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HTM 05-03 Operational provisions Part K – Guidance on fire risk assessments in complex healthcare premises

 
 
 
 
 
 
 
 
 
 
Firecode – fire safety in the NHS Health Technical Memorandum 05-03: Operational provisions
 
 
 
Part K: Guidance on fire risk assessments in complex healthcare premises
 
 
 
 
 
 
Firecode – Fire safety in the NHS Health Technical Memorandum 05-03: Operational provisions
 
 
 
Part K: Guidance on fire risk assessments in complex healthcare premises
 
 
 
 
 
? Crown copyright 2013
 
Terms of use for this guidance can be found at http://www.nationalarchives.gov.uk/doc/open-government-licence/
 
 
 
 
 
 
 
 
About Health Technical Memoranda
 
Health Technical Memoranda (HTMs) give comprehensive advice and guidance on the design, installation and operation of specialised building and engineering technology used in the delivery of healthcare.
 
The focus of Health Technical Memorandum guidance remains on healthcare-specific elements of standards, policies and up-to-date established best practice. They are applicable to new and existing sites, and are for use at various stages during the whole building lifecycle.
 
main source of specific healthcare-related guidance for estates and facilities professionals.
 
The core suite of nine subject areas provides access to guidance which:
 
? is more streamlined and accessible;
 
? encapsulates the latest standards and best practice in healthcare engineering, technology and sustainability;
 
? provides a structured reference for healthcare engineering.
 
 
Figure 1 Healthcare building life-cycle
 
 
DISPOSAL
 
CONCEPT
 
 
RE-USE
 
 
OPERATIONAL MANAGEMENT
 
 
 
DESIGN & IDENTIFY OPERATIONAL REQUIREMENTS
 
 
 
 
 
MAINTENANCE
 
 
 
 
 
COMMISSIONING
 
 
Ongoing Review
 
SPECIFICATIONS TECHNICAL & OUTPUT
 
 
 
 
PROCUREMENT
 
 
 
 
 
INSTALLATION
 
CONSTRUCTION
 
 
 
 
Healthcare providers have a duty of care to ensure that appropriate governance arrangements are in place and are managed effectively. The Health Technical Memorandum series provides best practice engineering standards and policy to enable management of this duty of care.
 
It is not the intention within this suite of documents to unnecessarily repeat international or European standards, industry standards or UK Government legislation. Where appropriate, these will be referenced.
 
Healthcare-specific technical engineering guidance is a vital tool in the safe and efficient operation of healthcare facilities. Health Technical Memorandum guidance is the
 
Structure of the Health Technical Memorandum  suite
The series contains a suite of nine core subjects: Health Technical Memorandum 00
Policies and principles (applicable to all Health
Technical Memoranda in this series)
 
Health Technical Memorandum 01 Decontamination
 
Health Technical Memorandum 02 Medical gases
 
 
 
 
 
 
Health Technical Memorandum 03 Heating and ventilation systems
 
Health Technical Memorandum 04 Water systems
 
Health Technical Memorandum 05 Fire safety
 
Health Technical Memorandum 06 Electrical services
 
Health Technical Memorandum 07 Environment and sustainability
 
Health Technical Memorandum 08 Specialist services
 
Some subject areas may be further developed into topics shown as -01, -02 etc and further referenced into Parts A, B etc.
 
Example: Health Technical Memorandum 06-02 represents:
 
Electrical Services – Electrical safety guidance for low voltage systems
 
In a similar way Health Technical Memorandum 07-02 represents:
 
Environment and Sustainability – EnCO2de.
All Health Technical Memoranda are supported by the initial document Health Technical Memorandum 00 which embraces the management and operational policies from previous documents and explores risk management issues.
 
Some variation in style and structure is reflected by the topic and approach of the different review working groups.
 
DH Estates and Facilities Division wishes to acknowledge the contribution made by professional bodies, engineering consultants, healthcare specialists and
NHS staff who have contributed to the production of this guidance.
 
