NHS FORTH VALLEY. Fire Safety Policy

NHS FORTH VALLEY Fire Safety Policy Date of First Issue 30 / 03 /2011 Approved 14 / 08/ 2013 Current Issue Date 14 / 08/ 2013 Review Date 01 / 04 /2015 Version Version 1.2 EQIA Yes 30 / 03 / 2011 Author / Contact Risk Management Department Tel 01324 614325 Fv-uhb.fvsafetyandrisk@nhs.net Group Committee Final Approval NHS Forth Valley Health and Safety Committee This document can, on request, be made available in alternative formats Version 1.2 14 th August 2013 Page 1 of 23

NHS Forth Valley Consultation and Change Record Contributing Authors: Edward Hattie, Fire Safety Advisor Alan McGeachie, Fire Safety Advisor Peter Mackie, Head of Risk Management Consultation Process: Risk Management Team Health and Safety Committee Distribution: Risk Management intranet website Change Record Date Author Change Version 09/03/2011 Edward Hattie Content reviewed and agreed with staff side Version 1 18/2/13 Peter Mackie Due to management restructuring, content updated and agreed with Director of Strategic Projects and Facilities (DSPF) - Director Responsible for Fire (also Nominated Officer (Fire)) Version 1.1 17/05/2013 Alan McGeachie Update Policy content to reflect CEL 11 and Fire Safety Group ToR. Content reviewed Version 1.2 Version 1.2 14 th August 2013 Page 2 of 23

Table of Contents 1. The Policy Statement...4 2. Policy Objectives...5 3. Fire Safety Arrangements...6 Chief Executive Officer...6 Director of Strategic Projects and Facilities (DSPF) - Director Responsible For Fire...6 General Managers / Senior Departmental Managers Deputy Nominated Officer Fire...7 Site Fire Officer (Sfo)...7 Line Managers / Ward Managers / Others With Similar Departmental Management Responsibilities...8 All Other Staff...9 Fire Safety Advisors (Fsa s)...9 4. Supplementary Report...10 Fire Marshall / Fire Wardens...10 NHS Forth Valley Fire Safety Group...10 Appendix 1 - Fire Procedures...11 Appendix 2 - Fire Procedures for Persons with a Disability...12 Appendix 3 - Workplace Inspections...13 Appendix 4 - Working in the Community...14 Appendix 5 - Fire Safety Training...15 Appendix 6 - Keeping of Records...16 Appendix 7 - Management of Security Arrangements in Psychiatric and Secure Wards/... Units...18 Appendix 8 - Recording of Fire Incidents and Reduction of Unwanted Fire Signals...19 Appendix 9 - Fire Safety Group -Terms of Reference... 20 Appendix 10 - Fire Safety Organisation Flowchart...22 Version 1.2 14 th August 2013 Page 3 of 23

1. The Policy Statement NHS Forth Valley (NHS FV) is committed to establishing a fire safety culture in the workplace and places the safety of all its employees, patients and other persons who may be affected by fire, at the heart of the organisation. It shall make fire safety matters an integral part of any decision concerning the workplace environment, the equipment used in the workplace, the systems of work adopted by staff and the management arrangements of the organisation. They shall do this by ensuring that staff are appropriately trained on fire safety matters and are fully aware of the corporate fire safety objectives and arrangements for managing fire safety. Adequate resources shall be provided so that the objectives contained in this policy can be met. NHS FV will maintain this fire policy and the associated fire procedures, and shall regularly review them to ensure they remain appropriate to all the circumstances of the organisation. The standard of fire safety in NHS Forth Valley premises shall not in any case be less than that contained in the applicable fire safety legislation, associated compliance guidance standards and associated NHS Scotland Firecode guidance. However where a higher standard is justified as a consequence of risk assessment or other evaluation, then that standard shall be adopted. In particular, that: The conditions of The Fire (Scotland) Act 2005 as amended and the Fire Safety (Scotland) Regulations 2006, are complied with And the requirement to carry out, record and implement the findings of a fire risk assessment in the workplace, is met The mandatory conditions of Fire Safety Policy for NHS Scotland; CEL 11(2011) are met The Practical Fire Safety Guidance for Healthcare Premises (Scottish Government: Safer Scotland) and NHS Scotland Firecode are in each case used as the benchmark Fire Safety Standards to ensure statutory compliance and that appropriate standards of Fire Safety are met This will be subject to Fire Risk Assessment findings, and any resulting action plan to resolve the issues as a consequence of them. NHS Forth Valley recognises the need to routinely test and maintain fire safety installations in the workplace and shall do so in accordance with the relevant best practice guidance including manufacturer s maintenance and test instructions and/or schedules of test and relevant codes of practice. These arrangements shall include the testing and maintenance of fire alarms, fire extinguishers and emergency lighting systems and any other items that may impact on the provision of a safe working environment. Professor Fiona McKenzie Chief Executive NHS Forth Valley Version 1.2 14 th August 2013 Page 4 of 23

