Procedure: WLFS07 Fire Procedures for the Tony Hillis Wing

Transcription

1 Procedure: WLFS07 Fire Procedures for the Tony Hillis Wing Procedure Relates to Primary Policy: F1 Fire Safety Policy and Strategy Version: 08 RED ALERT Approved by: Security Steering Group Date approved: 18 th July 2018 Title of Author: Senior Nurses and Ward Managers Responsible ED: Responsible Senior Manager Director of High Secure & Forensic Services Paula King, Service Director Governance Committee Security Steering Group Date of Procedure 4 th June 2018 Date issued: 1st August 2018 Review date: Target audience: Disclosure Status Prior to ward moves to Medway Lodge All staff and service users within the THW B: Can be disclosed to patients and the public 1 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

2 Version Control Sheet Version Date Title of Author Status Comment Senior Nurses & Ward Managers Senior Nurses & Ward Managers Senior Nurses & Ward Managers, Deputy Fire safety Manager Approved at SSG on Chairman s approval on Approved at SSG on Review in 1 year To be presented to SSG on for information Review prior to ward moves. 2 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

3 OPERATIONAL SECURITY PROCEDURE FIRE PROCEDURES THE TONY HILLIS WING INDEX 1 Introduction 2. Description of the building 3. Description of the fire alarm system 4. Action to take on hearing the alarm 5. Action on discovery of fire 6. Evacuation of wards 7. Evacuation Routes & Assembly Points (Read in Conjunction with Flash Cards) 8. General responsibilities - all staff 9. Role of the unit coordinator 10. Ward manager / heads of departments' responsibilities 11. Fire marshal responsibilities 12. Training 13 Flash cards Appendix 1 Fire Safety Measures to implement in bedrooms occupied by Identified arson risks Appendix 2 Guidance Notes for completing a PEEP for a service user in seclusion. Appendix 3 PEEPS (for staff and service users) 3 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

4 Operational Fire Procedure (Tony Hillis Wing) 1 Introduction 1.1 A Fire can have catastrophic consequences causing death and injury, widespread damage to buildings and disruption of services. The risk from fire is high with service users suffering from mental health problems, so it is of vital importance that all possible measures are taken to prevent a fire. This risk is compounded when in a secure setting with locked exit routes and fire fighting equipment. It is essential that if a fire does occur that it s effect is minimised by early detection, effective containment, rapid and correct response by staff. To achieve this all staff, including agency/temporary, contractors and visitors must take ownership of this policy and local policy to ensure a safe environment for all. 1.2 This Procedure has been prepared as a requirement of fire safety legislation and to meet the requirements of the Trust F1 Fire Safety Policy and Strategy document. This procedure document is for use as a local reference document for West London Mental Health Trust staff working at the Tony Hillis Wing. 1.3 This procedure should be read in conjunction with F1 the Trust s F1 Fire Safety Policy and Strategy document. The WLMHT F1 Policy can be accessed through the Trust Exchange on all WLMHT networked computers. 1.4 This Policy applies to all Trust staff and all contractors and temporary workers who are engaged to work on Trust premises. 2 Description of the building The THW building accommodates the following: B Block (Ground Floor) 1 x 18 bedded male rehab ward (Bevan) (1 ST Floor) 1 x 16 bedded male rehab (Avebury) (2 nd Floor) 1 x 18 bedded ward (Vacant) C Block (Basement) 1 x Gymnasium (Basement) 1 x Hairdressers (Basement) 1 x Work Rehabilitation (Basement) 1 x Archives (Ground Floor) 1 x reception / waiting room (Ground Floor) 1 x Staff Locker Room (Ground Floor) 1 x Search Room (Ground Floor) 1 x Games/Cafe Room 4 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

5 D Block (Ground Floor) Store Room (Ground Floor) Meeting Rooms (Ground Floor) 1 x Staff Room (Ground Floor) Offices / Meeting Rooms (Ground Floor) 1 x Child Visiting Room (Ground Floor) Therapies areas (Ground Floor) Bank (Ground Floor) Store Room (1 st Floor) Therapies Corridor (1 st Floor) Meeting Rooms (1 st Floor) Lecture Theatre (1 st Floor) Patients Education Room (2 nd Floor) Administration Corridor (2 nd Floor)Regeneration Kitchen / Offices (2 nd Floor) Multi-faith Room (2 nd Floor) Meeting Rooms (Ground Floor) 1 x 17 bedded rehab ward (Barron Ward) (Ground Floor) 1 x 8 bedded ward (Tennyson Ward) (Ground Floor) ADL kitchen (1 st Floor) 1 x 16 bedded male assertive rehab ward (Solaris ward) (2 nd Floor) 1 x 18 bedded male acute admissions ward (Derby ward) (2 nd Floor) Primary Healthcare Suite (2 nd Floor) Decant Ward. 3. Description of the fire systems and evacuation plan 3.1 Fire alarm and detection system In order to minimise disruption and distress to service users and to maintain the required levels of security, Thames Lodge has adopted a progressive evacuation plan. This means that the building is divided in to distinct areas, all of which are separated from each other by fire resisting construction, and therefore allows occupants to evacuate from an area that may be affected by a fire or smoke to a different area of the building where they may remain in safety while the incident is being managed. It is of course also possible to evacuate to the outside of the building if required and to remain within the secure perimeter of the site, subject to the location of the fire and the areas it may have affected In order to support the progressive evacuation plan, each area of the building is identified as a different fire alarm zone. This allows the alarm to be raised only in targeted areas/zones, subject to the location of a fire alarm s origin, and for occupants to remain in other zones that are not affected. 5 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

