Fire Safety Management Policy

Transcription

1 HEALTH AND SAFETY, FIRE & SECURITY POLICY Fire Safety Management Policy Who Should Read This Policy Target Audience All Inpatient Service Areas All Community Service Area Estates & Facilities Information Technology Contractors Version 1.0 February 2015

2 Ref. Contents Page 1.0 Introduction Purpose Objectives Process - Fire Safety Management Emergency Maintenance Contact Numbers Procedures connected to this policy Links to Legislation, National Standards, Policies and References Roles and Responsibilities for this policy Training Equality Impact Assessment Data Protection Act and Freedom of Information Act Monitoring policy s effectiveness Policy Details 43 Appendices 1.0 Personal Emergency Evacuation Plan (PEEP) Local Fire Safety Guidance and Fire Precautions Local Fire Emergency Plans Fire Warden Checklist Fire Door Checklist 41 Version 1.0 February

3 Explanation of terms used in this policy Compartment - A building or part of a building, comprising one or more rooms, spaces or storeys, constructed to prevent the spread of fire to or from another part of the same building, or an adjoining building. Fire Alarm - Fire detection and fire alarm system are a group of components including the control and indicating equipment which when arranged in (a) specific configuration(s) is capable of detecting and indicating a fire, and giving warning signals for appropriate action. Fire Doors - A door or shutter provided for the passage of persons, air or objects which, together with its frame and furniture as installed in a building, is intended when closed to resist the passage of fire and/or gaseous products of combustion and is capable of meeting specified performance criteria to those ends. Progressive Horizontal Evacuation - Evacuation of occupants away from a fire into a fire free compartment or sub-compartment on the same level. Local Fire Procedure - This is the document (Appendix 3) which thoroughly explains the fire safety details, actions and responsibilities for a specific area. All employees should fully read and understand their local procedure and comply with any actions documented in this procedure in the event of fire alarm activation or fire. Means of Escape - can be defined as: a structural means forming an integral part of the building whereby a person can walk away from fire to a place of safety. Fire Wardens - Fire wardens should be appointed to be the focal point for fire safety issues for local staff, where the organisation considers this necessary. They should act as the fire safety eyes and ears within their local area, but not have an enforcing role. The local fire warden reports fire safety issues to their line manager who in turn will report to their management. Fire Teams - (Inpatient areas /Hospital only) identified persons who respond on notification from the control room in order to escort the Fire & Rescue Service vehicles through various security gates. Personal Emergency Evacuation Plan - Documented procedures in place for evacuation of all staff, members of the public and anybody identified as being less able. Version 1.0 February

4 1.0 Introduction This Fire Safety Management Policy reflects the importance that the Black Country Partnership NHS Foundation Trust (the Trust) attaches to the implementation of the statutory requirements of the Regulatory Reform (Fire Safety) Order 2005 (RRFSO) and to Fire Safety Management. The Trust is committed to achieving good practice in the management of fire safety by assessing and managing fire risks to prevent harm to staff, patients and visitors and anyone else who may be affected by its activities. The instruction contained within this policy document will demonstrate that the Trust recognises fire safety is an important function and is committed to the integration of fire safety into the management of activities and facilities. 2.0 Purpose The aims and purpose of this policy are to outline the Trusts strategic aims, objectives and duties for the successful management of fire safety to secure the health, safety and welfare of service users, staff, visitors, contractors and any person who maybe affected by our activities. 3.0 Objectives The objectives of this policy is to inform staff, patients, visitors and contractors associated with the Trust of the operational procedures in place to support the overall fire policy. The main task in managing occupied buildings is to minimise the risk of fire occurring, and if a fire does occur, to prevent it escalating into a serious incident. 4.0 Process 4.1 Managing Fire Safety Precautions: The Trust is committed to managing fire precautions and fire risks through processes of risk assessment and risk control measures in respect to all facilities, which it owns or leases. The Trust will: a) Provide appropriate Safe Means of Escape in the case of fire and ensure all the means of escape are kept free from obstruction at all times; b) Provide and maintain in working order the fire alarm systems; c) Provide and maintain in working order all fire extinguishing appliances, and equipment and facilities that are provided for the use by the Fire and Rescue Service; d) In the event of a fire, to take all reasonable practical steps to ensure the safety of persons (including visitors) on Trust property who are at risk from fire on the premises, from death or injury in the event of a fire or associated explosion. e) Seek to reduce fire incidents by: I. Minimising the potential for fire to occur and disrupt the operational function of Trust services and cause damage to property and the environment; II. Minimise the potential for unwanted fire alarms to occur, which disrupt work and place an undue burden on the Fire and Rescue Service; III. Provide appropriate instructions, information and/or training for all persons, including contractors and temporary staff as necessary, on the actions to be taken in the event of fire; Version 1.0 February

5 IV. Provide relevant Duty Holders with general Fire Risk Assessments, Local/Departmental Fire Emergency Action Plans stating the precautions to be observed and steps to be taken to protect people and property; V. Ensure measures, that are commensurate with the risks and significance of consequential losses, are taken to protect buildings, installations and equipment from fire with an emphasis on business continuity and containing and preventing the spread of fire Testing Inspection and Maintenance: The Head of Estate & Facilities will implement an appropriate programme of planned testing, inspection and maintenance of facility support systems in accordance with relevant statutory requirements, guidance and best practice to provide assurances that fire protection systems and equipment will function when needed. Upon installation, all protection systems will be inspected and acceptance tested by a competent person before being put into operation. All fire protection systems and equipment will be inspected and recorded as required by statutory requirements, with follow-up corrective actions recorded and tracked for completion; this is the responsibility of the appropriate facilities manager and will be auditable in a maintenance log Fire Risk Assessments: As required by the Regulatory Reform (Fire Safety) Order 2005 every building/ department and/or area shall be covered under a specific fire risk assessment. Fire Risk Assessments and Audits will focus primarily on the condition and adequacy of the building s fire safety provision, firefighting equipment; persons at risk and facilities. The Audit will look at general departmental fire safety management and training requirements and will be carried out in a way which takes account of the size of the department and complexity of its activities and premise which it occupies. Fire risk assessments will be undertaken by either the Trusts Fire Safety Advisor or a suitable qualified Authorising Engineer (AE) or Appointed Person (AP). Risk assessments undertaken must be completed using the Trust s approved fire risk assessment documentation. The fire risk assessment will be reviewed on at least an annual basis or in the event of any structural changes or change of use of the building / area and this review must be documented. All managers must ensure all persons who may be affected by its activities understands the nature of the arrangements for fire safety management as outlined in the Fire Risk Assessment and Emergency Plans relevant to the buildings occupied by the department. 4.2 Departmental Fire Responsibilities Health and Safety All Employees, Visitors: The attention of all staff is drawn to their legal responsibilities under the RRFSO: Article 23 and the Health & Safety at Work Act (Section 7) (HSWA) These statutory regulations require all employees to take reasonable care of themselves and all others who may be affected by their acts and omissions, and to comply with the Trust and Departmental policies and arrangements regarding fire precautions and general fire safety. Version 1.0 February

