Fire Safety

Policy

Version: 1

Status: Final

Title of originator/author: Health, Safety and Security Manager

Name of responsible director: Executive Director of Nursing

Developed/revised by group/committee and Date:

Health and Safety Group 17 June 2014

Approved by group/committee and Date:

Health and Safety Group 17 June 2014

Effective date of issue: (1 month after approval date)

01 August 2014

Next annual review date: 01 June 2017

Date Equality Impact Assessment Completed

10 June 2013

Regulatory Requirement: Regulatory Reform (Fire Safety) Order 2005

Health and Safety at Work etc. Act 1974

Fire Safety Policy

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Trust Policy Foreword

South Western Ambulance Service NHS Foundation Trust (SWASFT) has a number of specific corporate responsibilities and obligations relating to patient safety and staff wellbeing. All Trust policies need to appropriately include these.

Health and Safety - SWASFT will, so far as is reasonably practicable, act in accordance with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and associated legislation and approved codes of practice. It will provide and maintain, so far as is reasonable, a working environment for employees which is safe, without risks to health, with adequate facilities and arrangements for health at work. SWASFT employees are expected to observe Trust policy and support the maintenance of a safe and healthy workplace. Risk Management - SWASFT will maintain good risk management arrangements by all managers and staff by encouraging the active identification of risks, and eliminating those risks or reducing them to the lowest level that is reasonably practicable through appropriate control mechanisms. This is to ensure harm, damage and potential losses are avoided or minimized, and the continuing provision of high quality services to patients, stakeholders, employees and the public. SWASFT employees are expected to support the identification of risk by reporting adverse incidents or near misses through the Trust web-based incident reporting system. Equality Act 2010 and the Public Sector Equality Duty - SWASFT will act in accordance with the Equality Act 2010, which bans unfair treatment and helps achieve equal opportunities in the workplace. The Equality Duty has three aims, requiring public bodies to have due regard to: eliminating unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act; advancing equality of opportunity between people who share a protected characteristic and people who do not share it; and fostering good relations between people who share a protected characteristic and people who do not share it. SWASFT employees are expected to observe Trust policy and the maintenance of a fair and equitable workplace. NHS Constitution - SWASFT will adhere to the principles within the NHS Constitution including: the rights to which patients, public and staff are entitled; the pledges which the NHS is committed to uphold; and the duties which public, patients and staff owe to one another to ensure the NHS operates fairly and effectively. SWASFT employees are expected to understand and uphold the duties set out in the Constitution. Code of Conduct and Conflict of Interest Policy - The Trust Code of Conduct for Staff and its Conflict of Interest and Anti-Bribery policies set out the expectations of the Trust in respect of staff behaviour. SWASFT employees are expected to observe the principles of the Code of Conduct and these policies by declaring any gifts received or potential conflicts of interest in a timely manner, and upholding the Trust zero-tolerance to bribery. Information Governance - SWASFT recognises that its records and information must managed, handled and protected in accordance with the requirements of the Data Protection Act 1998 and other legislation, not only to serve its business needs, but also to support the provision of highest quality patient care and ensure individual’s rights in respect of their personal data are observed. SWASFT employees are expected to respect their contact with personal or sensitive information and protect it in line with Trust policy.

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CONTENTS

1 PURPOSE ....................................................................................................................... 4

2 SCOPE ............................................................................................................................ 4

3 DEFINITIONS .................................................................................................................. 4

4 DUTIES, RESPONSIBILITIES AND REPORTING ......................................................... 5

5 FIRE SAFETY RISK ASSESSMENTS ............................................................................ 9

6 TRAINING REQUIREMENTS ......................................................................................... 9

7 MONITORING ................................................................................................................. 9

8 REFERENCES .............................................................................................................. 10

9 ASSOCIATED DOCUMENTS ....................................................................................... 10

APPENDIX A – PREVENT AND DETECTION OF FIRE ................................................... 11

APPENDIX B – VERSION CONTROL SHEET ................................................................. 21

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Fire Safety Flowchart

OLM/Line Managers to implement the Fire Safety Policy by ensuring the following is carried out by nominated persons at each station/premise:-

Local Induction of safety

arrangements for new staff

Annual Fire Risk Assessment

Completion of Fire Log Book

Ensure that all staff completes the e-learning

Completed form to be forwarded to:

Completed assessment to be forwarded to:

Health, Safety and Security Manager/Officers to ensure that the following is undertaken for all Trust

premises

Health Safety and Security Department to:

• Record and monitor actions identified from the Fire Risk Assessment

• Record and monitor the numbers of staff who complete the e-learning

Appropriate Department i.e.