2. Policy Objectives 1. To ensure that a policy setting out the core functions for fire safety is available for NHS Forth Valley staff to follow and from this policy, procedures to be taken in the event of fire are established, implemented and periodically reviewed thereafter. 2. To ensure that all staff and other persons who work in NHS Forth Valley property are trained in what to do in the event of fire, that they are aware of the contents of the fire safety policy, the objectives and the procedures to adopt in the event of fire. 3. To ensure that management arrangements are established so that fire safety matters are appropriately addressed, and that a local fire plan detailing escape routes and fire safety equipment and installations, is displayed and kept up to date. 4. To ensure that adequate means of escape in case of fire are provided that will consider all persons who might attend NHS Forth Valley and when necessary will provide personal evacuation plans for those requiring them. 5. To ensure that Young Persons as defined as those not having attained the age of 18 years and are employed in NHS Forth Valley, will have their working arrangements assessed in accordance with the provisions of the Fire Safety (Scotland) Regulations 2006 part 2 ;(5), in regard to risks, and measures put in place to mitigate such risks 6. To ensure that sources of ignition are identified and eliminated if possible, or such controls put in place so that the risk is reduced to as low as reasonably practicable. In particular that the risk in regard to dangerous substances as detailed in the Fire Safety (Scotland) Regulations 2006; part 2;(6) are assessed and measures put in place to mitigate such risks 7. To ensure that all equipment used in NHSFV premises is procured, tested and maintained appropriately so that it presents the lowest possible potential for causing fire. 8. To ensure that premises for which NHS Forth Valley are responsible are provided with adequate means for giving warning in case of fire; and for providing adequate measures for automatic detection of fire in accordance with SHTM guidance and other relevant guidance. 9. To ensure that all NHS Forth Valley premises are provided with suitable and appropriate signs for indicating exit and escape routes from fire, means for ensuring that all fire safety measures will be available in event of fire and suitable and sufficient fire routine notices. 10. That the nationally agreed system of Fire Risk Assessment is adopted, that it adequately identifies fire related hazards and puts adequate procedures in place to identify and deal with fire safety failures identified in the fire risk assessment. 11. That all services provided within NHS Forth Valley take account of the diversified resources and roles of other agencies in partnership with NHS Forth Valley and incorporate them fully and encourage them in pursuing the objectives of the NHS Forth Valley Fire Policy. 12. That NHS Forth Valley is committed to reduce the number of fire events and unwanted fire signals in all areas for which it has a responsibility. Version 1.2 14 th August 2013 Page 5 of 23

3. Fire Safety Arrangements The arrangements for ensuring that fire safety is properly managed shall be as follows: Chief Executive Officer Has ultimate responsibility for fire safety and will ensure that fire safety is properly represented at board level. Shall ensure that sufficient financial resources are provided to address fire safety issues and failures and that appropriate steps are taken to do so, particularly with regard to any failures identified during the fire risk assessment process. Shall receive an annual report of fire safety performance from the Director of Strategic Projects and Facilities (DSPF), the Executive Director with responsibility for fire safety. Director of Strategic Projects and Facilities (DSPF) - Director Responsible for Fire (also Nominated Officer (Fire)) Shall keep the Chief Executive informed as to fire safety issues and reports of fire. Shall ensure the fire safety interests of patients, staff and other visitors to NHS Forth Valley Health premises are properly represented at board level. Nominated Officer Fire (NoF) Shall be responsible for overseeing the operational management of fire safety. Shall ensure that appropriate arrangements are in place to provide fire safety training for all staff, including bank staff volunteers etc. In addition, ensure that relevant specialist fire training is provided including provision of courses such as deputy nominated officer (fire), site fire officer, fire marshal/fire warden courses and any other role related fire training that might be required. Shall ensure that appropriate arrangements are in place to ensure that the testing and maintenance of all fire safety equipment is performed in accordance with best practice and associated guidance e.g. PAT testing, electrical systems, fire alarm systems, fire fighting equipment, emergency lighting etc. Shall receive Fire Safety concerns from staff and shall instigate action to remedy any fire safety failures whether as a result of a fire risk assessment or otherwise. Shall ensure that the Chief Executive is informed of any significant fire safety failures that require immediate attention because they incur a significant potential for harms to persons, or harm to the healthcare activities of NHS Forth Valley Health. Shall assume and undertake the general duties of Nominated Officer Fire as specified in the Fire Safety Policy for NHS Scotland; CEL 11(2011). Shall communicate and work in close liaison with any partnerships or stakeholders to ensure that they are all working towards the objectives, aims and arrangements as specified in the NHS Forth Valley Health Fire Policy. Shall instigate corrective action when any fire safety partnerships are failing to achieve the fire safety objectives and inform the Chief Executive of any significant failures in the fire safety arrangements with those partnerships. Version 1.2 14 th August 2013 Page 6 of 23

