Avon Fire and Rescue Service: Causes of concern revisit letter

Letter information

From
Michelle Skeer OBE QPM
His Majesty’s Inspector of Constabulary
His Majesty’s Inspector of Fire & Rescue Services

To
Simon Shilton
​Chief Fire Officer/Chief Executive
​Avon Fire and Rescue Service​

Sent on
24 October 2024

Background

Between May and July 2023, we inspected Avon Fire and Rescue Service. During our inspection, we identified two accelerated causes of concern about the service’s risk information process and its mobilisation system. We also raised two causes of concern about prevention and the service’s values and culture.

On 16 August 2023, we issued this accelerated cause of concern and made the following recommendations:

On 22 November 2023, we issued two further causes of concern and made the following recommendations:

On 9 January 2024, you submitted an updated action plan setting out how you would address the areas of concern and our recommendations.

Between 4 and 8 December 2023 and 19 and 20 March 2024, we carried out two revisits to review progress on the two accelerated causes of concern. On 19 January 2024 and 22 May 2024 we published our findings.

Between 2 and 11 September 2024, we carried out an additional revisit to review progress against the action plan. During the revisit we interviewed staff who were responsible for developing this plan, including senior leaders in the service. We also interviewed managers and staff across the service with responsibility for the risk information process, the mobilisation system, prevention, and values and culture, together with colleagues from their teams. On 18 September 2024, we shared our initial findings with you. This letter provides an update on our findings.

Governance

We found appropriate and clear governance arrangements in place to monitor progress of your action plan. These include:

• regular meetings with the lead officers to make sure progress is being made;
• regular reporting to the fire and rescue authority; and
• a service improvement board that oversees all aspects of the causes of concern.

The service has added the causes of concern to its corporate risk register. This brings more focus and attention to these areas and provides greater scrutiny of the progress made. The National Fire Chiefs Council (NFCC) has also completed an audit to review the two accelerated causes of concern and has provided recommendations. The service has developed an internal improvement board to provide greater oversight. But it should make sure all the current completed actions are based on evidence and are effective.

Action plan

The service has an action plan that covers the causes of concern. The plan identifies senior responsible officers, deadlines and people assigned to each task. But the service should simplify its action plan to clearly show the progress made against each concern and its associated recommendations. This information wasn’t always available. For example, the action plan contains limited information on how the service provides appropriate support for those staff raising workforce concerns. This makes it difficult for the service to continually review progress.

We recognise that communications have gone out to the workforce about the four causes of concern. But we received mixed messages from staff about the way in which the service shared the information. The service would benefit from providing regular updates to all parts of the workforce and should consider publicising its action plan further.

Progress against causes of concern

The service has made improvements to the risk information process but there is still more to do

The service has continued to invest staff resources within the site-specific risk information (SSRI) team. And it is evident that there is a continued focus on improving the risk information process. We previously reported that the service has set an ambitious target to revisit all 610 premises requiring a SSRI record. This is to make sure that all risk information concerning buildings and places of risk is effective, accurate and up to date. At the time of our revisit, we were pleased to find that the service had completed SSRI records for 97 percent of these premises. The SSRI team, and particularly wholetime firefighters and wider staff, should be praised for their determined effort to make sure SSRI is effective, accurate and up to date.

The service has begun the next phase of the project, which will identify up to 1,400 new premises requiring a SSRI record. We look forward to seeing how this work progresses.

The service has provided SSRI training to wholetime firefighters and wider staff. This included a full day of face-to-face training, including a practical exercise. The SSRI team provided additional support and guidance to operational teams by accompanying them during visits. We have now closed this recommendation. The staff we spoke to were positive about the training. But they would welcome further guidance on how to complete SSRI in more complex premises.

The service told us that most wholetime staff have received SSRI training. But the service needs to improve the way it records this as it can’t provide assurance that all its staff are appropriately trained. For example, following a data request, the service confirmed that only 48 percent of wholetime firefighters and fire control staff and 66 percent of wholetime supervisory managers (including fire control) have received SSRI training. But the service told us these figures are much higher. Although we have closed the recommendation, the service should make sure all the appropriate staff have received SSRI training and there are clear processes in place to record this information.

