Burton Hospitals NHS Foundation Trust. On: 27 April Review Date: March Corporate / Directorate. Department Responsible for Review:

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POLICY DOCUMENT Burton Hospitals NHS Foundation Trust FIRE POLICY Approved by: Trust Executive Committee On: 27 April 2016 Review Date: March 2019 Corporate / Directorate Clinical / Non Clinical Corporate Non Clinical Department Responsible for Review: Distribution: Essential Reading for: Estates and Facilities All Staff Information for: All Staff Policy Number: Version Number: 91 8 Signature: Helen Scott-South Chief Executive Date: 27 April 2016 Fire Policy / Version 8 / April 2016

Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Fire Policy Original Issue Date: December 1996 Date of Last Review: March 2016 Responsibility: Fire Safety Manager Stored: Intranet Linked Trust Policies: Health & Safety Policy Risk Management Strategy Policy for Reporting Adverse Incidents and Near Misses Bariatric Policy E & D Impact assessed? EIA 200 Consulted Health and Safety Group Executive and Associate Directors Heads of Departments Estates and Facilities Managers Fire Safety Advisor Fire Policy / Version 8 / April 2016

REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 8 Update March 2019 Addition of appendices and consolidation of alterations of responsibilities. Fire Policy / Version 8 / April 2016

Paragraph Number Subject FIRE POLICY CONTENTS Page Number 1 Policy Statement 1 2 Introduction 1 3 3 Fire Safety Structure and Responsibilities 3 6 3.1 The Chief Executive 3 3.2 Director with Responsibility for Fire 3 3.3 Executive / Clinical Directors / Associate Directors / General Managers 3.4 Fire Safety Manager Head of Estates 3 4 3.5 Deputy Fire Safety Manager 4 3.6 Fire Safety Advisor 4 5 3.7 Fire Safety Group 5 3.8 Departmental Managers / Senior Nursing and Medical Staff and Non Clinical 3.9 Fire Wardens Clinical and Non Clinical areas 6 3.10 All Trust Personnel including all employed and all volunteer staff 3 5 6 4 Risk Management Arrangements 6 7 5 Operational Response Arrangements 7 8 6 Monitoring and Review 8 7 Fire Management Structure 9 Appendix 1 Fire Procedure for Staged Evacuation Areas - Queens 10 Appendix 2 Fire Procedure for Full Evacuation Areas - Queens 11 Appendix 3 Fire procedure for Samuel Johnson - Lichfield 12 Appendix 4 Fire Procedure for Sir Robert Peel - Tamworth 13 Appendix 5 Response to a fire call Switch Board Staff 14 15 Appendix 6 Response to a fire call Portering Staff 15 Appendix 7 Response to a fire call Night Practitioner 16 Appendix 8 Response to a fire call Duty Electrician 17 18 6 Fire Policy / Version 8 / April 2016

Burton Hospitals NHS Foundation Trust FIRE POLICY 1. POLICY STATEMENT Fires have the potential to cause loss of life or serious injury and can cause major damage to Trust assets as well as adversely affecting patient care and service delivery. Burton Hospitals NHS Foundation Trust is committed to providing a secure and safe environment, from fire, for all its patients, employees, service users and any other visitors entering Trust property. The Trust will liaise with all management representatives of non-trust premises, located within the Queen s Hospital site and at both community hospitals; to ensure appropriate fire precautions and fire safety procedures are in place for Trust employees who have cause to carryout work activities therein. In order to achieve a secure and safe environment the Trust has developed a Fire Policy and is supported by a number of associated procedures. Fire Safety Management structure, which identifies key roles and responsibilities within the Trust for generic and specific Fire Safety precautions Risk Management Arrangements, which are designed to prevent fires or fire situations occurring and empower all departments and employees to take ownership of their appropriate fire safety precautions Operational Response Arrangements, which are designed to aid the necessary staged or full evacuation, contain or extinguish a fire, minimise fire spread and fire damage and aid service recovery. 2. INTRODUCTION The purpose of this policy is to ensure that the Trust, its premises and its employees are compliant with the current statutory requirements and guidance documents as listed below. It also provides an agreed framework for the Trust and all employees to ensure a secure and safe environment from fire. The Regulatory Reform Fire Safety Order 2005 Health and Safety (safety signs and signals) Regulations 1996 Health and Safety at Work Act 1974 Management of Health and Safety at Work regulations 1999 Relevant Firecode Health Technical Memorandum in particular HTM 05-01 Managing Healthcare Fire Safety. Fire Policy / Version 8 / April 2016 1