Estates, to program and carry out any work identified

OLM or Appropriate Line Manager to ensure local

remedial actions are carried out and to program a review of

Fire Risk Assessment

Human Resources for

filing

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1 Purpose 1.1 South Western Ambulance Service NHS Trust (hereafter referred to as the Trust)

is committed in complying with the Regulatory Reform (Fire Safety) Order 2005 and the obligations the Trust has under the following supporting legislation:

● Health and Safety at Work Act 1974; ● Workplace (Health, Safety and Welfare) Regulations 1992; ● Equality Act 2010; ● The Health and Safety (Safety Signs and Signals) Regulations 1996; ● The Management of Health and Safety at Work Regulations 1999; ● Buildings Regulations 2000: Approved Document Part B, Fire Safety Vol 2; ● Dangerous Substances and Explosives Atmospheres Regulations 2002; ● NHS Firecode - Policy and Principles Document

1.2 The Trust recognises the consequences a fire can have, such as loss of life,

equipment, premises and vehicles not to mention the effect this may have on the service provided to the general public. Therefore, this policy aims to ensure that:- so far as reasonably practicable, fire does not occur in any property owned by the trust; where a fire does occur that it is detected, effectively contained (to allow for evacuation of personnel) and rapidly extinguished;

1.3 That a thorough investigation is carried out into the cause(s) of the fire and a

lessons learned approach is shared across the Trust.

2 Scope

2.1 This policy applies to all employees employed by the trust, visitors and contractors and the guidance provided within should be adhered by all. This policy applies throughout the Trust; however specific arrangements may vary from place to place (to accommodate for variances in the estate).

2.2 The effectiveness of this policy will be reviewed at each premises during the annual Fire Risk Assessments and if earlier changes warrant a policy review (such as legislation). All employees have a duty to read this policy and become familiarised with the contents herein. Specific responsibilities are defined later for each level of management in order to ensure that Fire Safety is managed effectively by the Trust.

3 Definitions

3.1 Firecode A national NHS guidance document which supports the management of fire in

NHS buildings; 3.2 Fire Risk Assessment Is a means of identifying fire hazards, identifying those at risk, evaluating and

reducing the risks posed and recording and monitoring the control measures implemented to prevent a fire starting;

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3.3 Hot Work A source of ignition for a fire to start through any process that involves the usage

of flammable materials, such as grinding, cutting, soldering, brazing, welding, burning and drilling;

3.4 Fire Log Book A means that is used which allows the Trust to effectively manage fire safety and

the associated risks; 3.5 Responsible Person

This is someone who has control, or a degree of control, over premises and fire-prevention systems within premises. They are therefore also responsible for the safety of everyone who might lawfully be on the premises at any time.

3.6 Relevant Person The relevant person is any person (including the responsible person) who is or

may be on the premises, and, any person in the immediate vicinity of the premises who is at risk from a fire on the premises.

3.7 Competent Person A person who has adequate skills, knowledge, training and experience and can

ensure that the duties of the employer under relevant legislation are adhered to.

4 Duties, Responsibilities and Reporting

4.1 Chief Executive As the ‘Responsible Person’, the Chief Executive of the Trust carries overall responsibility for implementation of the Fire Safety Policy on behalf of the Trust Board.

4.2 Executive Directors

Executive Directors are responsible for ensuring that the Trust’s Fire Safety Policy is implemented and that suitable control measures are adhered to.

4.3 Head of Operations

The Head of Operations for each area are responsible for ensuring the implementation of the Trust’s Fire Safety Policy and that adequate resources are made available to comply with statutory requirements.

4.4 Operational Locality Managers/Line Managers

The Operational Locality Managers and Line Managers are responsible for the following:-

• Implementing the Fire Safety Policy at a local level and for ensuring that directly managed employees receive adequate training upon

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commencement of employment and at regular intervals thereafter (this may be done through e-learning);

• Ensuring that a local induction of fire safety arrangements is carried out for all new employees and existing employees who have been transferred to new premises. The following points should be covered at the local induction:

o the actions in event of fire and in the event of a fire evacuation drill;

o a walk around of all escape routes; fire alarm call points, automatic fire detectors, fire points and the type and use of fire-fighting equipment;

o the existence and location of the Fire Safety Policy.

o completion of the Fire e-learning

• Ensuring that all employees have knowledge of local fire precautions and arrangements, including fire exits and extinguishers and have undergone fire evacuation drills;

• Ensuring that the Health, Safety and Security Manager is informed at the earliest opportunity to any fire(s) that involve the Trust's premises or equipment;

• Ensuring that fire safety information is displayed appropriately, (Fire Log Book, Fire Precautions: Instruction to Staff) and that the Fire Log Book is maintained and stored and is available for inspection;

• Ensuring that all visitors to premises sign in and out and are aware of the procedures that are required to be taken in the event of a fire. Contractors must ensure that their own staff is aware of fire safety instructions;

• Ensure that weekly fire alarm tests are carried out;

• Ensuring that fire doors are kept in good condition, are kept closed at all times, are defect free and that they are in good working order to ensure a speedy and safe evacuation;

• Ensuring that all firefighting equipment has been maintained;

