AGENDA ITEM 4.4 Fire Enforcement Report Executive Lead: Director of Planning Author: Senior Fire Safety Adviser, Capital Planning & Estate Management Contact Details for further information: Frank Barrett, ext 42292 SITUATION This report provides an overview of the current status of the Enforcement Actions issued by the South Wales Fire Authority (SWFA) against breaches in Fire Legislation. Key issues highlighted in the report include: Completing all agreed actions of the Enforcement Action previously issued for ITU/HDU Llandough Hospital. The remaining Enforcement Action in relation to Whitchurch Hospital Site. Progress in meeting the requirements of the notices within the required time scales. BACKGROUND The purpose of this report is to enable the Committee to provide assurances to the UHB Board that the Enforcement Notices issued by South Wales Fire Authority are being managed and monitored appropriately. This report provides the current status of the Enforcement Notices in respect of progress. ASSESSMENT Two Enforcement Notices are in force, one at Whitchurch Hospital and one at University Hospital Llandough. (1) Whitchurch Hospital Enforcement Notice EN 56/12 The Enforcement Notice for Whitchurch Hospital is site wide and includes a number of items that would require a considerable capital investment to bring up to current standards. South Wales Fire Service accept that it would be unrealistic to complete all the taking into account the age of the building, costs and the life expectancy of the buildings. As a result they have given 24 Fire Safety Enforcement Report Page 1 of 9 Health and Safety Committee
months to complete all the issues in the knowledge that the Health Board will be vacating some areas within this time span. Although 24 months has been given to achieve compliance, the Fire Service is expecting efforts to be made to raise the standard of fire safety. Where it is reasonable and possible we will complete the issues raised in the notice that do not require significant capital investment. Regular audits will be carried out by the Fire Service to confirm progress is being made. We have also met on site SWFA on the 12 th June to discuss what is reasonable and practical to provide an acceptable level of fire safety. It has been agreed that they will be satisfied if we complete a number of improvements which will not have significant financial implications, such as new smoke seals on doors, and these s are in the process of being Action Plan is attached as Appendix 1. (2) University Hospital Llandough Enforcement EN 34/12 The enforcement notice at UHL relating to the ITU/HDU was originally due to be reviewed within 90 days from the issue date of 17 th October 2012. Due to the time required to receive tenders for the structural s the time was extended and was due for review on the 30 th April 2013. On the 1 st May SWFA revisited ITU/HDU and now consider the premises currently demonstrates suitable and sufficient measures to satisfy the requirement of the fire legislation and have lifted the enforcement notice. RECOMMENDATION The Health and Safety Committee is asked to: NOTE the content of the report. Financial Impact Quality, Safety and Experience Standards for Health Services No accurate figures are available at this time as to the cost of obtaining full compliance with the fire safety guidance and legislation. The completion of all remedial actions detailed in the Enforcement Notices and Informal Notices as a result of Fire Service Audits will improve patient, visitor and staff fire safety. Fire risk within the UHB, further enforcements and potential prosecution for non compliance will also be reduced. The impact of this report of the delivery of the Standards for Health Services is as follows: 12. Environment Organisations and services comply with legislation and Fire Safety Enforcement Report Page 2 of 9 Health and Safety Committee
guidance to improve environments, that are: (a) Accessible (b) Well maintained (c) Fit for purpose (d) Safe and secure (e) Protect privacy; and (f) Sustainable 22. Managing Risk and Health and Safety Organisations and services will have systems and processes in place which complies with legislation and guidance that: Risks and Assurance (a) Applies best practice in assessing, managing and mitigating risk. (b) Implements policies and arrangements for reviewing and continuously improving all aspects of their activities and environment to protect and improve the health, safety and wellbeing of their patients, service users, carers, staff and the public, and (c) Acts upon safety notices, alerts and other such communication. Equality and diversity The Equality Act has been considered to ensure fair and equitable services for all employees and service users. There are no immediate equality and diversity implications from this paper. Fire Safety Enforcement Report Page 3 of 9 Health and Safety Committee
Capital Planning and Estate Management Department Appendix 1 Enforcement Notice Number EN56/12 Whitchurch Hospital Park Road Cardiff Ref No. Estates Actions Responsible Lead Date of Closure of Action Ref No. Management Actions Responsibl e Lead Date of Closure of Action 1.1.1 The roof void should be sub divided with materials that offer 30 minutes of fire and smoke resistance and be placed in line with sub compartment and compartment walls/partitions on the floor below. Any doors/openings provided for access in the materials should offer the same standard of fire resistance. Action: Due to the magnitude of the s required to address this action, further discussions are required at the next meeting 20/04/2013 1.2.1 The damaged seating within the lounge area of West Homes should be removed and replaced with furnishings which conform to the relevant standard. Alternatively the furniture should be permanently repaired. For a relevant standard please refer to "The Furniture and Furnishings (Fire) (Safety) Regulations 1988 (amended 1989 and 1993)". Certification/evidence should be produced to the effect that such standards have been obtained 25/04/2013 Fire Safety Enforcement Report Page 4 of 9 Health and Safety Committee
