NHS Tayside Fire Safety Policy Policy Manager Mark Anderson, Head of Property Policy Group Fire Safety Policy Review Group Policy Established Last Updated April 2014 Policy Review Period/Expiry April 2017 This policy does apply to Medical/Dental Staff UNCONTROLLED WHEN PRINTED 1
CONTENTS Section Title Page 1. INTRODUCTION 1.1 1.8 3 2. POLICY AND OBJECTIVES 2.1 Scope 4 2.2 Policy Statement 4 2.3 Objectives 4-6 FIRE SAFETY MANAGEMENT STRUCTURE 7 3. ROLES AND RESPONSIBILITIES 3.1 Management Structure 8 3.2 NHS Tayside 8 3.3 Chief Executive 8-9 3.4 Nominated Officer (Fire) 9 3.5 Deputy Nominated Officer (Fire) 9-10 3.6 Fire Safety Adviser 10-11 3.7 Responsible Person (Fire) 11-12 3.8 Deputy Responsible Person(s) (Fire) 12 3.9 Executive Service Leads 12-13 3.10 Duty Holders 13 3.11 All Other Staff 13-14 2
Fire Safety Policy Version Control Version Number Purpose/Change Author Date 1.0 Version Control was introduced in July 2011 and the previous versions of this policy, prior to this date, are available in the Electronic Document Store. 2.0 Changes made following review of principal policy areas Margaret Moulton October 2009 Margaret Moulton August 2010 2.1 Policy updated to include : Guidance on Version Control Update to approval / endorsement route Update to Workforce Policy route map Additional responsibility for Policy Managers to ensure all Policies clearly indicate if policy is applicable to medical/dental staff 2.2 Policy Update to remove reference to Delivery Unit and replace with Improvement and Quality Committee. Appendix 5 amended to introduce Policy being discussed at the WAG. 2.3 Policy Update to remove all references to Safety Governance and Risk and insert Chief Executives department Corporate Services. To include Clinical Quality Forum in flowcharts. Margaret Moulton/ Alison Davie Margaret Dunning/ Nicola Owen Margaret Dunning/ Nicola Owen June 2011 June 2012 August 2012 3
1 INTRODUCTION 1.1 The Scottish Government has retained powers of direction under the NHS & Community Care Act 1990, which requires NHS health care premises to comply with the provisions of NHS in Scotland hereafter referred to as Firecode throughout this document. 1.2 The removal of Crown immunity from 1st April 1991 exposes the NHS, its staff and advisers, to the full rigours of legislation providing for the safety of persons, from fire, within health care premises. It also exposes bodies corporate, their managers and employees to the full powers, which may be exercised by the appropriate enforcing authorities. 1.3 NHS Tayside management and other employers occupying premises on NHS property acknowledge their responsibilities for ensuring that their fire safety policy complies fully with both the requirements of the law and all applicable sections of Firecode. 1.4 Those charged with the responsibility for fire safety in NHS properties should consider that fire safety is not a stand-alone issue but one to be dealt with alongside others in the overall risk management of health & safety matters. 1.5 This paper outlines a system to make provision for the management of fire safety and, in addition to general staff responsibilities, details specific responsibilities placed upon individual members. 1.6 Subject to discussion with the Fire Safety Advisers, agreed fire procedures, strategies and responsibilities can be developed for specific sites and together with operational procedures, will be included in a Site Operational Plan. 1.7 A bi-annual review and, where required, amendments to the Fire Safety, Arson Policy & Strategy will be instigated by the Senior Fire Safety Advisor NHS Tayside. Clinical Groups Directorates/Departments will be advised of these amendments via the Intranet s staff bulletin and e-mail and also Risk Management/Health and Safety reporting structures. 1.8 This document provides guidance and highlights staff responsibilities and is intended to be flexible in its application to allow the general principles to be applied to all NHS Tayside sites. 4
2 POLICY AND OBJECTIVES 2.1 Scope The fire safety policy and management structure are agreed and accepted fire safety criteria to be adopted by all employers and their employees occupying premises on NHS Tayside sites. 2.2 Policy Statement NHS Tayside recognise the significant risks a fire within hospitals and health care premises pose to the safety of all persons within. In particular, the difficulties and dangers associated with the emergency evacuation of patients, many of whom will be highly dependent. NHS Tayside acknowledges its duty of care to safeguard all persons on its premises from the dangers of fire. NHS Tayside will take all reasonable steps to meet its fire safety responsibilities to all who could be adversely affected by fire and will seek to continuously improve fire safety performance. This policy is intended to supplement the respective Health and Safety Management Policies. Our aim is to comply with all statutory and mandatory requirements relevant to healthcare premises and we are committed to achieving adequate standards of fire safety appropriate to the risk. In the main this will be effected by compliance with Firecode in Scotland and the Fire (Safety) Scotland Act 2005 as amended and The Fire Safety (Scotland) Regulations 2006. 