• Ensuring that any defects are reported to the appropriate manager for remedial action to be carried out;

• Ensuring that electrical equipment is properly used and Portable Appliance Register for each site is up to date;

• The co-ordination of the response to fire incidents in shared premises will be the responsibility of the Local Manager and/or most senior person on duty in all premises;

• Ensuring that all emergency lighting systems break glasses and door override systems are tested;

• Report any loss, use, misuse or damage to fire equipment immediately to the Estates Manager;

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4.5 Health, Safety and Security Manager

The Health, Safety and Security Manager is responsible for the following:

• Promote and provide information to managers of numbers of complete on-line Fire e-Learning training;

• Provide Fire warden training as and when required;

• Receiving and collating information on fire/potential fire incidents in all Trust premises;

• Receiving and collating all completed ‘Fire safety risk assessment of the workplace’ proformas (Fire Log Book);

• Advising the Health and Safety Group of trends and the status of fire safety across the Trust;

• Distributing any advice on fire safety or related matters;

• Liaising with Operational Locality Managers/Line Managers to ensure effective implementation of this policy at a local level;

4.6 Health, Safety and Security Officer(s)

The Health, Safety and Security Officer(s) will:-

• Make recommendations on updating the Fire Safety Policy;

• Report to the Health, Safety and Security Manager on trends and the effectiveness of fire safety arrangements across the Trust;

• Undertake annual fire risk assessments for each Trust premises using the ‘Fire safety risk assessment pro-forma’. Once completed a copy of the fire safety risk assessment should be sent to the OLM to be held at the premises/station. A copy should also be sent to the Health, Safety and Security Department for filing.

4.7 Estates Manager The Estates Manager will be responsible for the following:

• Ensuring that all portable electrical appliances and fixed electrical installations are serviced and maintained annually;

• Ensuring that all firefighting equipment installed in Trust premises is serviced and maintained (including evacuation chairs);

• Ensuring, by arranging for the servicing, maintenance and repair of fire safety measures and installations including fire alarms, that all Trust premises are safe for staff and visitors with regards to fire safety;

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• Supervising the day to day arrangements and maintenance of fire precautions across the Trust including defining the intervals at which testing and inspections are carried out;

• Ensuring that the annual Certificate of Fire Code Compliance is obtained, as appropriate;

• Ensuring, as far as reasonably practicable, that ambulance staff accommodation located in non-Trust or on shared sites are included on local alarm systems, where they exist, and that adequate fire safety procedures are in place to protect staff;

• Ensuring that advice received from the fire service requiring remedial action to the Trust’s physical resources is acted upon promptly.

4.8 Fleet Manager Ensuring that the Trust’s vehicles are fit for purpose and that all necessary precautions have been taken to reduce and control the risk of fire. This includes ensuring that all Trust vehicles (front line vehicles, fleet cars and pool cars) have a suitable extinguisher onboard that is regularly tested and serviced in accordance with this policy.

4.9 Fire Wardens

Where possible and practicable, Fire Wardens will be appointed and trained. The Fire Warden(s) has the following responsibilities:

• Supervise the effective day-to-day upkeep of the Fire Log Book; and support the Local Manager in arranging fire drills, fire alarms, emergency lighting and fire extinguishers are regularly tested;

• Co-ordinate and direct the actions of staff during an evacuation procedure or fire drill and liaise with the Fire Service after checking their area is evacuated. In the event of an emergency fire situation in a building of shared occupancy, the fire warden or deputy may assist other nominated individuals to carry out their responsible roles;

• Report any fire to their Operational Locality Manager/Local Manager/Health, Safety and Security Manager.

4.10 Employees

Trust employees have the following responsibilities:

• All employees are responsible for completing fire training (this may be done through e-learning) and drills in line with the Trust’s Fire Safety Policy and to co-operate with the Trust in ensuring that the policy and procedures are achieved at all times;

• To be familiar with this policy and to understand the fire safety arrangements for the premises (or vehicle) in which they work (this includes the evacuation procedures, position of break call points, extinguishers and escape routes);

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• To take the appropriate measures to prevent fire where reasonably practicable (e.g. - keep fire doors closed, comply with the Trust’s No Smoking Policy, ensure personal portable electrical appliances are tested);

• To identify and report any fire hazards and suspicious changes in relation to security to their manager;

• To ensure they are familiar with the sound of fire/smoke alarms in their work area;

• To ensure they do not interfere with or misuse any equipment that is provided for prevention of fire or for fighting fire and to take care of themselves and others who could be harmed by their acts or omissions;

• Ensure that the Trust is acting in accordance with The Regulatory Reform (Fire Safety) Order 2005. This will involve ensuring that fire exit escape routes are maintained, fire exits are kept clear and closed and equipment is readily available for fighting fires. Any abnormalities must be reported to their line manager at the earliest opportunity.