General Managers / Service Managers Deputy Nominated Officer Fire (DNoF) The Deputy Nominated Officer Fire shall ensure that departmental or other managers under their control, effectively manage fire safety matters in their respective services, departments or areas of control and that the fire safety arrangements are consistent with the NHS FV Fire Policy, the regulatory requirements of the Fire (Scotland) Act 2005 as amended and the Fire Safety (Scotland) Regulations 2006. In addition, they shall (as necessary) liaise with the Nominated Officer Fire (NOF) and the Fire Safety Advisor. They shall ensure that: Fire Risk Assessments have been carried out in the areas/departments in their control and that they are properly recorded, action plans provided and action taken as necessary and reviews carried out regularly. All staff under their control are trained on fire safety matters relevant to their place of work. That the fire safety measures in place for the service, department, ward, health centre or other place within NHS Forth Valley s jurisdiction are sufficient to ensure a safe place of work for the treatment of patients and other persons affected. Maintenance and routine testing on fire safety equipment and installations is conducted and that formal records are kept. They liaise closely with the fire safety advisor on all of the foregoing matters. They shall report significant fire safety issues to the Nominated Officer Fire i.e. the Director of Strategic Projects and Facilities (DSPF). Site Fire Officer (SFO) The NHS person appointed to administrate all fire related NHS activities on a particular site shall be known as the NHS Site Fire Officer (SFO). In all cases a deputy must also be nominated. They shall: Act as the liaison and point of contact for NHS Forth Valley in all matters relating to fire safety and ensure that a suitable deputy is trained and available to assume these duties in their absence. Be the local link with the Fire Service during fire safety incidents on their site. Work with all other stakeholders on the site to ensure policies and strategies for fire safety are implemented, are adequate and known to all staff. Ensure that a suitable Fire Risk assessment has been carried out in all areas within their site and that an action plan is put in place to deal with any faults Attend user group meetings to discuss and communicate all fire related matters Brief the Deputy Nominated Officer or Nominated Officer (Fire) on any deficiencies or areas of concern in relation to fire safety Ensure all staff receive adequate training, are familiar with the fire plans and test the fire evacuation strategy for the site as required, involving all other service providers or other relevant persons on that site. Version 1.2 14 th August 2013 Page 7 of 23

