FIRE SAFETY POLICY AND STRATEGY

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1 FIRE SAFETY POLICY AND STRATEGY 1

2 1 Policy : Fire Safety Policy and Strategy Executive Summary: The purpose of this policy is to provide an unambiguous statement on fire safety, outlining the responsibilities and the operational procedures in place to demonstrate compliance with this legislation and associated Fire Code documents. This policy has been drawn up taking into account the guidance contained in HTM Managing healthcare fire safety (second edition) Supersedes: Fire Safety Policy and Strategy V2 Description of This policy incorporates the latest guidance from HTM 05-01: Managing Amendment(s): Healthcare Fire Safety This policy will impact on: All Trust Staff Financial Implications: Policy Area: Corporate Affairs and Governance Document Reference: ECT Version Number: 3 Effective Date: March 2017 Issued By: Author: (Full Job title ) Deputy Director of Corporate Affairs and Governance (Fire Safety Manager) Fire Safety and Resilience Manager Review Date: July 2020 Impact Assessment Date: APPROVAL RECORD 01/03/2017 Consultation: Committees / Group Fire Estates Group Risk Management March 2017 March 2017 Date Approval Committee Risk Management Sub-committee May 2017 Ratified by Committee: Clinical Management Board 14 July 2017 Received for information: OMT members July

3 SECTION CONTENTS PAGE 1.0 Introduction and Purpose Roles and Responsibilities Implementation Scope Fire Safety Strategy Fire Risk Assessment Fire Prevention and Fire Detection Prevention of Arson Fire Containment Training Fire Safety Information Manuals Record Keeping Fire Emergency Action Plan Personal Emergency Evacuation Plans (PEEP s) Evacuation Drills Control of Contractors Community Premises Shared Premises Incidents of Fire or Unwanted Fire Signals Information for the Fire and Rescue Service Medical Gases Construction and Refurbishment Emergency Planning and Business Continuity Fire Fighting Equipment Measuring Performance Audit Review 15 Appendix 1 Definitions 16 Appendix 2 Fire Safety Management System Structure 18 3

4 1.0 INTRODUCTION AND PURPOSE East Cheshire NHS Trust has statutory duties under the Health and Safety at Work Act (1974) and the Regulatory Reform (Fire safety) Order 2005 to ensure that it has robust fire safety arrangements in place within its premises. The purpose of this policy is to provide an unambiguous statement on fire safety, outlining the responsibilities and the operational procedures in place to demonstrate compliance with this legislation and associated firecode documents. This fire safety policy aims to minimise the incidence of fire throughout all activities provided by, or on behalf of, East Cheshire NHS Trust. Where fire occurs, this policy aims to minimise the impact of such occurrence on life safety, the delivery of patient care, the environment and property. This policy has been drawn up taking into account the guidance contained in HTM Managing healthcare fire safety (second edition). An equality analysis has been undertaken of this policy and no adverse impact on individuals with protected characteristics has been identified as a result of its implementation. 2.0 ROLES AND RESPONSIBILITIES This section outlines the roles and responsibilities required to adequately address fire safety management in East Cheshire NHS Trust. 2.1 Trust Board The Trust Board has overall accountability for the activities of the organisation, which includes fire safety. The Trust Board discharges the responsibility for fire safety through the Chief Executive. 2.2 Chief Executive The Chief Executive will, on behalf of the Board, be responsible for ensuring that current fire legislation is complied with and, where appropriate, Department for Health Fire code guidance is implemented in all premises owned, occupied or under the control of the trust. The Chief Executive discharges the day-to-day operational responsibility for fire safety to the Director of Corporate Affairs and Governance who has executive fire safety responsibility. 2.3 Director with Fire Safety Responsibility The Director of Corporate Affairs and Governance has delegated accountability for fire safety and ensures ensuring that fire safety issues are highlighted at Board level. At an operational level they will: ensure that the trust has in place a clearly defined fire safety policy and relevant supporting protocols and procedures; ensure that all work that has implications for 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 requirements (including DH s Firecode); ensure that all proposals for new buildings and alterations to existing buildings are referred to the Fire Safety Manager before building control approval is sought; ensure 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; 4

