Fire Safety Policy Date: August 2014 review Version number: 6 Author: Reviewer: Director of Clinical Services Lawson Bisset Head of Estates Review Date: August 2017 If you would like this document in an alternative language or format, please contact Corporate Services on 01595 743069.
NHS SHETLAND DOCUMENT DEVELOPMENT COVERSHEET* Name of document Fire Safety Policy Registration Reference Number CE POL 006 New Review Author Executive Lead Lawson Bisset Ralph Roberts Proposed groups to present document to: Fire Committee Staff Governance Health and Safety Committee Executive Management Team (EMT) DATE VERSION GROUP REASON OUTCOME 5 Feb 2015 10 June 2015 1 July 2015 27 August 2015 September 2015 5 Fire Committee PO Meeting cancelled 6 Fire Committee PO Approved 6 Health and Safety Committee PO Approved 6 Staff Governance PO Approved 6 EMT PO Approved Examples of reasons for presenting to the group Professional input required re: content (PI) Professional opinion on content (PO) General comments/suggestions (C/S) For information only (FIO) Examples of outcomes following meeting Significant changes to content required refer to Executive Lead for guidance (SC) To amend content & re-submit to group (AC&R) For minor revisions (e.g. format/layout) no need to re-submit to group (MR) Recommend proceeding to next stage (PRO) 1
DATE CHANGES MADE TO DOCUMENT 25 Oct 12 Format standardised to NHS Shetland template 25 Oct 12 Changes made to match Oct 12 management structure 25 Oct 12 Term Fire Marshall changed to Fire Warden 25 Oct 12 Training requirements changed to make annual fire lecture attendance compulsory and on line training optional 25 Oct 12 Contents page edited 25 Oct 12 25 Oct 12 Silencing alarms section changed duty officer will not have the authority to silence alarms JMCM title changed to Chief Nurse Acute and Specialist Services 29 Oct 12 Nursing Officer changed to Senior Nurse 29 Oct 12 GP independent contractors and practice manager responsibilities added 16 Oct 13 Various amendments 3 March 15 Various amendments 2
TABLE OF CONTENTS Section Page 1. Introduction 1 2. Objectives 2 3. Arrangements and responsibilities 4 4. Evacuation exercises 12 5. Wilful fire raising 12 6. Review of policy 13 3
SHETLAND NHS BOARD FIRE SAFETY POLICY 1 Introduction 1.1 This policy shall be known as the NHS Shetland Fire Policy and supersedes any other fire safety policy issued before the date of this policy. It details the fire safety objectives of NHS Shetland the arrangements for managing fire safety and sets down the fire safety procedures that will be adopted by staff in the event of fire. 1.2 In any case, all staff at every level of the organisation shall be adequately and appropriately trained in what to do in the event of fire, having regard to their role, responsibilities and work activities as well as any disability they may have, and the contents of this policy shall form part of the induction of new staff and the ongoing training of established staff. 1.3 Shetland NHS Board (the Board) is committed to establishing a fire safety culture in the workplace and asserts that the safety from fire of all its employees, and other persons who may be affected by what it does, will be given the highest risk appropriate priority. It shall make fire safety matters an integral part of any decision concerning the workplace environment, the equipment used in the workplace, the systems of work adopted by staff and the management arrangements at all levels of the organisation. This will be achieved by ensuring that staff are appropriately trained on fire safety matters and are aware of the corporate fire safety objectives, including the arrangements for managing fire safety. Adequate material and resources shall be provided so that the objectives contained in this policy can be met. The fire safety policy and the associated fire procedures shall, from time to time, be reviewed to ensure it remains appropriate and sufficient for all the operational activities of the organisation. 1.4 Employees and contractors working for the Board have a legal responsibility under the Fire Regulations and Standards to ensure the safety of themselves and others who may be affected by their acts or omissions within the workplace, in particular patients and visitors. 1.5 The standard of fire safety in all our premises shall not in any case be less than that required by virtue of the fire safety legislation, associated compliance guidance and NHS Scotland Firecode, and where a higher standard is shown to be necessary as a consequence of risk assessment or other evaluation, then that higher standard shall be adopted. In particular, that: The conditions of The Fire (Scotland) Act 2005 as amended and the Fire Safety (Scotland) Regulations 2006, are complied with Fire risk assessments shall be carried out, recorded, and that the significant findings of a fire risk assessment shall be met and subsequently reviewed The mandatory requirements of the Fire Safety Policy for NHS Scotland; CEL 11 (2011), are met