6 The attention of all staff and visitors is drawn to their legal responsibility, under the RRFSO: Article 23 and the HSWA: Section 8, not to interfere with or misuse anything, whether appliances, systems, building elements, or systems of work provided by the Trust in the interests of fire safety Reacting to Fire Alarms: All members of staff and other occupants are required to comply with the fire safety instructions approved by the Trust in particular, In the event of a fire alarm sounding in any Trust occupied premises all occupants are required to diligently evacuate the building and may only reenter upon the instructions of the Fire Safety Advisor (or designated fire safety representative), or a member of the Fire and Rescue Service Evacuation Procedures: Depending on the type of property and the fire safety features incorporated into the building, there are two types of evacuation procedure in the event of a fire, these are: Full Evacuation - All occupants SHALL evacuate the building to an external designated place of safety. Full evacuations are applicable to all NON Inpatient buildings e.g. offices, community based locations, outpatient areas and consultation suites etc. Progressive Horizontal Evacuation - Applicable to all Inpatient residential facilities. All occupants in a fire zone where the alarm is ringing continually SHALL move progressively horizontally and vertically (if appropriate) through a series of fire doors to an adjacent fire compartment away from the fire and ultimately to an external place of safety. (Refer to appendix 2 & 3) Local Fire Induction Training (staff including temporary staff employed by the Department): The Managers of Departments shall provide Local Fire Safety Induction Training as part of their local safety arrangements for permanent new and temporary staff, whether or not directly employed by the Trust. This staff training is required at the following periods or events and shall be provided as soon as reasonably practicable after starting, or changing location of work. A written record shall be kept by the Managers of Department of those persons trained: At the time when they are first employed and thereafter annually. In their being exposed to new or increased risk because of: I. being transferred to another building or given a change of responsibilities; II. the induction of new work equipment, a change in the work equipment already in use, or the introduction of new technology; III. the introduction of a new system of work or a change in the system of work already in use. Version 1.0 February

7 Local Fire Induction Training shall include: Action on raising the alarm on discovering a fire; Action on hearing the fire alarm; Action to call the Fire and Rescue Service; Type of fire appliances and how to use them; A physical walk around local escape routes; Routes to, and the location of, the building s Fire Assembly Points (including safe refuge areas); Any relevant hazards, processes or other relevant information Fire Wardens: Managers of departments shall appoint a sufficient number of staff within each building/workplace for which they have delegated responsibility to become Fire Wardens with responsibility for the co-ordination and control of the building/ workplace in the event of a fire emergency. Managers shall ensure that Fire Wardens are available on site day and night irrespective of sickness and /or leave of absence. The Fire Wardens essentially will be the Eyes and Ears within that local area but will not have an enforcing role. They will report any issues identified to their immediate departmental line manager and/or the Fire Safety Manager/Advisor. (Refer to Appendix 3 Fire Warden Checklist). The Fire Warden shall: Act as the focal point on fire safety issues for the local staff. Organise and assist in the fire safety regime within local areas. Raise issues regarding local fire safety with their line management. Assist with the coordination of the response to an incident within the immediate vicinity. Assist in roll calls following any building evacuations. Be trained to tackle fire with first aid firefighting apparatus where appropriate. To undertake monthly documented fire safety inspections of their department/ ward/ office or building in accordance with this Fire Policy Local Fire Safety and Fire Emergency Evacuation Plan: Managers of all buildings/ departments/ offices in consultation with the Trust s Fire Advisor will develop a Local Fire Safety / Emergency Evacuation Plan. A copy of this document must be located in the Fire Safety Information folder and maintained in each ward/ department and or office. The basic instructions for evacuation will be detailed on Fire Action Notices displayed within the escape routes, adjacent to the fire alarm call points. The fire emergency action plan will be based on one of the following two principles, where a full evacuation takes place immediately and where progressive horizontal evacuation is used and a full evacuation does not take place (refer to 4.2.3). The plan will be written by the Manager in consultation with the Fire Safety Advisor using the approved format at Appendix 3. Version 1.0 February

8 4.2.7 Personal Emergency Evacuation Plans (PEEP) Managers when necessary must complete a PEEP for any member of staff or inpatient who has a disability that could affect their ability to evacuate their workplace. The plan must outline the additional measures or assistance that is likely to be needed by the individual in order for them to evacuate safely with their colleagues or a member of staff. The plan should be put together by managers in consultation with the Trust Fire Advisor following the guidance contained in Appendix Evacuation Drills The effectiveness of any evacuation procedure must be tested via Fire Evacuation Drills. Managers of buildings/ departments and offices shall undertake Fire Evacuation Drills at least once every 6 months. Depending on the size and complexity of the building, the drills can include the whole building, part of the building or individual areas. Whilst the Fire Safety Advisor may not be present for each drill he/ she will provide support as necessary. Inpatient service areas: Fire drills will not take place within secure inpatient settings where the risk of absconding and risk associated with specific conditions e.g. disabilities; dementia outweighs the statutory requirement for drills to take place. In place of these drills staff will take part in evacuation training and simulated evacuations as detailed in the Trusts Training Needs Analysis for fire safety training. This will ensure staff can become competent about evacuating their area. Fire drills will be performed with the minimal of disruption to service and include on occasions some scenario of a blocked exit so that staff learn to consider alternative routes and/ or role play of using staff as patients where this is relevant. It is important to record every drill in the fire safety information manual as evidence that staff training is being undertaken. 4.3 Fire Response Teams Managers of Inpatient service areas in consultation with the Trust Fire Advisor will establish fire response teams. Local site circumstances will best determine the quantity of people, and skill profile required (the Trust Fire Safety Advisor will provide onsite training of this duty).. Fire Response Teams shall be responsible for: Securing areas and confirm the causation of all fire alarm calls; Assuming control, call and brief the Local Fire and Rescue Service; Evacuating service users to a safe place; Contacting the On-Call-Director who will inform the Chief Executive; Contacting Estates to re-set the fire alarm panel Fire Response Team Leader(s) Managers of Inpatient service areas will nominate a senior manager day/night to act as the Fire Response Team Leader to ensure initial control of a fire emergency (The Trust Fire Safety Advisor will provide onsite training on this role). Version 1.0 February