5 ensure cooperation between other employers where two or more share trust premises; ensure through senior management and line management structures that full staff participation in fire training and fire evacuation drills is maintained; ensure that agreed programmes of investment in fire precautions are properly accounted for in the trust s annual business plan; ensure that an annual audit of fire safety and fire safety management is undertaken, and the outcomes communicated to the Trust Board; fully support the Fire Safety Manager function. 2.4 Fire Safety Manager The Deputy Director of Corporate Affairs and Governance is the appointed Fire Safety Manager for the Trust. This is primarily a managerial role suitable for a senior operating manager. The role does not necessitate the duty holder to possess fire safety competencies provided that they have sufficient access to competent fire safety advice provided either from an internal Fire Safety Adviser or an external source. The Fire Safety Manager acts as a focus for all fire safety matters in the organisation, and therefore the role will be carried out by one person. The Fire Safety Manager is tasked with developing and managing the fire safety management system, and will be responsible for: the day-to-day implementation of the fire safety policy; reporting of non-compliance with legislation, policies and procedures to the Director with fire safety responsibility; obtaining expert advice on fire legislation; obtaining expert technical advice on the application and interpretation of fire safety guidance, including DH s Firecode; raising awareness of all fire safety features and their purpose throughout the trust; the development, implementation, monitoring and review of the organisation s fire safety management system; the development, implementation and review of the organisation s fire safety policy and protocols; ensuring that fire risk assessments are undertaken, recorded and suitable action plans devised; ensuring that risks identified in the fire risk assessments are included in the trust s risk register as appropriate; the operational management of fire safety risks identified by the risk assessments; the development, implementation and review of the organisation s fire emergency action plan; ensuring that requirements related to fire procedures for less-able staff, patients and visitors are in place; the development, delivery and audit of an effective fire safety training programme; the reporting of fire incidents in accordance with trust policy and external requirements; monitoring reporting and initiating measures to reduce false alarms and unwanted fire signals; liaison with external enforcing authorities liaison with trust managers; monitoring the inspection and maintenance of fire safety systems to ensure it is carried out; ensuring that suitable fire safety audits are undertaken, recorded and the outcomes suitably reported providing a link to the relevant trust committees 5

6 ensuring an appropriate level of management is always available by the establishment of Fire Response Teams for trust sites or premises. 2.5 Head of Safety Risk and Resilience The Head of Safety Risk and Resilience is responsible for the management and delivery of clinical and non-clinical risk management function across the Trust, including the provision of highly specialist advice and ensuring the Trust meets its regulatory and statutory obligations to provide a safe, secure and healthy environment for staff and patients. In relation to fire safety the Head of Safety Risk and Resilience is responsible for:- contributing to the delivery of the through overseeing the activity of the competent person for fire safety and monitoring key performance indicators in relation to the delivery of the Corporate Fire Safety Action plan. implementing a system for investigating, reviewing and monitoring the outcomes of serious incidents requiring investigation ensuring that key performance indicators are met in terms of quality, timelines and effectiveness of learning. 2.6 Head of Estates The Head of Estates is responsible for:- Establishing and maintaining procedures for the management and control of contractors, implementing arrangements for the statutory inspection, examination and maintenance of fire safety related equipment in accordance with relevant statutory requirements; Ensuring all aspects of building and equipment design, purchasing, use, decommissioning, inspection, maintenance and repair activities are carried out in compliance with relevant fire safety related legislation and safe practice within available resources; Implementing a Fire Safety Work Programme, based on the findings of the Fire Integrity Survey, which includes preventative and protective fire safety measures. Providing assurance and progress reports to the Fire Safety Manager, including escalation of risks. 2.7 Associated Directors, General Managers / Department Heads / Matrons and Local Management The responsibilities of Associated Directors, General Managers / Department Heads / Matrons and Local Management are: monitoring fire safety within their respective workplaces and ensuring that contraventions of fire safety precautions do not take place; ensuring local fire risk assessments are undertaken and maintained up-to-date; notifying the Fire Safety Adviser of any proposals for change of use, including temporary works that may impact on the risk assessment, within their area; reporting any defects in the fire precautions and equipment in their area and ensuring that appropriate remedial action is taken; ensuring that local fire emergency action plans are developed, brought to the attention of staff and adequately rehearsed to ensure sufficient emergency preparedness; ensuring that local fire emergency action plan is revised in response to changes, including temporary works, which may affect response procedures; 6