The Practical Fire Safety Guidance for Healthcare Premises (Scottish Government: Safer Scotland) and NHS Scotland Firecode and other established and recognised guidance as appropriate, are in each case used as the benchmark fire safety standards to ensure statutory compliance and that appropriate standards of fire safety are achieved. 1.6 The Board recognises the need to routinely test and maintain fire safety installations in the workplace and shall do so in accordance with the relevant best practice guidance including maintenance and test instructions and/or schedules of test and relevant codes of practice. These arrangements shall include the testing and maintenance of fire alarms, fire extinguishers and emergency lighting systems and any other matters that may impact on the provision of a safe working environment, in any case consistent with their statutory obligations. Ralph Roberts Chief Executive Shetland NHS Board 2 Objectives The fire safety objectives of the Board are as follows; 2.1 Buildings and Structures To ensure that any buildings or structures which are workplaces shall be provided with appropriate structural fire safety, including fire containment, means of escape, facilities for discovering and giving warning of fire and other fire safety measures as appropriate. All such provisions shall be properly tested and maintained. 2.2 Policy & Procedures To ensure that a fire safety policy and procedures for what to do in the event of fire are established, implemented and thereafter reviewed periodically to ensure they remain appropriate for the needs of the organisation. Procedures shall be specific to the different departments and/or activities carried on. 2.3 Training & Drills To ensure that all staff are trained in what to do in the event of fire, are aware of the contents of the fire safety policy, these objectives and the procedure to adopt in the event of fire. Such training shall include an awareness of the dangers of fire, the potential for deliberate fire-raising and the measures to limit the possibility of it, what to do if a fire occurs or a warning of fire is heard and how to respond to it, and how to implement and conduct an evacuation. Fire drills shall be conducted periodically to test the operational procedures. 2.4 Management Arrangements and Fire Plans To ensure that comprehensive management arrangements are established so that fire safety matters are appropriately addressed at all levels of the organisation, and that a fire plan detailing escape routes and fire safety equipment and installations, is displayed and kept up to date. 2
2.5 Means of Escape & Persons with a Disability To ensure that adequate means of escape in case of fire are provided for all persons, including any person with a mental, physical, mobility, sight or hearing disability. Disabled persons shall be provided with a Personal Emergency Evacuation Plan (PEEP), and shall receive support and assistance for evacuation consistent with their needs. 2.6 Employment of Young Persons To ensure that, where young persons under the age of 18 years are employed, their working arrangements are properly assessed, taking into account their age and experience in the workplace, in accordance with the Fire Safety (Scotland) Regulations 2006; Part 2;(5), in regard to fire risks, and that appropriate control measures shall be put in place to mitigate any specific risks that are identified. 2.7 Fire Prevention & Dangerous Substances To ensure that sources of ignition are identified and eliminated if possible, or otherwise mitigated so that the potential for fire is reduced to the lowest possible level. In particular that the risks in regard to dangerous substances as detailed in Fire Safety (Scotland) Regulations 2006; Part 2;(6), are assessed and measures put in place to mitigate such risks. 2.8 Work Equipment To ensure that work equipment is procured, tested and maintained appropriately so that it presents the lowest possible potential for causing fire. 2.9 Warning of Fire To ensure that premises are provided with appropriate means for giving warning in case of fire and for automatically detecting fire when necessary. 2.10 Fire Fighting Equipment & Supporting Provisions To ensure that all premises are provided with appropriate means for dealing with an outbreak of fire (fire extinguishers), escape signs indicating exit routes, and notices detailing the fire routine for the premises. 2.11 Fire Risk Assessments That a system of fire risk assessment is followed out to identify fire hazards, that the assessment is recorded together with the measures necessary to address any fire safety failures identified in the assessment including the allocation of resources to carry out work identified through the risk assessment process. 2.12 Community and Other Services That this policy and related fire procedures shall take account of all the circumstances in which services are provided, including those employed in a community setting such as health centres and surgeries, visiting patients homes or while working in premises shared with, or owned by others. 2.13 Reduction of Fires and Unwanted Fire Signals That the Board is committed to reduce the number of fires in its estate, and also the number of unwanted fire alarm signals i.e. fire alarm activations not due to the presence of fire. 3