9 The Fire Response Team Leader shall: Respond to confirmed fire events; Take responsibility for the direction of the fire response team; Liaise with the fire Incident Manager; Liaise with the attending Fire and Rescue Service; Instigate the Local/internal Major Incident Plan (if required) Fire Incident Manager The most senior person in charge of an area (ward/ department/ building) and present at the time that an incident occurs shall assume the role of Fire Incident Manager. The Fire Incident Manager will: Take control of the incident; Direct the local response; Ensure that the fire alarm system has been activated and staff in the area are notified of the incident; Initiate the local fire emergency plan; Determine if evacuation of building is necessary and commence the evacuation if appropriate; Liaise with the Fire Response Team and Fire Response Leader on their arrival. 4.4 Fire Fighting & Fire Fighting Equipment Firefighting is always secondary to life safety. In most Trust premises, fire extinguishing appliances comprise of portable fire extinguishers. These may be supplemented by: Hose reels; Fire blankets (e.g. in kitchens). It is only intended that staff use the appliances in order to extinguish a small fire while it is still safe to do so or to safeguard their escape route. People must not put themselves at risk and should understand the limitations of tackling fires with portable extinguishers, etc Fire Fighting Equipment: Portable fire extinguishers and fire blankets are provided to deal with the size and type of fire likely to be encountered in NHS premises. All portable fire extinguishers will be subjected to an annual safety inspection carried out by the Trust Approved Person(s) or Authorising Engineers. Managers must ensure that portable extinguishers are located in areas where they cannot be misused by service users and portable fire extinguishers remain readily available for use by staff at all times. Any deficiencies noted during User inspections are to be reported to the Estate Help Desk on Ext Version 1.0 February

10 4.5 Fire Doors & Means of Escape Nothing must be undertaken which would affect the correct function of opening or closing of a fire door or cause any obstruction to a doorway or general means of escape from a fire. Line managers and persons with responsibility of work areas are to ensure regular checks are undertaken (using the Fire Door Checklist at Appendix 4) to ensure: Fire emergency escape routes are kept clear and free from obstruction to allow free and un-hindered access/egress at all times; Fire doors are not damaged or wedged open by an un-approved device and remain fit for purpose at all times. Any deficiencies/ damages noted should be reported immediately to line managers and the Estates Help Desk on Ext 8010 during normal working hours or NORLANDS the Trust contracted maintenance provider 24hrs on (refer to Section 5 for further emergency numbers). 4.6 Fire Safety Folders The Trust Fire Safety Advisor will provide specific fire safety information and guidance pertinent to each ward, department or area. This will be provided in the form of a local fire safety information folder. The fire safety information folder must be maintained in each department by the manager or his/her designated person. The folder will contain the following information: A copy of the Trust Fire Policy; A copy of the Local Fire Action & Emergency Plan; A copy of the building / depts fire risk assessment; Monthly fire warden inspection checklist; Details of fire evacuation drills; Details of staff fire safety training; Details of all fire related incidents including causation of call point activations; Details of any maintenance works carried out in dept; Sign off sheets for fire safety visits by the Fire Advisor or other Competent Persons. The information contained within the fire safety information manual should be freely available to be reviewed by any member of staff, patient or patient s representative. 4.7 Fire Prevention Strategies General preventative measures include the following: The control of smoking and sources of ignition with all inpatient areas; Smoking restriction within confines of premises to designated areas; Good housekeeping. i.e. bedding and linen areas kept tidy; Combustible materials kept to a minimum; Waste materials stored correctly and removed on a regular basis; Routine cleaning for removal of dust and cobwebs from ledges and electrical fittings; Circulation escape routes kept clear and free from obstruction; Electrical equipment testing and disposal of defective equipment; Arson prevention by storage of materials in designated, secure areas/facilities; Version 1.0 February

11 Control of contractor work activities likely to produce excessive heat; Control of ignition sources and flammable substances/atmospheres. 4.8 Information Non employees Managers must inform non-employees, such as temporary or contract workers, of the relevant risks to them, and provide them with information about who are the nominated competent persons e.g. Fire Wardens, and about fire safety procedures for the premises. 4.9 Shared/ Leased Premises Where the Trust shares premises with another employer, each employer will be responsible for managing fire safety within their own area. The Trust will establish formal arrangements to share information about the risks, emergency procedures, staff training and individual organisational responsibilities. For the common areas of the premises (such as corridors etc.), the host employer will have the responsibility for managing fire safety. The Trust will cooperate fully with the other employer to ensure that fire safety measures are not compromised. Where no single manager has overall site responsibility, Departmental Managers will assume responsibility for the implementation of the Fire Policy and Procedures within their area of control and will ensure relevant information is shared with all stakeholders Community Premises Within the community setting, Managers and Team leaders will be responsible for the following within their Wards/Departments/Services: The implementation of Local Fire Action Plans relating to their Ward/ Department/ Service arising from fire risk assessments; Collaborating with the Fire Safety Adviser in relation to fire evacuation procedures/ drills Actions before Leasing / Renting Premises Before buildings (or any part thereof) are leased or rented; appropriate checks must be made by the Trust (the Organising Person) that appropriate systems for fire are in place and maintained: Fire alarm system; Emergency lighting; Firefighting equipment; Fire doors (current standards or older standard upgraded to meet current compliance); Fire stopping material; Plus a copy of the building/premises fire risk assessment and shared fire risk assessment of other occupiers. Prior to any building being leased by the Trust, in order to save unnecessary costs of upgrading a newly leased building, the fire safety adviser must be informed so that fire safety questions can be raised. It is advised that the fire safety adviser visits any proposed premises prior to any lease being formalised. Version 1.0 February

