PEEPs in care homes: the personal emergency evacuation plan every resident needs

A personal emergency evacuation plan, or PEEP, is a short written plan for one named person that says how they will get to a place of safety if there is a fire and they cannot do it unaided. In a care home almost every resident needs one from the day they move in, and the duty to have it sits with the responsible person under the Regulatory Reform (Fire Safety) Order 2005. This guide covers who needs a PEEP, what it must contain, how night-time staffing changes the answer, and how to test and review it so it is a plan and not a form.

The short answer

Assess every resident for evacuation on the day of admission and expect nearly all of them to need a PEEP. Write it to match your building's evacuation strategy, which for most care homes is progressive horizontal evacuation into the next fire compartment rather than out to the car park. Record how the person will know there is a fire, how they move, how many staff they need, what equipment is used and where they go. Then test it against your lowest staffing level, usually two or three staff at night, because that is when a fire is most likely to go wrong. Review it after any room move, change in mobility or change in night staffing, drill it, and make sure agency staff can find it in thirty seconds.

Who needs a PEEP in a care home

Anyone who may need help to evacuate. That is far wider than people who use a wheelchair. It includes residents who walk slowly or use a frame, who cannot manage stairs, who are in bed for long periods or are hoisted, who have a learning disability, dementia or a mental health condition that means they may not recognise the alarm or follow an instruction, who are deaf or have poor sight, who take sedating medication at night, who may refuse to leave or hide, or who are on oxygen or attached to equipment.

For a residential, nursing, learning disability or mental health home the honest answer is: everyone gets assessed, and nearly everyone gets a plan. It is quicker to write a short PEEP for the one resident who could genuinely walk out unaided than to argue about whether they need one. Staff with a disability need a PEEP too, and so do regular visitors and volunteers who might be on the premises when the alarm sounds.

What the law actually requires

The Regulatory Reform (Fire Safety) Order 2005 makes the responsible person, usually the provider and in practice the registered manager, accountable for the safety of everyone on the premises. Article 9 requires a fire risk assessment. Article 15 requires procedures for serious and imminent danger, which is the evacuation plan. Article 21 requires training. The Order does not use the word PEEP, but the government's guide Fire safety risk assessment: residential care premises makes clear that people who need assistance must have an individual plan, and fire and rescue authorities expect to see them.

Alongside the Order sit Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which is why CQC inspectors ask about fire evacuation too. Two regulators, one set of documents. The Fire Safety Act 2021 clarified that the structure, external walls and flat entrance doors are within scope of the fire risk assessment, which matters for converted houses with residents' rooms behind bedroom doors.

At a glance: evacuation strategies and what the PEEP must say

Your fire risk assessment tells you which strategy applies to each part of the building. Every PEEP must match it. A PEEP that says evacuate to the car park in a building designed for horizontal evacuation is wrong, and a fire officer will spot it immediately.

PEEP, GEEP and fire risk assessment: three different documents

The fire risk assessment covers the building: detection, alarm, compartmentation, escape routes, extinguishers, emergency lighting, the evacuation strategy, and the significant findings. It is carried out by a competent person and reviewed at least annually. A generic emergency evacuation plan, or GEEP, is a general plan for a class of people who might be on the premises without an individual assessment, such as visitors who use a wheelchair. It says what staff will do for anyone in that situation.

A PEEP is different from both. It is for one named person and answers one question: how do we get this individual to safety with the staff we actually have, at the time of day when it is most likely to go wrong. It sits underneath the fire risk assessment and depends on it. A home with thirty residents and one line in the fire risk assessment saying staff will assist residents to the nearest exit has a fire risk assessment. It does not have PEEPs. This is a form of care home risk assessment, and it should be built and reviewed with the same discipline as the falls or choking assessments in a resident's file. For that wider framework see risk assessments in social care.

Understand your building's evacuation strategy first

Before writing a single PEEP, read the evacuation strategy in your fire risk assessment and walk the building with it. Know where the compartment lines are. Know which doors are fire doors and which are not. Know where the refuges are and whether they have communication points. Know which staircase is protected. If you cannot draw a rough compartment plan of your home from memory, you are not ready to write PEEPs, and neither are your seniors.