The Trust places a high degree of importance on minimising the risk of fire and caring for all its patients, employees, service users and visitors alike and ensuring processes and procedures are in place to deal with fire when it occurs. All employees should also be aware of their individual responsibilities in relation to complying with the Trust s Fire Policy and the implementation of fire safety precautions in the workplace. 3. FIRE SAFETY STRUCTURE AND RESPONSIBILITIES 3.1 The Chief Executive Has overall responsibility for the effective provision and maintenance of the Trust s fire safety precautions Is responsible for ensuring the compliance and implementation of statutory requirements and Firecode guidance in all Trust owned premises Agrees with the Director for Fire Safety and the Fire Safety Manager an annual fire precautions investment programme. 3.2 Director with Responsibility for Fire (this will be the Director responsible for Estates and Facilities) Assumes Board level delegated responsibility for fire safety Responsible for ensuring that programmes of investment in fire safety are accounted for within the Trust Business Plan Responsible for the implementation of Firecode including: - appointment of the Fire Safety Manager and Deputy Fire Safety Manager. Requirement to submit an annual report on fire safety to the Board of Directors. 3.3 Executive / Clinical Directors / Associate Directors / General Managers Responsible for the co-ordination and support of fire safety activities within their directorate, particularly the departmental fire safety annual review and any resultant fire safety action plans Responsible for ensuring that decisions are implemented within their directorate in accordance with this policy Responsible for supporting and setting up the Trust s Fire Warden scheme within their directorate and ensuring all staff attend appropriate specialist/mandatory fire safety training 3.4 Fire Safety Manager Head of Estates Produce an annual Fire Safety report to the Trust Director for Fire to include: progress on capital investment on Fire Precautions, Fire Risk Assessments, fire drills, incident reports and development of local procedures Supervise the day to day compliance of the Fire Policy Fire Policy / Version 8 / April 2016 2

Responsible for Estates maintenance support staff at fire and false alarm situations Receive reports and guidance from the Trust Fire Safety Advisor and in liaison with the Trust Director for Fire ensure the contents are acted upon as appropriate Ensure the availability of a Deputy Fire Safety Manager at all times when the Fire Safety Manager is unavailable Ensure all fires and false alarms are investigated and the appropriate local fire authority false alarm forms are completed and submitted Liaise with the Trust Director for Fire on implementing fire safety action plans and or submitting and monitoring appropriate fire safety issues onto the Trust risk register. 3.5 Deputy Fire Safety Manager Designated Estates Manager The Deputy will assume the full duties of the Fire Safety Manager in his/her absence and are therefore required to be fully conversant with the Trust s fire safety procedures and policies. The Deputy will act as support to the Fire Safety Manager for all daytime fire incidents and may be directed to assume full responsibility from the Fire Safety Manager at false alarms or other small incidents. 3.6 Fire Safety Advisor The Fire Safety Advisor will assist the fire manager in meeting the roles and responsibilities outlined above. Additional responsibilities will include: Providing the Board of Directors, the Chief Executive and Director with responsibility for Estates & Facilities with professional technical expertise to enable them to effectively fulfil their duties Providing professional expert advice on the application and interpretation of fire legislation and fire safety guidance, including Firecode An awareness of all fire safety features together with their purpose A full knowledge of all fire safety risks particular to Burton Hospitals NHS Foundation Trust as well as at those premises used as host premises Contributing to and developing the Trust s Fire Safety Policy Contributing to the development of the Trust s Fire Strategies Undertaking, compiling and reviewing fire risk assessments for all relevant areas/departments within the Trust Providing each area/department with a Fire Safety Action Plan. Fire safety actions plans will be completed in accordance with Regulatory Fire Policy / Version 8 / April 2016 3

