrelevant standards and Department of HumanServices guidelines. New electrical services shallbe installed in accordance with AS3000. Thestatus of existing electrical wiring shall bechecked by a qualified electrician and reportsretained by the facility concerned. Methods suchas thermal imaging may be adopted to identifyoverloaded circuits.

6.31 Consideration should be given to providingprotection against, or minimising the risk from,electrical surges.

6.32 Where the mains, main earth or switchboardof existing installations are not in accordancewith AS3000, they shall be brought intocompliance as soon as practicable. The adequacyof the existing electrical system shall be checkedby a qualified electrician. The electrician shallrecommend the frequency of subsequent


6.38 Where a resident exhibits potential fire riskbehaviours, the management shall conduct anappropriate assessment and implement strategiesto address the risk.

6.39 In all congregate care facilities, all newlypurchased upholstered furnishings, mattresses,curtains and the like shall be flame-retardant ortreated with flame-retardants to minimise therisk of ignition. In facilities for the mentally ill,intellectually disabled or occupants likely tocause injury to themselves or others, it isrecommended that the foam fillings are treatedwith flame-retardants to minimise the risk ofignition if any protective coverings are removed.

6.40 At the time of preparation of this guideline,the availability of suitably tested materials andfurnishings was limited. For furnishings it isrecommended, subject to availability, that fillingsand covering materials should be tested inaccordance with AS3744.1 (smoulderingcigarette) and AS3744.2 (small flaming) ignitionsources in addition to individual materials orcomposites. They should not exhibit any of thenominated criteria in the Standards for ignition.

6.41 Preference should be given to flame-retardant materials that maintain theireffectiveness without the need for reapplication.However, some materials, such as curtains, mayrequire special washing methods or reapplicationof retardants after washing.

6.42 It must, however, be recognised that the useof flame-retardants interferes with thecombustion processes and as a side effect mayincrease the concentration of the smoke (soot)and toxic gases produced. The reduction of thenumber of fire starts and of the number of largerfires resulting from the use of flame-retardantswill usually justify the selection of this strategy.

6.43 Electrical, heating and other equipment thatappears faulty may present a risk of ignition orfire hazard and shall be withdrawn from serviceuntil repaired or replaced by an appropriatelyqualified person.

Fire Emergency Procedures andTraining6.44 Emergency procedures shall be documentedand reviewed at least annually in accordancewith appropriate Standards and the Departmentof Human Services framework document.

• Procedures covering fire and other buildingemergencies shall be prepared anddocumented for each building or unit on asite. The procedures shall include separatesections covering actions in the event ofactivation of a smoke or heat detector,discovery of a fire/smoke incident or suspectconditions by staff, evacuation procedures, firenotices and emergency plans. The proceduresshall be developed and documentedspecifically for staff in each facility, taking intoaccount client characteristics, staffing levels,fire protection systems, facility layout and soon, and shall be reviewed yearly as aminimum.

• Procedures shall be prepared and reviewedaccording to the requirements of theDepartment of Human Services Fire andEmergency Response Procedures and TrainingFramework.

• A site-specific training program shall bedeveloped for each site. The training programshall be according to the requirements of Fireand Emergency Response Procedures andTraining Framework.

• The procedures shall be consistent with thefire safety strategy for the site.

6.45 All staff in congregate care facilities shall beassessed according to the requirements of theDepartment of Human Services framework atintervals not exceeding 12 months and shallreceive further training if levels are not met.

6.46 Where clients are capable of receiving fireemergency training, they should be included intraining programs. Clients need not participate inthe assessment process.

6.47 Exercises and drills are to be conductedwith sufficient frequency so that staff on allrosters become familiar with the procedures.

6.48 Refer to the Fire and Emergency ResponseProcedures and Training Framework for furtherinformation.

Fire Orders and Evacuation Plans6.49 Building or site-specific fire orders suitablefor each building shall be developed, along witha plan showing MCPs, fire extinguishers,evacuation routes, and assembly points and shallbe displayed in appropriate prominent locations.The assembly points should be defined by therelevant fire safety engineer. It is theresponsibility of relevant Regional managementto ensure that procedures are implemented andreviewed. For further information, refer to theFire and Emergency Response Procedures andTraining Framework.

Resident Capability and CaseManagement6.50 The congregate care accommodationprovided or funded by the Department ofHuman Services is for clients with a broadvariation with regard to the ability to respondand evacuate in the event of a fire emergency. Itwould be expected that the evacuationcapabilities of clients in facilities would rangefrom low to, in some cases, nil.

6.51 In some instances adoption of a defend inplace strategy may be appropriate because of therisk of injury during an evacuation.

6.52 The aged, mentally ill and those withintellectual disabilities all present greater risks offire starts due to, for example, a lack ofunderstanding of their actions and theconsequences of their actions.

6.53 All residents in congregate care facilitiesshould be treated as exhibiting high fire riskbehaviour and the facility management shallconduct client assessments and implementstrategies to address the risk.

6.54 Consideration of client capabilities shouldbe under continual review and should be basedon both the client capabilities and associatedfactors such as staffing levels, egress provisions,

fire compartmentation and so on.. Broad detailsof client characteristics for specific care groupingswithin the congregate care category aresummarised in appendix 1 of this guideline.Nevertheless, assessments by staff withknowledge of a facility and the individual clientswithin that facility should be used to give a moredetailed representation of client capabilities.

6.55 An indication of the abilities of clients toevacuate can be determined from factors such asevacuation drills and assessments made by staff,in addition to expert judgement applied by thefire safety engineer. Consideration of the client’sabilities to evacuate must include scenarios whenstaff/client ratios are at a minimum, clients arenot awake and circumstances are difficult.