 
 
Figure 2  Engineering guidance
 
 
 
 
 
 
HTM 08
Specialist Services
 
 
HTM 01
Decontamination
 
 
 
 
 
 
 
HTM 07
Environment & Sustainability
 
HTM 02
Medical Gases
 
 
HTM 00
Policies and Principles
 
 
 
HTM 06
Electrical Services
 
HTM 03
Heating & Ventilation Systems
 
 
 
HTM 05
Fire Safety
 
HTM 04
Water Systems
 
 
 
 
 
 
 
 
This Health Technical Memorandum provides guidance on fire risk assessments in complex NHS healthcare premises. It is supplementary to the guidance in the “FSO Green Guide” (Department for Communities and Local Government (2006)) and supersedes the guidance contained in Health Technical Memorandum 86 – ‘Fire risk assessment in hospitals’ and ‘Fire risk assessments in Nucleus hospitals’.
 
Fire risk assessments using the guidance in this Health Technical Memorandum are required by the Regulatory Reform (Fire Safety) Order 2005 (hereafter referred to as the Fire Safety Order), which came into effect on
1 October 2006.
 
The guidance in this Health Technical Memorandum can be used to:
 
? review, revise and update an existing fire risk assessment; or
 
? undertake a fire risk assessment for healthcare premises for the first time.
 
A fire risk assessment template is appended to this document here.
 
The major part of this Health Technical Memorandum (Chapter 5, ‘Risk assessment in patient-access areas’) considers fire safety in areas of healthcare premises to which patients have access. Where the main purpose of a department is patient treatment or care, the guidance in Chapter 5 should be applied.
 
Where the main purpose of an area/building on a hospital site is not patient treatment or access (for example main kitchen, stand-alone office block, main laundry), other guides to the Fire Safety Order should be applied.
 
Note
 
For fire safety law that applies to buildings to which patients do not have access, see the set of relevant guides on the website of the Department for Communities and Local Government.
 
 
 
 
 
 
 
 
Acknowledgements
 
 
 
 
 
 
The following individuals and organisations have contributed to the production of this guidance:
 
 
 
Peter Aldridge – National Association of Healthcare Fire Officers
 
Gordon Allen – Health Facilities Scotland Steve Brady – Chief Fire Officers’ Association Phil Cane – Building Research Establishment
David Charters – Building Research Establishment Phil Harding – Chief Fire Officers’ Association John Judd – Building Research Establishment  John Morgan – Department of Health
Anthony Pitcher – Welsh Health Estates
 
Alan Raynor – Chief Fire Officers’ Association
 
Paul Roberts – Department of Health
 
George Weir – Health Estates Northern Ireland
 
 
 
 
 
 
 
Preface
Executive summary Acknowledgements
1 Introduction and scope1
General application
Scope of this Health Technical Memorandum Use by competent persons
Correlation between Health Technical Memorandum 86 and the five-step risk-assessment process
New healthcare premises
Alternative methods of fire risk assessment
2 Glossary of terms4
3 Statutory requirements8
Introduction
Compliance monitoring by fire authorities Compliance code
Unwanted fire signals (UwFS)
“As low as reasonably practicable” (ALARP)
Detection of fire by observation and by automatic fire-detection systems Staircases
Enforcement action Fire safety audit process
4 Assessment areas 12
5 Risk assessment in patient-access areas 13
Introduction Managing fire safety
Step 1: Identifying fire hazards Introduction
Identify sources of ignition Identify sources of fuel Identify sources of oxygen
Step 2: Identifying people at risk Introduction
Dependency of patients
Step 3: Evaluate, remove, reduce and protect from risk Introduction
Evaluate the risk of a fire occurring Evaluate the risk to people  Remove or reduce the hazards
Remove or reduce sources of ignition Remove or reduce sources of fuel Remove or reduce sources of oxygen Flexibility of fire protection measures Fire detection and warning systems
 
 
 
 
 