Reform order (Fire safety) 2005 and Operational Provision Manual: Part K Developing a suitable training programme for annual fire training and fire warden training, including delivery of the training Liaising, where necessary, with enforcing authorities on technical issues Communicating with managers, staff and other premises responsible persons on fire safety issues Reporting of fire incidents in accordance with current practice Monitoring and reducing the number of unwanted fire incidents (false alarms). As a member of the Fire Safety committee provide fire safety information on behalf of the Trust The Fire Safety Advisor will review/investigate and make comment on fire Incidents once the investigation is completed the relevant paperwork will be finally approved by the Fire Safety Advisor. 3.7 Fire Safety Group The Fire Safety Group is led by the Fire Safety Advisor and effectively reviews all Trust fire safety precautions on an annual basis. The group will meet quarterly and shall comprise of the following personnel, Fire Safety Adviser Fire Safety Manager Deputy Fire Safety Manager Estates Maintenance Manager Transport, Telecoms, Portering Manager Representatives from the three Trust Divisions. 3.8 Departmental Managers / Senior Nursing and Medical staff Clinical and Non Clinical Oversee the day-to-day implementation of the fire safety precautions for their designated area. Liaise with the Fire Safety Manager or deputies on Trust generic or site specific fire safety policies and procedures Ensure that the departmental fire risk assessments are carried out, acted upon and reviewed accordingly Assist the Executive/Clinical Directors to set up and maintain the fire warden scheme and support the actions of the designated fire wardens Ensure all staff attends the appropriate specific/mandatory fire safety training Ensure the necessary full or scenario fire drills are organised and implemented and any outcomes noted and responded to Fire Policy / Version 8 / April 2016 4

Ensure that new staff attend appropriate induction courses and receive the necessary local site specific fire safety information and guidance Liaise with other managers in shared premises to ensure appropriate fire safety arrangements are implemented Implement and co-ordinate fire safety procedures (with fire warden support) in relation to discovering a fire or on activation of the fire alarm in their designated area of responsibility Implement and co-ordinate fire safety procedures (with fire warden support) in relation to requests for assistance from other areas of the Trust in the event of fire and patient evacuation Liaise with the Fire Safety Manager and or Deputy Fire Safety Manager on their arrival in relation to command and control at fire related/emergency situations. 3.9 Fire Wardens Clinical and Non Clinical areas Liaise with the departmental manager and risk assessor on fire safety precautions within their department/building. This includes local fire routines Liaise with the Fire Safety Manager or deputies on fire safety precautions for their department/building and or any changes to working practices which may affect fire precautions Be familiar with the Trust fire safety plans and procedures Carry out rapid and methodical area searches and evacuation procedures. Give encouragement to other employees, patients, visitors and reassure them during fire related incidents Ensure that fire escape routes remain available for use at all times Identify and report fire hazards in or close to the workplace Assist with departmental fire safety awareness training Ensure that departmental fire safety records are available and Trust records are updated. 3.10 All Trust Personnel including all employed and all volunteer staff All personnel should conduct themselves in a safe manner. They should carry out their duties in accordance with the Trust Fire Policy and the local fire safety procedures. Raise the alarm and report all fires Attend a fire safety awareness training programme annually Participate in local fire safety training and fire drills Understand the hazards involved in their working environment and bring fire safety concerns to the attention of the fire wardens and or departmental managers Practice and promote an excellent fire safety culture and carryout effective fire safety procedures whenever necessary. 4. RISK MANAGEMENT ARRANGEMENTS Reducing and eliminating the risk of fire is a high priority in any health care establishment. Effective risk management combined with a positive fire safety Fire Policy / Version 8 / April 2016 5

culture afford the best opportunity to work and provide care in a safe environment. In order to achieve these goals the Trust will set in place, monitor and review the Fire Risk Management Procedures. Each Fire warden shall ensure that there own departmental fire risk assessment has been completed and forwarded to the Estates Department on an annual basis. In depth Fire Risk assessments will be carried out by the Fire Safety Advisor and appropriate action plans will be formulated by the Fire Safety Manager/Fire Safety Committee & Fire Safety Manager Deputies The Trust estates & facilities department will ensure an appropriate level of planned preventative maintenance is carried out internally and or via contact with regards to: Fire alarm systems Dry risers Fire doors Fire compartments/means of escape Emergency lighting Fire fighting equipment PAT and electrical tests Department Managers/Fire Wardens will ensure that an annual fire drill/exercise is carried out for their area. The Trust estates & facilities will ensure an effective waste management system is in place and that an appropriate disposal system is available and complied with. 5. OPERATIONAL RESPONSE ARRANGEMENTS The Trust recognises that, even with an excellent fire safety culture and extensive risk management arrangements, fire situations still occur. The Trust will take all reasonably practical steps to provide the appropriate levels of Operational Response. Operational response includes the appropriate policies and procedures, passive and active installations, adequate establishment levels and the necessary internal and external stakeholder collaboration. These operational response arrangements are designed to aid the safe implementation of staged or full evacuation, to contain or extinguish a fire, to minimise fire spread and fire damage and to aid service recovery. Queens Hospital site Burton Main Hospital, Treatment Centre & Geoffrey Hodges wing are all Staged Evacuation refer to Appendix 1 Some areas of main Hospital & GH Wing and all other premises Full Evacuation refer to Appendix 2 Fire Policy / Version 8 / April 2016 6

