Fire Safety Policy SH HS 06. Version: 3. Summary:

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1 SH HS 06 Version: 3 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: The sets out the Trusts approach to a proactive fire safety culture to protect its staff patients and service users and properties. Fire, training, premises, procedures and assessments. All staff employed by Southern Health NHS Foundation Trust. Next Review Date: February 2017 Approved and Ratified by: Health and Safety Forum Date of meeting: 29 January 2015 Date issued: Author: Sponsor: David White, CMIOSH, FIFSM, MIIRSM, GIFireE. LCGI. Fire Safety Manager Chief Finance Director 1

2 Version Control Change Record Date Author Version Page Reason for Change Sept 2013 D White 01 All Document review in compliance with SHFT Policy Dec 2014 J Pearce 03 All Document review in compliance with SHFT Policy July 2015 Louise 3 12 Updated TNA (Appendix 1) Hartland Reviewers/contributors Name Position Version Reviewed & Date R Lindsay Fire Safety Advisor Version 2 / Sept 2013 J Pearce Fire Safety Advisor / Dec

3 Contents Section: Page: 1. Introduction 4 2. Scope 4 3. Definitions 5 4. Duties and responsibilities 5 5. Fire Evacuation 7 6. Fire alarm systems 8 7. Fire doors 8 8. Emergency lighting 8 9. Portable fire fighting equipment Disabled staff Fire Risk Assessments Training requirements Monitoring compliance Policy review Associated documents References 10 Appendix: 1 Training Needs Analysis 12 Appendix: 2 Equality Impact Assessment 13 3

4 1. Introduction: 1.1 Southern Health NHS Foundation Trust acknowledges its responsibilities under the Regulatory Reform (Fire Safety) Order 2005, and will ensure that fire risk assessments are carried out on its premises to determine the general fire precautions and protective measures needed to comply with the articles imposed under this order. 1.2 Where directly responsible for the fire arrangements, the Trust will appoint a competent person to assist with implementing the requirements of the RRFSO The trust will make and give effect, where responsible, to such appropriate organisational arrangements for the effective planning, organisation, control, monitoring and review of its preventive and protective measures. The Trust will implement such general fire precautions and will ensure, so far is reasonably practicable, the safety of its service users, employees, contractors and visitors. This general fire precaution will be implemented on the basis of the following principles from schedule 1 part 3, article 10 of this order; 1) Avoiding Risks; 2) Evaluating the risks which cannot be avoided 3) Combating the risk source; 4) Adapting to technical progress 5) Replacing the dangerous by the non-dangerous or less dangerous; 6) Give appropriate instructions to employees, and, as specified in article 4 of the order, these general fire precautions will include: a) Measures to reduce the risk of fire on the premises and risk of the spread of fire on the premises. b) Measures in relation to the means of escape from the premises. c) Measures for security that, at all material times, the means of escape can be safely and effectively used. d) Measures in relation to the means for fighting fires on the premises and giving warning in the case of fire on the premises. e) Measures in relation to the arrangements for action to be taken in the event of fire on the premises, including: I. Measures relating to the instruction and training of employees; II. Measure to mitigate the effects of the fire; 2. Scope: 2.1 This policy encompasses the management of the fire safety in all Southern Health NHS Foundation Trust (SHFT) premises which may be owned or occupied. 2.2 Fire is a potential hazard in all NHS premises, hospitals, clinics, health centres, community and nursing homes. The consequences of fire in hospitals or other health care premises can be especially serious because of difficulties and dangers associated with the emergency evacuation of clients, many of whom may be highly dependent. 4

