First reported 10 May 2017•Latest report 3 Oct 2024
Definition
What this concern includes
Includes failures of controls specifically intended to prevent, detect or respond to cigarette-related fires involving vulnerable people who smoke, including smoking-risk assessment, supervision or protective equipment requirements, and prohibitions on unsafe smoking assistance.
Not included
Generic deficiencies in care planning, documentation, staffing or training that are not explicitly tied to smoking-related fire safety.
Medication, clozapine, food or fluid refusal, falls, self-harm, or other hazards merely involving people who smoke.
Smoking-related leave or nicotine-replacement guidance where the reported unsafe condition is absconding or mental-health risk rather than cigarette-related fire risk.
General fire-safety deficiencies not specifically connected to smoking by vulnerable people.
Reports
6
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2017–2024
First to latest report issue date
Stated actions
18
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission2
Bupa1
Devon County Council1
Guinness Care and Support Limited1
Lewisham Safeguarding Adults Board1
London Borough of Newham1
London Fire Brigade1
Ministry of Housing, Communities and Local Government1
The Royal Society For The Prevention Of Accidents1
Welsh Government1
Health and social care service regulator2
Multi-service care provider2
Devolved government1
English county council1
Fire and rescue service1
London borough council1
Ministerial department1
Other public body1
Registered charity1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
East London
Concerns raised1
Failure to convey home fire safety findings to responsible carers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
Stated by London Fire BrigadeStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
Action
Review Home Fire Safety Visit booking questions to identify in-home care and recommend that carers attend visits.
Stated by London Fire BrigadeStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
Action
Scope options for leaving bespoke fire-safety information with residents, family members or carers, engaging other fire services to identify best practice.
Stated by London Fire BrigadeStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
Action
Update Home Fire Safety Visit policy, guidance and staff training where necessary following the process review.
Stated by London Fire BrigadeStated plannedThe respondent said that this action was planned when they made their response on 4 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing policy authorises sharing advice only with a resident who can understand and retain it, so staff followed the correct process.
Stated by London Fire BrigadeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Care providers are responsible for planning and delivering care based on risk assessments, including assessing and mitigating fire risk.
Stated by London Fire BrigadeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Riding and Hull
Concerns raised1
Ongoing foreseeable risk of cigarette-related fires in vulnerable individuals permitted to smoke on the premises
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review and update website information materials on fire safety in sheltered premises.
Stated by Royal Society for the Prevention of Accidents (RoSPAStated plannedThe respondent said that this action was planned when they made their response on 9 August 2024.
Action
Explore collaboration with sheltered-accommodation professionals to promote fire awareness.
Stated by Royal Society for the Prevention of Accidents (RoSPAStated plannedThe respondent said that this action was planned when they made their response on 9 August 2024.
Manchester South
Concerns raised1
Failure of smoke detection systems to provide sufficiently early warning of cigarette-related fires
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to recognise that carers were not obliged to facilitate smoking despite the fire risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Use Care Act assessments, risk-based analysis and care planning to identify and address fire risks through support or assistive technology.
Stated by Devon County CouncilStated completedThe respondent said that this action was complete when they made their response on 25 August 2018.
Action
Share incident learning and alerting options with the Provider Engagement Network, including reminders about robust risk assessment and escalation of concerns.
Stated by Devon County CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 August 2018.
Action
Conduct comprehensive customer, environmental and activity-specific risk assessments, with six-monthly or change-triggered reviews, led by trained senior care workers.
Stated by Guinness CareStated completedThe respondent said that this action was complete when they made their response on 25 August 2018.
Action
Provide carers with induction health and safety training covering risk assessment, hazardous substances and fire safety.
Stated by Guinness CareStated completedThe respondent said that this action was complete when they made their response on 25 August 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The provider should determine measures for carers facilitating dangerous activities under its internal policies, practices and CQC requirements.
Stated by Devon County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Wales Central
Concerns raised1
Failure to prohibit carers assisting the service user to smoke in bed
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Issue general guidance to care providers on assessing and mitigating smoking-related health and fire risks, including expectations for assisting service users to smoke.
Stated by Care Inspectorate WalesStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Action
Continue reviewing regulated providers’ risk-management systems through inspections to identify unsafe care and care-plan breaches.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
A blanket smoking-assistance ban cannot be imposed because the regulator lacks power to make law or issue statutory guidance.
Stated by Care Inspectorate WalesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A blanket prohibition lacks stakeholder support and could compromise service users' choice and control.
Stated by Care Inspectorate WalesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A blanket prohibition on assisting smoking is not considered appropriate because person-centred care requires case-by-case risk assessment.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised2
Failure to document required smoking-risk mitigations and responses to their refusal
Failure to recognise immobility and require supervision in smoking risk assessments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Conduct an independent Safeguarding Adult Review into the death, examining events, care, risk management, practice standards, causes and remedial actions.
Stated by Lewisham Safeguarding Adults BoardStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2022.
Action
Hold learning and service development seminars and produce and circulate a briefing note to disseminate review learning for service, policy and practice transformation.
Stated by Lewisham Safeguarding Adults BoardStated plannedThe respondent said that this action was planned when they made their response on 7 October 2022.
Action
Carry out a comprehensive inspection following the incident to assess risk assessments and staffing shortages.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Action
Undertake an unannounced comprehensive inspection of Manley Court, review documentation, and consider whether measures reduce risk.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 7 October 2022.
Action
Revise the smoking risk assessment process to require apron offers, capability assessment, pendant alarms for garden smokers, and supervision where protective clothing is declined.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Action
Require all safe smoking assessments to follow the updated Bupa Smoking Policy BFM 20.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A capable resident’s right to make an unwise decision prevents smoking without supervision or an apron being prohibited wherever possible.
Stated by BupaUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures of controls specifically intended to prevent, detect or respond to cigarette-related fires involving vulnerable people who smoke, including smoking-risk assessment, supervision or protective equipment requirements, and prohibitions on unsafe smoking assistance.