12 4.10 Arson Prevention Arson prevention, control and detection must form an essential element of the fight against crime in all NHS premises. This must be considered as part of the fire risk assessment. Where there is a known risk of arson from any inpatient service user, managers must clearly document this within care plans to ensure appropriate risk management of individuals. Alertness on the part of staff to suspicious actions by strangers, the securing of premises, security checks, the provision of CCTV, intruder alarms, the interlink of fire alarm systems from remote or unoccupied premises and the prompt removal and safe disposal of combustible waste will help to frustrate the activities of those who start fires deliberately. All staff are encouraged to report the presence of strangers, particularly in isolated, infrequently visited, strategically important or vulnerable locations Smoking Smoking is prohibited on all premises owned or managed by the Trust. Managers of inpatient service areas must ensure that service users do not smoke in their rooms and if necessary manage control and secure sources of ignition such as matches and lighters. In addition staff who work in premises owned/ managed by a third party should comply with the building owner/ landlord s No Smoking Policy E-Cigarettes, Batteries & Chargers (Fire Hazard) A number of incidents have been reported across the UK involving e-cigarettes that have exploded or ignited to cause a fire while recharging or in use in an oxygen rich environment. Incidents have occurred in premises and vehicles. Recharging modes included connection to a computer USB Port, car cigarette lighter and connection to a mains recharger. Recommended Safety Precautions: Outpatient/Inpatient Areas: Prevent the unsupervised re-charging of e- cigarettes in all outpatient/ inpatient areas by patients and visitors in particular within oxygen enriched environments. Inpatient Areas: Staff must identify inpatient service users who use e-cigarettes and also identify a designated safe area where supervised re-charging can be undertaken (e.g. staff office) ensuring the following precautions at all times: - Only use the batteries or chargers that come with the e-cigarettes. To prevent batteries/ chargers being mixed up, each must be clearly labelled with the patient s name. - The individual instruction for each brand of e-cigarette must be checked and followed by staff. - When the charge is complete disconnect battery and remove charger from USB port/ socket this is usually indicated by a light on the device. - Do not charge or use batteries which appear to be leaking, discoloured, rusty or deformed or otherwise appear abnormal. Version 1.0 February

13 - Store batteries and chargers in cool dry place at normal room temperature. Do not leave in hot places such as direct sunlight. - Keep away from any source of ignition and flammable objects, liquids, oxygen supply system/ cylinders, sparks and electrical equipment. - Do not immerse batteries or chargers in water or otherwise get them wet. - Do not disassemble, puncture, modify, throw, drop or cause any other unnecessary shocks to the batteries or chargers Procedures and Emergency Measures in Respect to Dangerous Substances (RRFSO: Article 12 & 15) The Head of Health and Safety, Fire and Security in consultation with managers of departments shall, where necessary provide effective and appropriate procedures to safeguard Relevant Persons from accident, incident or emergencies related to the presence of dangerous substances on Trust premises Fire Incident / Unwanted Fire Signals All fire incidents, whether genuine or false alarms must be reported immediately via Datix, the Trusts incident reporting procedure. The Fire Safety Adviser will make an initial investigation into all incidents where fires have occurred and all unwanted fire signals. The Fire Safety Advisor will manage any further investigations including root cause analysis. The Trust wishes through operational management and analysis of signal activations to reduce the amount of unwanted fire signals to as low as is reasonably practicable. There are 3 main drivers for this: Reduce staff complacency to fire alarm activations by ensuring within reason that the only activations are real; Prevent any malicious activations by service users; Reduce the burden upon West Midlands Fire & Rescue service in attending false alarms at Trust properties Information Fire & Rescue The Fire Advisor will provide information on office buildings and inpatient fire safety facilities, together with the major risks on site (e.g. bulk oxygen, gas storage etc) to the West Midlands Fire and Rescue Service. A copy of all buildings floor plans showing the location of the main risks are kept in the RED Fire Boxes by the main fire control panel of each building. The Fire Safety Advisor will request that operational fire crews from West Midlands Fire and Rescue Service carry out familiarisation visits on each inpatient site every 12 months Competent Person (Fire Maintenance Contractors) Installers and Maintainers of Fire Safety Equipment will be commissioned by the Estates Operational Management Team and/ or the Fire Safety Manager. Competent Persons must be able to demonstrate a sound knowledge and specific skills in the specialist service being provided. This may include the installation and/ or maintenance of related fire safety equipment/ services such as: Fire alarm and detection systems; Version 1.0 February

14 Portable firefighting equipment; Fire suppression systems; Fire dampers; Firefighting hydrants etc; Weekly testing of fire actuation call points Authorising Engineer (Fire) [External Specialist] As required, an Authorising Engineer (Fire) will be commissioned by the Director of Estates & Facilities to provide specialist fire safety support as deemed appropriate. Where it is deemed necessary to commission an Authorising Engineer (Fire) for a specific task, the Trust will ensure that, the appointed Authorising Engineer (Fire) is: A member of the Institution of Fire Engineers or the Association of Fire Consultants; or that these specialist organisations are contacted for further guidance and/or information. The Authorising Engineer (Fire) will be required to demonstrate competence in their particular field of expertise Fire Safety Arrangements Trust projects Management of Construction Work The Head of Estates & Facilities shall implement systems and procedures to enable the management and control of the means of escape and the risk of fire during construction works. Where construction work is to be carried out in occupied premises, the Responsible Project Manager shall ensure suitable arrangements and risk assessments are in place to establish the extent of the building s fire safety arrangements likely to be affected by the works. Where projects are notifiable under the Construction, Design and Management Regulations 2007 (CDM) the appointed CDM Co-ordinator (CDM-C) is responsible for ensuring they have all the relevant information to provide risk assessments to the principle Contractor as part of the Pretender Safety Plan. The Trust requires suitable safety control measures to remove, reduce, protect or mitigate the risk of fire and provide suitable Means of Escape and warning of Fire for the duration of the Pre-tender Safety Plan. The Principle Contractor must include in the Construction Phase Safety Plan Fire Risk Assessments and safety control measures for the work activities and procedures to be adopted on site for the duration of the project. Fire prevention and control measures implemented by the Principle Contractor in relation to his activities on Trust premises must meet or exceed the requirements set out in the HSE s and any other relevant statutory and/or Trust fire safety guidance Control of Contractors Contractors on Trust premises must be controlled by managers at all times in accordance with the Trust s Management of Contractors Policy. In particular with regard to fire safety: A Permit to Work must be in force for any Hot Work; Version 1.0 February