1.1.2 A large number of the fire resisting partitions and doors throughout the main corridors do not provide adequate fire resistance e.g. Medical Staff Area, Pharmacy and Shop. An assessment of the whole area should take place to ensure all doors, walls, partitions, hatches, glazing and any reception area located within the escape routes are constructed to give a minimum fire resistance of 30 minutes. 2.1.1 The Responsible Person should devise a suitable emergency evacuation plan for all occupants likely to be in the premises, including disabled people, and how that plan will be implemented. Meetings have taken place and a fire evacuation exercise is to be carried out in September Action: Trevor and 1.1.3 There were a number of breaches in compartmentation throughout the hospital site: Ventilation grilles located at ceiling height above fire resisting doors provided to bedroom areas in Ward East 2A, Ward East 1 and Ward West 2A. Air transfer grille provided in the office wall of Ward East 5A. The office poses a significant hazard and is located within a sleeping compartment. Hole in main compartment fire resisting door leading to Ward 4.1.4 At the time of the audit, a number of fire resisting doors were being wedged in the open position. Wedges, hooks and any other device in use at the present time as a means of holding self closing doors in the open position shall be removed to ensure that the doors are effectively self closing. In areas where doors are required to be open for operational or observation 20/04/2013 Fire Safety Enforcement Report Page 5 of 9 Health and Safety Committee
West 2A. Hole in panelling above fire resisting door at first floor level of staircase leading to West Homes. Additionally it must be ensured that the panelling consists of fire resisting materials. Ward East 2A linen/stock cupboard which is breached due to the radiator. It was agreed to remove the ignition source from this area, removing the risk. reasons, a suitable hold-open device should be provided linked to the fire alarm system. Action: Trevor and 12/06/2013 12/06/2013 3.1.1 Provide a heat detector within the smoking room of Ward West4A. The detector is to be linked into the fire alarm system, sited and installed in accordance with a relevant standard. 1.1.4 The bathroom area of Ward East 1 has changed use to a store room and is now considered a hazard room. This room should be returned to its original use or upgraded Action: Due to the nature of the s required to address this action, further discussions are required at the next meeting 4.1.1 All fire resisting doors should be fitted with: A positive action self-closing 4.2.1 The emergency escape route from the General Managers office is single direction and 12/06/2013 Fire Safety Enforcement Report Page 6 of 9 Health and Safety Committee
device. Doors to storerooms need not be fitted with a self-closing device providing that they are kept locked shut when not in use. Intumescent strips and smoke seals.& three brass/steel hinges. the travel distances are currently excessive. There was previously an alternative exit door available at the base of the stairs that should be reinstated. Action: Trevor and 4.1.2 There were a large number of doors provided to hazard rooms that were not fire resisting which have been detailed within the fire risk assessment carried out by the health board's fire advisor; e.g. the majority hazard rooms in Ward East 1, Ward West 2A staff room, treatment room and bedrooms and Ward West 3 smoking room. An assessment of such areas should be made and replacement doors installed to provide a minimum of 30 minutes fire resistance. Panels or partitions above or at the sides of the doors should provide a similar degree of fire resistance. 4.3.1 Escape routes, and the means provided to ensure they are used safely should be managed and maintained to ensure that they remain usable and available at all times the premises are occupied. The escape corridor from West Homes contained storage which should be removed and subsequent conditions maintained. 26/04/2013 Action: Trevor and Fire Safety Enforcement Report Page 7 of 9 Health and Safety Committee
4.1.5 The nursing office area of Ward East 2 was housing two oxygen cylinders necessary for patient care. Any rooms used for storing 02 cylinders when not in use should be 30 minutes fire resisting, provided with adequate ventilation to outside and warning signage on the door to the room. Action: To be disputed with the Fire Service Frank Barrett 12/06/2013 5.1.1 During the audit it was established that staff members had no recollection of previous participation in a fire drill exercise. Therefore, once an effective emergency evacuation plan is devised, a simulated evacuation drill is to be carried out to ensure the adequacy of the plan and also of fire training received. Meetings have taken place and a fire evacuation exercise is to be carried out in September 4.4.1 During the inspection it was found that the external escape route from Ward East 3 was in poor condition with slippery surfaces. This route is to be cleaned to ensure the surface is free from slip hazards. Action: Trevor and 6.1.1 During the audit it was noted that a large number of the fire resisting doors provided were inadequate and require replacement or upgrade. The following common deficiencies were noted: Intumescent and cold smoke seals missing 20/04/2013 3.1.2 Where key operated manual call points are provided, it must be ensured that all staff are equipped with the appropriate key at all times in order to operate the fire alarm system at the earliest opportunity. This is particularly necessary within Ward East 5A. 7.1.1 4.1.3 On questioning a number of ward managers it was evident that not all staff had received fire training. All staff should receive fire training as per the Health Boards fire safety policy. The rear fire exits from the 12/06/2013 01/07/2013 Fire Safety Enforcement Report Page 8 of 9 Health and Safety Committee
Excessive gaps between fire resisting doors and frames Warped and ill fitting fire resisting doors Doors held open on magnetic retention devices that are faulty Self closing devices missing, damaged or ineffective Glazing provided in fire resisting doors not fire resisting Action: Trevor and ward areas lead into a communal lobby/staircase enclosure which housed a number of store rooms. These store rooms had varying quantities of combustible items and a number were left open. These areas were often strewn with discarded smoking materials and it must be ensured they are secured shut and clearly marked 'FIRE DOOR - KEEP LOCKED SHUT'. Additionally, although the doors to these areas were substantial, flexible smoke seals are required to enable the door set to be capable of resisting the passage of smoke or flame for a minimum period of 30 minutes, or such other time specified, when tested in accordance with a relevant standard. Fire Safety Enforcement Report Page 9 of 9 Health and Safety Committee