Fire-fighting equipment and facilities Escape routes and strategies Emergency escape lighting
Signs and notices Surface finishes
Fire-resisting structures
Installation testing and maintenance
Step 4: Record, plan, inform, instruct and train Record the significant findings and action taken Emergency plans
Inform, instruct, cooperate and coordinate Information and instruction
Cooperation and coordination Fire safety training
Step 5: Review
6 Examples of alternative solutions35
Introduction
A  Ground to second floor with very high dependency patients
B. Ground to second floor with patients with a high propensity to start fires
C. Ground to second floor with poor observation of patients’ beds
D. Floors on or above the third-floor level accommodating patient-care areas
E. Dependent patients with highly infectious diseases
F. Delayed evacuation of very high dependency patients Hospitals designed to the Nucleus standards
“Nucleus-related”
7 Example of recording of significant findings39
8 Provision and use of electronic locks on doors40
Introduction
Escape routes and security Electrical locking devices
Time-delay devices on escape routes
Design, installation and management of electronic exit-door control devices
9 Basement escape and protection43
10 Access and facilities for fire-and-rescue services44
11 References45
 
1 Introduction and scope
 
 
 
 
 
 
 
General application
 
1.1 This Health Technical Memorandum provides guidance on fire risk assessments in complex NHS healthcare premises. It is supplementary to the guidance in the “FSO Green Guide” (Department for Communities and Local Government (2006)) and supersedes the guidance contained in Health Technical Memorandum 86 – ‘Fire risk assessment in hospitals’ and ‘Fire risk assessments in Nucleus hospitals’.
 
1.2 Fire risk assessments using the guidance in this Health Technical Memorandum are required by the Regulatory Reform (Fire Safety) Order 2005 (hereafter referred to as the Fire Safety Order), which came into effect on 1 October 2006.
 
1.3 The guidance in this Health Technical Memorandum can be used to:
 
? review, revise and update an existing fire risk assessment; or
 
? undertake a fire risk assessment for healthcare premises for the first time.
 
1.4 A fire risk assessment template is appended to this document here.
 
1.5 The major part of this Health Technical Memorandum (Chapter 5, ‘Risk assessment in patient-access areas’) considers fire safety in areas of healthcare premises to which patients have access. Where the main purpose of a department is patient treatment or care, the guidance in ‘Risk assessment in patient-access areas’ should be applied.
 
1.6 Where the main purpose of an area/building on a hospital site is not patient treatment or access (for example main kitchen, stand-alone office block, main laundry), other guides to the Fire Safety Order should be applied.
 
 
 
 
 
 
 
 
Note
 
For fire safety law that applies to buildings to which patients do not have access, see the set of relevant guides on the website of the Department for Communities and Local Government.
 
 
Scope of this Health Technical Memorandum
 
1.7 This Health Technical Memorandum describes how the “five-step” approach to fire risk assessment can be applied to complex healthcare premises. Guidance is also given on fire precautions and management measures, and an example of how the fire risk assessment can be recorded is provided.
 
1.8 It considers the full range of factors that affect fire safety in healthcare premises. In addition to the physical fire precautions that may be provided, it also considers:
 
? fire prevention (to reduce fire hazards and the likelihood of fire);
 
? those at risk from fire (particularly the dependency of patients);
 
? management policies and procedures; and
 
? the availability of sufficient adequately trained staff (to ensure the facilitation of fire safety measures, particularly evacuation procedures).
 
Use by competent persons
 
1.9 This Health Technical Memorandum is intended for use by competent persons, as defined in the Fire Safety Order 2005 Pt 2 Article 18(5), but all employers, managers, occupiers, and owners of premises providing healthcare (including private healthcare premises) may find it useful.
 
1.10 It has been written to provide guidance for complex healthcare premises: that is, those providing invasive procedures and other similar treatments which place a dependence on staff for evacuation.
 
 
 
 
 
 
1.11 A person who has comprehensive training or experience in fire risk assessment should assess complex healthcare premises. However, this guide can also be used for multi-occupied buildings to address fire safety issues within individual healthcare occupancies.
 
1.12 Where an existing fire risk assessment is being revised, this guide should be used in conjunction with the suite of Firecode documents in making the risk “as low as reasonably practicable” (ALARP).
 
1.13 It may also be useful for:
 
? estates and fire safety staff;
 
? other employees;
 
? employee-elected   representatives;
 
? trade-union-appointed health and safety representatives;
 
? enforcing authorities;
 
? all other people who have a role in ensuring fire safety in premises providing healthcare.
 
