Trust Policy and Procedure Document Ref. No: PP (017) Policy Statement Statement of Intent 4 LEGISLATION.5

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1 Trust Policy and Procedure Document Ref. No: PP (017)014 Fire Safety Strategy For use in: For use by: For use for: Document owner: Status: The Trust All Staff, Visitors, Patients & Contractors Fire prevention and Fire safety management Estates & Facilities Directorate Approved Contents Page 1. Policy Statement Statement of Intent 4 LEGISLATION.5 2. Relevant Legislation Building Regulations Approved Document B 2013 Vol Regulatory Reform (Fire Safety) Order INTRODUCTION General Building Description Occupancy.6 MANAGEMENT OF FIRE SAFETY Management Overview Details of the Responsible Person(s) for Fire Safety Reporting Structure of Fire Safety Reporting structure for Fire Safety deficiencies Procedures for Review and Authorisation Trust Officers responsibilities and actions Chief Executive Director of Operations Fire Safety Managers Compliance officer Portering Supervisors Switchboard Operators Site Clinical Practioners Managers & Heads of Department All Staff Contractors Community Compliance officer Prevention of Fire Fire prevention standard 12

2 5.2 Procedure for Risk Assessment Housekeeping Procedures Control of Processes Maintaining Compliance Control of works within the building that could impact the strategy Maintenance of Fire Systems Compliance Audits Review the Efficiency of Fire Precautions Training Fire safety training Contractor training Fire evacuation drills Training reviews..15 EVACUATION STRATEGY Means of Escape Means of Escape requirements Identification of primary and secondary Means of Escape Progressive horizontal travel requirements Vertical travel requirements Illumination of escape routes and provision of signage Special provision for mobility impaired individuals Prevention of Fire Type of evacuation process Warning arrangements Performance criteria...16 FIRE AND SMOKE CONTROL STRATEGY Control of Fire spread Control measures for external spread of fire via walls Control measures for external spread for fire via roofs Control of Internal Fire spread (linings) Ease of Ignition ratings of materials Spread of fire ratings of materials Control of Internal fire spread (structure) Building stability requirements Control of spread of fire between connected buildings Requirements for internal fire compartments and separations Control measures for the prevention of fire spread via concealed spaces Smoke control and Management Ventilation and extract arrangements for ground and upper levels Ventilation and extract arrangements for basements and sub basements levels Control measures for the containment of smoke and products of combustion Measures for the protection of escape routes 19 FIRE FIGHTING STRATEGY First Aid fire fighting..19 Source: Compliance Officer Status: Approved Page 2 of 65

3 15. Fire Service intervention Fire Fighting water supplies Access arrangements...20 FIRE PROTECTION STRATEGY Detection of Fire Warning of Fire Control of the movement of Smoke and Fire Suppression of a Fire Maintaining Integrity of Compartmentation 23 FIRE SAFETY Training requirements Incident Reporting form Instructions for switchboard operators Evacuation procedures Main Hospital building Treatment Centre Education Centre MRI department Inpatient Theatres Quince House Fire Assembly Points Internal Fire assembly points Fire assembly points Progressive horizontal evacuation plans Evacuation plan lower ground floor Evacuation plan ground floor Evacuation plan first floor Evacuation plan satellite buildings Site map 58 Annex A Personal Emergency Evacuation Plan..60 Source: Compliance Officer Status: Approved Page 3 of 65

4 1. Policy Statement Statement of Intent The West Suffolk NHS Foundation Trust, under the Health and Safety at Work etc, Act 1974 and the Regulatory Reform (Fire Safety) Order 2005, has a responsibility to take all reasonable precautions to prevent or control the harmful effects of fire to residents, patients, visitors, staff and other persons working at or using its premises and will also provide a structured framework for the prevention of fire. This fire safety strategy document applies to all Trust premises and its aim is to maintain a structured Procedure and Reporting Schedule, for the Management and Control of fire risks in compliance with current Legislation, Guidelines and best practice current at the time of application. The primary defence strategy for reducing the risks posed by fire will be through a risk based approach. This regime may be supplemented by additional training requirements and extra fire safety management procedures to reduce the risk from fire as far as reasonably practicable. The Trust will: - Ensure the safety and welfare of our patients, employees and any other parties affected by our activities, so far as is reasonably practicable; Support the allocation of adequate management time and resources to ensure that the risks from fire are controlled at all times; Promote the co-operation of all our employees through clear senior management commitment, staff consultation, and by the provision of awareness and training programmes; Appoint the staff designated in this strategy and empower them to complete their designated roles and responsibilities; Monitor this strategy to ensure that objectives are being achieved. It will be reviewed, and if necessary amended in light of legislative or organisational change; Ensure that the Fire safety Group is represented by key stake-holders and that it is empowered with the required authority to make necessary decisions; Ensure that suitable and sufficient risk assessments are carried out annually, or when risk dictates in accordance with legislation. The risk assessment will be representative of the site, systems and services present at each site and will clearly identify all hazards, risks with a recommended action plan within each fire risk assessment; Ensure that any Contractors or Service Providers adhere to this strategy and the supporting legislation and guidance; Appoint formally the designations stated in this document, and ensure that they are suitably trained and competent. Professor Dr Stephen Dunn Chief Executive Officer Source: Compliance Officer Status: Approved Page 4 of 65

5 LEGISLATION 2. Relevant Legislation The following Regulations and Fire Safety legislation and guidance apply to all Trust premises. Note: this list is not exhaustive and further legislation and guidance applies. 2.1 Building Regulations 2015 With due regard to fire related issues West Suffolk NHS Foundation Trust must demonstrate that compliance was achieved with the Building Regulations (2015). 2.2 Approved Document B 2013 Vol 2 Approved Document B (ADB) has been produced in support of the Building Regulations and contains guidance and recommendations aimed to provide compliance with the regulations. It should be observed that the Approved Document suite is not legislative and provides only one method by which Building Regulation compliance can be achieved. Therefore the Building Regulations may be demonstrated to have been satisfied by: Compliance with the prescriptive guidance contained in HTM s, HBN s, BS: 9999 or any other associated documents referenced therein; or A fire engineered solution that is demonstrated to provide an acceptable level of protection to the occupants of the building, by use of the guidance of BS: 7974, it s associated published documents and/or any other relevant fire engineering documentation; or The use of one document to supplement the other in support of a fire engineered solution. This report will use ADB to demonstrate compliance with the building regulations, where necessary, with the support of other documents such as BS 9999 and BS Regulatory Reform (Fire safety) Order 2005 Once the departments/wards are completed and handed over to the end user, the Regulatory Reform (Fire Safety) Order 2005 becomes the governing legislation. The order replaces legislation such as the Fire Precautions (Workplace) Regulations 1997 and the Fire Precautions Act 1971 and imposes the general duty to take relevant fire precautions to ensure the safety of the building users and those in the vicinity. By virtue of the order, the responsible person is required to carry out a risk assessment of the premises; which must be suitable and sufficient for the risks and exposure of the occupants to such risks. The order also places responsibility on the relevant person for the servicing and maintenance of all fire safety systems throughout the life of the building. Source: Compliance Officer Status: Approved Page 5 of 65

6 INTRODUCTION 3. General The following report deals with strategic fire safety issues regarding all buildings belonging to West Suffolk NHS Foundation Trust. It is the intention of this stage of the Fire Strategy to outline the requirements, necessary to demonstrate that the proposed layout of the development will satisfy the functional requirements of the Building Regulations (2015) in regards to life safety in the instance of a fire. 3.1 Building Description Main Hospital - The main building in any area is no higher than a 2 storey building. The building is constructed of reinforced concrete ring beam with air rated concrete infill panels. The building has a flat roof which houses several boiler rooms and a multitude of plant rooms. Education centre - The building in any area is no higher than a 2 storey building. The building is a steel frame construction with brick cladding around the bottom and a metal sheet cladding on the top with a metal roof. Day Surgery - The building in any area is no higher than a 2 storey building. The building is a steel frame construction with brick cladding around the bottom and a metal sheet cladding on the top with a metal roof. Residences The 6 residence blocks Pine, Birch, Willow, Larch, Cedar & Oak are all 3 storey buildings, there construction is made up of concrete panels. The 2 residence blocks Rowan House A & B are both 2 storey buildings, their construction is brick and block work construction. Quince House The building comprises of 3 stories which includes Sterile Services department on the ground floor and a further 2 floors of office accommodation. The construction of the building is made up of a steel frame structure with concrete floors, which is clad with insulation panels in certain areas and glazing panels to the front of the building. Sterile Services department The building is single storey in all areas. The building is of brick and block work construction. 3.2 Occupancy The Main Hospital building represents Purpose Group 2 (a), 3 & 4 occupancy (ADB Table D1) Offices for some of the lower ground floor, offices for some of the ground floor along with retail outlets and clinical wards. The first floor comprises of office space and clinical areas. The Education Centre is represented as a Purpose Group 3 & 5 occupancy comprising of offices, lecture rooms and a library. The Treatment Centre represents Purpose Group 2 (a) & 3 occupancy comprising of offices and mainly clinical areas. The Residences represents Purpose Group 2 (b) comprising of mainly accommodation. The Quince House complex represents purpose Group 3 & 6 which is mainly office accommodation and an Industrial services on the ground floor. The Sterile Services department represents Purpose Group 6 comprising of cleaning rooms. Source: Compliance Officer Status: Approved Page 6 of 65