Special Provisions6.56 Appropriate measures must be taken tominimise the risk to occupants associated withadopting the nominated fire safety measures.

For example, if clients are likely to be prone toinflicting self-harm, care must be taken in theselection and installation of fire protectionequipment to reduce, as far as reasonablypracticable, hazards and minimise harm toclients.


7. Interim Measures


7.1 Based on findings from a fire safety auditand a risk assessment, the fire safety engineer, inconsultation with the facility CEO or equivalent,should determine if interim measures arenecessary to address a high risk to life pendingthe required upgrade works.

7.2 Identified interim measures must beimplemented as soon as practicable. Measuresmay comprise a mix of human and physicalprecautions. See CDG 7.2 for further details.


8.1 The major works are identified in the finalreport of the fire safety audit and risk assessmentas defined in CDG 7.2. If facilities are notprovided with an automatic smoke detection andalarm system that satisfies the prescribedrequirements of this guideline, it isrecommended that, as a minimum, the detectionand alarm system is upgraded or installed aspriority 1 works after completion of interimworks. In some instances, provision of a fullycompliant smoke detection system may beincluded as interim works.

8.2 The remaining works shall be prioritisedand an implementation program established.Refer to CDG 7.2 for further information.

8. Prioritisation



Bibliography


Reference was made to the followingpublications during the development of thisdocument:

Australian Building Codes Board (ABCB) 1996,Building Code of Australia 1996.

Building Act 1993

Building (Amendment) Regulatory 1997

Building Regulations 1994

Department of Health and Community Services,Draft Guideline for Fire Detection and Alarm Servicesin Domestic Accommodation (Class 1B).

Department of Human Services CapitalDevelopment Guideline 7.1 Fire Risk ManagementPolicy and Procedures, Edition 2.

Department of Human Services CapitalDevelopment Guideline 7.2 Fire Risk ManagementEngineering Guidelines, Edition 2.

Health Technical Memorandum 88 Fire RiskManagement in Healthcare Premises: Guide to FirePrecautions in National Health Services Houses in theCommunity for Mentally Handicapped (or MentallyIll) People, 1986.

National Fire Protection Association, USA,National Fire Protection Association Code for Safetyto Life from Fire in Buildings and Structures 1997.


Appendix 1: Client Capabilities


A1.1 IntroductionThe following is a summary of typical clientcapabilities for some of the broad care typecategories contained within the classification ofcongregate care related to fire safety. It should,however, be noted that the capabilities of clientsvary considerably and a site-specific assessmentmust be made in each case.

A1.2 The summary is based on informationprovided by Department of Human Servicesprogram personnel at an information seminar,and a statistical and literature review of fireincidents in Australia and the United States ofAmerica.

A1.3 GeneralBroad findings related to client capabilities andbehaviour from the statistical and literaturereview indicated the following:• Many fires started in client sleeping areas and

day/lounge areas and resulted in injuries orfatalities.

• Many fires started from the misuse ofsmoking materials.

• Clients could become confused in the case of afire and make poor decisions with regard tonot taking the most appropriate action inorder to evacuate.

• Clients having evacuated have attempted tore-enter the building.

A1.4 Psycho-Geriatric CareFacilitiesClients in psycho-geriatric care facilities can bedescribed as potentially having the followingattributes:• Elderly (age 65+).• Many suffering from varying degrees of

dementia, however some suffering from other:• Forms of mental illnesses• Behavioural disturbances• Reduced sensory capability.

• Some not ambulant.• Some frail or with limited mobility.

• Some may be on prescribed medications thatcould affect their response to an alarm and theability to evacuate.

• May have heightened states of confusion atnight.

• Some may require intensive assistance of staffin order to evacuate.

• Some may be resistive or violent in the case ofan evacuation.

• Some may have fire lighting tendencies.• Some may have suicidal tendencies.• Some may have a tendency to abscond.

A1.5 Disability Support ServicesClients can be categorised as potentially havingthe following attributes:• In an acute stage of mental illness.• Age 16-64.• Predominantly ambulant.• Some may be on medications that could affect

their response to an alarm and the ability toevacuate.



A1.6 Disability Support ServicesThere is a broad range of disabilities coveredwithin this category, including clients with anintellectual disability, physical disability, visual orhearing impairment, both mental and psychiatricdisabilities, or a combination of several of these.

The capabilities of clients can be very broad,depending on the particular disability and thedegree of impairment. It is considered that staffassistance will be required to evacuate the clientsin the case of an emergency.

Clients considered to have severe and/ormultiple disabilities can be categorised aspotentially having some of the followingattributes:• May be of limited mobility and may require

wheelchairs for movement.

• May be taking medications that could affecttheir response to an alarm and the ability toevacuate.

• May have difficulty comprehending an alarm.• May not respond to an alarm.• May not be able to take instructions in an

emergency.• Likely to need assistance of staff to evacuate.• Some may be resistive or violent in the case of

an evacuation, and may have to be enticed toevacuate.

• Clients having been evacuated may re-enterthe building.

• Some may have fire lighting tendencies.• Some may not perceive risks associated with

fire.

A1.7 Nursing HomesClients in nursing homes are typically frail agedpeople who cannot live independently and canbe categorised as potentially having some of thefollowing attributes:• Elderly (age 65+).• Many suffering from varying degrees of

dementia.• Behavioural disturbances.• Reduced sensory capability.• Many non-ambulant.• Frail or limited mobility.• May be taking prescribed medications that

could affect their response to an alarm and theability to evacuate.

• May have heightened states of confusion atnight.

• Many may require the intensive assistance ofstaff in order to evacuate.




Documents

Capital Development Guideline