FIRE SAFETY POLICY June 2014

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FIRE SAFETY POLICY June 2014

Policy Title Fire Safety Policy Reference Number Corpo11/002 Implementation Date June 2014 1 st Review Review Date June 2017 Responsible Officer Director of Performance and Service Improvement

Summary Title: Fire Safety Policy Fire is a potential hazard in all HPSS premises. The consequences of fire in a health and social care premises can be especially serious given the risks associated with evacuating clients, staff and visitors. It is the policy of the Western Health and Social Care Trust (hereafter Trust ) to ensure as far as reasonably practical, that all steps are taken to prevent fire, and minimise its effects in all premises owned or occupied by the Trust. Policy Purpose Policy aims to prevent fire, and to ensure arrangements are in place to initiate prompt and effective action in the event of a fire incident, and to ensure clients, staff and visitors can be safely evacuated. Policy details how the Trust strategically meets its obligations in respect of fire safety. Policy Objectives In accordance with The Fire Safety Regulations (Northern Ireland) 2010, this policy aims to outline Trust fire safety management arrangements, and to detail Chief Executive and Board commitment to fire safety. Policy Statement(s) The Trust is committed to a high quality approach to maintaining a fire safe environment. The Trust shall ensure effective management arrangements are in place in accordance with relevant legislation and Firecode guidance. In accordance with The Fire Safety Regulations (Northern Ireland) 2010, the Trust will undertake a programme of fire risk assessment in all premises, and remove or reduce fire risks in its Estate as far as reasonably possible. This policy the underpinning mechanism for managing fire safety within the Trust, and is implemented by Trust Fire Safety Manual. Page 3 of 9

1.0 Introduction Fire is a potential hazard in all HPSS premises. The consequences of fire in a health and social care premises can be especially serious given the risks associated with evacuating clients, staff and visitors. It is the policy of the Trust to remove, reduce and manage fire risks across its Estate. 2.0 Scope Scope of this policy extends to all areas owned or occupied by the Trust. Policy applies to all employees, lessors, lessees and those undertaking service provision and activities on behalf of the Trust. 3.0 Roles and Responsibilities Trust Board Trust Board shall ensure that the organisation complies with fire safety legislation and guidance, and that adequate resources are made available to meet Trust s fire safety requirements. Trust Board s corporate responsibility for ensuring the implementation of fire safety arrangements is devolved through Chief Executive. Chief Executive Chief Executive has ultimate accountability for ensuring that the organisation and arrangements for fire safety are effective in providing a safe working environment. Executive Director (Fire) Director of Performance and Service Improvement has overall responsibility for Trust fire safety arrangements to ensure compliance with fire safety legislation and guidance (including application of Firecode), and that agreed programmes for investment are included in annual business plan. Responsibility is devolved through Assistant Director of Facilities Management to Head of Estates Management (Trust Nominated Officer Fire). Directors Directors are responsible for fire safety arrangements within Directorate to ensure compliance with this policy, legislation and guidance. Directors must ensure that adequate Nominated Officers (Fire) are appointed in each premises to ensure cover at all times, and ongoing effective management of fire safety arrangements within Directorate. Page 4 of 9

Assistant Directors Assistant Directors are responsible to ensure compliance with this policy and for fire safety arrangements within area of responsibility to ensure compliance with legislation and guidance. Trust Nominated Officer (Fire) Head of Estates Management (Trust Nominated Officer - Fire) is responsible to assist Executive Director (Fire) to implement fire safety policy. As Chair of Fire Safety Working Group, Trust Nominated Officer (Fire) is responsible to coordinate Trust fire safety arrangements at operational level to ensure compliance with legislation and guidance, and provision of safe working environment across Trust Estate. Head of Estates Management is assisted in role by: Head of Specialist Services & Medical Engineering (Nominated Deputy) Estates Environment Manager Specialist Fire Safety Advisers Nominated Officers (Fire) Nominated Officers (Fire) across the Trust are responsible for management of fire safety arrangements on day-to-day basis within area of responsibility in accordance with Trust Fire Safety Manual. Nominated Officers (Fire) must ensure effective arrangements to prevent fire; and in the event of a fire incident - coordinate action of staff (in accordance with site specific fire emergency procedures). All Staff Each employee is responsible to conduct their work in accordance with fire safety arrangements for their area, including attendance at fire safety training. Trust Fire Safety Working Group Trust multi-discipline group to coordinate and monitor fire safety arrangements across Trust - to ensure compliance with legislation and guidance, and provision of safe working environment. Estates Fire Safety Operational Group Estates technical group to monitor and review fire safety arrangements across Trust to provide specialist advice on compliance with legislation and guidance, and provision of safe working environment. Page 5 of 9