6 3.1.3 The zone from which the alarm has been raised will be given an evacuation message by the alarm: the zones either side, and above or below, will receive an alert signal, in order to warn of fire spread and movement of evacuated occupants through the building. The alarm will not usually be raised in unaffected areas remote from the fire, other than in plant rooms If fire or smoke does spread between zones then the alarm message will change from alert to evacuate, indicating to staff the requirement to progress the evacuation to another area of the building where the alarm is not sounding, or is still sounding only an alert message Automatic fire detectors are installed in all areas of the building. These devices can detect an unexpected rise in heat or the presence of smoke and will raise the alarm automatically should they do so. In order to avoid false alarm activations, the detectors are configured to respond only to heat within kitchens, laundry areas and plant rooms Manual fire alarm call points are installed throughout the building and by the exits. In order to avoid malicious or accidental activations these call points are key operated, and only staff will be issued with the keys Fire alarm control panels are installed in central staircase at each level and in Reception with a monitoring panel in the Contact Centre. These are all connected to each other and they permanently monitor the alarm devices. The panels will clearly indicate to staff the zone/area in which the fire alarm system is activated The fire alarm system will be monitored by the Contact Centre, and if a fire is confirmed the Contact Centre will summon the Fire Brigade if necessary. 3.2 ASSA Key System Key AB or perimeter key opens the fire exits which lead to secure areas. Perimeter key opens all main ward doors and fire exits leading to non-secure areas, the AB key also opens the gates at the bottom of the external fire exit stairs leading to the walk-way and garden. All ward main entrances throughout the building are sited on the ASSA key system Several doors are also held by mag locks (as well as ASSA locks), which release on the activation of the fire alarm in that area. These are situated in C Block, first floor (old entrance door), in the C Block basement, Work Rehab workshop and in the 2 nd floor secretarial corridor. N.B. Vacant Ward Perimeter key opens the door from the balcony to the external fire exit stairs. The AB key opens the exit at the bottom of the stairs leading to the garden. 3.3 Two-way radios are available within all ward areas for communication during emergencies. 3.4 A PEEPs (Personal Evacuation Emergency Plan) must be completed for any visitor who has mobility problems or other physical issues and may require assistance in the event of a fire alarm being activated. The Reception 6 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

7 service will ask visitors if they have any mobility / other issues which will require this form to be completed. 3.5 A PEEP must be completed for every episode of seclusion Bariatric mats and evacuation chairs are available at the top of each stairwell to evacuate service users, staff or visitors who have a mobility issue Only trained staff are permitted to use the bariatric mats and evacuation chairs. 4. Action to take on hearing the alarm 4.1 ACTION by Staff during Intermittent Sounding Get all service users and visitors in to day area if safe to do so. To resolve cause and effect. Staff in admin areas should remain alert in the event of 4.2. Reception will communicate via the two-way radios the source of the alarm. Communication to other wards and the unit coordinator can be achieved over the Two Way Radios to communicate the alarm message, and all response nurses for the building to report to affected area. 4.2 ACTION by Staff when intermittent sound changes to continuous Should the Intermittent warning alarm change to a continuous ringing, you MUST immediately begin to prepare to evacuate service users, staff and visitors to a safer area. For non-clinical areas, all staff must evacuate the building. If safe to do so, one member of staff must remain in the nursing station to await further information from the Contact Centre. Close windows and doors in your immediate area if safe to do so. The nurse in charge/fire marshal will allocate staff to evacuate service users, visitors and staff from the affected area to a place of safety. The nurse in charge/fire marshal must gather or allocate responsibility to collect the nominal list, the service users leave book, medicine cards and the duty rota book If any person is missing, staff should inform a fire marshal or the unit coordinator immediately. West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July

8 4.3 ACTION by Staff during Continuous Sounding When the unit coordinator communicates a fire message via the two way radio, all other radio activity must cease except in an emergency. The nurse in charge/fire marshal must prepare to evacuate the area to another area of relative safety is required. Contact must be maintained with the Unit Coordinator to advise them of the situation via the two-way radio or telephone. The nurse in charge of each Ward / Service area is required to establish the whereabouts of all service users, staff and visitors and mobilise them to the designated assembly area. Following confirmation of an incident, response staff from other wards or areas will attend the scene and assist. if safe to do so and if directed by unit coordinator or person in charge. Following the fire alarm activation message from reception, the person in charge/fire marshal must inform the Unit Coordinator, by means of a two way radio, of the following THE LOCATION OF THE FIRE THE INTENSITY OF THE FIRE ANY INJURIES OF ANY KIND ARE ALL PERSONS ACCOUNTED FOR OR NOT ANY PEOPLE WHO HAVE SPECIAL NEEDS AND ACTIVATION OF PEEPS ANY OTHER RELEVANT INFORMATION NB All non-essential radio traffic must be kept to a minimum during the sounding of the fire alarms and/or discovery of a fire. 5. Action upon discovery of a fire 5.1 Raise the alarm immediately you discover or suspect a fire by activating the nearest Fire Alarm Call Point. Staff may attempt to extinguish the fire if it is considered safe to do so, and they have received adequate training on the use of fire extinguishing equipment. 5.2 The Fire Brigade will automatically be called by the Contact Centre. The Tony Hillis Wing West London Mental Health NHS Trust Uxbridge Road Southall, UB1 3HW 8 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