7 MANAGEMENT OF FIRE SAFETY 4. Management Overview 4.1 Details of the Responsible Person(s) for Fire Safety. West Suffolk NHS Foundation Trust has a regulatory duty to appoint a responsible person for Fire Safety. Due to the size of its undertakings and complexity it has a fire safety management structure and this is outlined within this document. In accordance with this document, the Trust has delegated the responsibility to the Chief Executive who is the Responsible Person in the context of Article 3 of the Regulatory Reform (Fire Safety) Order 2005 RR(FS)O Heads of Departments/Wards are responsible, as Duty Holder(s), for the fire precautions and safe management of fire risks in all workplaces under their authority and control. Heads of Departments/Wards are also responsible for fire safety within the areas occupied by their Department/Wards in other buildings and for ensuring that departmental activities do not place staff, patients or relevant persons at risk of injury from fire. As Duty Holders, Heads of Departments/Wards have a duty to the Responsible Person. Further information on the management of fire safety at West Suffolk NHS Foundation Trust can be sort from the Estates & Facilities Compliance Officer on Ext 3468 in the Estates and Facilities Directorate. 4.2 Reporting Structure of Fire Safety The West Suffolk NHS Foundation Trust, Fire Safety Group meets quarterly to discuss policy and procedures. The group sits within the Risk Management structure. The Estates & Facilities Compliance Officer updates the Health and Safety committee with reports on current issues including numbers and types of Fire incidents. The information is then presented to the Corporate Risk Committee. The Fire Group consists of; Estates Manager Compliance Officer Community Compliance Officer Building Design and Projects Manager Clinical, Capital & Services Planning Manager A member of the lead Nurses Group A member of the Fire Response Team Leaders Group Emergency Planning Lead. A representative of the Suffolk Fire and Rescue Service* Trust Health, Safety and Risk Manager * Co-opted members - as required. Source: Compliance Officer Status: Approved Page 7 of 65

8 FIRE REPORTING STRUCTURE Source: Compliance Officer Status: Approved Page 8 of 65

9 4.2.1 Reporting structure for Fire Safety deficiencies During normal working hours, fire safety defects may be identified by any member of the Trust staff. When fire safety defects are identified the current procedure is to contact Estates Help Desk to report such defects on Telephone Extension The Estates & Facilities Compliance Officer regularly carries out routine inspections of Trust buildings and when defects are identified, the Compliance Officer completes a job request on the help desk and sends an to the head of Department/Ward to confirm the job has been identified and reported. If during normal working hours, defects that prejudice the means of escape are identified, then any staff member can report such defects directly to the Compliance Officer on Ext 3468 who will arrange for the issue to be rectified. Portering/Security can also be contacted on Extension 3522 for any security issues that interface with Fire Safety, for example, regarding locked doors on escape routes. 4.3 Procedures for Review and Authorisation Progress in the implementation of new and revised arrangements for fire safety management is monitored throughout the year in accordance with the Terms of Reference of the Fire Safety Group. The Chair of the Health and Safety Committee is responsible to the Chief Executive for the planning, consultation and dissemination of the arrangements made within the Fire Safety Group and for monitoring the adequacy of its implementation. The Chair of the Health and Safety Committee will ensure that; competent persons are available to provide sufficient advice, guidance and assistance on fire risks in all Trust buildings to management at all levels, to enable them to formulate fire safety arrangements, which are adequate for West Suffolk NHS Foundation Trust to discharge its legal duties. 4.4 Trust Officers responsibilities and actions Set out below are the roles and responsibilities of those individuals accountable for Fire Safety arrangements across the Trust The Chief Executive, as the Responsible Person and the Board of Directors are responsible for ensuring an appropriate fire safety policy and procedures are in place and in line with the Regulatory Reform (Fire Safety) Order 2005 and the objectives of HTM 05 Fire code are met Board level Director/ Director of Operations is responsible for bringing Fire Safety issues before the Board The Fire Safety Manager/ Estates Manager is responsible for - An awareness of all Fire Safety features and their purpose. Fire safety risks to the Trust. Fire procedures to cover requirements for mobility impaired staff and patients. Ensure appropriate levels of management are always available to make decisions. Compliance with legislation. Development and implementation of the organisations Fire Safety Policy. Source: Compliance Officer Status: Approved Page 9 of 65

10 Development of Trust Fire Safety Strategy. Development of an effective training programme. Cooperation & Co-ordination between employers sharing premises. Reporting of Fire incidents. Monitoring and mitigation of unwanted Fire incidents. Liaison with enforcing authorities. Monitoring of inspection and maintenance of Fire Safety systems. The Estates Manager/Fire Safety Manager is responsible for the weekly testing of the Fire Alarm system in accordance with BS 5839 Tuesday morning between 0830 and 1000 hours. The testing and maintenance of all fire extinguishers, fire doors and all Fire safety equipment is the responsibility of the Estates Manager. All tests and maintenance work to be recorded and kept in the Estates department. The Estates Manager is responsible for ensuring there is an on-call engineer and on-call craftsman available out of hours to advise or attend and deal with any fire alarm system fault or any technical requirements following a fire incident Estates & Facilities Compliance Officer Provide regular training sessions for all staff and ensure all attendances are recorded. Provide regular training for the Fire Response Team and monitor their response and actions Liaise with Estates management and staff relating to maintenance, testing, and repairs of all Fire safety equipment and ensure that a record of all work is logged. Liaise with Suffolk Fire and Rescue Service and other relevant official bodies. Carry out Fire Risk Assessments and annual updates in accordance with the Regulatory Reform (Fire Safety) Order 2005 Update the Fire Safety Strategy when required. Organise, monitor and produce written reports for Fire Drills Advice on new and refurbishment works, liaising with design consultants and Facilities design team to ensure compliance with statutory Building and Fire Regulations and BS Standards Development of the Trusts Fire Strategy Liaising with managers and staff To support the Fire safety manager/estates manager in undertaking their duties Portering Supervisor Responsibilities Maintain control of Portering resources throughout the incident. Allocate resources to best protect patients, staff and property. Gather information for any reports. Timely completion of any documentation. Carry out actions as listed below. Actions in the event of a Fire Attend all alarm signals in all Trust buildings. Inform switchboard of the nature of the incident and state whether the Fire Service is required to attend. Take charge of Portering staff and ensure there is sufficient staff available to carry out the required tasks, as listed.. Assist with any evacuation that is necessary. If patient evacuation needs to be implemented then the Site Clinical Practitioner Bleep holder 888 (out of hours) or Medical Bleep holder 933 and/or Surgical bleep holder 390 (during work hours) to attend and take charge of the patients. Control access and egress in the Fire zone. Check all rooms in the Fire zone are cleared, unless medical situation does not permit the patient to be moved immediately, then they must be aware of numbers and location of the patient(s) and staff left in area. Supply any equipment which may be required, wheelchairs, medical gas cylinders, etc. Return all porters to their regular duties as soon as possible. Source: Compliance Officer Status: Approved Page 10 of 65