2.3 Objectives To achieve this aim we will ensure that: Nominated Officer (Fire) and Deputy Nominated Officer (Fire) is appointed. Specialist Fire Safety Advisors are appointed Responsible Person(s) (Fire) and Deputy Responsible Person(s) (Fire) are appointed Duty Holders (Fire) are identified to undertake the role as identified by NHS Tayside. Fire Safety Management will be coordinated throughout all NHS parts of those premises owned or managed by NHS Tayside/where NHS Tayside staff are employed. All statutory requirements in respect of fire safety are met; The guidance detailed in NHS Scotland Firecode documents, Scottish Building Standards Agency Non Domestic Handbook and the Scottish Government Practical Fire Safety Guidance for Healthcare Premises are applied in all NHS Tayside Site premises; 5
A programme for improving and maintaining fire precautions is in place; All reasonable and practical fire precaution measures are taken; Fire Safety Operational Policies will be prepared and updated. Means of receiving reports of all fire incidents from NHS Tayside Fire Safety Advisors, informing the Chief Executive of their contents and arrange for them to be acted upon. Fires involving death or serious injury are reported to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. Whenever buildings or parts thereof occupied by NHS Tayside are in use, the senior members of staff present, or Duty Holders, have an appointed responsibility for Fire Safety consistent with the requirements of the Fire (Scotland) Act as amended and that they are provided with appropriate training to enable them to undertake their duties effectively. When procuring services from third-party providers, the physical Fire Safety measures intended for supply of those services are adequate and that the management, staff, training and evacuation arrangements (including numbers of day and night staff) are appropriate for the safety of patients and staff who may be placed in that facility Procedures to deal with outbreaks of fire and the emergency evacuation of patients, visitors and staff are in place; Appropriate Emergency Response Teams are established and that sufficient staff are available at all times to provide assistance with evacuation in a fire emergency Adequate training exercises are undertaken at a frequency appropriate to the identified risk, for the Fire Response Teams and other staff who are involved in patient evacuation. Arrangements to ensure alarms of fire are appropriately responded to and supervised including arrangements for liaising with the Scottish Fire and Rescue Service and resetting alarms. Developments of fire safety strategies take account of the requirements of the Disability Discrimination Act. Procedures are in place to undertake and review Fire Safety Risk Assessments and record outcomes in accordance with the Fire (Scotland) Act and related subordinate legislation within NHS parts of all premises owned, occupied or managed by NHS Tayside Fire Manager" software is utilised as the primary means of meeting the aims of the Fire Risk Assessment requirements 6
A system to record all fire safety management related matters (Fire Folder) is in place for all areas of NHS Tayside. The Fire Safety Duty Holder has the responsibility to ensure management of fire safety is implemented, as identified in the NHS Tayside Fire Folder, for their area of responsibility and records maintained within the Fire Folder. Procedures are in place to provide appropriate and sufficient training based on a formal analysis of the training needs of persons in the particular facility being considered. Effective communication and co-operation is maintained between management, staff and staff representatives regarding fire safety issues; Effective communication and co-operation with the Scottish Fire and Rescue Service, Building Control Officers and other statutory bodies relating to fire safety matters, as required, is maintained. 7
NHS Tayside Fire Safety Management Structure \ Chief Executive NHS Tayside Board Overall Command and Responsibility Nominated Officer (Fire) (Director of Operations) Deputy Nominated Officer (Fire) Fire Safety Advisors Responsible Person (Fire) Carseview Responsible Person (Fire) NHS Tayside (Other than Carseview) Deputy Responsible Person (Fire) Carseview Deputy Responsible Person (Fire) Dundee Deputy Responsible Person (Fire) Angus/Perth and Kinross Executive Service Leads Executive Service Leads Executive Service Leads Duty Holders Duty Holders Duty Holders Staff Staff 8 Staff