2.14 Risks to Fire-Fighters That the risks to fire-fighters who arrive to tackle a fire are minimised through the provision of appropriate facilities to assist them e.g. an adequate supply of water for fire fighting, access to buildings, control of onsite car parking, fire protected stairways and ventilated lobbies that may be used as a fire fighting bridgehead, fire fighting access lifts, dry or wet rising water mains and other measures appropriate for the premises. 2.15 Maintenance and Record Keeping That appropriate records shall be kept to verify the testing and maintenance of all fire safety equipment and installations, in each case consistent with best practice guidance. Comprehensive records shall be maintained of fire safety training and drills covering at least the current and three preceding years. Departmental duty holders shall be responsible for ensuring staff under their control receive appropriate fire safety training and participate in fire drills and shall ensure that records are kept of all those attending, and a summary of the training content. Fire safety advisors or other competent fire safety trainer provider shall undertake such training on request by mutual agreement with duty holders and shall keep records of their training activity. 3 Arrangements and responsibilities NHS in Scotland Firecode regulations place overall responsibility for Fire Safety at the highest level with the Board as the employer. The arrangements for ensuring that fire safety is properly managed in Shetland NHS Board are set out in the following section. 3.1 Chief Executive The Chief Executive as the responsible officer is responsible for: Shall have ultimate command and responsibility for fire safety. Ensure that fire safety matters are properly represented at Board level. Will manage fire strategy through the Senior Management Team. Ensure clear guidelines for those tasked with the compliance of legislative guidance and statutory standards. Shall ensure that appropriate financial resources are provided to address fire safety failures where necessary and maintain buildings and other fire safety facilities, equipment, installations and other provisions appropriately. Shall receive an annual report of fire safety performance from the Nominated Officer (fire). 4
3.2 Head of Estates and Facilities The Head of Estates and Facilities acts in the role of Executive Director responsible for: The overall strategy of all fire related matters. The application of NHS in Scotland Firecode. Liaising with the Nominated Officer (Fire) to ensure the Boards Fire Safety Policy is understood and applied across all areas of the Board. Agreeing with the Nominated Officer (Fire), a fire strategy compliance programme for both passive and active measures in both existing buildings and new projects. Ensuring that an annual audit and review of fire risk assessment is undertaken. 3.3 Nominated Officer (Fire) The Nominated Officer (Fire) (NoF) is Head of Estates and Facilities who shall: Assume and undertake the general duties of Nominated Officer (fire) as specified in the Fire safety policy for NHS Scotland; CEL 11 (2011). Ensure that suitable and efficient fire safety risk assessments are undertaken in relation to NHS Shetland estates. Ensure the findings of fire risk assessments are appropriately acted upon and followed. Ensure fire safety risk assessments are regularly reviewed. Monitor all fire safety provisions including the provision and review of local fire evacuation plans, staff training at all levels, the keeping of records in relation to the testing and maintenance of systems and staff training and fire drills. Ensure that regular reports of the fire safety performance of the organisation are provided to the Executive Director with fire safety responsibility Receive reports of fire and unwanted fire signals and shall instigate and monitor actions to mitigate the potential for their recurrence Liaise with the fire safety adviser in regard to these and any other relevant fire safety matters. Keeping records of all fire incidents and ensuring that fire reports are prepared and reported as necessary Managing and supervising the provision, siting and maintenance of all fire fighting equipment, fire safety signs and notices. Shall ensure that the organisation is informed of any significant fire safety failures that require immediate attention because they incur a significant potential for harm to persons, or harm to the healthcare activities of the Board. The above roles and responsibilities maybe deputised to any of the two Deputy Nominated Officers (Fire) 3.4 Fire Safety Adviser The Fire Safety Adviser shall be an external appointment to NHS Shetland. The Fire Safety Advisor shall assume and undertake the general duties of Fire Safety Advisor as listed in the Fire safety policy for NHS Scotland; CEL 11 (2011). This person shall provide specialist technical support including the following: 5