Community Hospitals Samuel Johnson refer to Appendix 3 Sir Robert Peel refer to Appendix 4 The following members of staff will form a fire response team with their roles and responsibilities in the relevant annex Switchboard Staff Appendix 5 Portering Staff Appendix 6 Night Practitioner Appendix 7 Duty Electrician Appendix 8 6. MONITORING AND REVIEW The Fire Safety Manager/Fire Safety Committee and deputies will produce a quarterly Fire Safety report to the Head of Estates to include: Progress on capital investment on fire precautions, fire risk assessments, fire drills, incident reports, development of local procedures; along with:- Receive reports and guidance from the Trust Fire Safety Advisor and in liaison with the Trust Director for Fire ensure the contents are acted upon as appropriate Ensure the availability of a Deputy Fire Safety Manager at all times when the Fire Safety Manager is unavailable Keep accurate records of all fire incidents and ensure appropriate Firecode fire reports are submitted to the NHS estates on the prescribed forms Ensure all fires and false alarms are investigated and the appropriate local fire authority false alarm forms are completed and submitted Liaise with the Trust Director for Fire on implementing fire safety action plans and or submitting and monitoring appropriate fire safety issues onto the Trust risk register. Fire Policy / Version 8 / April 2016 7

Burton Hospitals NHS Foundation Trust 7. Fire Safety Management Structure Chief Executive & Board of Directors Trust Director for Fire Fire Safety Advisor Fire Safety Manager & Deputy Fire Safety Group Fire Response Teams Switchboard Porters Electricians Engineers Security Dept Managers Fire Wardens All Departments All Staff Fire Policy / Version 8 / April 2016 8

Appendix 1 Burton Hospitals NHS Foundation Trust Fire Procedure for Staged Evacuation Areas Queen s Hospital Site The Trust operates a Progressive Staged Evacuation Procedure from many areas of the Main Hospital, Treatment Centre and Geoffrey Hodges Wing. It is generally where patients are unable to evacuate easily due to their condition/situation i.e. all hospital wards, Critical Care areas, Operating theatres and main Out patients etc. On Discovering a Fire Close the door if appropriate and raise the alarm by setting off a break glass call point (red box). Switchboard receives automatic notification of a fire situation on the fire panel & then they will initiate the fire response team and dial 9-999 for the Fire Service where necessary Dial the 5678 direct line to switchboard and confirm there is a definite fire situation and the location etc. If the fire service knows there is a definite fire they send more fire engines. Also dial 5678 to inform the switchboard of definite false alarms Senior medical/nursing staff (with fire warden support) will assess the situation and consider Horizontal Staged Evacuation (patients, visitors and staff) away from the fire into the next fire compartment behind fire doors. If vertical evacuation becomes necessary only go down one floor and only go outside if absolutely necessary Extinguishers should only be used in emergencies to aid escape or when an individual is confident and if it is safe to do so. Do not delay or jeopardize the evacuation procedure. On Hearing a Continuous Alarm two tone alarm This indicates that the alarm has been activated in the immediate area and a fire may be present. Senior medical/nursing staff with fire warden support should initiate a rapid assessment of the area to determine whether there is a fire situation in their area i.e. smoke or flames. If a fire is located then contact the switchboard on 5678 and consider the horizontal evacuation procedures for your area. You should already be aware of your means of escape options. If there is no sign of fire you should remain in your area on alert and prepare your area for a possible staged evacuation. Do not start any new procedures or get distracted from a possible evacuation situation. Fire Wardens will check the nearest fire alarm panel for information and communicate this back to the affected area On Hearing an Intermittent Alarm single tone (only on two stage alarm system Main Hospital, Treatment Centre and Geoffrey Hodges Wing) This indicates that an alarm has been activated in an adjacent area (above, below or to the side). There is no need to evacuate; however, senior medical/nursing staff with fire warden support should be aware of the possible fire situation and on standby to assist in other locations if required. Do not send people around the Hospital. Fire Policy / Version 8 / April 2016 9

