Fire Safety Policy and Procedures Incorporating the Arson Prevention Policy. Document Title. Date Valid From: 01 November 2013

Transcription

1 POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department of Health), or Trust Board decision. For guidance, please contact the Author/Owner. Document Title Date Issued/Approved: Fire Safety Policy and Procedures Incorporating the Arson Prevention Policy Date signed Date Valid From: 01 November 2013 Date Valid To: 01 March 2016 Directorate / Department responsible (author/owner): J Robin Gatenby, Health & Safety Manager Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Outline the Trust arrangements for the management of fire safety and arson prevention. Furthermore, to provide information on the practical management of Fire Safety within the Trust Fire, Fire Safety, Fire Risk Assessment, Fire Alarm, Detection, Fire Fighting, Fire Extinguisher, Fire Warden, Fire Training, Evacuation, PEEP, Disability, Arson, Smoke RCHT PCH CFT KCCG Chief Operating Officer Date revised: March 2013 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Health & Safety Committee Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Director of Estates Not Required {Original Copy Signed}

2 Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Internet & Intranet /Estates/General Intranet Only Various see original governance information Various see original governance information Yes This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

3 Fire Safety Policy and Procedures Incorporating the Arson Prevention Policy V4.0 November 2013

4 Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions/Glossary Ownership and Responsibilities Chief Executive Officer Director of Fire Safety (Board Level) Fire Safety Manager Authorising Engineer Fire Fire Safety Advisor (FSA) Competent Person Director of Estates Head of Estate Operations Head of Estate Development Fire Safety Officer Fire Wardens Fire Champions Fire Response Team Learning and Development Team Role of the Managers Role of Individual Staff Fire Safety Management and Committee Structure Standards and Practice Fire Risk Assessment Liaison with the Fire & Rescue Service Fire Alarm Activation Unwanted Fire Signals Fire Training Fire Alarm Systems Fire suppression Systems Fire Safety Signage Fire Compartmentation Evacuation Premises Information Boxes Arson Fire Drills & Exercises Page 2 of 55

5 6.14. Franchise Operations Contractor Sites Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Equality and Diversity Equality Impact Assessment Appendix 1. Governance Information Appendix 2. Initial Equality Impact Assessment Form Appendix 3.Fire Safety Management Structure Appendix 4. Fire Safety Committee Reporting Structure Appendix 5. Fire Warden Action Card Appendix 6. Fire Response Team Fire Officer/Fire Co-Ordinator Appendix 7. Fire Response Team Assembly Point Officer Appendix 8. Fire Response Team Switchboard Operator Appendix 9. Fire Response Team Security Officers & Porters Appendix 10. Fire Response Team Estates Engineer Appendix 11. Fire Response Team Staff at Muster Point Appendix 12. Local Induction Fire Safety Appendix 13. Pre-Agreed Messages for Fire Control Appendix 14. Fire Safety Training Matrix Appendix 15. Fire Risk Action Prioritisation Appendix 16. Fire Compartmentation Appendix 17. Instructions in Case of Fire Page 3 of 55

6 1. Introduction 1.1. The aim of this Policy is to highlight the steps that the Royal Cornwall Hospitals NHS Trust is taking to ensure, staff, patients, visitors contractors and members of the public are protected from fire whilst on Trust premises Fire is a potential hazard in any premises. The consequence of fire in some premises could be particularly serious because many of our patients are highly dependent and maybe unable to act for themselves in the event of a fire The aim at all times is to ensure that outbreaks of fire do not occur. If fire should occur, it must be detected rapidly, contained effectively and if possible, extinguished quickly and the area evacuated ALL STAFF, WITHOUT EXCEPTION, including agency and bank staff, contractors and visitors in the Trust have a legal obligation to observe the site Fire Precautions at all times. It is imperative that they understand what to do in the event of fire, to ensure the safety of their patients, visitors their colleagues and themselves Effective staff training is vitally important and our policy is to ensure that every person working within Trust premises receives the statutory basic instruction in fire precautions. This training will include understanding the effects of fire, the fire hazards involved in the working environment and the action to be taken if a fire breaks out This policy meets or exceeds the requirements of the following legislation and guidance:- Firecode HTM and related HTM s The Regulatory Reform (Fire Safety) Order 2005 Health and Safety at Work etc. Act 1974 Fire and Rescue Services Act This document underlines the duty of every employee and those working within its premises to observe the Fire Safety Policy and the Fire Procedures applicable to the Trust; and should be read in conjunction with other Trust policies and procedures that are relevant to fire safety, e.g: Health and Safety Policy Policy for Management of Contractors Site Rules Disability Equality Scheme Major Incident Plan Waste Management Policy Security Policy Smoking Policy Medical Gases Policy 1.8. This version supersedes any previous versions of this document. Page 4 of 55

