Fire Safety Group. The minutes of the meeting held on 25 th March 2013 were accepted as a true record. 12/27 & 12/37 Clinical Fire Arrangements

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AGENDA ITEM 5.2.2 Fire Safety Group Minutes of the Meeting held at 11:00 on Friday 12 th April 2013 at the Large Meeting room, Capital Planning and Estates, UHW Present: Mr G Walsh Mr C Darling Mr F Barrett Ms D Jones Mr C Dalton Mrs Z Brooks Mrs L Topham Mr I Wile Apologies: Mr P Hollard Mr R Steed Mr S Careless Ms R Thomas Ms S Follows Mr P Welsh Mr J McGarrigle 13/18 Minutes of the Meeting ACTION The minutes of the meeting held on 25 th March 2013 were accepted as a true record. 13/19 Action Log 12/27 & 12/37 Clinical Fire Arrangements It was agreed to progress the item within the Local Fire Procedure actions. 12/40.3 Local FSG Feedback - CRI Onsite Fire Training at CRI. Frank Barrett to contact Rachel Thomas, to discuss issues around training. FB 12/48 Fire Safety Procedures Since the last FSG meeting, a meeting had been arranged for the Deputy Fire Safety Managers; unfortunately due to a number of apologies this meeting was cancelled. Charles Dalton proposed that he would look at these procedures, and modify to produce a more common format. Once the procedures have been modified, they will be circulated to the Deputy Fire Safety Managers and a meeting will be arranged to discuss any issues. CD Fire Safety Group Page 1 of 9

12.49.1 Local FSG Feedback St Davids Lynne Topham raised concerns around switchboard cover at St Davids. Due to staff shortage, there is only one member of staff covering a number of duties. It was agreed that a meeting will take place between Lynne Topham, Neil Paul and Geoff Walsh This was noted as an urgent matter. GW 12/57.1 External Training WHE briefing. It was agreed that Frank Barrett and Charles Dalton to meet with WHE Fire Adviser to consider C&V Policy in regards to DFSM formations, to give reassurance to the group on compliance. 12/60.3 West Wing Ramp Access CD Frank Barrett confirmed that Estates were contacted and asked to make the ramp more secure. Estates and Dave Cox met and it was agreed that pegs were to be used to resolve the issue around slipping. Delyth Jones raised the issue around her previous meeting with Estates maintenance, who at the time stated that pegs were not appropriate to use on the ramp due to weight etc. Geoff Walsh to resolve. GW 13/20 Revised Fire Safety Policy Charles Dalton advised the meeting that amendments had been made to the policy to reflect changes. Comments were received and Charles Dalton thanked the meeting for these. The Policy has been put out for consultation on the intranet No comments were made. The Chair has taken action to formally agree, and the policy will be submitted to the Health and Safety Committee on the 23 rd April 2013. Delyth Jones highlighted the confusion around the title of the NOF s. Two titles were used in the policy, these being Nominated Officers (Fire) and Deputy Fire Safety Officers. It was agreed that the title of DFSM be used; policy to be updated accordingly. CD Both Delyth Jones and Lynne Topham raised matters around wording in the policy with regards to 5.6 and also escalation procedures. The meeting agreed that a reference should be made within the policy, for the need for Escalation Procedures. Fire Safety Group Page 2 of 9

13/21 Enforcement Notices 13/21.1 Whitchurch Hospital enforcement is to run over a two year period. An Action Group has been formed, and is due to meet on the 19 th April 2013. Geoff Walsh thanked Ian Wile and his team and also Frank Barrett, Trevor Edger and Charles Dalton for their efforts to meet requirements of the enforcement notice in a short time scale. 13/21.2 Frank Barrett reported that enforcement notice EN34/12 (12 Oct) ITU and HDU Llandough Hospital, had been given an extension for work to be completed by 30 th April 2013. Fire doors are to be fitted on the 12 th April 2013. An evacuation drill has taken place. 13/22 Feedback from DFSM Development Training has been completed. 13/22.1 Lynne Topham stated that she found the training helpful and that it gave her a better insight of what was expected of her as a DFSM. Lynne Topham also expressed that she believed that St Davids would benefit from having a Fire Service Link; Frank Barrett to discuss this possibility with the Fire Service. 13/22.2 It was agreed to circulate the Whitchurch Action Log with other members. 13/22.3 Delyth Jones highlighted that the Action Log should contain a completion by date. The meeting agreed; amendments to be made to the Action log. FB IW 13/23 Fire Service Inspection Status Report Frank Barrett informed the meeting that he has spoke with the Fire Service, to request a schedule. It has been confirmed that they are planning an inspection for the whole of Llandough over the next two years, and are also planning to revisit all areas that they have previously inspected. 13/24 Risk Assessments Priority Plan Charles Dalton informed the meeting that he believed that an annual review needed to be prioritised. Frank Barrett explained to the meeting that sleeping accommodation are assessed annually, but other areas such as clinics and offices are carried out every two to three years. 13/25 WHE Audit Fire Safety Group Page 3 of 9

