DIRECTORATE OF ESTATES AND FACILITIES PROCEDURE AND INFORMATION MANUAL EPM HS31 Fire Safety Management Policy Document originated: July 2016 By: CSU Issue number: 2 No of pages: 6 Approved by: DOEF Status: Working document Last revised: October 2018 By: Policy & Procedure WG Next revision: July 2021 By: CSU The purpose of this document is to set out how the Directorate of Estates and Facilities (DOEF) discharges its duties under the Regulatory Reform (Fire Safety) Order 2005 1
CONTENTS Section Page No s 1 Introduction 3 2 Fire Risk Assessment and Fire Remedial Works 3 3 Items requiring action identified in the FRA 3 4 Remedial works strategy.. 4 5 Governance 5 6 Operational Fire Plans 5 7 Routine and cyclical maintenance on physical fire safety installations 5 8 Fire Signage.. 5 9 Monitoring 5 Figure 1 Directorate of Estates and Facilities Governance Meeting Structure. 6 2
1.0 1.1 1.2 1.3 Introduction This document sets out the Directorate of Estates & Facilities arrangements in relation to fire safety and how it intends to meet the requirements of the Regulatory Reform Order (Fire Safety) 2005 (RRO). These arrangements deal specifically with the physical estate in relation to fire safety. All matters relating to fire safety management can be found within Chapter 7 Fire Safety arrangements. 2.0 Fire Risk Assessment and Fire Remedial works 2.1 2.2 2.3 2.4 The Directorate of Estates & Facilities (DOEF) will undertake fire risk assessments for all buildings where it is deemed the University has a responsibility under the RRO. Fire risk assessments will be completed by competent persons engaged via the DOEF procurement Framework. The frequency of fire risk assessments will be on a risk based approach. Fire risk assessments will be undertaken in accordance with the fire risk assessment schedule. Fire risk assessments will be provided by suppliers completed in accordance with the standard format as agreed as part of the procurement process and retained within the DOEF FRA database (GRATiK). The fire risk assessment programme will be managed by the Design Services Unit and an appointed Project Manager/Client Representative will ensure co-ordination takes place for access, notification to key building users, and agreement on programme delivery and agreed costs. All completed fire risk assessments are returned to the Client Services Unit Fire Team, for scrutiny and processing the findings. This team will focus on priority items identified within the fire risk assessments and package them into concise work packages for presentation to the DOEF Project Allocation process to allow for remedial works to be actioned. 3.0 3.1 Items requiring action identified in the FRA Items requiring action as a result of a fire risk assessment fall within three clear categories, these being: 1. Management arrangements that need addressing i.e. flammables left on a corridor 2. Remedial repairs that are needed i.e. replace broken closer 3. Major upgrade works to the fabric of the building i.e. provide additional compartmentation 3.2 Category 1. Management issues are, via the GRATIK system, directed to agreed individuals within each building. It is deemed the responsibility of the Head of School via the School Safety Advisor to address these items in a timely manner as agreed with Fire Safety Team. 3
3.3 Category 2 Items reactive remedial repairs processed via the Fire Team directly to the DOEF Help Desk for the attention of the Maintenance Services Unit to complete or towards Design Services Unit small works team. 3.4 Category 3 Major upgrade works these are assessed in detail by the Fire Team on a building by building basis taking into account the issues raised and the fire risk assessment risk priority of each issue. 4.0 4.1 4.2 Remedial works strategy Major upgrade works- It was previously agreed between DOEF and Safety Services that due to funding limitations DOEF would aim to address all Priority 1 and 2 items in the first instance, taking into consideration other Priorities across campus. Remedial Repairs- All repairs identified within the fire risk assessment will be completed irrespectfully of the priority rating. NOTE- University Fire Team will use their knowledge, training and expertise to determine whether works is required. 