5 2.3 The aim of SHFT is to ensure, as far as possible, that outbreaks of fire do not occur. If an outbreak cannot be prevented it must be rapidly detected, effectively contained and quickly extinguished without risk to staff, clients or visitors. A commitment to be aware of fire precautions is a basic duty of all staff and an essential obligation for everyone with management responsibility. 3. Definitions: 3.1 The following definitions are used throughout this policy SHFT Southern Health NHS Foundation Trust RRFSO 2005 Regulatory Reform (Fire Safety) Order 2005 PEEP Personal Emergency Evacuation Plan BS British Standards FRA Fire Risk Assessments 4. Duties and responsibilities: 4.1 Chief Executive The Trust s Chief Executive has overall responsibility for ensuring that the Trust has robust systems and policies in place in respect of general fire precautions and training, and that these are implemented. The Chief Executive will sign annually the certificate of compliance to the NHS Executive. The Chief Executive is responsible for fire safety throughout the Trust and is responsible for ensuring that: This policy on Fire Safety is implemented in every operational area of the Trust: Arrangements in place to enable the effective planning, organisation, control, monitoring and review of Health and Safety in every operational area of the Trust: A board level director has been appointed to act on their behalf to ensure adequate structures are in place to ensure, so far is reasonable and practicable, the health, safety and welfare of staff, patients and all relevant persons affected by the Trusts undertaking: A suitably qualified Fire Safety Manager has been appointed to advise the director responsible for the management of fire safety on all matters relating to fire safety under the RRFSO Board of Directors The board of directors have the responsibility of setting the strategic direction of the Trust and overseeing the implementation of this policy and objectives including those related to fire safety. It is the board of Directors responsibility for decision making on the management of all types of health and safety risks within the organisation. 4.3 Chief Finance Director The Chief Finance Director is the nominated board level director to undertake the role has health and safety sponsor, this includes all aspects of fire safety within the Trust. 5

6 4.4 Health and Safety - Fire Safety Manager The Fire Safety Manager is responsible to the Board level director for Health and Safety, and ensuring all aspects of the RRFSO 2005 and Firecode are adhered to in all SHFT premises these include: Having an awareness of all fire safety features and their purpose Fire safety risks, particularly to the organisation Advising management on technical fire matters Attending fires and preparing reports on all incidents Requirements for disabled staff including each disabled member of staff as a PEEP Ensure appropriate levels of management are always available to ensure decisions can be made at all times, day or night Compliance to current fire safety legislation Develop and implement the Trusts Develop and implement the Trusts Fire Safety Strategy Review the Trusts fire safety policy and fire safety strategy at regular intervals Development and delivery of an effective training programme in all aspects of fire safety, including. Planning and giving lectures to all staff on fire precautions. Liaise and conduct fire safety audits with the local fire authority Monitoring and reducing unwanted fire signals Liaise with all site managers Cooperation between other employers where two or more share the same premises The reporting of fire related incidents in accordance with Ulysses (Safeguard) Advising on fire precautions on all plans for capital/revenue developments Fire safety instructions and procedures for all premises 4.5 A fire risk assessment which is suitable and sufficient shall be conduct for each premise Occupied by SHFT staff; these will be conducted at regular intervals in compliance to the RRFSO Each assessment will have an action plan with achievable deadlines for improvements following the FRA. 4.6 FIRECODE states that the Fire Safety Manager is given necessary authority and resources to discharge the functions. 4.7 Line Managers and Departmental Heads Line Managers and Departmental Heads are entrusted with the day-to-day responsibilities of ensuring the effectiveness of fire safety arrangements in buildings within their area of control. 4.8 On larger sites this responsibility may be shared with local site manager who will be able to take a strategic view and co-ordinate the fire safety arrangements for the whole site. 4.9 The manager s principal role should be to act as the focal point for fire safety issues affecting local staff, patients/clients, visitors and contractors The manager should appoint sufficient numbers of Fire wardens for each area The Manager, in conjunction with their fire wardens will conduct fire safety inspections. This will ensure that the exciting, essential fire safety features, including 6