9 5.3 Then call the Contact Centre on 3333 to inform them of a confirmed fire. 5.4 On hearing the alarm, the receptionist on duty will inform the building, via a two-way radio of the exact location of the fire. 5.5 Evacuate the immediate area, closing all doors and windows, taking service users, staff, visitors and your own safety into consideration. 5.6 The nurse in charge of the immediate area must establish contact with the Unit Coordinator detailing The location of the fire The intensity of the fire Any injuries of any kind Are all persons accounted for or not Any people who have special needs (please see Flashcard) Other relevant information 5.7 On discovery of a fire, the nurse in charge must gather or allocate responsibility to collect the following The service users nominal roll The staff duty rota Two way radio Service user leave book / Observation Charts Service user prescription charts 5.8 The nurse in charge/fire marshal, in conjunction with other available staff, will mobilise all service users and visitors and check the immediate area. All service users, visitors and staff will assemble in the main ward area. 5.9 Visitors and staff will commence horizontal evacuation to a place of safety if and when instructed to do so. NOTE - Do not attempt to use a lift in a fire or fire alarm situation. - Nobody will be allowed to enter or re-enter the building during a fire or fire alarm situation unless instructed by the Unit Coordinator 5.10 The nurse in charge/fire marshal must have first-hand knowledge of the location of all service users, staff and visitors. Service users who are on leave or attending therapy sessions must be accounted for As a backup, if the alarm does not sound or if an alarm point cannot be accessed, dial 3333 which will go to the Contact Centre & confirm that there is a real fire. 6. Evacuation of wards Please refer to Flash Cards. 9 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

10 7. Evacuation routes & assembly points (read in conjunction with flash cards) 7.1 The decision to evacuate a ward / service area will be taken by the Unit Coordinator / nurse in charge or other designated person in charge of the area at the time. 7.2 The Unit Co-ordinator for the premises are to make themselves easily identifiable by wearing a high visibility vest and MUST meet the Fire Brigade on their arrival and inform them of the current situation and of any person(s) not accounted for. 7.3 It is the responsibility of each member of staff to know the location of the fire exit key on their ward so that fire exits may be accessible without delay as the need arises. Following continual alarm activation, staff will control these exit points to ensure effective evacuation of an area is achieved. 7.4 In the event of a fire in the Main Unit Reception Area, evacuation will be through the gardens (if safe to do so). Reception staff can then advise staff of the situation and ensure that this information is passed throughout the building. In the event that the reception is out of use or unsafe and the Unit Co-ordinator is unable to leave the building, the Three Bridges Medium Secure Unit Coordinator will be instructed, by the THW Coordinator, to collect the THW perimeter keys from the Three Bridges MSU reception. The Three Bridges MSU Unit Coordinator will wait for the Fire Brigade at the entrance to The Tony Hillis Wing. Check keys are available and locks are working. 7.5 The main reception area leads into main corridors to the wards In the event of a fire in one of the corridors there are a number of alternative designated exit routes. 7.6 The Therapy staff will manage evacuation from the Therapy areas with support from ward staff as allocated by the Unit Coordinator. 7.7 The Plant rooms are located at the central core of the building. Maintenance staff and contractors working in the plant room will be subject to the Trust permit to work system. 7.8 As part of the permit to work system, all contractors are to be made fully aware of special requirements in respect of the means of escape. Evacuation of these areas will be required on activation of a continuous or intermittent alarm in that area. 7.9 Secure Gardens are available as a safe point of evacuation from other areas of the Unit. These areas are to be kept locked, and members of staff will control evacuation to them. If evacuation from the secure garden is necessary, assistance will be required from other agencies such as the Police, Fire Service, etc. Do not wait to collect any belongings. Do not use lifts 10 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

