Directorate of Facilities and Information POLICY FOR FIRE SAFETY MANAGEMENT Reference: FMP021 Version: 1.1 This version issued: 21/12/11 Result of last review: Minor changes Date approved by owner (if applicable): N/A Date approved: 17/11/11 Approving body: Trust Governance Committee Date for review: September, 2013 Owner: Director of Facilities and Information Document type: Policy Number of pages: 12 (including front sheet) Author / Contact: Ahmed Hussain, Health & Fire Safety Advisor Northern Lincolnshire and Goole Hospitals NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the protected characteristics as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.
Contents Section... Page 1.0 Purpose... 3 2.0 Area... 3 3.0 Duties... 3 3.1 Chief Executive (Responsible Person)... 3 3.2 Director of Facilities and Information (Executive Director, Fire Safety)*... 3 3.3 Health and Safety Manager (Fire Safety Manager)... 4 3.4 Senior Managers (or Rostered On-Call Senior Manager)... 4 3.5 Health and Fire Safety Advisor (Authorised Person Fire)... 5 3.6 Line Management... 6 3.7 Fire Wardens (formally Awareness Co-ordinators)... 7 3.8 All Staff... 7 3.9 Fire Safety Committee... 7 4.0 Relevant Fire Safety Policies/Procedures... 7 5.0 Training Requirements... 8 5.1 Induction Training... 8 5.2 Refresher/Update Training... 8 5.3 Specific Training... 9 6.0 Monitoring Compliance and Effectiveness... 9 7.0 Arson Prevention... 9 8.0 Textiles and Furnishings... 10 9.0 References... 11 10.0 Definitions... 11 Appendix A - Fire Safety Management Structure... 12 Printed copies valid only if separately controlled Page 2 of 12
1.0 Purpose 1.1 This policy has been developed to enable the Trust to meet its statutory obligation to achieve acceptable standards of fire safety and to have appropriate programmes of work for maintaining and improving fire precautions for all its premises. 1.2 The Trust is committed to the provision of written procedures to ensure that fire safety and precautions are in force for all persons in Trust premises. 1.3 The Fire Management Structure and Designated Officers are indicated in Appendix A. 2.0 Area This policy and the procedures contained herein, apply to all premises throughout the Trust. 3.0 Duties 3.1 Chief Executive (Responsible Person) 3.1.1 Is responsible, on behalf of the Trust Board as a corporate body, for all fire safety issues, including operational matters which will be delegated to the following Director/Senior Managers and for ensuring that appropriate policies, procedures and arrangements are in place. 3.1.2 Receives (along with other Board members) the annual report of compliance with statutory provisions and Firecode (see below) to ensure that the Board are assured of fire safety management within the Trust. 3.2 Director of Facilities and Information (Executive Director, Fire Safety)* 3.2.1 The Director of Facilities & Information is responsible for championing Fire Safety issues at Board level and for advising the Chief Executive on all fire safety matters. These duties will include: Ensuring that the Trust has an effective fire safety management system in place Ensuring that Fire Safety is a standing agenda item at meetings of the Health, Safety and Fire Steering Groups with the annual Fire report being reported to the Trust Governance Committee Is responsible for all matters of fire safety in particular for ensuring that agreed programmes of investment in fire precautions are properly accounted for in the Trust s annual business plan Is responsible for ensuring that there is an annual fire safety action plan/work programme in place and for ensuring that an annual report is submitted to the Trust Board regarding fire safety management within the Trust and giving Board members assurance that adequate arrangements are in place to control fire risks which cannot be eliminated Printed copies valid only if separately controlled Page 3 of 12
* Whilst the Director of Facilities & Information is the nominated Executive Director for Fire Safety, and is responsible for ensuring that the physical aspects of the Trust's fire safety arrangements are effective, the Head of Governance & Trust Secretary will lead on the compliance and assurance aspects of fire. The Health & Safety Manager, on behalf of the Head of Governance & Trust Secretary, will fulfil the role of 'Fire Safety Manager (see below). 3.3 Health and Safety Manager (Fire Safety Manager) 3.3.1 The role of Fire Safety Manager is a held by the Health and Safety Manager. 3.3.2 The Fire Safety Manager is responsible for co-ordinating the fire policy and compliance with appropriate regulations to which the duties include: Supervising the effective day to day implementation of the Trust s Fire Safety Policy Ensuring that Fire Safety and Evacuation Training is scheduled on a regular basis for staff to attend Co-ordinating the preparation and awareness to staff of written fire safety procedures and evacuation strategies and action plans/work programmes relating to fire safety Ensuring that procedures exist for the reporting of fire hazards to management and that such reports are acted upon Advising of fire safety measures generally and recommending the order of priority Surveying and reporting on the standard of Fire Safety in all premises that the Trust owns or any premises from which Trust employees operate from when undertaking their normal range of duties e.g. leased premises Being the point of contact and liaising with the fire authority and other bodies having mandatory or advisory fire precaution responsibilities Working with Facilities Management in relation to maintenance requirements of current systems and drawing up capital funding bids for future requirements 3.4 Senior Managers (or Rostered On-Call Senior Manager) 3.4.1 The responsibilities detailed below apply to Senior Managers during their normal hours of duty and in their absence (e.g. nights and weekends) to the duty Site Manager. 