A CQC inspector and a fire safety officer can walk the same corridor in the same week and ask completely different questions about the same door.
The inspector wants to know whether the home is safe and well run, and whether the manager can show it. The fire officer wants to know whether the door will hold when it counts, and whether someone competent has been keeping it that way. Both will ask for records.
The stakes on a care home fire door are higher than almost anywhere else, because the evacuation strategy usually relies on moving residents a short distance into the next compartment and keeping them there. If the doors between compartments fail, the strategy fails with them.
What CQC is looking at
CQC assesses fire safety through the Health and Social Care Act regulations rather than fire law directly. Regulation 12 requires premises to be safe to use and used in a safe way. Regulation 15 requires them to be properly maintained. Regulation 17 requires the governance to prove both. Under the single assessment framework, fire safety sits within the Safe environments quality statement, which expects effective arrangements to monitor the safety and upkeep of the premises.
In practice the inspector is looking for a system, not a snapshot. A wedged fire door is a Regulation 12 finding on its own, and CQC inspection reports have recorded breaches and served warning notices for exactly that. The deeper question is whether anyone would have noticed the wedge without the inspector, and what would have happened next. CQC has said for years that it escalates fire safety concerns to the local fire and rescue authority, so a weak answer to one regulator invites a visit from the other.
What the fire service is looking at
The fire and rescue authority enforces the Regulatory Reform (Fire Safety) Order 2005 directly. Article 9 requires a suitable and sufficient fire risk assessment, which should identify the doors protecting escape routes and compartments and say how they are to be kept in order. Article 11 requires fire safety arrangements: the procedures, checks and responsibilities that turn the assessment into routine. Article 17 requires the doors, as part of the fire precautions, to be kept in efficient working order and good repair through a suitable system of maintenance.
The quarterly and annual fire door checks introduced by Regulation 10 of the Fire Safety (England) Regulations 2022 apply to residential buildings containing flats with a storey above 11 metres. They do not apply to care homes. What applies to a care home is the Article 17 maintenance duty and whatever frequency the fire risk assessment sets, informed by the Home Office guide for residential care premises. The check regime should be risk-based, written down and followed, not borrowed from a block of flats.
What evidence actually means for a door
Both regulators are asking the same underlying question: can you prove this door has been looked after? A convincing answer has five parts.
- A register: every fire door in the home, where it is, what rating it should carry and what it protects.
- A check record for each door: date, who did it, what was checked (gaps, seals, closer, hinges, glazing, signage, condition) and the outcome.
- A defect trail: what was found, when it was reported, who it went to, when it was fixed and who confirmed the fix.
- Certification for any replacement or upgrade: the doorset’s fire certificate, the installer’s details and confirmation that the door was fitted as the certificate assumes.
- A link back to the fire risk assessment: the frequency and scope of checks should match what the assessment says.
A binder holding the first two and nothing else is where many homes sit. It shows a home that checks its doors and cannot show what happened when one failed.
The consistency challenge across a care group
For a single home this is manageable. For a group of five or fifteen it becomes a question of consistency, and that is where the trouble usually starts. Home A logs checks in a diary, Home B uses a spreadsheet, Home C has a form the previous manager designed. The regional manager cannot compare them, the board cannot summarise them, and when a fire officer visits one home, the standard of record at that home is the standard the group is judged by.
The Care Pro case in East Sussex shows how that plays out. In July 2024 two directors of a company running four care homes in Bexhill were ordered to pay a combined £124,455 in fines, costs and surcharge after pleading guilty to twelve offences under the Fire Safety Order. The district judge said the number of vulnerable residents put at risk by defective fire doors and inadequate detection raised the level of harm, and that the owners should have taken the time to understand the published regulations and guidance. The doors in question separated the only escape route from bedrooms, kitchens and lounges.
Getting the record consistent
Whatever a group uses to hold its records, three things keep them defensible across sites.
First, one format everywhere. The same door register fields, the same check items and the same defect workflow at every home, so a record from any site reads the same to a regional manager, a CQC inspector or a fire officer.
Second, named ownership at each home and at group level. Every check and every fix carries a name and a date, and someone above home level is responsible for reviewing the defect list and closing it.
Third, evidence that survives staff turnover. Records that live in one manager’s head or on one manager’s laptop leave with them. The home should be able to produce its door history on the day of an unannounced visit without that manager present.
None of this requires a particular system. It requires the group to decide what good looks like once, apply it everywhere and check that it is happening. That is what both regulators are testing, whether they ask in the language of Regulation 17 or Article 11.
Kemble Nagan is Managing Director of DoorTRACE, a UK fire door inspection and compliance platform. This article is for general information and is not legal advice. Responsible persons should take advice on the requirements for their own premises.