There is an effective quality assurance process in place. This involves the supervisory manager approving risk information records. The station manager and SSRI team then sample and quality assure the records. We found evidence of the quality assurance process taking place. For example, feedback was provided to an operational team who weren’t completing the required fields. We also found that there are effective strategic oversight arrangements in place and senior leaders regularly scrutinise performance. The service has made enough progress to allow us to close this recommendation.

The service has an internal process in place to manage and share information about temporary risks, including individual vulnerabilities. During our last inspection, we confirmed that the service has a formalised process to exchange risk information with others when necessary. For example, we were told that response staff are alerted to hoarding risks. This is where a person has collected so many belongings in their house that it poses a fire risk. But many staff are unclear about whose responsibility it is to make sure vulnerability information is kept up to date and accurate. During our revisit, we found the service still doesn’t have a clear management arrangement for reviewing individual vulnerabilities within the risk information system. And the action plan contains limited information on progress made on this recommendation. We found that a considerable amount of risk information recorded on the system wasn’t up to date. We were told that the service is waiting for a system upgrade before managing this risk information. The recommendation will remain open.

We sampled nine records as part of our desktop review of risk information. We found most of them were effective, accurate and up to date. But we found two of the nine records sampled had no SSRI record completed. This includes a commercial office located over 14 floors and a student accommodation building located over 7 floors. We were told that these two premises will be visited in the next phase of the project. There are approximately 200 high-rise buildings in Avon. In our last inspection, we reported that the service has completed a fire safety inspection on all high-rise buildings within the service area. The service should continue to work with its business fire safety department to identify and make sure all high-rise buildings have a completed SSRI record. Without a SSRI record, the evacuation strategy hasn’t been identified. Should a fire occur, this strategy helps fire control staff provide accurate advice to occupants. We also found three records that weren’t uploaded in a timely manner. One record we sampled took almost four months to upload onto the mobile data terminal following the original visit. Two other records took approximately two months to be uploaded. This was due to the service implementing the new process. The recommendations on identifying all premises that require a SSRI record, the time it takes to upload a SSRI record and fire control staff’s access to evacuation strategies will remain open.

During our last revisit, we found the service had purchased new mobile data terminals. At that time, the service had begun to install them in the rear of fire engines. We spoke to firefighters who were positive about the changes. They felt the new terminals were more reliable than the previous tablets. As an interim measure, the service also stores hard copies of SSRI records. We were told that the hard copies of SSRI records will be removed following our revisit.

IT systems are still a frustration for many firefighters. Many staff that we spoke to felt that IT was a hindrance to the SSRI process. They told us the process was still convoluted and that the transfer of risk information records should be automated rather than manual.

The service has marked all points in the action plan relating to risk information as complete. And we were encouraged that firefighters told us they find the risk information useful when responding to an incident. But senior leaders must make sure all the completed actions are effective.

The mobilisation system is more reliable and stable

During our last inspection, we reported that the mobilisation system crashed on some consoles while the fire control operator was taking emergency calls. This unnecessarily delays the mobilisation of resources and results in the public receiving a slower response to emergencies.

During our revisit in March 2024, we were encouraged to find that the system was more reliable after the service had escalated the matter with the third-party supplier. But the system still wasn’t free from technical faults.

The service, alongside its third-party supplier, had identified the diagnostic tool as the fault causing some consoles to crash during emergency calls. The diagnostic tool (also known as the lock tool) collects data logs and stores them locally on the clients’ consoles. Engineers then dial in to the consoles for retrieval and investigation. We found that the diagnostic tool has been reinstated onto all consoles and the system has remained stable during emergency calls. We are pleased to report that the service has now made enough progress for us to close the accelerated cause of concern and the associated recommendations.

The operating system used by the fire control department has been updated to Windows 10. And the third-party supplier has upgraded the mobilisation system. Although there have been glitches during emergency calls, this hasn’t prevented the mobilising of resources. The service continues to have regular meetings with the third‑party supplier and the supplier’s performance response times are being monitored more regularly.

Staff continued to speak positively about the fire control user group, which encourages two-way communication between the fire control department and senior staff. Staff can report or escalate issues to senior managers using the internal escalation process. Those we spoke to were confident in recording any issues onto the system.

