Fire safety policy

1 Introduction

The regulatory reform (fire safety) order 2005 (RRO) sets out in detail the roles and responsibilities for those charged with fire safety management in any organisation. The order is enforced by the local fire authority and failure to comply with any aspect of the Order can result in significant fines, enforcement action or custodial sentences.

The NHS has issued specific guidance related to healthcare premises’ fire code, fire safety in the NHS, health technical memorandum (HTM) 05-01.

Managing healthcare fire safety’ and supporting documents to this are included in HTM 05-02 and 05-03.The guidance in these documents states that NHS organisations should include a carefully prepared programme for dealing with fire prevention, firefighting, and moving patients and building occupants to a place of safety in an emergency. The programme should include the implementation of precautionary measures to prevent the occurrence of fire, and provisions for dealing with outbreaks of fire.

Policies should also include how instruction and training will be provided to ensure that every member of staff has a clear understanding of their role in fire safety.

An effective fire safety management system should ensure that all staff understand their roles and responsibilities in managing fire safety and have the knowledge and skills to deal with any fire related incidents.

2 Purpose

The purpose of this policy is to describe the arrangements which the trust has put in place to comply with its responsibilities under the RRO, the NHS suite of guidance and to ensure that fire safety is managed on a risk basis. This includes but is not limited to; describing the arrangements for fire safety at the trust, describing the roles and responsibilities of staff and the process for ensuring that fire risk assessments are carried out for all premises which are under the control of the trust with the aim of ensuring the personal safety of staff, patients and visitors and protection of the trust’s buildings and assets.

3 Scope

This policy applies to all trust staff and other persons who carry out activities on the trust’s premises. Where trust staff work in premises which are in the control of other organisations, this policy and the policy of the other organisation must be followed. Staff from other organisations who work in premises under the trusts control must comply with this policy. This policy sets out:

the arrangements at the trust for managing the risks from fire and identifying accountability and responsibilities of staff
the precautions to be taken for reducing the risks from fire and for preventing fires
the training requirements for fire safety including action to be taken in the event of a fire and for building evacuation
the measures for means of escape
the process for alerting persons who need to take action in the event of a fire alarm, including the requirements for fire detection, fire alarm systems and the requirements for emergency lighting and fire-fighting equipment
the process for assessing the fire integrity and other fire protection requirements of buildings

This policy aims to provide specific guidance on fire safety whilst signposting staff to other policies which are relevant to fire safety. This policy must be read in conjunction with other relevant trust policies.

4 Responsibilities, accountabilities and duties

The trust’s management have a duty, so far as is reasonably practicable; to ensure that there is a regime in place for fire safety.

4.1 The chief executive

The chief executive has overall accountability for fire safety which includes ensuring that the trust’s legal duties are met and adequate resources are made available to meet its obligations for fire safety. Whilst the responsibility for managing fire safety is delegated to other officers in the trust, the accountability remains with the chief executive.

The chief executive should appoint a board level director to act on their behalf to ensure that adequate structures are in place to ensure, so far as is reasonably practicable, to ensure that fire safety is effectively managed.

4.2 Executive board director accountable for fire safety, director of finance

The director of finance is the executive director who is appointed to champion fire safety at board level within the trust. Duties of the director of finance include:

appoint a fire safety manager to advise on the management of fire safety and on all matters related to fire safety
advise the chief executive in the event of a serious fire incident

4.3 Fire safety manager, head of estates and facilities

The trust’s head of estates and facilities is appointed to carry out this role. The key requirement of this role is to ensure that structures are in place to ensure that as far as is reasonably practicable, arrangements are in place to comply with legislation and guidance and reduce the risks from fire. Duties of the head of estates and facilities include:

to keep abreast of fire safety legislation and guidance
to develop a fire safety policy
to monitor the effectiveness of the trusts fire risk assessment programme
to put in place measures for fire safety risks particular to the trust, including fire safety requirements for disabled staff and patients

4.4 Fire safety advisor

The fire safety advisor is the competent person employed by the trust to advise on all fire safety matters in relation to the RRO.