Advising on the application of the provisions of legislation, NHS Scotland Fire Safety Management, NHS Firecode and other appropriate guidance in respect of fire safety in premises owned, occupied or managed by NHS Shetland. Involvement with appropriate staff in fire safety audits, fire safety risk assessments and recording, and, assisting with reports to management. Preparing training programmes, organising regular fire drills and staff training, witnessing the effectiveness or otherwise of the fire drills. Recommending remedial action when necessary, and arranging for accurate records of staff training and fire drills to be kept centrally. Where applicable, advising on the specific and more onerous requirements for the specialist evacuation of patients. 3.5 Senior Management Team Shall assist and be responsible to the Chief Executive in the implementation of the Fire Safety Policy for Shetland NHS Board. They shall monitor the relevant reviews including the fire safety policy, local fire safety procedures, the conduct and progress of fire risk assessments and the fire safety training performance of the organisation. They shall receive a report of the annual fire safety audit conducted by the fire safety advisor, and shall allocate and approve appropriate funding whenever necessary for essential fire safety matters. They shall approve and endorse this fire safety policy and subsequent reviews of it. 3.6 Fire Safety Committee The Fire Committee is a sub-committee of the Health and Safety Committee. The remit of the Fire Committee is to ensure the Board s compliance to Firecode and all other relevant regulations. This includes ensuring that correct safety procedures are in place and properly observed by all patients, visitors, contractors and our own staff in all Board properties. The Fire Committee is to provide input to ensure that procedures are in place to monitor and audit fire exits and fire evacuation corridors, and that all heads of departments are made aware that there is a legal requirement for all fire exits and fire evacuation corridors to be kept clear. The Committee shall adopt a positive supporting role in the promotion and pursuit of fire safety objectives. In particular the Committee shall represent the interests of employees and provide a forum through which they may express any significant issues or concerns they feel should be addressed in regard to fire safety in the workplace. They shall report to the Health and Safety Committee which in turn reports to the Senior Management team. The Nominated Officer (fire) and the Fire Safety Advisor shall be the Chair of the Fire Safety Committee such meetings. 6
The Fire Committee members are as follows Title Head of Estates and Facilities Estates Maintenance Manager Chief Nurse Acute & Specialist Services Nominated Sister/Charge Nurse Facilities Manager Local Fire Brigade Station Officer Staff Development Manager CHP Manager Health & Safety Manager Staff side trade union representative Role Nominated Officer (Fire) Deputy Nominated Officer (Fire) Member Member Member Member Member Member Member Member 3.7 Senior Departmental managers, Directors and GP independent practices Shall ensure that Departmental or other managers effectively manage fire safety matters in their respective departments or areas of control and that the fire safety arrangements are consistent with the regulatory requirements of the Fire (Scotland) Act 2005 as amended and the Fire safety (Scotland) regulations 2006, and this policy; and shall co-operate and liaise with the Nominated Officer (Fire) and Fire safety Advisor. To this end they shall ensure that; Fire risk assessment/s have been carried out in the area/departments in their control and that they are properly recorded, action plans provided and action taken where necessary, and reviews carried out regularly. Staff are appropriately trained on fire safety matters relevant to their place of work, their work activities and level of responsibility. That the fire safety measures in place are sufficient to ensure a safe place of work and treatment for patients and others. That maintenance and routine testing is conducted on fire safety equipment and installations. That records are kept of all routine tests and maintenance. Shall liaise closely with the Nominated Officer (Fire) on all of the foregoing matters. Shall report significant fire safety issues to the Executive Director with responsibility for fire safety. 3.8 Line managers, Ward managers GP practice managers and others with similar departmental management responsibilities Shall ensure the effective day-to-day management of fire safety within their respective departments, wards or area of responsibility and to that end; Shall ensure that deficiencies, faults or failures of fire safety are properly reported for repair promptly, and a record kept of the action carried out. 7