Line Managers / Ward Managers / Others with Similar Departmental Management Responsibilities Shall ensure the effective day- to -day management of fire safety within their respective departments, wards, health centres or area of responsibility and to that end: Shall ensure that any deficiencies, faults or failures relating to fire safety are reported for repair promptly, and that a record kept of the action carried out Shall be responsible for monitoring the fire safety training requirements of the staff under their control and shall make a request for training to the Fire Safety Advisor in good time. Shall ensure that new staff, including agency, temporary or part time and volunteers are included in the general training arrangements, and that they receive a local department, ward or area walk round induction at the commencement of their employment so that they are aware of the exits routes, door fastenings and other fire safety provisions relevant to their place of work. Shall ensure that all staff in their control are made aware of the fire safety procedures for their place of work and know what to do in the event of fire, and a record of this is kept on file. Shall ensure that all staff at the commencement of employment are enrolled in the corporate induction session with the appropriate provider. Shall ensure that a monthly walk round inspection is conducted in their departments, wards, health centres or areas of responsibility, and that the results as well as the action taken to remedy any failures the inspection has identified are recorded. Shall ensure that exit routes and doors are unobstructed and available for use at all times and that any security arrangements have been notified to the fire safety advisor and approved. Shall ensure that general storage arrangements are consistent with good fire safety working practices e.g. combustible materials are not allowed to accumulate and are stored safely in allocated storage spaces and away from public and escape routes That waste materials are not allowed to accumulate unreasonably in the workplace and are dealt with regularly in accordance with the corporate waste management policy. Shall if they suspect that any changes made, may have altered the fire safety arrangements for their department/ward/health centre or area of responsibility that they might be no longer satisfactory, then they will report the matter to the Fire Safety Advisor or their immediate line manager in order that the matter can be reviewed. Version 1.2 14 th August 2013 Page 8 of 23

All Other Staff The corporate fire safety objectives are the responsibility of all members of staff and other persons working in NHS Forth Valley Health Premises. It is a statutory duty to cooperate with the employer in pursuit of the fire arrangements in place. They shall in particular: Ensure all exit routes and fire escape exits and routes are kept free from obstructions 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 they are familiar with all fire instructions and fire safety arrangements for all areas in which they may work. Ensure that they comply and manage effectively the NHS Forth Valley No Smoking policy Ensure that they know how to use the fire extinguishers for their area Ensure that they know the findings of the current Fire Risk Assessment for their area and any related action plans Ensure they comply with the Fire Safety Advisors instructions in relation to fire safety and actively assist them to ensure the highest level of fire safety is maintained. Fire Safety Advisors (FSA s) The Fire Safety Advisors shall be competent to carry out this function and are responsible for carrying out risk assessments, (unless other arrangements are made for their completion) and shall provide recommendations and action plans based on those risk assessment findings. The FSA s shall provide fire safety training for staff, unless other arrangements are made to do so, and shall maintain comprehensive records of the fire safety training activity of the organisation. In addition, locally, the line manager or other supervisor in the Department, Ward or Health Centre shall keep a record of the training of each staff member. They will in particular recognise the training needs of persons working in their areas who have not attained the age of 18 years. The FSA s shall maintain a close liaison with the Nominated Officer (Fire) and keep them informed of the fire safety activities in the organisation, and shall provide advice and guidance on request of any fire safety matters. The FSA s shall ensure that adequate means of escape from fire are provided across NHS FV and that arrangements are in place to ensure they are kept clear and free from obstruction and accumulations of combustible materials and waste. The FSA s shall liaise with the local Fire and Rescue Services and act on any communications received from them as well facilitating close cooperation between them and NHS Forth Valley. They shall assume and undertake the general duties of Fire Safety Advisor as listed in the Fire Safety Policy for NHS Scotland; CEL 11 (2011) Version 1.2 14 th August 2013 Page 9 of 23

4. Supplementary Report The foregoing arrangements for fire safety will be supplemented by other delegated and supporting arrangements as follows; Fire Marshal / Fire Wardens Fire Marshals and Fire Wardens will be provided with additional training over and above the general Fire Awareness training. This training is at a more specialised level and will relate specifically to checking and sweeping of fire incident areas and evacuation techniques, management and control. They will: Organise and assist in the fire prevention regime within their working area Co-ordinate an evacuation procedure within the immediate vicinity of the fire in the event of a major incident Be trained to tackle fire by portable fire fighting media Support the line managers in fire drills and testing NHS Forth Valley Fire Safety Group Report directly to the NHS FV Health and Safety Committee Receive reports from the Management Units or Departmental sub groups for fire safety The Group shall adopt a positive supporting role in the promotion and pursuit of fire safety objectives. Provide a high level of technical and professional knowledge to the fire safety issues of NHS FV Identify any shortcomings in the NHS FV arrangements for fire safety and where practical, produce an action plan with potential resolutions to identified shortcomings. Represent the interest of employees and provide a forum through which they may express any significant issues they feel should be addressed in regard to fire safety in the workplace. Fire Safety Group - Terms of Reference See Appendix 9 Version 1.2 14 th August 2013 Page 10 of 23