3. ROLES AND RESPONSIBILITIES 3.1 Management Structure a) The management structure has been developed to meet the specific requirements for the management of fire safety throughout NHS Tayside sites whilst complying with the statutory and mandatory obligations of Fire Safety and Health and Safety legislation. The application of the roles of management and staff is intended to be flexible and should be determined by the size and complexity of the specific site. It is not the intention that all roles will be fulfilled at each site. b) The structure must be practical and functional. It is designed with reference to NHS in Scotland Firecode s Model Management Structure for Fire Safety guidance, which acknowledges the employer's duty of care. c) The Operational Unit Risk Management/Health and Safety Group chaired by the Director of Operations will oversee and monitor fire safety issues. The committee will comprise members of Clinical Groups, other support Directorates, representatives of employers occupying NHS Tayside premises, including the University of Dundee, together with specialist advisers. Scottish Fire & Rescue Service will also be represented if required. Fire Safety Management will be reviewed and reported within each of the Risk Management/Health and Safety identified groups including Locality and Site based groups which report to the Operational Unit Risk Management/Health and Safety Group. 3.2 NHS Tayside Board Is accountable and responsible for determining NHS Tayside policy together with a fire safety regime for the prevention of fire and the provision of adequate fire precaution measures. To ensure compliance with all fire safety statutory and mandatory requirements. Ensure that all newly commissioned Healthcare buildings for owner occupation, leasing newly constructed buildings from another party or occupying buildings provided under a PPP/PFI contract comply with all statutes bearing upon the Fire Safety of newly constructed buildings. Consider the appointment of an Approved Certifier of Design and Construction in accordance with the optional provision under the Building (Procedure) (Scotland) Act 2004, as a means of achieving compliance verification. Ensure that as far as practicable all NHS Tayside Premises are accessible to comply with the requirements of the Disability Discrimination Act 1995 and that adequate arrangements are in place for safe evacuation in the case of fire. 3.3 Chief Executive 9
Has overall command and responsibility within the fire safety policy. Ensures clear guidelines for those tasked with the compliance of statutory and mandatory requirements. Ensures, so far as is reasonably practical, that there are adequate resources available to meet fire safety requirements. 3.4 Nominated Officer (Fire) (Director of Operations) The Executive Director (Director of Operations) will accept the role of Nominated Officer (Fire) with overall responsibility for ensuring that an appropriate fire safety structure is in place and implemented. That all statutory and mandatory requirements are met. That Firecode s mandatory requirements are implemented. Ensuring that the Chief Executive is provided with advice and guidance to allow the Chief Executive to fulfil his/her statutory responsibilities. The appointment of specialist Fire Safety Advisers. Ensure the formulation of a Fire Safety compliance programme Ensuring that the fire safety policy is in place and fire emergency evacuation procedures are prepared for all NHS Tayside sites. Ensuring that a suitable system is in place to record all fire safety management information.(fire Safety Folder). Ensuring that the capital plan includes a financial provision for the fire safety improvement program and that the plan is implemented. Receive all fire investigation reports regarding fire incidents and ensure that any recommendations to prevent reoccurrence are implemented as soon as practicable. Receive reports for unwanted fire signals and shall instigate and monitor actions to mitigate the potential for their reoccurrence. Any incident involving death or serious injury is reported in accordance with NHS Tayside Health & Safety Incident Reporting Procedures. 3.5 Deputy Nominated Officer (Fire) The Deputy Nominated Officer Fire is required to support the development and implementation of a strategic management structure in order to ensure effective Fire Safety delivery and ensure compliance with all aspects of Fire Safety Legislation. 10