Shall be responsible for monitoring the annual fire safety training of the staff under their control and shall request training to be carried out when necessary. Shall ensure that new staff, including agency, temporary or part time staff are included in the general training arrangements, and that they receive a local induction at the commencement of employment so that they are aware of the exit routes, door fastenings and other fire safety provisions relevant to their place of work. Shall ensure that all staff in their control are aware of the fire safety procedures for their place of work and know what to do in the event of fire. Shall ensure that all staff at the commencement of employment are enrolled on a corporate induction session with the appropriate provider. Shall ensure a monthly walk round inspection is conducted in the area, ward or department, and that the results are recorded and action taken to remedy any failures the inspection has identified. Shall ensure exit routes and doors from them are unobstructed and available for use at all times and that the general storage arrangements are consistent with good fire safety practices e.g. combustible materials are not allowed to accumulate and are stored neatly and properly in allocated storage spaces; that waste materials are not allowed to accumulate unreasonably in the workplace and is dealt with regularly in accordance with the corporate waste management policy. 3.9 All other staff The corporate fire safety objectives are common to all staff. All staff therefore have a responsibility to ensure that fire safety measures are maintained appropriately i.e. Exit routes and doors are not obstructed, Flammable waste is not permitted to accumulate and is dealt with in accordance with the corporate waste policy. Shall co-operate with the reasonable instructions of their employer in regard to fire safety in the workplace e.g. shall attend fire safety training when asked to do so. Shall familiarise themselves with the fire safety procedures of their workplace. Shall assist their employer by taking a constructive attitude to fire safety matters to promote and sustain a positive fire safety culture. Shall co-operate with managers in maintaining appropriate fire safety measures and shall report any fire safety failures they identify. Attend a Fire Lecture on an annual basis 3.10 Fire reporting The Nominated Officer (Fire) is responsible for reporting all fires involving death, injury, or damage which results in significant disruption to patient services. These must be notified immediately by telephone, fax or e-mail to: Mr Ian Grieve Scottish Government Health Directorates Health Finance Directorate/Property Branch St Andrew s House Regent Road 8
Edinburgh EH1 3DG Email: ian.grieve@scotland.gsi.gov.uk Tel: 0131 244 2777 Fax: 0131 244 2323 3.11 Duty Officer In the case of a fire incident, The Duty Officer will have the responsibility to report to the central fire assembly point within the site, organise communications and staffing levels, and set up communications within the immediate fire area. The Duty Officer in the Hospital will be the senior nurse on duty. The Duty Officer in the Health Centres will be the Practice Manager or other designated member of staff. The Duty Officer in Breiwick will be the local departmental manager or other designated member of staff. The Duty Officer in Montfield will be the Montfield Care Home Manager or other designated member of staff. The Duty Officer in the Laundry will be the Laundry manager. In all other Health Board properties the Duty Officer will be the tenant or the key holder or local departmental managers. 3.12 Duty Officers will: 1. Understand and implement the Fire Safety Policy. 2. Attend fire meetings if and when asked to do so. 3. Attend fire drills and fire evacuation training. 4. Co-ordinate an evacuation procedure within the immediate vicinity of the fire in the event of a major incident. 5. Be trained to tackle fire with portable fire fighting media; and 6. Support the Nominated Officer (Fire) in the fire drills and tests. 7. The duty officer shall not silence fire alarm sounders. This will be done by the Estates department on instruction from the Fire Brigade. 3.13 Senior charge nurses and Heads of Department Senior charge nurses and Heads of Department will: 1. Understand and implement the Fire Safety Policy. 2. Ensure that Fire Safety Policy documentation is available in all relevant areas. 3. Ensure staff commitment to the Fire Safety Policy and fire prevention within their work areas. 4. Assist the Nominated Officer (Fire) to arrange and carry out fire drills, and 5. Ensure staff attends fire lectures, fire drills and fire evacuation training when asked to do so. 9
6. Shall ensure that deficiencies, faults or failures relating to fire safety are properly reported for repair promptly, and a record kept of the action carried out. 7. Shall be responsible for monitoring and recording the fire safety training requirements of the staff under their control and shall make a request for training to the Learning & Development department and or the Nominated Officer (fire) in good time. 8. Shall ensure that new staff, including agency, temporary or part time staff are included in the general training arrangements, and that they receive a local department, ward or area walk round induction at the commencement of their employment so that they are aware of the exit routes, door fastenings and other fire safety provisions relevant to their place of work. 9. Shall ensure that all staff in their control are aware of the fire safety procedures for their place of work and know what to do in the event of fire. These arrangements include reference to the additional needs of disabled people and those who are non-english speakers. 10. Shall ensure that all staff at the commencement of employment is enrolled on a corporate induction session with the appropriate provider. 