Correlation between Health Technical Memorandum 86 and the five-step risk- assessment process
 
1.14 Table 1 indicates where the worksheets contained in Health Technical Memorandum 86 most readily correspond to the five-step fire risk assessment process contained in this guidance. Some worksheets address several steps for one aspect.
For example, worksheet 5 ‘Ignition sources – work processes’ addresses:
 
? identification of hazards;
 
? training of staff; and
 
? particular hazard areas and additional fire precautions.
1.15 
In these cases the reference is to the part of the five- step process that is most closely associated with the bulk of the specific guidance in the worksheet. The relevant guidance in the main report is boxed and contains a reference to the appropriate worksheet.
 
New healthcare premises
 
1.16 Where the building has been recently constructed or significantly altered, the fire detection and warning arrangements, escape routes and facilities for the fire-and?rescue service should have been designed, constructed and installed in line with current building regulations by following Health Technical Memorandum 81 or its successor Health Technical Memorandum 05-02 – ‘Guidance in support of functional provisions for healthcare premises’. In all cases, the principle of maintaining the risk “as low as reasonably practicable” must be maintained in accordance with the finding of the fire risk assessment and all future reviews.
 
1.17 This Health Technical Memorandum should not be used to design fire safety in new buildings. Where alterations are proposed to existing premises, they may be subject to the Building Regulations and Health Technical Memorandum 05-02. However, this guide can be used to assist in the development of a fire safety strategy for the building.
 
Alternative methods of fire risk assessment
 
1.18 This Health Technical Memorandum does not set prescriptive standards, but provides recommendations and guidance for use when assessing the adequacy of fire precautions in premises providing healthcare. Other fire risk assessment methods may be equally valid to comply with fire safety law.
 
 
 
 
 
Table 1 Summary of Health Technical Memorandum 86 fit with respect to the five-step risk assessment process
 
Health Technical Memorandum 86 worksheet
Steps in Fire Safety Order risk assessment process
 
1 Identify fire hazards
2 Identify people at risk
3 Evaluate, remove, reduce, and protect from risk
4 Record, plan, inform, instruct and train
1 Patients
 
Mostly
Partly
 
2 Ignition sources – smoking
 
 
Mostly
 
3 Ignition sources – fire started by patients
Mostly
 
Partly
 
4 Ignition sources – arson
Partly
 
Mostly
 
5 Ignition sources – work processes
Mostly
 
Partly
Partly
6 Ignition sources – fire hazard rooms
Partly
 
Mostly
 
7 Ignition sources – equipment
Partly
 
Mostly
Partly
8 Ignition sources – non-patient-access areas
Mostly
 
Partly
 
9 Ignition sources – lightning
Partly
 
Mostly
 
10 Combustible material – surface finishes
Partly
 
Mostly
 
11 Combustible material – textiles and furniture
Partly
 
Mostly
 
12 Combustible material – other materials
Partly
 
Mostly
 
13 Prevention – management
Prior to step 1
 
 
 
14 Prevention – training
 
 
 
All
15 Prevention – fire notices and signs
 
 
All
 
16 Communications – observation
 
 
All
 
17 Communications – alarm and detection systems
 
 
Partly
 
18 Means of escape – single-direction escape
 
 
All
 
19 Means of escape – travel distance
 
 
All
 
20 Means of escape – refuge
 
 
All
 
21 Means of escape – stairways
 
 
All
 
22 Means of escape – height above ground
 
 
All
 
23 Means of escape – escape lighting
 
 
All
 
24 Means of escape – staff
 
 
Mostly
Partly
25 Means of escape – escape bed lifts
 
 
All
 
26 Containment – elements of structure
 
 
All
 
27 Containment – compartmentation
 
 
All
 
28 Containment – subdivision of roof and ceiling voids
 
 
All
 
29 Containment – external-envelope protection
 
 
All
 
30 Containment – smoke control
 
 
All
 
31 Extinguishment – manual fire-fighting equipment
 
 
All
 
32 Extinguishment – access and facilities for fire- and-rescue  services
 
 
All
 
33 Extinguishment – automatic suppression
 
 
All
 
 
 
 
 
 
 
 
 
2 Glossary of terms
 
 
 
 
 
 
 
For the purposes of this Health Technical Memorandum the following terms are defined:
 
Access room: a room through which the only escape route from an inner room passes.
 