15 All relevant aspects of the work in progress must have been risk assessed both with regard to preventing fire and to mitigating the effects of any fire that does occur; If the work affects the continuing functions of the fire alarm and automatic detection systems, the prior approval of the Estates Manager must be obtained; Any holes or breaches made in fire resisting walls or above ceiling fire barriers must be repaired, as part of the work in progress Information & Technology (IT) Contractors In accordance with the Trust policy on Control of Contractors the IT Department will ensure that all proposed electrical works involving the breaching of walls is firstly discussed with the Estates Operational Team and that work is supported with a Method Statement, Safe Systems of work and Risk Assessments. The IT Department will also ensure that where there have been breaches to the compartmentation of walls that these breaches are sealed with fire resistant materials Young Persons Managers, where persons under the age of 18 are employed in their area, will provide a copy of their current Fire Risk Assessment to the parent/ guardian of the under 18. Version 1.0 February

16 4.21 Fire Safety Management Structure 5.0 Emergency Maintenance Contact Numbers Organisation Contact number BCPT Ext 8010 Norlands out of hours Norland Walsall RYDON out of hours Dudley Property Service New Cross Estates Ext 8999 Fire & Rescue Service (9) 999 Version 1.0 February

17 6.0 Procedures connected to this Policy There are no standard operating procedures connected to this policy. 7.0 Links to relevant Legislation Health and Safety at Work Act a.htm The Regulatory Fire Reform (Fire Safety) Order The Management of Health and Safety at Work Regulations Links to Other Key Policy/s HM Government Fire Safety Guides - HM Government has produced a series of fire safety guides in respect of the RRFSO appertaining to different types of premises. These guides assist the Responsible Person and Duty Holder(s) to comply with the requirements of the RRFSO, which are available from the following web site: Health and Safety Policy Risk Management Strategy and Procedures Policy No Smoking Policy Business Continuity Policy COSHH Policy Security Management Policy Control of Contractors 7.2 References Health and Safety at Work Act 1974 The Regulatory Fire Reform (Fire Safety) Order 2005 The Management of Health and Safety at Work Regulations 1999 The control of Substances Hazardous to Health (COSHH) 2002 Firecode Fire Safety in the NHS Managing Healthcare Fire Safety Firecode HTM 83 General Fire Precautions in Healthcare Premises Firecode HTM 82 Fire Alarm Detection Systems Firecode HTM 87 Textiles and Furniture BS Specifications for Fire Hydrants BS Code of Practice Portable Fire Fighting Equipment BS Fire Alarm Systems BS Escape Lighting Systems Version 1.0 February

18 8.0 Roles & Responsibilities Fire Safety Management Policy Title Role Responsibilities Chief Executive Executive Director of Nursing Head of Estates & Facilities Directors Accountable Officer Executive Director for Health and Safety Accountable Officer for Building Management & Maintenance Director of Trust Services The Chief Executive on behalf of the Trust Board is responsible for ensuring that current fire legislation is met and that, where appropriate, Firecode guidance is implemented in all premises owned or occupied by the Trust. The Chief Executive will ensure that appropriate fire safety policies and programmes of work are in place in order to improve and maintain fire precautions within the Trust s premises. The Executive Director of Nursing is the Trust Board nominated executive director responsible for championing all health and safety and fire safety issues at Board level. Part of this will include proposing programmes of work relating to fire safety for consideration as part of the annual capital programme and business planning. At an operational level the Fire Safety Manager is tasked with developing and managing the fire safety management system, and will be responsible for: - Ensuring that all work which has implications on fire precautions in new and existing Trust buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory fire safety legislation (including NHS Firecode). - Ensuring that all proposals, for new buildings and alterations to existing buildings, are referred to the Fire Safety Manager/Advisor before Building Control approval is sought. - Ensuring that all passive and active fire safety measures and equipment are maintained and tested in accordance with the latest relevant legislation/standards, and that comprehensive records are kept - Implementing adequate Permit to Work systems to ensure safe working by directly employed and contract building operatives; - Obtaining expert advice on fire legislation and technical advice on the application and interpretation of fire safety guidance, including DH s Firecode; - Ensuring written Fire Risk Assessments are carried out for each building and reviewed annually. - Upon receipt of the Fire Risk Assessments prioritise the contents and formulate a programme for compliance in respect of each report - Ensuring that risks identified in the fire risk assessments are included in the trust s risk register as appropriate and that such risks have an operational management plan - Ensuring that an annual Fire Safety Statement (FSS) is presented to the Board All Trust Directors of services provided within Trust owned/and or leased premises shall ensure that their managers and staff demonstrate full compliance with the contents of the Fire Policy in particular the duties of undertaking fire warden training as directed by the Head of Health and Safety Fire & Security. Version 1.0 February

