The Royal Wolverhampton NHS Trust

The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 2 June 2014 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private: (with reasons if private) References: (eg from/to other committees) Appendices NHS Constitution: (How it impacts on any decision-making) Annual Fire Safety Report An annual report on fire safety in the Trust is produced as evidence against outcome 10 of the Essential Standards of Quality and Safety. It summarises activity in regard to the Trust s Fire Safety policy, training, risk assessments and incidents during the year. To receive assurance from the report. Chief Operating Officer Keith Massen, Fire Safety Manager Tel - 01902 307999 ext 8159 Email Nil Public Session Trust Fire Safety Policy keith.massen@nhs.net Department of Health - Firecode HTM 05 series Nil In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny Background Details 1 An Annual Statement of Fire Safety must be produced and signed by the CEO. It does not now need to be submitted to the DH, however we are required to keep the document as evidence of performance against Outcome 10 of the Essential standards of quality and safety. The Trust Fire Policy (section 3.1) requires the report to be presented to the Board via the COO. Overall there has been good progress during the year. A greater standard of training has been achieved. There have been two minor fires where partial evacuation has taken place, however no major fire incidents have been recorded, and no enforcement notices have been served against the organisation. Fire Safety Annual Report TB 02 06 14

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2013 Annual Report of Fire Safety 1 01.01.13 31.12.13

Contents Section Page 1 Introduction 3 2 Executive Summary 4 3 Report 6 3.1 Fire Policy 6 3.2 Fire Safety Committee 6 3.3 Risk Register 6 3.4 Fire Risk Assessment 7 3.5 Compartmentation Surveys 7 3.6 Training 7 3.7 Unwanted Fire Signals 8 3.8 Fires 10 3.9 Enforcement Notices 10 3.10 Conclusion 10 Appendix A - Annual Statement of Fire Safety Certificate 11 Appendix B - Action plan 13 Author Department Position K. Massen GIFireE Estates and Facilities Fire Safety Manager 1 Introduction 2

The Regulatory Reform (Fire Safety) Order, that came into force on 1st October 2006, requires 'general fire precautions' to be put in place 'where necessary and to the extent that is reasonable and practical' for the protection of the 'relevant persons'. Responsibility for complying with the Fire Safety Order rests with the responsible person. Broadly, in a workplace this would be the employer or any person who has control of any part of the premises (for example the occupier or owner). Where there is more than one responsible person such as in multi-occupied premises, all must take reasonable steps to co-operate and coordinate with each other. The Chief Executive Officer is responsible for ensuring that, through appropriate delegation of responsibility within the organisation, current fire legislation is met and that, where appropriate, Firecode guidance is implemented in all premises owned or occupied by the Royal Wolverhampton Trust. The Chief Operating Officer is the Executive Director with delegated responsibility for fire safety issues across the organisation and the delivery of a safe responsive system. This report has been developed to provide the Trust Board of Directors accountable for the activities of the organisation with relevant information concerning the management and delivery of fire safety to the Trust during 2013, and a brief forecast into the year ahead, as in accordance with Healthcare Technical Manual 05-01: Managing Healthcare Fire Safety. Note The outcome of this report should be used as the basis on which to formulate the annual statement of fire safety, which is to be retained by the organisation and may be presented to the CQC along with supporting documentation as evidence of performance against Outcome 10 of the Essential standards of quality and safety. 2 Executive Summary 3

Good management of fire safety is essential to ensure that fires are unlikely to occur; that if they do occur they are likely to be controlled or contained quickly, effectively and safely; or that, if a fire does occur and grow, everyone in the premises can escape to a place of total safety easily and quickly. The following summary gives brief details of this Trusts development towards compliance with the mandatory requirements for the NHS in England (considered as best practice for NHS Foundation Trusts). REQUIREMENT PROGRESS R A G Clearly defined fire policy Board Level Director accountable to the Chief Executive for fire safety Fire Safety Manager to take the lead on all fire safety activities Compliant Compliant Compliant Have an effective fire safety management strategy which enables: Preparation and upkeep of the Report - sec 3.2 organisation s fire safety policy Fire Safety Committee - responsible for the monitoring and review of fire policy and protocols. Adequate means for quickly detecting and raising the alarm in case of fire Means for ensuring emergency evacuation procedures are suitable and sufficient for all areas, without reliance on external services Staff to receive fire safety training appropriate to the level of risk and duties they may be required to perform Reporting of fires and unwanted fire signals Partnership initiatives with other bodies and agencies involved in the provision of fire safety. Compliant Report sec 3.6 Formulation of a fire response strategy to mitigate the amended response by West Midlands Fire Service to be completed May 2013 Report sec 3.7 Mandatory training KPI is compliant. Additional training sessions for fire warden completed during 2013 to improve resilience Compliant Compliant Risks ID Description 3479 Old Eye Infirmary - Arson endangering life 3531 Compartmentation - Block 32 Amber fire risks 2835 Compartmentation - Block 80 2959 Compartmentation -Block 14 5 2854 Management of fire risks Date Total 4