5 Fire Safety Risk Assessments

5.1 Suitable and sufficient Fire Safety Risk Assessments should be completed annually or following any significant changes to the premises to which it relates;

5.2 A completed copy of all Fire Risk Assessment forms should be held within the

station’s Fire Log Book. A copy of the completed Fire Risk Assessment form should also be forwarded to the Health, Safety and Security Department for filing;

5.3 Where premises are shared (e.g. where Fleet workshops are located or premises

are shared with another employer) then Local Managers must work in partnership with each other to ensure that assessments are carried out in a coordinated manner.

6 Training Requirements

6.1 Staff should be trained about the nature of fire, fire prevention, fire drills, evacuation procedures and firefighting equipment (this training is done through e-learning) which is completed on an annual basis.

6.2 Such training will be carried out via core induction, local induction sessions and on

an ongoing basis in accordance with any training needs analysis. Staff should also receive training in the event of any changes in the workplace.

6.3 Where staff has been nominated as Fire Wardens additional training will be

provided by the Health, Safety and Security Department.

7 Monitoring

7.1 This policy will be monitored by the Health, Safety and Security Department. In order to monitor the policy the Trust will carry out the following;

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• auditing of Trust documentation in order to determine the compliance with the requirements of this policy during site visits and fire risk assessments

• the review of Trust premises with the requirements of this policy at annual reviews (if not earlier).

• this policy will be reviewed every three years following any legislative or operational changes.

8 References

• Regulatory Reform (Fire Safety) Order 2005;

• Health and Safety at Work Etc Act 1974;

• Workplace (Health, Safety and Welfare) Regulations 1992;

• NHS Firecode - Policy and Principles Document;

• Buildings Regulations 2000: Approved Document Part B, Fire Safety Volume 2; CLG; Publication – Fire Safety Risk Assessment for Health Care Premises

• Equality Act 2010;

• Health and Safety (Safety Signs and Signals) Regulations 1996

• The Management of Health and Safety at Work Regulations 1999

• Dangerous Substances and Explosives Atmospheres Regulations 2002

• Reporting of Injuries, Dangerous Diseases and Occurrences (RIDDOR) Regulations 1995 (amended 2013)

• Control of Substances Hazardous to Health (Amendment) Regulations 2002 (COSHH)

• Electricity at Work Regulations 1989

9 Associated Documents

9.1 The policy links to: -

• Bombs, Explosives, Suspicious Letters and Packages Policy;

• Control of Contractors Policy;

• Health and Safety Policy; Incident Reporting Policy;

• Medical Gases Policy;

• Control of Substances Hazardous to Health (COSHH) Policy; • No Smoking Policy.

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Appendix A

Prevention of Fire

1.1 It is important that the highest possible standards of fire prevention are maintained throughout the estate. Most fires can be prevented by good discipline, good security measures and common sense. The prevention of fire must be a priority for all employees.

1.2 All staff will be trained in fire prevention via induction training and subsequent information, instruction and training. Good housekeeping and effective cleaning (especially the removal of dust from ventilation and ducting systems) are essential fire prevention measures. All workplaces must be checked regularly to ensure that there is no undue accumulation of rubbish (especially in high risk fire areas – such as garages, server rooms and flammable stores).

1.3 Storage of combustibles must not be in close proximity to ignition sources, therefore items such as clinical waste bins and other waste receptacles are to remain clear of battery charging areas and shore line charging points. Furthermore, combustibles such as paper, cardboard and plastics and flammable cleaning products are not to be stored within electrical cupboards. Furthermore, combustible items and flammable items are not to be stored under staircases, particularly if this is the only evacuation point from the floor above.

1.4 Fire escape routes such as corridors, stairways and landings must be maintained and no flammable stored items should be kept on these routes as this can impede the safe evacuation process, not to mention be significant to a fire starting and such hamper escape attempts. All flammable materials such as liquids, vapours and gases must be handled, transported, stored and used properly.

1.5 Implementation of the Trust’s No Smoking Policy will assist in the prevention of fire and further advice can be found within this policy.

1.6 Ceiling tiles that have been left out of the ceiling grid are likely to increase the spread of fire and smoke along ceiling cavities and thus should be replaced after contactors have completed works. Ceiling tiles that require to be replaced should be done so in liaison with the estates department. Holes that have been created in walls (particularly breaches in fire walls) should be reinstated to prevent the spread of fire and smoke through buildings.

1.7 No hot working shall be carried out on any Trust premises without prior approval and in all such instances the requirements of the Trust’s ‘Fire Precautions: Code of Practice for Contractors’ must be complied with in full. Where deemed necessary a formal Permit to Work system will be employed. Particular attention should be paid to hot work within workshops in that hot work should not be carried out in an area that is close to fuel supplies, flammable substances or combustible items.

Note: The Trust’s ‘Fire Precautions: Code of Practice for Contractors’ is a brief document issued to contractors by the Estates Department when hot working is to be carried out as part of a major project.