11 8. General responsibilities all staff 8.1 All staff have a duty to be familiar with the requirements for fire prevention, fire precautions, fire fighting and evacuation procedures as detailed in the Local Fire Policies and Fire Safety Plans. 8.2 All staff are required to attend a mandatory fire lecture at least once a year and participate in fire drills that are held locally. 8.3 Every member of staff has a duty to report to their Manager or the Workplace Fire Marshal or Deputies of any instances where proper procedures are not being implemented. 8.4 All members of staff are responsible for ensuring that fire escape routes, fire exits and fire fighting equipment are maintained free from obstruction and that clear access and egress is maintained at all times. 8.5 All fire alarm activations points in areas accessed by patients are key operated. It is therefore essential that all staff carry fire alarm activation keys at all times. 8.6 All staff should familiarize themselves with the location of all fire alarm points and fire fighting equipment in their areas of responsibility, and their place of work. 8.7 All fire fighting equipment in patient access areas is housed within secure boxes and all staff must carry keys to these boxes at all times. 8.8 All defects are to be reported to the ward manager immediately 8.9 All staff are to be made aware of the following points FIRE CHECKS / EQUIPMENT All Unit staff must familiarise themselves with the location of all fire alarm points, fire fighting equipment and methods of opening all electronic fire exits. Keys to be carried at all times. All fire alarms are tested on a regular basis. Check that all Unit personnel have access to all fire fighting equipment at all times. All electronically operated fire exits must be tested routinely. Smoking in prohibited areas must be actively discouraged especially in bedrooms. Fire exits must be kept clear at all times. Fire doors to be kept closed at all times. Two-way radios must be checked on a shift by shift basis for function. High visibility vests for fire marshals must be kept in an accessible place. 11 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

12 9. Role of the Unit Coordinator NOTE: In the event of a fire incident the Unit Coordinator acts as Fire Officer for the building and will be dressed in a fluorescent tabard (available from reception). The responsibilities associated with this role are as follows: 9.1 Identifying the location of the activated alarm by means of the nearest fire alarm display panel / fire bleep / two-way radio. 9.2 Informing all areas of the point of activation by means of the two-way radio. 9.3 Proceed to the affected area if possible and conduct an assessment of the situation 9.4 Communicating decisions to all areas via the two-way radio. The Unit Coordinator or competent deputy nominated by the Unit coordinator will if confirmed fire will proceed to reception and await the arrival of the fire brigade or delegate this task to an appropriate fire marshal 9.7 Communicating from reception with all areas via the two-way radio, whilst awaiting the arrival of the fire brigade. Controlling the incident and advising all non-affected areas. 9.8 Advising the fire brigade upon their arrival, including the following information: The location and scale of the incident The number and possible location of any missing persons Any other relevant factors 9.10 Offering all possible assistance to the fire brigade and acting on their advice at all times. 9.9 In the event of the reception area becoming inaccessible due to fire or smoke, the Three Bridges MSU Unit Coordinator will be instructed by the THW Unit Coordinator, to collect the THW perimeter keys from the Three Bridges MSU reception and wait for the Fire Brigade at the entrance to the THW At the commencement of every shift the Unit Coordinator must ensure that all two- way radios are fully functional by carrying out a radio check In the event of a major incident the Unit Coordinator must inform the following people at the earliest opportunity The Senior Nurse on Call on normal working days during the week and out of hours throughout the week 9.12 It is the responsibility of the Unit Coordinator to instruct all personnel to reenter the building once it is deemed safe to do so by the Fire Brigade The Unit Coordinator to request a full head count for all service users. 12 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

13 9.14 The Unit Coordinator must ensure they are aware of action to be taken in the event of a fire in the Wolsley Wing See Flashcard Ward manager/heads of departments responsibilities 10.1 Ward managers/ Heads of Departments have the following responsibilities in addition to those described within the Fire Procedures. It is the responsibility of all Managers to co-ordinate the preparation of Local Fire Procedures and Fire Safety plans and to manage Fire Safety in the areas for which they are responsible in accordance with these Policies and Plans. Fire Marshals will be nominated for each stand-alone building, ward, unit, department, etc Ward Managers/ Heads of Department have a special responsibility in respect of new staff, including agency and temporary. They must ensure that new members of staff are briefed on the Local Fire Policy on their first day in the ward/department, and on the use and locations of alarm points, extinguishers and emergency escape routes. They must also ensure that the Workplace Fire Marshal, deputy or an appointed person keeps records of this training Managers must ensure, where necessary, personnel have both basic instruction in fire safety and fire training appropriate to their own particular role and the specific needs of their place of work Managers must also ensure that all staff carry with them at all times the KEYS to operate the Fire Alarm Call Points, keys for the extinguisher boxes and have access to Fire Exit door keys etc Co-ordination and recording of staff fire training appropriate to their duties 10.6 Ensure that fire safety incidents are reported by the designated persons as per the incident reporting procedure 10.7 Ensure fire drills are undertaken as required 10.8 Consult with staff and appointed safety representatives on fire safety matters 10.9 Ensure that local fire safety instructions and action plans are in place and the contents brought to the attention of staff, and are observed by staff Complete an Incident Report form after every activation of the Fire Alarm Attend major Fire Drills Monitor fire safety precautions within the workplace and initiate actions to correct any shortfalls Notify the Estates Department of any proposed change of use of the areas within their control Inform the Estates Department of any items which relating to Fire Safety that become defected or damaged 13 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

