SH HS 06 Fire Safety Policy Summary: Keywords: Target Audience: The Fire Safety Policy sets out the Trusts approach to a proactive fire safety culture to protect its staff, patients, service users, all relevant persons and properties, and meet statutory requirements of the Regulatory Reform (Fire Safety) Order 2005 (RRO) and the Health Technical Memorandum guidelines (HTM s). Fire, Training, Premises, Procedures, Assessments All staff employed by Southern Health NHS Foundation Trust Next Review Date: March 2020 Approved & Ratified by: Health and Safety Forum Date of meeting: 5 th Date issued: Author: Director: Peter Pritchard-Smith Fire Safety Manager Paula Anderson Chief Finance Officer 1
Version Control Change Record Date Author Version Page Reason for Change Sept D White 02 All Document review in compliance with SHFT Policy 2013 Dec J Pearce 03 All Document review in compliance with SHFT Policy 2014 July Louise Hartland 3 12 Updated TNA (Appendix 1) 2015 July 2017 3 Version 3 reinstated, review date extended to October 2017 16/10/17 4 Policy currently being reviewed to meet the HTM guidelines. Review date extended to January 2018 2017 Peter Pritchard-Smith 04 All Align to HTM Guidance Reviewers/contributors Name Position Version Reviewed & Date R Lindsay Fire Safety Advisor Version 2 / Sept 2013 J Pearce Fire Safety Advisor Version 3 / Dec 2014 Mick Hand Fire Safety Officer HRFS-PAS Version 1, October 2017 2
Quick Reference Guide For quick reference, this page summarises the actions required by this policy. This does not negate the need to be aware of and to follow the further detail provided in this policy. Southern Health NHS Foundation Trust acknowledges its responsibilities under the Regulatory Reform (Fire Safety) Order 2005 and Health Technical Memorandum (HTM) and will ensure that fire risk assessments are carried out on its premises to determine the general fire precautions and protective measures needed to comply with the articles imposed under this order. This policy encompasses the management of the fire safety in all Southern Health NHS Foundation Trust (SHFT) premises which may be owned or occupied. The Trust s Chief Executive has overall responsibility for ensuring that the Trust has robust systems and policies in place in respect of general fire precautions and training, and that these are implemented. The Chief Executive will sign annually the certificate of compliance to the NHS Executive. The board of directors have the responsibility of setting the strategic direction of the Trust and overseeing the implementation of this policy and objectives including those related to fire safety. It is the board of Directors responsibility for decision making on the management of all types of health and safety risks within the organisation. The Fire Safety Manager will report to the Board level director on all Fire Safety matters throughout the Trust, and ensure that all aspects of the RRFSO 2005 and Fire code are adhered to in all SHFT premises. Line Managers and Departmental Heads are entrusted with the day-to-day responsibilities of ensuring the effectiveness of fire safety arrangements in buildings within their area of control. Fire Wardens should be appointed in all departments where deemed necessary under article 15 of RRFSO 2005. All SHFT employees have a duty to ensure that they comply with the fire safety arrangements and procedures within their workplace and they do not commit acts which lead to the outbreak of fire. All employees have a duty under the Health and Safety at Work Act 1974, to take reasonable care of their own safety at work, and that of others who may be affected by their acts or omissions. All SHFT employees are required to complete annual fire safety training in accordance with Fire Safety Training Needs Analysis (Appendix 1) and to familiarise themselves with the evacuation procedures of the work place 3
Contents Section Title Page 1. Introduction 5 2. Policy Aims and Purposes 5 3. Applications 5 4. Definitions 6 5. Facilitation 6 6. Implementation 6 7. Monitoring 7 8. Policy review 7 9. Associated trust documents 7 10. Supporting references 8 Appendix 1 Training Needs Analysis 9 Appendix 2 Equality Impact Assessment 12 4
Fire Safety Policy 1. Introduction 1.1 The Fire Safety Policy has been prepared as per Health Technical Memorandum 05-01: Managing Healthcare Fire Safety, second edition and Fire code-fire Safety in the NHS Health Technical Memorandum 05-03: Operational Provisions, Part A: General Fire Safety. It is based on the current legislative requirements in the form of the Regulatory Reform (Fire Safety) Order 2005. Both the legislation and guidance documents require businesses to implement Fire Safety Policy and subsequent Fire Safety Management Protocols and Procedures Document, which covers all SHFT sites across England in regards to their fire prevention and protections arrangements. The preparation, approval, implementation and review of this policy doctrine is the responsibility of the designated Board Director for Southern Health NHS Foundation Trust. 