Appendix 1 Fire Procedures The Fire Safety procedures for all NHS Forth Valley premises will include: The method for raising the Fire Alarm The method for summoning the Fire and Rescue Service The action taken on hearing the Fire Alarm The procedure for dealing with an outbreak of Fire. These principles contained within the document are an integral part of the NHSFV Fire Safety Policy and as such will be documented within a Fire Strategy Plan. Each area/building will have its own specific Fire Strategy Folder which will be available as a reference document to all duty holders and will reflect the particular circumstances of the place or location it is intended to cover. Not all the Fire Safety principles may be applicable to all workplaces e.g. progressive horizontal evacuation applies only to those areas where patient care is provided therefore wards/departments/health centres or other areas must make themselves aware of the content of their own Fire Safety Strategy. Version 1.2 14 th August 2013 Page 11 of 23

Appendix 2 Fire Procedures for Persons with a Disability Disabled persons in any premises controlled by NHS Forth Valley must not under any circumstances be placed in greater danger from fire simply by virtue of their disability. Disability in this context means: Any person who has a degree of mobility impairment, for example, they can walk only with the assistance: they have to use a walking aid: they are slow and unsteady on their feet due to age or infirmity: they use a wheelchair. Any person whose ability to hear, interpret and/or respond to a Fire Alarm signal however provided, is limited due to sight, hearing, mental incapacity, cognigative or any other impairment. The evacuation of disabled persons from NHS Forth Valley premises shall be based on the principles and guidance contained in the national guidance document titled `Practical Fire Safety The Evacuation of Disabled Persons from Buildings. This document may be accessed at http://www.infoscotland.com/firelaw Due to the nature of the healthcare environment it would be impossible to provide a Personal Emergency Evacuation Plan ( PEEP ) for every person who comes through our doors. Patients who become non ambulant due to the treatments they receive or the illness or condition they have will be covered by NHSFV s General Fire Safety Strategy. Visitors will also be included in this strategy and will be required to follow the guidance of NHS staff or their partners staff guidance in the event of a fire alert. All NHS staff or third parties employed by NHSFV who have some form of disability or impairment that may affect their ability to follow the instructions given during a Fire Alert will be provided with a local PEEP. The creation, enforcement and ongoing update of the PEEP will be the responsibility of Line Managers of relevant staff. These evacuation plans will be reviewed periodically by the Fire Safety Advisors. Version 1.2 14 th August 2013 Page 12 of 23

Appendix 3 Workplace Inspections It is recognised by NHS Forth Valley that Fire is an inherent risk. All passive and active measures to prevent a fire or at least limit its effects can help to reduce the chance of any fire causing death or injury to any member of staff, patients, visitors or others including attending fire crews and other emergency personnel. The measures NHSFV put in place must be maintained and checked in accordance with all relevant guidance codes and procedures as set down in NHS Forth Valley Fire Policy. As part of NHS Forth Valley Policy any partnership with other service providers, agreements with external agencies to manage buildings, facilities, or systems must ensure that all monitoring, maintenance and testing programmes are of the same or a higher standard as outlined in the NHSFV Fire Policy A system of fault rectification must be in place and a system of monitoring its effectiveness must be part of the agreement. Legal and moral obligations and responsibilities of all stakeholders must be understood and a record of this duly recorded. Department Heads/ Ward Managers must ensure that: They have in place a system and guidance note for reporting any faults and that staff are familiar with this process. In areas with a Fire Panel a daily check confirms that the power supply to the Fire Panel indicates healthy and no fault lights are displayed.? A monthly fire check list is completed and any faults reported. Note: where any highly dangerous faults are suspected these must be reported immediately to the person in charge for prompt action. Patient evacuation lists are up to date recording patient numbers, specific needs and locations. Sufficient staff levels and trained persons are in place to cover evacuation needs. All fire incidents and near misses are recorded through the IR1 system. Staff records show that all staff have participated in a Fire Drill in the preceding 12 months. There is a record to show that all staff have received Fire Safety Induction and Fire Awareness training.(dept. specific & e-learning) There is a current Fire Risk Assessment in place for the area. P eriodic review of the Fire Risk Assessment is carried out. Version 1.2 14 th August 2013 Page 13 of 23