7 2. Purpose of this Policy/Procedure 2.1. The guidance contained within the Trust s Fire Policy aims to ensure that the premises it owns, or occupies to provide healthcare are constructed, equipped, maintained and operated in a manner which ensures the safety of patients, visitors and staff and which protects the premises from fire Knowing how to respond in the event of fire or suspected fire is regarded as a basic duty of all staff employed either directly by the Trust and anyone else working within its premises e.g. staff employed by other healthcare organisations, contractors etc. This Policy is designed to provide a basic knowledge of the fire actions and procedures applicable to the Trust. 3. Scope 3.1. This policy is applicable to all Trust staff members and shall be made available to contractors as part of on-going consultation and communication with them during the delivery or services to the Trust. 4. Definitions/Glossary The Trust The Royal Cornwall Hospitals NHS Trust. Trust sites Arson Hazard Harm Risk FRA All areas, sites, buildings or premises owned, occupied or controlled by the Trust. Deliberate act of setting a fire with malicious intent. Any process, activity or physical aspect, with the potential to cause or contribute to fire and the spread of fire, smoke, etc. Including damage to property, injury to persons (staff, patients, visitors, contractors etc.) and damage to the finances or reputation of the Trust. The likelihood of the harm posed by the hazard being realised. Fire Risk Assessment Control Measure Fire Alarm System The steps taken to minimise the risks associated with the area, activity or process being undertaken. Fixed and portable hardware and software designed to detect components of fire, provide facility to raise an alarm in the event of a fire and equipment for raising alarms and notifying relevant staff of the location of any fire alarm activation. Fire Fighting Equipment Portable and fixed equipment designed to extinguish or reduce a fire. Datix The Trusts electronic incident and risk assessment tool accessed via the Trust intranet site. Page 5 of 55

8 Staff Contractors Fire Service UwFS PEEP CFRS HTM All persons who are employed by the Trust whether on permanent or temporary contracts (Written or implied), paid or unpaid, and shall include persons employed through recruitment and employment agency providers to assist the Trust in delivery of services, but excluding contractors and third parties undertaking works for or on behalf of the Trust. Any person employed by or working for a third party organisation working for or acting on behalf of the Trust. The body with statutory responsibility for fire fighting and enforcement of fire safety legislation. Unwanted Fire Signals false and unwanted activations of the fire alarm system. Personal Emergency Evacuation Plan Cornwall Fire & Rescue Service Health Technical Memorandum 5. Ownership and Responsibilities 5.1. Chief Executive Officer The Trust s Chief Executive is accountable for the overall compliance with statutory duties and obligations in relation to all fire safety legislation. Responsibility for day-to-day and functional implementation of these duties is delegated through the organisational management structure The Chief Executive will appoint key personnel to undertake specific roles identified in the Department of Health Fire Safety Policy (HTM ). The roles responsible for undertaking these nominated positions are detailed in Appendix 3.Fire Safety Management Structure The Chief Executive will also ensure that sufficient resources are provided within the Trust to ensure compliance with the requirements of statutory legislation, this document and current best practice guidance The Chief Executive Officer will authorise this document by signature to meet the requirements of the HTM Director of Fire Safety (Board Level) Appointed by the Chief Executive, the Director responsible for Fire Safety shall: Take formal responsibility for the overall management of fire risk and fire safety matters Liaise with the Trust Board in matters relating to Fire Safety Ensure that the Trust has in place a clearly defined fire safety policy and relevant supporting procedures Fully support the Fire Safety Manager function Undertake appropriate training to allow the fulfilment of the role. Page 6 of 55

9 5.3. Fire Safety Manager Appointed by the Chief Executive, the Fire Safety Manager is responsible for the day to day activities. This role by one person, and is accountable for fire safety matters directly through the Board level Director Staff undertaking the role of the Fire Safety Manager shall be sufficiently empowered and have access to adequate resources to enable them to perform their duties effectively Ensure Co-operation between organisations where more than one organisation, within or without, the health community share any premises or part there of The operational management of fire safety risks identified by the risk assessments Undertake appropriate training to allow the fulfilment of the role Authorising Engineer Fire An Authorising Engineer (Fire) will be commissioned by the Fire Safety Manager to provide specialist fire safety support as deemed appropriate Where it is deemed necessary to commission an Authorising Engineer (Fire) for a specific task, the Trust will ensure that, the appointed Authorising Engineer (Fire) is a member of the Institution of Fire Engineers or the Association of Fire Consultants or that these specialist organisations are contacted for further guidance and/or information The Authorising Engineer (Fire) will be required to demonstrate competence in their particular field of expertise Fire Safety Advisor (FSA) The Trust has an appointed FSA in compliance with HTM Managing Fire Safety in Healthcare The duties and responsibilities of the FSA are as follows: Raising awareness of all fire safety features and their purpose throughout the Trust Compliance with legislation in relation to fire safety Reporting of noncompliance with legislation, policies and procedures to the Fire Safety Manager Ensuring that requirements related to fire procedures for lessable staff, patients and visitors are in place The development, implementation and review of the Trust s Fire Safety Policy and Procedures Developing and implementing the Trust s Fire Safety Strategy Developing and delivering of an effective fire safety training programme The reporting of fire incidents in accordance with Trust s policy and external requirements Monitoring and reporting of unwanted fire signals. Page 7 of 55