Air transfer grille (fire & cold smoke): a device that will allow the passage of air in normal use, but when activated will contain both cold smoke and hot gases – usually activated by heat and an electrical interface with the detection and alarm system.
 
ALARP: as low as reasonably practicable.
 
Alterations notice: if the premises are considered by the enforcing authority to be high-risk, they may issue an alterations notice, as defined in the Regulatory Reform (Fire Safety) Order 2005 Pt 3 Article 29, which requires the Responsible Person to inform the fire authority before making any material alterations to the premises.
 
Automatic fire-detection system: a means of automatically detecting the products of a fire and sending a signal to a fire warning system. See Fire warning system.
 
Automatic release mechanism: a device that will automatically release either a locking mechanism on an exit route or a hold-open device to a door or roller shutter. It should operate on the actuation of the fire warning or detection system, or on failure of the power supply, and be able to be manually overridden.
 
Automatic suppression: mechanical methods of fire suppression which are activated automatically – such systems may include sprinklers and gaseous flooding systems.
 
Basement: a storey with a floor which at some point is more than 1200 mm below the highest level of ground adjacent to the outside walls.
 
Cavity barrier: a construction provided to close a concealed space against the penetration of smoke or flame, or provided to restrict the movement of smoke or flame within such a space.
 
Child: a person who is not over compulsory school age, as construed in accordance with section 8 of the Education Act 1996.
 
Circulation space: corridors, internal lobbies etc within a department for moving between rooms/spaces within the department. Definition also includes hospital streets, corridors, staircases etc that provide access between departments.
 
Class 0 surface spread of flame: the classification achieved by a material or composite product which is either:
 
a. composed throughout of materials of limited combustibility; or
 
b. a class 1 material (when tested in accordance with BS 476-7:1971 or 1987) which, when tested in accordance with BS 476-6:1981 or 1989, has a fire propagation index (I) of not more than 12 and a subindex (i1) of not more than 6.
 
Class 0 is not a classification identified in any British Standard test.
 
Compartment: a building or part of a building, comprising one or more rooms, spaces or storeys, constructed to prevent the spread of fire to or from another part of the same building, or an adjoining building.
 
Compartment floor: a fire-resisting floor used to  separate one fire compartment from another and having a minimum period of resistance of 60 minutes.
 
Compartment wall: a fire-resisting wall used to separate one fire compartment from another and having a minimum period of resistance of 60 minutes (or
30 minutes in single-storey buildings).
 
Competent person: a person with enough training and experience or knowledge and other qualities to enable them properly to assist in undertaking the preventive and protective measures.
 
Complex healthcare premises: hospital or other healthcare premises providing invasive procedures and
 
 
 
 
 
 
other similar treatments which place a dependence on staff for evacuation.
 
Dangerous substance:
 
a. a substance or preparation which meets the criteria in the approved classification and labelling guide for classification as a substance or preparation which is explosive, oxidising, extremely flammable, highly flammable or flammable, whether or not that substance or preparation is classified under the CHIP Regulations;
 
b. a substance or preparation that – because of its physico-chemical or chemical properties and the way it is used or is present in or on premises – creates a risk; and
 
c. any dust, whether in the form of solid particles or fibrous materials or otherwise, which can form an explosive mixture with air or an explosive atmosphere.
 
Emergency lighting: lighting provided to illuminate escape routes when the normal lighting fails.
 
Enforcing authority: the fire and rescue authority or any other authority specified in Article 25 of the Regulatory Reform (Fire Safety) Order 2005.
 
Escape lighting: that part of the emergency lighting which is provided to ensure that the escape routes are illuminated at all material times. (This may be part of the normal lighting system that is maintained on an essential supply.)
 
Escape route: route forming that part of the means of escape from any point in a building to a final exit.
 
External escape stair: stair providing an escape route, external to the building.
 
FA: fire-and-rescue authority.
 
False alarm: a fire signal, usually from a fire warning system, resulting from a cause other than fire.
 
Final exit: the termination of an escape route from a building giving direct access to a place of safety outside the building.
 
Fire-and-smoke damper: fire damper which when tested in accordance with BS EN 1366-2 meets the ES classification requirements defined in BS EN 13501-3: 2005 and achieves the same fire resistance in relation to integrity as the element of the building construction through which the duct passes.
 