2. Policy Aims and Purposes 2.1 To provide an unambiguous statement of fire safety policy applicable to the Southern Health NHS Foundation Trust sites, including premises where patients receive NHS Funded Treatment or care. 2.2 The aim of the Fire Safety Policy is to assist the Trust Board: a) To discharge its fire safety responsibilities as a provider to healthcare by ensuring that suitable and sufficient governance arrangements are in place to manage all fire related subjects and matters that arise concerning fire safety across the Trust. b) To proactively support development of working partnerships initiatives with all relevant stakeholders and appropriate bodies to facilitate the provision of the fire safety where reasonably practicable. c) To provide a clearly defined management structure for the delivery of and maintaining suitable and sufficient controls and monitoring measures for all the fire safety related subjects throughout the Trust. d) To assess and provide appropriate levels of investment in relation to fire safety measures across the estate and personnel to facilitate the maintenance to existing fire safety arrangements and support the implementation of suitable fire safety precautions as required. 3. Applications 3.1 The Trust Fire Safety Policy will be applied throughout all Trusts premises or parts of premises that the Trust owns, occupies or for which the Trust holds responsibility. 5
4. Definitions 4.1 The following definitions are used throughout this policy SHFT Southern Health NHS Foundation Trust RRFSO 2005 Regulatory Reform (Fire SAFETY) Order 2005 FEEP Fire Emergency Evacuation Plan BS British Standards HTM 05:03 Health Technical Memorandum 5. Facilitation 5.1 The Trust Board expects those tasked with managing aspects of fire safety to: a) Diligently to discharge their fire responsibilities as befits their position. b) Develop and manage the implementation of monitoring mechanisms that are relevant and suitable for the management of fire safety throughout the Trust. c) Develop Fire Evacuation Emergency Procedures (FEEP) that are pertinent to each area/building/department throughout the Trust to ensure fire safety of all relevant persons, protect the associated property, protect the maintenance of service delivery and where possible support the defence of the environment. d) Design and implement a programme of Fire Risk Assessments to review and identify associated fire risks across all relevant areas of the Trust. e) Develop, implement and support appropriate action plans, procedures and suitable control measures to support the mitigation of fire risks. f) Design and implement a programme for Fire Safety training for all Southern Health staff to include bespoke training for relevant inpatient areas. 6. Implementation 6.1 The Trust Board will have overall accountability for the Fire Safety activities and will discharge fire safety responsibilities through the Chief Executive of the Trust. a) The Trust Board will ensure that appropriate assurance is received in relation to current fire safety legislation and relevant fire codes. b) The Trust Board discharge the delivery of Fire Safety to competent persons to: 1. Liaise with external agencies, enforcing authorities and Trust authorised engineers, (fire). 2. Obtain expert advice and information on fire safety legislation 3. Ensure that the Trust sites have an appropriate level of Fire response teams. 4. Constantly raise awareness of all fire safety issues and practices and their purpose throughout the Trust. 6
5. Ensure Fire Safety compliance is met in accordance with Fire Safety legislation and relevant British Standards. 6. Develop, Implement and review the Trusts Fire Safety policy and procedures and report where non-compliance exists to the relevant Trust directors. 7. Develop and deliver effective training programmes for all fire safety. 8. Support the operational management of Fire Safety risks identified by the Fire Risk Assessment process. 9. Support the development and implementation of the Trust Fire Safety strategy. 10. Ensure that suitable and sufficient Fire Risk Assessments are undertaken, recorded and that identified deficiencies are suitably reported. 11. Provide a suitable link to the relevant Trust Committees. 12. Ensure Fire incidents are reported accordingly and the appropriate level of investigation is undertaken. 7. Monitoring a) The Trust Board will monitor this document to ensure its effectiveness and to assure compliance is maintained in relation to Fire Safety across the Trust. b) Fire Safety Manager will take lead on monitoring all issues with regards to the fire safety and will engage with all relevant persons and stakeholders. c) The Fire Safety Manager will report on compliance within the Health and Safety Forum which reports to the Quality and Safety Committee quarterly and Compliance and Assurance groups quarterly. Element to be monitored Lead Tool Frequency Completion of Fire Safety Training Compliance with the key principles outlined in this policy Completion of Fire Risk Assessment (FRA s) Fire Safety Manager Fire Safety Manager Fire Safety Manager Outlined in the Trust Learning and Education Policy Reporting arrangements Health & Safety Forum Audit Annual Health & Safety Forum Audit Annual Health & Safety Forum 8. Policy review 8.1 This policy will be reviewed two-yearly and or following any significant changes in legislation, whichever occurs first. 9. Associated trust documents 9.1 Fire Safety Strategy 7
