AGENDA ITEM 4.1 FIRE SAFETY 2013 ANNUAL REPORT Executive Lead: Director of Planning Author: Senior Fire Safety Advisor Contact Details for further information: Frank Barrett 02920742292 SITUATION This paper provides an update on progress made during 2013 and summarises the 2014/15 action plan. Key issues: Appointment of Deputy Fire Safety Managers for UHW Statutory and Mandatory Requirements Site Update Incidents and Unwanted Fire Signals Training update Existing Enforcement Notice from South Wales Fire Service and two rescinded. BACKGROUND Cardiff & Vale University Health Board is committed to ensuring the protection from fire and explosion, so far as is reasonably practicable, of its employees and persons other than employees (e.g. patients, members of the public, contractors, visitors etc.) who use the Health Board s premises, or may be affected by its activities. ASSESSMENT 1.0 Statutory Requirements The principle fire safety legislation applicable to all the Health Board s premises is the Regulatory Reform (Fire Safety) Order 2005 enforced by the Local Fire Authority. To be compliant with this legislation a Fire Risk Assessment must be completed for every building and the Fire Safety Advisers are continually reviewing and updating the assessments. 2.0 Mandatory Requirements - Firecode It is a mandatory requirement that an annual audit is completed utilising the online Fire Audit Information System and is available to view with the following link. http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=254&id=327180 Fire Safety Annual Report Page 1 of 6 Health and Safety Committee
In accordance with Health Technical Memorandum 05 01 the Health Board has appointed a Fire Safety Manager and a number of deputies; however until deputies have been appointed for the UHW site we are not fully compliant with the Health Board s Fire Safety Policy as derived from Firecode which is a mandatory document. Site Specific University Hospital of Wales (UHW) As the Heath site is by far the largest site, with the main block extending over 11 floors with extensive occupation including dependent and highly dependant patients it is the highest risk. The fire strategy involves restricting a fire to a limited area by fire resisting construction and fire and smoke dampers in order for any patients to be safely moved horizontally to a safe location. Over a period of time the structural fire compartmentation has been compromised by passing cables, pipes and other services through fire compartment walls and ceilings and not carrying out the required fire stopping to these penetrations. Fire stopping work has been carried out on some floors in a rolling programme and this needs to be accelerated as much as possible due to the risk involved. The fire dampers having been installed 50 years ago do not comply with current standards and partly due to limited or no access have not been adequately maintained. Due to the substantial cost of upgrading these dampers they are presently only being replaced as an area undergoes a major refurbishment. Llandough Hospital A number of major developments have recently been completed or are under construction. Recently completed works include the new Stoke Unit, Mental Health Services for Older People Assessment Unit and the Multi Storey Car Park. Work has commenced on the new Acute Adult Mental Heath Unit to replace Whitchurch Hospital and the Concourse as an addendum to the main entrance of the hospital. The Fire Advisers are closely involved with these projects. Rookwood Hospital Risk assessments at Rookwood have identified a number of non-compliance issues of a minor nature and the patient areas are all on a single level with progressive horizontal evacuation possible. The risk is further reduced as the services are gradually being relocated. West Wing A comprehensive review of West Wing has been carried out and an estimated cost of upgrades to achieve compliance was calculated at 20,000. As it is the intention to relocate the services from West Wing in April 2014 this capital spending has not been approved. Fire Safety Annual Report Page 2 of 6 Health and Safety Committee
Barry Hospital NHS Wales Shared Services Partnership conducted an in depth review of fire safety at Barry Hospital. The significant findings and recommendations of their report were those of compartmentation including the fire dampers and staff training and in particular the ability of staff to carry out the vertical evacuation of patients. Whilst we do not disagree with the findings of the audit report as Barry Hospital is only two storeys high and has ample scope for progressive horizontal evacuation in two directions the risk is minimal compared with UHW. St David s Hospital A Private Finance Initiative Hospital which is maintained by Balfour Beatty, the Health Board Fire Advisers carry out the fire risk assessments which are all up-to-date and with no significant life safety issues. Whitchurch Hospital As Whitchurch Hospital dates back to 1904 it does not fully comply with current fire safety legislation. There have been significant issues with mental health patients and discarded smoking materials resulting in three Enforcement Notices being issued by South Wales Fire Service. After significant efforts two Enforcement Notices have been lifted