4.3 Academic/Non Academic Buildings Within the Academic/Non Academic property portfolio it has been identified that whilst Priority 1 and 2 items raised in the FRA continue to be addressed year on year there are a number of buildings with lower Priorities 3 to 6, that due to funding restrictions and the current DOEF strategy of delivery these items will be considered for addressing over a longer period of time. Therefore following a number of years of completing Priority 1 and 2 items it has been devised that the Fire Team will draft up a list of their Top 10 buildings (using the building scoring matric based on risk) in terms of fire safety risk, and that all priority items within the buildings resulting from the next round of fire risk assessments (2017) will be addressed. This will go some way to address the varying risk profile that exists across this portfolio of buildings. Attention will be focused on the higher risk buildings and a higher building will therefore be treated as a high priority using this approach. 4.4 Residences & Sports Buildings Residential Building This portfolio of buildings has a very even risk profile as all buildings contain a sleeping risk. Therefore we will continue with addressing Priority 1 and 2 items as a priority, across this portfolio, due to funding constraints. Sports Building This portfolio of buildings has a very even risk profile. Priority 1and 2 items will be continually addressed across the portfolio, due to funding constraints. 4
5.0 Governance 5.1 Fire safety across the Directorate of Estates & Facilities is currently managed via a series of meetings, steering groups and committees to ensure fire safety standards are maintained. Figure 1 below sets out the hierarchy of these and indicative frequency of meetings. 6.0 Operational Fire Plans 6.1 The aim of the University operational fire plans is to provide a consistent approach identifying hazards and risk supporting the Fire and Rescue Service to gather information on University properties to deliver their core functions safely. 6.2 This information is collated by the Fire and Rescue Service and entered in their Operational Information System (OIS) using two methods; firstly local crews visit buildings to gather the information updating the OIS and the University Fire Officer forwards operational fire plans to the Fire and Rescue Service to maintain currency of information, allowing the Fire and Rescue Service to update their OIS. 6.3 Data for the operational fire plans is regularly updated on a risk based schedule, the higher the risk the more frequent the audit and review. 6.4 The Operational fire plans includes a Hazard and Risk Questionnaire which is forwarded via Faculty Estate Teams to responsible persons in University premises for completion. The data is collated by the University Fire Officer and shared with the Fire and Rescue Service. This information is held in a red document box (which contains the University operational fire plans for that building) provided in each building adjacent to the fire alarm panel for use in the event of an emergency incident. 7.0 Routine and cyclical maintenance on physical fire safety installations 7.1 The arrangements and frequency of maintenance for items such as fire alarms, emergency lighting, fire suppression systems, firefighting equipment, and emergency egress equipment such as evacuation chairs etc. are all detailed within the DOEF procedures document EPM FM1 Maintenance Strategy. This document should be read in conjunction with EPM FM1 8.0 Fire Signage 8.1 DOEF management of signage requirements for fire safety signage is detailed within the Estates and Facilities document EPM HS30. This document should be read in conjunction with these arrangements. 9.0 9.1 Monitoring arrangements The university fire team attends a number of meetings with regards to major upgrades and remedial repair projects. These meeting are arranged by project managers and are undertaken on a monthly basis. 5
9.2 9.3 9.4 At these meeting, progress is reviewed against the issues raised and actions are assigned to the relevant persons to ensure work progresses. Should any items of works identified in the major upgrades and remedial repair project which are prevented from progressing, these are reported at these meetings. The implementation of the fire risk assessment schedule is monitored to ensure it is fulfilled and within the correct time periods. Any issues regarding delays are communicated from the project manager to the fire team, and appropriate action to achieve progress is taken. Fig 1 DIRECTORATE OF ESTATES & FACILITIES GOVERNANCE MEETING STRUCTURE FSAG (Quarterly) TECHNICAL FIRE SAFETY WORKING GROUP (Monthly) FIRE REMEDIAL PROJECTS STEERING GROUP (Monthly) FIRE SAFETY SERVICES FRAMEWORK MANAGEMENT MEETING (Monthly) CSU FIRE TEAM MEETINGS (Monthly) 6