14 10.15 Ensure that fire risk assessments are undertaken for all areas of their responsibility and the outcomes of the risk assessments are communicated to all staff and safety representatives. 11. Fire Marshal responsibilities The appropriate Ward / Team Manager will ensure there is a Workplace Fire Marshal and deputy responsible for each ward, unit and department, whenever the area is occupied. Workplace Fire Marshals are to ensure that a deputy is always available to assume the duties specified below during occupation of the area. In the event of an emergency these deputies should be able to take command until the Unit Coordinator/or Fire Brigade arrives and to act as a focus for liaison purposes thereafter. The responsibilities are: To supervise the effective day-to-day upkeep of the ward/department evacuation routes and Local Fire Safety Procedure established for the premises. To ensure the checks are carried out and recorded. To support the Ward / Team manager in the management of fire safety matters. To assist the Fire Safety Advisor in fire safety inspections and risk assessments the area for which they are responsible. To ensure with the estates officer that all fire safety equipment is inspected and tested on a regular basis and local records are kept. Any defects recorded and reported to the Estates Department. To support the ward /dept. manager ensuring all staff undergo fire safety training and take part in fire drills. To attend Fire Drills at their designated area. To be responsible for the co-ordination and direction of service users, staff and visitors actions at a fire evacuation, in accordance with the ward/unit/department evacuation procedures and Local Fire Safety Procedure. To liaise with the Trust s Fire Advisor, in relation to all fire matters and ensure such matters are acted upon as appropriate. 14 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

15 12. Training It is a MANDATORY requirement under Health & Safety legislation that all directly employed staff and staff employed by long-term Contractors to the Trust attend training on fire policy and procedures as part of their induction, on appointment and thereafter annually. An introduction to the workplace must be completed immediately upon commencement, covering local fire issues and procedures. It is the responsibility of Ward manager /Team Manager to ensure that they and their staff comply, and a record of attendance is maintained. Managers must also ensure, where necessary, personnel have both basic instruction in fire safety and fire training appropriate to their own particular category and the specific needs of their place of work. It is essential that all personnel engaged to work within the Trust understand the principles of Fire Safety to ensure that: Outbreaks of fire reduce by reducing the fire hazards in their working environment. Know how to raise the alarm if they discover or suspect a fire. Know and follow the procedures on Action to be taken, if a fire breaks out. Understand the character and hazards of fire, smoke and toxic fumes. If staff feel it is safe, attempts may be made to extinguish the fire. Know the safe means of escape for evacuation to places of safety for everyone on the premises. Understand the importance of fire compartmentalisation/ zoning to prevent the spread of fire and smoke. All qualified staff on each ward must be trained as fire marshalls in order to facilitate covering shift patterns, annual leave and sickness. 13. Flash Cards 15 West London Mental Health NHS Trust Procedure Date: First issued 04/2007 Current Version 08 July 2018.

16 Flash Card 1 PERSONAL EMERGENCY EVACUATION PLANS (PEEPs) EVACUATION EQUIPMENT Evacuation equipment is available at the top of every staircase in order to assist the evacuation of a patient/visitor/member of staff who has mobility problems or other physical issues which may require assistance in the event of a fire alarm being activated. SERVICE USER IN SECLUSION A PEEP must be completed for every episode of seclusion. (Please see Appendix 2 (Guidance Notes) and Appendix 3.) STAFF AND SERVICE USERS A PEEP must also be completed for any service user or member of staff who has mobility problems or other physical issues which may require assistance in the event of a fire alarm being activated. (Please see Appendix 3.) VISITORS A PEEP (Personal Emergency Evacuation Plan) must be completed for any visitor who has mobility problems or other physical issues which may require assistance in the event of a fire alarm being activated. The Reception service will ask visitors if they have any mobility issues which would require this form to be completed. (Please see Appendix 3.) West London Mental Health NHS Trust Page 16 of 38 Policy: NN 04/2007 This is current version 05/02/2016

17 FLASH CARD 2 EVACUATION OF RECEPTION FIRE EVACUATION PLAN RECEPTION Reception staff should remain in reception (if safe to do so) unless instructed to evacuate the building by the Unit Coordinator or a member of the fire brigade. Upon hearing the fire alarm the security receptionist will use the two way radio to inform the building of the location of fire. The receptionist will take account of all service users, staff and visitors within the building and convey this information to the Unit Coordinator or Fire Officer if requested. The receptionist will be responsible for ensuring that all visitors, staff and service users in the reception area are instructed to vacate the building. No attempts should be made to re-enter the building for whatever reason unless on the advice of the Unit Coordinator of an officer of the fire brigade. The car park at the side of the building is the designated fire assembly point for staff and visitors. Keys must not be provided to any member of staff during a fire or fire alarm. Other than the following personnel, all staff must be advised not to enter the building: Fire Officer Clinical Security Fire Brigade Estates Officer Senior staff on call Response Team if authorised by the Unit Coordinator NOTE: - Do not attempt to use the lifts during a fire or fire alarm situation - Kitchens are fitted with Heat Sensors only. - Evacuation of reception should be as a last resort. The Reception staff must ensure they are aware of action to be taken in the event of a fire in the Wolsley Wing See Flashcard 18. Find flashcard 18 West London Mental Health NHS Trust Page 17 of 38