Appendix 4 Working in the Community The model for health care in the community can be complex and NHS Forth Valley recognises that multi functional premises within a community setting may involve other partner agencies occupying or sharing the same accommodation or premises. Irrespective of who owns the premises, all parties involved have a legal obligation to work together to ensure a suitable and effective Fire Safety Management System is in place. NHS Forth Valley shall ensure that the management of Fire Safety in premises with different occupiers whether leased, owned or part of a public private partnership or other arrangement, have a Fire Safety Plan in place. NHS FV will also ensure that persons are appointed to liaise and coordinate with all other building users to cooperate, communicate and formulate Fire Safety policies and evacuation management procedures in line with this policy and compliance with other fire safety statutes and associated guidance. Version 1.2 14 th August 2013 Page 14 of 23

Appendix 5 Fire Safety Training Fire Safety Training for employees is a statutory requirement. NHS Forth Valley shall make provision to ensure adequate Fire Safety Training is provided in accordance with its legal responsibilities and ensure that the guidance in SHTM 83 is followed when formulating the type and frequency of Fire Safety Training. NHS FV s Training Policy is that: Training in all aspects of Fire Safety is provided for all staff and managers irrespective of their role. All Fire Training will be consistent with NHS Forth Valley policies and procedures All training is properly monitored and audited Resources shall be made available to ensure training needs are met Periodic analysis of training needs are conducted Attainment of training targets are subject to periodic reports to the Chief Executive All staff, whether part time, agency or volunteers must receive Fire Safety Awareness training All new staff will receive specific Fire Safety Training relative to their place of work. NHS FV FIRE SAFETY TRAINING COURSES AVAILABLE Topic Frequency Induction Mandatory Refresher Training Nominated / Deputy Nominated Officer Fire Training Site Fire Officer training Fire Marshall / Fire Warden Training Specialist Fire Door Training (Estates staff only) Evacuation Techniques Specialty Fire Safety Training On commencement of employment in NHS FV Every 2 years Initially on designation then refreshed every 3 years Initially on designation then refreshed every 3 years Initially on designation then refreshed every 2 years One off training, updated if changes in technology or legislation One off training, refreshed during Annual Evacuation Drills One off training, refreshed during Annual Evacuation Drills Version 1.2 14 th August 2013 Page 15 of 23

Appendix 6 Keeping of Records As part of any Fire Safety Management System it is essential that all fire safety equipment and systems both passive and active are maintained and tested in accordance with the appropriate guidance standards. NHS Forth Valley shall ensure that all Safety Management Systems relating to these services will have records to satisfy any authorised inspector. This will include: Fire alarm and detection systems, fire suppression and sprinkler systems, fire fighting equipment and systems, fire hydrants, fire risers. foam inlets, fusible links, emergency lighting systems and generators. Passive Fire Safety precautions: Fire doors, fire dampers, fire shutters, door opening and closing devices, smoke control systems, fire curtains, communications links and back up call arrangements. Fire Safety Training will be recorded in accordance with the schedules and details to include: Type of instruction/drill/exercise, name of attendees, location and duration of training, person delivering training. Note: The above lists are not exhaustive. It is the Line Manager s responsibility to ensure the following is carried out, and ensure that proper records are kept of the following: On induction all staff must receive familiarisation of their workplace to highlight: Means of Escape from the building Location of the Break Glass Call Points The method of raising Fire Alarm and the Fire Alarm sound tones The types and location of Fire Fighting equipment Any particular dangers or hazards in their working environment, e.g. electrical chemicals, gas, etc. The Evacuation Strategy and the patient evacuation procedure Department Supervisors shall ensure: All new staff whether part time, agency, volunteers or peripatetic staff receive induction training which includes the Fire Evacuation Strategy and a familiarisation of the facilities. Records are kept and signed by persons receiving and giving instruction. All staff attend annual Fire Awareness Training and records kept. Version 1.2 14 th August 2013 Page 16 of 23

