Annual Fire Safety Report: April 2014 to March 2015 To NHS Lanarkshire Board Prepared for: Director of Strategic Planning and Performance by the

Transcription

1 Annual Fire Safety Report: April 2014 to March 2015 To NHS Lanarkshire Board Prepared for: Director of Strategic Planning and Performance by the General Manager, Property and Support Services Division

2 CONTENTS Page 1. Executive Summary Introduction 5 3. Statutory Enforcement Authority- Scottish Fire And Rescue Service Responsibilities and Powers Performance Fire incidents Unwanted Fire Alarm Signals Actual Fire Incidents Significant Fire Incidents Fire incidents 2008/09 to 2014/ Fire Hazards Fire Risk Assessment General Monklands Hospital Fire Risk Assessment Review Programme Planned Fire Safety Works 2014/ Monklands Planned Fire Safety Works 2014/ Fire Safety Compliance Audits Conducted by Scottish Fire and Rescue Service Fire Safety Training Emergency Fire Evacuation Drills NHS Lanarkshire and Scottish Fire And Rescue Service Partnership Working Concordat of Partnership Working Joint Partnership Meetings NHS Lanarkshire and Scottish Fire and Rescue Partnership Initiatives Health Facilities Scotland National Fire Safety Group Fire Safety Group Fire Policy and Procedure Fire Safety Control Book Fire Safety Work Plan 2014/ Summary References 15 NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 2 of 16

3 Executive Summary This executive summary provides highlights from the Annual Fire Safety Report April 1 st 2014 to 31 st March This Report has been prepared by the General Manager Property and Support Services Division, in his capacity as Nominated Officer Fire (NOF) for the Director of Strategic Planning and Performance who has Executive Lead for Fire Safety Compliance. 1.1 Statutory Enforcement Authority Scottish Fire and Rescue Service (SFRS) Responsibilities and Powers This report details the responsibilities and powers under the Fire (Scotland) Act 2005 (as amended) and the Fire Safety (Scotland) Regulations 2006 of SFRS as the Enforcing Authority. (See main report section 3). 1.2 Report Statistics The report includes yearly statistics on: Fire Incidents Unwanted Fire Alarm Signals Fire Risk Assessments Statutory Compliance Notices issued by the Enforcing Authority Attendance by staff at Fire Safety Awareness Training, General and Specific Fire Evacuation Drills. 1.3 Fire Incidents The total number of Fire Incidents for year 2014/15 was 165. (See main report section 4.1). 1.4 Unwanted Fire Alarm Signals (UFAS) The total number of UFAS for this reporting period 2014/15 totalled 132. (See main report section 4.1.1) 1.5 Actual Fires Incidents The total number of Actual Fire Incidents reported and investigated during 2014/15 was 15. (See main report section 4.1.2). 1.6 Actual Fires Incidents of Significant Interest. The total number of Fires of Significant Interest reported during 2014/15 was 4. None of the incidents met the criteria which required reporting to Scottish Government Health and Social Care Directorate. (See main report section 4.1.3). 1.7 Fire Incidents (2009/10 to 2014/15) Analysis over a six-year period from 2009/10 to 2014/15 has shown a continued overall decrease on the number fire incidents experienced by NHS Lanarkshire (NHSL). 1.8 Fire Risk Assessments (FRAs) NHSL continues to use the Estates Asset Management Data System (EAMS) for recording all FRAs, The current total number of FRAs areas is 465of which 462 are completed and entered into the EAMS. The outstanding FRAs for the 3 new health centres recently occupied have been commenced and are scheduled for completion in September NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 3 of 16