Most purpose-built care homes use progressive horizontal evacuation. The floor is divided into two or more compartments separated by fire-resisting walls and doors, and a fire in one compartment is contained for long enough to move residents through the doors into the next one. That movement is what the PEEP describes: from this room, through this door, to this corridor or lounge, with this equipment and this many staff. Only if the fire spreads is the next stage triggered. In a smaller converted home with no compartmentation the strategy is usually full evacuation, and the plan is longer and harder. Either way the PEEP is only as good as the strategy it sits on.

Assess on the day of admission, not the week after

The PEEP is the first risk assessment you write for a new resident. It is written before they sleep in the building for the first time, because the fire does not wait for the assessment cycle. That means the pre-admission assessment must capture the evacuation questions: mobility, hearing, sight, cognition, behaviour on hearing an alarm, night sedation, equipment. Where the person is admitted at short notice from hospital and you do not have full information, write a cautious provisional PEEP on the day and refine it in the first week.

A practical rule that has worked in my own homes: the resident's room is not allocated until the PEEP is drafted, because the room decides the compartment and the route. A person who cannot manage stairs and needs two staff to move should not be in the room furthest from the compartment door on the first floor. The PEEP process should influence the room allocation, not just describe it afterwards.

The PEEP template, field by field

One template, used for every resident, staff member and regular visitor. These are the fields it needs and what to put in them.

Person and location

Name, room number, floor, fire compartment, date, author and version number. The compartment is the field most templates miss. It is the single most useful piece of information for the staff member reading the plan at 3am.

Awareness

Can the person hear the alarm? Will they recognise what it means? Will they follow a verbal instruction from a member of staff? Will they follow a stranger, such as a firefighter? Record what you know, including anything from a previous placement or from family. For a person with dementia or a learning disability the answer is often no to all four, and the plan needs to say so plainly.

Mobility

Walks unaided, walks with a frame or one member of staff, uses a self-propelled wheelchair, uses an attendant-propelled wheelchair, bed-bound, hoisted. Note the difference between day and night. A resident who walks with a frame in the afternoon may be unable to get out of bed unaided at night.

Assistance and equipment

The number of staff needed and the method: verbal prompt, guiding arm, wheelchair, evacuation sheet or ski sheet on the mattress, evacuation chair for stairs. Name the equipment and where it is kept. If an evacuation sheet is fitted under the mattress, say so and check it is actually there.

Route and place of safety

From the room to the compartment door, to the safe area, and if necessary onward. Name the door. Name the corridor or lounge. Name the refuge if one is used and what happens next.

Behaviour and communication

Anything specific: may refuse, may hide under the bed, becomes distressed by loud noise, responds best to a named phrase, needs a hand held. This is the field that makes the difference in learning disability and mental health services.

Night-time note

The number of staff on at night and whether the plan still works. If it does not, say what changes: the order in which residents are moved, or the point at which fire service assistance is assumed.

Review

Next review date, review triggers, and a record of each drill in which this person's plan was tested.

Night-time staffing: the test that matters

A PEEP that works with eight staff on a weekday afternoon and fails with two waking night staff is not a plan. Most fires in care homes that lead to deaths happen at night. The realistic exercise is this: take your night rota, take the compartment with the most dependent residents, and work through the PEEPs in order. Two staff, six residents in that compartment, four of whom need two people to move. How long does it take? Which order? What do the other residents in the building do while that is happening?

The answer will often be uncomfortable, and that is the point. It may mean changing room allocations so that the most dependent residents are nearest the compartment door. It may mean a third waking night staff member. It may mean investing in evacuation sheets on every bed so that one person can move a bed-bound resident. It may mean a conversation with the fire and rescue service about their attendance time and what your staff are expected to achieve before they arrive. Whatever the answer, it is written into the PEEPs and the fire risk assessment, and it is the single thing an experienced fire officer will ask about. Rota planning that keeps night cover realistic is part of fire safety; see care home rota planning for how the two connect.

Equipment: sheets, chairs and refuges

Evacuation sheets, sometimes called ski sheets or rescue sheets, are fitted under a mattress and allow one or two staff to pull a bed-bound resident, mattress and all, along the floor and through doors. They are the single most useful piece of kit in a nursing home and should be under every bed where the resident cannot walk. They need checking: staff pull the straps out from under the mattress during a drill and find they were never fitted. Evacuation chairs are for stairs and need trained users; two staff with an evacuation chair is a realistic minimum for most residents.