11 Replace glass in call point. Reset Fire Alarm as soon as practicable (unless Fire Service are attending) Complete documentation as soon as possible and pass to the Compliance Officer. On arriving at an incident to which the Fire Service has not been called the Portering Supervisor may still request their attendance. He must give the Fire Service precise details so they may decide on the appropriate response Switchboard Operators Switchboard staff will initially receive a message on the main Fire panel showing the location of the incident and may receive a follow up call (2222) from a staff member or the duty Portering Supervisor requesting the Fire Service. Responsibilities Call the Fire Service (999) if requested on receipt of a 2222 call, or the alarm activates unless there are instructions to the contrary from the Fire Response Team Leader. Put out a call to Portering Supervisor. If the Portering Supervisor requests the attendance of the Fire Service after they have investigated the incident, then all relevant information must be passed to the Fire Service using a 999 call. The Fire Response Team only investigate during the hours Mon Fri 0900hrs to 1700hrs, Weekends & bank holidays 0900hrs to 1400hrs. If a Fault signal comes up on the panel, then the following action is to be taken: Monday to Friday hours put out Group call to Estates and Portering Supervisor. All other times call Portering Supervisor. The Portering Supervisor may request the on-call engineer be contacted. Fill in the appropriate form and forward to Trust Fire Advisor Site Clinical Practitioner Responsibilities The Site Clinical Practitioner is responsible for managing patient evacuation and will be informed immediately a Fire incident occurs which may involve patient evacuation. During working hours this is the responsibility of the Medical bleep holder 933 and/or the Surgical bleep holder 390, the responsibility out of working hours is bleep holder 888. The movement of patients is to be carried out under the control of the duty Site Clinical practitioner (SCP) or may delegate to Assistant Site Practitioner. Actions in the event of Fire Instruct staff to move patients and identify a holding area All Managers and Heads of Department Responsibilities It is the responsibility of all Managers and Heads of Departments to ensure that all members of staff are aware of Fire Safety instructions and attend Fire Training sessions annually. All new staff regardless of grade, full or part time or bank staff should have an induction session with their Manager or Head of Department immediately they commence work in their department. Action in the event of a Fire Source: Compliance Officer Status: Approved Page 11 of 65

12 It is the responsibility of the Manager or Head of Department to ensure that all procedures involving flammable liquids, chemicals, medical gases and electrical equipment are used and stored in accordance with departmental procedures. All Managers and Heads of Departments must ensure that all electrical equipment is switched off when not in use and that all fire exits are clear of obstructions and usable at all times. Fire fighting equipment must be kept clear of obstructions and kept in its designated place. All faults and defects in Fire safety equipment are to be passed to the Helpdesk and specified as urgent. If the test date for fire fighting equipment has expired then this must be reported to Helpdesk All Staff General Duties and Responsibilities All grades of staff, full/part time, bank and agency, volunteers and individuals not employed by the Trust but working in Trust premises or on Site have duties and responsibilities in respect of Fire safety. It is a mandatory requirement for each member of staff to attend fire training also to practice and promote Fire Safety. Each member of staff has a duty to report to the Compliance Officer any violation of Fire Safety procedures e.g. fire doors wedged open, escape routes obstructed. All waste material should be correctly stored until collected to prevent risk of fire Contractors All Contractors should be aware of Trust Fire procedures covered in the Contractors Code of Conduct. In the event of a fire incident in the area in which contractors are working, they must raise the alarm and ensure the individuals or their equipment will not impede any evacuation from adjacent areas, on Escape routes. The Senior contractor on-site is responsible for ensuring that all their staff are accounted for. Contractors must have suitable fire fighting equipment and a means of raising the alarm, if they interfere with the hospital means of detection or raising the alarm for a set period of time due to their works, then they must install a standalone system available at all times. Their staff must be competent in the use of the fire fighting equipment. Any incidents of fire occurring in the contractors area must be reported immediately to the Facilities department or the Portering Supervisor outside normal working hours Community Services Compliance Officer To ensure the properties we occupy as a tenant were we provide clinical services are compliant for fire safety. To liaise with the landlord on any issues or outstanding works within buildings we occupy. To relay communications or fire issues back to the Fire safety manager, to provide information and assurance to the Trust board 5. Prevention of Fire 5.1 Fire prevention standard West Suffolk NHS Foundation Trust is committed to managing fire precautions and adhering to the principals of prevention. Further information on the Trust s Fire Prevention Standards can be sort from the Compliance Officer. 5.2 Procedure for Risk Assessment Source: Compliance Officer Status: Approved Page 12 of 65

13 The RR(FS)O 2005 requires a risk based approach where the Responsible Person(s) and Duty Holders for premises must decide how to address the fire risks identified, while meeting certain basic requirements and standards. By adopting a risk based approach, the Responsible Person(s)/Duty Holders will need to look at how to prevent fire from occurring in the first place, principally by removing or reducing hazards and risks (ignition sources) and then looking at precautions to ensure that people are adequately protected, if a fire were still to occur. Fire Risk Assessments and Audits will focus primarily on the condition and adequacy of the building s fire safety provision together with the fire brigade equipment and facilities. The audit will look at general departmental fire safety management, training requirements and will be carried out in a way which takes account of the size of the department and complexity of its activities as well as the premises which it occupies. The Trust s Fire Risk Assessments will normally be carried out annually by the Compliance officer or the frequency determined by the risk. 5.3 Housekeeping Procedures Good housekeeping should be adhered to at all times and is fundamental in achieving a good level of fire safety in every building. All combustible materials should be removed on a regular basis. This includes recycling receptacles, which should not be placed in corridors. If combustible materials are allowed to build up it can provide a potential fire risk. Heads of Departments/Wards and the Departmental Health and Safety link persons should liaise with the Portering department to ensure excessive waste is not allowed to accumulate in buildings as a result of their undertakings. 5.4 Control of Processes Heads of Departments have a duty to ensure that all staff, patients, visitors or members of the public that may be affected by their acts or omissions, are mitigated from exposure to fire risks and explosions as far as reasonably practicable within their Department/Ward occupied space and responsibilities. These risks include: Sources of ignition leading to fires, Cause and effects of chemicals and gases, Explosive or harmful atmospheres, Flammable or dangerous substances, Ionising radiation exposure, biohazards, Experimental or industrial processes etc. Heads of Departments are required to undertake simple (local) fire safety reviews in respect of their areas of responsibility at least annually but may need to be more frequent if significant hazardous activities are undertaken within the Department/Wards or premises. These simple fire safety reviews serve the purpose of interim reviews and should focus on The Department/Ward fire and emergency arrangements, Liaison with other departments, occupiers of the building, The management of risks & hazardous processes generated by the Department, staff responsibilities. Ensuring fire precautions have been addressed locally. Fire safety training for staff, on arrival, annually and changes of job or location etc, The enforcing authorities may require evidence of these fire safety reviews to show that arrangements for fire safety in Departments are adequate and in place. Further advice is available from the Compliance Officer. 6. Maintaining Compliance Source: Compliance Officer Status: Approved Page 13 of 65

14 6.1 Control of works within the building that could impact on the strategy Where works are carried out on Trust buildings, such as refurbishment and new construction, systems and procedures must be developed by Estates to enable the management and control of the means of escape and the risk of fire during works, under CDM Regulations. Where construction or refurbishment work is to be carried out in occupied premises, the responsible Project Manager must ascertain the extent to which the building s fire safety arrangements are likely to be affected by the works. Procedures must be implemented in consultation with the Estates & Facilities Compliance Officer to ensure that where necessary appropriate fire safety measures are employed by the Principle Contractors to ensure these affects are mitigated. 6.2 Maintenance of Fire Systems The maintenance of the fire safety systems is carried out primarily by service contractors or by the Estates department or their designated representatives. The maintenance of these systems are essential and legally required to ensure the safety of the occupants and to protect the property from spread of fire should one occur. A suitable system of maintenance must be in place so that the fire safety systems are in an efficient state, in efficient working order and in good repair. 6.3 Compliance Audits There is no external auditing procedure that currently exists for the Trust fire safety systems. The Trust is however subject to audits of the fire safety measures by the enforcing authorities for the RR(FS)O Review the efficiency of Fire Precautions The Estates and Facilities Compliance Officer is required by the Chair of Health and Safety committee to monitor the effectiveness of the Fire Safety procedures throughout the year. The Trust is also subject to regular inspection from the Local Enforcing Authority. 7. Training 7.1 Fire Safety Training All staff must receive adequate training in Fire and the evacuation procedures annually or if there are changes in the procedures or the building layout, especially for dealing with patient movements. The Fire Response Team should have enhanced training to deal with minor incidents under the direction of the duty Portering Supervisor. If a patient evacuation is necessary then the Site Clinical Practitioner will take charge of the incident. Any areas that may not be able to evacuate due to Critical Care or an Operation will be given sufficient practical training to extinguish a small fire in the event of having to defend themselves, until the Fire Response Team or Suffolk Fire & Rescue Service arrive to deal with the incident. The Fire Response Team will be trained to carry out investigations, to evaluate the need for evacuation in conjunction with the Site Clinical Practioner. The medical lead will always have primacy over the decision to evacuate due to the medical condition of the patients. On the arrival of the Suffolk Fire and Rescue Service, the Site Clinical Practioner will still have primacy over the Fire service for evacuation, however the Fire Service will evacuate if there is a risk of fatalities from the fire. 7.2 Contractor Training All Contractors should be aware of Trust Fire procedures covered in the Contractors Code of Conduct. In the event of a fire incident in the area in which contractors are working, they must Source: Compliance Officer Status: Approved Page 14 of 65