4 1.9 Fire Risk Assessments Review Programme During this reporting period 2014/15 a total of 79 reviews were completed. (See main report section 4.3.3) Planned Fire Safety Works (2014/15) A total of circa 1.5 million has been expended on fire safety works. This funding was utilised to address significant risks recorded in the EAMS. The focus for this investment was Mental Health and Care of the Elderly wards and Monklands Hospital. (See main report section 4.4.1) SFRS Compliance Audits SFRS conducted 18 Fire Safety Audits in NHSL premises. No formal enforcement action was taken and SFRS noted only issues of minor deficiency for 11 premises and no issues for 7 premises. Actions plans have been actioned for each premise with deficiencies recorded and SFRS advised accordingly (See main report section 4.5) Fire Safety Training A total of 76% of NHSL staff received fire safety training. This figure indicates 3% increase on the previous reporting period (See main report section 4.6) Emergency Fire Evacuation Drills A total 224 drills were conducted. This figure indicates 51.8% decrease on the previous reporting period 2013/14. (See main report section 4.7) 1.16 Fire Safety Groups The management & reporting, performance on fire safety compliance is by a structured set of Fire Safety Groups which meet quarterly (See main report section 7) Fire Policy and Procedure The review of NHSL Fire Policy by the NHSL Fire Safety Group was completed in May The revised policy includes detail of the new NHSL FRA Review Prioritisation Methodology and the Fire Safety Control Book (FSCB) (See main report section 8) Fire Safety Control Book The FSCB is now operating across all NHSL sites. The current total FSCBs issued is 262. During reporting period 2014/15 a total of 91 FSCBs were audited (See main report section 9) Fire Safety Work Plan 2015/16 The NOF has developed an annual Fire Safety Work Plan for reporting period 2015/16 in order to develop and progress fire safety within NHSL to ensure compliance with current fire safety legislation and that the risk from fire is effectively managed (See main report section 10). NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 4 of 16

5 2 Introduction This Report has been prepared by the General Manager Property Support Services Division, in his capacity as Nominated Officer Fire (NOF), on behalf of the Director of Strategic Planning & Performance (Executive Director Fire Safety Compliance). The report provides details of the management and reporting on fire safety activities across NHSL in the reporting period from 1 st April 2014 to 31 st March 2015, including statistics on Unwanted Fire Alarm Signals. Fire Incidents. Fire Risk Assessments. Statutory Compliance Notices issued by the Enforcing Authority. Attendance by staff at Fire Safety Awareness Training, General and Specific. Emergency Fire Evacuation Drills. 3 Statutory Enforcement Authority- SFRS Responsibilities and Powers 3.1 The SFRS is the Enforcing Authority for fire safety across Scotland. NHSL continues to deal with locally based Fire Safety Enforcement Officers and Operational Fire Crews. 3.2 The Fire Scotland Act 2005 (as amended) and the Fire Safety (Scotland) Regulations 2006 introduced a National Framework setting out Government expectations of the Fire & Rescue Service enforcement regarding fire safety provision required for all premises. 3.3 The Fire Scotland Act 2005 (as amended) and The Fire Safety (Scotland) Regulations 2006, require all fire safety requirements to be based on fully documented Fire Risk Assessments being available for all premises owned or occupied by NHSL. 3.4 The powers of the enforcement officers in relation to premises for which they have enforcement responsibilities are listed in section 62 of the Fire Scotland Act 2005 (as amended) and are summarised below. Enforcement officers may do anything necessary to allow them to enforce their fire safety duties, including; Entering premises for inspection at any reasonable time, or at any time if the officer has reason to believe that the situation is dangerous. Requesting information, records etc, or assistance from any persons with fire safety duties. Inspecting, copying or removing any relevant documents from the premises. Carrying out any inspections, measurements or tests considered necessary on the premises or any article or substance found on the premises. Taking samples of any article or substance found on the premises. Dismantling articles found on premises which appear likely to cause danger from fire. Taking possession of an article for purposes of examination or use as evidence. 3.5 If the Enforcing Authority is dissatisfied with the outcome of the fire safety risk assessment or the action taken, or the fire safety measures in place, it has the power to take action which could be; Informal action. Formal enforcement action which could result in the issue of an enforcement notice that requires specified action to be taken (Enforcement Notice). In extreme cases, a prohibition notice may be issued that restricts the use of all or part of the premises until specified matters are remedied. Reporting the matter for prosecution. Failure to comply with a notice issued by the enforcing authority or placing persons at risk by failing to carry out any duty imposed by fire safety law is an offence. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 5 of 16