7 ensuring the availability of a sufficient number of appropriately trained staff at all times to implement the local fire emergency action plan; ensuring that the duties outlined in this document and relevant fire safety instructions are brought to the attention of staff through local induction and ongoing staff briefings; ensuring that every member of their staff attends fire safety training as set out in the trust s fire safety training matrix; ensuring that all new staff, on their first day in the ward/department, are given basic familiarisation training within their workplace. ensuring staff at all levels understand the need to report all fire alarm actuations and fire incidents as detailed in the fire safety protocols; 2.7 Fire Safety and Resilience Manager The Fire Safety and Resilience manager acts as the Trust s competent person for fire safety and is responsible for the Fire Safety Advisor. They will provide specialist advice and direct support to the Fire Safety Manager to ensure Trust compliance with the Regulatory Reform ( Fire Safety) Order 2005 Department of Health - Firecode Health Technical Memorandum suite of documents. Their responsibilities are :- ensure that regular inspections are carried out for owned premises and other premises where Trust staff are resident to investigate all outbreaks of fire and prepare and preparation of post-incident fire reports for the Fire Safety Manager review and amend (where necessary) the Fire Policy / Strategy provide regular reports to the Fire Safety Manager and relevant committees ensure weekly walk arounds are undertaken action taken to address any deficiencies ensure the identification and logging of any risks to fire safety on the corporate risk register, ensuring action plans are in place and are monitored 2.8 Fire Safety Adviser The Fire Safety Adviser will be accountable to the Fire Safety Manager for matters of fire safety. They provide competent fire safety advice. Their responsibilities are; undertaking, recording and reporting fire risk assessments; providing expert advice on fire legislation; providing expert technical advice on the application and interpretation of fire safety guidance, including Department for Health 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; the assessment of fire risks within premises owned, occupied or under the control of the trust; the preparation of fire prevention and emergency action plans; the investigation of all fire-related incidents and fire alarm actuations; liaison with the enforcing authorities on technical issues; liaison with managers and staff on fire safety issues; liaison with the Authorising Engineer (Fire). 2.9 Fire Incident Manager The most senior person in charge of an area and present at the time that an incident occurs should assume the role of the Fire Incident Manager. The Fire Incident Manager will: 7

8 take control of the incident; direct the local response; ensure that the fire alarm system has been activated and that staff in the area are aware of the incident; initiate the local fire emergency action plan; determine whether evacuation is necessary and commence the evacuation if appropriate; liaise with the Fire Response Team and the Fire Response Team Leader on their arrival Fire Response Team Leader The bed manager / night sister, or in their absence the security staff will be the Fire Response Team Leader to ensure initial control of an emergency. The Fire Response Team Leader is required to: respond to confirmed fire events; take responsibility for direction of the Fire Response Team; liaise with the Fire Incident Manager; liaise with the attending fire and rescue service; instigate the internal major incident plan (if required) 2.11 Fire Response Teams The Fire Safety Manager has established a Fire Response Team on the trust site at Macclesfield. The team will respond to reports of fire on the Macclesfield District Hospital site. The fire response team consists of:- Security staff Charge hand porter Rotary porter Bed manager Site manager/night sister On call electrician Fire or Health and safety advisor (limited to hours on site/duty) The primary responsibilities of the fire team:- Secure the area and confirm the reason for the alarm Meet the fire service at the main entrance If an evacuation is required co ordinate their assistance with the Incident Manager Fire Warden 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 matron and/or head of service or departmental managers and if necessary on Datix and to the Fire Safety Adviser or Fire Safety Manager. The responsibilities of fire wardens are to; act as the focal point on fire safety issues for the local staff; assist in the fire safety regime within local areas; 8