15 raise the alarm and ensure the individuals or their equipment will not impede any evacuation from adjacent areas, on Escape routes. The senior contractor on-site is responsible for ensuring that all his staff are accounted for. Contractors must have suitable fire fighting equipment and a means of raising the alarm available at all times. Their staff must be competent in the use of the fire fighting equipment. Any incidents of fire occurring in the contractors area must be reported immediately to the Facilities Directorate or the Portering Supervisor outside normal working hours. 7.3 Evacuation Drills Annual Fire Evacuation Drills will be arranged by the Compliance Officer for all of the Residences and Satellite buildings controlled by the Trust; these are an important training activity and should be fully supported by all Trust staff and senior management. Duty Holders will not be notified in advance, but the evacuation drills will be planned so they do not interfere with patient care and continuity, etc. A record of the drill and any significant findings are kept and recorded by the Compliance Officer. 7.4 Training Reviews Details of all individuals given Enhanced Fire Training are held on a database by the Compliance Officer. When this training has elapsed and the member of staff has not completed refresher training in the previous two years, they are contacted to encourage them to attend the next available course. It is the Heads of Departments responsibility to ensure there is an adequate number of staff given Enhanced Fire training for their building at all material times The Trust E learning package is reviewed every year and updated with any current statistics and changes in legislation. The mandatory training is a combination of a brief and DVD presentation, the brief is updated with any current statistics and changes in legislation. The feedback forms used on the Induction training programme are analysed and used to revise the training content. EVACUATION STRATEGY 8. Means of Escape Approved Document B-Building Regulation B1: The building shall be designed and constructed so that there are appropriate provisions for the early warning of fire, and appropriate means of escape in case of fire from the building to a place of safety outside the building capable of being safely and effectively used at all material times 8.1 Means of Escape requirements Purpose Group, different occupancies, travel distance, storey exits, access control provisions. 8.2 Identification of primary and secondary Means of Escape Protected corridors, protected stairs, circulation corridors, fire resistance, final exits, designated evacuation lifts 8.3 Progressive horizontal travel requirements Single escape routes, travel distance, number of storey exits, access control provisions, dead end corridors, inner rooms, width/capacity of escape routes, discounting, sub division of corridors, external escape routes, exit capacity. Source: Compliance Officer Status: Approved Page 15 of 65

16 8.4 Vertical travel requirements Storey exits/number of escape stairs, mixed occupancy, refuges in each protected storey, width/capacity of escape stairs, discounting, pinch points, lobby protection, final exits, and basement stairs 8.5 Illumination of escape routes and provision of signage Emergency lighting provision as per Table 9 ADB i.e. all escape routes including external, accommodation, switch/battery rooms, emergency control room, electricity and generator rooms, emergency signage and fire alarm call points and all toilet accommodation over 8m². Adequate signage-direction of travel to be clear in all areas including disabled refuges. 8.6 Special provision for mobility impaired individuals Refuge points and locations, refuge main control panel location, accessibility of refuge, in place of relative safety. Vibrating devices adopted in building. PEEP subjects in building a copy of a PEEP can be found at Annex A. Flashing beacons/detectors. Sounders provided. Tactile surfaces. Way finding systems. 9. Prevention of Fire 9.1 Type of evacuation process All satellite buildings adopt a simultaneous evacuation procedure. On operation of the fire alarm system all occupants immediately evacuate the building and proceed to the buildings assembly point. The main hospital building operates a horizontal progressive evacuation procedure, on operation of the fire alarm clinical areas evacuate to adjacent areas or a fire assembly point which will be internal until clinical areas can be found or made available to resume patient care. The nonclinical areas should evacuate to a fire assembly point which may be internal or external depending on the location within the hospital. Fire response team operatives proceed to the designated area and liaise with a member of staff from the affected area to gain information before investigating and also to liaise with the Fire Service on attendance. 9.2 Warning arrangements On operation of an automatic detection device or manual call point the fire alarm sounds immediately. There is no double-knock or investigative period in any Trust buildings. In accordance with, BS and the recommendations in the Approved document B, The building has a category L1 Automatic Fire and Detection Alarm system. 9.3 Performance criteria All fire alarm system panels are inspected by Estates for faults. Where faults are identified during the inspection routine they are rectified to ensure it retains its designed operational capacity. FIRE AND SMOKE CONTROL STRATEGY 10. Control of Fire spread Approved Document B-Building Regulation B4: Source: Compliance Officer Status: Approved Page 16 of 65

17 (1) The external fire walls of the building shall adequately resist the spread of fire over the walls and from one building to another, having regard to the height, use and position of the building. (2) The roof of the building shall adequately resist the spread of fire over the roof and from one building to another, having regard to the use and position of the building Control measures for external spread of fire via walls Appropriate Fire Resistance as per Appendix A, Table A1. Relevant/notional boundaries, acceptable unprotected areas and fire resistant glazing identified Control Measures for Spread for Fire via Roofs Roof-lights and roof coverings 11. Control of Internal Fire Spread (linings) Approved Document B-Building Regulation B2: (1) To inhibit the spread of fire within the building, the internal linings shall: (a) Adequately resist the spread of flame over their surfaces; and (b) Have, if ignited, a rate of heat release or a rate of fire growth, which is reasonable in the circumstances. (2) In this paragraph internal linings mean the materials or products used in lining any partition, wall, ceiling or other internal structure Ease of Ignition Rating of Materials All materials used for internal linings should be selected in accordance with tables A1-A8 in Approved Document B, Appendix A. All furnishings should comply with the Furniture and Furnishings Regulations Statement that on document creation, randomly selected furnishing items were inspected for conformity i.e. Labels Spread of Fire Rating of Materials All materials used for Walls and Ceilings should conform to Table 10, Classification of Linings- Approved Document B, Section 6. Consideration should also be given to Tables A1-A8 when selecting any materials used for internal linings. Statement identifying common materials used i.e. Plasterboard, masonry etc and industry accepted levels of fire resistance. Carry out St Andrews cross method where possible for multiple paint layer application? 12. Control of Internal Fire Spread (structure) Approved Document B-Building Regulation B3: (1) The building shall be designed and constructed so that, in the event of a fire, its stability will be maintained for a reasonable period. (2) A wall common to two or more buildings shall be designed and constructed so that it adequately resists the spread of fire between those buildings. For the purposes of this sub Source: Compliance Officer Status: Approved Page 17 of 65

18 paragraph a house in a terrace and semi-detached house are each to be treated as a separate building. (3) Where reasonably necessary to inhibit the spread of fire within the building, measures shall be taken, to an extent appropriate to the size and intended use of the building, compromising either or both of the following: (a) Sub-division of the building with fire-resisting construction; (b) Installation of suitable automatic fire suppression systems. (4) The building shall be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited Building stability requirements Elements of structure such as structural frames, beams, columns, load bearing walls (internal and external), floor structures and gallery structures should have at least the fire resistance given in Appendix A, Table A1. Comment on any Fire boarding of structural elements or intumescent paint application and its condition and quality. Have any warranties/guarantees been provided in the past? Insert levels of applicable fire resistance for each element of structure based on purpose group Control measures for spread of fire between connected buildings Walls dividing buildings, walls common to or more occupancy, do walls run to top of frame? Fire door ratings also condition and management of space Requirements for internal fire compartments and separations Maximum compartment size, sprinklers? Separation of different parts and areas i.e. laboratories from offices, enclosing of special areas of fire hazard, fire door ratings and conditions, 12.4 Control measures for the prevention of fire spread via concealed spaces Are shafts enclosed in fire resisting construction i.e. service shafts? Standard of fire stopping visible-types i.e. mortars/pastes or pillows/collars etc.? Provision of cavity barriers with 30 minutes fire resistance as per ADB i.e. between roof and ceiling=10m max and any other cavity=20m max before reaching cavity barrier? Fire dampers fitted to duct work? 13. Smoke control and Management 13.1 Ventilation and extract arrangements for ground and upper levels General-provision of any ventilation systems in protected stairwells, escape routes, automatic/non-automatic vents, smoke extract systems, their location, what are the air handling systems installed-circulating or intake? 13.2 Ventilation and extract arrangements for basement and sub-basement levels Are there smoke outlets for the basement? Not applicable in the building Control measures for the containment of smoke and products of combustion Source: Compliance Officer Status: Approved Page 18 of 65

