Fire Risk Assessment for GP Surgeries — A Complete 2026 Compliance Guide

If you manage or own a GP surgery in England or Wales, you are the responsible person under the Regulatory Reform (Fire Safety) Order 2005 (RRO 2005). That means you have a legal duty to carry out a suitable and sufficient fire risk assessment — and keep it up to date.

This guide explains what the law requires, what makes a GP surgery different from a standard workplace, and how to stay compliant with the RRO 2005, CQC standards, and sector guidance.

Is a Fire Risk Assessment a Legal Requirement for GP Surgeries?

Yes. Under Article 9(1) of the Regulatory Reform (Fire Safety) Order 2005, the responsible person must make a suitable and sufficient assessment of the risks to which relevant persons are exposed for the purpose of identifying the general fire precautions needed.

Since 1 October 2023, when section 156 of the Building Safety Act 2022 took effect, the assessment must be recorded in writing regardless of the size of the practice. The previous exemption for employers with fewer than five employees no longer applies. Article 11(2) separately requires the fire safety arrangements themselves to be recorded.

A GP surgery is a non-domestic workplace, so the Order applies in full. Your local Fire and Rescue Authority can inspect at any time. Failure to comply is a criminal offence under Article 32, carrying an unlimited fine and, in serious cases, up to two years' imprisonment.

How CQC Fits Into Fire Safety Compliance

The Care Quality Commission (CQC) does not enforce the RRO 2005 directly — that is the role of the Fire and Rescue Service. However, CQC inspectors assess whether premises are safe under Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (safe care and treatment).

In practice, a CQC inspector will ask to see your fire risk assessment, your emergency plan, and your staff training records. If the Fire and Rescue Service has issued an enforcement notice or if your fire risk assessment is out of date, the CQC will view this as a failure to meet the "Safe" standard. That can affect your rating and, in serious cases, your registration.

What Makes GP Surgery Fire Risk Assessment Different

A GP surgery is not an office with examination rooms. The defining feature is the occupants. Patients may be elderly, frail, hard of hearing, in a wheelchair, mid-consultation, or recovering from a minor procedure. Few of them can evacuate on the first sounding of the alarm without staff assistance.

The premises add their own hazards. Medical oxygen cylinders and nitrous oxide are oxidising gases — they do not burn, but they make everything else burn faster and fiercer. Their presence brings Article 12 of the RRO 2005 and the Dangerous Substances and Explosive Atmospheres Regulations 2002 (DSEAR) into play. Where the risk cannot be eliminated, Article 12(3) requires the measures in Part 4 of Schedule 1 to the Order.

The Five-Step Fire Risk Assessment for GP Surgeries

The Home Office recommends a five-step approach for all non-domestic premises. For a GP surgery, each step has specific considerations.

Step 1: Identify Fire Hazards

Ignition sources: Electrical equipment is the most common ignition source in medical premises. X-ray machines, autoclaves, sterilisers, compressors, and IT equipment concentrate electrical load in small rooms. Fixed wiring inspection reports (EICR) and portable appliance testing (PAT) records must be current.

Fuel sources: Paper records, soft furnishings, waiting-room chairs, clinical waste, cleaning materials, and alcohol-based hand gels all contribute to fire load. Clinical waste awaiting collection is a particular arson risk if stored in unsecured external bins.

Oxygen and oxidising gases: Medical oxygen cylinders stored on-site must comply with BCGA Code of Practice 4 — ventilated storage, segregated from combustibles, and secured upright. Nitrous oxide is a strong oxidiser in its own right. Both must be considered under DSEAR 2002.

The surgical fire triad: In any practice conducting minor surgery, implants, or oral surgery, three elements can combine: alcohol-based skin preparation that has not been allowed to dry, supplemental oxygen, and an ignition source (electrosurgery, cautery, laser). This recognised hazard must appear in the assessment with specified drying times and drape control.