3.4.2 With regard to fire safety, each Senior Manager should: Ensure that the person in charge of any area will, initially be in charge of any fire incident and will be relieved as soon as possible by a Senior Manager Liaise with Fire Safety Manager to ensure that fire safety is managed in line with the organisation s policy and site-specific fire safety procedures Produce and maintain local site-specific fire safety procedures as co-ordinated by the Fire Safety Manager Printed copies valid only if separately controlled Page 4 of 12
Be responsible for the Line Managers in relation to fire safety management Represent their area of responsibility in fire emergency planning and impact within the organisation s contingency plans Take responsibility for co-ordination in a fire incident Instigate the emergency plan (if required) Ensure that all staff within their department, attend planned fire safety training and record and report on attendance Be involved in departmental fire emergency planning and ensure that plans are in place and maintained to reflect changing operational requirements as they arise Ensure that any incident is reported using the Trust reporting procedure and the Health and Fire Safety Advisor is notified of all incidents (including False Alarms) and the Fire Safety Manager is notified of all fire incidents 3.5 Health and Fire Safety Advisor (Authorised Person Fire) 3.5.1 The role of Health and Fire Safety Advisor (Authorised Person Fire) is primarily to support the Fire Safety Manager in fire safety activities. This role is of prime importance in large Healthcare organisations where the Competent Person will concentrate on tasks such as performing risk assessments, fire safety audits, staff training etc. An exemplar person specification is included in Appendix B of Health Technical Memorandum 05-01: Managing Healthcare Fire Safety. 3.5.2 The Health and Fire Safety Advisor should: Support the Fire Safety Manager in fire safety advice and activities Deputise for the Fire Safety Manager when necessary Conduct/be involved in fire safety audits and contribute to periodic reports to management regarding fire safety provision in the premises occupied by the Healthcare organisation Conduct/be involved in the identification and assessment of fire risks within the premises, prepare reports to management recommending prioritised actions in respect to fire safety improvements Prepare and deliver training programmes in line with the training curriculum developed by the Fire Safety Manager Be involved with new projects from the onset to determine fire risks either during the project as well subsequently after completion having sign off in relation to fire safety Maintain the fire risk assessments on the SHE system including monitoring of actions (following up on any highlighted as outstanding) Printed copies valid only if separately controlled Page 5 of 12
Deliver Fire Warden training to nominated staff and maintain a register of Fire Wardens within the Trust 3.6 Line Management Line Managers should: Being the person in charge of any area will initially be in charge of any fire incident. The Line Managers must therefore ensure that they and any personnel under their control likely to be in charge at any time is prepared and trained for such responsibility Understand and implement the fire safety policy, fire strategy and site-specific procedures Ensure that fire safety policy documentation, in terms of local hazards and procedures, is available in relevant areas Liaise with their Senior Manager and Fire Safety Manager to arrange and carry out fire drills Ensure a staff commitment to the fire safety policy, site-specific procedures and to fire safety Make provisions to ensure that every member of staff can participate in fire safety training and drills and to record and report such attendance Managers are responsible for ensuring that their staff receive fire safety training and that staff receive basic instruction in fire safety, and training appropriate to the specific needs of their workplace Ensure that trained staff will be available should an outbreak of fire occur at anytime Ensure deficiencies in fire safety measures are remedied or reported to Senior Manager (whilst copying the Fire Safety Manager on correspondence) Compile and submit an incident report for fire incidents to the Fire Safety Manager, and ensure that details of all incidents including false alarms are submitted via the electronic reporting system to the Health and Fire Safety Advisor Ensure that all staff under their control are informed of the fire risks identified through risk assessments, audits and inspections and are trained in measures necessary to eliminate or reduce such risks Assist in the development of departmental fire emergency plans and ensure kept up to date Act as immediate liaison with Fire Service during an incident as The Incident Co-ordinator Printed copies valid only if separately controlled Page 6 of 12