9 raise issues regarding local fire safety with their line management; support line managers with any fire safety issues All Staff, Contract Staff and Volunteers All staff and volunteers have a responsibility to comply with the Trusts health and safety policies to ensure their own safety and a safe working environment. The responsibilities of all staff, contract staff and volunteers are; comply with the trust s fire safety protocols and 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 false alarm signals in accordance with trust s protocols and 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 members of the public, visitors and students when leaving trust premises take with them an attitude of mind that accepts good fire safety practice as normal. 3.0 IMPLEMENTATION 3.1 Scope This policy is applicable to East Cheshire NHS Trust staff and to premises where patients of East Cheshire NHS Trust receive treatment or care, excluding a single private dwelling. This policy applies wherever East Cheshire NHS Trust owes a duty of care to service users, staff or other individuals. The scope of this policy includes the following documents, Fire Risk Assessment Procedure Fire Safety Training Procedure Fire Safety Information Manual Procedure Fire Emergency Action Plan Procedure Personal Evacuation Plans Procedure Fire Response Team Procedure 3.2 Fire Safety Strategy The fire strategy is developed to inform the 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. Where there is a loss of service due to fire, i.e. a Ward is out of action and therefore alternative arrangements will have to be made to ensure that normal services can be maintained, this will be treated as a Major Incident and managed in line with the major incident plan. The fire safety strategy includes the following elements; Fire Risk Assessment Fire Prevention and Fire Detection Prevention of Arson Fire Containment 9

10 Staff Training Fire Safety Information Manuals Record Keeping Fire Emergency Evacuation Plans Personal Emergency Evacuation Plans Evacuation Drills Control of Contractors Community Premises Shared Premises Incidents of Fire or Unwanted Fire Signals Information for the Fire and Rescue Service Medical Gases Construction and refurbishment Emergency planning and Business Continuity Fire Fighting Equipment Fire Risk Assessment Fire risk assessment is the process of identifying fire hazards and evaluating the risks to people, property, assets and the environment arising from them, taking into account the adequacy of existing fire precautions, and deciding whether the fire risk is acceptable without further fire precautions. There is a legal duty to carry out a fire risk assessment under the Regulatory Reform (Fire Safety) Order 2005 and for it to be reviewed regularly and when changes occur. The risk assessment will be undertaken in line with the Trusts Fire Risk Assessment Procedure, once completed it will be reviewed and an action plan developed, a copy will be kept in the fire, health and safety information manual and is available to all relevant staff on Datix Fire Prevention and Fire Detection The Trust will ensure that key tasks and considerations to reduce the risk of fire, including housekeeping, routine disposal of waste, policies for the procurement and storage of furniture, textiles and flammable liquids are in place/carried out. The use of all electrical equipment must be in line with the Trusts electrical and equipment policies. In all Trust owned premises, suitable alarm and detection systems will be installed in line with national recommendations. The primary function of these systems is to alert staff to the presence of heat or smoke in order that the fire procedure can be initiated. Further information on fire prevention will be contained within the fire safety information manual Prevention of arson Arson is a significant cause of fire in all types of premises. It is a cause for concern to those who are required to meet the costs of such fires especially healthcare providers because of the inherent life risk in most of the premises they occupy and the impact that fire damage may have on the wider provision of healthcare. Arson prevention is a component of the overall management strategy and fire risk assessment used to deal with the range of fire safety risks. Arson, from whatever quarter or motive, should 10

11 be viewed as preventable at least to such a degree that its possible effect is reduced to the lowest practicable level, taking into account all the circumstances. Prior attention to the threat presented by an arsonist should limit their ability to dislocate services, damage property and waste scarce resources. All staff are encouraged during the Trusts fire safety training to report the presence of strangers, particularly in isolated, infrequently visited, strategically important or vulnerable locations. 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. Measures to prevent arson will be considered for each building when its fire risk assessment is completed or reviewed. When identifying suitable controls, the responsible manager for each building should take into account external lighting, site access, unfrequented areas, bin stores, plant rooms, gas storage, workshops, disused or derelict buildings. Smoking, including e cigarettes is prohibited on all premises owned or managed by the Trust. Where it is safe to do so, staff should challenge anyone found smoking on their premises. Staff who work in premises owned/managed by a third party must in addition comply with the building owner/landlord s smoking policy. A knowledgeable, informed and observant staff team is the most effective defence against arson Fire Containment Measures to stop the spread of fire and smoke will be provided in all Trust owned premises. These will include structural fire separation, surface finishes and fire retardant materials to retard the spread of fire. Compartmentalisation is designed to provide added fire protection within working environments, usually thirty minutes fire resistance within departments, and one hour fire resistance separating departments. All building alterations will comply with the relevant Health Technical Memorandum s and Building Regulations. A Fire Integrity Survey has been undertaken for the Trust and an action plan has been devised to prioritise and resolve the issues identified in the report Training Fire safety training will ensure staff are able to identify fire hazards, understand how a fire starts, how to raise the alarm, the action to take in the event of a fire, use of fire fighting equipment, means of escape etc. Fire warden training is only required for staff who have been nominated for such roles. Fire warden training will enable them to assist with the local management of fire safety in line with their roles and responsibilities. Some Trust premises with more than one floor may have evacuation aids provided to manoeuvre people down the stairs in an emergency situation. Fire wardens and other 11