10 Liaison with external enforcing authorities Liaison with Trust Managers Liaison with the Authorising Engineer (Fire) Monitoring the inspection and maintenance of fire safety systems to ensure it is carried out Undertaking, recording and reporting of Fire Audits and Fire Risk Assessments Providing expert advice on fire legislation Providing expert technical advice on the application and interpretation of fire safety guidance, including HTM s BS & EN Standards Providing a link to the Risk and Governance Committees via the Trust Health and Safety Committee Ensuring an appropriate level of management is always available by the establishment of fire response teams for Trust sites or premises Fires involving death or injury will also be reported to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 in accordance with the Trust Incident Reporting Policy To network with professional associations, including but not restricted to:- Page 8 of 55 NAHFO (National Association Healthcare Fire Officers) FPA (Fire Prevention Association) IFE (Institution of Fire Engineers) Maintain CPD (Continual Professional Development) status for the relevant organisations To regularly review and update the Trust Fire and Arson Policy as necessary and ensure local procedures reflect these changes Competent Person Competent persons will be appointed to provide advice, information and expertise around various aspects of fire safety management. This will primarily involve two groups of personnel: Fire Safety Advisors will provide information and advice around the operational requirements of fire safety, undertaking risk assessments, monitoring and evaluating training, fire drills, and exercises as well as advising during the planning and build and refurbishment of the estate Other specialist engineers will maintain fire detection and alarm systems, physical aspects of the estate maintenance and infrastructure required to maintain fire safety standards, including, but not restricted to: Fire alarm and detection systems Portable fire fighting equipment Fire suppression systems

11 Fire dampers Fire fighting hydrants and water supplies Emergency lighting Fire shutters and screens Fire compartmentation and doors All competent persons will maintain suitable levels of training and competence in their relevant fields through CPD or similar processes Director of Estates The Trust s Director of Estates will: Ensure that all fire safety issues are brought to the attention of the Chief Executive Develop programmes of work relating to fire safety for consideration as part of the annual business planning process Ensure a permit to work system is implemented for all penetrations and breaches of fire compartmentation and the appropriate controls are applied throughout and on completion of the works; including temporary fire stopping where works are suspended overnight, weekend periods etc Including the management of the fire related components of the capital programme and future allocation of funding Ensure through senior management and line management structures and full staff participation in fire training and fire evacuation drills are maintained Ensure that agreed programmes of investment in fire precautions are properly scoped in the Trust s Annual Capital Programme Head of Estate Operations The Trust s Head of Estate Operations will ensure that: Sufficient resources and priority of materials and labour are provided to address issues relating to fire safety Ensure that all passive and active fire safety measures and equipment are maintained and tested in accordance with the latest relevant legislation/standards, and that comprehensive records are kept Fire compartmentation is maintained at all times including the provision and maintenance of appropriate permit to work systems Priority is given to works identified as urgent through the Fire Risk Assessment process or other means identified by the Authorising Engineer, Fire Safety Advisor and/or competent persons Emergency lighting, fire dampers, shutters and all other fire safety related equipment is maintained and serviced in accordance with the manufacturers recommendations and best practice standards. Page 9 of 55