Any young person (persons not having attained 18 years) receives Fire Safety Instruction with any particular training needs recorded. Any staff requiring Specialist Fire Training attend the relevant courses Staff receive refresher training at the period stipulated in the organisations training manual. Records are available for Fire Incidents, Fire Risk Assessments, Fire Risk Action Plans, Reviews and action plans to correct faults found during Fire Risk Assessment inspections, Evidence that staff have been briefed on findings of Fire Risk Assessment. Daily Ward Managers shall on daily basis: Ensure where applicable, that the patient evacuation list is updated on the commencement of the shift and that all evacuation aids are in place. Ensure any Fire Panel located in their area is functioning and the power supply indicates healthy (green light) and that there are no fault lights (amber light) Relevant contact numbers are available to report faults. Monthly Ward/Department Managers shall: Complete a Monthly Fire Risk Assessment Check and submit it to their supervisors Record any significant risks highlighted during this audit and indicate these to staff Report any defects to the appropriate department for rectification Seek advice from the Fire Advisors if required Quarterly Deputy Nominated Officer Fire (DNOF) shall: Carry out Fire Safety & Fire Awareness audits of their workplaces Report any defects or problems to the Estates or Facilities Department and the Fire Safety Advisor Seek advice from the Fire Safety Advisor or Estates Department as required Annually Nominated Officers Fire (NOF) shall: Ensure each member of staff has attended or completed the relevant Fire Safety Instruction at least once during that year The instruction highlights and reinforces the action to be taken on the discovery of fire That the method of raising the Fire Alarm and confirming the Fire Alert is known by all staff Version 1.2 14 th August 2013 Page 17 of 23

That the evacuation of all patients and visitors to a predetermined assembly pointor location has been practiced That the roll call procedure has been established (where applicable) Appendix 7 Management of Security Arrangements in Psychiatric and Secure Wards/ Units It is recognised that some clients accommodated in NHS Forth Valley premises will require additional security arrangements. Introducing any such arrangements must not delay any means of escape in the event of fire. Any security arrangements must be fully risk assessed and approved before being implemented. Department Managers will ensure that there will be sufficient staff available to implement any necessary special procedures. All staff should know these arrangements and managers must document their effectiveness following their implementation. Any special risks associated or relating to clients in secure units must be regularly assessed to ensure they are adequate. This should be confirmed during the Fire Safety Audit. Patients or clients that present a particular risk to staff, other patients, visitors and members of the public will be subject to a specific risk assessment. The interests of the patient must also be considered. All staff must report fire related incidents or near misses in order that a review of the particular circumstances can be undertaken and any necessary additional action implemented. Any secure locking arrangements must be capable of being overridden in a fire incident emergency without causing any delays. Non standard methods of securing doors and exits with padlocks or keys will not be introduced without a full and proper Fire Risk Assessment. Version 1.2 14 th August 2013 Page 18 of 23

Appendix 8 Recording of Fire Incidents and Reduction of Unwanted Fire Signals A key element of the NHS Forth Valley Fire Policy will be the intended reduction of fire incidents and Unwanted Fire Alarm Signals (UwFAS) - see guidance note SFPN 11. Reducing UFAS from within our premises will be a major target and measures will be put in place to ensure this target is achieved. The Incident Management System will be used to record these incidents with further investigation as necessary into the causes. Advice will be given on actions required to reduce the chances of a reoccurrence. Annual figures on the number and locations of such incidents and the effectiveness of interventions will be produced through the Risk Management quarterly and annual reports. The Director of Strategic Projects and Facilities (DSPF) and the Nominated Officer(s) Fire will receive regular reports on fire statistics and be made aware of any significant increases or worrying trends. Appropriate action plans aimed at removing or minimising these incidents will be produced All Department Managers shall: Ensure a record of all incidents are submitted and actions implemented The Fire Safety Advisor is informed Record incident as unknown if a reason cannot be ascertained Highlight any unacceptable rises in Fire Alarm activations Ensure arrangements are in place to call out engineers to re-set Fire Alarm Panel Ensure arrangements are put in place in the event of a Fire Alarm failure Points to Note: Unwanted Fire Signals are often due to: Large number of detector heads (a ratio of UwFAS that might be acceptable is given in the appropriate standard referred to in SFPN 11 Wrong type of detector for risk area Malicious activation of Break Glass Call Points (security covers can limit these) Unauthorised Smoking Aerosols or Sprays, Toasters, Cooking, Showers (steam) etc. Recurring Fire Panel faults Dusty atmospheres due to contractor activity Old or faulty detector heads Electromagnetic interference/thrips Version 1.2 14 th August 2013 Page 19 of 23