6 3.6 Additionally, if the premises pose a serious risk to persons in respect of harm, caused by fire, or would pose such a risk if particular changes were made to the premises, the authority may issue an alterations notice that obliges the recipient to inform the enforcing authority before making specified changes to the premises. 3.7 SFRS crews will visit premises to enable crew members to gain familiarisation with them in the event they are called to a fire in the premises. This type of visit is unlikely to include an assessment of compliance with fire safety law. The fact that a fire and rescue service visit has taken place should not be interpreted as an endorsement of fire safety measures and procedures being applied in the premises. 4 Performance 4.1 Fire Incidents The total number of Fire Incidents recorded for year 2014/15 was 165. This includes categories Unwanted Fire Alarm Signals(UFAS), Actual Fire Incidents, Fires of Significant Interest, False Actuation of the fire alarm system due to Malicious Intent, False Actuation of the fire alarm system due to Good Intent. The total represents an increase of 4.4 % from year 2013/14. The table below provides a comparison of the numbers of fire incidents across the 3 Acute Hospital sites, Corporate Services and CHP North & South Operating Divisions along with the general classification of the cause of fire alarm activations. Fire Incidents 1 st April 2014 to 31 st March 2015 H/myres M/lands Wishaw Corp. Serv. North CHP South CHP Total Unwanted Fire Alarm Actual Fire Incidents False Good Intent False Malicious Intent Total No of Incidents Breakdown, Cause of UFAS Burnt Food Smoking Steam Aerosol Spray System Faults Accidental Activations Fumes Dust Water ingression Unknown Accidental Contractor Unwanted Fire Alarm Signals The term Unwanted Fire Alarm Signal is used by SFRS to describe any actuation of an automatic fire alarm system, which is not the result of an actual fire and was considered to be avoidable (not including false actuations due to malicious or good intent). The number UFAS SFRS attend is one of approximately 12 KPIs used to measure the effectiveness of SFRS Demand Reduction Strategy. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 6 of 16

7 NHSL recognises the importance of this KPI and has demonstrated a continued commitment through its joint working with SFRS to reduce the level of UFAS as far as is reasonably practical. UFAS activity is discussed as a standing agenda item at NHSL/ SFRS joint partnership meetings. The NHSL Fire Safety Groups monitor the number of UFAS, examines trends, & undertakes the appropriate preventive actions as considered necessary. The number of UFAS for the current reporting period 2014/15 totalled 132; this represents an increase of 9.1% on the figures (121) for the previous reporting period 2013/14. Although the increase recorded is disappointing investigations were able to attribute the majority of the increase to the following areas; Monklands Hospital 111 % rise in the number of UFAS was recorded (18 in 2013/14 to 38 in 2014/15). This can be attributed to the extension and upgrading of the fire warning and detection system and extensive roof repairs carried out in ward 2. Wishaw Hospital 28.5 % rise in the number of UFAS was recorded (21 in 2013/14 to 27 in 2014/15). This can be attributed to an increase in systems faults with the fire warning and detection system. The number of UFAS recorded by North CHP operating division decreased by 19.2% (26 in 2013/14 to 21 in 2014/15), South CHP operating division decreased by 28% (25 in 2013/14 to 18 in 2014/15) and Hairmyres Hospital decreased by 37.5% (40 in 2013/14 to 25 in 2014/15). SFRS have recognised the commitment and progress made by NHSL in this matter over the last 6 years (43.8% reduction) and as result; SFRS have indicated they will continue not to use the number of UFAS as a trigger to carry out a Fire Safety Compliance Audit on NHSL premises. Although the rise in the number of UFAS during the current reporting period 2014/15 is disappointing efforts will continue to reduce the overall number of UFAS across all sites to maintain the overall downward trend. It is expected that the number of UFAS experienced at Monklands Hospital should fall in the new reporting period 2015/16 following the completion of the roof repairs carried out in ward 2 and that the teething problems which are normal with the installation of a new fire warming and detection system have been identified and rectified. The General Manager PSSD has requested SERCO investigate and report on the increased UFAS at Wishaw Hospital due to system faults in order that appropriate corrective action can be implemented in the new reporting period 2015/ Actual Fire Incidents There were a total of 15 Actual Fire Incidents reported and investigated during reporting period 2014/15. Four of the fires were considered as being of significant interest and 11 incidents did not result in any building damage or injuries being reported. This is a 25% increase on the number of Actual Fire Incidents reported during the reporting period 2013/14. Several incidents of deliberate fire raising in the grounds of Coathill Hospital Coatbridge have been recorded which gives cause for concern. Property Support Services Division has carried out repairs to boundary security fencing in an attempt to prevent further occurrences. Local Managers have also met with Police Scotland Community Officers to discuss the issue Actual Fire Incidents of Significant Interest There were 4 Fire Incidents of Significant Interest reported during the reporting period 2014/15. The premises involved were; Monklands Estate Office NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 7 of 16