12 5.9. Head of Estate Development The Trust s Head of Estate Development will ensure that: All work which has implications on fire precautions in new and existing Trust buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory fire safety legislation (including current HTM s, British and EU standards) All proposals, for new buildings and alterations to existing buildings, are referred to the Fire Safety Manager before Building Control approval is sought Permits to work for all penetrations and breaches of fire compartmentation lines are issued and the appropriate controls are applied throughout and on completion of the works; including temporary fire stopping where works are suspended overnight, weekend periods etc The Trusts Fire Safety Officers will also check and sign off design drawings prior to approval and build Contractors are fully briefed on the requirements of this document and comply with contained herein Project teams include relevant and competent persons to provide advice, information and guidance on both statutory and best practice standards as well as practical application to attain best whole life value Project design and build/refurbishment processes appropriately identify and address fire safety standards, where appropriate improving standards to meet current requirements and best practice Fire Safety Officer The Trust s Fire Safety Officer will: Assist the Fire Safety Manager in providing technical expertise to the Trust Lead on the application and interpretation of fire legislation and fire safety guidance, including HTM s BS & EN Standards Lead on the policing of the Trust s Fire Safety Policy Ensure fire drills are carried out safely on Trust premises Carry out Fire Risk Assessments of all the Trust s premises, draw up action plans and ensure all action plans are completed To attend the Health, Safety Committee meetings and to ensure the Committee is regularly updated with changes in legislation. To update the Committee on training, fires and false alarms To advise the Trust in specialist areas i.e. Critical Care Teams etc Support the Learning and Development team in the preparation and monitoring of fire safety training Respond to fire alarm activations during working hours to act as Fire Co-ordinator To liaise as required with: Page 10 of 55

13 Managers and Staff on fire safety matters Estates staff and managers in relation to remedial and alterations to existing areas The Authorising Engineer (Fire) and other competent persons for Fire Safety. Estates Development team on matters involving new build, extensions, or any alterations to buildings or leased premises. Local Fire Authority /Fire and Rescue Service. Local Authority and third party (Accredited) Building Control advisors/officers Architects and design services. Specialist consultants and advisors Collate and monitor Fire Training Records. Fire Incident Reports Develop networks with fire professionals and associations, including but not restricted to; NAHFO National Association Healthcare Fire Officers FPA Fire Prevention Association IFE Institution of Fire Engineers Maintain CPD (Continual Professional Development) status for the relevant organisations Regularly review and update the Trust s Fire and Arson Policy as necessary and ensure local procedures reflect these changes Actively participate in training relevant to the role undertaken Fire Wardens Fire wardens will be appointed in each operational area. In clinical areas this will usually be the most senior member of staff on shift. In nonclinical areas the fire warden role should be undertaken by a member of staff who is generally located in the building or area during operational periods The Fire Warden will: Prepare for and initiate the immediate evacuation of any area in the event of a fire incident. Co-ordinate the immediate response from local staff on the activation of the fire alarm. Be responsible for ensuring all persons are accounted for/building is clear during an incident. (Non-inpatient areas). Liaise with the Fire Co-ordinator/Fire Officer on arrival at any incident. Page 11 of 55

14 Be trained to tackle fire with first aid fire fighting apparatus where appropriate. Support line managers on fire safety issues The actions for the fire warden are contained in the action card found at Appendix Fire Champions Fire Champions will be appointed in each area to facilitate and support the maintenance of high standards of fire safety Fire Champions shall: Act as the focal point on fire safety issues within the local staff group Support staff new to the area with orientation and emergency actions Monitor outstanding actions from inspections and Fire Risk Assessments Support the local managers in implementing fire safety controls Attend training relevant to their responsibilities Fire Response Team Upon the activation of the fire alarm the Fire Response Team will be notified and respond immediately The team will comprise of Fire Officer (during office hours, 08:00 17:00, Mon Fri) Fire Co-ordinator (at all other times), an Assembly Point Officer (usually a porter), two estates operatives (including at least one electrician) a second porter and two Security Officers. In addition each ward/area where the alarm is sounding intermittently will nominate one member of staff to attend the internal Fire Muster Point Detailed Action Cards for the Fire Response Team are contained in appendices 5 to Learning and Development Team The Learning and Development Team will facilitate all fire safety related training in accordance with the Training Matrix and will: Maintain records of Fire Safety Related Training Participate in Train the Trainer training as required Provide regular reports on training compliance to the Fire Safety and Health and Safety Committees in accordance with the Terms of Reference Provide training compliance data for divisional PAF (Performance Assurance Framework) reporting. Page 12 of 55