Appendix 9 - Fire Safety Group Terms of Reference Purpose The purpose of the Fire Safety Group (FSG) is to help ensure that NHS Forth Valley (NHSFV) meets the statutory obligations of the Fire (Scotland) Act 2005 and the Fire Safety (Scotland) Regulations 2006 and that the conditions of the Fire Safety Policy within NHS Forth Valley Board Area are met. The Fire Safety Group (FSG) has been formed to create a platform for the stakeholders of NHS Forth Valley to discuss all aspects of Fire Safety. It plays a key role in helping NHS Forth Valley adopt a consistent and effective approach to the ownership of Fire Safety at both strategic and operational levels. The FSG will play a key part in the implementation of new developments and publication of local operational policy, standards, strategy and technical guidance for NHS Forth Valley. The FSG is responsible for the management of all aspects of professional and technical fire advice, fire engineering, and fire training and will also provides advice to all of NHS Forth Valley departments and staff. Terms of Reference The FSG shall meet bi-monthly prior to the H&S Committee meeting. The agenda for the meetings of the Group will cover the agreed core areas: Update and Summary on Fire Risk Assessments Update and Summary on incidents recorded for premises Unwanted Fire Signals New Project development update Fire Strategy documentation update Site specific Fire Emergency Procedures Evacuation Procedures and Fire Drills Fire Training Updates Matters relating to Scottish Fire & Rescue Service site activity Fire & Rescue Service audits and any enforcement actions Group members will be invited to submit agenda items AOCB will be at the discretion of the chair of the meeting. Action notes shall be taken of group meetings; these in turn shall be forwarded to the group membership. Remit of Group All Fire Safety matters meet the statutory obligations of The Fire (Scotland) Act 2005 and the Fire (Scotland) Regulations 2006 and all relevant NHS SHTM documents and CEL 11/2011 Version 1.2 14 th August 2013 Page 20 of 23

To develop the working procedures for Fire Safety within NHS Forth Valley Board Area Agree a strategy for the long term management of Fire Safety matters Formulate a process for communication and storage of information with key stakeholders Monitor action taken on Fire Risk Assessments, Maintenance and Fire Incident investigation findings Agree timescales for actions and meetings The Fire Safety Group (FSG) will report to the Health & Safety Committee Escalate any issues that cannot be resolved to the Health and Safety Committee Measure and report Fire Safety performance as required The FSG will discuss and resolve strategic Fire Safety issues that are relevant to all NHS Forth Valley premises or any other premises shared with other employers to deliver healthcare related services. The FSG will promote Fire Safety awareness throughout the organisation by supporting local NHS Forth Valley Fire Safety Groups The FSG will provide a vehicle for discussion on issues relating to Fire Safety and be a support network for colleagues to facilitate problem solving and the sharing of good practice The FSG will advise on operational policy in the field of Fire Safety The FSG will provide tools to facilitate a consistent good practice approach to the management of Fire Safety The FSG will act as a reference group on published guidance The FSG will support the development and maintenance of links with other stakeholders, public and private sector organisations to pursue common agendas on Fire Safety The FSG will provide technical support and advice on Fire Safety matters to other NHS professionals. FSAG Membership Composition Representatives from all service areas within NHS Forth Valley will be invited to become members of the FSG to include: Director of Strategic Projects and Property General Managers representing individual Units and CHP Head of Risk Management NHS Forth Valley Fire Safety Advisors Head of NHS Forth Valley Estates NHS Forth Valley Stakeholders (when applicable) Representative from Corporate Services Staff side representative Version 1.2 14 th August 2013 Page 21 of 23

Appendix 10 Fire Safety Organisational Flowchart 1 Fire Safety Advisors CHIEF EXECUTIVE OFFICER (CEO) DIRECTOR OF STRATEGIC PROJECTS AND FACILITIES (DSPF) NHS FV Board 3 2 Fire Marshall s Fire Wardens NOMINATED OFFICER FIRE (NOF) DEPUTY NOMINATED OFFICER FIRE (DNOF) General Managers SITE FIRE OFFICER (SFO) Service Managers or WARD /MANAGER H&S Committee Fire Safety Group 5 4 ALL STAFF Structure 1. Fire Safety Advisors support, assist and advise at every level of the organisation 2. Fire Marshalls and Wardens support all staff, Wards/Departments/Health Centres and Site Fire Officers locally 3. CEO and DSPF report directly to the Board 4. Fire Safety Group supports all operational levels and reports to the H&S Committee 5. H&S Committee reports via Staff Governance to the Board Version 1.2 14 th August 2013 Page 22 of 23

Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net Version 1.2 14 th August 2013 Page 23 of 23