8 Roofing contractors using hot work whilst carry out essential roofing repairs set fire to roofing timbers. The fire was quickly extinguished with no significant damage caused. SFRS attended but took no fire fighting action. Monklands Ward 24 A patient set fire to a waste bag and hand drying wipes. Staff quickly extinguished the fire using a water type fire extinguisher. Fire damage was contained to a small area of the floor. SFRS attended but took no fire fighting action. Law House Gardeners Cabin The fire was caused by a defective electrical socket. The incident did not result in any fire damage. SFRS attended but took no fire fighting action. Hairmyres Hospital Elderly Patient placed a pillow under a chair and set fire to it using a lighter. The fire was extinguished by a member of staff using a jug of water. Fire damage was contained to the pillow and chair. The room suffered very slight smoke damage. SFRS attended but took no fire fighting action. NHSL Fire Advisors carried out an investigation of the 4 incidents and compiled a report on behalf of the NOF. None of the incidents met the criteria which required them to be reported to Scottish Government Fire Incidents 2009/10 to 2014/15 The table below provides a comparison of the number of incidents recorded across NHSL over a 6 year period from 2009/10 to 2014/15. Fire Incidents 2009/10 to 2014/ / / / / / /15 Unwanted Fire Alarms Actual Fire Incidents False Good Intent False Malicious Intent* Total No of Incidents * Note the category False Malicious Intent, was introduced for report 2011/2012 Despite there being a slight increase in the total number of fire related incidents reported during reporting period 2014/15 The total number of Fire Incidents (165) is lower than the 6 year mean average (193) This represents a 14.5% reduction on the average figure. 4.2 Fire Hazards In last reporting period a new category Fire Hazards was introduced as part of the reporting facility to report fire related issues on Datix. This category is to allow staff to report issues which may present a fire hazard with regards to the potential to cause fire or affect the ability of persons to make their escape in the event of a fire. During this reporting period 2014/15 a total of 2 fire hazards were recorded. These related to obstruction of escape routes. 4.3 Fire Risk Assessments (FRAs) General As reported in the Annual Fire Safety Report for April 2013 to March 2014, NHSL continues to use the Estates Asset Management Data System (EAMS) for recording all FRAs, as mandated by Scottish Government and in accordance with NHS Scotland Fire Safety Policy CEL 11 (2011). The current total number of FRA areas, is 465 of which 462 are completed and entered into the EAMS NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 8 of 16