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1.8 Employees that use portable spotlights (that are prone to getting very warm) are to ensure that these are kept away from combustible materials such as paper, wood and plastics.

1.9 Cooking facilities that are used by Trust employees are to be regularly cleaned to prevent buildup of materials such as fats/oils and crumbs in toasters from being a source of a fire starting.

1.10 Where fire doors (smoke stop doors) are fitted in circulation and general areas they must be clearly labeled

• ‘Fire Door - Keep Shut’, on both sides and should have self-closing devices. Plant rooms, store rooms etc., will have a sign on one side only which says ‘Fire Door - Keep Locked’ or similar and should comply with BS 5499 ‘Fire safety signs, notices and graphic symbols’.

• Where fire doors are installed the standards should be denoted as FD20/20 and FD20/30 and comply with BS 476, Parts 8 and 22. Doors that require intumescent material to be fitted post manufacture have a red core on a colour background. Doors that have intumescent material fitted during manufacture have a green core on a colour background.

• Where automatic fire doors are fitted in circulation these must be labeled ‘Automatic Fire Door – Keep Clear’ and should comply with BS 5839: Part 3 ‘Fire Detection and alarm system for buildings’.

• Exit doors in all buildings must be kept clear, free from obstructions and accessible at all times and the external sides of final exit doors must be labeled as ‘Fire Door – Keep Clear’. Particular attention should be paid to the labeling of fire doors, especially where the door does or does not appear to be a fire door. It is often very difficult to tell if a door is a fire door without a qualified specialist taking the door apart. Having said that there are some points which can help to distinguish whether a door is likely to be a fire door. Fire doors are often heavy and are usually approximately 44mm thick, they are fitted with self-closers, intumescent seals, open in the direction of escape and usually have three hinges. To prevent confusion, particular attention should be paid to the labeling of doors, especially where a door appears to be a fire door, however some of the aforementioned is missing or does not appear to be a fire door but has been labelled as so. Therefore, consideration should be had, as to whether the label should be removed. Fire doors are often fitted in long corridors to separate (or compartment an area) and high risk areas such as boiler areas, kitchens, protected escape corridors and entrances to garages. Fire doors should be checked daily, formally checked monthly, kept in good condition, closed and maintained. Fire doors should not be wedged open with materials or fire extinguishers as neither are designed for this purpose or are effective when this happens. After the monthly check is carried out completion of Fire Log Book, ‘Fire doors, Means of escape – record of defects, obstructions’ is required.

1.11 Numbering of all firefighting equipment, break glasses (including doors), emergency lighting and fire systems should be carried out to demonstrate the testing of each in the Fire Log Book.

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2 Industrial/Medical/LPG gases 2.1 Industrial/medical gases should be stored within secure storage areas away from

buildings where possible. 2.2 Notices MUST be displayed stating the locations of full and empty cylinders in order

to prevent accidental mixing (Fire Log Book, Storage Plan for Medical Gases). 2.3 Notices should be prominently displayed on all entrances to premises storing

compressed gas cylinders stating whether the gases are flammable or non-flammable. They should read: ‘Medical Gas Cylinders (Flammable/ Non Flammable) - No Smoking or Naked Light’ or similar, as dictated by current legislation and the Trust’s No Smoking Policy. Signage can be obtained through the Health, Safety and Security Department or from BOC gases.

2.4 Furthermore, the storage of Liquefied Petroleum Gases (LPG) for usage with

station BBQ’s should be (where possible) kept out with the premises in a secured LPG storage cage. Furthermore, the siting of these cages should be away from escape routes and in areas that are adequately lit and are unlikely to allow vandalism.

2.5 Further advice on the storage of Medical gases can be found in the Medical Gas

policy.

3 Flammable Liquids

3.1 Flammable liquids in bulk should be stored in buildings or compounds reserved solely for the storage of such liquids. Any containers, both empty and full should be stored in the upright position with their caps tightly closed.

3.2 The quantities of flammable liquids held in workshops should be limited to the amount required for daily usage.

3.3 Receptacles containing flammable liquids (or rags or cloths used to mop up or apply flammable liquids) should be closed after use and stored in a metal locker provided specially for this purpose. The locker should be identified by a notice stating:- ‘Flammable Store - No Smoking Or Naked Light’. Any spilt liquid should be covered immediately with sand, authorised absorbent granules or by usage of a foam extinguisher.

3.4 Under no circumstances should petrol be used for cleaning purposes. Bunkered fuel supplies should be adequately signed with information regarding the contents, maximum fuel storage, emergency contact details of the fuel supplier and external signage for the fire brigade in order to alert them, prevent confusion and allow them to understand the risks involved within the premises (if any).

3.5 Oxidising and corrosive chemicals are to be kept away from flammable chemicals as these can cause a fire through combustion. Further guidance is available from the Health, Safety and Security Department and from the Material Safety Data Sheet (MSDS) that accompanies every product.