15 5.15. Role of the Managers Divisional General Managers, Matrons, Heads of Department, Ward Managers, etc. are responsible for: Monitoring fire safety within their respective workplaces and ensuring that contraventions of fire safety precautions do not take place Ensuring that the Trust s Fire Safety Policy and instructions are brought to the attention of staff through local induction and on-going staff briefings Ensuring that every member of their staff attends fire safety training as set out in the Trust training matrix Ensuring that all staff attend evacuation and fire drill training as detailed in the training matrix Ensuring that all new staff, on their first day in the Ward/Department. Are given basic familiarisation training within their workplace, to include information contained in Appendix 12 Local Induction Keeping a record of staff attendance at fire safety training and notifying the Learning and Development Team for inclusion in the electronic records Notifying the Fire Safety Manager and the Operational Estates Management Team of any proposals for change of use within their area Participating in local fire risk assessments and ensure that management actions are completed within the given time frame Ensuring staff at all levels understand the need to report all fire alarm actuations and fire incidents as per Trust policy on reporting of incidents Ensure that the Staff record is completed and returned denoting how this document has been brought to the attention of staff Ensure that sufficient Fire Wardens are identified and appointed for their specific areas of responsibility and released to participate in training as required Ensure that a Fire Champion is appointed and trained for each area of responsibility Role of Individual Staff All staff members are responsible for: Ensuring that they are familiar with this document and local fire procedures and arrangements Participate in fire safety training and fire evacuation exercises where applicable Report deficiencies in fire precautions to Line Managers and Fire Champions and record physical defects and deficiency via the Estates reporting system Report fire incidents, and unwanted fire alarm signals in accordance with Trust incident reporting procedures. Page 13 of 55

16 Ensure the promotion of fire safety at all times to help reduce the occurrence of fire and unwanted fire alarm signals Set a high standard of fire safety by personal example so that, members of the public, visitors and students when leaving Trust premises take with them an attitude of mind that accepts good fire safety practice as normal Fire Safety Management and Committee Structure Fire Safety will be monitored through the structure set out in Appendix The Trust Health and Safety Committee will receive quarterly reports providing a comprehensive overview of fire safety matters from the Fire Safety Committee The Fire Safety Committee will meet quarterly in accordance with the Terms of Reference to provide the review of all fire safety matters and provide a report to the Health & Safety Committee, Trust Management Committee (Governance) and the Trust Board The Fire Safety Management Group will be formed to review and monitor specific work when required, i.e. in the event of major works, outside of a planned project, are identified The external Authorising Engineer (Fire) will act as an independent professional adviser, monitoring the performance of fire safety management and provide an annual audit report to the Director of Fire Safety. 6. Standards and Practice 6.1. Fire Risk Assessment All areas of the Trust will be subject to a Fire Risk Assessment, undertaken by a member of the Fire Safety Team at intervals not exceeding 12 Months The risk assessment process will identify actions that fall into two primary categories: Physical actions Defects and deficiencies relating to the physical structure of the environment, escalated to Estates as part of the assessment process with a priority action level Management Actions Defects and deficiencies noted or observed that relate to the management of the area, such as housekeeping, storage or training. Such actions will be the responsibility of the local manager to address All actions will be prioritised in accordance with the table found at Appendix 15. Fire Risk Action Prioritisation Actions arising from the risk assessment process will be monitored and reported to the Fire Safety Committee with management actions outstanding also reported to the Divisional Performance Assurance Framework (PAF) Staff undertaking risk assessment will be provided with training and updates in accordance with Pre-Agreed Messages for Fire Control. Page 14 of 55

17 6.2. Liaison with the Fire & Rescue Service The Safety, Fire and Security Manager will act as the primary liaison contact with the Fire & Rescue Service Regular review meetings will be held with representatives of the Fire & Rescue Service to review progress Audit, inspection and investigation visit by the Fire & Rescue Service will be co-ordinated and accompanied by a member of the Safety, Fire & Security Management Team Fire Alarm Activation On the activation of the fire alarm key staff will undertake their designated duties in accordance with the Action Cards contained in appendices 5 to 11 of this document The Switchboard operator will contact the Fire & Rescue Service Control using the direct dial number to provide all known information and provide update information as available, including the pre agreed messages detailed in The Switchboard staff will not request that the Fire & Rescue Service stand down to any incident they are attending at the Trust, even if requested by the Fire Control Room Operator. If appropriate, the Switchboard Operator may transfer the call to Fire Control to the Fire Officer attending the incident for further clarification Unwanted Fire Signals The Trust recognises the disruption to patients, staff, operational arrangements, the Fire and Rescue Service and the wider community caused by unwanted fire signals and is committed to minimise such activations so far as is reasonably practicable It is recognised that a large and complex fire alarm system will, from time to time develop faults that may cause unwanted fire alarm activations In order to minimise UwFS the Trust will maintain the zero tolerance approach to areas where staff activity or in action has caused or contributed to the activation, for example the removal of toasters or the issue of 24 hours notice to quit to tenants of residential blocks Where it is likely that a manual call point may be mistaken for a door release or in a similar location that may result in the accidental activation transparent covers will be fitted to the call point. Similarly manual call points in locations that may be vulnerable to accidental damage will be mechanically protected If a particular manual call point location is identified as frequently being responsible for UwFS, then subject to a risk assessment it may be possible to change, relocate or remove the device In areas where a specific activity is carried out and attributed to the unwanted activation of automatic detection the area and activity will be assessed, if the activity cannot be changed or relocated it may be possible, subject to risk assessment, to replace, relocate or modify the local device. Page 15 of 55