12 nominated staff within these buildings will be given evacuation aid training on site so they are competent to operate them safely. Staff who have not received the training should not attempt to handle the evacuation aids. There are a variety of roles for which a separate training needs analysis identifies the additional fire safety training required. This analysis is contained in the Trusts Fire Safety Training Procedure Fire Safety Information Manuals While fire safety policies and procedures provide detailed information applicable to the whole organisation, in larger and more complex healthcare organisations, specific information pertinent to each ward, department or area will be provided to staff that work within that area. This will be provided in the form of a local fire safety information manual. The fire safety information manuals for Macclesfield District General Hospital and other Trust occupied premises will be provided within DATIX in line with the guidance contained within the Trusts Fire Information Manual Procedure. 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 Record Keeping The records of testing and maintenance of all fire safety facilities for Trust owned premises are managed centrally by the Estates department Fire Emergency Evacuation Plan Each building is required to have a fire emergency evacuation plan. A copy will be located in the Fire Safety Information Manual. The basic instructions for evacuation should also 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 where progressive horizontal evacuation is used and a full evacuation does not take place. The plan will be written in line with the Trust s Fire Emergency Evacuation Plan Procedure Personal Emergency Evacuation Plans (PEEP) A PEEP should be documented for any member of staff who has a disability that could affect their ability to evacuate their workplace. The plan will 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. The plan should be put together following the guidance contained in the Trusts Personal Emergency Evacuation Procedure Evacuation Drills The effectiveness of any evacuation procedure must be tested via drills. These should be undertaken at least once a year. Depending on the size and complexity of the building, the drills can include the whole building, part of the building or individual areas. Fire drills will not take place within the main hospital where the risk to patients outweighs the statutory requirement for drills to take place. In place of these drills staff will take part in 12

13 evacuation training and simulated evacuations as detailed in the Trusts Fire Safety Training Procedure. This will ensure staff can become competent in evacuating their area. Fire drills should 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. Fire drills should be arranged for different times of the day so that all staff to include different staff groups. Wherever possible, wardens or designated staff should observe the drill. The outcomes can then be recorded on a fire drill report. This will enable senior managers and fire wardens to identify any failings within the exercise and communicate to staff where weaknesses may still exist. It is important to record every drill in the fire safety information manual Control of Contractors Contractors on Trust premises must be controlled at all times in accordance with the Trust s Safe Management of Contractors Policy. In particular with regard to fire safety: A Permit to Work must be in force for any Hot Work. 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 Officer 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 Community Premises Within the community setting, Managers and Team leaders will be responsible for the following within their Wards/Departments/Services: the implementation of action plans relating to their Ward/ Department/ Service arising from fire risk assessments collaborating with the Fire Safety Adviser(s) in relation to fire evacuation procedures/ drills. Please see the Procedure to Manage Fire, Health and Safety at Community Locations for further information Shared 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 usually 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. Please see Shared Third Party Premises Health and Safety Responsibility Procedure for further information Incidents of Fire or Unwanted Fire Signals All fire incidents, whether genuine or false alarms, must be reported immediately via Datix, the organisations incident reporting procedure. The Fire Safety Advisers will make an initial 13