Fires Women s and Neonatal Unit Maxillo Facial Laboratory Old Wolverhampton Eye Hospital Description 03/2013 Small fire on roof - Evacuation of Maternity Ward 06/2013 08/2013 Small fire involving compressor - Evacuation of area Deliberate ignition -Three vagrants located inside, rescued by the fire service. 3 Unwanted Fire Signals - Recorded New Cross Hospital Reduction of 19% from 2012 216 West Park Rehabilitation Centre 2 3 Report 5

3.1 Fire Policy HS: 26 Amended May 2013, the document embraces recent statutory and organisational changes and provides a sound logical fire safety protocol. The Trust Fire Safety Manager presented the policy to staff at the Senior Managers briefing on Thursday 18 th July 2013. Particular attention was given to the following amendments; the position of fire safety within the Trust reporting framework mandatory refresher fire safety training protocol for fire risk assessment fire procedures evacuation of disabled staff 3.2 Fire Safety Committee The Fire Safety Committee has continued to meet monthly, to manage fire safety and fulfil the requirements of Firecode ensuring measures are in place to meet the mandatory requirements of the NHS England. The frequency of meetings has been reviewed; meetings will now convene every two months. 3.3 Risk Register The Trust risk register acts as a repository for all risks identified by the organisation. Fig 1 indicates relevant amber fire safety risks currently documented by the organisation: Fig 1 Title ID Description Controls Level Management of Fire Risks 2854 Not all departments have received training prior to receipt of fire risk assessment documents Fire Safety Training Routine fire checks Block 14: A&E/Children s Wards Block 32: Women s Neonatal Unit Block 80 : Deanesly Centre Offsite: Wolverhampton Eye Infirmary - Compton Road 2959 3531 3599 Breaches in fire compartmentation on all floors Breaches in fire compartmentation on all floors Breaches in fire compartmentation on all floors 3479 Risk of arson endangering life Good exit routes, Fire Extinguishers & staff training. Compartmentalisat ion survey completed. Good exit routes, Fire Extinguishers & staff training. Compartmentalisat ion survey completed. Good exit routes, Fire Extinguishers & staff training. Fee proposal received Increased Security Patrols Installation of security barriers. 3.4 Fire Risk Assessment 6

The 2013 fire risk assessment programme consisting of 156 assessments has successfully been completed. Fire risk assessment documentation is a component of the newly developed Departmental Fire Safety Manual currently being distributed to all departments Trust wide. As part of the delivery procedure managers are provided with familiarisation training, this provides managers with an opportunity to ask any relevant questions and confirm understanding of how the manual is expected to be used. There has been a slight delay in the completion of hand overs; approximately 70 manuals are still outstanding. This issue has been recorded as a fire safety risk and entered onto the Trust risk register (ID 2854). Progress is being monitored by the Fire Safety Committee. 3.5 Compartmentation Surveys Compartmentation in relation to building design and construction is the dividing up of a building into fire tight cells to prevent fire spread in order to support progressive horizontal evacuation. A strategy has been developed (based on the significant findings indicated within the Fire Risk Assessments) to survey vulnerable buildings that contain clinical areas where fire evacuation could be compromised in the event of a serious fire. The following buildings have been identified: Block 32 Women s and Neonatal Unit Block 14 all floors including Accident and Emergency Department Block 8 Deanesly Centre. Blocks 32 and 14 have been surveyed and require remedial works to be undertaken to resolve. Each area has been entered onto the Trust risk register (see 3.3) 3.6 Fire Response Management Developed to provide board assurance that Trust staff are capable of responding to the initial stages of a fire emergency without reliance on the attendance of the fire service. Full twenty four hour response is now operational and operates in accordance with Trust fire policy HS 26. 3.7 Training The provision of fire safety training is a legal duty placed upon the organisation by the Regulatory Reform (Fire Safety) Order 2006. The following information indicates how training has progressed within key areas. Induction Delivered as face to face training to all staff joining the organisation, by a member of the fire safety team. 671 members completed during 2013. Mandatory Fire Refresher Delivered either face to face or by staff accessing the e-learning module on the Trust Kite site. There is no distinction on individuals training record to indicate which type of training they have attended. Currently 95% (5980 of 6295) members of staff have completed fire refresher training to date. The Trust mandatory target of 75% is significantly surpassed. Note: The Department of Health has recently reviewed its guidance, emphasising that staff that are in direct care of patients may need to receive face to face instruction more frequently than those who may only be required to evacuate a building on the sounding of the fire alarm. 7