10. Supporting references 10.1 Regulatory Reform (Fire Safety) Order 2005 10.2 HTM 05-01: Managing Healthcare Fire Safety 10.3 Health & Safety at Work Act 1974 10.4 Building Regulations 2000 (approved document B) 10.5 Care Commissioning Core Standards 10.6 The Building Act 1984 10.7 Management of Health and Safety at Work Regulations 1999 10.8 Control of Substances Hazardous to Health Regulations 1977 10.9 The Safety Representatives and Safety Committee Regulations 1977 10.10 Construction, Design and Management Regulations 2004 10.11 Equality Act 2010 8
Appendix 1: Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance on 02380 874091) before the policy goes through the Trust policy approval process. Training Programme Frequency Course Length Delivery Method Annual Face to Face Fire Safety Awareness training Annual 1 hour Face to Face Directorate Service Target Audience Facilitators Corporate Health and Safety Recording Attendance LEaD Strategic & Operational Responsibility Strategic - Director of Finance Operational - Fire Safety Officer Adult Mental Health All clinical and non-clinical staff who work in inpatient areas. MH/LD Specialised Services All clinical and non-clinical staff who work in inpatient areas. Learning Disabilities All clinical and non-clinical staff who work in inpatient areas. Business Units 1,2, 3 & 5 Older Persons Mental Health All clinical and non-clinical staff who work in inpatient areas. Business Units 1,2, 3 & 6 Adults All clinical and non-clinical staff who work in inpatient areas. Business Unit 4 Childrens Services Director of Nursing Medical Director Chief Executive Chief Financial Officer Development Director People and Communications Property and Estates Strategy Director 9
Training Programme Frequency Course Length Delivery Method Facilitators Recording Attendance Strategic & Operational Responsibility Face to Face Fire Safety Awareness every 2 years supplemented by Fire Safety Clinical Community e-learning training in interim year. Annual 1.0 hour face to face 0.5 hours e-learning Directorate Service Target Audience Face to Face and e-learning Corporate Health and Safety LEaD Strategic Director of Finance Operational - Fire Safety Officer Adult Mental Health All clinical staff who work in community teams. MH/LD Specialised Services All clinical staff who work in community teams. Learning Disabilities All clinical staff who work in community teams. Business Units 1,2, 3 & 5 Older Persons Mental Health All clinical staff who work in community teams. Business Units 1,2, 3 & 6 Adults All clinical staff who work in community teams. Business Unit 4 Childrens Services All clinical staff Director of Nursing All clinical staff Medical Director Chief Executive Chief Financial Officer Development Director People and Communications Property and Estates Strategy Director All clinical staff 10
Training Programme Frequency Course Length Face to Face Fire Safety Awareness every 3 years supplemented by Fire Safety Non-Clinical e-learning training in interim years. Annual 1.0 hour face to face 0.5 hours e-learning Directorate Service Target Audience Delivery Method Face to Face and e-learning Facilitators Corporate Health and Safety Recording Attendance LEaD Strategic & Operational Responsibility Strategic - Director of Finance Operational - Fire Safety Officer Adult Mental Health All non-clinical staff who are NOT REQUIRED to complete annual Face to face Fire Safety Awareness Training MH/LD Specialised Services All non-clinical staff who are NOT REQUIRED to complete annual Face to face Fire Safety Awareness Training Learning Disabilities All non-clinical staff who are NOT REQUIRED to complete annual Face to face Fire Safety Awareness Training Business Units 1,2, 3 & 5 Older Persons Mental Health All non-clinical staff who are NOT REQUIRED to complete annual Face to face Fire Safety Awareness Training Business Units 1,2, 3 & 6 Adults All non-clinical staff who are NOT REQUIRED to complete annual Face to face Fire Safety Awareness Training Business Unit 4 Director of Nursing Medical Director Chief Executive Chief Financial Officer Development Director People and Communications Property and Estates Strategy Director Childrens Services All non-clinical staff All non-clinical staff All non-clinical staff All staff All staff All staff All staff All staff All staff 11
Appendix 2: Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010. Stage 1: Screening Date of assessment: 21 October 2017 Name of person completing the assessment: Job title: Responsible department: Peter Pritchard-Smith Fire Safety Manager Estates Services Fire Safety Who was involved in the consultation of this document? Policy authors and the virtual policy group. Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found by following the link: www.legislation.gov.uk/ukpga/2010/15/contents Protected Characteristic Positive impact Negative impact Age Disability Gender reassignment Marriage & civil partnership Pregnancy & maternity Race Religion Sex Sexual orientation Stage 2: Full impact assessment What is the impact? Mitigating actions Monitoring of actions 12