During our last revisit, we found that our recommendation that all fire control staff should receive welfare support hadn’t been met. We are pleased to report that members of the health and well-being team have now visited all staff in fire control to provide training. There are plans to provide refresher training in the future. We have now closed this recommendation.

Prevention is now more focused on high-risk occupants

We found that the service has made good progress in developing its prevention strategy. The strategy is linked to the service plan and covers the four-year period from 2024–28. It details key areas, such as HFSVs, youth engagement, road safety, water safety and safeguarding. You also include the service’s approach towards prioritising HFSVs to those people most at risk of fire. There are plans to create a video to publicise this further across the service.

The service has developed a new HFSV risk stratification process to assess risk and determine which occupants should be prioritised for a HFSV. The scoring system (which assesses 25 vulnerabilities) produces an overall risk scoring of very high, high, medium and low risk. Each risk score gives clear timescales for visiting the occupant. A high-risk visit will now be prioritised over a low-risk visit. The service has adopted the NFCC ‘Person Centred Framework’. We found that wholetime firefighters are visiting higher risk occupants and can fit additional equipment for those who may have hearing or eyesight impairments. We have now closed this recommendation.

We are pleased to find that the service has put clear strategic oversight arrangements in place and there are detailed key performance indicators for HFSVs. Therefore, this recommendation is closed. The prevention manager produces a monthly performance report, which is reviewed by middle and senior leaders across the service. The report includes (among other information):

• the number of completed HFSVs;
• HFSVs completed within the required time frames;
• HFSV activity completed by specialist prevention staff and operational staff; and
• details of outstanding and overdue HFSVs.

The prevention manager monitors this data weekly.

During our inspection in June 2023, we found prevention resources were stretched and 249 HFSVs were overdue. We were concerned to find that some vulnerable people had been waiting for more than six months for a HFSV. During our revisit, we were pleased to find that the service has cleared the backlog. Therefore, this recommendation is now closed. Staff across the service prioritised this work and the service now monitors any HFSVs that are overdue. At the time of our revisit in September 2024, there were 28 HFSVs overdue but the service had made contact with those occupants.

In our last inspection, we found that HFSVs completed by wholetime firefighters were typically arranged between 2pm and 4pm and between 6pm and 8pm. This has remained broadly the same. But the central administration team are using a more flexible approach to arranging visits based on the needs of the public. We spoke to some firefighters who found this frustrating as they would like to arrange their own HFSVs. But we recognise that it is more efficient for a central team to arrange HFSVs. This approach removes administrative tasks from firefighters, which allows them to spend time on other activities. It also gives the occupants a single point of contact should they wish to rearrange the visit.

The service has developed a quality assurance process for its specialist prevention officers. But this is yet to be implemented. There isn’t a quality assurance process for wholetime firefighters yet. But we were told that this will be completed by November 2024. The service has also developed a prevention training package. We spoke to firefighters who were positive about the face-to-face training they had received. The service aims to train its wholetime workforce by November 2024 and its on-call workforce by 31 December 2024.The two recommendations in relation to HFSV quality assurance and training will remain open.

We sampled ten HFSV records. We were encouraged to find that the new risk stratification process had been followed and firefighters had access to vulnerability details in advance of visits. But most of the records completed by wholetime firefighters lacked detail. One record we sampled showed an occupant was at risk of arson. The HFSV should have been completed within seven days, but it took almost six weeks for the visit to happen. We also found another case where the occupant was at risk of arson, but an arson-proof letterbox couldn’t be installed at the occupant’s address. Instead of referring the case to a specialist prevention officer, firefighters advised the occupant to buy their own arson-proof letterbox from a hardware store.

We previously said that the service should consider whether the prevention department has enough resources and review whether wholetime firefighters can offer more capacity to prevention activities. Since our last inspection, the service has carried out a review of prevention staff resourcing. At the time of our revisit, a senior leader was considering a proposal that may lead to more staff working in prevention. This increase would provide extra resilience in the prevention department and allow it to progress some of our recommendations. The number of HFSVs completed by wholetime firefighters has increased. The service’s senior leaders are considering whether firefighters could offer more capacity. This recommendation will remain open.