The fire safety advisor should provide advice and assistance to trust staff on all fire related matters and for monitoring of fire safety policies and procedures within the trust. Duties include but are not limited to:

carrying out fire risk assessments to identify areas of concern and noncompliance
advising and assisting in the interpretation and application of fire safety legislation and NHS guidance related to healthcare premises, which should include, but not be limited to:
- ensure that premises are provided with appropriate means of escape and these can be used at all times
- ensure that appropriate firefighting equipment is provided in premises
- check that staff are completing daily fire inspections
- ensure that premises have arrangements for action to be taken in the event of fire on the premises, including taking measures relating to the instruction and training of employees; and taking measures to mitigate the effects of the fire
- liaison with trust staff, estates managers and architects in the design, construction of new buildings and alterations to existing buildings in consultation with building control and the Fire authority
- liaison with the managers in preparing and participating in fire evacuation drills
- arranging for inspection and servicing of all firefighting equipment
- ensuring all staff are aware of the incident reporting procedure and encourage incident reporting for fire related incidents
- to carry investigations of fire related incidents and provide a report with recommendations
- to respond to any fire incident during normal working hours and take a lead role of the incident until the fire service arrives
- to report fire incidents in accordance with current guidance
- liaison with enforcing authorities
- providing fire safety information for the annual health and safety report
- development of an effective training programme
- develop procedures for co-operation between other organisations where two or more share premises

When the fire safety advisor is not available, the trusts Safety team will deputise for any urgent fire safety matters.

4.5 Managers, heads of departments, persons in charge of a ward or department

Managers, heads of departments, persons in charge of a ward or department have the delegated responsibility for the implementation and management of the fire policy and strategy in areas of their control. These responsibilities include and are not limited to:

liaising with other organisations in multi occupied premises through cooperation and co-ordination with other responsible persons
ensuring that staff in their areas of control are provided with a local induction and complete a fire induction check sheet which must be retained in the fire manual
conducting evacuation drills at intervals as recommended by the fire safety advisor or Safety team. All fire drills must be recorded in the fire manual
monitoring that the daily fire safety inspection reports are completed and keeping the records in all sections of the fire manual up to date
ensuring that all staff under their control receive fire training and are trained in the hazards related to the storage and use of oxygen. Where a piped oxygen system is in use, persons in charge must be familiar with the procedure for isolating the oxygen supply
co-ordinating and directing staff actions in the event of a fire incident, which may include co-ordinating with the fire brigade and accounting for all persons who were present in the building prior to the incident
ensuring that persons in areas of their control who have a mobility impairment or other disability which may affect either their awareness of a fire situation or affect their ability to evacuate have an individual personal emergency evacuation plan (PEEP) completed
advising the fire safety advisor or Safety team of fire incidents or false alarms and report through the incident reporting system.
assisting with investigations into fire related incidents
assisting the trust’s fire safety advisor or safety team or fire service officers in conducting fire risk assessments and taking action to remedy all significant findings that have been identified during the audit process.
ensuring that staff in areas of their control are aware of the location of all fire-fighting equipment
ensuring that the means of escape are kept clear of obstructions
ensuring that in the event of a fire system activation or discovery of a fire, that the procedures set out in section 5 of this policy are followed and in particular, familiarise themselves with the operation of the local fire alarm panels
ensuring that all staff on duty have keys at on their person at all times to activate manual call points, to release locked doors on fire escape routes and to access fire extinguishers which are kept securely locked

When the fire alarm system is activated a senior person on duty (known as ‘the nominated senior person’) will take charge and act as a fire marshal to co-ordinate and direct others. Additional training is available to those staff who may act as a nominated senior person.

4.6 Local fire services

Local fire services are the enforcing authority for the RRO and will audit the trust’s premises to ensure compliance with RRO on a risk-based approach.

4.7 Switchboard and reception staff at the Tickhill road site

Switchboard and reception staff have the delegated responsibility for carrying out the procedures set out in part 5.4 of this policy.

4.8 All staff

All staff have duties and responsibilities in respect of the RRO and under the Health and Safety at Work Act 1974 to reduce the risk from fires. Duties of staff include and are not limited to:

complying with trust fire policies and procedures
familiarising themselves with the fire safety arrangements for areas where they work including temporary work locations
ensuring that a fire induction check sheet is completed which must be retained in the rear of the fire manual
completing the daily fire safety inspection reports when requested to do so
ensuring that fire safety training is carried out as required
taking an active part in any fire evacuation drills
assisting the trust’s fire safety advisor or fire service officers in conducting fire risk assessments
where oxygen is stored, or in use, ensure that suitable and sufficient training in the precautions for its safe use and storage is carried out prior to use Where a piped oxygen system is in use, persons in charge must be familiar with the procedure for isolating the oxygen supply
familiarising themselves of the location and operation of all fire-fighting equipment
ensuring that the means of escape are kept clear of obstructions
ensuring that in the event of a fire system activation or discovery of a fire, that the procedures set out in section 5 of this policy are followed and, familiarise themselves with the operation of the local fire alarm panels
ensuring that when on duty, keys are kept for activating manual call points, to release locked doors on fire escape routes and to access fire extinguishers which are kept securely locked
inspecting electrical equipment before each use in accordance with the trusts electrical systems policy, which includes, where practicable, switching off appliances when not in use
ensuring that cooking appliances are not left unattended and that they are regularly cleaned to prevent build-up of food debris, and grease

