Fire Safety Report & Audit

Fire Safety Report & Audit 2010/2011 GP Tibbs Fire Safety and Security Manager CONTENTS Introduction... 2 2010 11 Progress Report... 2 Staff Training... 2 Unwanted Fire Signals (UwFS)... 2 Fire Risk Assessments and Action Plans... 4 Fire Safety Maintenance 2010 11... 4 Fire Safety and Security Manager s Conclusion... 4 Action Plans and Priorities for Fire Safety Development in 2011 2012... 4 Fire Safety Policy/Procedures... 4 Training... 4 Unwanted Fire Signals... 5 Fire Safety Management... 5 Capital Investment for Fire Safety 2011/12 and Future Years... 5 APPENDIX A Fire Safety Training Delivery 2010 11... 7

Fire Safety Annual Report & Audit 1 Introduction Nottingham University Hospitals NHS Trust (NUH) has a statutory responsibility to ensure that all of the premises owned and/or operated by it comply with current fire safety legislation. The Trust has to ensure that suitable and sufficient arrangements are in place for the management of fire safety and for the implementation of any necessary improvements relating to increased fire safety measures as required under the Regulatory Reform (Fire Safety) Order (2005). The Firecode fire safety in the NHS Memorandum 05 01 (2006) DoH, describes that an Annual Audit should be undertaken and presented to the Trust Board via the relevant board level director regarding : current fire safety management procedures, including maintenance procedures changes in the use of premises effectiveness of communications systems, including fire alarm and detection devices local fire safety policies training and incident management and their related records action following risk assessment. This report presents a summary of the condition of the fire safety systems at the end of the 2010 11 financial year, and the proposed targets and developments in 2011 12. 2 2010 11 Progress Report 2.1 Staff Training Fire Safety Awareness training was delivered in 2010 11 through the Trust s Mandatory Training programme, supported by specialist ward/departmental training delivered in the workplace. 9891 staff (of total staff circa 11000) attended fire safety awareness training (464 sessions). 192 staff were trained as fire wardens; this is a new role in the Trust to support the Trust s fire safety policy and culture. 2.2 Unwanted Fire Signals (UwFS) Unwanted Fire Signals (UwFS) are incidents that result in the undesirable activation of fire detection and alarm systems. A significant proportion of UwFS result from working practices that adversely effect automatic fire detection equipment. Typical sources are the use of cooking equipment [toasters, kettles, microwaves, etc.] and the practice of wedging kitchen doors open. Inappropriately triggered fire signals are a matter of concern and a subject of management focus. They generate and reinforce a reduced reaction culture among those who are repeatedly affected by such fire signals the crying wolf reaction). This significantly increases the overall risk if a fire does break out. They lower public and patient confidence in the Trust s fire safety and fire control systems. They are disruptive to normal working and can be irritating to our patients and staff. They divert manpower and time resources from patient care and waste money. The number of UwFS in 2010 11is shown in Table 1. Despite the modest improvement on City campus, the number remains higher than the requirements of NHS Guidance [Firecode HTM 05/03 Part H]. Page 2 of 7

Table 1 UwFS by campus 2009 10 & 2010 11 Campus Number of UwFS Number of UwFS Change 2009 10 2010 11 Ropewalk House 4 4 = City campus 223 204 8.5% QMC campus 252 250 = Total 479 467 2.5% QMC Campus QMC campus maintained a performance grading of A for the management of UwFS (<12 actuations per 1000 devices). No specific improvement action is needed at QMC campus. City Campus City campus s 204 UwFS from 11,000 trigger devices represents 20 actuations per 1000 devices. This is a performance grading of B, an improvement from the C grading in 2009 10. To attain an A grading will require the number of UwFS to reduce a further 25%. This is a target for 2011 12. UwFS are not generated solely by NUH activities. Fire detection devices in the Trust s premises occupied by other organisations also contribute, notably on QMC campus where 6000 of the 30000 devices are in premises occupied by the University of Nottingham Medical School. 2.3 Staff response to UwFS alarms Even as we work to reduce the number of UwFS, we are endeavouring to increase staff reporting of fire alarms by the 2222 emergency call system (to Trust Switchboard). This is stressed in mandatory fire safety training for all staff. All departmental line managers have been asked to support enforcement of the 2222 response. Table 2 Staff Response to Fire Alarms Fire alarm activations Number 2222 calls made Alarm Reaction Rate 2010 11 of fires 467 13 * 184 39.4% (36% in 2009 10) * Small equipment and bin fires 2.4 Potential Changes in Fire Service Response to Unwanted Fire Signals As reported in 2009 10 the Nottinghamshire Fire and Rescue Service are considering widening call challenging to include acute NHS premises between 07:00 and 18:00. The Fire Service will contact the premises from which a fire alarm signal has been received to confirm that the alarm does indeed denote a fire and is not an unwanted activation of the alarm system. Only after confirmation by the NHS facility will the Fire and Rescue Service despatch fire control appliances. This proposed call challenge will make it even more important for NUH staff to respond correctly to all fire alarms and to call 2222 to the Switchboard, to ensure that the correct response is given to the emergency services by the Trust s Fire Response Team(s). The Fire Safety and Security Manager will keep the H&S Committee and the Quality, Risk and Safety Committee up to date with these proposals. Page 3 of 7