 
Note
 
Intumescent fire dampers may be tested to ISO 10294-5.
 
Fire containment air transfer grille: a device that will allow the passage of air in normal use, but when activated will restrict the passage of fire and hot smoke.
 
Fire damper: mechanical or intumescent device within a duct or ventilation opening which is operated automatically and is designed to prevent the passage of fire and which is capable of achieving an integrity E classification and/or an ES classification to BS EN 13501-3:2005 when tested to BS EN 1366-2:1999.
 
Note
 
Intumescent fire dampers may be tested to ISO 10294-5.
 
Fire door: a door or shutter provided for the passage of persons, air or objects which, together with its frame and furniture as installed in a building, is intended when closed to resist the passage of fire and/or gaseous products of combustion and is capable of meeting specified performance criteria to those ends.
 
Fire engineering: the application of scientific and engineering principles to the protection of people, property and the environment from fire.
 
Fire-fighting lift: a lift, designed to have additional protection, with controls that enable it to be used under the direct control of the fire-and-rescue service when fighting a fire.
 
Fire-fighting shaft: a fire-resisting enclosure containing a fire-fighting stair, fire mains, fire-fighting lobbies and, if provided, a fire-fighting lift.
 
Fire-fighting stair: a specially protected staircase under the direct control of the fire-and-rescue service capable of use by fire-fighters to facilitate fire-fighting and rescue operations within the building.
 
Fire hazard: a set of conditions in the operation of a product or system with the potential for initiating a fire.
 
Fire hazard room: a room or other area which, because of its function and/or contents, presents a greater hazard of fire occurring and developing than elsewhere.
 
Fire resistance: the ability of an element of building construction, component or structure to fulfil, for a stated period of time, the required load-bearing capacity, fire integrity and/or thermal insulation and/or other expected duty in a standard fire resistance test.
 
 
 
 
 
 
Fire safety manager: a nominated person with responsibility for carrying out day-to-day management of fire safety. (This may or may not be the same as the Responsible Person.)
 
Fire Safety Order: the Regulatory Reform (Fire Safety) Order  2005.
 
Fire Safety Order (FSO) Green Guide: the Regulatory Reform (Fire Safety) Order 2005 guide entitled ‘Fire safety risk assessment: healthcare premises’.
 
Fire safety strategy: a number of planned and coordinated arrangements designed to reduce the risk of fire and to ensure the safety of people if there is a fire.
 
Fire stop: a seal provided to close an imperfection of fit or design tolerance between elements or components, to restrict the passage of fire and smoke.
 
Fire warning system: a means of alerting people to the existence of a fire (see Automatic fire-detection system).
 
Hazardous substance: See Dangerous substance. A substance subject to the Control of Substances Hazardous to Health Regulations 2002 (COSHH).
 
Healthcare building: a hospital, treatment centre, health centre, clinic, surgery, walk-in centre or other building where patients are provided with medical care by a clinician.
 
Height of a building (or storey): the distance from ground level at the lowest side of the building measured to the finished floor level of the top storey.
 
Highly flammable: generally liquids with a flashpoint of below 21?C. (The Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 (CHIP) give more detailed guidance.)
 
Hospital street: a special type of compartment which connects final exits, stairway enclosures and department entrances, and serves as a fire-fighting bridgehead and a safe evacuation route for occupants to parts of the building unaffected by fire.
 
Inner room: a room from which escape is possible only by passing through another room (the access room).
 
L1: Type of fire detection and alarm system that is installed throughout all areas of the building. The objective of a category L1 system is to offer the earliest possible warning of fire, so as to achieve the longest available time for escape. (For further guidance, see Health Technical Memorandum 05-03 Part B – ‘Fire detection and alarm systems’.)
 
Licensed premises: any premises that require a licence under any statute to undertake trade or conduct business activities.
 
Material change: an alteration to a building, process or service, which significantly affects the level of risk to people from a fire in those premises.
 