18 Flash Card 3 FIRE EVACUATION PLAN VACANT WARD (previously Solaris Ward) EVACUATION: VACANT WARD, D BLOCK (second floor) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the two-way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The Nurse in Charge will liaise with the Unit Co-ordinator via two-way radio to give information about the fire (if it is on the vacant ward) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the Nurse in Charge must gather or allocate responsibility to collect the following: (a) The service users nominal roll; (b) The staff duty rota; (c) A two-way radio; (d) Prescription charts; (e) The leave folder and observation charts; (f) Inform the receiving ward of vacant ward s evacuation. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION Depending on the location of the fire, the evacuation route will be into Derby Ward via C Block. The alternative evacuation point is down the back stairs to Avebury Ward and out in to the secure garden. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 18 of 38

19 Flash Card 4 FIRE EVACUATION PLAN DERBY WARD EVACUATION DERBY WARD, D BLOCK (SECOND FLOOR) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The nurse in charge will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is on Derby) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following a) The service users nominal role b) The staff duty rota c) The 2-way radio d) Prescription chart e) The Leave folder / observation charts f) Inform the receiving ward of Derby ward s evacuation plans. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Depending on the location of the fire, the evacuation route will be into Solaris Ward via C Block. The alternative evacuation point is Tennyson Ward via the Primary Healthcare Suite / annexe stairwell. If the back exit needs to be used for evacuation, the route should be down one flight of stairs to Barron Ward. This should be a last resort as this exit is not secure. Response nurses must be present to assist. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 19 of 38

20 FLASH CARD 5 FIRE EVACUATION PLAN AVEBURY WARD EVACUATION AVEBURY WARD, B BLOCK (FIRST FLOOR) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The nurse in charge will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is on Avebury) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following (a) The service users nominal roll (b) The staff duty rota (c) The 2-way radio (d) Prescription chart (e) The Leave folder / observation charts (f) Inform the receiving ward of Avebury ward s evacuation plans. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Depending on the location of the fire, the evacuation route will be into R The Lecture Theatre The alternative evacuation point is through the balcony and down the outside staircase or via the main stairs to the secure garden. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 20 of 38

21 FLASH CARD 6 FIRE EVACUATION PLAN BEVAN WARD EVACUATION Bevan Ward, B Block (GROUND FLOOR) Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The nurse in charge will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is on Bevan) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following (a) The service users nominal roll (b) The staff duty rota (c) The 2-way radio (d) Prescription chart (e) The Leave folder / observation charts (f) Inform the receiving ward of Bevan ward s evacuation plans DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Depending on the location of the fire, the evacuation route will be into Barron Ward. The alternative evacuation point is through the ward balcony in to the secure garden. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 21 of 38

22 Flash Card 7 FIRE EVACUATION PLAN SERVICE USER/THERAPIES AREA EVACUATION Service User / Therapies Area C Block /Conference Room 2nd FLOOR) All therapy groups must do a radio check with the Unit Coordinator prior to and on completion of a group. Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All service users and staff will assemble in their specific areas (if safe to do so). The session coordinator will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is in that area) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the session coordinator must ensure that prior to evacuation the session coordinator must (a) Account for all service users. (b) Account for all staff (c) Ensure they have a two-way radio (d) Secure any dangerous objects (if safe to do so) (e) Inform the receiving ward of the Service User Therapies Evacuation Plans Do NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. In the event of a fire alarm await instructions from the unit coordinator. All staff in these areas, with clients, will escort them to a ward area if safe to do so (Derby). In the event of these areas being inaccessible then the alternative route in down the stairway to the 1st floor wards (into the Lecture Theatre. Therapists must remain with the service user and remain responsible for the duration of the evacuation. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 22 of 38

23 Flash Card 8 FIRE EVACUATION PLAN COMMUNAL AREAS C Block, GROUND FLOOR Communal Areas to include Offices Staff Room Child Visiting Room Tribunal Room Games room/cafe Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All staff will make their way to evacuate the building from Reception if safe to do so. If not safe to evacuate via reception go to the basement and exit in to the secure garden. Do NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Once evacuated a head count of staff and patients will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 23 of 38

24 Flash Card 9 FIRE EVACUATION PLAN COMMUNAL AREAS C Block, 1st FLOOR Communal Areas to include All offices Lecture Theatre (non-clinical use) Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All staff will make their way downstairs and evacuate the building from the ground floor (via reception). If not safe to evacuate via reception go to the basement and exit in to the secure garden. DO NOT WAIT TO COLLECT YOUR BELONGINGS. ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Under extreme circumstances, in the event of the main stairwell being unsafe to use, staff will evacuate via the external metal stairwell, accessed from the patients bank side of the corridor. Once evacuated a head count of staff and patients will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 24 of 38

25 Flash Card 10 FIRE EVACUATION PLAN COMMUNAL AREAS C Block, 2nd FLOOR Communal Areas to include Offices (forensic staff and catering) Kitchen Conference room (non-clinical use) Multi faith room Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All staff will make their way downstairs and evacuate the building from the ground floor (via reception) If not safe to evacuate via reception go to the basement and exit in to the secure garden. DO NOT WAIT TO COLLECT YOUR BELONGINGS. ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Under extreme circumstances, in the event of the main stairwell being unsafe to use, staff will evacuate via the external metal stairwell, accessed from the patients bank side of the corridor. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 25 of 38