It was confirmed that the completed audit for 2012/13 has finally been sent to WHE. However 2013/14 is now required. Access to the audit for DFSM was identified as a problem, It was agreed that Charles Dalton would circulate the response submitted to the 12/13 and the meeting would consider the suitability for 13/14 submission, so that it could be submitted on time. Delyth Jones suggested that there should be an action plan to reflect the gaps. Charles Dalton agreed with this and felt that these items should be discussed at each meeting. It was agreed that these action will be reviewed at May s meeting. Zoe Brooks to produce action log from Welsh Estates Audit. 13/26 Fire Warden Training Frank Barrett reported that there was a backlog on Fire Warden Training. A number of Fire Wardens are booking onto courses but are failing to attending. It was suggested that DNA (did not attend) letters are sent out to managers, to inform them of these failings. 13/27 Local Fire Safety Group Feedback Barry Hospital Chris Darling informed the meeting that the Barry Fire Safety Procedure has been updated with input from users. Charles Dalton stated that he has not finalised this, as he is waiting for the outcome of the Unified Fire Safety Procedure so this can be taken into account within the procedure for Barry Hospital. Chris Darling requested that the Barry procedure be finalised within the next 4 6 weeks given the input from users to update the procedure. Chares Dalton agreed to develop the Unified Fire Safety Procedure and then update the Barry Fire Policy within the next 4 weeks working with Chris Darling. It was also noted that the annual Fire Risk Assessments (for the high risk areas) have been carried out and management and estates actions needed to be looked at. Geoff Walsh requested that Chris Darling send him the list of outstanding estates actions linked to the Fire Risk Assessments. C Darling A Fire evacuation exercise at Barry Hospital is to be carried out / planned on the 21st May, it is encouraged that all users attend. Chris Darling stated that Kevin Harrington is arranging with input from the Fire Service. 13/28 Date and Time of Next Meeting Wednesday 22 nd May at 14:30-16:00 Boardroom West Wing Fire Safety Group Page 4 of 9

Fire Safety Group Minutes of the Meeting held at 14:30 16:30 at Boardroom West Wing on 22 nd May 2013 Present: Mr J McGarrigle Mr C Darling Mr F Barrett Ms D Jones Mr C Dalton Mrs Z Brooks Mr R Steed Mr P Welsh Mrs R Thomas Mrs S Paul Apologies: Mr P Hollard Mr G Walsh Mr S Careless Ms R Thomas Mrs J Collett Mr I Wile Mrs L Topham 13/29 Minutes of the Meeting ACTION 13/30 Action Log The minutes of the meeting held on 12 th April 2013 were accepted as a true record with the following amendment:- 13/27 Barry Fire evacuation exercise was carried out on the 20 th May and not 21 st. 12/40.3 Local FSG Feedback - CRI Onsite Fire Training at CRI. Mr F Barrett confirmed that he had emailed Mrs R Thomas, to discuss issues around training. Mrs R Thomas informed the meeting that training dates have been arranged. 12.49.1 Local FSG Feedback St Davids It was agreed in the last minutes that a meeting would take place between Lynne Topham, Neil Paul and Geoff Walsh, to discuss issues around switchboard arrangements at St Davids Jon McGarrigle to chase the progress on this and report at next meeting. JMcG 12/56 Fire Risk Assessment Jon McGarrigle confirmed that The Risk Assessments and The Fire Service Inspections are currently still on separate databases. Eleri Crudgington queried whether the Risk Assessments could be put into a Microsoft Office format as Risk Assessments are currently in a PDF format and it is not possible to amend. Fire Safety Group Page 5 of 9

Frank Barrett agreed that this would be beneficial, although raised concerns around third parties amending the online system. The system format is managed by the WHE and is outside of the Health Boards control for amendments. Frank Barrett and Charles Dalton to discuss this possibility with Anthony Pitcher, at their meeting on the 4 th June. CD/FB 12/60.3 West Wing Ramp Access The previous minutes stated the following:- Delyth Jones raised the issue around her previous meeting with Estates maintenance, who at the time stated that pegs were not appropriate to use on the ramp due to weight etc. Geoff Walsh to resolve. No update was given on this. Jon McGarrigle to report any update at next meeting. JMcG 13/05 Fire Risk Assessments Frank Barrett confirmed that review of Risk Assessments were being undertaken on a priority basis, of those areas where there are sleeping accommodations being assessed annually. DFSM requested a mechanism for each DFSM showing review of these areas due for review, within their areas. Frank Barrett confirmed that the system would identify this detail and would be brought to the relevant meeting, by the Fire Adviser. 13/05 Action Log It was agreed that Mrs Z Brooks is to include a completion by date to the Action log for the next meeting. 13/31 Fire Safety Policy Mr C Dalton stated that the policy was circulated and amended to reflect the comments; it was then taken to the Health & Safety Committee for approval. Mr C Dalton confirmed that the policy was approved. Mr C Dalton suggested that prior to the next review date, the document undergo a full scale review. 13/32 Fire Safety Procedures Mr C Dalton produced a draft copy of Fire Safety Procedures for Community Hospitals and presented it to the meeting. It was reported that a meeting took place on the 16th May between Mr F Barrett, Mr C Dalton, Mr C Darling and Ms Angela Stephenson Fire Safety Group Page 6 of 9