5 Procedure or implementation

5.1 Action to be taken on activation of the fire alarm system

If the fire alarm system is activated in the building, the following action must be taken:

proceed to the fire alarm panel to ascertain where the alarm has been activated. Communication and co-ordination between staff is essential. Two members of staff are to proceed to the affected area to determine the cause of the activation
if the cause of the activation is not a fire or a fire which has been extinguished, dependant on the location of the building, the following action must be taken
for the Tickhill Road or Woodfield park sites dial the emergency extension number 22222 and give the switchboard operator the exact location and cause of the fire system activation and state that the fire service is not required.
for sites with an automatic system that alerts an alarm monitoring centre contact the fire alarm monitoring centre and state that that the fire service is not required
for all other sites or buildings, the fire alarm system may be silenced once the cause of the activation has been determined. The fire alarm system may be reset on instruction from estates
estates may need to attend to reset equipment which has been tripped by the activation of the fire alarm

If the cause of the activation is a fire and the fire is not under control and the alarm system has not activated, staff must activate the fire alarm system by breaking the glass or operating a key in the nearest call point. The following action must then be taken.

one member of staff must be directed to call the fire brigade by dialling 999. For the Tickhill Road or Woodfield Park Sites contact the switchboard operator on extension number 22222 and request them to contact the fire service and alert other persons
if a fire can be fought without risk to yourself and others, the fire may be tackled with an extinguisher. If the fire is not tackled, the doors to the room affected by the fire must be left closed
other staff must move patients, themselves, and others away from the location of the fire; this may be by progressive horizontal evacuation or complete evacuation of the building. Ensure all persons are accounted for. Ensure that the latest ward bed state or department register record is available and check that all persons are accounted for. If patient movement has been rapid, two members of staff must carry out a sweep of the ward, checking all rooms, without putting themselves at undue risk
on the arrival of the fire service the senior person in charge must inform the fire service officer in charge of the following:
- location and type of fire
- Whether or not all persons have been accounted for
- If the area has been searched
- any hazards which are present in the location of the fire, for example, piped oxygen or cylinders, flammable liquids, asbestos if known, isolation points gas, electricity, and others etc
in all cases where the fire alarm system has been activated, complete an incident report which identifies the root cause of the fire alarm activation and the procedures that were taken. Estates may need to attend to reset equipment which has been tripped by the activation of the fire alarm. Further advice is on tackling fires and progressive horizontal evacuation is available from the fire safety advisor and will be provided in face-to-face training sessions

5.2 Action to be taken on hearing an intermittent fire alarm sounder

Some areas which are not directly affected by the fire or fire alarm may have an audible intermittent fire alarm signal sounding or a flashing beacon. The purpose of this is to alert staff that the fire alarm system has been activated in a nearby area who may need support. Staff should attend the nearest fire alarm panel, determine the location of the fire, and should send any available staff to attend the affected area and offer assistance. Staff should be aware of an adjacent incident and be ready for the possibility of an evacuation into their area should this be necessary.

5.3 Fire evacuation

Evacuation of a fire compartment or building or should be a rapid disciplined movement of people exiting the fire area.

In the event of a fire, it may be appropriate and cause less harm to patients to move patients away from the area of the fire to a place of safety within the building which is unaffected by the fire. To do this safely there should be a minimum of two sets of fire doors between the fire and the place of safety and a clear route to the nearest fire exit.

Evacuation time will be extended if non-ambulant persons who require assistance for evacuation are present. Therefore, arrangements must be in place for adequate staffing levels, agreed procedures and any equipment required to evacuate non ambulant persons. Where evacuation equipment is provided, all staff including bank and agency staff must undergo suitable, sufficient, and regular training, to ensure safe use.

Patient admittance procedure which incorporates the moving and handling assessment refers to PEEP (personal emergency evacuation plan), patient care plans should identify any physical disabilities or behavioural difficulties that would impact on the service user being evacuated in the event of a fire. Specialist provision should be made for those identified as bariatric with support from the Safety team and the Moving and Handling team. Ward managers must ensure that any equipment or procedures that are in place are practiced on during every fire evacuation exercise.