19 All buildings in the Trust are fitted with ventilation extraction systems linked in to the fire alarm via a building management system which shuts down extraction and ventilation containing the smoke in the affected area. The Trust has a strict CoSHH regime, to ensure all combustible products are correctly stored when not in use Measures for the protection of escape routes from smoke Smoke seals fitted to fire doors, condition of fire doors; does ductwork pass through escape routes? Are there fire dampers provided on escape routes where duct work enters? Is there ventilation in escape routes? Fire Fighting Strategy 14. First Aid Fire Fighting 14.1 Personnel and training requirements for occupants Fire Evacuation training is provided by the Fire Safety Advisor on an annual basis. Heads of Departments should ensure there are an adequate amount of staff trained for their respective areas. One aspect of the Enhanced Fire Training course is fire extinguishers and their practical application Provision of first aid fire-fighting equipment Fire extinguishers have been provided in accordance with BS and are maintained in accordance with BS The current level of provision meets regulatory requirements. All fire extinguishers will be located in escape routes, correctly signed and each fire point shall consist of both Foam based, and a CO2 extinguisher to cover electrical and liquid risks. If there is a requirement for a particular extinguisher, for example to cover a specialist process/substance then these will be provided in the room that houses the risk. 15. Fire Service Intervention 15.1 Attendance Criteria Suffolk Fire and Rescue Service Control have confirmed that any attendance to Trust Buildings would be a minimum of a one pump attendance. This would increase if a confirmed fire was reported Vehicular Access Detail Vehicle Access route and dimensions. Based on the floor area of the building, in m² and the height of the top floor in accordance with Table 19 ADB Fire Service escort arrangement The SFRS is aware of the current requirements at West Suffolk hospital with regards to the attendance procedure. On Fire Service arrival at the Trust, they should contact the Portering Supervisor assigned to the incident. Portering will continue to liaise with the Fire Service until they have left the Trust site Access to fire equipment and systems Source: Compliance Officer Status: Approved Page 19 of 65

20 All fire protection equipment and systems installed shall be detailed in the Fire Safety Wallet and this document will be located at the Emergency department entrance in the Fire Service box. This will detail the Main Fire Alarm panel location, control switches for protection systems, service isolation switch locations for gas, electricity and water, location of refuges, nearest hydrant(s) and any other ancillary information. 16. Fire Fighting Water Supplies 16.1 Details of provisions Statement to be made, detailing main supply pipe size and distance to the nearest hydrant(s) as per identification plate. Are dry/wet mains fitted? Booster pumps/pressure/gravity tanks installed? 16.2 Layout and accessibility Location of the nearest hydrant and details of how to reach them. Location of fire mains Special requirements Due to the special fire risk of electrical installations such as IT server rooms and the Main Power plant room also the main kitchen; these rooms have been fitted with Fire Suppression Systems. 17. Access Arrangements 17.1 Arrangements for fire service access into buildings Trust Fire Response Teams attend all Fire Alarm activations. On arrival, the Fire Service will be met by the Fire Response Team who will relay information regarding the Fire Alarm activation. Such information may include any persons reported, location of fire alarm activation, confirmation of a fire outbreak and anything that is deemed relevant to the situation Arrangements for fire service access to upper or lower levels The lifts in all Trust buildings are not fire fighting lifts and any access to the first floor is by the protected stairwells or the access ramp at the back of the main building. Lifts will still operate as long as they are not in the affected zone Access criteria to fire system control and indicating equipment Location of isolation switches, suppression stop valve location, location of main fire alarm panel, ventilation operations-manual/automatic, emergency lighting switches are all signed and locations shown in the fire wallet Arrangements for fire service access to special areas If, on arrival there is evidence of a fire in a room that cannot be accessed by conventional means due to the locking mechanism not failing safe, then the Fire Service will have to use manual entry techniques. However, this should be viewed as being a last resort. In some cases Portering/Security may be able to give Fire-Fighters access to such rooms but only if it is safe to do so. Rooms or areas that may require such access in this building are located in the Fire wallet 17.5 Access for Emergency vehicles called to the rear of the hospital a. In event of Emergency vehicle called to Wedgewood or Hospice or any other department, then the department is to ring Car Park Office and inform Legion staff that a blue light is coming to whichever unit. If required Legion will ask for assistance by ringing portering supervisor via switch board. Source: Compliance Officer Status: Approved Page 20 of 65

21 b. If there is only one member of Legion staff on duty they will open the barrier from the office ready for the emergency vehicles to drive through. c. If another member of Legion staff is available, one will stay in office and manually open/close barrier, when informed by the staff member who is at the barrier. d. In the event of a busy period when entrance road is full of cars usually Mon to Fri mornings, Legion Staff will man the road and ensure that cars move over to let Blue Lights through ensuring barrier is open. e. Once vehicles are clear of entrance then Legion staff will stand-down and close barriers accordingly. Fire Protection Strategy 18. Detection of Fire 18.1 Type of detection required For all Trust buildings that fall into any Purpose Group Profile, there is a minimum requirement to have a L2 Fire Alarm system to allow occupants to raise the alarm on discovery of a fire in accordance with BS 5839: A2: The Trust addresses this requirement and details the types of detector, call points etc, that are deemed fit for purpose. This guidance is to be used in conjunction with the relevant British Standards and Control bodies. Attention is also drawn to the RR (FS) O 2005 and the requirement to take General Fire Precautions Coverage In the main building the coverage of Automatic Fire Detection conforms to a type L1 system with detection provided in all areas except shower and bathrooms and manual call points are located on the escape routes and storey exits to conform to building regulations. There is additional detection with Suppression systems that operate on head actuation in high hazard areas such as IT servers and Electricity supply power plants. Also, a Wet chemical suppression system; in the main kitchen Control and Indicating equipment The main fire alarm panel is located the Estates department with a second panel in the switchboard room for 24 hour cover with repeater panels in strategic areas around the Trust and the system is manufactured and maintained by Static Systems group Performance requirements The Trusts objectives from the operational/installation of the fire safety system are to protect the strategic, financial, resilience and business continuity of the services that the Trust provide Interfaces with other devices The Fire Alarm interfaces with the building management system which operates with-mag locks on doors, hold open/shut devices, also doors fail safe, fire curtains, drenchers, fire dampers, gas solenoid valve, lifts ground on actuation of alarm 19. Warning of Fire 19.1 Type of warning system required Source: Compliance Officer Status: Approved Page 21 of 65

22 In addition to providing detection in premises, there is also a regulatory requirement to provide warning in case of fire. Warning devices may include, but are not limited to sounders (audible), beacons (visual). They also include electric sounders for small, simple premises. All of which should be interfaced with the installed Fire Alarm system. In certain buildings, specific considerations have to be incorporated into the Fire Safety management system to accommodate for example, disabled persons or the Home Office guidance to the sounder types used. In all cases they must be to an extent that is appropriate for the premise. Attention is also drawn to the RR (FS) O Coverage Coverage of sounders and beacons are used and they are appropriate Control and Indicating equipment Location of sounders and beacons which are appropriate are installed in line with current guidelines. They are all interfaced with the fire alarm system. Evidence can be obtained in the O+M s for the fire alarm system Remote indication of fire Remote monitoring systems could include self-contained suppression systems to cover server rooms for example that send signal to fire alarm panel on actuation. Air monitoring systems that send a pre-alarm signal to the fire alarm system and duct work detectors can also be considered remote detection devices Performance requirements What are the Trusts objectives from the operation/installation of the fire safety system? They are to provide an early warning/indication of an incident occurring giving the Trust sufficient time to respond and investigate, also to suppress the fire if required. 20. Control of the Movement of Smoke and Fire 20.1 Type(s) of system required There is a requirement to manage any smoke and fire movement within a building and this should have been addressed during the design phase. Part 20-Smoke Control and Management of this document addresses the active smoke control systems that are installed. Part 12-Control of Internal Fire Spread (structure) addresses passive fire protective measures that can be adopted and installed where compartments have been penetrated. All means of escape must be protected from smoke or fire entering into it. Common methods include ensuring that no duct work passes through the means of escape. If this is found to be the case then any duct work should be fire rated and/or fire dampers fitted System arrangement criteria All ductwork is fitted with fire dampers or fire protected where it passes through a means of escape route. Any device installed for the control of smoke is interfaced through the building management system to the fire alarm system Performance requirements The Trusts objectives from the operational/installation of the fire safety system are to protect the strategic, financial, resilience and business continuity of the services that the Trust provide 21. Suppression of a Fire Source: Compliance Officer Status: Approved Page 22 of 65

