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Approved by: Date of approval: September 2015 Originator: Helen Garfield, Chief Executive Officer Policy Statement The safety of staff, patients, volunteers and visitors in the event of fire is an issue of fundamental importance to Primrose Hospice and will receive the same managerial attention as any other business activity. It is our aim to ensure that the working and patient care environment is as safe from fire as can reasonably be achieved and that should a fire occur, all staff and volunteers are well trained in fire routine procedures for safe evacuation. Related Hospice policies/procedures: Health and Safety Policy Risk Management Policy Fitness of Premises Policy and Procedure Equipment Management Procedure Responsibility/Accountability The ultimate responsibility for ensuring the implementation, monitoring and review of the Fire Safety Policy at Primrose Hospice rests with: Title: Chair of the Board of Trustees Responsibility for operational implementation of the Fire Safety Policy on a day-to-day basis rests with the Chief Executive Officer who is supported as follows: Ref: RM0003 Page 1 of 8 Revision due by: 09/18

Fire Officer in Charge CEO/Director of Finance/Director of Care/Senior Fire Warden Senior Fire Wardens Coppice and Day Hospice building as per boxes Coppice Head of Family Support Family Support Administrator Day Hospice Building Director of Care Director of Finance Nurse Team Leader Fire Wardens Nurse Team Leader Volunteer s Manager Day Hospice Administrator Fundraising Manager/Staff Finance Officer Family Support Staff General Fire Precautions 1. Fire Action Notices will be displayed by each fire alarm point. 2. All fire safety documentation will be kept in a fire folder at the reception desk in each building. 3. All staff and volunteers will be made aware of the approved fire routine, including location of firefighting equipment and emergency exits as part of their induction. 4. All staff and volunteers are to maintain high awareness of fire safety, of keeping fire exits clear and of generally reducing fire risk at all times. 5. The signing-in procedure is to be adhered to at all times. 6. Fire drills will be held at least every 6 months. Participation will be recorded as well as issues or problems identified during the drill. Results will be used to change practice or seek advice to improve practice if necessary. Ref: RM0003 Page 2 of 8 Revision due by: 09/18

7. The fire alarm systems will be tested weekly at a different call point in rotation and the results recorded. They will also be regularly maintained and serviced. 8. Emergency lighting will be tested monthly and the results recorded. 9. Fire exit doors will be tested and the results recorded on a monthly basis. 10. Accurate Fire Drawings will be maintained for the buildings showing means of escape and physical fire precaution arrangements. Master copy with Maintenance Person and complete set in red fire box on reception in Day Hospice. 11. The fire precautions required by the local Fire Authority will be observed at all times. 12. No alterations to or change of use of the premises will be made without adequate prior notification to the Fire Authority and the CEO. 13. After a fire, any oxygen cylinders which have been damaged should be returned to BOC. Procedures 1. In the event of discovering a fire 1.1 If you discover a fire raise the alarm by activating the nearest fire alarm. 1.2 Only tackle the fire if you are competent to use the correct type of fire extinguisher and it is safe to do so 1.3 Then follow the instructions set out in point 2. 2. If the fire alarm sounds 2.1 The Fire Officer in Charge (or in the case of Coppice, the Senior Fire Warden, who will alert the Fire Officer in Charge) will go immediately to the Fire Alarm Indicator Panel, to ascertain whether there is a fault or a fire. 2.2 If the panel shows a fire, the Fire Officer in Charge will verify the location within the building. If the fire is in the Coppice Centre, the fire warden will identify the location and alert the Day Hospice building to call for a Fire Officer in Charge and collect the red box. Ref: RM0003 Page 3 of 8 Revision due by: 09/18

2.3 If there is a fire, the Fire Officer in Charge will appoint someone to call the Fire Brigade immediately. 2.4 Receptionists are asked to take out the signing in book and any patient and driver lists as well as the red fire box. The Fire Officer in Charge will appoint someone to take the roll call. 2.5 The Fire Officer in Charge will appoint someone to wait at the gate to direct the Fire Brigade. 2.6 The fire alarm must continue to sound at least until the Fire Brigade arrives. 2.7 The Fire Officer in Charge will ensure that staff in the other building are aware that there is a fire. 2.8 The Fire Officer in Charge must ensure that enough staff are assisting patients and allocate others if necessary. 2.9 The Fire Officer in Charge will decide on a safe location for patients to move to e.g. Day Hospice patients to the Coppice Centre and vice versa. If not deemed safe to stay in either building, arrangements are in place to access the Tennis Club. The Fire Officer in Charge will assign someone to liaise. Contact details must be kept in the red box on reception. 2.10 The Fire Officer in Charge will assume sole charge of the Hospice at a fire scene until the arrival of the Fire Brigade and may instruct fire wardens to stand guard on entry doors to ensure no-one re-enters the building until safe to do so. 2.11 If the fire is in the Day Hospice, the fire brigade must be informed on arrival by the Fire Officer in Charge that there are a number of portable oxygen cylinders on the premises, located in the sluice (next to the Day Hospice lounge). 2.12 Oxygen dependent patients will require use of the portable oxygen cylinders rather than the concentrator. 2.13 Staff or volunteers not involved as fire wardens or in chaperoning patients should evacuate the building and wait at the assembly point in the car park unless asked by the Fire Officer in Charge to undertake a specific task. When leaving the room you are in, ensure windows and doors are closed if safe to do so. Ref: RM0003 Page 4 of 8 Revision due by: 09/18