The trust does not have any evacuation lifts installed within any of its premises; therefore, lifts provided in buildings must not be used for evacuation purposes in the event of a fire.

5.3.1 Fire evacuation exercises

The effectiveness of procedures for dealing with an outbreak of fire and testing the effectiveness of training be should be tested by conducting fire evacuation exercises or drills.

Managers or heads of departments, with the assistance of the Safety team, are responsible for scheduling and conducting these in their areas of responsibility. These should be recorded in the Fire Manual and should identify the staff who took part

Inpatient areas should carry out a 6-monthly exercise or drill, these may consist of a talk through exercise or drill, which can be undertaken during a team meeting, however, a full exercise or drill must be carried out on a minimum 12-month basis. Other areas should carry out a full exercise on an annual basis

5.4 Action to be taken by the switchboard or receptionist at the Tickhill
Road or Woodfield park site

On activation of the fire alarm system at the site into a fire condition the switchboard or receptionist at the Tickhill Road or Woodfield park site shall respond as below:

if no immediate information is received from the affected area on the emergency telephone, an attempt to contact the affected area should be made to ascertain if the activation is a false alarm or fire situation. If no contact can be made with the affected area and no information is received from the affected area on the emergency telephone within 2 minutes, the fire service shall be contacted and requested to attend
if the cause of the activation is confirmed as not a fire or a fire which has been extinguished and where the fire service is not in attendance the alarm may be silenced at the switchboard fire panel and subject to instruction from the person in charge of the area, manager on call, or from estates or a member of the Safety team, the fire alarm system may be reset If the cause of the activation is confirmed as a fire, during normal working hours, inform a member of the Safety team or if out of hours contact the duty director. contact estates to attend the incident. The fire service may wish to see the fire alarm system to determine which detector(s) has activated before the system is reset. When the fire service has given permission to reset the system, it may be reset by the switchboard.
note that some buildings have a local panel which may need to be reset by the person in charge of the area, by estates or by a member of the Safety team before the fire panel in switchboard can be reset

In all cases where the fire alarm system has been activated, complete an incident report. Estates may need to attend to reset equipment which has been tripped by the activation of the fire alarm.

5.5 Naked flames or candles

The use of candles, matches, cigarette lighters or any naked flame is prohibited for use within trust buildings and vehicles.

5.6 Prevention of arson and smoke free policy

Arson is a cause of several fires at the trust. Fires started deliberately can be particularly dangerous because they generally develop much faster and may be intentionally started in escape routes. The trust operates a smoke free policy and with the exception of St Johns Hospice, smoking is not permitted in any indoor or outdoor areas across the trust. Although smoking is allowed outside the boundaries of trust sites, smoking and the use of naked flames to light cigarettes presents a high risk of fire and these is a risk that patients will be use lighters to set fires within their rooms. Measures to prevent or reduce the effects of arson include

maintaining good housekeeping standards, both internally and externally. Unattended combustible items should not be left or stored in, corridors or unattended areas. These are an easy target for would be fire raisers
ensure that combustible waste is placed in designated waste bins and kept locked in their designated areas
designated high risk areas will be provided with fire retardant bed covers, such as sleep knit covers
ensure that the building is secure from intruders and report any suspicious persons or activities
fit secure metal letter boxes or fire resisting types on the insides of letter flaps to contain any burning materials that may be pushed through
in wards areas, bins must be either metallic or fire retardant and fitted with self closing lids

5.7 Cooking

It is the duty of all members of staff to remain in attendance whilst using cooking or toasting appliances. The fire door to the area containing the cooking or toasting appliances must not be wedged open.

5.8 Automatic fire doors

Where automatic doors are installed these will close automatically when the fire alarm system is activated. In some areas these doors are held open by magnetic devices, which hold the doors open until a fire alarm is activated. When the fire alarm is activated the magnetic device releases and the doors close. Automatic fire doors are safety devices and must never be wedged open or blocked.

5.9 Access for emergency vehicles

Vehicle parking and vehicle waiting restrictions must be observed in order to leave free access for emergency vehicles in accordance with the trust parking policy.