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3.6 Further advice on the storage of Flammable liquids can be found in the Control of Substances Hazardous to Health (COSHH) Policy.

4 Arson

4.1 Arson is an act of deliberately starting fires and thus all employees of the Trust must be aware of the nature of flammable materials.

4.2 All Trust main entry and exit doors (including vehicular doors) should remain closed in order to prevent the spread of fire and to reduce the risk of perpetrators accessing a Trust location and starting a fire.

4.3 Waste bins should be (where possible) kept away from Trust buildings to reduce the chances of waste bins being used to start fires. Particular attention should be paid to buildings that have external escape staircases and no waste bins should be stored underneath.

4.4 Furthermore, no aerosols should be stored near letter boxes as these also could assist the spread of fire (particularly the rapid spread of fire). If any employee feels that there is a risk posed to them from arson, then this must be reported as soon as possible to their line manager. They should also complete a Trust Incident Report Form on the Datix system.

4.5 If the Operational Locality Manager/Line Manager and/or Fire Warden can safely address the matter then they should do so. If they cannot safely address the matter then must notify their manager, the Health, Safety and Security Manager and the Estates Manager of their concerns so that appropriate action can be taken.

5 Fire Detection 5.1 Fire systems will be tested and maintained to BS5839: Part 1 ‘Fire detection and

alarm systems for buildings’ and detector heads should be cleaned during maintenance.

5.2 Many types of fire/smoke alarm are fitted across the Trust. Alarms are not

mandatory, but if fitted, they must be clearly audible throughout the entire premises/working environment. In low risk premises or where the volume of employees is low, the fitting of manual detectors is acceptable providing that this has been assessed. Furthermore, detection should be considered in high risk areas such as garages, electrical cupboards, server rooms and boiler areas. Furthermore, where fitted fire safety isolation valves to boilers and generators and automatic fire door closures should be tested on an annual basis to ensure that these operate under the activation of a fire/fire alarm activation.

5.3 Where provided fire/smoke alarms must be tested weekly (in a rotational zone

system) at times agreed with the Operation Locality Manager/Line Manager. Records of weekly alarm tests must be maintained (Fire Log Book, ‘Fire Alarm System – Record of Tests’). Furthermore fire detection systems must be kept unobstructed and easily accessible.

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5.4 Consideration during the Fire Risk Assessment should be given to whether fire detection is required in void areas.

5.5 In the event of a fire, the alarm must be activated regardless of the size of the fire.

6 Classes of Fire/Fire Extinguishers 6.1 The Fire Risk Assessments will determine the correct location of fire extinguishers

in Trust premises. As a guide, they should be easily accessible, on exit routes and near fire doors and in high risk areas (such as vehicle garages and electrical plant rooms).

6.2 The following now demonstrates the classes, colours and uses of fire extinguishers;

6.3 It should be noted by all employees that the above is only a guide and the correct

areas of usage are displayed on the body of the extinguisher. CO2 extinguishers are loud, prone to freezing and care should be taken when using in confined spaces.

6.4 Fire blankets – Are to be used in areas of food preparation, specifically for Class B

fires to smother oil or fat fires. These can also be used by employees to escape a fire by using the blanket as a shield.

6.5 Hose Reels – Only to be used on Class A fires and must comply with BS 5306; Part

1 ‘Fire Extinguishing installations and equipment on premises’.

CLASS A – SOLIDS SUCH AS PAPER, PLASTICS AND WOOD WATER EXTINGUISHERS ARE THE BEST EXTINGUISHING MEDIUM. NOT SUITABLE FOR CLASS B FIRES OR

ELECTRICAL FIRES

CLASS B – FLAMMABLE LIQUIDS SUCH AS OILS, PARAFFIN AND PETROL FOAM EXTINGUISHERS ARE THE BEST EXTINGUISHING MEDIUM. ALSO CAN BE

USED FOR CLASS A FIRES.

NOT SUITABLE FOR ELECTRICAL FIRES

CLASS C – FLAMMABLE GASES SUCH AS BUTANE, METHANE AND PROPANE DRY POWDER EXTINGUISHERS ARE THE BEST EXTINGUISHING MEDIUM AND CAN BE

USED GENERALLY ON ALL CLASS OF FIRE

CLASS D – COMBUSTIBLE METALS SUCH AS ALUMINUM, MAGNESIUM AND TITANIUM DRY POWDER EXTINGUISHERS ARE THE BEST EXTINGUISHING MEDIUM AND CAN BE

USED GENERALLY ON ALL CLASS OF FIRE

ELECTRICAL FIRES – SUCH AS PHOTOCOPIERS, OVERLOADED CIRCUITRY AND CO2 EXTINGUISHERS ARE THE BEST EXTINGUISHING MEDIUM. DRY POWDER CAN

ALSO BE USED.