Refuges are protected areas, usually within a staircase enclosure, where a person can wait safely for assistance. They should have a means of communication and be shown in the PEEP if used. In most care homes a refuge is a staging point rather than a destination, and the PEEP must say who comes back for the person and when. Do not write a PEEP that leaves a resident in a refuge with no next step.

Residents who refuse, hide or become distressed

An alarm at night is frightening. Residents with dementia may hide under the bed or in a wardrobe. Residents with autism may be unable to tolerate the noise and refuse to move. Residents with a mental health condition may lock themselves in. The PEEP is where this is recorded and where the staff response is set out: the phrase that works, the person who is most likely to be trusted, the decision about whether to use a physical intervention and under what authority, and the point at which a member of staff must leave and hand over to the fire service.

That last point deserves a plain sentence. A member of staff cannot be expected to remain in a smoke-filled compartment with a resident who will not move. The plan should say what has been tried, when to stop, and that the fire service is told immediately where the person is. Recording that decision in advance protects both the resident and the staff member, and it is exactly what a coroner would expect to see.

Bariatric, bed-bound and oxygen-dependent residents

A bariatric resident needs a plan that names the equipment rated for their weight, the number of staff, and whether the doors on the route are wide enough. Some rooms have to be chosen for this alone. A bed-bound resident with pressure damage needs a plan that balances the harm of moving them on a sheet against the harm of not moving them, with a clear answer. A resident on oxygen needs the concentrator switched off and cylinders noted in the plan, because oxygen enrichment in a fire is a serious hazard, and the fire service must be told where cylinders are stored.

In nursing homes it is realistic that several residents in one compartment fall into these groups. That is why room allocation and the night-time exercise matter so much. It is also why a nursing home risk assessment for fire cannot simply be copied from a residential home template. The dependency profile is different and the plan has to reflect it.

Learning disability and autism: making the plan work for the person

In learning disability services the PEEP must reflect how the person actually communicates and copes. A visual or easy-read version of the plan, shared with the person and practised with them, is good practice and shows involvement. Some people cope far better if they have taken part in drills and know the routine. Others become more anxious with each drill, and the plan should say how often to involve them and how. Flashing beacons or vibrating pillow alerts may be needed for people who are deaf, and the plan says which room has them.

Sensory issues matter. A resident who will not walk through a door held open by a stranger, or who must carry a particular object, or who will only move if a particular member of staff speaks to them, has a plan that says so. This is consistent with the Right support, right care, right culture guidance: the plan is built around the person, not the building.

Mental health services: locked doors and self-harm risk

Mental health residential services often have doors that are locked or keypad-controlled, either for the security of residents or because of a DoLS authorisation. The fire risk assessment must show how those doors release on alarm or how staff open them, and every PEEP for a resident behind such a door must state it. Where a resident has a history of self-harm or absconding, the PEEP should say how the risk is managed at the assembly point or safe area, because an evacuation is a moment of low supervision and high distress.

It is also worth saying that some residents in mental health services may set fires. That is a matter for the individual risk assessment and the fire risk assessment, but the PEEPs for other residents in the same compartment should reflect the higher likelihood. Honest scoring here is not stigmatising the resident. It is planning properly.

Staff and visitors with disabilities

A member of staff with a hearing impairment, a mobility problem or a health condition that could be triggered by an alarm needs a PEEP in the same way a resident does. This is often forgotten because staff are seen as the rescuers. The plan says how they will be alerted, what their role is in the evacuation, and who supports them if needed. Regular visitors, such as a relative who visits daily in a wheelchair, should be offered a PEEP too. For occasional visitors a GEEP covering wheelchair users and people with sensory impairments is enough, as long as staff know it exists.

Writing it so staff can use it in thirty seconds

The full PEEP can run to two pages. The version that matters in a fire is the grab sheet: one line per resident, ordered by compartment, with room number, mobility code, number of staff, equipment and one behavioural note. It lives at the fire panel, in the night office and in the grab bag at the assembly point. It is reprinted every time a PEEP changes and every time a resident moves room. In a digital system it can be generated automatically from the individual plans, which removes the risk of the printed sheet being three room moves out of date.

Whatever the format, the test is simple. Hand it to an agency worker who has never been in the building and ask them to tell you how to get the resident in room 12 to safety. If they cannot answer in thirty seconds, the sheet is not doing its job.