19 Title Role Responsibilities The Head of Health, Safety, Fire & Security will carry out the role of Fire Safety Manager and be responsible for the day to day fire safety activities and taking the lead on all fire safety matters. Accountability for all fire safety matters will always be through the Board Level Director. Head of Health, Safety, Fire and Security Fire Safety Advisor Fire Safety Manager Fire Advisor The Fire Safety Manager will be sufficiently empowered and have access to adequate resources to enable him / her to perform their duties effectively. Responsibilities will include the following: - Ensuring that the Trust has in place a clearly defined fire safety policy and relevant supporting procedures including the day-to-day implementation of the fire safety policy and day to day arrangements for fire safety management; - Ensuring written Fire Risk Assessments are carried out by the Fire Safety Advisor and reviewed annually; - Ensuring that risks identified in the fire risk assessments are included in the trust s risk register as appropriate and that such risks have an operational management remedial plan; - Ensuring that Fire Response Teams are available and trained throughout all Inpatient services; - Obtaining expert advice on fire legislation and technical advice on the application and interpretation of fire safety guidance, including DH s Firecode; - Liaising with Local Enforcing Fire Authorities, the Authorising Engineer (Fire), Trust Managers; - Development of an effective fire safety training programme for all employees; - Ensuring that an annual audit of fire safety and fire safety management is undertaken and outcomes communicated to the Board; - Reporting of non-compliance with legislation, policies and procedures to the Executive Director of Fire Safety; - Ensuring the preparation of fire prevention and emergency plans; - The investigation of all fire related incidents and fire alarm actuations. Refer to HTM for further duties The Fire Safety Adviser's role is to provide technical expertise to the Fire Safety Manager to enable them to fulfil their duties effectively. Therefore, the Fire Safety Adviser will be responsible for the following: - Undertaking, recording and reporting fire risk assessments of all Trust owned/leased premises; - The assessment of fire risks within Trust owned / leased premises; - Providing expert advice on fire legislation and expert technical advice on the application and interpretation of fire safety guidance, including DH s Firecode; - Assisting with the review of the content of the Trust s Fire Safety policy; - Assisting with the development and delivery of a suitable and sufficient training programme for staff such as Fire Warden and Fire Response Team Training; - The preparation of fire prevention, PEEPS and emergency action plans for each building; - The investigation of all fire-related incidents and fire alarm actuations; - Liaison with the enforcing authorities on technical issues and the Authorising Engineer (Fire). - Liaison with managers and staff on fire safety issues including supervision of fire evacuation drills. Version 1.0 February

20 Title Role Responsibilities Fire Marshals will be appointed by each local manager / Local Fire Safety Manager for their departments / services/ buildings. Fire Safety Management Policy Fire Wardens Employees, Contractors Staff Bank/Agency Staff Volunteers Contractors Fire Safety Assistant Adherence Adherence Adherence The Fire Wardens should: - Act as focal point on fire safety issues for local staff; - Organise and assist in the fire safety regime within local areas; - Raise issues regarding local area fire safety with line management; - Assist with coordination of the response to an incident within the immediate vicinity; - Assist Managers in roll-call during an evacuation - Support line managers on fire safety issues. All staff, contractors and volunteers shall; - Comply with the Trusts Fire Safety Policy and local fire procedures. - Participate in fire safety training and fire evacuation exercises where applicable. - Report deficiencies in fire precautions to Line Managers and Fire Wardens. - Report fire incidents, and unwanted fire alarm signals in accordance with Trust procedures. - Ensure the promotion of fire safety at all times to help reduce the occurrence of fire and unwanted fire alarm signals. - Set a high standard of fire safety by personal example so that, service users, visitors and members of the public, when accessing Trust premises develops an attitude of mind that accepts good fire safety practice as normal. All staff, including Agency and Bank personnel, must co-operate to ensure the workplace is safe from fire and its effects, and must not do anything that will place themselves or other people at risk. Each and every member of staff has an individual responsibility to help prevent the outbreak of fire, to help maintain the integrity of fire precaution measures, and to follow the established procedures for the management of any actual or suspected fire incident. It is essential that every member of staff: - Observes the Trust no smoking policy; - Understands the character of fire, smoke and toxic fumes; - Knows the fire hazards involved in their working environment; - Practices and promotes fire prevention; - Knows the correct action to take if fire breaks out; - Assists the Fire Wardens to evacuate patients and visitors; - Report of incidents relating to fire safety to their line manager or immediately to the Fire Advisor. All appointed contractors working on the Trust s premises must adhere to the Trust s fire safety and other policies and procedures. Private contractors working within the Trust's sites must be afforded the same protection from the hazards of fire as any other visitor or member of staff. Contractors similarly have the same duty of care as the Trust's staff not to create risk of fire or impede or impair fire prevention arrangements and facilities. The manager and department responsible for arranging any contract work must ensure that the contractor is advised of our policy and procedures and the requirement to comply with them. There must also be adequate supervision of that contract work to ensure compliance as far as that is practical. Since comprehensive supervision is not always possible, all staff are required to be vigilant of contractors activity when this takes place in their working area and report any untoward incidents to the supervisor of the contract, or their department's manager. Version 1.0 February

21 9.0 Training Fire Safety Awareness training is to be an integral part of organisational training and education. The Fire Safety Manager shall devise and facilitate a programme of fire safety training which reflects staff responsibilities for fire safety and set in place appropriate means for recording, and monitoring, staff attendance during fire training. Fire safety training programmes will be promulgated on the Trust intranet where staff can select a suitable training venue. Managers of staff unable to attend promulgated venues are to make suitable arrangements with the Fire Safety Manager for training to be delivered within specific workplaces. All staff are to receive training that is consummate to maintain a level of competency that is appropriate to their duties. What aspect(s) of this policy will require staff training? Basic Fire Awareness Which staff groups require this training? All staff groups Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? Yes refer to Trust Training Needs Analysis If no, how will the training be delivered? Who will deliver the training? Learning & Development How often will staff require training Annually Who will ensure and monitor that staff have this training? Learning & Development Fire Warden Training All staff will receive Fire Warden Training No Classroom setting Fire Advisor At the start of employment followed by 3 yearly update Head of Health, Safety, Fire & Security Fire Response Team Training All staff working within inpatient settings No On site at individual units and classroom setting Fire Advisor Annually Head of Health, Safety, Fire & Security 10.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext or EqualityImpact.assessment@bcpft.nhs.uk 11.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. Version 1.0 February