Senior leaders need to continue to build the workforce’s confidence in improving the culture

In our last inspection, we said that we were concerned that some behaviours we were told about didn’t meet the standards expected. The culture of the organisation didn’t always align with its values. And there isn’t a strong culture of challenge within the service.

Following the publication of our inspection report, the service briefed its staff through a combination of senior leader visits, vlogs and regular bulletins. But, during our revisit, we spoke to many staff who felt the service needs to improve the way it communicates what it is doing to address the cause of concern. There was limited awareness of the existence of the action plan.

We recognise that changing the culture in an organisation takes time. And measuring success can be challenging. But some staff that we spoke to said they have little confidence in the service’s commitment to improve. And others felt that senior leaders haven’t taken full ownership of the findings from our previous inspection report.

One of our recommendations is that the service should make sure that its values and behaviours are understood and demonstrated at all levels of the organisation. This includes senior and middle managers. The service has its own values (respectful, honest, courageous, ambitious, inclusive and transparent). In the weeks leading up to the revisit, a decision was made by senior leaders to keep its existing values and to amalgamate them with the Core Code of Ethics. It is important that staff are involved in any decisions that affect them. Some staff that we spoke to didn’t know the difference between the service values and the Core Code of Ethics. Some staff felt that the service’s values are dated.

Since our last inspection, the service has arranged face-to-face training days for all staff at supervisory manager level and above, which is provided by the equality, diversity and inclusion team and HR. Line managers receive training in service values, ethics and behaviours. The training also includes guidance on setting the appropriate standards to make sure there is a positive and inclusive culture in every team. At the time of our revisit, 47 percent of managers had received this training. And the service was arranging further sessions later this year.

The service has distributed two surveys to gather feedback from staff. Staff completed the latest survey between April and May 2024. The service recognises that the response rate was low, with just 22 percent of staff (184 out of 854) responding to the survey. We found that only 15.6 percent of the responses were from wholetime staff and 5.8 percent were from on-call staff. There were three themes that the survey highlighted:

• the need to do more to level up collaborative working opportunities between all staff groups;
• redesigning the celebration and rewards process so it is accessible and inclusive; and
• addressing the cultural resistance to the celebration and rewards process.

The newly formed people services department, which incorporates HR, equality, diversity and inclusion, and training (among other departments), was working on projects to address the themes at the time of our revisit. The service needs to consider how it communicates with all staff to achieve a better response rate to the staff survey. It has introduced coffee mornings which allow you to provide an update on key milestones across the service. These events also allow staff an opportunity to ask you any questions. This wasn’t reaching all sections of the workforce. But we recognise that the service is extending this approach to run during the evening to reach on-call staff.

In August 2023, the service published an independent reporting line that is hosted by an external organisation. This allows staff to report any workforce concerns. A QR code is provided to help access information more quickly. Since its introduction, 12 reports have been received. Three cases have progressed to formal investigations and others have been addressed informally and locally. We were told by staff that this initiative was poorly communicated initially. This resulted in fear and the term “being QR coded” often being used. For example, some staff felt scared about speaking about certain topics as they feared that whatever they said may be “QR coded”. The service provided further communication to its workforce to address the concerns. But some staff felt more needs to be done. The service would benefit from evaluating its independent reporting line to review how effective it is.

We found that the service has trained most middle managers on investigative practices. An external organisation runs the training and provides support for those who may carry out work related investigations, such as grievances and disciplines. The managers we spoke to were highly complimentary about the training they received. The service was due to publish a new grievance and disciplinary policy shortly after our revisit. It has also updated the intranet to provide greater transparency about the latest outcomes of disciplinary cases and the number of times the independent reporting line was used.

The service has established a professional standards board that includes staff from different parts of the organisation. It also includes external organisations who attend in an advisory capacity. This group of staff acts as decision-makers of discipline investigations. The service has recruited an employment lawyer to help with professional advice. Most staff that we spoke to weren’t familiar with the professional standards board. They also had reservations about how the service completes investigations and the length of time they take. And some felt the service needs to be better at managing allegations and incidents of bullying, harassment and discrimination.