9 The total number of FRAs areas, recorded at the end of this reporting period 2014/15 has increased by 73 from the previous reporting period 2013/14, this is mainly as a result of the review of Monklands Hospital completed in February The number of FRA Areas for Monklands Hospital has increased from 29 to 69 to allow a common approach in line with the other 2 acute sites with regards to the size and make up of a FRA area. The outstanding FRAs for the 3 new health centres recently occupied have been commenced and are scheduled for completion in September The total number of FRAs will continue to be subject to change as new premises are acquired, old premises disposed of, and operational changes are made within existing premises Monklands Hospital The specific review of Monklands Hospital FRAs was completed in February 2015 which has resulted in the number of FRAs for the hospital increasing from 29 to 69. Monklands Hospital will now be included as part of the established FRA review programme Fire Risk Assessment Review Programme Regulation 3 of The Fire Safety (Scotland) Regulations 2006 places a requirement on duty holders to review FRAs on a regular basis. To satisfy this requirement NHSL has an established rolling programme of FRA reviews. The frequency a premise FRAs are the subject of review is based on the level of fire risk. During this reporting period 2014/15, 79 FRAs were reviewed by NHSL Fire Advisors Planned Fire Safety Works 2014/15 Allocation of circa 1.500, 000 has been expended on fire safety works during this reporting period 2014/15. This funding was utilised to target outstanding red and amber risks as identified in the FRAs and prioritised works identified during Fire Safety Audits conducted by SFRS Enforcement Officers. The funding was mainly targeted at, Mental Health and Care of the Elderly premises and Monklands Hospital Monklands Planned Fire Safety Works 2014/15 Investment for Monklands Hospital continued to be dealt with separately where the main focus was on improvements to the existing Fire Warning and Detection System. Allocation of circa 1,000,000 has been made, 4.5 Fire Safety Compliance Audits Conducted by SFRS During this reporting period 2014/15 SFRS conducted 18 fire safety audits in the under noted NHSL premises. The premises involved where; Planned Routine Audits Parksprings Care Home Motherwell Lady Home Hospital Douglas Kello Hospital Biggar Lockhart Hospital Lanark Wester Moffat Hospital Airdrie Stonehouse Hospital StoneHouse Kirklands Hospital (Kylepark Ward) Bothwell Beckford Lodge Hamilton Wishaw Hospital Staff Residences West of Scotland Laundry Wishaw NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 9 of 16

10 Monklands Hospital Main Kitchen Post Fire Audits Monklands Hospital Estates Office. Coathill Hospital Coatbridge Glen Affric Ward Coathill Hospital Coatbridge Glencairn Ward Coathill Hospital Coatbridge Glen Orchy Coathill Hospital Coatbridge Glen Nevis Hairmyres Hospital Ward 9 Hairmyres Hospital Wards 19 and 20 None of the audits resulted in formal enforcement action being taken by SFRS. Enforcements Officers noted only issues of minor deficiency for 11 premises. No issues were recorded for Monklands Estates Office, Monklands Main Kitchen, West of Scotland Laundry and all buildings audited at Coathill Hospital. Corrective actions plans have been actioned for each premise with deficiencies recorded and SFRS advised accordingly. 4.6 Fire Safety Training During this reporting period 2014/15, Property & Support Services Division staff and identified staff from CHP North and South Divisions delivered fire safety awareness training sessions on a regular basis throughout the year. Fire Safety Training is part of the NHSL mandatory training programme. Current Fire Safety Legislation and NHSL Fire Risk Management Policy require all staff to participate in fire safety training a minimum of once annually Staff Participation in Fire Safety Training 76% of staff participated in fire safety training during this reporting period 2014/15. This figure indicates 3% increase on the number of staff who attended training during the previous reporting period 2013/14. The table below provides a breakdown of the number of staff who participated in fire safety training during reporting period 2014/15 and the percentage level of staff attendance. Acute/ Operating Division Fire Safety Training 1 st April 2014 to 31 st March 2015 Staff Learn Pro Attendance Numbers Employed Percentage Hairmyres % Monklands % Wishaw % Total % Corporate Corporate Services & Other Services % PSSD % Total % North CHP Division Mental Health & Learning Disabilities % North East Unit % North West Unit % Total % South CHP Division South East Unit % South West Unit % 1 Total attendance exceeds 100% as a result of some personnel completing both face to face and online training NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 10 of 16