26 Flash Card 11 FIRE EVACUATION PLAN SERVICE USER THERAPIES AREA EVACUATION Service User/Therapies Area C Block (Lecture Theatre) - 1 st FLOOR including Patients Events All therapy groups must do a radio check with the Unit Coordinator prior to and on completion of a group. Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All service users and staff will assemble in their specific areas (if safe to do so). The session coordinator will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is in that area) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the session coordinator must ensure that prior to evacuation the session coordinator must a) Account for all service users. b) Account for all staff c) Ensure they have a two-way radio d) Secure any dangerous objects (if safe to do so) e) Inform the receiving ward of Service User Therapies evacuation plans DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. In the event of a fire alarm await instructions from the unit coordinator. All staff in these areas, with clients, will escort them to a ward area if safe to do so (Avebury Ward). In the event of these areas being inaccessible then alternative routes are down the main stairway to the ground floor wards (Barron Ward) Therapists must remain with the service users and remain responsible for the duration of the evacuation. Once evacuated a head count of staff and patients will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 26 of 38

27 Flash Card 12 FIRE EVACUATION PLAN PATIENT THERAPIES EVACUATION Patient/Therapies Area C Block GROUND FLOOR) - All therapy groups must do a radio check with the Unit Coordinator prior to and on completion of a group. Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All service users and staff will assemble in their specific areas (if safe to do so). The session coordinator will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is in that area) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the session coordinator must ensure Prior to evacuation the session coordinator must (a) Account for all service users. (b) Account for all staff (c) Ensure they have a two-way radio (d) Secure any dangerous objects (if safe to do so) (e) Inform the receiving ward of Service UserTherapies ward s evacuation plans DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. In the event of a fire alarm await instructions from the unit coordinator. All staff in these areas, with service users will escort them to a ward area if safe to do so (Bevan Ward). Alternative route is down the stairway via the walkway in to the secure garden. Therapists must remain with the service user and remain responsible for the duration of the evacuation. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 27 of 38

28 Flash Card 13 FIRE EVACUATION PLAN WORK REHAB/HAIRDRESSERS AND GYM EVACUATION Work Rehabilitation/Hairdressers & Gymnasium C Block BASEMENT) - Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All service users and staff will assemble in the central corridor (if safe to do so). The session coordinators will liaise with the Unit Co-ordinator via the 2- way radio to give information about the fire (if it is in that area) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the session coordinators must ensure Prior to evacuation the session coordinator must (a) Account for all service users. (b) Account for all staff (c) Ensure they have a two-way radio (d) Secure any dangerous objects (if safe to do so) (e) Inform the receiving ward of the basement evacuation plans DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. All staff in these areas, with service users, will escort them to the secure garden area via the external walkway if safe to do so. In the event of the secure garden being inaccessible then the alternative evacuation route is via the stairway in to the ground floor and then to a ward area (Barron Ward) if safe to do so. Therapists must remain with the service user and remain responsible for the duration of the evacuation. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 28 of 38

29 Flash Card 14 FIRE EVACUATION PLAN SOLARIS WARD EVACUATION: SOLARIS WARD, D BLOCK (first floor) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the two-way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The Nurse in Charge will liaise with the Unit Co-ordinator via two-way radio to give information about the fire (if it is on Solaris Ward) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following: (g) The service users nominal roll; (h) The staff duty rota; (i) A two-way radio; (j) Prescription charts; (k) The leave folder and observation charts; (l) Inform the receiving ward of Solaris Ward s evacuation. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION Depending on the location of the fire, the evacuation route is Avebury Ward via internal exit. The alternative evacuation point is the secure garden via the balcony fire escape. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 29 of 38

30 Flash Card 15 FIRE EVACUATION PLAN BARRON WARD EVACUATION: BARRON WARD, D BLOCK (ground floor) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the two-way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The Nurse in Charge will liaise with the Unit Co-ordinator via two-way radio to give information about the fire (if it is on Barron Ward) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following: (a) The service users nominal roll; (b) The staff duty rota; (c) A two-way radio; (d) Prescription charts; (e) The leave folder and observation charts; (f) Inform the receiving ward of Barron Ward s evacuation. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION Depending on the location of the fire, the evacuation route is Bevan Ward via internal exit. The alternative evacuation point is the secure garden. Evacuating to the car park by Mott House via the door at the far end of the main ward corridor should be a last resort as this exit is not secure. Response nurses must be present to assist. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 30 of 38

31 Flash Card 16 FIRE EVACUATION PLAN PRIMARY HEALTHCARE SUITE EVACUATION PRIMARY HEALTHCARE SUITE, D BLOCK (2 nd FLOOR) Reception staff will also identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. Alternatively, contact should be made with reception to identify the location of the fire. All service users and staff will assemble in the day area (if safe to do so). The person in charge will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is on the PHC) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the person in charge will take: (a) Account for all service users (b) Account for all staff (c) Account for all visitors (d) Ensure they have a two way radio (e) Secure any dangerous objects (if safe to do so) (f) Inform the receiving wards of the PHC evacuation plans. DO NOT WAIT TO COLLECT YOUR BELONGINGS ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Depending on the location of the fire, the evacuation route is Derby Ward via internal exit from the Primary Healthcare Suite. In the event of these areas being inaccessible then the alternative route is via the secure stairwell down to Tennyson Ward Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator West London Mental Health NHS Trust Page 31 of 38