Appendix 2 Burton Hospitals NHS Foundation Trust Fire Procedure for Full Evacuation Areas Queen s Hospital Site On Discovering a Fire Close the door if appropriate and raise the alarm by setting off a break glass call point (red box) Switchboard receives automatic notification of a fire situation on the fire panel & then they will initiate the fire response team and dial 9-999 for the Fire Service where necessary Dial the 5678 direct line to switchboard and confirm the definite fire situation and the location etc. If the Fire Service knows there is a definite fire they send more fire engines. Also dial 5678 to inform the switchboard of definite false alarms All staff, visitors and patients (everyone) should evacuate via the nearest available fire exit The fire warden or senior staff should initiate a swift search of the area to ensure everyone has evacuated Proceed to your agreed assembly point outside the building and await instructions from the Trust response team and or the Fire Service. Do not stop to pick up personal possessions and do not re-enter the building until authorised by the Trust response team and or the Fire Service. Extinguishers should only be used in emergencies to aid escape or when an individual is confident and if it is safe to do so. Do not delay or jeopardize the evacuation procedure. On Hearing a Continuous Alarm two tone This indicates that the alarm has been activated in the immediate area and a fire may be present. All staff, visitors and patients (everyone) should evacuate via the nearest available fire exit The fire warden or senior staff member should initiate a swift search of the area to ensure everyone has evacuated. Proceed to your agreed assembly point outside the building and await instructions from the Fire Service or Trust representative. Take a staff/visitor roll call if possible. Do not stop to pick up personal possessions and do not re-enter the building until authorised by the Fire Service. Extinguishers should only be used in emergencies to aid escape or when an individual is confident and if it is safe to do so. Do not delay or jeopardize the evacuation procedure. On Hearing an Intermittent Alarm single tone (only on two stage alarm system Main Hospital and Geoffrey Hodges Wing) This indicates that an alarm has been activated in an adjacent area (above, below or to the side). There is no need to evacuate; however, senior medical/nursing staff with fire warden support should be aware of the possible fire situation and on standby to assist in other locations if required. Do not send people around the Hospital. Fire Policy / Version 8 / April 2016 10

Appendix 3 Burton Hospitals NHS Foundation Trust Fire Procedure Samuel Johnson - Lichfield If you discover a fire Raise the alarm by activating a break glass alarm point red box Contact the fire service on 9-999 ( 9 for outside line) Shut the doors and windows if safe to do so and then evacuate to the main car park outside the building ( all staff, patients and visitors) Only fight the fire if safe to do so Liaise with Trust staff to inform them that all of your staff are safe and evacuated Staged Evacuation Areas (patient areas wards etc) If the continuous fire alarm is activating Fire Zone Assess the immediate area to check for fire & smoke If a fire is located contact the fire service on 9-999, evacuate everyone to a safe fire zone in the Hospital or outside to be safe If no fire present then check the main fire panel for information and remain on alert. If any problems consider evacuation to a safe fire zone in the Hospital or outside Liaise with Trust personnel on site Full Evacuation areas (non patient areas admin, pharmacy etc) If the continuous fire alarm is activating Fire Zone Evacuate everyone to the main car park immediately Do not delay the evacuation or stop to pick up personnel items Do not re enter the building until authorised by Trust personnel or the Fire Service If the intermittent fire alarm is activating all non fire zones No need to automatically evacuate but always investigate your area Check the nearest fire alarm panel for information and respond accordingly Liaise with Trust personnel Remember the fire alarm system at Samuel Johnson is not directly linked to the Fire Service and you must phone 9-999 to inform them of a real fire Fire Policy / Version 8 / April 2016 11

Appendix 4 Burton Hospitals NHS Foundation Trust Fire Procedure Sir Robert Peel - Tamworth If you discover a fire Raise the alarm by activating a break glass alarm point red box Contact the fire service on 9-999 ( 9 for outside line) Shut the doors and windows if safe to do so and then evacuate to the main car park outside the building ( all staff, patients and visitors) Only fight the fire if safe to do so Liaise with Trust staff to inform them that all of your staff are safe and have evacuated Staged Evacuation Areas (patient areas wards etc) If the continuous fire alarm is activating whole building at SR Peel Assess the immediate area to check for fire & smoke If a fire is located contact the fire service on 9-999, evacuate everyone to a safe fire zone in the Hospital or outside to be safe If no fire present then check the main fire panel for information and remain on alert. If any problems consider evacuation to a safe fire zone in the Hospital or outside Liaise with Trust personnel on site Full Evacuation areas (non patient areas admin, pharmacy etc) If the continuous fire alarm is activating whole building at SR Peel Evacuate everyone to the main car park immediately Do not delay the evacuation or stop to pick up personnel items Do not re enter the building until authorised by Trust personnel or the Fire Service If the intermittent fire alarm is activating all non-fire zones No need to automatically evacuate but always investigate your area Check the nearest fire alarm panel for information and respond accordingly Liaise with Trust personnel Remember the fire alarm system at Sir Robert peel is not directly linked to the Fire Service and you must phone 9-999 to inform them of a real fire Fire Policy / Version 8 / April 2016 12