Fire drills: testing the plans, not just the alarm

A fire drill that consists of the alarm sounding and staff walking to the panel is an alarm test. A drill tests the PEEPs. Run them at least twice a year, and include at least one that simulates night staffing. This is how to run one that proves something.

1. Choose a compartment and a scenario: fire in room 8, alarm activated at 02:30, two staff on duty.
2. Brief the residents beforehand where that is appropriate, and decide which residents will be moved for real and which will be simulated with a note on the door. Never move a resident in a way that puts them at risk for a drill.
3. Start the drill. Time it from the alarm to the last resident being clear of the compartment.
4. Observe: did staff go to the panel, identify the zone, and go to the right compartment? Did they use the grab sheet? Did they use the equipment named in the PEEPs? Did they follow the order of priority?
5. Debrief with the staff involved on the same day. Record what went well and what did not, in their words.
6. Update the fire risk assessment, the PEEPs affected and the training plan. Record the drill against each resident whose plan was tested.
7. Repeat with a different compartment and a different shift.

Drills in which every resident is simulated teach less than drills in which a few are moved. Drills where seniors run everything teach less than drills where the newest staff member leads. Vary them.

Review triggers

A PEEP has a review date, usually six-monthly or annually in line with the fire risk assessment cycle, but the triggers matter more. Review immediately on: any room move; any change in mobility, including a fall or a new walking aid; any new sedating medication; any change in hearing, sight or cognition; any change in behaviour that affects how the person responds to staff; any change in night staffing levels; any change to the building's compartmentation or doors; and after any drill or real activation in which the plan was tested. Write the triggers into the plan and connect them to the care planning process, so that the senior reviewing a care plan after a fall is prompted to open the PEEP as well.

Agency, bank and new staff

Agency staff must know the evacuation strategy and the PEEPs for the residents they are supporting, before they start the shift, not when the alarm sounds. A ten-minute fire briefing at the start of the first shift covering the panel, the compartments, the grab sheet and the equipment is the minimum, and it should be recorded. The same applies to bank staff on their first shift in a different unit. If your agency staff have today-only system access, make sure the PEEP and the grab sheet are within that access. For the wider picture on agency workers see agency staff in care homes.

New permanent staff should walk the evacuation routes with a senior during induction and take part in a drill within their probation period. Their training record should show it, and a training matrix that flags fire training expiry stops the annual refresher slipping.

Fire and rescue service audits

Fire and rescue authorities audit care homes under the Fire Safety Order, sometimes on a risk-based cycle and sometimes after a complaint or an incident. The fire safety officer will ask to see the fire risk assessment, the evacuation strategy, the PEEPs, the drill records, the training records and the maintenance records for the alarm, emergency lighting and fire doors. They will walk the building and check that doors close, that routes are clear and that equipment named in PEEPs exists. They can issue an enforcement notice or, in serious cases, a prohibition notice that stops you using part of the building. Treat their visit as you would a CQC inspection. The documents overlap almost entirely with what CQC expects under the Safe key question, so one well-organised fire folder serves both.

Linking PEEPs to care records and audits

The PEEP is a risk assessment, and it should live where the other risk assessments live, with the same version history, review dates and audit trail. When it is a separate paper document in a fire folder, it goes out of date silently. When it is created in the same system as the falls and choking assessments, a change in mobility recorded in the care plan can prompt the PEEP review, and the grab sheet can be regenerated from the live plans. Kiwi is built this way: every risk assessment is scored and versioned, PEEPs come first because every resident needs one, and the fire audit checklist sits in the same place as the drill records, so the fire folder and the care records stop disagreeing with each other. See CQC compliance for how the audits and evidence sit together, and care records for the risk assessment side.

PEEP audit checklist

Run this monthly, or quarterly at minimum, and record it.