CLASS F – COOKING OILS AND FATS USED FOR CATERING PURPOSES WET CHEMICAL EXTINGUISHERS ARE THE

BEST EXTINGUISHING MEDIUM

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6.6 Sand Buckets – Are often found within boiler rooms and garages. These are to be refilled after usage and not used as waste bins.

6.7 Portable hand held fire extinguishers are designed for use by staff who have been

adequately trained in their correct method of usage. 6.8 In accordance with current European Standards all new and replacement fire

extinguishers will have a red body with colour coded labels to indicate the extinguisher type and must comply with BS EN3 ‘portable fire extinguishers’ for new extinguishers and BS 5423 ‘Portable fire extinguishers’ for that are already in usage.

6.9 They will be positioned so that a person is no more than 30 metres (100 feet) from

the nearest extinguisher. In order to ensure that extinguishers are easily lifted from their wall mounts, heavy extinguishers should be positioned 1 metre from the floor.

6.10 Fire extinguishers need to be regularly checked and maintained annually by a

competent person. 6.11 Fire extinguishers should be checked every month that they are still in their correct

position, in good condition, have not been damaged, used, lost pressure, blocked or are used to wedge open fire doors. Any spare extinguishers should also be checked.

7 Other Extinguishing medium

7.1 Where sprinkler systems are installed on Trust premises these must be tested and serviced by a competent person. They must comply with BS 5306: Part 2, ‘Fire-extinguishing installations and equipment on premises’.

7.2 Where gas extinguishing medium (such as Argon systems) are installed on Trust

premises these must be tested and serviced by a competent person(s). They must comply with BS 5306: Part 4 ‘Fire extinguishing installations and equipment on premises’.

8 Fire Signage 8.1 All signage must comply with the standards set out in the EC directive and BS

5499: ‘Fire Safety signs, notices and graphic symbols’ and The Health and Safety (Safety, Signs and Signals) Regulations 1996. The Trust will ensure that signage is clear to see and that redundant signage is removed. Signage will be installed in all premises to aid escape. Fire Action signs should be located throughout buildings and should be a standard sign throughout the building (and Trust where possible). All parts of the sign should be completed to inform employees of the requirements.

8.2 Further advice on signage can be found in the Trust’s Safety, Signs and Signals

Policy.

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9 Electrical Testing and emergency lighting

9.1 There is a high incidence of fires caused by both faulty electrical equipment and its misuse.

9.2 Care must be taken not to overload any electrical circuit as this can “blow” a fuse or

lead to a fire starting. The following MUST not be allowed on Trust premises, multi-block adaptors, electrically powered air fresheners, daisy chaining extension leads and coiled extension reels in use, as all of these are well known to be the sources of fires (through overheating).

9.3 Emergency lighting should be maintained and tested under BS 5266: Part

1,’Emergency Lighting’ and the records of testing should be documented in ‘Safety Lighting Systems - Records of Tests’.

10 Fire Evacuation

10.1 In the event of a fire/ alarm sounding, employees must follow the fire evacuation procedures (Fire Log Book, ‘Fire Precautions: Instruction to Staff’).

10.2 The most senior person on duty and/or the Fire Warden must ensure that the Fire

Service is called immediately. 10.3 As soon as an evacuation is thought to be complete, a roll call should be taken

which will have regard to any visitors to establish whether everyone is accounted for. If anyone is not accounted for the Fire Service should be informed immediately upon their arrival.

10.4 Nobody should be allowed to return to the building in which a fire has occurred, for

any reason, unless advised that it is safe to do so by the Fire Service. 10.5 A fire drill/practice must take place at each site at least once a year, however it is

preferable that is carried out bi-annually to ensure that all new members of staff are aware of the evacuation procedures. Drills are to involve a daytime and night-time practice and that this is documented within the Fire Log Book under ‘Training, Fire Instructions and Drills’.

10.6 A map of the building should be located at the entrance to Trust property (if possible

away from public sight) which should distinguish the location of exits, firefighting equipment, mains fire panel, main isolation for gas, electricity and water along with fire hazards such as storage of fuels and cylinders.

10.7 A fire log book (in North Area sites, this may be a red bag) should be located at the

main entrance of Trust property which should contain the fire log book, roll call lists and any other information that is required in the event of a fire. Furthermore, details of the location of Asbestos Containing Materials (ACMS) should also be kept within evacuation documentation in order to alert the fire brigade to the presence of ACMS when dealing with a fire.

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10.8 Furthermore, the location of gas and electrical isolation points should also be passed to the fire brigade to assist them to carry out their job. Where fire – fighter’s isolation switches are in position, these should be prominent through signage or through painting. To avoid confusion, unused switches should be removed to prevent fire fighters believing these will assist them to isolate energy supplies.

11 Fire Evacuation from a Trust vehicle

11.1 In the event of a fire in a Trust vehicle, the safety of staff, patients, relatives and other health workers will always be the main priority.