2.5 Fire Risk Assessments and Action Plans All 2010 11 scheduled fire risk assessments were completed. The results were reviewed by a Trust wide multi disciplinary team using the Trust s risk assessment methodology and the revised backlog maintenance risk methodology. This has helped inform the priorities for capital investment in the Fire Protection Infrastructure in 2011 12 and beyond. 2.6 Major Fire Safety Works completed in 2010 11 This year fire dampers were installed in West Block, and fire compartmentation and stopping were full surveyed in East, West and South Blocks. Areas requiring management actions have been brought to the attention of Directorate management teams. Action plans for each particular area of concern have been developed and are monitored by the Fire Safety Officers and the Trust H&S Committee. 2.7 Fire Safety Maintenance 2010 11 An in year internal Firecode compliance review (corroborated by an external audit in late 2010) described a number of issues relating to regular maintenance, testing and inspection of the following fire systems: Emergency escape lighting Fire door inspection and maintenance Fire damper inspection and testing Portable fire fighting equipment Fire Hydrants/riser inspection and maintenance Heating and ventilation systems Many of these items were being addressed in the Deep Clean Programme (full specification), but changes to that programme delayed completion of some of the necessary works. The Estates Operational Team has responded by reviewing the Planned Preventative Maintenance (PPM) resources, and by prioritising these resources to carry out these works. 2.8 Conclusion In 2010 11 NUH improved its fire safety position in relation to current legislative requirements. 3 Action Plans and Priorities for Fire Safety Development in 2011 2012 3.1 Fire Safety Policy/Procedures The supporting guidance underpinning the 2010 revised Fire Safety Policy will be further developed [Table 3]. Table 3 Fire Safety Policy Guidance : 2011 12 timetable 3.2 Training Guidance Document Present stage Due Date Management Workplace Handbook Ongoing complete over haul for re submission Sept 2011 Guidelines for Unwanted fire signals Awaiting approval by Trust Directors Group June 2011 Arson Policy (revision) Awaiting approval by Trust Directors group June 2011 In 2010/11 the fire safety team developed further training modules, notably for evacuation planning including crowd control. The major objectives for 2011 12 are to Page 4 of 7

roll out the practical evacuation training and fire evacuation exercises, and to deliver the practical fire fighting training modules. 3.3 Unwanted Fire Signals In 2011 12 revised Trust guidelines will be introduced. The guidelines will help ensure that all that is reasonably practicable is done to reduce the number of UwFS from Trust premises. Table 4 Unwanted Fire Alarm Signal Reduction Targets for 2011 12 QMC campus City Campus Ropewalk House 10% reduction (to a target of 180 alarms) 25% reduction (to a target of 190 alarms) 50% reduction 3.4 Fire Safety Management Roll out of trained fire wardens, nominated by Directorates, will continue in 2011 12. Fire Safety Officers will deliver Fire Forums to supplement mandatory training. The Fire Safety Team will identify areas for improvement in local evacuation plans, and will assist managers of those areas to formalise their location specific evacuation plans. All areas will have improved and updated evacuation plans by March 2012. 2011 12 will see continued efforts to develop a full evacuation strategy for the Trust to enable the Trust to be well prepared to carry out the total evacuation of any of its premises or sites, should, the need arise. This process will be undertaken in conjunction with the Trust s Emergency Planning and Business Continuity Teams. During 2011/2012 the systems for the response to chemical incidents will be reviewed and updated in conjunction with the Trust s Health and Safety, Emergency Planning and Business Continuity Teams, to ensure that appropriate detailed response plans and procedures are fully implemented to address the specific chemical hazards. A Fire Safety Web site is in development to provide detailed technical information, training resources and general advice and information to all staff at the Trust. 3.5 Capital Investment for Fire Safety 2011/12 and Future Years The Trust will invest 1m on fire improvement works during 2011 12. These investments include: Campus Project City City City North Corridor Out Patients Department to Maternity Fire precaution works Cityside Restaurant replacement fire alarm system Derwent Block 5 upgrading fire alarm system QMC Fire precaution works to West Block (Phase 1) Following completion of the risk assessment exercise, a range of Fire Safety improvements have been identified. The Trust s Health and Safety/Regulatory capital sub group and the Estates Infrastructure capital sub group consider this list of improvements, and prioritises investment from the annual capital allocations accordingly (funding from Approved Backlog Maintenance Business Case). The list of future improvement works for consideration in 2012/13 and onwards is as follows: Page 5 of 7

o o o o Fire Alarm System Upgrades in St Francis, X Ray and associated buildings, Heathfield House, ALAC building, Estates Workshops, Accommodation blocks A and B, and Ropewalk House. Improved means of escape at City Campus (various) Fire Precaution works at City Campus (various) Fire Precaution works at QMC Campus (various) Page 6 of 7

APPENDIX A Fire Safety Training Delivery 2010 11 Number of Fire Training Courses Delivered 2010/11 Course Total Number of Trust Non Attendees Staff Trust Staff Corporate Induction 11 1023 1023 0 Basic Fire Safety [FS01] Specialist Fire Safety [FS02] 38 2230 1929 301 105 2600 2571 28 Average Attendance per course. 93 Evacuation from Low / Medium dependency patient areas [FS03a] 193 2708 2329 379 14 Evacuation from High dependency patient areas [FS03b] 56 901 901 0 16 Advanced Fire Safety for Managers [FS04] 14 110 110 0 8 59 25 Fire Warden Training [FS04] Fire Responder Training [FS04] Evacuation Exercises 31 192 192 0 6 4 19 19 0 5 12 108 108 0 9 Total 464 9891 9182 709 21 Page 7 of 7