whilst one remains in force. In recognition of the age of the building and its planned closure South Wales Fire Service (SWFS) have given the Health Board two years to comply with the Notice by which time services will start to be transferred to the new location at Llandough Hospital. Part of this agreed strategy including the running down of facilities at the site and as patients and staff are relocated the risk is reducing. The Health Board has since requested certain areas to be reoccupied for either storage or office space and although SWFS have agreed to these additions they have expressed this is going against the previous agreement and are unlikely to agree to anymore use of the site. 3.0 Policy and Procedures The Fire Safety Policy has been reviewed and amended to reflect changes required to address the issues identified in the Enforcement Notice received from SWFS in relation to the management of smoking in mental health premises. The Fire Safety Policy is now available on the Health Board s Intranet Site. The Fire Procedures for all sites are now under review and will be completed shortly for approval. 4.0 Fire Training Extensive efforts have been made to improve the training figures and targeting relevant groups to make their training specific to their needs. In addition to normal training, out of hours sessions have been offered to improve the figures for the night staff who may find it hard to attend a day session. Training senior Fire Safety Annual Report Page 3 of 6 Health and Safety Committee
nursing staff to cascade to members of their team has been provided and L.E.D introduced Mandatory May when fire training is held on every week day in the month of May. The training figures have shown an improvement on the previous year with a compliance rate of 61%; however there are still some further improvements required before the Health Board is fully compliant. 5.0 Fire Wardens Fire warden training is ongoing and during 2013 an additional 109 wardens were trained. The courses are always fully booked several months in advance and it is very disappointing when a high percentage (13%) of applicants fail to turn up on the day. 6.0 Incidents and Unwanted Fire Signals Any instances of unwanted fire signals lead to disruption of service and patient care, increased costs and unnecessary risk to those required to respond to the alarm. As UHB sites are fitted with very large complex alarm systems unwanted alarms are inevitable. Across all sites the Health Board received 489 unwanted fire signals in 2013 a small reduction on previous years despite the fact the systems are being continually expanding. Fire Advisors continue to respond to all fire alarm activations whilst on site to try to identify causes and take action to prevent the same occurrences. Site Fire Malicious Good Intent Cooking Contractors System Fault Others Total UHW 11 3 8 37 45 149 253 CRI/WW 0 0 0 9 3 6 18 RKW 2 0 0 0 2 4 8 UHL 4 20 0 16 13 83 136 Whitchurch 2 12 0 2 50 20 86 Barry 0 0 0 1 0 2 3 St David s 1 0 0 2 0 2 5 Total 20 35 8 67 113 266 509 There have been 20 reportable fires in 2013. Electrical faults were the main cause of fires and the remainder were within mental health services. 7.0 Routine Fire Safety Inspections In order to help to ensure statutory and Firecode compliance the Fire Safety Advisers continue to carry out routine fire safety inspections. Audit fire safety inspections have also been carried out by Fire Service Personnel and the NHS Wales Shared Services Partnership. SWFS have advised us of an extensive list of audits they intend to carry out on UHW premises this year. Fire Safety Annual Report Page 4 of 6 Health and Safety Committee
8.0 Action Plan 2014 Appoint Deputy Fire Safety Managers for the UHW site. Continue to review/update site Fire Safety Procedures. Amend and update all existing fire risk assessments for all Cardiff and Vale Health Board premises in compliance with legislation The Regulatory Reform (Fire Safety) order 2005. Develop action plans to overcome identified risks and communicate these to responsible managers. Continue training programme for Fire Wardens on a Health Board wide basis. Continue to improve fire training figures by engaging local managers. Continue the investment programme to meet Firecode and Statutory Requirements. To promote personal development and skills of the Fire Safety Advisory Team. To continue investigating all unwanted fire signals and where possible take action to reduce occurrences RECOMMENDATION The Health & Safety Committee is asked to: NOTE and CONSIDER 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. This report is fundamental to the safety and quality of both staff and patients 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 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 Fire Safety Annual Report Page 5 of 6 Health and Safety Committee
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 Equality and diversity (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. The Report supports the Risk Register by ensuring that all actions are appropriately recorded with local and Central Risk Registers. It also gives assurance that actions identified are being progressed 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 Annual Report Page 6 of 6 Health and Safety Committee