5.10 Portable electrical equipment

Any electrical equipment must be selected, used, and maintained in accordance with the trust’s Electrical systems policy.

where practicable electrical appliances should be switched off when not in use
fan type heaters and convector heaters are not permitted on trust premises. Oil filled convector heaters are allowed in exceptional circumstances
the charging of E-cigarettes is not permitted
extension leads must not be overloaded beyond their design capacity. Extension leads must not be plugged into other extension leads (daisy chaining) in your place of work. Coiled drum type extension leads are not permitted on trust premises
all seasonal decorations must be inherently fire or flame retardant. All decorative lights must have low voltage lights (24 volts or less) and be inspected by staff for damage before each use

Refer to the trust’s electrical systems policy for further guidance.

5.11 Personal emergency evacuation plan (PEEP)

A personal emergency evacuation plan may need to be prepared for any person who has mobility, sight, hearing or cognitive impairments, pregnancy or other circumstances that would impede evacuation in emergencies, and it is the responsibility of the person in charge of the area to complete a risk assessment with the individual and create a PEEP. When the needs of service user or staff change then the manager should review the PEEP assessment to reflect these changes.

5.12 Fire risk assessment reporting process

Significant findings found during the fire risk assessment will be provided in writing on a fire risk assessment proforma to the manager of the area at the end of the inspection and a copy will also be sent to the assistant director or senior manager with responsibility for the area.

All significant findings should either have an action plan in place or be completed within 28 days from the date of the fire risk assessment.

After 21 days from the date of assessment the manager will be requested to send a progress report.

If after 28 days from the date of the assessment a response has not been received the findings will be sent to the assistant director or senior manager with responsibility for the area for action.

Managers who report defects identified from the significant findings through estates must continue to monitor these defects until their completion.

Where trust services occupy areas, which are not in the control of the trust, managers should request a copy of the fire risk assessment from the organisation which is in control of the building.

For significant findings in the common areas of the premises which are not under trust control the trust manager must report these findings to the building owner or landlord.

5.13 Maintenance and testing of fire safety equipment

The head of estates and facilities is responsible for planned preventative maintenance and repairs to all to fire safety installations in premises controlled by the trust. Details of the testing regime are contained in appendix C.
Any defects in fire-fighting equipment, fire doors, exit doors or fire alarms and emergency exit signs, etc., must be reported to estates.
Fire fighting equipment is inspected and serviced every 12 months. however, any equipment used, missing, or found to be defective must be reported immediately.
Fire equipment availability and serviceability should be checked and signed for on the frequencies indicated in the fire manual.

5.14 Adaptations and alterations to buildings

Any adaption or alteration to a building must be approved by the Safety team via the form ’building development fire safety checklist’ which is available in the appendices. Unapproved alterations may result in the fire strategy for the building being severely compromised.

6 Training implications

All trust staff should be made aware of the key points within this policy, and any local procedures that may accompany this policy. Awareness campaigns will be communicated through the trust intranet, trust publications, departmental team brief, organised training days (including manual handling) and strategically placed posters and information leaflets.

Where appropriate, either by legislative requirement or as identified in a risk assessment, information training and any associated equipment will be provided by the trust. This should take place at local induction to a service.

6.1 Fire training

The Learning and Development team are responsible for programming both induction and on-going of fire safety training sessions and are responsible for the recording of staff fire training records on the ESR system. The trust’s Safety team facilitates fire training, and this is delivered at various locations within the trust. Managers are responsible for ensuring that that all staff under their control, including temporary, bank, and agency staff are compliant with the trusts fire training requirements. Managers should monitor ESR to ensure their staff have carried out periodic fire training.

6.2 Induction fire training

All new trust employees undertake a corporate induction course when they first join the trust. The corporate fire induction training is given during this course.

6.3 Departmental fire induction training

Managers and heads of departments will undertake this training to all new, temporary, or permanent trust staff immediately on joining the department. This training should cover all the points identified on the departmental fire induction check sheet which is available in appendix A. Staff must sign each section of the departmental fire induction check sheet on completion of this training. The completed forms should be kept in the fire manual.

6.4 Refresher fire training

Refresher training can be a mix of face to face and e-learning. All staff must complete fire training on an annual basis. E-learning and face to face training should be completed on an alternating basis. Training on the use of fire- fighting equipment may be provided to nursing staff as part of the face-to-face training.

7 Monitoring arrangements

7.1 All reported fire related incidents, including near misses and actual fires

How: Investigated by the fire safety advisor and any identified preventative action is taken.
Who: Fire safety advisor and relevant managers.
Reported to: Health, safety and security forum on a bimonthly basis.
Frequency: Each Incident.

7.2 All reported fire related incidents, including near misses and actual fires

How: Summary report.
Who: Fire Safety Advisor or Health and Safety team.
Reported to: Health, safety and security forum on a bimonthly basis.
Frequency: Bi-monthly.