• Every resident has a PEEP dated within the review period, with a version number
• Every PEEP names the correct room and compartment, checked against the current room list
• Every PEEP matches the evacuation strategy in the fire risk assessment
• Every PEEP states the number of staff needed and the equipment used
• Equipment named in PEEPs exists, is in place and is in date, including sheets fitted under mattresses
• The grab sheet at the panel and in the night office matches the current PEEPs
• Night-time staffing has been tested against the most dependent compartment and the result recorded
• Drill records show at least two drills in the last twelve months, one simulating night staffing
• Agency and new staff briefings are recorded
• Staff and regular visitors with disabilities have PEEPs

Common mistakes

• One generic sentence in the fire risk assessment standing in for thirty individual plans
• PEEPs that say evacuate to the assembly point in a building designed for horizontal evacuation
• Plans written for day staffing that have never been tested against the night rota
• Equipment named in the plan that is not fitted, not serviced or not where the plan says
• Room moves and mobility changes that do not trigger a PEEP review
• Grab sheets at the panel that are several room moves out of date
• Drills that test the alarm and the panel but never move a resident or use a sheet
• Agency staff starting a night shift without a fire briefing

What good looks like on inspection day

Whether the visitor is a fire safety officer or a CQC inspector, the evidence they want is the same. A fire risk assessment by a competent person, reviewed within the last year, with the significant findings actioned. An evacuation strategy that staff can explain. A PEEP for every resident that matches the room list and the strategy, with the number of staff and the equipment stated. A grab sheet that matches. Drill records with times, observations and actions, including a night-staffing scenario. Training records showing fire training at induction and refreshed at least annually, with practical drill participation. Maintenance records for the alarm, emergency lighting, extinguishers and fire doors.

Then they will ask a member of staff, ideally the newest or an agency worker, to explain what they would do if the alarm sounded now. If the answer matches the documents, that is inspection-ready evidence. If the folder is perfect and the care worker looks blank, the folder does not count. The homes that do well here are the ones where fire safety is treated as part of care, rehearsed by the whole team, and recorded in the same place as everything else about the resident. If you would like to see how PEEPs, drills and fire audits look when they are held in one system with the care records, book a demo and we will walk you through it.

Final conclusion

A PEEP is the first risk assessment you write for a new resident and the one most likely to be tested by events rather than by inspectors. Get the building's evacuation strategy clear, assess everyone on admission, write one plan per person with the compartment, the staff, the equipment and the behaviour that matters, and then test it honestly against the night rota. Review it on room moves and mobility changes, drill it with real residents where safe, brief agency staff before they start, and keep the grab sheet current. Do that and the fire folder stops being a compliance exercise and becomes the thing that gets people out.

Frequently asked

Is a PEEP a legal requirement in a care home?

In effect, yes. The Regulatory Reform (Fire Safety) Order 2005 requires the responsible person to have evacuation procedures that work for everyone on the premises, and government guidance for residential care premises expects an individual plan for anyone who needs help. Fire and rescue authorities and CQC both ask to see them.

How often should a PEEP be reviewed?

At least annually alongside the fire risk assessment, and many homes use six months. More important are the triggers: review straight away after a room move, a change in mobility, new sedating medication, a change in night staffing or after any drill that tested the plan.

Do agency staff need to see PEEPs?

Yes, before the shift starts. A short fire briefing covering the panel, the compartments, the grab sheet and the equipment should be given and recorded on their first shift. If agency staff have limited system access, the PEEPs and grab sheet must be inside that access.

What is progressive horizontal evacuation?

It is the strategy most purpose-built care homes use. The floor is divided into fire compartments, and residents in the affected compartment are moved through fire doors into the next compartment rather than out of the building. Full evacuation only happens if the fire spreads, and every PEEP must describe the horizontal move first.

What should a PEEP include for a resident with dementia?

Whether they will hear and recognise the alarm, whether they will follow staff instructions, how they move at night, the number of staff needed, the equipment used and any behaviour to expect, such as hiding or refusing. It should name the approach that works for that person and the point at which staff hand over to the fire service.

How many fire drills should a care home do each year?

Government guidance for residential care premises expects drills at least annually and most homes do two or more, covering different shifts. At least one drill should simulate night-time staffing, because that is the scenario most likely to fail. Record the time taken, what was observed and what changed as a result.

Who is the responsible person for fire safety in a care home?

Under the Fire Safety Order it is the person with control of the premises, which is usually the provider, with the registered manager carrying it out day to day. The responsible person must ensure the fire risk assessment, the evacuation procedures, the PEEPs and staff training are in place. The duty cannot be delegated away by putting it in a job description.

Sources

• Regulatory Reform (Fire Safety) Order 2005
• GOV.UK: Fire safety risk assessment: residential care premises
• Fire Safety Act 2021
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulations 12 and 15
• CQC: Right support, right care, right culture
• National Fire Chiefs Council: guidance on evacuation in specialised housing and care premises