7 fire fighting equipment and management systems are being maintained in accordance to relevant BS and manufactures recommendations Managers should ensure that all staff, including those new or transferred to the department are adequately trained in fire safety procedures, including the staff working in the community Fire Wardens Fire Wardens should be appointed in all departments where deemed necessary under article 15 of RRFSO The Fire Warden should:- Act as focal point on fire safety issues liaising with all staff. Organise and assist in the fire safety regime within local areas Raise issues regarding fire safety with management. Assist with co-ordinating of the response to an incident within the local vicinity. Take responsibility for taking the roll call during the evacuation of the premise. Be trained in the use of portable fire fighting equipment. Support management in fire safety issues and undertake safety inspections. Participate in taking a fire warden course and transfer this information into the workplace Responsibilities of all staff All SHFT employees have a duty to ensure that they comply with the fire safety arrangements and procedures within their workplace and they do not commit acts which lead to the outbreak of fire. All employees have a duty under the Health and Safety at Work Act 1974, to take reasonable care of their own safety at work, and that of others who may be affected by their acts or omissions. All SHFT employees are required to attend annual fire safety training or complete an on-line assessment, and to familiarise themselves with the evacuation procedures of the work place. 5. Fire Evacuation: 5.1 The basic concept is that all occupants of a building should be able to turn their back on a fire, wherever it occurs, and move away from it using circulation spaces and stairways to a place of relevant safety or ultimate safety which is free from the effects of heat and smoke. 5.2 In Healthcare premises, the strategy depends on the principle of progressive horizontal evacuation. This involves the movement of patients, public and staff from an area affected by fire through a fire resisting compartment (normally fire resisting doors) to an adjoining area on the same level, designed to protect the occupants from the immediate dangers of fire and smoke. This may be an adjoining room, staircase or refuge. 5.3 Independent patients, public and staff are expected to vacate the affected areas immediately using the designated emergency exit routes and assemble at fire evacuation muster points. 7

8 5.4 Each building and work area within the Trust has their own fire evacuation procedure, which is designed for the use and occupancy of each area and reflects these principles. 5.5 Access to and egress from premises including fire exits, staircase enclosures and lift lobbies must remain free from obstruction at all times. 6. Fire Alarm Systems: 6.1 The primary function of the detection and fire alarm systems is to give early warning to alert staff and thus initiate a planned response. 6.2 The trust has comprehensive fire detection and alarm systems that meet all the requirements of BS 5839 part 1 and All buildings across SHFT sites are provided with their own fire alarm system and all have fire alarm indicator panels. These panels are generally situated in entrance lobbies. 6.4 Routine fire alarm testing is undertaken by the estates department on each site in accordance with the guidance set out within BS 5839 part 1. Records of such tests are kept on each site within the compliance log book. 6.5 We have numerous outside contractors that service our alarms annually and provide out of hours emergency cover in the event of failure. 7. Fire doors: 7.1 Each building will be fitted with fire doors that are suitable and sufficient. 7.2 The FRA plan will confirm the location of Fire Doors, as per compartmentalisation and means of escape. 7.3 These doors will be identified by signage and will be constructed to BS 476. They will be checked as part of the quarterly fire safety checks completed by the responsible person. And should be checked annually by a suitable contractor. 7.4 All checks to be recorded in the compliance log book. 8. Emergency lighting: 8.1 Emergency escape lighting systems are installed generally throughout all SHFT buildings in compliance with HTM and BS 5266 part The FRA plan will confirm the location of the emergency lighting 8.3 The lighting will be maintained under a PPM. 8.4 All tests recorded in the compliance log book 8

9 9. Portable fire-fighting equipment: 9.1 Portable fire - fighting equipment is strategically placed throughout all SHFT premises for use by staff to control or extinguish small fires in the early stages. In locations of special risk where water-based fire-fighting equipment is not suitable, fire extinguishers of a suitable type according to the risk will be provided. 9.2 The equipment will be maintained in accordance to BS 5306 part 6 and EN These checks will be recorded in the compliance log book. 10. Disabled staff: 10.1 Under the Equalities Act 2010 where staff members have a disability, additional control measures may be needed to reduce the risks in the event of an emergency. These staff will require PEEP s The Disability Rights Commission identifies under the RRFSO 2005, the need for employers to take responsibility for ensuring that all relevant people, can leave the building safely in the event of a fire. 11. Fire Risk Assessments: 11.1 A Suitable and sufficient Fire Risk Assessment will be in place for each of the Trusts premises The FRA will follow the requirements of the RRFSO 2005 and will be carried out by the trust Fire Safety Department The FRA will be reviewed regularly, after alteration or incident by the trust fire safety department and made available to all staff An action plan will be developed from the FRA, as required and implemented by the Responsible Person who will ensure the Trusts Fire Safety Department is informed when all significant findings have been completed. 12. Training requirements: 12.1 Statutory training Fire Safety training is a statutory requirement of article 21 of the RRFSO that all staff without exception and the nature of their duties, receive instruction, training and information as regards the fire safety procedures that are in operation within the Trust. The Trust will provide: Fire Safety Induction Training (Statutory) Annual Fire Safety Awareness Training (Essential training days) Annual Fire Safety Awareness electronic on-line assessment Fire Warden Training Site specific training can be delivered by the Fire Safety Department on request 9