Appendix 5 Burton Hospitals NHS Foundation Trust Response to a fire call Switchboard Staff Ensure that you have the correct location of the fire alarm from the fire panel 1. Porters Put a message over the Porter s radio channel Fire alarm sounding.. and repeat. Turn the volume up on the radio unit so you can hear what is being relayed to you. At this point the Porter s will investigate whether or not there is a fire so do not call the Fire Brigade until you have had radio contact with a Porter or a call from a member of staff to confirm there is a fire. The only time you call the Fire Brigade immediately is if the fire alarm location is given as one of the following: - Basement area Roof spaces or roofs Plant rooms Medical Gas House Flammable Gas House Other high risk areas Chemical Spill Inform the Porters you will be calling the Fire Brigade for these area s only Pick up the fire pager from the top of the fire panel and monitor any further fire alerts. If an alert appears on the pager for the same area then call the fire brigade immediately. Go to action number 3 until a fire is confirmed 2. As soon as a fire is confirmed dial 9-999 or #6400 for the Fire Brigade, giving the name and address of the Hospital and location of the fire alarm. 3. In hours activate the fire crash team 03 (fire group which includes Electricians) Fire alarm sounding repeat. Out of hours call the Electrician on call. 4. If a fire is confirmed then call the Engineer, do not ring unless a fire is confirmed. 5. If a fire is confirmed call the Fire Officer, Neil Morrell on his mobile 07784 857385 Notes: If a confirmed fire is in the IT department Clock Tower Wing the Porter will also ask you to call the Health Informatics on-call person in. If the Porters find that a fire alarm for a high risk area is a false alarm then they will ask you to cancel the Fire Brigade by ringing 9-999 again. Fire Policy / Version 8 / April 2016 13

PLEASE NOTE When calling the Fire Brigade relay the maximum information possible. OUTSIDE THE HOSPITAL BUILDINGS e.g. CAR PARK On this type of call if it were for a litter bin outside the buildings radio the Porters who will go and check the fire, if they need you to call the Fire Brigade they will call you back via the radio s. If it was a car fire or something similar put the caller through to 9-999 or ask them to call 999 and also radio the Porters Recording Fire Calls on the Estates database: - Go on the intranet Press on Directorates Estates and Facilities Estates and Facilities homepage Programs Estates and Facilities Database Log On Insert your username and password Telecoms Fire Alarms Create record Log details (Fill all boxes, if there is no detail use a dash symbol, as the programme will not accept it). Fire Policy / Version 8 / April 2016 14

Appendix 6 Burton Hospitals NHS Foundation Trust Response to a fire call Portering Staff There are a number of key fire safety issues that all Portering staff should be aware of when responding to fire calls. Areas of Interest: On activation of the fire alarm system or informed via the radio from the switchboard the duty porters are to carry out the following. Liaise with the switchboard personnel, collect and return the keys & access codes Respond to the affected area/building with keys/codes and try to confirm if it is a fire or false alarm. If it is a fire wait the arrival of the Emergency Services, the Estates electrician and on duty/on call engineer. If it is a false alarm inform the switchboard as soon as possible to ensure the fire service is not called. Liaise with the Estates personnel Electrician and duty engineer Direct the Emergency Services to the correct building/departmental area Liaise with departmental Managers, Fire Wardens. Do not proceed if you are met with smoke & flames, instead call the switchboard on 5678 or radio and give details of the fire location and severity. Ensure any fire service paperwork is handed to duty engineer or Estates department. Do not fight fires unless it is safe to do so. Do not enter empty premises or isolated areas alone, always in pairs with other members of staff. Do not enter premises or areas where there is evidence of smoke or flames. Do not direct Patient areas to fully evacuate, they should consider staged evacuation into an adjacent area only if a fire is present. Non-Patient areas must carry out full evacuation to their external assembly points when the fire alarm is activated, whether there is a fire or not evident. Do not put yourself at risk to fight a fire or carryout rescues. If possible make the area safe, raise the alarm and wait for the Emergency Services to arrive. Do not become complacent and assume it is a false alarm. Always treat each incident as a potential fire situation. The officer in charge from the attending emergency vehicles must confirm the situation and agree before any fire panels are reset or silenced and before any personnel are allowed back into the premises. Fire Policy / Version 8 / April 2016 15