22 12.0 Monitoring this policy is working in practice What key elements will be monitored? (measurable policy objectives) Annual completion and review of fire risk assessments Testing and maintenance of physical fire detection systems in line with legislation Where described in policy? How will they be monitored? (method + sample size) Physical check against each building owned/ leased by the Trust Review of contractors PPM and maintenance schedule Who will undertake this monitoring? Head Of Health, Safety, Fire and Security The Estates Compliance Manager How Frequently? Annually Quarterly Group/Committee that will receive and review results Health and Safety Committee Health and Safety Committee Group/Committee to ensure actions are completed Quality and Safety Committee Quality and Safety Committee Evidence this has happened Minutes of meetings and reports from health and safety Minutes of meetings and Estates Compliance Reports The completion of local fire safety procedures Physical check against each building/ department to ensure local fire plans in place Fire Safety Advisor Annually Health and Safety Committee Quality and Safety Committee Inspection of local fire procedures Fire warden appointments Course attendance / nominal roll Audit of locations to ensure fire wardens have been appointed and rained Head Of Health Safety Fire and Security 6 monthly Health and Safety Committee Quality and Safety Committee Copies course of nominal roll Fire incidents Review of fire related incident Head Of Health Safety Fire and Security As required Health and Safety Committee Quality and Safety Committee Incident and accident investigation reports Staff Training 8.0 Review of staff training records by location Fire Safety Advisor 6 monthly Health and Safety Committee Quality and Safety Committee Fire safety compliance report Version 1.0 February

23 PERSONAL EMERGENCY EVACUATION PLAN (PEEP) Appendix 1 Version 1.0 February

24 Legal Obligations Disability manifests itself in many ways, some more obvious than others. One element remains constant, the requirement for hospital/ward/unit/departmental managers to plan the safe and effective evacuation of disabled patients/staff/visitors from premises in the event of a fire emergency. Amongst other legal obligations the NHS mandates on Trusts the requirement: NHS organisations in England will (have): Means for ensuring emergency evacuation procedures for all areas, at all times the premises are occupied, without reliance on external services; (extract from DoH Fire Policy, HTM para 1.3) What is a PEEP? Personal Emergency Evacuation Plans (PEEPs) are the method of assisting persons, who may require assistance, to evacuate premises in the case of fire or other emergency. Again this can take many forms: Providing equipment interfaced with the existing fire alarm system to alert persons who cannot hear the sound clearly; Buddy system to lead or assist persons to a place of safety; Providing emergency evacuation equipment should it be necessary (e.g. Evac chairs, ski pads or ski sheets). Manager s Responsibilities 1. Ascertain if in the event of an emergency there are people in your department who would require extra assistance in evacuating the premises; 2. Discuss with the person what assistance s/he would require. Ensure that you consider multi-site working if appropriate; 3. Formulate plan to include agreed method of evacuation and number of persons and/or equipment required to execute it; 4. Inform and train all staff affected; 5. Practise your procedure. Generic Assistance Requirements If you are responsible for an area in which multiple occupants have the same generic need for assistance during a fire evacuation, this must be clearly covered within the Local Fire Safety Procedure. PEEP Paperwork Record the PEEP on the Trust template; Record the subject(s) of the plan; Record results of the practise; Ensure all staff involved in the plan have a copy of it (or at least access to a copy) Attach a copy to your Local Fire Safety Procedure (Appendix 3.); Seek advice regarding your plan with the Health and Safety Department if deemed necessary; Review the plan annually. Version 1.0 February

25 Personal Emergency Evacuation Plan (assessment documentation) To be completed by a competent person appointed by the Head of Department, with the assistance of the disabled person. Name of: Employee/Service User/Visitor/ (Delete as appropriate):.. If applicable, Name of Advocate for the above person:.. Site, Building, Floor & Work Area:..... Responsible Manager & Designation:.. Assessment Undertaken by:..... Date of Assessment:.. Ser ISSUES Yes No A Hearing Impairment 1 Do you have a hearing impairment? (if no, go to section B) 2 Can you hear the fire alarm in normal circumstances? 3 If you have difficulty in hearing the fire alarm, would a visual indicator assist? 4 Is there, to your knowledge, any special or purposely designed hearing system or device available, which might assist in you hearing the fire alarm more clearly? Please provide details: 5 Would your response to the fire alarm being activated be helped by an assistant(s), who could provide support in the fire evacuation procedure? 6 Would a vibrating paging unit, that operated when the fire alarm was actuated, be of assistance? Ser ISSUES Yes No B Visual Impairment 1 Do you have a visual impairment, which would have an impact on your leaving the building unassisted in an emergency? (if no, go to section C) 2 Do you use an aid to help you move around the building for example: a cane, wheelchair or other equipment? Please provide details: Version 1.0 February

26 Ser ISSUES Yes No B Visual Impairment 3 How long would it take you to leave the building in an emergency using the nearest available exit from your place of work, unaided? Time in minutes:. 4 Could you find your way to exit the building by an alternative route should your normal route be unavailable? 5 Do you think that the speed at which you are able to leave the building, may have the potential to hold-up other people leaving the building in corridors and stairways, or that they may cause you injury as they pass you more quickly? 6 Would tactile signage or floor surface information be of assistance to you? Please provide details: 7 Are there any other problems you would wish to highlight or solutions / measures that might assist you? Please provide details: Ser ISSUES Yes No C Mobility 1 Do you have mobility impairment? (if no, go to section D) 2 Can you leave the building unassisted? 3 If not do you require help from an assistant to leave the building? 4 Do you need or use a wheelchair? 5 Is the wheelchair required for all circumstances? Can it be dispensed with for short periods? 6 Is the wheelchair a standard size or an electrically powered type with wider dimensions? Normal Electrical Width.. cm 7 Are you able to self-transfer to an evacuation chair / stair descent device if required? 8 Could the medical nature of your disability be aggravated by the use of such a device? 9 Has a member of staff and a deputy been assigned to assist you in an emergency? Name(s) Contact details: 10 Any other problems / observations / or solutions? Please provide details: Ser ISSUES Yes No D General Information Version 1.0 February

27 1 Do you understand the concept of a Fire Safety Refuge area? 2 Might the measures needed for you to escape from the building in an emergency adversely affect the safe escape of other occupants? If yes, why/how? 3 Do you think that any special staff training is required to give you the assistance that you would need in an emergency? 4 Are you aware of the emergency escape procedures which operate in the building(s) in which you work or visit? 5 Do you require written emergency escape procedures? 6 Are the signs which mark the emergency exits and the routes to the exits clear enough? 7 Could you raise the alarm if you discovered a fire? Notes: Name: Ward/Department: Working Location: Awareness of Procedure I am alerted of the need to evacuate the building by Existing alarm system Pager device Visual alarm system Other (please specify). Designated Assistance The following people have been designated to give me assistance to get out of the building in an emergency. Name(s) Contact details. Name(s)... Contact details..... Name(s).... Contact details..... Version 1.0 February