14 investigation into all incidents where fires have occurred and all unwanted fire signals. The investigation of such accidents/losses, together with analysis of incidents, will be used as a tool to identify causation, lessons learned and reduce future incidents. The Fire Safety Manager will manage any further investigations including root cause analysis. East Cheshire NHS 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 2 main drivers for this; Reduce staff complacency to fire alarm activations by ensuring within reason that the only activations are real emergencies. Reduce the disruption to the treatment and care of patients and reduce the burden upon Cheshire Fire & Rescue service in attending false alarms at East Cheshire NHS Trust properties Information for the Fire and Rescue Service Information on the hospital fire safety facilities, together with the major risks on site (e.g. bulk oxygen storage) have been provided to Cheshire fire and Rescue Service. A copy of the hospital floor plans showing the location of the main risks are kept in the hospital reception. Operational fire crews from Cheshire Fire and Rescue Service carry out familiarisation visits on site every 12 months. In addition their Community Fire Protection Officers carry out a fire safety audit of the main hospital buildings every 12 months to ensure compliance with the Regulatory Reform (Fire Safety) Order Medical Gases Piped medical gases are supplied within buildings to clinical departments in line with the Trust s policy for Medical Gas Pipeline Systems, they may include; Oxygen Nitrous oxide, and Compressed air. The shift leader is responsible for authorising gases shut-off in the event of an emergency Construction and Refurbishment All building alterations will be carried out by an approved contractor and will be designed and carried out in line with the relevant Health Technical Memorandum s and Building Regulations Emergency Planning & Business Continuity Emergency planning and business continuity for the Trust is carried out in accordance with the Trusts Emergency Planning and Business Continuity plans 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. Very high risk areas e.g. electrical transformer room and main IT server, are fitted with automatic total flood gaseous systems to protect the equipment. 14

15 4.0 MEASURING PERFORMANCE AND COMPLIANCE Fire risk assessments will be carried out throughout the Trust in line with the Trusts fire risk assessment procedure which will inform/update the Trusts risk profile. Fire warden checklists will be carried out in line with the Trusts Fire Prevention procedure and form part of the six monthly Workplace (Health & Safety and Fire Safety) inspection check. Staff will undertake fire safety training in line with the Trusts Fire Safety Training Procedure. Key performance indicators will be used to measure performance: 90% of staff completed the Trusts corporate induction (fire training) 90% of staff completed the Trusts core statutory and mandatory (fire safety) e learning module every 3 years 100% of areas to have a fire warden 66% (minimum) of staff working with dependant or highly dependent patients trained in evacuation procedures 90% fire team members trained in fire safety 90% site managers trained in fire safety. Performance against indicators above will be included within bi-monthly reports to risk Management sub-committee and six month assurance reports to Clinical Management Board 5.0 AUDIT Compliance with this policy will be audited internally via Fire Safety team weekly walkabouts and the trust premises are audited externally at regular intervals by Cheshire Fire and Rescue Service. The external audit findings and any trends, themes and learning identified from walkabouts will be reported to the Risk Management Sub-committee as part of the Fire Safety and Resilience Managers report. The Fire Safety Manager will submit an annual assurance report to the Clinical Management Board for review. 6.0 REVIEW This policy will be reviewed in line with the policy schedule 7.0 ASSOCIATED PROCEDURES The following guidance procedures for staff are available from the Infonet and Risk Management Team Fire Risk Assessment Procedure Fire Safety Training Procedure Fire Safety Information Manual Procedure Fire Emergency Action Plan Procedure Personal Evacuation Plans Procedure Fire Response Team Procedure 15