The Deputy Nominated Officer (Fire) is directly responsible for fire safety matters to the Nominated Officer (Fire) / (Director of Operations). Ensures that the Nominated Officer (Fire) is appraised at all times of fire related matters. Ensures the application of Firecode throughout all NHS Tayside premises under his/her control. Liaises with NHS Tayside Fire Safety Advisers on all aspects of fire safety. Ensures an appropriate staff fire safety training programme is developed as required by Fire Safety Advisers. Receives all fire investigation reports regarding fire incidents and ensure that any recommendations to prevent reoccurrence are implemented as soon as practicable. Receives all Scottish Fire and Rescue Audit and Fire Safety Advisor Reports and ensure that any recommendations are implemented as soon as practicable. Ensures the completion of fire risk assessments and provide adequate resources to implement the outcomes. Ensures that a system for recording and retaining all fire safety management records is devised. (Fire Safety Folder). 3.6 Fire Safety Adviser To provide specialist advice on the interpretation and application of the provisions of statutory and mandatory requirements, Firecode and other official fire safety guidance in NHS Tayside premises. Advising management of their initial and continuing responsibilities in respect of all NHS Tayside Premises to ensure they comply with the necessary provisions of the Fire (Scotland) Act 2005 and the Fire Safety (Scotland) Regulations 2006. Identify and assess fire risks. Compile fire safety risk assessments for all premises occupied by NHS Tayside and ensure, where appropriate, Duty Holders/Site and Property Management are aware of the significant findings. To liaise with Property Department/ local Building Standards Agency and Scottish Fire and Rescue in the specification of fire safety measures in new and existing premises. To liaise with Property Department to ensure that the presence and activities of contractors and their employees are monitored and comply with NHS Tayside fire safety procedures and official fire safety guidance while employed to work on NHS sites. 11
Preparing training programs for all staff employed in NHS premises. Observing the effectiveness or otherwise of fire Evacuation Training. Providing assistance and direction regarding fire and evacuation procedures to NHS Tayside. Investigating and keeping records of all unwanted fire signals and fire incidents. Making recommendations regarding action required to prevent recurrences of unwanted fire signals. Preparing reports regarding fire safety lecture attendance's, fire drills, fires and unwanted fire signals and submitting them to NHS Tayside as appropriate. Preparing a Fire Safety Reports to NHS Tayside Board, as appropriate in accordance with Corporate Governance Timelines. 3.7 Responsible Person (Fire) Responsible Person(s) (Fire) are required to assist in the creation and implementation of Fire Safety Management Procedures and Arrangements. The Responsible Person(s) (Fire) is directly responsible for fire safety management matters to the Nominated Officer Fire (Director of Operations). Ensures there are adequate fire safety management procedures for sites within their control with professional advice from the Fire Safety Adviser. Ensures that all physical areas/sites have an appointed Duty Holder (Fire) identified to undertake the role and duties, as identified within the NHST Fire Folder. Ensures that the Nominated Officer (Fire) and Deputy Nominated Officer (Fire) are appraised of all fire safety management related matters. Liaises with NHS Tayside Fire Safety Advisers on all aspects of fire safety. Ensures that appropriate programs of staff fire safety training are distributed and publicised as required by Fire Safety Advisers. Ensures that all staff participate regularly in fire safety and fire evacuation training. Ensures that efficient procedures are in place to provide an effective and appropriate fire safety team response to all fire alerts appropriate to each site/premises. Liaises with the Fire Safety Adviser to ensure that Duty Holders and Fire Response Teams are provided with appropriate training to carry out their emergency response duties. Ensures that all site/s are subject to monthly fire awareness checks and all faults noted are reported (see Appendix 1) to the appropriate person or department for action as required. 12
Ensures that Fire Response/Emergency Response Teams are identified and are appropriate to the requirements of each site/premises. Ensure that regular Fire Safety Management review meetings are held and are representative of all NHST site/premises Ensure the system for recording and retaining all fire safety management records is maintained. (Fire safety folder). Ensuring that either a Duty Co-ordinator or a suitable member of staff is available at each site during all periods when the premises are occupied, who will respond, in the first instance, to each fire alert. 3.8 Deputy Responsible Person(s) (Fire) Deputy Responsible Person(s) (Fire) are required to assist the Responsible Person(s) (Fire) in the development and implementation of Fire Safety Management Procedures and Arrangements. This includes any of the above Responsible Person (Fire) responsibilities. 