Fire safety mandatory training is being evaluated, to determine the future training needs of the organisation and what is required to achieve Department of Health recommendations. Fire Warden The 2013 fire warden training programme has been successfully completed. Currently 151 members of staff have successfully been trained this year. This has significantly increased fire safety provision throughout the Trust and provides departments with dedicated local support. Fire safety training is continuing to develop and improve. 3.8 Unwanted Fire Signals (UWFS) False fire alarms are unwanted, an interruption to business continuity, costly and can compromise patient care. RWH initiated 216 unwanted fire signals during 2013, a reduction of 50 from the same period last year. This still exceeds the maximum number of UWFS considered tolerable (related to acceptable levels of unwanted fire signals and in accordance with HTM 05-03: Part H Reducing Unwanted Fire Signals in Healthcare Premises) for acute hospital premises of this magnitude. Fig 2 indicates the total number of activations each month that have occurred during 2012. Fig 3 indicates findings following investigation and analysis into the cause and location of alarm activations. From the data acquired a robust strategy is in place to raise awareness of the consequences of unnecessary fire alarm activations and our statutory duty to reduce them. This strategy includes: Targeted Fire Risk Assessments in areas with a high number of activations Replacement of unsuitable equipment Additional Fire Safety Training Attending meetings Fire Safety Information Bulletins Posters Healthcare Technical Memorandum 05-03 Part H Reducing unwanted fire signals in healthcare premises recommends a minimum reduction of 10% activations during the next 12 month period. It is anticipated that this hospital will at least achieve this target during 2014. Fig 2 8

Fig 3 9

Offsite Locations: Offsite reporting is inconsistent and needs to be reviewed (see action plan). 3.9 Fires The following information gives brief details of significant fires that have been reported to the Fire Safety Committee. Date ID Location Details Action Taken March 2013 June 2013 August 2013 100955 108428 108554 Women s and Neonatal Unit Maxillo Facial Laboratory Old Wolverhamp ton Eye Hospital Small amount of debris on fire following hot works. Smoke travelled into ward areas. Fire Service Attendance. Fire involving electrical compressor. Evacuation of ground floor and fracture clinic. Fire Service in attendance Fire in disused first floor area. Vagrants sleeping inside had to be rescued by the fire service Fire Extinguished. Evacuation of ward D10. Extinguished by fire service Extinguished by fire service. Building boarded Damage Minor Confined to the compressor Confined to room 3.10 Enforcement Notices There have been no Enforcement Notices issued to this Trust during 2013. 3.11 Conclusion During the twelve month period from 1 st January until 31 st December 2013, The Royal Wolverhampton NHS Trust has significantly improved its fire safety provision in relation to current legislative requirement. 10

Appendix - A Annual Statement of Fire Safety 2013 I confirm that for the period 1 st January 2013 to 31 st December 2013, all premises which the organisation owns, occupies or manages, have fire risks assessments that comply with the Regulatory Reform (Fire Safety) Order 2005, and (please tick the appropriate boxes): 1 There are no significant risks arising from the risk assessments. N/A OR 2 OR 3 The organisation has developed a programme of work to eliminate or reduce as low as reasonably practicable the significant fire risks identified by the fire risk assessment. The organisation has identified significant fire risks, but does NOT have a programme of work to mitigate those significant fire risks.* *Where a programme to mitigate significant risks HAS NOT been developed, please insert the date by which such a programme will be available, taking account of the degree of risk. Date: 4 During the period covered by this statement, has the organisation been subject to any enforcement action by the Fire and Rescue Authority? (Delete as appropriate) No If Yes - Please outline details of the enforcement action in Annex A - Part 1. 5 Does the organisation have any unresolved enforcement action pre-dating this statement? (Delete as appropriate) No If Yes-Please outline details of unresolved enforcement action in Annex A - Part 2. AND 6 Fire Safety Manager The organisation achieves compliance with the Department of Health Fire Safety Policy, contained within HTM 05-01, by the application of Firecode or some other suitable method. Name: Keith Massen Contact details: Email: keith.massen@nhs.net Telephone: Ext 8159 Chief Executive Name: Signature of Chief Executive: Date: Name: David Loughton CBE Completed Statement to be retained for future audit 11

Part 1- Outlines details of any enforcement action during the past 12 months and the action taken or intended by the organisation. Include, where possible, an indication of the cost to comply. None Part 2- Outline details of any enforcement action unresolved from previous years, including the original date, and the action the organisation has taken so far. Include any outstanding proposed action needed. Include an indication of the cost incurred so far and, where possible, an indication of costs to fully comply. None 12