11 Total % Overall Total for NHSL % Additional Training 695 Specific Fire Training 120 The above figures include General Fire Safety Awareness Training (Face to Face), General Fire Safety Awareness Online Training (Learnpro), Induction, and Specific Fire Safety Training. Fire safety training provided by NHSL was made available to Serco & ISS staff at Wishaw and Hairmyres Hospitals, although their attendance is not included in NHSL figures. The requirement for staff to undertake fire awareness training is detailed in The Fire Safety (Scotland) Regulations 2006 (Regulation 20) Staff Participation in Fire Safety Training 2009/10 to 2014/15 The table below provides a comparison on the percentage of staff attendance at General Fire Safety Awareness Training across NHSL over a 5 year period from 2009/10 to 2014/15. General Fire Safety Awareness Training 2010/11 to 2014/15 Division 2010/ / / / /15 Acute 49% 41% 60% 71% 65% Corporate Services & Other Services 54% 75% 71% 94% 93% North CHP 2 61% 68% 81% 51% 84% South CHP 57% 71% 56% 65% 84% Managing Fire Safety Online Module During this reporting period the NOF launched the new Managing Fire Safety on line module during this reporting period 2014/15. This package provides managers with necessary training and information to effectively manage fire safety within buildings or areas which they have responsibility for. During reporting period 2014/15 a total of 395 staff completed the Fire Safety Managers online training package Monklands Hospital Fire Safety Table Top Exercise The NOF at the request of the Director Hospital Services (Monklands Hospital) facilitated a fire safety table top exercise to test existing Emergency Fire Evacuation Procedures and Fire Response Procedures. Hospital Senior and Ward Management, The NOF, SFRS and Police Scotland Senior Officers participated in the exercise Rosepark Care Home Case Study Lessons Learned During this reporting period the NOF provided a programme of fire safety training to all staff based at Monklands Hospital which focused on a lessons learned case study of the Rosepark Care Home Fire which occurred in January Feedback from staff who participated in this programme indicated the programme was worthwhile and thought provoking. The NOF will offer the programme to the Director of Hospital Services for Hairmyres and Wishaw Hospitals in the new reporting period 2015/ Fire Safety Training for Consultants NHSL Fire Safety Advisors delivered specific fire safety training for Consultants based at Wishaw Hospital. The training covered general fire safety and focused on the role of a Consultant in the event of a fire. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 11 of 16

12 4.6.7 Corporate Induction Training During this reporting period NHSL Fire Advisors assisted Organisation Development in the revision of the Corporate Induction Programme. The revised programme includes a new fire safety module which consists of a face to face presentation, use of the online fire safety module and specific fire safety training provided locally. NHSL Fire Advisors will assist Organisation Development to monitor and assess this programme in the new reporting period 2015/16. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 12 of 16

13 4.7 Emergency Fire Evacuation Drills (fire drills) The NOF raised concern at the April and October 2015 Risk Management Steering Group meetings regarding the low number of emergency fire evacuation drills (drills) that were being conducted at the 3 acute sites. The NOF highlighted that an insufficient number of drills were being conducted to enable each member of staff to participate in a minimum of one drill annually. The estimate was that each ward or department required to conduct approximately 10 drills per year, less than one per month and that the numbers conducted fell far short of this target. The figures below detail the number of fire drills conducted and recorded during this reporting period 2014/15 Emergency Fire Evacuation Drills 1 st April 2014 to 31 st March 2015 Acute/ Operating Division No of Fire Drills Conducted Hairmyres 54 Monklands 88 Wishaw 9 Total 151 Primary Care No of Fire Drills Conducted No of Fire Drills Planned South CHP North CHP Mental Health 9 8 Total The number of fire drills recorded has decreased by 51.8% on the number of drills (465) recorded in the previous reporting period 2013/14. It should be noted that North and South Community Care Partnership and Mental Health met planned targets In order to provide support to ward staff PSSD have planned additional Specialist Emergency Fire Evacuation training for 2015/16 for all acute inpatient care areas. This training will concentrate on planning and organising drills. This training has been previously provided and staff who participated in the training provided positive feedback that the training was well delivered and worthwhile and met its objective. Anecdotal evidence would suggest the number of drills being conducted exceeds the number of drills being recorded and reported. During the new reporting period 2015/16 an increased emphasis will be placed on the requirement for managers to plan, record and report fire drills. 5 NHSL and SFRS Partnership Working 5.1 Concordat of Partnership Working The Concordat of Partnership Working between NHSL and Strathclyde Fire & Rescue which was officially signed on the 2 nd July 2012 continues to be the officially recognised document underpinning the partnership arrangements between NHSL and SFRS pending the development of a new National Concordat of Partnership Working by HFS and SFRS. After the launch of the new National Concordat of Partnership Working a new local document between NHSL and SFRS North and South Lanarkshire Areas will require to be developed to replace the existing Concordat of Partnership Working and underpin the continued joint fire safety activity. NHSL continues to deal with local enforcement officers and operational crews. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 13 of 16