23 21.1 Type of system required Suppression systems can be water based such as sprinklers or drenching systems or powder/gaseous extinguishing systems. There is guidance for specifying the types of system to be adopted but the type of buildings in which they are found generally include storage facilities, theatres and specialist installations such as Oil/Gas rigs for example. Where installed, they can provide an increased level of fire safety and offer business continuity protection. In some cases, they can be a compensatory feature to reduce or increase other fire safety regulatory requirements as per BS9999. The Trust does have specific requirement to have suppression systems installed in its buildings to provide business continuity to strategic installations such as IT server rooms and major electrical power plant rooms. Where they have been installed, they have been done so to offer an increased level of protection System arrangement criteria All systems installed in the Trust are a gaseous type except the one in the main kitchen which is a wet chemical type. They are all interfaced with fire alarm system Performance requirements The Trusts objectives from the operational/installation of the fire safety system are to protect the strategic, financial, resilience and business continuity of the services that the Trust provide. 22. Maintaining Integrity of Compartmentation 22.1 Type(s) of system required Every building has a maximum compartment size under HTM s, this can be increased with the provision of sprinklers. This, in effect, limits the fire size in the building. The level of building compartmentation afforded is outlined in HTM s. Where a building or part of a storey is divided into compartments it is vital that this compartment line is defined in the buildings documentation, and is maintained. When improvement works are undertaken by contractors in this area, this information should be relayed to them to ensure temporary fire stopping is installed during the works and all compartmentation is permanently restored before completion and handover.. Subsequently, such fire stopping either temporary or permanent should be inspected by a competent person on completion. Attention is also drawn to the requirement to define competency of contractors through 3rd party accreditation from schemes such as Warrington Research accreditation scheme FIRAS or membership to an accredited body such as the Association of Specialist Fire Protection Performance requirements All compartmentation should be designed, installed and maintained in accordance with Approved Document B-Appendix A. Comprehensive guides, such as the ASFP Red Book Current Edition should also be consulted and adopted to help identify current levels of fire protection in addition to inadequate fire stopping systems. Attention is drawn to Table 1 of the ADB document for a quick reference guide to generic fire stopping systems. This document attempts to identify such passive fire protection systems that are incorporated into the building and detail their location. The inspection will be generally non-intrusive and will include the lifting of ceiling tiles, entering service cupboards, examining cable/service penetrations and the location of fire dampers. All existing building information held by Estates will be incorporated into the finalised fire strategy System arrangement criteria What are the Trust objectives from the operation/installation of the fire safety system? The Fire compartmentation is sealed using passive and active fire measures which are interfaced with the fire alarm system. Source: Compliance Officer Status: Approved Page 23 of 65

24 FIRE SAFETY 23. Training requirements TRAINING Requirements for Staff Working on Trust Premises This Training Programme is for Key Personnel who make up the Fire Response Team. PORTERING SUPERVISOR GENERAL PORTERS ENGINEERS CRAFTSMEN 1. Recognise the new Fire Alarm signals. 2. Familiarisation of the information given on Sector and Repeater panels. 3. Accept/Silence informative messages. 4. Responsibility for resetting system. 5. Fire Service response to Automatic Fire Alarm signals. PORTERING SUPERVISOR Attend all incidents. Detail Portering staff to carry out their required task. Send informative message back to Switchboard (2222). Dealing with Residents. Resetting system. HOW TO DEAL WITH MINOR INCIDENTS Basic searching techniques. Electrical/Cooking incidents. First aid fire fighting equipment. Evacuation procedures. TRAINING Requirements for Staff Working on Trust Premises STATIC FIRE ALARM SYSTEM This system is only installed in the Main Hospital Building and the Education centre, but all other external buildings are linked to the main system. ALL STAFF 1. Explanation of new Fire Alarm system and Fire Alarm panels. 2. New regulations and how they affect the Trust. 3. Fire Service response to Automatic Fire Alarm signals across the Site. 4. Role of the Trust Fire Response Team. HOW TO DEAL WITH MINOR INCIDENTS Raising the alarm. Passing information to the Switchboard Fire Assembly Points. First aid fire fighting equipment. Evacuation procedures. Source: Compliance Officer Status: Approved Page 24 of 65

25 24. Incident Reporting Form FIRE ALARM INCIDENT REPORTING FORM Date Time: Location: Residence: Yes No House: Flat No: Persons present Kitchen Yes No Ward/Department: Room No: Detector No Break Glass No Fire Pre-warning False Alarm Fault Cause of the Incident: Did Suffolk Fire & Rescue service attend? Yes/ No Name of Supervisor Signature of Supervisor: Procedure ATTEND THE INCIDENT INVESTIGATE THE INCIDENT RING 2222 TO INFORM SWITCHBOARD(FIRE SERVICE REQUIRED) ALL CALLS TO SWITCHBOARD RELATING TO THE INCIDENT MUST BE MADE ON 2222 Source: Compliance Officer Status: Approved Page 25 of 65

26 RESET THE FIRE ALARM PANEL IF THE SITUATION ALLOWS COLLECT ALL AVAILABLE RELEVANT INFORMATION COMPLETED FORM TO BE SENT TO THE TRUST FIRE ADVISOR 25. Instructions for switchboards operators INSTRUCTIONS TO SWITCHBOARD OPERATORS RELATING TO THE STATIC FIRE ALARM SYSTEM On receipt of a Fire Alarm signal followed by a 2222 call reporting a fire the following procedure is to be carried out. a. Call 999 and request Fire Service attendance. b. Send out group call for the Fire Response Team. On receipt of a Fire Alarm signal, not followed by a 2222 call send out Group call for Fire Response Team. If there is no response within 10 minutes dial 999 immediately. If the Portering Supervisor arrives at the incident and decides he requires the Fire Service to attend then they will call 2222 and request a 999 call be made. The message to be relayed to the Fire Service control must contain all details of the incident. The Fire & Rescue Service expect the Fire Response Team to do the initial investigation during the following hours Mon Fri 0900hrs to 1700hrs, Weekends & bank holidays 0900hrs to 1400hrs investigate. Calls originating from any of the peripheral buildings will appear on the STATIC Fire Alarm panel. They will show on the panel as follows:- The Education Centre The Day Surgery Unit Rowan House Residences Front Residences INSTRUCTIONS TO SWITCHBOARD OPERATORS WHEN A FAULT IS SHOWN ON THE STATIC FIRE ALARM PANEL Between 0800 hours (8.00 am) and 1630 hours (4.30 pm) Monday to Friday put out a Group call to Estates and Portering staff. At all other times call Portering Supervisor. This applies to all buildings on site with the exception of the St Nicholas Hospice, Wedgwood Unit and the Busy Bees Nursery, which are not on our system. Source: Compliance Officer Status: Approved Page 26 of 65

27 26. Evacuation procedures 26.1 Main Hospital building WEST SUFFOLK HOSPITAL FIRE PROCEDURE MAIN HOSPITAL BUILDING Action in case of Fire notices are displayed in prominent positions throughout the building It is the responsibility of all members of staff to familiarise themselves with current fire procedures. The following procedures to be carried out by staff on discovery of smoke/flames ACTIVATE nearest break glass call point and ring 2222 and ask switchboard operator to call the Fire Service. The Fire Response team will attend the incident. If a smell of smoke/burning is sensed or a piece of equipment is overheating ACTIVATE nearest break glass call point. RING The Fire Response team will attend. When the Fire alarm activates the following events will take place, In the Fire zone a two tone signal will sound. An informative message will appear on all main fire and repeater panels, giving location of the incident and will give an audible signal. The two plasma screens, one in Time Out and one on wall of the newsagents (opposite Courtyard Cafeteria) will give the same information in diagrammatic form In adjacent zones an Alert signal intermittent mono tone will sound. Flashing beacons fitted in public areas to comply with Disability Regulations will activate. In these areas the following series of events will take place. All Fire doors will close. All Security doors will release Plant/machinery may be shut down Lifts will return to ground floor, doors will open, lifts cannot be used. Fire Response team will be in attendance. Every attempt will be made to deal with the incident quickly to cause minimum inconvenience, but safety must take priority. Wards/departments hearing the Alert signal should take note of the message on the fire panel and be prepared in case the adjacent area decides to evacuate into their area. Source: Compliance Officer Status: Approved Page 27 of 65