11.2 Definitive procedures cannot be written for every type of incident. These procedures

are therefore general enough for common sense to prevail providing other health and safety considerations are adopted.

11.3 In all cases of fire, either evident or suspected, the driver must stop the vehicle as

soon as practicable and with due consideration to other road users. The vehicle is to be positioned as close to the nearside as possible, the handbrake applied, the ignition switched off and battery isolated by activating the vehicle’s isolator switch.

Required Action - No Patients onboard - Driver: (where safe to do so):-

• Put on reflective jacket;

• Release the bonnet catch (do not fully open the bonnet catch as this may aggravate the situation);

• Direct cab fire extinguisher nozzle into gap created by the bonnet release catch (do not fully open the bonnet as this may aggravate the situation).

Required Action - Attendant: (where safe to do so):-

• Contact Clinical Hub on a priority message;

• If the radio cannot be used because the attendant thinks it unsafe or the radio has been damaged or isolated, then the attendant must use the nearest telephone to:- i) Contact the Fire Service direct using the ‘999’ system; ii) Inform Clinical Hub.

• Following the communication arrangements the crew can then tackle the fire, but only if safe to do so. If the fire becomes unmanageable then the crew should retire to a place of safety wearing their reflective jackets.

Required Action - Patients onboard

• The driver should leave the cab and assist the attendant with the evacuation of patient(s).

• The patient(s) and escort(s) should be placed well away from the vehicle in a place of safety.

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• Consideration should be given to any life sustaining equipment required.

• The attendant should remain with the patient(s) and escort(s).

• The driver should then carry out the procedure mentioned above

• If it safe to do so, remove any oxygen and entonox cylinders.

12 Personal Emergency Evacuation Plan’s (PEEP’s) 12.1 There are no specific instructions set out in legislation with regards to how to

evacuate disabled employees from buildings; however the Trust is required to ensure that local PEEP’s are prepared in order to consider the safe evacuation from Trust premises of wheelchair users and those with impaired vision or hearing.

12.2 When considering the evacuation of disabled persons, it must be considered that

assistance from a designated person may also be required. Where it is considered that evacuation chairs are necessary for emergency usage, employees that are likely to use this must be trained and these chairs must be inspected and tested regularly (on an annual basis). Where it is deemed applicable some trust premises may have fire refuges in place and this should form part of the Fire Risk Assessment and local evacuation plan. Where employees that have hearing or visual impairments work within Trust premises, it should be assessed as to whether other means of notification of the fire alarm sounding are required (such as vibrating devices or visual flashing beacons).PEEP’S should also be considered for lone workers, workers in confined spaces and those working under safe systems of work (such as contractors).

12.3 Where applicable, fire evacuation lifts that have been installed for the evacuation of

disabled persons must comply with BS 5588: Part 8 ‘Fire precautions in the design, construction and use of the building’.

12.4 The PEEP form can be found on the intranet under Health Safety and Security

13 Buildings of shared occupancy 13.1 Where premises are shared with other occupants, agreed plans and procedures

should be established between all parties in order to safely evacuate the building. Furthermore, communication and coordination of fire and health and safety issues should be jointly agreed and Trust employees must co-operate with these.

13.2 Where Trust employees are required to work in premises owned by other

organisation’s, the Trust has a responsibility for these employees and such the Local Manager will establish what the arrangements are for the management of fire safety in each of the respective premises.

13.3 Where Trust employees have identified issues, these should be addressed through

their line Manager and by completing Datix reports.

14 Recording and Reporting a Fire

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14.1 Any incident that involves any of the following must be reported via Clinical Hub and the adverse incident reporting system:- a) The Fire Service has been called; b) Fire alarms have been activated; c) Fire extinguishers have been discharged; d) Flames or smoke have been extinguished by any other means; e) Any potential suspicious/arsonist attempts have been made.

14.2 Having completed initial enquiries, Clinical Hub will inform the Duty Officer who will then inform the Health, Safety and Security Manager and relevant director, if appropriate.

14.3 All fires must be subsequently reported within 48 hours to the Operational Locality

Manager/Line Manager who will complete a written report to the Health, Safety and Security Manager using the Trust’s Incident Reporting System (Datix).

14.4 In accordance with Health Technical Memorandum 05 (Firecode) any burn

sustained by a member of staff, patient or any other person whilst on Trust premises or in Trust vehicles must be reported to the Health Safety and Security Manager within 24 hours using the Trust’s Incident Reporting System (Datix).

14.5 Any fatality or serious injury involving a fire will be reported to the appropriate

enforcing agencies according to the Trust’s Incident Reporting Policy and in line with the Reporting of Injuries, Dangerous Diseases and Occurrences (RIDDOR) Regulations 1995 (amended 2013).

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Appendix B

Version Control Sheet

Version Date Author Summary of Changes

1 09/04/14 Scott Crichton

Health, Safety and Security Officer

Harmonisation of policies