16 Appendix 1 Definitions For the purposes of this document the following terms are defined: Assembly point: a pre-determined area of safety where persons should assemble in the event of an emergency. Child: a person who is not over the compulsory school age. Compartmentation: the fire-resisting elements including walls, floors, and where applicable, roofs and/or other structures used in the separation of one fire compartment from another. Competence: where a person is required to be competent, he/she must be able to demonstrate through training and experience or knowledge and other qualities that they have the ability to properly assist in undertaking the preventative and protective measures. Competent Person (Fire): a person who can provide skilled installation and/or maintenance of fire-related services (both passive and active fire safety systems). Complex healthcare organisations: hospitals or other healthcare premises that perform invasive procedures and other treatments that place a dependence on staff for evacuation. Fire emergency action plan: the pre-determined plan that describes the actions necessary in the event of a fire to protect relevant persons and facilitate their safe evacuation. Fire engineering: the application of scientific and engineering principles to the protection of people, property and the environment from fire. Fire-fighting equipment: the fire extinguishers, fire blankets and other equipment made available to trained personnel for the purpose of fighting fire. Fire resistance: the ability of an element of building construction, component or structure to fulfil, for a stated period of time, the required load-bearing capacity, fire integrity and/or thermal insulation and/or other expected duty in a standard fire resistance test. Fire risk assessment: the process of identifying fire hazards and evaluating the risks to people, property, assets and the environment arising from them, taking into account the adequacy of existing fire precautions, and deciding whether the fire risk is acceptable without further fire precautions. Fire Safety Adviser (Authorised Person Fire): a person who has sufficient training and experience or knowledge and other qualities to enable them to properly assist in undertaking preventative and protective measures. Fire safety management system: a robust framework of protocols and processes used to ensure that an organisation can fulfil all tasks required to achieve the fire safety objectives set out in the fire safety policy. Fire Safety Manager: the person within the organisation tasked with coordinating fire safety issues throughout the organisation s activities. Fire Safety Order: The Regulatory Reform (Fire Safety) Order Fire safety policy: a high level statement of intent, as expressed by the board, partners, or equivalent controlling body, setting out clear fire safety objectives for the organisation. Fire safety procedure: a detailed document setting out each step of a process intended to prevent fire, maintain fire precautions, minimise fire hazards or effectively respond to a fire incident. Healthcare building: a hospital, treatment centre, health centre, clinic, surgery, walk-in centre or other building where patients are provided with medical care, diagnostics or other associated treatment. 16

17 Hot works: Operations involving the use of open flames or the local application of heat or friction such as welding, soldering, cutting or brazing. Material change: A change in arrangements or circumstances that may have an impact on the validity of fire risk assessments, fire precautions, fire emergency action plans etc. Management level: standard or quality of the organisational fire risk management system. Occupant dependency: the categorisation of occupants on the basis of their likely need for assistance to effect their safe evacuation in an emergency. The following categories are referred to in this Health Technical Memorandum: Independent: occupants will be defined as being independent: if their mobility is not impaired in any way and they are able to physically leave the premises without staff assistance; or if they experience some mobility impairment and rely on another person to offer minimal assistance. This would include being sufficiently able to negotiate stairs unaided or with minimal assistance, as well as- Dependent: all occupants except those classified as independent or very high dependency. Very high dependency: those whose clinical treatment and/or condition creates a high dependency on staff. This will include those in critical care areas, operating theatres, coronary care etc and those for whom evacuation would prove potentially life-threatening. Place of relative safety: an initial place away from the immediate danger of fire and from which further evacuation is possible to a place of safety. Place of safety: a place where persons are in no danger from fire. Premises: the land, building, or part of a building which is owned, occupied or managed by the organisation. Preventative and protective measures: the measures which have been identified by the responsible person in consequence of a risk assessment as the general fire precautions necessary to comply with the requirements and prohibitions imposed by the Fire Safety Order. Progressive horizontal evacuation: evacuation of patients away from a fire into an adjacent fire-free compartment on the same level. Relevant person: any person who may be lawfully on, or in the immediate vicinity of, the premises and who is at risk from a fire on the premises. Responsible person: the employer of persons working at the premises, a person who has control of the premises, or the owner of the premises. Young person: any person who has not attained the age of

18 Appendix 2 Fire Safety Management System Identify hazards through fire risk assessments Identify relevant legal, NHS and other requirements PLAN Evaluate and rank significance Set objectives FIRE POLICY DO IMPROVE EMERGENCY MANAGEMENT CONTROL Management Programme Training Communication Fire Emergency Action Plans Fire Drills Permit to work Records Roles & Responsibility Fire Safety Information Manual Fire Risk Assessment Review Incident Management System (DATIX) Fire Warden Checks CHECK & ACT Fire Safety Audit Fire and Rescue Audit CONTINUAL IMPROVEMENT REVIEW Clinical Management Board Risk Management sub-committee Emergency Planning & BC Group Fire/ Estates Group 18

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