28 Source: Compliance Officer Status: Approved Page 28 of 65

29 26.2 Treatment Centre FIRE INSTRUCTIONS FOR THE DAY TREATMENT CENTRE If smoke/flames are visible, activate the nearest Fire Alarm Call Point, ring 2222 and ask switchboard to dial 999 for the Fire Service. The Fire Response team will also arrive. If the alarm is raised for smell of smoke/burning or other related Fire problem then activate the Fire Alarm Call Point and wait the arrival of the Fire Response team This building has three Fire alarm zones, 2 on the ground floor and 1 on the upper floor. When the Fire alarm sounders are activated, the fire zone will sound the continual signal and the other zone will sound the intermittent signal. The initial evacuation, on the ground floor will be from the danger zone to the disabled car park at the front of the building if necessary; the patients will be ferried into the main hospital building. If operations are being carried out and the patient cannot be moved then the Fire Response team or Fire Service need to know the location and the numbers of staff remaining with the patient. If one of the ground floor zones signals Fire, then the fire panel at reception on the first floor needs to be checked to find the location of the fire. Preparations should be made for everyone on the first floor to proceed to the staircase; at the opposite end of the building should evacuation become necessary. If the first floor zone signals Fire then patients need to be moved to either staircase, unless one is inaccessible. If patients need to be assisted down the stairs, then the reception area or the admin area at the opposite end of the building can be used as refuge areas until the Fire Response team arrives. The safety of these areas will depend on all Fire doors being closed. Fire Alarm tests are held on Tuesday between 0800 and 1000 hours. Fire Drills will be held at various times during the year. Source: Compliance Officer Status: Approved Page 29 of 65

30 Source: Compliance Officer Status: Approved Page 30 of 65

31 26.3 Education Centre FIRE INSTRUCTIONS FOR THE EDUCATION CENTRE When the Fire alarm actives the building will be evacuated and all persons in the building will assemble in the designated area i.e. In CAR PARK at bottom of the ramp adjacent to FIRE ASSEMBLY POINT SIGN. If smoke/flames are visible activate the nearest Fire Alarm Call point, ring 2222 and ask switchboard to dial 999 for the Fire Service. The Fire Response team will arrive quickly. If the alarm was raised for smell of smoke/burning or other fire related problem, then activate Fire Alarm Call Point and wait arrival of the Fire Response team. The Portering Supervisor will liaise with the Centre Manager to ensure all areas have been checked and all persons have left the building. All persons should have assembled clear of the ramp so that the Fire response team and the Fire Service, if called; have unhindered access. The Librarian or Assistant is responsible for clearing the Library and Computer rooms and reporting to the Centre Manager. All Tutors/instructors/lecturers are responsible for all persons attending their session and on arrival at the Fire Assembly Point should make a roll call check. Then report to Centre Manager/Portering Supervisor or Fire Service, if in attendance. Source: Compliance Officer Status: Approved Page 31 of 65

32 Source: Compliance Officer Status: Approved Page 32 of 65

33 26.4 MRI department FIRE INSTRUCTIONS FOR THE MRI DEPARTMENT Action in case of Fire notices are displayed in prominent positions throughout the building It is the responsibility of all members of staff to familiarise themselves with current fire procedures The following procedures are to be carried out by staff on discovery of smoke/flames ACTIVATE the nearest break glass call point and ring 2222 and ask the switchboard operator to call the Fire Service. The Fire Response team will attend the incident; they must liaise with the most Senior MRI Radiographer. Out of hours they must contact them via Switchboard. If fire suspected in the MRI department with a continuous alarm the department will be evacuated to fire assembly point 15. Outside the Macmillan department. Dangers associated with Magnetic Field. If fire suspected close to the MRI scanners please press the Quench Button Quench Button kills the magnetic field This button is on the panel in both MRI control rooms. Please evacuate the local area and ensure the vent pipes are clear of personnel. (Ref: MRI Local operational policy with respect to MRI safety). MRI compatible CO2 extinguishers are sited around the MRI department for use in the magnetic field. No other fire fighting equipment will be taken into the scanning rooms without quenching the magnetic field. This is when the magnet power is switched off. When the Fire alarm activates the following events will take place, In the Fire zone a two tone signal will sound. An informative message will appear on all main fire and repeater panels, giving location of the incident and will give an audible signal. The two plasma screens, one in Time Out and one on wall of the newsagents (opposite Courtyard Cafeteria) will give the same information in diagrammatic form In adjacent zones an Alert signal intermittent mono tone will sound. Flashing beacons fitted in public areas to comply with Disability Regulations will activate. In these areas the following series of events will take place. All Fire doors will close. All Security doors will release Plant/machinery may be shut down Lifts will return to ground floor, doors will open, lifts cannot be used. Fire Response team will be in attendance. Every attempt will be made to deal with the incident quickly to cause minimum inconvenience, but safety must take priority. Wards/departments hearing the Alert signal should take note of the message on the fire panel and be prepared in case the adjacent area decides to evacuate into their area. Source: Compliance Officer Status: Approved Page 33 of 65

34 QUENCHING BUTTON MAP Source: Compliance Officer Status: Approved Page 34 of 65

35 Source: Compliance Officer Status: Approved Page 35 of 65

36 26.5 Inpatient Theatres FIRE INSTRUCTIONS FOR THE INPATIENT THEATRES Action in case of Fire notices are displayed in prominent positions throughout the building It is the responsibility of all members of staff to familiarise themselves with current fire procedures The following procedures are to be carried out by staff on discovery of smoke/flames ACTIVATE the nearest break glass call point and ring 2222 and ask the switchboard operator to call the Fire Service. The Fire Response team will attend the incident; they MUST liaise with the Theatre Suite coordinator on duty. If Fire is suspected in the Theatre department with a continuous alarm:- 1. All work should stop as far as reasonably practicable. Non-essential staff should be evacuated. 2. All doors should be closed, manually or automatically, and gas and electrical supplies should be shut down in order to confine the fire. 3. If evacuation is required, staff and equipment required to move the patient and evacuate to the pre-planned area should be identified. 4. Staffs working in an active theatre are to stay with the patient and await instructions, i.e. prepare for a full evacuation. 5. All patients NOT under General Anaesthetic or having surgery are to be removed from the area via recovery, the airlock or into the rear corridor via CDS or the rear exit. 6. All other staff must leave the department and remain in the Fire assembly point to wait further instructions from senior staff. 7. The Recovery staff will prepare to receive patients from theatre and on the instruction from the suite co-ordinator, will commence returning patients to the wards using staff from the assembly point. The suite co-ordinator will ensure all working theatres are kept continuously informed of the situation. If the situation is serious enough, the suite co-ordinator will affect a full evacuation of the Department. Full evacuation 1. All procedures are terminated. 2. Surgeon to prepare patient for moving by getting to a point in the surgery to allow the evacuation of the patient. 3. Patients transferred to their beds whilst Anaesthetist and anaesthetic practitioner maintain patient s anaesthesia with anaesthetic machine and support pack. 4. Surgeon and other team members will assist in getting the patient clear of hazards and immediately go to fire assembly point where patients can be stabilised (e.g.; Recovery, Critical Care Services whilst a decision is taken on whether to await the Fire officers permission to return to theatre or to transfer patient and team to Emergency department or Day Surgery Unit. Source: Compliance Officer Status: Approved Page 36 of 65

37 Source: Compliance Officer Status: Approved Page 37 of 65

38 26.6 Quince House FIRE INSTRUCTIONS FOR THE QUINCE HOUSE Action in case of Fire notices are displayed in prominent positions throughout the building It is the responsibility of all members of staff to familiarise themselves with current fire procedures The following procedures are to be carried out by staff on discovery of smoke/flames ACTIVATE the nearest break glass call point and ring 2222 and ask the switchboard operator to call the Fire Service. The Fire Response team will attend the incident; they MUST liaise with the Fire wardens from the building during working hours. If Fire is suspected in the department with a continuous alarm:- 1. All work should stop and all staff should be evacuated. 2. All doors should be closed, manually or automatically, and gas and electrical supplies will shut down in order to confine the fire. 3. If evacuation is required, staff and visitors should move to the fire assembly point. 4. Staff working in an intermittent zone should remain in their area and await instructions, i.e. prepare for a full evacuation. Although there is a phased evacuation if the situation is serious enough, the fire wardens will affect a full evacuation of the building. Source: Compliance Officer Status: Approved Page 38 of 65

39 Source: Compliance Officer Status: Approved Page 39 of 65

40 27. Fire Assembly Points 27.1 Internal Fire Assembly points All FAPs are located at the corners of the hospital streets with the exception of FAP 5, which is located near Breast imaging. IFAP 1 IFAP 2 IFAP 3 IFAP 4 IFAP 5 IFAP 6 IFAP 7 IFAP 8 IFAP 9 Ground floor Hospital Street corner at the rear of A + E Ground floor Hospital Street corner outside Ward G8 Ground floor Hospital Street corner outside Ward G1 Ground floor Hospital Street corner at rear of OPD Ground floor G4/G5 corridor (outside breast imaging) 1st. floor Hospital Street corner outside F7/F8 & F9/F10 link corridors 1st floor Hospital Street corner opposite F12 1st floor Hospital Street corner outside F1 1st floor Hospital Street corner outside F3/F4 & F5/F6 link corridors Source: Compliance Officer Status: Approved Page 40 of 65