7.3 All reported fire related incidents, including near misses and actual fires

How: Summary report.
Who: Fire Safety Advisor or Health and Safety team.
Reported to: Quality Committee.
Frequency: Bi-annually.

7.4 Compliance with the regulatory reform (Fire Safety) Order 2005 and the trust fire policy

How: Fire safety advisor or Health and Safety team will complete an inspection of all trust premises, with the manager of the area.
Who: Fire Safety Advisor, Health and Safety team and area manager.
Reported to: Health, safety and security forum.
Frequency: Bi-annually.

7.5 Compliance with the regulatory reform (Fire Safety) Order 2005 and the trust fire policy

How: Summary as part of the health safety, security and fire report.
Who: Fire Safety Advisor and Health and Safety team.
Reported to: Quality Committee.
Frequency: Bi-annually.

7.6 Compliance with the training and update requirements for fire safety

How: Attendance records analysis.
Who: Fire safety advisor, head of learning and development.
Reported to: Health, safety and security forum.
Frequency: Bi-annually.

7.7 Compliance with the training and update requirements for fire safety

How: Summary as part of the health safety, security and fire report.
Who: Fire Safety Advisor or Health and Safety team.
Reported to: Quality committee.
Frequency: Bi-annually.

7.8 Completion of fire manuals

How: Audit by Fire Safety Advisor and Safety team members annually or unannounced visit.
Who: Fire Safety Advisor and Health and Safety Team.
Reported to: Health, safety and security forum.
Frequency: Bi-annually.

7.9 Completion of fire manuals

How: Summary as part of the health safety, security and fire report.
Who: Fire Safety Advisor and Health and Safety team.
Reported to: Quality committee.
Frequency: Bi-annually.

8 Equality impact assessment screening

The completed equality impact assessment for this policy has been published on this policy’s webpage on the trust’s website.

Link to policy equality impact assessment: Fire safety policy EIA.

8.1 Privacy, dignity and respect

The NHS constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no effects on the provision of privacy and dignity or respect within this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

10 References

The Regulatory Reform (Fire Safety) Order 2005
The Health and Safety at Work Act 1974
The Management of Health and Safety at Work Regulations 1999
The Building Regulations 2010
Fire code, fire safety in the NHS. Health Technical Memorandum (HTM) 05 series (Department of Health)

11 Appendices

11.1 Appendix A Departmental fire induction check sheet

Appendix A Departmental fire induction check sheet

11.2 Appendix B Alterations adaptations to buildings

Appendix B Alterations adaptations to buildings

11.3 Appendix C Fire alarm system testing and maintenance

The British Standard for Fire Alarm Systems (B.S 5839) was revised in 2017. The maintenance programme below is broadly based on the recommendations contained in the standard. The frequency of testing has been adjusted based on risk and the available resource to carry out the testing.

11.3.1 Daily inspection of the fire alarm panel

All fire alarm systems should have a daily inspection of the panel. Any faults or anomalies should be reported to estates. The daily panel check should be recorded by the user as part of the daily fire check.

11.3.2 Weekly alarm test

A weekly test of the alarm system should be carried out at all areas which are deemed high risk. This should be carried out by the user at most non-inpatient sites. On larger sites the alarm system is tested by estates. The larger sites are:

Tickhill Road and Woodfield Park
Great Oaks
Woodlands
Swallownest Court
Emerald Lodge

The weekly test should be accrued out at approximately the same time each week and occupants should report any instance of poor audibility of the fire alarm signal. Ancillary devices such door release systems must be observed and recorded as functioning correctly as part of the test. The tests should be recorded in the fire manual. The test frequency may be extended to once a month for areas such as ground floor office buildings which may be designed as a relatively lower risk.

It is preferable to test a different call point on every occasion; the duration of the test should be around 5 seconds.

11.3.4 Inspection and testing

This is currently carried out by a competent fire servicing organisation on a minimum of a six-monthly basis in accordance with B.S 5839 (2017).

Document control

Version: 8.1.
Unique reference number: 210.
Approved by: Corporate policies approval group
Date approved: 11 January 2024.
Name of originator or author: Fire safety advisor or head of estates and facilities.
Name of responsible individual: Estates and facilities sub committee
Date issued: 12 January 2024.
Review date: July 2024.
Target audience: All staff employed by the trust, all staff from other organisations and contractors working on trust premises.

Page last reviewed: April 26, 2024
Next review due: April 26, 2025

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