Step 2: Identify People at Risk

Everyone lawfully on the premises must be considered — staff, patients, visitors, contractors. The assessment must identify:

• Patients with mobility impairments (wheelchair users, those with walking aids)
• Patients with sensory impairments (hearing or sight loss)
• Patients with cognitive conditions who may not understand an alarm
• Patients mid-procedure or recovering from sedation
• Staff members with disabilities (who need their own personal emergency evacuation plans)
• Lone workers, particularly in branch surgeries with reduced staffing

The evacuation plan must work at the lowest anticipated staffing level — a Saturday morning clinic with one receptionist and one clinician is very different from a full weekday rota.

Step 3: Evaluate, Remove or Reduce Risk

The assessment must evaluate whether existing fire precautions are adequate and identify what needs to be added. For a GP surgery, this includes:

• Fire detection and alarm system (normally to BS 5839-1 Category L1 or L2 for medical premises)
• Emergency lighting to BS 5266-1, particularly in windowless treatment rooms
• Fire doors with intumescent seals and self-closing devices on consulting rooms (typically FD30S)
• Protected escape routes wide enough for wheelchair evacuation
• Fire extinguishers — typically CO₂ for electrical risks, water additive or foam for general combustibles, serviced annually to BS 5306-3
• Clear signage and fire action notices
• Personal Emergency Evacuation Plans (PEEPs) for patients who cannot self-evacuate
• A General Emergency Evacuation Plan (GEEP) covering the building's overall strategy

Step 4: Record Findings, Prepare an Emergency Plan, Provide Training

Under Article 9(6) and (7) and Article 11(2) of the RRO 2005, the significant findings must be recorded. The record must include:

• Premises details and date of assessment
• Hazards identified and people at risk
• Existing fire precautions
• Actions required, with priorities and target dates
• Date of next review

The emergency plan, required under Article 15(1), must document:

• Action on discovering a fire
• Procedure for calling the Fire and Rescue Service (dial 999)
• Evacuation procedures including PEEPs for vulnerable patients
• Staff duties during evacuation
• Assembly point location
• Liaison with the Fire and Rescue Service on arrival

All staff must receive fire safety training. Under Article 18, the responsible person must appoint a sufficient number of competent persons to assist with fire safety duties. Training should cover the evacuation plan, use of extinguishers, and the specific needs of patients who require assistance.

Step 5: Review Regularly

There is no fixed legal interval for review, but industry guidance — including PAS 79-1:2020, the recognised UK methodology for fire risk assessments — recommends at least every 12 months. Review sooner after:

• A fire or near miss
• Building alterations or refurbishment
• Change in practice size, patient demographic, or services offered
• New legislation or official guidance
• Changes to staffing levels or shift patterns

Key Statistics from 2026

According to the Ministry of Housing, Communities and Local Government (MHCLG) Fire Prevention and Protection Statistics, England: April 2025 to March 2026 (published September 2026):

• Fire and Rescue Authorities carried out 50,195 fire safety audits during the year
• Only 60% (29,909) had a satisfactory outcome
• 3,355 formal notifications were issued — an 11% increase from the previous year and 46% higher than six years ago
• Breaches of Article 14 (emergency routes and exits) were the most frequently cited reason for non-compliance

This rising enforcement trend means GP surgeries are increasingly likely to be inspected and must have their documentation in order.

Where to Find the Authoritative Guidance

The Home Office fire safety risk assessment guide for healthcare premises is the relevant sector guidance. For NHS-managed premises, the NHS Firecode suite — HTM 05-01, HTM 05-02, and HTM 05-03 — sets out functional fire safety standards. Private practices are not legally required to follow Firecode, but adopting it as a benchmark demonstrates that you have taken suitable precautions.

All guidance is subordinate to the legal duty: the Regulatory Reform (Fire Safety) Order 2005 itself.