2.14 Fire Wardens wearing fluorescent jackets must report to the Fire Officer in Charge and make themselves available for tasks as needed. 2.15 Using the signing in books, the designated person will complete a roll call to ensure that all those who have signed in are accounted for. 2.16 A roll call will be taken in the other building if people are not accounted for. 2.17 All identified people must remain at the assembly point or agreed safe area until everyone is accounted for and the building is declared safe. 2.18 People may only re-enter the building when the all clear has been given by the Fire Service or the Fire Officer in Charge. 2.19 People are asked not to leave the site without prior permission of the Fire Officer in Charge as movement of cars may obstruct and delay the emergency services from attending. 3. Allocated Fire Wardens Day Hospice Senior Fire Warden Fire Warden Reserve Nurse Team Leader Staff Nurse Staff Nurse Director of Care DH Administrator PaH Administrator Director of Finance Volunteer s Fundraising Manager/Staff Manager Coppice Centre Head of Family Support Family Support Administrator Administrator Head of Family Support Macmillan Children & Families Practitioner /Administrator/Family Support Worker Macmillan Children & Families Practitioner or Complementary Therapy Leader/ Family Support Worker Ref: RM0003 Page 5 of 8 Revision due by: 09/18

Policy Monitoring and Review Monitoring of the policy will be achieved by inclusion in the annual Health & Safety inspection and a regular agenda item at the H&S quarterly meetings: The written fire risk assessment Staff attendance at fire safety training Record of fire drills and action plan Record of equipment testing Incident reporting/near misses This policy will be reviewed every three years, or sooner if legislation requires Compliance with Statutory Requirements The Hospice will ensure that it is compliant with all relevant current legislation. Scope All aspects of the running of Primrose Hospice to ensure that fire safety is maintained at all times, including: Maintenance of a written fire risk assessment. Maintenance of a written preventative maintenance plan and the provision of all necessary fire exit routes, emergency lighting, firefighting equipment, fire alarm system, smoke detectors and fire exit signs. All new employees and volunteers will be required to read, and sign that they have read the. Annual fire safety training for all employees and Hospice based volunteers. Consideration of fire safety as a part of every development and every purchase of textiles, furniture and equipment etc. Visitors attending meetings, seminars, etc. will be advised at the start of proceedings of the fire safety arrangements and whether any alarm tests are planned. Regular users of the building out of hours e.g. choir, will be made aware of the policy and asked to nominate their own fire wardens. Staff Training Requirements All staff and Hospice based volunteers will receive induction and annual instruction in the following fire safety prevention and action areas:- Action to be taken on discovery of a fire Action to be taken on hearing the fire alarm Raising the alarm Ref: RM0003 Page 6 of 8 Revision due by: 09/18

Roles to be undertaken by staff in the event of a fire Location and use of firefighting equipment Identifying risks in patient care areas, offices, kitchens, workshops Knowledge of escape routes Understanding the importance of fire doors Methods of emergency evacuation Regular fire evacuation drills A record must be kept of: - Signed staff and volunteer attendance on the day of training An ongoing record of training attended in each personal file Fire drills carried out and their results Maintenance of the fire alarm system Maintenance of the emergency lighting system Maintenance of fire door mechanisms Maintenance of fire extinguishers and other firefighting equipment. Staff training (see chart under point 3): Fire Officer in Charge Senior Fire Wardens Fire Wardens Contents of Red Fire box must be: Fire drawings showing means of escape Senior Managers and key/admin. staff contact details Bromsgrove Cricket, Hockey and Tennis Club contact details X3 LED torches X1 High visibility jacket X8 Emergency blankets Disability Any member of staff or regular volunteer who has mobility issues and who may need assistance to evacuate in an emergency will be asked to complete a PEEP (Personal Emergency Evacuation Plan). (Appendix 1). Specific instructions for people using the upstairs of The Coppice Centre who are not able to evacuate independently, are as follows: Be moved to the safe point at the top of the stairs, if safe to do so. If not they must wait in a suitable safe place e.g. Poplar, ideally with 2 fire doors between them and the source of fire. Ref: RM0003 Page 7 of 8 Revision due by: 09/18

The Fire Warden responsible for the upstairs must report to the Fire Officer in Charge the number of people remaining in the building, their mobility constraints (e.g. wheelchair user) and location point. The lift must NOT be used in a fire. Ref: RM0003 Page 8 of 8 Revision due by: 09/18