3.7 Fire Wardens (formally Awareness Co-ordinators) The Fire Warden should: Act as focal point for fire safety issues for local staff Organise and assist in the fire safety regime within local workstations and other relevant areas Raise issues regarding local area fire safety with line management Assist with the Co-ordinated response to an incident within the immediate vicinity Support Line managers with fire safety issues 3.8 All Staff 3.8.1 All staff have a duty of responsibility in respect of fire safety. 3.8.2 All staff should: Practice and promote fire safety and mitigate the occurrence of fire and unwanted fire signals Attend and participate in fire safety training and drills as defined by the Fire Safety Manager. Report fire incidents or unwanted fire signals in accordance with the organisation s policy via their line manager Raise issues regarding fire safety with Fire Warden and / or line manager Respond to incidents as appropriate Be vigilant with respect to behaviour associated with arson and report any such suspicions to the person in control of their area of work. Assist with risk assessments and audits as appropriate 3.9 Fire Safety Committee To meet a requirement for the formation of a Trust Fire Safety Committee (consisting of managers, staff representatives and Fire Safety Advisers), Fire Safety is incorporated into the relevant site Health, Safety and Fire committee. Fire safety will be a standing item on those groups agendas. 4.0 Relevant Fire Safety Policies/Procedures Further information, guidance, fire safety tips is published on the Fire Safety Intranet pages. Printed copies valid only if separately controlled Page 7 of 12
5.0 Training Requirements 5.1 Induction Training 5.1.1 Basic fire safety procedures must be included in all induction training for new staff at their first attendance at a workplace, whenever there is a change of staff or in the risks in case of fire at a location. They must understand the action required of them in the event of fire, namely: Raise the alarm, inform the main telephone switchboard and request assistance Remove patients (and others) in immediate danger to a place of safety Evacuate the area in accordance with the emergency evacuation plan Close all doors, windows, hatches etc to prevent further spread of fire, smoke and toxic fumes Understand the phasing of fire evacuation procedures Fight the fire, if it is safe to do so with approved appliances (through practical training) 5.1.2 Therefore, all new employees to the Trust will receive first day local induction (departmental training) by their managers or deputy irrespective of length of employment. 5.1.3 Attend the first available Trust Induction course. 5.1.4 Attend a practical fire-training course (incorporated into Trust induction). 5.2 Refresher/Update Training 5.2.1 All staff must undertake theory Fire Safety Training as set out in the model below: Staff Year 1/2 Year 3/4 All staff Competent person lecture E-learning *(see note below) *(see note below) Note If e-learning is accessed in years 1/2 then competent person lecture must be accessed in years 3/4. Therefore e-learning cannot be accessed twice in any 4 year cycle. Additional in-house training can be delivered by fire wardens/ward managers as part of general multi topic updates. However, such training cannot be used as evidence of compliance with statutory fire training requirements (although general updates are still required to be recorded on OLM). 5.2.2 Year 3/4 can be replaced with a fire lecture delivered by the competent person if preferred. However (as noted above) E-learning would not be permitted to be used twice in the 4 year cycle. 5.2.3 The fire training refresher lectures will be available through a series of programmed lectures on all sites presented by the Fire Safety Advisor (or suitable competent person when required), as arranged by Training Department. Printed copies valid only if separately controlled Page 8 of 12
5.2.4 Fire wardens training should follow the training model above. However the requirement for a competent person lecture is replaced by a specific fire warden training course (i.e. if you attend a Fire Warden training session this will count as attending a fire safety lecture as well). 5.2.5 Practical extinguisher fire training is a statutory requirement and is required to be completed every five years. This five year cycle runs concurrently with the model above. N.B. attendance at a lecture does not constitute as extinguisher training. 5.2.6 Further practical training should include fire drills/escape walk through exercises. These should be carried out wherever possible in live work areas or on new wards after refurbishment and prior to formal occupation; this will be arranged in conjunction with the Fire safety Advisor in accordance with the annual fire work plan. 5.3 Specific Training 5.3.1 Medical staff will receive Fire Safety Training by way of scheduled refresher sessions arranged by the Training Department for Junior Doctors. All new medical staff will be given basic procedure training at the medical staff integration/induction day. 5.3.2 Managers who are engaging contractors for work will ensure that contractor staff are briefed on fire safety procedures, arson prevention and requirements for incident reporting through implementation of the control of contractors policy. 5.3.3 The medical staff who participate in the core mandatory training will receive refresher training in accordance with the programme. 6.0 Monitoring Compliance and Effectiveness 6.1 The Directorate of the Medical Director will continuously monitor compliance with this policy on an annual basis and ensure the findings are reported to the Chief Executive as part of the annual fire safety report. Also the Health, Safety and Fire sub Groups will monitor issues in relation to Fire Safety and escalate any identified issues where appropriate to the Trust Governance Committee (or Trust Board). 