Fire Safety Advisers Trust has four directly employed specialist Fire Safety Advisers. Fire Safety Advisers are responsible to provide technical expertise and advice on application and interpretation of fire safety legislation and guidance (including Firecode) to staff at all levels across Trust. 4.0 Policy Objectives Trust recognises its duty in respect of fire safety legislation and guidance, and is committed to eliminate or minimise the risk to all those who are within or are affected by its Estate. In all premises owned or occupied by Trust, duty will be discharged insofar as is reasonably practical - by ensuring: compliance with fire safety legislation and guidance (including Firecode) persons with fire responsibilities are nominated fire risks are assessed and recorded by fire risk assessment monitoring and audit of fire safety arrangements documented site specific emergency evacuation plans/procedures provision of appropriate fire safety training to staff co-operation and communication with other users monitoring and reporting of fire incidents 5.0 Implementation Policy approved by Trust Board. In order to ensure effectiveness of policy, Trust will seek to gain confidence of all stakeholders by communicating policy fully across the organisation. Policy will be electronically available on Trust Intranet (internal communication) and Trust Internet site (external communication). Policy is implemented by Trust Fire Safety Manual, and effectiveness of policy will be monitored and reviewed by Fire Safety Working Group. Page 6 of 9

6.0 Sources (s) / Evidence Base PRIMARY LEGISLATIVE INSTRUMENTS The Health and Safety at Work (NI) Order 1978 Fire Safety Regulations (NI) 2010 Building Regulations (NI) 2000 Housing (NI) Order 2003 Housing (Management of Houses in Multiple Occupation) Regulations (NI) 1993 Management of Health and Safety at Work Regulations (NI) 2000 Health and safety (Safety Signs and Signals) Regulations (NI) 1996 Dangerous Substances and Explosive Atmosphere Regulations 2002 Corporate Manslaughter Act 2007 SUBSIDIARY LEGISLATIVE INSTRUMENTS: LIST APPROPRIATE HTMs: NI Firecode Policy and Principles NI Firecode: A model management structure for fire safety NIHTM 81 Fire Precautions in new healthcare premises NIHTM 82 Alarm and detection systems NIHTM 82 Alarm and detection systems: supplement A NIHTM 83 Fire Safety in healthcare premises : general fire precautions NIHTM 84 Fire risk assessment in residential care premises NIHTM 85 Fire precautions in existing healthcare premises NIHTM 86 Fire risk assessment part 1: community healthcare premises NIHTM 86 Fire risk assessment part 2: healthcare premises NIHTM 87 Textiles and furniture HTM 88 Guide to fire precautions in NHS housing in the community. Firecode HTM O5-01, 02 and 03 series. NIFPN 3 Escape bed lifts NIFPN 4 Hospital main kitchens NIFPN 5 Commercial enterprises on hospital premises NIFPN 6 Wilful fire raising NIFPN 7 Fire precautions in patient hotels NIFPN 10 Laboratories in hospital premises NIFPN 11 Reducing unwanted fire signals in healthcare premises 7.0 Consultation and Review Process The Regional Policy Sub-Group in consultation with nominated specialists from each Trust has developed this Policy. This policy will be reviewed regularly by Trust Fire Safety Working Group to take cognisance of changes in legislation and guidance. Page 7 of 9

8.0 Equality Screening This policy has been screened for equality implications as required by Section 75, Schedule 9 of the Northern Ireland Act, 1998. Using the Equality Commission s screening procedure, no significant equality implications have been identified. This policy has been considered under the terms of the Human Rights Act, 1998, and was deemed to be compatible with the European Convention Rights contained in that Act. The following Equality issues were identified:- Specific needs of people with disabilities Communication support needs of people whose first language is not English Actions taken to address these needs in Policy:- In our staff / client training on occasion we bring in sign language interpreters for clients with hearing impairments. All our procedures take into account that many patient / clients have mobility issues. Fire exit signs have symbols that people with learning disability would understand. Nominated Officers (Fire) will be aware of any staff with disabilities in their section and will ensure their safe evacuation in the event of a fire. Consider incorporating into training how we can better communicate with patients, clients and visitors whose first language is not English. 9.0 Other Policies Other Trust policies impact on fire safety arrangements. Examples include: Risk Management Policy Health & Safety Policy Incident Reporting Policy Security Policy Environment Policy 10.0 Procedure(s) This policy is implemented by Trust Fire Safety Manual, Fire Emergency Plans and associated emergency procedures. Fire Safety Manual details a set of step-by-step instructions that describe the appropriate method for carrying out tasks or activities to achieve the highest standards possible and to ensure efficiency, consistency and safety. Page 8 of 9

Fire Safety Management Structure Appendix 1 TRUST CHIEF GOVERNANCE BOARD EXECUTIVE COMMITTEE DIRECTOR OF PERFORMANCE & SERVICE IMPROVEMENT Board Level Director (Fire Safety) RISK MANAGEMENT SUB-COMMITTEE ASSISTANT DIRECTOR FACILITIES MANAGEMENT ESTATES HEAD OF ESTATES TRUST FIRE SAFETY Trust Nominated Officer (Fire) FIRE SAFETY OPERATIONAL CHAIR WORKING GROUP (Fire Safety-Working Group) GROUP FIRE SAFETY ADVISERS NOMINATED OFFICERS (FIRE) WARD/DEPARTMENT/FACILITY COMPETENT PERSONS (Fire) Inst/Maintenance Engineers STAFF Page 9 of 9