32 Flash Card 17 FIRE EVACUATION PLAN TENNYSON WARD EVACUATION TENNYSON WARD, D BLOCK (GROUND FLOOR) Reception staff will identify the location of the fire (from the Fire Panel located in Reception) and will inform the building via the 2 way radio. All service users, staff and visitors will assemble in the open dining area (if safe to do so). The nurse in charge will liaise with the Unit Co-ordinator via the 2-way radio to give information about the fire (if it is on Tennyson) or receive instructions regarding the evacuation. Once the decision to evacuate has been made, the nurse in charge must gather or allocate responsibility to collect the following (a) The service users nominal role (b) The staff duty rota (c) The 2-way radio (d) Prescription chart (e) The Leave folder / observation charts (f) Inform the receiving ward of this ward s evacuation plans ALL DOORS MUST BE CLOSED EN-ROUTE DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION. Depending on the location of the fire, the evacuation route is Barron Ward via internal exit. Or, exit door opposite nursing office to secure area within the perimeter fence. The alternative evacuation point is Bevan Ward. Once evacuated a head count of staff and service users will be carried out. This will be communicated to the Unit Coordinator. West London Mental Health NHS Trust Page 32 of 38

33 Flash Card 18 FIRE EVACUATION PLAN WOLSEY WING SHOULD EVACUATION BE INTO THE FORENSIC SERVICES AREA THE UNIT COORDINATOR MUST CONTACT THE FORENSIC UNIT COORDINATOR (BY MEANS OF THE TWO-WAY RADIOS) INFORMING THEM OF THE SITUATION. A MEMBER OF THE ADJACENT FORENSIC WARD WILL PROCEED TO THE DIVIDING DOOR BETWEEN LOCAL SERVICES AND FORENSIC SERVICES AND PREPARE TO UNLOCK THE DOOR IF INSTRUCTED TO DO SO BY THE UNIT COORDINATOR. DUE TO SECURITY REASONS THIS PROCEDURE WILL ONLY BE USED IN EXTREME EMERGENCY CONDITIONS. The Wolsey Wing fire procedures are a Red Alert procedure for all unit coordinators and reception staff. West London Mental Health NHS Trust Page 33 of 38

34 Appendix 1 Safety Measures to implement in bedrooms occupied by identified Arson Risk service users. The following lists a range of measures that can be implemented to reduce the risk of fire from a client that displays or has reported Arsonistic Tendencies Try to provide a room that, if set on fire, will present as low a risk as possible to other clients (End of Dead End etc) Provide a Crib 7 mattress. Provide a Duvet instead of blankets With long-term clients, consider replacing a combustible bed frame (Timber etc) with a non-combustible type. No carpets or Rugs to be allowed Strictly no matches or lighters Individual Care Plans should be in place. Provide increased level of Observation Provide Vistamatic viewing panel in the bedroom door. Ensure that personal possessions and other combustible items within the room are kept to a reasonable minimum Restrict the use of aerosols and electrical equipment Generally; Consider reducing the amount of paper towels and toilet roll in WC s to that needed for one days use. (This makes excellent fuel for an Arsonist) West London Mental Health NHS Trust Page 34 of 38

35 Appendix 2 IN CONFIDENCE GUIDANCE NOTES TO COMPLETE A PERSONAL EMERGENCY EVACUATION PLAN (PEEP) FOR A SERVICE USER IN SECLUSION SERVICE USER IN SECLUSION PERSONAL EMERGENCY EVACUATION PLAN (PEEP) CSU Ward Patient Name West London Forensic Service NATURE OF SPECIAL REQUIREMENT (PLEASE tick all fields that are relevant to the service user) MOBILITY SIGHT HEARING LANGUAGE COMPREHENSION Wheel Chair Partial Impaired Walking Aid Blind Deaf Assistance Risk of Violence INDIVIDUALS SPECIAL NEEDS OR REQUIREMENTS IDENTIFIED FOR EVACUATION In the event of Fire alarm activation the nurse in charge must carry out the necessary assessments to determine whether there is a need to prepare for evacuation as per local fire procedure. It is the nurse in charge of the ward who is ultimately responsible for the safety of everyone on that ward; this includes service users, staff and visitors. If there is evidence of a fire / smoke within the ward environment, the nurse in charge must consider whether the affected area can be isolated by closing the fire doors to contain the risk and spread of the fire/smoke so as to allow time to seek further resources and advice from the designated fire marshal for that ward/area. (The nurse in charge must work in close collaboration with the unit coordinator to identify safe containment zones within the ward that is in line with their local fire procedures. If there is an immediate need to implement strategies to evacuate all staff and patients to a place of safety, the nurse in charge must deploy staff to immediately escort those who are risk manageable to the nominated place of safety. This must be demonstrated through necessary, proportionate and justifiable responses. Once this has been achieved and the appropriate resources are available, the nurse in charge or appropriate fire marshal will make the necessary risk assessments to plan and execute the West London Mental Health NHS Trust Page 35 of 38