We were told by a few staff about behaviour that wasn’t in line with the service’s values. The service needs to review the support it provides to staff raising workforce concerns and those who may be subject to an investigation. Well-being support is offered in correspondence sent to the affected parties, but staff felt this was a “tick box exercise”. We also spoke to those staff who may be assigned the welfare officer role and required to provide additional support. But they haven’t been provided with the appropriate training or guidelines and processes that they should follow. The action plan contains limited information on the progress made in providing appropriate support to those raising workforce concerns.

Senior leaders are continuing with the workplace visits. We found that the equality, diversity and inclusion team also completes workplace visits and records its key findings. This is a positive step and a good way for the service to continually ask for feedback from staff on issues that may affect them.

The service has existing dignity and respect toolkits and zero tolerance statements. These should be further communicated across the organisation as they aim to reduce the likelihood of staff facing unacceptable behaviours and discrimination.

The service should consider what more it can do to work with all parts of its workforce to build trust and confidence. It should consider how it can limit the influence of the service’s previous poor culture and unacceptable behaviour on the changes it is trying to make. It also needs to review and evaluate how effective its initiatives and actions have been and whether they are having the intended impact to improve the culture of the organisation. The cause of concern and the five associated recommendations will remain open.

Conclusion

The progress the service has made in response to the four causes of concern is welcome. But more work is needed to consolidate these developments. Senior leaders should continue to establish and build confidence with staff. They should make sure improvement takes place across the service and is accepted and understood by everyone.

The service has invested time and resources to develop the action plan and have established robust monitoring and governance arrangements. It has asked for additional resources and support from partner organisations, including the NFCC. The service should continue to communicate its progress across the workforce, including our revisit findings and how it intends to address the associated recommendations. This will demonstrate the service’s commitment to being more open and transparent. As we reported after our last revisit, the service would benefit from revisiting the action plan to make sure all the recommendations are included, and the completed actions are effective. The introduction of the internal service improvement board will support this.

We found significant improvements have been made to the mobilisation system to make sure it is reliable and stable. This has resulted in the closure of the accelerated cause of concern. Despite the closure, the service should continue to focus on fire control. For example, it should continue the oversight arrangements it has put in place with its third-party supplier so any faults are investigated and rectified in a timely manner. It should also continue the new initiatives it has introduced, such as the fire control user group, as this has a positive impact on staff.

We were pleased to speak to firefighters who have noticed a considerable improvement to firefighter safety since our last inspection. They find SSRI records are effective, accurate and up to date, which assists them when responding to an incident. Although the commitment to improve the SSRI process is evident, more work is required to address the four outstanding recommendations. The service still needs to make sure that all high-rise buildings within the service area have a completed SSRI record and that each record is uploaded in a timely manner. This will help protect firefighters, the public and property during an emergency. And the service needs to have clearer management arrangements in place to review individual vulnerabilities, to make sure the information on the system is up to date.

We recognise the service has prioritised the two accelerated causes of concern. But good progress has also been made to address the prevention cause of concern and its associated recommendations. There are performance measures in place and the service has cleared its HFSVs backlog. There is a clear risk stratification process in place, which means that a higher-risk visit is now prioritised. We note that there are longer timescales to address the three outstanding recommendations.

Improving the culture of the organisation will take time. And we don’t underestimate how much work is required to improve the culture. The service needs to continually evaluate the effectiveness of the initiatives that it has introduced to make sure they are achieving the intended outcomes. It is important to include all staff in any decisions made that may affect them, such as the steps needed to make sure everyone understands and accepts the Core Code of Ethics. The service must continue to communicate with its workforce and ask for continuous feedback from staff. This includes the need to increase its response rates to staff surveys. The face-to-face training provided to supervisory managers should continue. The service needs to consider how this will be rolled out to the rest of the workforce. This training will help staff to display the positive values and behaviours expected in every team across the service.

We are satisfied with the service’s current progress. But I have been in regular contact with you, as chief fire officer/chief executive, as I don’t underestimate how much improvement is needed. We will continue to monitor progress through updates from the service and hold checkpoint meetings where we will focus on the service’s improvements.

We will revisit the service on a date to be agreed in the near future to review progress against the remaining three causes of concern.

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Avon Fire and Rescue Service: Causes of concern revisit letter