THERE must be "total clarity" in the regulation of Scotland's care sector to avoid a repeat of the errors which led to the Rosepark tragedy, a charity for the elderly has warned.

The failure of a series of inspectors to notice fire safety breaches at Rosepark Care Home in Uddingston, near Glasgow, where 14 pensioners died in a blaze, was criticised in the findings of a fatal accident inquiry, which were published on Wednesday.

With the responsibility for regulating and inspecting care homes having passed from the Care Commission to a new body, Social Care and Social Work Improvement Scotland (SCSWIS), on April 1 this year there are calls to clarify the role of all regulatory bodies to avoid a repeat of the confusion leading up to the tragedy.

Greg McCracken, policy officer for Age Scotland, said: “The concern is that with the recent changes to the industry, there might be confusion over who has responsibility for what. Communication across the sectors is vital, especially in this transitional phase from the Care Commission to SCSWIS, not only to ensure that procedures are in place but also that there needs to be total clarity between the different authorities over who is responsible for what.”

Sheriff Principal Brian Lockhart noted that both Lanarkshire Health Board inspectors between 1992 and 2002 and, subsequently, Care Commission inspectors mistakenly believed fire safety checks were carried out by the fire brigade.

As a result a number of risk factors which ultimately caused or contributed to the tragedy -- including faulty electrical installations, open bedroom doors, and “haphazard” fire drills -- were missed.

Sheriff Principal Lockhart described the approach of the health board as “defective and conducted on the basis of a fundamental misunderstanding of the role of [Strathclyde Fire and Rescue] in the inspection of nursing homes during that period”.

Meanwhile, Care Commission inspectors “had no training in fire safety issues”.

Neither regulator realised that, at the time of the blaze on January 31 2004, fire and rescue authorities only carried out a fire safety inspection prior to a new care home opening.

After Rosepark opened in 1992, visits from fire crews were restricted to “familiarisation” tours of the premises -- not visits from fire safety inspectors.

Mr McCracken added: “In terms of this particular case, it’s very distressing to see the chapter of errors listed in this report. For relatives, hearing that the deaths were preventable must have been particularly difficult and we clearly hope the lessons have been learned.

“The experience at Rosepark is certainly not indicative of the industry as a whole, but it may be a welcome driver for other homes to review their own fire safety procedures.”

Changes to the law in 2005, now mean every care home in Scotland has an annual fire safety inspection by its regional fire and rescue authority.

However, Sheriff Principal Lockhart has also called for greater clarity among the various regulators.

In his determination, he said: “Scottish Ministers should facilitate an early opportunity to place on a formal footing the relationship among SCSWIS, the fire and rescue authorities and the Health and Safety Executive. As I have said, how they operate together in the Care Service sphere is not only desirable, but essential.”