Appendix B - Action Plan Action not on target. Action on target Completed AREA: ACCOUNTABILITY Ref Actions Required KPI Timescale Lead Delegated Current progress reported against Action Plan Evidence Written fire safety policies for all healthcare premises Review, revise and update existing Trust Fire Policy HTM 05-01 Managing Healthcare fire safety 05/13 COO FSM Consultation period completed - Policy amended and approved by Fire Safety Committee. Approved at Policy Group (05/13) subject to minor amendments. See item 3.1 Annual Report/ Statement of Fire Safety Prepare annual Trust fire safety report including statement of Fire Safety HTM 05-01- Managing healthcare fire safety 03/13 COO FSM Fire Safety Annual Report & Statement 2012 approved by Fire Safety Committee Report Reduce the number of unwanted fire signals Identify trends, develop strategies to reduce the number of activations. Include offsite locations HTM 05-03 Reducing unwanted fire signals in healthcare premises 04/13 FSM SFA Item 3.6 confirmation that there has been a 19% reduction of unwanted fire signals during 2013 Annual Report Datix 13

Action not on target Action on target Completed AREA: MANAGEMENT STRATEGY Ref Core Issue Actions Required KPI Timescale Lead Officer Delegated Officer Current progress reported against Action Plan Evidence Fire Risk Management Develop appropriate system that ensures all significant fire risks are managed effectively and necessary remedial action is taken to eliminate or reduce to ALARP Regulatory Reform (Fire Safety) Order 2005. HTM 05-03 Part K- Guidance for fire risk assessment in complex healthcare premises 06/14 FSM SFA See item 3.4 - Target extended until 06/2014 Trust Risk Register No 2854 Fire Risk Assessment; Develop robust rolling programme for fire risk assessment. Regulatory Reform (Fire Safety) Order 2005. HTM 05-03 Part K - Guidance for fire risk assessment in complex healthcare premises 04/14 FSM SFA Rolling program installed onto Planet FM and effective from 01/13. Fire Risk Assessments. Fire Compartments Identify relevant Trust Buildings (during fire risk assessment) that could in the event of fire, compromise effective horizontal progressive evacuation and undertake a survey of passive structural fire protection. Regulatory Reform (Fire Safety) Order 2005. HTM 05-03 Part K- Guidance for fire risk assessment in complex healthcare premises 12/14 FSM FSM Women s and Neonatal Centre. Block 14 including existing A&E department and Deanesly Centre identified in phase 1. See section 3.5 Trust Risk Register 14

Action not on target Action on target Completed AREA: MANAGEMENT STRATEGY Ref Core Issue Actions Required KPI Timescale Lead Officer Delegated Officer Current progress reported against Action Plan Evidence Fire Safety Training Review and develop training appropriate to the level of risk inc. workplace training. Liaise with Education. HTM 05-01- Managing healthcare fire safety 06/13 FSM SFA Current review of.the suitability of current Kite Training package and the feasibility of providing additional modules. Additional Fire Warden Training sessions programmed during 07/13 Fire Drills and Exercises Develop robust schedule for fire drill in and out of core hours for all sites; including simulation training for vulnerable areas. HTM 05-03- General fire safety 04/13 SFA To be determined by the Fire Safety Committee Community Sites and most non-clinical buildings completed during 2013. In patient areas require further attention. Deadline extended until 12/14 Evacuation Strategies Means for ensuring that emergency evacuation procedures for all areas at all times that the premises are occupied, without reliance on external services HTM 05-01- Managing healthcare fire safety 04/13 FSM SFA Trust Fire Response Team now have facility to operate evacuation equipment. Completed 15

Action not on target Action on target Completed AREA: MANAGEMENT STRATEGY Ref Core Issue Actions Required KPI Timescale Lead Officer Delegated Officer Current progress reported against Action Plan Evidence Disabled Evacuation Develop appropriate strategies to ensure that disabled staff and NHS service users can evacuate safely in the event of a fire related incident. Equalities Act 2010 CLG Guide for disabled evacuation 06/13 FSM To be determined by the Fire Safety Committee Embedded into amended fire policy However a robust strategy needs to be developed. Senior Managers informed during policy launch. Policy Appendix Departmental Fire Safety Manuals (Clinical) Review and revise existing manuals and distribute to designated departments. HTM 05-01- Managing healthcare fire safety 06/14 FSM SFA The strategy has changed; Fire Safety Manuals are being distributed with Fire Risk Assessment documents and awareness training provided. See section 3.4 of report Fire Safety Reference Manuals 16