SOUTHERN HEALTH NHS FOUNDATION TRUST

Transcription

1 SOUTERN EALT NS FOUNDATION TRUST REGULATORY REFORM (FIRE SAFETY) ORDER 2005 PERIODIC REVIEW OF FIRE RISK ASSESSMENT Address of Property: Person(s) consulted: Parklands ospital, Aldermaston Road Basingstoke RG24 9R Steve Webb Assessors Jerry Pearce Date of Fire Risk Assessment: 16 h July 2012 Date of Previous Fire Risk Assessment: 13 th July 2011 Suggested Date for Next Review 1 : July 2013 Signed: Date: 16 th July 2012 The purpose of this report is to review a previous assessment of the risk to life from fire in these premises, and, where appropriate, to make recommendations to ensure compliance with fire safety legislation. The report does not address the risk to property or business continuity from fire. 1 The original fire risk assessment should be reviewed again by a competent person by the date indicated above or at such earlier time as there is reason to suspect that it is no longer valid or there have been significant changes. 13 th July 2011

2 GENERAL INFORMATION 1. Significant changes identified since the time of the previous fire risk assessment in respect of: 1.1 The premises: Nil 1.2 The occupancy: No changes 1.3 The occupants (including occupants at special risk): No changes 1.4 Fire loss experience: None reported 1.5 Application of fire safety legislation: RRFSO 2005 is still applicable 1.6 Other relevant information: Since the 2010 / 2011 FRA s fire safety has improved greatly with enhancements to the AFA system, fire doors, signage and general housekeeping. This is due to the continuous improvement and proactive stance taken by Steve Webb and his team to ensure the building remains a safe environment. FIRE AZARDS AND TEIR ELIMINATION OR CONTROL 2. Significant changes in measures to prevent fire since the time of the fire risk assessment: 2.1 Are there adequate measures to prevent fire? Yes No x Comments and hazards observed: Trust Fire Policy in place Local Fire Policy in use PAT test haphazard 3.1 Are housekeeping and maintenance adequate? Yes X No Good housekeeping improvements in place since last FRA Under stair areas found free of combustibles 2

3 FIRE PROTECTION MEASURES 4 Significant changes in fire protection measures since the time of the fire risk assessment: 4.1 Are the means of escape from fire adequate? Yes x No All corridors and stairs were found to be free of obstacles Adequate signage leading to fire exits 4.2 Are compartmentation and linings satisfactory? Yes No x Elmwood Tapestries hanging as per FRA 2011 but not fixed to walls adequate Self closers to Elmwood patient bedrooms disconnected, tolerable due to FD60S fire doors compartmenting these areas and Trust No Smoking Policy enforced Kitchen door closer must be connected to contain smoke and maintain compartmentation to allow evacuation from bedrooms in the event of fire Some fire doors need adjustment 4.3 Is there reasonable emergency escape lighting 2? Yes x No Previously over tested, now tested and recorded each month 4.5 Are there adequate fire safety signs and notices? Yes No x Previous signage replaced and now compliant to BS7070, however some Fire Action notices do not show relevant information No Do Not Use Lifts In the Event Of Fire displayed 4.6 Are the means of giving warning of fire adequate 3? Yes x No New oneywell automatic addressable alarm system supplemented with manual call points throughout. 5 x BS420 Automatic Fire Alarm system repeater panels replaced on 23/2/12 to complete the system 4.7 Is the provision of fire extinguishing appliances adequate? Extinguishers found to be sufficient for risks Some extinguishers show last annual test date 11/4/11 Fire blankets in kitchens and beverage points Yes x No 4.8 Comments on other fixed fire protection systems? 2 Based on visual inspection only. 3 Based on visual inspection only. 3

4 None MANAGEMENT OF FIRE SAFETY 5 Significant changes in management of fire safety since the time of the fire risk assessment: 5.1 Are arrangements for management of fire safety adequate? Compliance Log confirms the following: AFA Weekly & Automatic Fire Door test last tested 12/7/12 Fire Door Quarterly test last tested 12/6/12 Fire Door Annual test 4/1/12 Emergency lighting Monthly test last tested 11/6/12 Yes No x Fire Extinguishers Annual Test last tested 18/7/11, some found to be 11/4/11 Fire Drills last carried out May 2012 Fires Nil Responsible Person Section completed with current Responsible Person and Deputy No PAT test records Dorgard no battery change records 5.2 Are fire procedures adequate? Yes x No Fire action Notices and Trust Seek & Search procedures posted throughout 5.3 Are the arrangements for staff training and fire drills Yes x No adequate? Staff attend annual Fire Safety Awareness, and Fire Warden courses delivered by Trust Fire Safety Site Specific training carried out by staff to new joiners on site. Annual Fire Evacuation exercise has been carried out in the last year and recorded 5.4 Are the arrangements for testing and maintenance of fire Yes No x protection systems and equipment adequate? Tests and inspections carried out by Basingstoke & North ampshire NS Foundation Trust - some ongoing issues with frequency 5.5 Are there adequate records of testing, maintenance, training and drills? Yes x No 4