6.2 Compliance will also be monitored through the review and analysis of incidents and review of fire risk assessments. Quarterly risk assessment reports will be submitted to and considered by the Health, Safety and Fire Committees in order to ensure that the necessary controls are in place. Where actions are identified, these will be communicated to the relevant Directorate/Group and/or incorporated within the annual fire action plan/work programme. 7.0 Arson Prevention 7.1 Arson is the deliberate setting on fire of buildings and other property whatever the motive. NHS statistics show that arson accounts for 29% of all fires in healthcare premises. 7.2 Arson prevention, control and detection must form an essential element of the fight against all crime in all NHS premises. It is paramount that a consistent approach to arson prevention is taken and that it is an integral part of the overall fire safety strategy for Hospitals and other healthcare premises. Printed copies valid only if separately controlled Page 9 of 12
7.3 The Health and Fire Safety Advisor is responsible for carrying out the Fire Risk Assessments for all the Trust s workplaces which will include assessing the risks arising from potential arson actions. 7.4 As well as all staff and outside contractors working within the Trust being vigilant to behaviour associated with arson they should ensure that they do not introduce any unnecessary arson risk. Where a risk is introduced, then it should be appropriately managed. 7.5 Factors to consider include: Security arrangements and access control. Fire Containment and Extinguishment. Housekeeping Client group (i.e. groups with learning difficulties or dementia) 7.6 Outside contractors must comply with any fire related conditions contained within their permit to work as statistics show that they are a causal factor for fire starting in a premises. 7.7 To further minimise the risk of arson close down procedures should be followed at the end of each working period and if the department is to be left unoccupied, it is essential to operate checking procedures to include the following: External doors locked with internal doors closed Windows closed and locked No unauthorised people in the department Machines should be switched OFF not put on standby Electrical power sources disconnected as appropriate No flammable liquids left accessible or near possible ignition sources No accumulation of rubbish/waste Security alarms (where fitted) should be ON if building is not occupied Outside illumination should be switched on (where installed) 8.0 Textiles and Furnishings 8.1 Fire statistics show that in terms of unwanted fires in healthcare premises, it is often a textile or textile-based material that is the item first ignited. Textiles are often easy to ignite and burn rapidly (especially in a vertical orientation) unless they are inherently flame-retardant or have been treated with a chemical flame-retardant. Printed copies valid only if separately controlled Page 10 of 12
8.2 It is important that the fire loading within healthcare premises is kept to a low level as is practicable as the mobility of patients may be such that the movement of these patients in an emergency fire situation may be difficult to achieve. 8.3 All persons specifying or using textiles and furnishings in the Trust s premises should 8.4 ensure that they only purchase such items through the Procurement Department who will ensure that these comply with relevant regulations. Assistance in this regard should be sought from the Fire Safety Advisors if there is any uncertainty. 9.0 References 9.1 The Health and Safety at Work etc Act 1974. 9.2 The Building Act 1984 (including The Building Regulations). 9.3 The Housing Act 2004. 9.4 Management of Health & Safety at Work Regulations 1999. 9.5 The Regulatory Reform (Fire Safety) order 2005. 9.6 Health Technical Memorandum 05-03: Operational Provisions Part F: The prevention and control of arson in NHS healthcare premises 9.7 Hospital Technical Memorandum 05-03: Operational Provisions Part C: Textiles and Furnishings. 9.8 The Furniture & Furnishings (Fire Safety) Regulations 1988 (as amended). 9.9 Notwithstanding the statutory obligations, the Trust also recognises the requirement by the Secretary of State for Health under the Community Care Act 1990, of the need to comply with the specialised technical guidance contained in the Firecode documents, memoranda and Fire Practice Notes. 10.0 Definitions 10.1 Line Management Line Managers, including Departmental managers, Operational Matrons, Emergency Bleep Holders, Clinicians and other Officers in Charge also have specific responsibilities for fire safety within the areas of their authority. 10.2 Fire Wardens Fire Wardens should be appointed as the focal point for fire safety issues for local staff. They should act as fire safety eyes and ears within their local area, but not have an enforcing role. The local Fire Warden will report fire safety issues to their Line Manager who in turn will report to their management. The electronic master copy of this document is held by Document Control, Office of the Medical Director, NL&G NHS Foundation Trust. Printed copies valid only if separately controlled Page 11 of 12
Fire Safety Management Structure Statutory & Firecode Requirements Appendix A Chief Executive Compliance & Assurance (Head of Governance & Trust Secretary) Executive Director Fire Safety (Director of Facilities & Information) Fire Safety Manager (Health & Safety Manager) FM Site Managers Health & Fire Safety Advisor Senior Managers Line Managers Fire Wardens All Staff Printed copies valid only if separately controlled Page 12 of 12