3.9 Executive Service Leads Directors/General Managers are accountable for staff activities and areas under their control. They are required to ensure that all staff within their remit are appropriately aware, attend training and undertake their duties in accordance with this policy. They are required to ensure that identified Duty Holder(s) (Fire) undertake duties identified within the Fire Folder and support in general the roles of the identified fire safety structure. To liaise with the Fire Safety Adviser/Nominated Officer (Fire)/Deputy Nominated Officer (Fire)/Responsible Person (Fire)/Deputy Responsible Person (Fire) and Duty Holders on all relevant matters to ensure compliance with statutory fire safety requirements and other official mandatory fire safety guidance. To liaise with the Fire Safety Adviser/Nominated Officer (Fire)/Deputy Nominated Officer (Fire)/Responsible Person (Fire)/Deputy Responsible Person (Fire) and Duty Holders Ensuring that all fire safety measures provided, within workplaces under their control, are maintained in efficient order and that all means of escape are kept clear of obstructions and combustible materials at all times. Ensure that a current Fire Risk Assessment is in place for all workplaces within their control. To ensure the fire risk assessment findings are implemented within given timescales. Responsible for Duty Holders in relation to fire safety management for all areas within their control. Ensuring that appropriate members of staff are appointed and trained by the Fire Safety Department, as Duty Holders within each workplace. Ensuring that trained Duty Holders are available within each workplace. 13
To ensure there are adequate and suitable arrangements in place to manage fire safety for all areas/sites and fire escape routes and fire exits, which are in their control and that all fire safety related records are kept within the fire safety folder, which has been designed to assist with this. Ensuring a Monthly Fire Awareness Check is carried out and actions reported and completed by the Duty Holder. Ensuring all staff, including students, bank or agency staff and temporary staff attend a fire safety lecture in accordance with the training needs analysis guidelines. Ensuring all staff, including students, bank or agency staff and temporary staff are familiar with and understand their fire safety and evacuation procedures and responsibilities. Ensuring there is a system for collating and recording Fire Safety Training and Fire Evacuation Training. 3.10 Duty Holders Duty Holders are directly responsible for fire safety matters for sites/departments within their control to Executive Service Leads Establish fire safety procedures for identified areas within their control and where necessary seek professional advice from the Fire Safety Adviser. Liaise with NHS Tayside Fire Safety Advisers on all aspects of fire safety. To collate and retain all fire safety information within the fire safety folder, which has been provided for this purpose for all areas within their control. Ensuring appropriate programs of staff fire safety training are distributed and publicised as required by Fire Safety Advisers. Ensuring that all staff participate regularly in fire safety and fire evacuation training. Be sufficiently trained and ensure effective delivery of duties as defined within the Fire and Arson Policy Ensuring that all areas within their designated areas are subject to monthly fire awareness checks and all faults noted are reported to the appropriate department for action as required. Ensure Fire Risk Assessments are reviewed annually and the line manager is informed of the outcomes. 3.11 All Other Staff 14
The corporate fire safety objectives are the responsibility of all members of staff and other persons working in NHS Tayside Health Premises. It is a statutory duty to cooperate with the employer in pursuit of the fire arrangements in place. All staff shall in particular: Understand the fire alarm warning sound, code or other method of giving the alarm for all areas in which they may work. Be aware of the emergency procedure for discovering a fire for all areas in which they may work. Know and understand all fire safety arrangements, evacuation procedures, evacuation routes to follow and fire assembly points for all areas in which they may work. The need to ensure the reporting of all fire escape routes are unobstructed, clear of all storage and combustible refuse and fire doors are not wedged open. Ensure all flammable materials, hazardous substances and combustible materials are stored and managed in line with policy e.g. COSHH Policy, Waste Management Policy etc. Ensure that they comply with all reasonable instructions for fire safety and that they report any defects and faults. Ensure they attend fire safety training as instructed Ensure that they comply and manage effectively the NHS Tayside No Smoking policy Understand the type of portable fire extinguisher; location and what to use in different circumstances. Ensure that they know the findings of the current Fire Risk Assessment for their area and any related action plans Ensure they comply with Fire Safety instructions in relation to fire safety and actively assist them to ensure the highest level of fire safety is maintained. 15
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