Fire safety policy

1 Introduction

The Regulatory Reform (Fire Safety) Order 2005 (FSO) is the primary legislation and requires general fire precaution duties to be taken by employers including but not limited to:

a general duty to ensure, so far as reasonably practicable, the safety of employees in all aspects of fire provision
a general duty in relation to non-employees to take such fire precautions, as may reasonably be required in the circumstances to ensure the premiss are safe
a duty to carry out fire risk assessments (FRA)

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 health technical memorandum (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.

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 Regulatory Reform (Fire Safety) Order (2005), and the NHS health technical memorandum suite of guidance and to ensure that fire safety is managed on a risk basis. This includes but is not limited to:

the arrangements for fire safety
the roles and responsibilities of staff
the fire risk assessment process

3 Scope

To provide specific guidance on fire safety whilst signposting staff to other relevant policies. 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 under the control of other organisations, the policy of the other organisation must be followed. This policy sets out:

the arrangements for managing the risks from fire and identifying accountability and responsibilities of staff
the action to be taken on activation of the fire alarm
the precautions to be taken fire prevention and risk reduction
the training requirements

4 Responsibilities, accountabilities and duties

The trust’s management have a duty, so far as it 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 development

The trust’s head of estates and development 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 development 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 Regulatory Reform (Fire Safety) Order (2005). Duties include but not limited to:

provide advice and assistance to all trust staff on all fire related matters
monitor and review fire safety policies and procedures
carrying out fire risk assessments to identify areas of concern, and noncompliance and good practice
advising and assisting in the interpretation and application of fire safety legislation and NHS guidance
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 fire safety 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 Health and 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. All fire drills must be recorded in the fire manual. Fire safety advisor can provide assistance if required.
monitoring that the 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 where applicable are trained in the hazards related to the storage and use of piped oxygen
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 affecting their ability to evacuate are either covered by a general emergency evacuation plan (GEEP) or personal emergency evacuation plan (PEEP) to enable a safe and timely evacuation
advising the fire safety advisor 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 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
ensuring that staff on duty always have keys on their person to activate manual call points, to release locked doors on fire escape routes and to access securely locked fire extinguishers

When the fire alarm system is activated a senior person on duty 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 Regulatory Reform (Fire Safety) Order (2005) and will audit the trust’s premises to ensure compliance with the Regulatory Reform (Fire Safety) Order (2005) 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 Regulatory Reform (Fire Safety) Order (2005) 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 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

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. If safe to do so, 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, dependent 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 2222 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 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 is not under control, 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 2222 and request them to contact the fire service
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 to commence evacuation following the fire evacuation procedure for their building or area, moving away from the location of the fire and if safe to do so carry out a sweep of the area whilst moving towards a place of safety or the final exit
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 all persons have been accounted for
- If the area has been searched
- any known hazards in the area, for example, piped oxygen or cylinders, flammable liquids and asbestos
- isolation points for utilities, plant or machinery
- estates may need to attend to reset equipment which has been tripped by the activation of the fire alarm
- complete an incident report which identifies the root cause of the fire alarm activation and the procedures that were taken
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

A progressive horizontal evacuation may be appropriate and cause less harm to patients to move them away from 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 personal emergency evacuation plan (PEEP), 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 Health and 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 should be tested by conducting fire evacuation exercises or drills.

Managers or heads of departments are responsible for scheduling and conducting these in their areas of responsibility. If required, the fire safety advisor can provide further guidance. 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 walk-through exercise or drill, which can be undertaken during a team meeting. Consideration should be given to increasing the frequency of walk-through drills to ensure all shift patterns are covered. 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 phone, 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 phone 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 detectors have 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.

6 Prevention and risk reduction

6.1 Naked flames or candles

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

6.2 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 except 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 this 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

6.3 Cooking and kitchen equipment

All using the facility and equipment have a duty to:

ensure the equipment is in good order, clean and free from food debris build-up, debris can cause a fire
kitchen equipment must only be used in the designated area, use outside the area has the potential to result in false activation of alarms
remain in attendance whilst using the kitchen equipment
make sure kitchen equipment is turned off after use
not place anything metal in microwaves or block the air vents

6.4 Fire escapes and automatic fire doors

Protected and non-protected fire escape routes will be designated in all premises owned, occupied or under control of the trust. In accordance with fire safety legislation and health technical memorandums. They provide safe routes out of the premises in the event of an emergency evacuation. Constructed to limit or prevent the spread of smoke and fire. Clearly marked to confirm direction of travel. They must remain clear and storage free. Unless agreed under the fire risk assessment process.

Where installed, these will close when the fire alarm system is activated. Automatic fire doors are safety devices and must never be wedged open or blocked.

6.5 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.

6.6 Portable electrical equipment

Any electrical equipment must be selected, used, and maintained in accordance with the trusts’ 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 fewer) and be inspected by staff for damage before each use

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

6.7 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 personal emergency evacuation plan. When the needs of service user or staff change then the manager should review the personal emergency evacuation plan assessment to reflect these changes.

6.8 Fire risk assessment (FRA) reporting process

For all buildings owned, occupied or under the control of the trust. Completion of a suitable and sufficient fire risk assessment is a legislative requirement. The findings of which are acted upon and kept up to date.

The fire risk assessment frequency is on a risk-based approach. Patient areas or higher risk areas will be annually. Office accommodation or lower risk areas will have a 3 yearly full fire risk assessment with an annual review. The review will focus on any outstanding issues from the last full fire risk assessment, critical human, and physical factors of fire safety to ensure life safety and compliance.

This meets the recommendations of health technical memorandum (HTM) 05-03. It states there is no maximum period between assessments and recommends a review period should not exceed 12 months.

A full fire risk assessment will be conducted in all areas following significant changes to the structure and, or use of a building.

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.

6.9 Information to contractors and visitors

Staff who have arranged attendance for contractors or visitors to premises owned, occupied or under the control of the trust will ensure they are informed of local fire safety arrangements.

6.10 Hot works

For all non-emergency works contractors’ risk and method statements must be approved prior to works commencing.

In all situations a permit to work must be issued by estates, prior to any works commencing.

6.11 Maintenance and testing of fire safety equipment

The head of estates is responsible for planned preventative maintenance, testing and repairs to all to fire safety installations in premises controlled by the trust.
Maintenance of all fire safety related equipment and infrastructure will be completed in line with relevant fire safety legislation, health technical memorandums, British standards and, or best practice.
Testing of all fire safety related equipment will be on a risk-based approach.
The information below provides an overview of the minimum maintenance and testing regimes undertaking within premises owned, occupied or under the control of the trust.

6.11.1 Fire detection and alarm systems

All installations will comply with relevant fire safety legislation, health technical memorandums, British standards and fire risk assessment’s recommendations based on size, complexity and use of the building.