18 The Trust will continue to investigate all fire alarm activations and establish robust and timely actions to prevent UwFS The attending Fire Officer/Co-ordinator will strive to identify the source of the activation swiftly and relay information to Fire Control, via the RCHT Switchboard, to facilitate an informed decision to stand down the Fire and Rescue Service attendance The Safety Fire & Security Management team will work with the Fire & Rescue Service to identify trends and agree management strategies to minimise disruption caused by UwFS Fire Training Fire Safety Awareness Training will be provided to all staff regardless of role or grade at induction and at regular intervals throughout their employment with the Trust Agency Staff will be provided with information, including fire safety information, in written format prior to arriving on site and be required to return an acknowledgement slip prior to commencing the first shift In addition to the Trust Induction, all staff will be provided with a local fire safety induction to local arrangements on their first day of duty in the work environment. Agency and other temporary staff will be given a short tour of the work environment with the fire safety procedures being explained at commencement of the first period of duty; where a temporary member of staff returns to a work area following a period of more than 3 months the fire and safety arrangements will be repeated Contractors will be provided with a copy of the Contractors Guide/Site Rules and are required to confirm receipt and understanding of the information. Major contractors employing sub-contractors will ensure that each person is inducted to both the Trust and contractors sites Role specific training will be provided for staff undertaking specific fire safety related roles within the organisation Fire Safety training is detailed in the Trust training matrix at 6.6. Fire Alarm Systems The Trust is committed to providing the maximum available protection to staff, patients, visitors and others, to this end the Trust will endeavour to achieve an L1 fire alarm system designed and maintained to BS 5839 Pt will be maintained throughout the Trust estate. Where appropriate the system will be upgraded existing to L1 requirements, prioritised on risk The fire alarm system shall provide an audible and/or, where appropriate, visual warning in accordance with the current requirements BS, EN and HTM standards. Where there is a variance between standards the highest reasonably practicable standard will be applied Where a location, space or void is identified without protection new or additional devices will be installed in accordance with the L1 standard and as prioritised by the level of risk posed Appendix 15. Fire Risk Action Prioritisation Maintenance will be carried out in accordance with the manufacturers recommendations and current best practice standards by competent engineers. Page 16 of 55

19 Service, test and maintenance records will be maintained and available for inspection by enforcement authorities and the Trust Safety, Fire and Security Management Team at all times Fire suppression Systems Automatic fire suppression systems will be installed and maintained in high risk locations, initially as identified within the requirements of the HTM guidance During the construction of new builds and major refurbishment of areas proper consideration will be given to the installation of suitable systems commensurate with the risk identified in accordance with the statutory requirements and best practice information available at the time All systems will be maintained, serviced and tested in accordance with the manufacturer s recommendations Service, test and maintenance records will be maintained and available for inspection by enforcement authorities and the Trust Safety, Fire and Security Management Team at all times Fire Safety Signage Fire related signage will be displayed prominently around all buildings to highlight safe egress routes, fire fighting equipment, fire alarm call points and other relevant information Signage will be produced to the current standards, Safety Signs and Signals Regulations 1997 and other relevant standards. Where there is a variance between standards the highest reasonably practicable standard will be applied Fire Compartmentation The Trust s strategy for the maintenance and management of fire compartmentation is contained in this document at Appendix 16. Fire Compartmentation Where it is necessary for any person (Trust employee or contractor) to breach any compartmentation barrier a permit to work must be requested from the Estates Department by the Project Manager/person commissioning the works. The permit will be issued subject to the submission of suitable Risk Assessments and Method Statements in accordance with the Trust s Management of Contractors Policy and the Site Rules Up to date drawings showing the current compartmentation lines will be provided to the Fire and Rescue Service with copies held in the Premises Information Boxes at the entrance to each of the main buildings Evacuation The primary aims of evacuation are: To remove patients, staff and others from immediate danger. To keep the distance of any movement as short as possible. To avoid routes which in the particular circumstances may need to be used by FireFighters fire fighters and others involved in fire fighting. Page 17 of 55