10 No staff member should go without fire safety training for a period longer than two years. Training records are kept centrally with the training department 12.2 Fire evacuation training Fire evacuation drills must be carried out at least annually for each of the sites occupied by SHFT staff, simulating conditions such as might be found in a fire. The objective of fire evacuation is to test systems and procedures, however, drills must be planned and managed in such a way as to ensure the safety and wellbeing of patients, staff and visitors. These should be arranged by a senior member of staff in liaison with the E&FM fire alarm test team for that premises, if applicable. 13. Monitoring compliance: 13.1 The following table outlines how the Trust will monitor compliance with the contents of this policy - Element to be monitored Completion of Fire Safety Training Compliance with the key principles outlined in this policy Lead Tool Frequency Fire Safety Manager Fire Safety Manager Outlined in the Trust Learning and Education Policy. Reporting arrangements Health and Safety Committee Audit Annually Health and Safety Committee Completion of Fire Risk Assessments (FRAs) Fire Safety Manager Audit Annually Health and Safety Committee 14. Policy review: 14.1 This policy will be reviewed bi-annually or following change in legislation, whichever occurs first. 15. Associated documents: 15.1 Fire Safety Strategy 15.2 Health and Safety Policy 15.3 Health and Safety Strategy 16. References: 16.1 Regulatory Reform (Fire Safety) Order HTM 05-01; Managing Healthcare Fire Safety 16.3 Health and Safety at Work Act Building Regulations 2000 ( approved document B) 16.5 Care Quality Commission Core Standards 16.6 The Building Act Management of Health and Safety at Work Regulations

11 16.8 Control of Substances Hazardous to Health Regulations The Safety Representatives and Safety Committees Regulations Construction, Design and Management Regulations Equality Act

12 Appendix 1 Training Needs Analysis July 2015 If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on ) before the policy goes through the Trust policy approval process. Training Programme Fire Safety Awareness Annual Frequency Course Length Delivery Method Facilitators Face to Face 1 hour Face to Face and E-video/E-assessment Fire trainers Directorate Service Target Audience Adult Mental Health All Staff Recording Attendance LEaD Strategic & Operational Responsibility Strategic Chief Financial Officer Operational Senior Fire Officer MH/LD/TQ21 Specialised Services Learning Disabilities All Staff All Staff TQtwentyone All Staff ISD s Older Persons Mental Health All Staff ISD s Adults All Staff ISD s Childrens Services All Staff Corporate All All Staff 12

13 Appendix 2 - Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. Name of policy/service/project/plan: Policy Number: SH HS 06 Department: Health and Safety and Fire Safety Lead officer for assessment: David White, Health and Safety and Fire Safety Manager Date Assessment Carried Out: June Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes The Fire safety policy sets out the Trusts approach to a proactive Fire safety culture to protect its staff patients and service users and properties. 2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions Data, research and information that 13

14 you can refer to 2.1 What is the equalities profile of the team delivering the service/policy? The Equality and Diversity team will report on Workforce data on an annual basis. 2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E- Assessment 2.3 What is the equalities profile of service users? 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis The Trust is preparing to implement the Equality Delivery System which will allow a robust examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations 14

15 Age Positive impact (including examples of what the policy/service has done to promote equality) Negative Impact No adverse impacts have been identified at this stage of screening Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Disability The Trust will provide support to disabled staff through PEEP s and individual risk assessments to facilitate a safe working environment Staff/patients with sensory disabilities may need a fire Incident bringing to their attention. Some physically disabled staff/patients may need assistance in the event of an evacuation. It is the responsibility of all staff to ensure that this group is assisted at all times if affected by a fire incident within the Trust. PEEP s Health & Safety Gender Reassignment Marriage and Civil Partnership No adverse impacts have been identified at this stage of screening No adverse impacts have been identified at this stage of screening Pregnancy and Maternity No adverse impacts have been identified at this stage of screening Race The Trust will 15

16 respond positively to provide information in alternative formats Religion or Belief Sex Sexual Orientation No adverse impacts have been identified at this stage of screening No adverse impacts have been identified at this stage of screening No adverse impacts have been identified at this stage of screening 16

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