Common Compliance Gaps Found in GP Surgeries

Based on inspection data and assessor experience, the most common deficiencies include:

1. No recorded fire risk assessment — the single most common failure, despite being a legal requirement for all premises since October 2023 2. Out-of-date assessments — assessments more than 12 months old without a recorded review 3. Inadequate fire door maintenance — propped-open doors, missing intumescent seals, gaps exceeding 4mm 4. No PEEPs for vulnerable patients — relying on improvisation rather than planned evacuation 5. Medical oxygen storage not assessed — cylinders stored in corridors, near heat sources, or without segregation 6. Staff training not documented — no record of who has been trained, when, or on what 7. Emergency lighting not tested — no monthly flick tests or annual full discharge tests recorded

FAQ

Does every GP surgery need a fire risk assessment?

Yes. Every non-domestic premises in England and Wales must have a suitable and sufficient fire risk assessment under Article 9 of the RRO 2005. There is no exemption for small practices.

Does a single-handed GP practice with two staff need a written fire risk assessment?

Yes. Since 1 October 2023, section 156 of the Building Safety Act 2022 removed the exemption for employers with fewer than five employees. All assessments must now be recorded in writing.

How often should a GP surgery fire risk assessment be reviewed?

At least every 12 months, or sooner after a significant change such as building alterations, a change of use, a fire or near miss, or changes to patient demographics.

Who is the responsible person for a GP surgery?

The responsible person is the employer (usually the practice partners or the provider company) or the person who has control of the premises. In a shared health centre, responsibilities may be split between the practice, the landlord, and NHS Property Services — each party's duties must be documented.

What happens if a GP surgery doesn't have a fire risk assessment?

Failure to comply is a criminal offence under Article 32 of the RRO 2005. The Fire and Rescue Service can issue an enforcement notice or a prohibition notice, and the responsible person faces an unlimited fine and, in serious cases, up to two years' imprisonment. CQC will also view this as a failure to meet the safe-care standard.

Does the CQC check fire safety?

Yes. CQC inspects premises safety under Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Inspectors routinely ask to see the fire risk assessment, emergency plan, and staff training records.

What about medical oxygen — does it need special consideration?

Yes. Medical oxygen enriches the atmosphere and dramatically accelerates fire spread. It must be assessed under Article 12 of the RRO 2005 and DSEAR 2002. Storage must follow BCGA Code of Practice 4 — ventilated, secure, and away from heat and combustible materials.

Can the practice manager carry out the fire risk assessment?

Only if they are competent to do so — meaning they have sufficient training, experience, and knowledge. Article 18 of the RRO 2005 requires the responsible person to appoint competent persons. For most GP surgeries, engaging an external NEBOSH-qualified assessor who understands healthcare premises is the safest approach.

Is NHS Firecode legally required?

No. HTM 05-01, HTM 05-02, and HTM 05-03 are guidance, not law. For NHS-managed premises, Firecode is the expected benchmark. Private practices are not legally bound to follow it, but doing so demonstrates a robust approach to fire safety.

Do I need a separate fire risk assessment for each building on a practice site?

Yes. Each non-domestic building that forms part of the practice requires its own suitable and sufficient assessment. A single assessment covering multiple buildings is acceptable only if it adequately addresses each building's specific risks and layout.

How HawkSwift Can Help

HawkSwift Ltd provides fire risk assessments for GP surgeries and medical centres across England and Wales. Our NEBOSH-qualified assessors produce court-defensible, RRO 2005-compliant reports within 5 working days, tailored to the specific risks of healthcare premises — from medical oxygen storage and DSEAR compliance to PEEPs and fire door inspections.

Book a GP surgery fire risk assessment — fixed price from £349, same-week appointments available.

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*This article provides general guidance on fire risk assessment requirements for GP surgeries under UK law. It does not constitute legal advice. For a premises-specific assessment, engage a competent fire risk assessor in accordance with Article 18 of the Regulatory Reform (Fire Safety) Order 2005.*