20 To remove patients to an area remote from the fire, a minimum of two sets of fire doors, and suitable for their comfort and continued treatment, possibly for some hours, and to take a roll-call The Trust s primary activities can be divided into three broad areas: In-patient, Non-patient/outpatient occupancies and treatment areas where immediate interruption of treatment may cause significant clinical complications and/or risk to life Upon the continuous sounding of the fire alarm the following evacuation responses will be implemented: In Patient Areas: The automatic and immediate evacuation of patients will not normally be required on the activation of the fire alarm in in-patient areas, except where there is an immediate danger to life. In these areas staff will respond by reassuring patients and visitors whilst making initial preparations should an evacuation be required Outpatient and administrative areas a full evacuation of all persons will be initiated High risk treatment areas (including but not restricted to: MRI, CT Scanning, LINAC treatment, Operating Theatres, Renal Treatment and chemotherapy): staff will respond by reassuring patients and visitors whilst making initial preparations should an evacuation be required but will not commence new treatment or procedures until the all clear has been received. Where an evacuation is required this will be undertaken with the clinical lead Where full or partial evacuation of any patient area is required this will follow a phased progressive, horizontal evacuation process as detailed in Appendix Aids to facilitate the safe evacuation will be provided in critical areas and staff trained in their use. All such equipment will be maintained and records kept. Damage, howsoever caused will be reported and steps taken to repair or replace the equipment as quickly as possible The manager of any area, where there is a person with a known disability that may impede their ability to evacuate the area in a timely manner, will advise the Fire Safety Advisor to arrange a Personal Emergency Evacuation Plan (PEEP). The plan will be developed with the individual and manager and reviewed on an annual basis. The manager is responsible for notifying, as soon as possible, any change to the individuals condition, working environment or the controls implemented to aid the evacuation Premises Information Boxes Premises information boxes are located inside the main entrance to the main buildings: Trelawny Wing Tower block Princess Alexandra Wing St Michaels Hospital West Cornwall Hospital Page 18 of 55

21 Cornwall Fire and Rescue Service have agreed to maintain the contents of the boxes with their information but will also request up to date plans of the sites and specific hazard details relevant to certain areas A unique RCHT key for the boxes will be held with the switchboard for each site. The Fire and Rescue Service are provided with sub master keys unique to each Fire Authority directly by the manufacturers Replacement keys may only be ordered directly from the manufacturer, Gerda, and the order must bear the authorised signature (currently Health and Safety Manager or DGM PF&E) Arson Introduction Arson is the malicious setting of fire. Home Office statistics for hospitals and other healthcare premises show 21% of fires attended by the Fire Service are recorded as having been started deliberately. Arson is preventable, if not in its entirety, then to a degree that will minimize its effects. Prior attention to the threat from arsonists will limit their ability to disrupt or close services, damage property and waste scarce resources Factors Providing Motivation for Arson Mental instability Economic or political activities Related criminal activities Arson by children/young persons Fraud Staff Evidence from attacks of arson on NHS premises shows that some arsonists are, or have been, members of staff Trust Responsibilities The Trust will ensure that management plan for combating arson is part of its overall strategy for dealing with fire safety issues The following topics should be included in local policies: Security arrangements for patients, visitors, members of the public and staff prior knowledge Fire containment and extinguishers General fire safety policies and procedures. If the arsonist/potential arsonist is a service user the responsibility for the management plan belongs to the Responsible Medical Officer If you suspect an arsonist, all employees have a duty to discuss the information with their manager and other service professionals working with the person, providing them with all relevant information The security of Trust premises with regard to Fire Safety and Arson Prevention should always take into account that an arsonist is assisted by one or more of the following: Site accessibility, often spanning 24 hours. The dispersed nature of the site. Many points of access and egress around the site. Page 19 of 55

22 The potential for unrestricted passage to other buildings on a number of levels, including service tunnels, plant rooms and underground walkways. The ever changing nature of hospitals population patients, visitors, staff. Poor housekeeping measures, poor management of waste collection, storage and disposal Security Arrangements Attention to security arrangements can make positive contribution to arson prevention Security can be improved by: Ensuring staff wear identity badges. Replacing worn/faded ID badges Encouraging staff to challenge unauthorised visitors. Identification of legitimate visitors and control of their access (particularly contractors and servicing personnel) After a fire incident where arson is suspected the police MUST be informed together with the Senior Manager responsible for the area or the oncall manager and the Trust Fire Advisor, a Datix incident form must be completed. Where possible the area must be isolated pending further investigation Senior managers for each area must ensure that these local arson guidelines are in place Fire Drills & Exercises Fire drills will be carried out in all areas of the Trust at least every six months in order that every member of staff participates in at least one fire drill per year, additional drills to ensure all members of staff participate including some out of hour s exercises Fire drills will be facilitated by fire safety team and a record maintained In in-patient areas a quarterly walk through drill will be undertaken with a discussion as to consider the local evacuation arrangements with all staff In non-clinical and out-patient areas the fire alarm will be activated without warning to staff and the duration to full evacuation and all persons being accounted for will be recorded In areas of high clinical risk a full evacuation drill will be arranged confidentially with the local manager at a time when staff are present but when no procedures are being undertaken Participants in all drills will be recorded and reported to the Learning and Development team for recording in the Trust training register From time to time staff monitoring or arranging the drill will add compounding factors such as the loss of a primary exit route, casualty or additional hazard Practical evacuation exercises will be facilitated whenever possible by the Safety Fire & Security Management Team. The timing of such exercises is Page 20 of 55