(Strategic Partnership and Planning Manager). A discussion took place around the outcome of this meeting and Mr C Dalton informed the meeting of the following suggestions:- Phase 2 fire to be declared as a Major Incident. To slim down current procedure. Four different procedures to reflect the different type of hospitals. (i) Community Hospitals Barry, CRI, West Wing, Rookwood. (ii) Acute Hospitals UHW, UHL (iii) Specials (PFI) St Davids (iv) Health Centres & Clinics 13/32.1 Mr C Dalton to confirm with Ian Wile which procedure, either Community Hospitals or Specials is Whitchurch to come under. 13/32.2 A long discussion ensued regarding Fire Procedures, highlighting areas of concern. It was agreed that a separate meeting would be held W/C 29 th May 2013, between all of the DFSM s to discuss these concerns. It was confirmed that Mrs Z Brooks is to circulate the Draft Fire Safety Procedures to all members and arrange a meeting for all DFSM s, Fire Safety Adviser and Charles Dalton. (This is in addition to the meeting being held by the DFSM s) CD DFSM 13/33 Enforcement Notices Mr F Barrett confirmed that there is one enforcement notice for Whitchurch Hospital; this is to run over a two year period. Many improvements have been implicated, although there is still a lot of outstanding work to be done. Mr F Barrett stated that he is due to meet with the Fire Service, to agree measures that need to be taken. 13/34 Fire Service Inspections Status Report Mr F Barrett informed the meeting that Audit complaints were to be suspended until September, and then inspections will take place after this time. Mr F Barrett is to meet with Estates to look at all areas. 75 areas are going to be revisited. Fire Safety Group Page 7 of 9

13/35 WHE Audit Review 2011/12 Audits were emailed to all members prior to the meeting. Mr C Dalton advised the meeting that 2012/13 audit was due and asked that members review their 2011/12 submission and update accordingly. It was noted that the document did not contain an audit for Rookwood or CRI, Mrs Z Brooks to update document to include both of these areas and re-circulate to members. All 13/36 EVACUATION EXERCISE BARRY An Evacuation Exercise took place in Barry Hospital on the 20 th May 2013. Mr C Darling thanked Mr F Barrett and Mr Kevin Harrington for their support on the day. Mr C Darling confirmed that he is awaiting feedback from Mr K Harrington. Mr C Darling informed the meeting that Barry User Group is to meet on the 23 rd May, to discuss the outcome of the evacuation exercise. Mr F Barrett highlighted concerns around extra training on evacuation equipment. It was apparent from the exercise that members of staff were not competent in using the vertical evacuation equipment and stated on the day that they had not received any training. Mr F Barrett questioned whether this is being included as part of the Manual Handling training. It was agreed that a separate meeting is to be held, for Mr C Dalton and Mr F Barrett to discuss these concerns. 13/37 Local Fire Safety Group Feedback 13/37.1 UHW It was noted in the meeting that Mrs S Follows was supporting Mr A Nelson with the DFSM role. Mr A Nelson is no longer in post and therefore; there is no DFSM for UHW. 13/37.2 UHL Mr P Welsh highlighted concerns around parking at UHL. The meeting was informed of an incident that occurred, where the fire service was unable to drive up to a location within the UHL site, due to parked cars blocking the route. Mr P Welsh informed the meeting that Mr G Walsh agreed to visit Fire Safety Group Page 8 of 9

the area to see if there were any temporary measures that could be put into place to stop this happening, until enforcement start later in the year 13/37.3 West Wing Mrs D Jones reported that a Fire safety Group for West Wing has been established. Mrs D Jones informed the meeting that she has produced a Terms of Reference for the West Wing Fire Safety group, and suggested that the Terms of Reference for this meeting be updated to reflect recent changes. Issues were raised around attendance of the meeting. It was highlighted that the same regular members were attending. It is important that if you are unable to attend, that you send a Deputy to represent in your place. All 13/38 Date and Time of Next Meeting 4 th July 2013 at 14:30 Manual Handling Unit, Denbigh House, UHW. Fire Safety Group Page 9 of 9