41 27.2 Fire Assembly points All FAP s are located externally outside of the main hospital. EFAP 10 EFAP 11 EFAP 12 EFAP 13 EFAP 14 EFAP 15 EFAP 16 EFAP 17 EFAP 18 EFAP 19 Grassed area next to the heath road car park barriers The rear delivery area of the main kitchen Disabled car park at the front of the Day Surgery Unit Car park E opposite Rowan house A & B Car park D at the side of the Education Centre Outside MacMillan Unit OPD in the car park area The grassed area, near G9 ward The front residences near Oak House Near the exit road leading away from Occupational Health The grassed area opposite the Emergency department Source: Compliance Officer Status: Approved Page 41 of 65

42 28. Progressive horizontal evacuation plans 28.1 Evacuation plan lower ground floor Progressive Horizontal Evacuation plan Lower Ground Floor G6 Occupational Health exits exits Occy Health FAP 18 G6 exits G7 FAP 15 G6 G7 exits G7 FAP 16 Source: Compliance Officer Status: Approved Page 42 of 65

43 28.2 Evacuation plan ground floor Progressive Horizontal Evacuation plan Ground Floor IT Dept G1 MacMillan Pharmacy MRI Rainbow Outpatients MacMillan Outpatients IT Dept FAP11 G1 MacMillan G1 MacMillan Rainbow Outpatients MRI Dept G2 Endoscopy MRI FAP15 Pharmacy Rainbow Outpatients MacMillan Outpatients G1 MacMillan IT Dept FAP11 Internal FAP3 Rear Hospital corridor FAP11 FAP15 FAP15 Macmillan Outpatients Main Entrance Source: Compliance Officer Status: Approved Page 43 of 65

44 Progressive Horizontal Evacuation plan Ground Floor G3 Cardiac G2 Endoscopy G1 MacMillan G2 Endoscopy G2 Endoscopy Internal FAP3 G3 Cardiac G3 Cardiac Internal FAP4 G5 G4 Internal FAP5 G5 G4 G4 FAP15 (via fire escape) G5 Internal FAP5 FAP16 (via fire escape) G9 Internal FAP5 G9 FAP16 Source: Compliance Officer Status: Approved Page 44 of 65

45 Progressive Horizontal Evacuation plan Ground Floor Therapies Dept Diabetes Internal FAP5 Hospital Street Diabetes Therapies Dept FAP18 FAP16 Fire exits Outpatients Department Hospital Street OPD A, B & C FAP18 Therapies Dept OPD D OPD A, B & C OPD D FAP19 Main Entrance corridor Source: Compliance Officer Status: Approved Page 45 of 65

46 Progressive Horizontal Evacuation plan Ground Floor Main Entrance Corridor Hospital Street Main Entrance corridor FAP19 OPD Main Entrance includes: Courtyard café Ambulance Liaison WHSmiths Friends Shop Voluntary Services Health Records Emergency Dept Fracture Clinic Hospital Street ED Entrance A&E Entrance Fracture Clinic FAP19 Emergency Dept (ED) FAP19 Health Records FAP19 Main Entrance corridor Rear Entrance corridor Staff Entrance Source: Compliance Officer Status: Approved Page 46 of 65

47 Progressive Horizontal Evacuation plan Ground Floor Pathology Chapel & Domestics Trust corridor Committee Room exit Female locker room Hospital Street Trust corridor FAP19 Chapel & Domestics FAP19 Pathology FAP18 Staff Entrance Hospital Street Hospital Street Trust corridor includes: Trust Offices Finance Dept Clinical Coding Risk Office Nursing Directorate Orthopaedic Offices Matron s Office Unison Office General Office/Patient Affairs West Suffolk Professionals Radiology & CT Medicine Hospital Street Radiology & CT Medicine Internal FAP1 Hospital Street Source: Compliance Officer Status: Approved Page 47 of 65

48 Progressive Horizontal Evacuation plan Ground Floor Pre-Assessment Clinic Pain Clinic Pre-Assess Clinic FAP19 CT Medicine Pain Clinic Hospital Street Pain Clinic FAP10 Pre-Assess Clinic Estates Dept Ramp area Estates Dept FAP10 Roller Shutter entrance Estates Dept includes: Works Dept Purchasing Laundry Room Linen Room Waste Station Portering Offices Social Services corridor Hospital Street Social Services corridor FAP10 Pre-Assess Clinic Social services corridor inc: Social Services Sewing Room Stroke Team COPD Operational Team Clinical Trials offices Source: Compliance Officer Status: Approved Page 48 of 65

49 Progressive Horizontal Evacuation plan Ground Floor G8 entrance G8 fire exits Friends Corridor Breast Imaging Renal Unit G8 Renal unit G8 Hospital Street Hospital Street Internal FAP1 Renal unit Internal FAP10 Breast Imaging FAP 16 Friends Corridor FAP 15 Social Services fire exit fire exit Breast Imaging Source: Compliance Officer Status: Approved Page 49 of 65

50 28.3 Evacuation plan first floor Progressive Horizontal Evacuation plan First Floor F1 Rainbow Hospital Street F1 Rainbow Internal FAP 9 F2 CCU Last Resort: staircase to ground floor F1 Rainbow F2 CCU F3 F4 F3 F2 CCU Internal FAP 9 F2 CCU F3 F4 Internal FAP 8 F3 F4 F5 Internal FAP 8 Source: Compliance Officer Status: Approved Page 50 of 65

51 Progressive Horizontal Evacuation plan First Floor F4 F5 F6 Last Resort: staircase to ground floor F6 F5 Internal FAP 6 F5 F6 F7 Internal FAP 6 F6 F7 F8 EAU F8 EAU F7 Internal FAP 7 F7 F8 EAU F9 Last Resort: staircase to ground floor Internal FAP 7 Source: Compliance Officer Status: Approved Page 51 of 65

52 Progressive Horizontal Evacuation plan First Floor F8 EAU F9 F10 F10 F9 F9 Internal FAP 7 F10 F11 Maternity Internal FAP 7 F10 F11 Maternity Antenatal F11 Maternity Labour Suite Antenatal OPD F11 Maternity Antenatal OPD Internal FAP 6 Entrance to Hospital Street Last Resort: staircase to ground floor Source: Compliance Officer Status: Approved Page 52 of 65

53 Progressive Horizontal Evacuation plan First Floor Neonatal Labour Suite Birthing Unit F12 Hospital Street Labour Suite Neonatal / Theatres Neonatal Entrance Internal FAP 8 F12 Birthing Unit F11 Maternity Labour Suite F11 Maternity Neonatal F1 Rainbow FAP 10 Rear external staircase Birthing Unit Entrance Birthing Unit Labour Suite Last Resort: staircase to ground floor Source: Compliance Officer Status: Approved Page 53 of 65

54 Progressive Horizontal Evacuation plan First Floor F14 Main Hospital Street F14 MTU F14 includes: Hospital at Night Admin Offices on link corridor Internal FAP 9 F14 MTU Respiratory Physiology MTU Internal FAP 9 Respiratory Physiology Hospital Street Respiratory Physiology Internal FAP 9 MTU Respiratory Physiology inc: Palliative Care Clinical Skills Office Tissue Viability PICC Lines Theatres Rear entrance / Labour Suite Theatres CCS Recovery Defend in situ Evacuation is a last resort Source: Compliance Officer Status: Approved Page 54 of 65

55 Progressive Horizontal Evacuation plan First Floor Recovery CCS ITU/HDU entrance Theatres CCS ITU / HDU Recovery Recovery Rear entrance ITU/HDU Defend in situ - Evacuation is a last resort This includes: Anaesthetics Dept Defend in situ - Evacuation is a last resort Cardiology Outpatients Hospital Street Cardiology Outpatients Internal FAP 8 Rear entrance Rear Hospital Street Dept entrance Rear Hospital Street Internal FAP 8 Dept entrance Rear Hospital Street inc: Dietetics Catering Office Operational Directorate Source: Compliance Officer Status: Approved Page 55 of 65

56 Progressive Horizontal Evacuation plan First Floor Timeout / Kitchens Hospital Street Timeout/ Kitchens FAP 11 Staircases Source: Compliance Officer Status: Approved Page 56 of 65

57 28.4 Evacuation plan satellite buildings Progressive Evacuation plans Satellite buildings DSU Eye Treatment Centre exits DSU / ETC FAP 12 exits Education Centre exits Education Centre FAP 14 exits Rowan House exits Rowan House A & B FAP 13 exits Residences exits Residences FAP 17 exits Includes: Oak Larch Birch Pine Cedar Source: Compliance Officer Status: Approved Page 57 of 65

58 Source: Compliance Officer Status: Approved Page 58 of 65

59 28.5 Site map Source: Compliance Officer Status: Approved Page 59 of 65