23 dependent on the availability of a vacant ward template. The Fire and Rescue Service will be invited to attend and/or participate in such exercises Joint emergency planning table top exercises will be planned in conjunction with the Fire and Rescue Service for personnel of both organisations to participate to test the procedures in place and to aid the understanding of each organisations actions and needs. Lessons learnt from these exercises will be utilised to amend training, policy and procedures Franchise Operations Certain parts of RCHT premises may be used for commercial purposes by a third party. e.g. W H Smith, Lloyds Pharmacy These premises will be subject to the same fire alarm procedures as the rest of the building within which they are situated. All staff will be expected to undertake mandatory RCHT fire safety training. Fire Risk Assessments must be carried out by the tenant and a copy provided to the Trust Fire Safety Advisors Contractor Sites All contractors on RCHT sites will have a site induction and be subject to site rules. In most circumstances, they will adopt the same procedures as visitors and will take instructions from Fire Response Team In situations where contractors are on site and located within a specific secured boundary for an extended period of time, the fire alarm procedure may be varied, subject to discussion, agreement and regular review with the Trust s Fire Safety Advisors Contractors will be permitted to have part of the fire alarm system isolated or provided with dust caps to minimise unwanted activations When undertaking hot works a permit to work is required and will include robust processes for the inspection of the work area prior to and following the works. In addition a fire watch must be maintained for 1 hour following the last aspect of hot works is completed Trust Fire Safety Advisors may attend any contractor site without notice, but subject to the site rules and regulations, to carry out an inspection of fire safety arrangements and observe the arrangements in process for building and/or maintaining the integrity of fire compartments. On the activation of the continuous fire alarm all contractor sites will be evacuated and a responsible member of the contractors staff posted at each entrance to the site to meet the attending Fire and Rescue Service Officer/Co-ordinator The Trust reserves the ability to levy a charge against contractors who cause or contribute to UwFS whilst working on site. Contractors may also be excluded from site and/or prohibited from future works for a given period. 7. Dissemination and Implementation 7.1. This document will be stored in the Trust online Document Library with free access to all staff and the general public The document will be distributed throughout the organisation the Health and Safety Committee with an all user message included within the One and All daily newsletter within 2 working days of publication. Page 21 of 55

24 7.3. Awareness of the document will also be raised through existing mandatory training sessions A full copy of the document will be provided to the Fire and Rescue Service for information. 8. Monitoring compliance and effectiveness 8.1. The Director of Estates is responsible for the implementation of this policy The Trust Health and Safety Committee will monitor the delivery of the implementation plan that supports the introduction of this Fire Safety Policy Copies of this policy will be made available via the Trusts Intranet. Copies of the Policy will be provided to Staff on request Additional monitoring will be via competence testing of fire safety training of Trust staff, reviewing the fire safety risks on the Trust and local risk registers. Regular fire safety management reports including details regarding staff attendance at fire safety training, the number and cause of unwanted fire alarm calls will be submitted to the Trust Health and Safety Committee and main points shared with the Quality, Risk and Safety Committee An Annual fire report regarding the management of fire safety across the organisation will be submitted to the Trust Board in April. Element to be i. Fire Safety Awareness Training monitored ii. Fire Warden Training iii. Implementation of this document iv. Attendance in fire drills Lead i. Learning and Development Team ii. Fire Safety Officers iii. Divisional General Managers iv. Divisional General Managers Tool i. Quarterly reports to the Health & Safety Committee ii. Fire Risk Assessment Process & quarterly report to Health & Safety Committee iii. Biannual Divisional Reports to Health and Safety Committee iv. Divisional reports to Health and Safety Committee and Learning & Development Training data Frequency i. Quarterly ii. Annual review quarterly report iii. Biannual report iv. Biannual divisional report and quarterly Learning & Development Report Reporting Health and Safety Committee, reporting to Governance Committee arrangements Acting on recommendations Health and Safety Committee will request action from Divisional Representatives; and escalate to Governance Committee as required. and Lead(s) Change in practice and lessons to be shared The document will be distributed via the Health and Safety Committee with request that it is raised at divisional board, governance and/or local meetings. The document will be stored on the document library for free access Page 22 of 55