3.14 Fire Wardens Fire Wardens are local managers and porters they will take appropriate action if a fire occurs. Their duties are as follows Ensure that escape routes are always unobstructed and available for use Keep and submit written reports of any observations to the fire advisor for action Ensure that their part of the premises are evacuated in the event of an emergency Ensuring that no person re-enters the building until it is safe to do so, the Fire and Rescue service senior fire officer will give this permission. 3.15 Employees All staff have duties and responsibilities in respect of fire safety. Line managers are responsible for ensuring that fire safety policies and instructions are brought to the attention of their staff. Line managers will ensure that every member of staff participates in fire safety training and drills. Where necessary, personnel will have both basic instructions in fire safety and, where appropriate, training relative to their place of work. All employees will ensure that fire exit routes and corridors are kept clear of equipment, rubbish and anything which could increase fire load and or impede safe evacuation. All staff are required to report any problems with fire doors and fire fighting equipment to the Estates Department by calling 3028 or 01595 743028 3.16 Fire Safety Training The Board will ensure that a system of fire training is place. This shall be by attendance at a fire lecture. All staff must either attend an annual fire lecture or complete the on line training including passing the assessment, at least once a year. 10
Training includes evacuation procedures and fire extinguisher training. Staff are encouraged to also complete the Learn Pro on line Fire Safety module. Fire extinguisher training will be available for staff on an annual basis with key staff prioritised on a risk basis. 3.17 Fire Response Team Gilbert Bain Hospital A fire response team will attend all fire alarms. During normal hours, this team subject to availability will consist of the Duty Officer, Nominated Officer (Fire) or deputy, Duty Senior nurse, Maintenance manager and Fire Wardens. Outwith normal hours the response team with be the Nurse in Charge and the on-call Estates person, and Porter. The team membership will depend on the area of the fire call, and all members will have clear identification so that they can be identified by staff visitors and patients. A Fire Emergency Management Plan has been prepared for the Gilbert Bain Hospital. 3.18 Fire Response Team Other Premises During normal hours this will consist of the Duty Officer and on call Estates person Out with normal hours this will consist of the Duty Officer and on call Estates person 3.19 Equipment The Head of Estates and Facilities will ensure that all fire alarm systems are tested, and test results recorded, for all NHS Shetland properties with fire alarm systems. All fire extinguishers will be tested on an annual basis, and test certificates will be kept on file. All fire doors will be inspected on a regular basis and maintained. 3.20 Estates Manager The Estates Manager will be responsible for operational matters to ensure all fire detection systems, fire control measures, workplace fire safety equipment and fire fighting equipment is: In good working order. Tested and inspected in accordance with legislative and Fire code requirements and as required as a result of premises fire safety risk assessment. Also to ensure all such inspections and tests are appropriately recorded and available for audit. Subject to a robust planned preventative maintenance schedule. Sited in the most appropriate location. Correctly signed. 3.2.1 Where it has been identified by fire safety risk assessment that additional works are required to bring premises up to the most recent standard of fire safety 11
compliance, the Estates Manager is responsible for ensuring that Action Plans are implemented and agreed in order that appropriate remedial action can be taken. The Estates Manager will have responsibility for future developments of both equipment and buildings and will have a leading role as part of any Project Team with regard to Fire Safety Planning and Development. The Estates Manager will ensure the availability of advice on technical matters from the specialised Fire Safety Adviser. 4 Evacuation Exercises The Duty Holder or the NoF will ensure that fire evacuation exercises in all Board properties are carried out annually. 5 Wilful fire raising 5.1 Wilful fire raising is increasing in all types of premises including hospitals and other healthcare premises. Many fires started in healthcare premises occur in parts of the building that are being used for storage, where materials or commodities stored may provide a ready ignition source for the fire raiser. 5.2 There are simple methods, which may be employed to reduce the likelihood of deliberate fire raising occurring. Challenging people who appear to be acting in a suspicious manner and ensuring good standards of housekeeping are employed are two examples. Ensure all waste is placed in the correct containers and stored in the designated areas and not allowed to accumulate in corridors etc. Do not allow waste to accumulate in areas where it may provide the fuel for a potential fire raiser All aerosols, flammable gas cylinders must be kept separate from general waste Ensure areas are well lit Good housekeeping and observation are effective tools in the fight against the fire raiser Fire Hazard Areas Only members of staff and authorised contractors are to be allowed entry into fire hazard rooms. These rooms include: Cleaners rooms and cupboards Chemical stores 12