14 5.2 Joint Partnership Meetings NHSL and SFRS Meetings between NHSL and SFRS have taken place quarterly during this reporting period 2014/15, with a number of initiatives, beneficial to both organisations undertaken; these have improved the profile and awareness of fire safety with NHSL staff and have been operationally beneficial to the SFRS. 5.3 Partnership Initiatives The partnership working relationship between NHSL and SFRS is now well established and continues to develop and bringing forward a number of joint initiatives; Group Commander Alan Smith SFRS delivered a presentation on the services new UFAS policy to Lanarkshire Fire Group. SFRS Senior Officers provided specialist operational advice with regards to managing increased fire risk during the period of the Monklands Hospital Theatres Project. NHSL Fire Safety Advisors regularly use the Rosepark Care Home DVD developed by SFRS and provided to NHSL at specialised fire training events. NHSL continues to facilitate familiarisation visits for SFRS operational fire crews to all NHSL premises. NHSL Fire Advisors provide information and assistance for SFRS Officers when completing operational risk assessments for NHSL buildings The established routine of quarterly meetings between local Station Commanders and Property Support Services Division staff to discuss issues relating to UFAS at Acute sites continues. SFRS Senior Officers from North and South Lanarkshire Areas participated in the Table Top Exercise run at Monklands Hospital in September Health Facilities Scotland 6.1 National Fire Safety Group (NFSG) Health Facilities Scotland hosts the NFSG whose membership includes Fire Safety Advisors from NHS Boards across Scotland, representatives from the Scottish Building Standards Agency, Scottish Government Health Department, and SFRS. NHSL Senior Fire Advisor is a member of this group which allows the opportunity for NHSL to contribute to the strategic management of fire safety within Scottish Healthcare and allows NHSL to keep abreast of forthcoming amendments to legislation or guidance and be aware of fire safety issues and performance across Scottish Health Boards. 6.2 Scottish Government Health Department (SGHD) Fire Policy CEL 11 (2011) The SGHD Fire Policy CEL 11 was due for revision in May SGHD have not indicated when a revised National Policy is likely to be issue. 7. Fire Safety Groups The management & reporting on fire safety compliance with current fire safety legislation, fire safety regulations and NHSL s Fire Risk Management Policy, is by a structured set of Fire Safety Groups, which meet on a quarterly basis. The Groups include appropriate representation in the membership. These Groups are- NHSL Fire Safety Group chaired by the General Manager, Property & Support Services Division, as the NOF (NOF). NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 14 of 16