5 The E&FM Compliance Log has improved greatly with full and comprehensive evidence to support that tests and drills are carried out FIRE RISK ASSESSMENT On the basis of the criteria set out in the original fire risk assessment, it is considered that the current risk to life from fire at these premises is: Trivial Tolerable x Moderate Substanti al Intolerable 5

6 ACTION ON PREVIOUS ACTION PLAN 6 ave all previous recommendations been satisfactorily addressed? Yes No x Brief details of recommendations not yet implemented Some extinguishers still out of test date The majority of Fire Doors are now compliant Fire doors to some offices still found wedged Self closing devices are disconnected to all rooms in Elmwood and need removing End 6

7 NEW ACTION PLAN FOR ADDITION FINDINGS It is considered that the following recommendations should be implemented in order to reduce fire risk to, or maintain it at, the level indicated in each case. Item Number & Potential azards & Risk Risk Recommended remedial action Target Date? PAT test haphazard but found to be ongoing, with no records. Some equipment without test tag. Risk that fuse protection does not function, some equipment may be dangerous given it s age. Elmwood Kitchen door closer must be connected to contain smoke and maintain compartmentation to allow evacuation from bedrooms in the event of fire. Risk that smoke will travel to bedrooms A small number of fire doors require adjustment or replacement to ensure fire compartmentation is maintained. Risk that smoke will escape through gaps larger than 3mm. PAT test found to be ongoing, when complete to be added to the E&FM Compliance Log Non compliant items to be discarded/recycled Appropriately trained person to reconnect closer The following doors need adjustment or replacement to meet:: RRFSO 2005 article 14 & 17 BS 9999 sections 5&7 ADB B1 sections 3&4 Elmwood Corridor to RMs FD60 B5 522/1 excessive gap lower half awthorn Corridor FD warped Completion Date 16/09/12 Oct 2012 PAT testing is reported & logged via our BNFT estates helpdesk as required. On receipt of this FRA Completed by Southern ealth Estates Department All Fire Doors as detailed have been adjusted as advised.. Completed by Southern ealth Estates Department Main Foyer to base of stairs A1 714 not 7

8 NEW ACTION PLAN FOR ADDITION FINDINGS It is considered that the following recommendations should be implemented in order to reduce fire risk to, or maintain it at, the level indicated in each case. Item Number Potential azards & Risk Risk Recommended remedial action Target Date? Some generic Fire Action Notices do not have relevant information on who to call and where to go in the event of fire. Risk that individuals do not take appropriate action No Do Not Use Lifts In the Event Of Fire notices displayed. Low risk as lift keeps are interfaced into AFA system but required as mandatory fire signage L closing fully First floor landing from Foyer 2 616/3 not closing fully, no top seal. Managers should ensure all Fire Action Notice blank sections in their areas are filled in with indelible pen or sticker to indicate relevant actions. All lifts to display Do Not Use Lifts In the Event Of Fire adjacent to external lift call buttons. Completion Date 31/7/12 All signage has been updated with relevant information 16/10/12 Signage has been put on adjacent walls by lifts & 5.4 Some extinguishers fall out of annual test period sample CO2 test date11/4/11. Risk that it will not operate when required to do so. Tester should ensure that all extinguishers are tested and maintained in accordance with BS 5306 and recorded in E&FM Compliance Log. Note: Existing B&N NS Foundation Trust extinguisher test record information should be added to the relevant section of the E&FM Compliance Log 16/11/12 Testing & maintainance carried out by Chubb via BNFT estates department. Latest report in compliance log book 8

9 NEW ACTION PLAN FOR ADDITION FINDINGS It is considered that the following recommendations should be implemented in order to reduce fire risk to, or maintain it at, the level indicated in each case. Item Number Potential azards & Risk Risk Recommended remedial action Target Date? No record of annual Dorgard battery change. Risk that door will not close on actuation of alarm if battery is discharged Note: There is a culture of door wedging which could lead to loss of fire compartmentation if fire doors remain held open. A simple form should be made up to record that each Dorgard device has it s battery changed annually. Form to be placed in E&FM Compliance Log Memo to be sent to all departmental managers to highlight the risks involved and the consequences of these actions. Completion Date 16/08/12 Battery replaced upon low power alarm Memo sent to all departments to remind staff not to wedge door open 9

10 NEW ACTION PLAN FOR ADDITION FINDINGS It is considered that the following recommendations should be implemented in order to reduce fire risk to, or maintain it at, the level indicated in each case. Item Number Potential azards & Risk Risk Recommended remedial action Target Date? Completion Date 10