Clothes or linen cupboards Disposal rooms Staff changing rooms/locker rooms Store rooms Kitchens Medical Records stores. Stationary cupboards. Contractors/maintenance stores. All buildings will have rooms where only Estates/facilities staff or authorised contractors will have access, such as: Lift motor rooms and other Plant rooms. Electrical intake rooms or cupboards. Boiler rooms and main gas intake rooms. Gas bottle storage / manifold rooms / enclosures. Workshops. Confined spaces (roof, ducts, voids, basements, etc.). Flammable liquid stores. Closing Down Procedures For buildings or part of buildings which do not have 24 hour staffing, the following should apply: At the close of day, briefly check all rooms and public areas. Close all doors and secure all windows. Switch off all unnecessary electrical appliances. Ensure security lighting, alarms etc., (where applicable) are switched on and that external doors are locked. In areas where there is 24 hour staff cover, the following procedures should be adopted during the silent hours: Check windows and doors are locked where safety permits. Carry out a brief check of all rooms and public areas to ensure visitors have left the building/department. Switch off all unnecessary electrical appliances, lights etc., but ensuring that permitted lighting (corridors, night lights, security lights) are left on. All such rooms must be kept locked at all times when not in use. 6 Review of the Policy The Fire Committee on an annual basis will review the content of this policy, as and when new legislative or guidance arrangements necessitate this. 13
References NHSScotland Firecode including Scottish Health Technical Memoranda (SHTM) SHTM 81: Fire precautions in new hospitals SHTM 82: Alarm and detection systems SHTM 82: Supp A: Automatic fire control and voice alarm systems SHTM 83: Fire safety in healthcare premises SHTM 84: Fire safety in residential care premises SHTM 85: Fire precautions in existing hospitals SHTM 86: Fire risk assessment in existing hospitals SHTM 87: Textiles and Furniture Scottish Fire Practice Notes (SFPN) SFPN 6: The prevention and control of deliberate fire raising in NHS Scotland healthcare premises SFPN 11: Reducing unwanted fire signals in healthcare premises NHSScotland A Model Management Structure for Fire Safety NHS Shetland Policies: o Waste Management Policy o Security Policy o Estates Maintenance Policy 14
15 1. Rapid Impact Checklist Fire Policy Which groups of the population do you think will be affected by this proposal? Other groups: minority ethnic people (incl. gypsy/travellers, people of low income refugees & asylum seekers) people with mental health problems women and men homeless people people in religious/faith groups people involved in criminal justice system disabled people staff older people, children and young people lesbian, gay, bisexual and transgender people N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be What positive and negative impacts do you think there may be? Which groups will be affected by these impacts? assessed. What impact will the proposal have on lifestyles? For example, will the changes affect: Diet and nutrition? Exercise and physical activity? Substance use: tobacco, alcohol or drugs? Risk taking behaviour? Education and learning, or skills? None Will the proposal have any impact on the social environment? Things that might be affected include: Social status Employment (paid or unpaid) Social/family support Stress Income Will the proposal have any impact on: Discrimination? Equality of opportunity? Relations between groups? None None 15
16 Will the proposal have an impact on the physical environment? For example, will there be impacts on: Living conditions? Working conditions? Pollution or climate change? Accidental injuries or public safety? Transmission of infectious disease? Will the proposal affect access to and experience of services? For example, Health care Transport Social services Housing services Education Positive Public and Staff Safety None 16
17 Positive Impacts (Note the groups affected) Rapid Impact Checklist: Summary Sheet Safe evacuation in the event of a fire All groups Negative Impacts (Note the groups affected) Awareness of Fire Alarm and what it means - BME Group - Some disability groups Additional Information and Evidence Required More information required on impact on BME and Disabled groups 4. Recommendations 1. Fire Committee consider possible negative impact on disabled patients, visitors and staff by June 2009 2. Scope any language issues with EAL group by June 2009 From the outcome of the RIC, have negative impacts been identified for race or other equality groups? Has a full EQIA process been recommended? If not, why not? Full process not recommended - appropriate adjustments have been made. Manager s Signature: Date: 17