Appendix 7 Burton Hospitals NHS Foundation Trust Response to a fire call Night Nurse Practitioner The Night Nurse Practitioner forms an integral part of the Queen s Hospital fire response. Whenever a fire alarm is activated switchboard will page the information to the designated individual for information and appropriate action. At this moment in time the Trust are concerned with response to Patient areas within the main Hospital (Phase I and II) and Geoffrey Hodges Wing. Please refer to Response to Intermittent Alarm. Response to Pager call Respond to the nearest addressable fire alarm panel and assess the information Only respond to the panel if your own area is safe Always check with adjacent areas first (incident may be close by) Do not proceed to the panel if smoke or flames are evident on your route. Contact switchboard on 5678 and return to your own Patient area. At the Addressable panel Liaise with other intermittent response personnel and assess the information on the addressable fire alarm panel. Respond as a group to the indicated Patient area. Do not respond to Non Patient areas, roof spaces, basement, unoccupied areas or other detached buildings. In these situations the Night Nurse Practitioner should respond to the switchboard to act as liaison with the emergency services and the porters. Do not proceed if smoke or flames are evident on your route. Contact switchboard on 5678 and return to your own Patient area. At the indicated Patient area liaise with the nursing staff/porter and organise assistance as necessary. In the event of no action required liaise with the nursing staff and emergency services to ensure normal services are resumed. Maintain communication with your own work area via internal Hospital phones. Keep them informed. Always ensure that any fire related incident is reported to the fire safety manager in Estates, this includes any fire incident forms provided by the attending emergency services and any false alarms. Fire Policy / Version 8 / April 2016 16

Appendix 8 Burton Hospitals NHS Foundation Trust Response to a fire call Duty Electrician 1. In Hours On activation of the bleep system regarding a fire incident the (duty/nearest) electrician is to proceed to the location of the fire call, if unsure of the area check on the closest fire panel. They are to ensure that they leave the current area in a safe state. Report to the scene of the fire call and assist in the implementation of fire procedures by liaising with the senior person from the department or the porter that has been sent to the incident. If it is a false alarm they are to confirm this by physically checking which detector has been activated and the reason why. Once they have conformation that the situation has been dealt with correctly they are to reset the fire alarm system. If it is a confirmed fire they are to liaise with the senior medical person and Fire Brigade Officer regarding closing down of essential services, i.e. electrical, natural/medical gas supplies, ventilation systems, alarm systems, etc. Ensure switch/plant room and lift keys are readily available for Fire Brigade use. On completion of the incident, fire or false alarm they are to re-set the fire alarm system after cause has been established. After this reset they are to ensure that any smoke dampers are reset within the given template. This information is to then be passed to the switchboard staff. 2 Out of Hours After receiving a call from the switchboard the duty electrician is to proceed in to work and collect any equipment from the Estates workshops. After collecting all relative equipment they are to confirm the location of the fire/unwanted call with switchboard and then proceed to the area. Report to the scene of the fire call and assist in the implementation of fire procedures by liaising with the senior person from the department or the porter that has been sent to the incident. If it is a false alarm they are to confirm this by physically checking which detector has been activated and the reason why. Once they have conformation that the situation has been dealt with correctly they are to reset the fire alarm system. Once this has been reset they are to reset the smoke dampers in the relevant template. Fire Policy / Version 8 / April 2016 17

If it is a confirmed fire they are to liaise with the senior medical person and Fire Brigade Officer regarding closing down of essential services, i.e. electrical, natural/medical gas supplies, ventilation systems, alarm systems, etc. Ensure switch/plant room and lift keys are readily available for Fire Brigade use. On completion of the incident, fire or false alarm they are to re-set the fire alarm system and any smoke dampers within the templates after cause has been established. This information is to then be passed to the switchboard staff. Fire Policy / Version 8 / April 2016 18