28 Emergency Escape Procedure (Include a step by step account beginning from the first alarm). Methods of Assistance (e.g. Transfer procedures, methods of guidance, etc.) Equipment Provided (Evac-chairs, stair descent device, hand held portable radios, etc) Safe Route(s) (Attach plan if appropriate) Version 1.0 February

29 Appendix 2 BLACK COUNTRY PARTNERSHIP NHS FOUNDATION TRUST Local Fire Safety Procedure Guidance Document For Trust Premises Name of Building/Dept/Unit Area: Date this Procedure was produced: Responsible Person & Designation: Version 1.0 February

30 General Fire Safety The purpose of this document is to familiarise building users with the various aspects of good fire safety practice, which includes: means of escape, prevention of fires, housekeeping, fire fighting equipment and emergency procedures. This information should be considered by all members of staff, in particular Responsible Persons. It is also essential that each intake of staff is informed of fire safety and emergency procedures applicable to the building(s)/area in which they will work. 1.0 MEANS OF ESCAPE Means of escape: divided into three stages: 1.1 Stage 1. Travel within rooms or enclosures. For this stage to be effective, it is important that all doors affording exit from a room or enclosure be kept clear of obstruction, and maintained easily openable without the need for keys. If security is required; panic bolts, panic latches or break glass bolt mechanisms may be used. Keys in glass-fronted box arrangements are not acceptable from a means of escape aspect. In secured areas; electronic fobs, swipe cards or security keys may form the normal means of escape. 1.2 Stage 2. Travel from rooms to stairways or final exits. All corridors or passages affording access to a stairway or final exit must be maintained clear of obstruction at all times. Any fire resisting doors along these routes must not be wedged or held permanently open using illegal devices. They are there to prevent the spread of fire and smoke at protect the escape route. 1.3 Stage 3. Travel within stairways to final exits. Stairways and their enclosures usually form part of a protected route from the upper floor of a building. The route must be kept clear and free from obstructions, and fire resisting doors in, or affording access to the stairway or enclosure, must not be wedged or permanently held open. 1.4 Final Exits. Doors not in normal, daily use should be opened weekly to ensure that they open easily and immediately. Any special release device should be checked for correct operation at the same time. Some fire resisting doors may be fitted with automatic release devices, which allow door to close when the fire alarm is actuated. If the device becomes defective, the door must not be held open using other means. The safe escape from building relies on the structural protection provided, being properly maintained. Fire resting doors illegally wedged or held permanently open will allow fire to race through the building putting lives at risk. Version 1.0 February

31 2.0 ESCAPE ROUTES AND EXITS All escape routes and exits from buildings should be clearly indicated by signs that conform to the relevant British Standard/Firecode HTM and it is important that the building users are familiar with their location. Escape routes should be walked by staff immediately after commencing employment and regularly thereafter. 3.0 ALTERATIONS No alterations of any description may be made within Departments without first consulting Estates and the Fire Safety Adviser as they may affect means of escape in case of fire. 4.0 HOUSEKEEPING AND PREVENTION OF FIRE Good housekeeping and sensible fire precautions will reduce the possibility of a fire occurring. Poor housekeeping, carelessness and neglect not only make the outbreak of fire more likely, but will allow a fire to spread more accurately. Common causes of fire include: Faulty electrical wiring, plugs and sockets which are overloaded or inadequately protected by the correct fuse or circuit breaker; Electrical equipment switched on when not in use (unless designated to be permanently connected); Smoking and the careless disposal of smoking materials; Accumulation or rubbish, paper or other materials that are easily ignitable; Combustible materials that are left too close to sources of heat; Obstruction to the ventilation of heaters, machinery or office equipment; Open flame sources left unattended; Careless use and disposal of flammable liquids (ensure that the quantities required in the work are kept to a minimum and bulk stocks kept in a separate preferably outside, store; Carelessness by contractors Note 1: Unoccupied areas such as basements, storerooms and cupboards, (especially those situated under stairways, or in areas where a fire could grow unnoticed) should be regularly inspected and cleared of non essential combustible materials. Note 2: Roof spaces, subways, plant rooms, switch rooms and generator houses are the responsibility of the Estates Department and where necessary, Approved Persons only. 5.0 FIRE FIGHTING EQUIPMENT 5.1 Fire Fighting General With all types of fire fighting appliances, it is essential that you know how to operate them. A few seconds spent reading the instructions will save time and embarrassment when you come to use them. Remember when using a fire Version 1.0 February

32 extinguisher, it is only a first aid appliance. A fire should only be tackled in its early stages. If there is the slightest doubt concerning the fire, its intensity, location and type of extinguisher to be used close the door on the fire and get out of the building. Leave it for the Fire Service to deal with Once a fire extinguisher has been used, or its seal broken; it must be re-filled or replaced. Contact the Fire Safety Adviser If further information or training on the use of fire fighting equipment is required, contact the Fire Advisor for the date of the next available Fire Safety course. Important fire fighting must never be allowed to delay the evacuation of a building. Important - It is always advisable to switch off the supply, where possible, before tackling a fire involving electrical apparatus Version 1.0 February

33 5.2 Table of Fire Extinguishers and Their Use Type of Fire Extinguisher Classification Suitable for extinguishing Water Foam Class A Fires Class B Fires Applicable to Class A fires Class C Fires Cloth Textile, furniture etc Wood, Rubber Paper Various plastics, Do Not use on electrical fires or burning fat/oils Fires involving: Solids Burning liquids, such as paint and petrol Safe on fires caused by electricity if tested to 35kV (dielectric test) and a 1m safety distance is adhered to. Not suitable for chip or fat pan fires. Multi-purpose can be used on Dry Powder C02 Applicable to Class A & B Fires Fires involving organic solids Live electrical equipment Liquids such as grease, fats, oil, paint, petrol and gas fires etc Do not use on chip or fat pan fires Liquid and electrical fires Live electrical equipment Wood, textile, solids etc. Care has to be taken not to asphyxiate people when using extinguisher in small confined spaces (do not use on chip fan fires) ventilate room after use Note: you should only use a fire extinguisher if you have been trained to do so and you do not compromise your safety and early evacuation Version 1.0 February