15 Three sites based Acute Hospital Fire Safety Groups, chaired by the Director of Hospital Services or Nominated Deputy as duty holder. A joint CHP North & South Operating Divisions Fire Safety Group, chaired by the Head of Support Services (PSSD). 8. Fire Policy and Procedure NHSL Fire Policy review was completed in May The aim of the review is to have a more condensed policy document which focuses on policy issues only. The revised policy has been renamed The Fire Risk Management Policy to reflect the addition duties now placed on NHSL following the introduction of The Fire (Scotland) Act 2005 and the Fire Safety (Scotland) Regulations The revised policy will be supported by a suite of procedural documents. The policy will continue to be a standing agenda item at NHSL and Local Fire Group Meetings. 9. Fire Safety Control Book (FSCB) The FSCB was approved by the Corporate Management Team and implemented in August The FSCB is now well established and operating across all NHSL sites. The current total FSCBs issued is 262. The FSCB continues to provide a focus and structure for Local and Site Designated Senior Managers to achieve fire safety compliance. The FSCB provides a co-ordinated system of management to control and minimise the risk of fire to NHSL Staff, Patients, and Visitors and to minimise the potential effects fire may have on Business Continuity. The FSCB assists NHSL Managers to have an awareness of the obligations imposed on them by fire safety legislation and regulation and to understand what is required and why. The FSCB provides assurance that fire safety is being effectively managed across the organisation Staff generally considers the FSCB to be an effective management tool for coordinating fire safety activity. To support Local and Site Designated Senior Managers in their duty to achieve fire safety compliance. The NOF operates a continued programme of sample auditing where a minimum of 25% of the FSCBs is audited annually. The programme of FSCB audits will continue in the new reporting period 2015/16. During reporting period 2014/15 a total of 91 FSCBs were audited The FSCB is endorsed by the Enforcing Authority as an example of best practice. 10 Fire Safety Work Plan 2014/15 Provide NHSL s Risk Management Group with update reports on Fire Risk Management and compliance progress. Investment needs, to address building and fire safety deficiencies throughout the NHSL Estate, will continue to be developed and recorded on a prioritised risk register and reviewed by NHSL s Fire Safety Group. A report for NHSL s Risk Management Group and Capital Investment Group has been prepared, which identifies the outstanding issues. These have been prioritised using a risk score, which considers all the relevant factors (e.g. client group, the level of fire protection, environmental hazards, and the standard Fire and Rescue service response).fire Safety Works at Monklands Hospital will continue to be a priority and dealt with separately as during the previous reporting period2014/15. The concentration for the new reporting period will be the completion of the improvement to the level of Fire Warning and Detection provided across the hospital and improvements to existing fire compartmentation. Continue with the Fire Risk Assessment review programme with a target of 100 reviews to be completed in the new reporting period 2015/16. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 15 of 16

16 Conduct a review of the Fire Safety Control Book to assess its effectiveness. Continue with the programme of Fire Safety Control Book sample audits were a sample of 25% of Fire Safety Control Books will be audited in the new reporting period 2015/16. Commence with the review of existing and the development of new fire safety procedures in order to create suite of procedural documents to support the new revised Fire Risk Management Policy. The programme for General Fire Awareness Training for the Acute Hospital Sites will continue to be provided beginning in April 2015 until March Fire Awareness training in the new North and South Health and Social Care Partnerships areas will be carried out by designated personnel under the arrangement for previous years. The General Fire Awareness Training online programme will continue to be available through the Learnpro platform. The programme of fire evacuation drills, within the three acute hospital sites, North and South Health and Social Care Partnerships areas and Corporate Services, will be implemented by local Fire Safety Sub Groups and the Site Designated Senior Managers to enable each member of staff to participate in a minimum of one drill within the new reporting period 2015/16. Conduct a review of the FSCB, and provide improvements as identified. Raise awareness of the requirement to record and report the completion of fire evacuation drills Continue to develop and strengthen links with SRFS. 11. Summary This report is presented to NHSL Board to provide key information and give assurance that the management of fire risk across The NHSL estate is being carried out in a planned and structured manner with the required reporting arrangements in place Via NHSL s Corporate Management Team. The report identifies those areas where positive improvements have been made in this reporting period 2014/15 and details a number of additional activities planned for 2015/ References The Fire (Scotland) Act 2005 (As Amended). Fire Safety (Scotland) Regulations Scottish Government Fire Safety Policy for NHS Scotland CEL 11(2011). NHS Scotland Firecode Suite of Documents. NHSL Fire Risk Management Policy June Scottish Government Practical Fire Safety Guidance for Healthcare Premises. NHSL Annual Fire Safety Report 1 st April 2014 to 31 st March 2015 Page 16 of 16