Material of limited combustibility: either:
 
a. a non-combustible material; or
 
b. any material of density 300 kg/m? or more which, when tested in accordance with
BS 476-11, does not flame, and whose rise in temperature on the furnace thermocouple is not more than 20?C; or
 
c. any material with a non-combustible core of 8 mm thickness or more, having combustible facings (on one or both sides) not more than
0.5 mm thick; or
 
d. any material of density less than 300 kg/m? which, when tested in accordance with BS 476- 11, does not flame for more than ten seconds and whose rise in temperature is not more than 35?C on the centre (specimen) thermocouple and not more than 25?C on the furnace thermocouple.
 
Means of escape: route(s) provided to ensure safe egress from premises or other locations to a place of total safety.
 
Non-combustible: any material which is capable of satisfying the performance requirements specified in BS 476-4, or any material which when tested in
accordance with BS 476-11 does not flame or cause any rise in temperature on either the centre (specimen) or furnace thermocouple.
 
Patient-access areas: those areas of the healthcare building to which patients have reasonable access either with or without supervision.
 
Place of relative safety: a place of temporary safety within a building. This may be an adjoining compartment or subcompartment capable of holding all those threatened, without a significant change in level and from which there is potential for further escape should that become necessary.
 
Place of safety: a place where persons are in no danger from fire and smoke.
 
Premises: any place, such as a building and the immediate land bounded by any enclosure of it, any tent, moveable or temporary structure or any installation or workplace.
 
 
 
 
 
 
Progressive horizontal evacuation: an escape strategy that allows the evacuation of patients away from a fire into a fire-free compartment or subcompartment on the same level.
 
Protected shaft: a shaft that enables persons, air or objects to pass from one compartment to another, and which is enclosed with fire-resisting construction.
 
Refuge: see Place of relative safety. Relevant boundary:
a. the actual boundary of the premises; or
 
b. the boundary of the site which the side of the building faces, and which is parallel, or at an angle of not more than 80?, to the side of the building; or
 
c. the centre line of a road, railway, river or canal which adjoins the actual boundary; or
 
d. a notional boundary established between buildings, if two or more buildings share the same site.
 
Relevant persons: any person lawfully on the premises and any person in the immediate vicinity, but does not include fire-fighters carrying out fire-fighting duties.
 
Responsible person: the person ultimately responsible for fire safety as defined in the Regulatory Reform (Fire Safety) Order 2005.
 
Self-closing device: a device that is capable of closing the door from any angle and against any latch fitted to the door.
 
Significant finding: the significant findings of a risk assessment (see ‘Statutory requirements’ section of this Health Technical  Memorandum).
 
Staged fire alarm: a fire warning system that can produce a number of staged alarms within a given area (that is, notifying staff, standby to evacuate, full evacuation).
 
Subcompartments: areas into which the building can be divided to reduce travel distance and which provide
30 minutes’ resistance to fire.
 
Subcompartment wall: a fire-resisting wall used to separate one subcompartment from another and having a minimum period of resistance of 30 minutes.
 
Travel distance: the actual distance to be travelled by a person from any point within the floor area to the nearest
 
adjoining compartment, subcompartment, escape stairway or external exit, having regard to the layout of walls, partitions, fittings and furniture.
 
Unprotected area: in relation to a side or external wall of building, this means:
 
a. a window, door or other opening; and
 
b. any part of an external wall which has a period of fire resistance less than that required for the elements of structure (integrity and load-bearing capacity only), and which provides less than 15 minutes’ fire resistance (insulation); and
 
c. any part of the external wall which has combustible material more than 1 mm thick attached or applied to its external face, whether for cladding or any other purpose.  (Combustible material in this context is a material which is neither “non-combustible” nor a “material of limited combustibility”.)
 
Vision panel: a transparent panel in a wall or door of an inner room enabling the occupant to become aware of a fire in the access area during the early stages.
 
Way guidance: low-mounted luminous tracks positioned on escape routes in combination with exit indicators, exit marking and intermediate direction indicators along the route, provided for use when the supply to the normal lighting fails, which do not rely on an electrical supply for their luminous output.
 
Where necessary: the Fire Safety Order 2005 requires that fire precautions (such as fire-fighting equipment, fire detection and warning, and emergency routes and exits) should be provided (and maintained) “where necessary”. These are the fire precautions provided (and maintained) to reasonably protect relevant people from risks to them in case of fire. This will be determined by the finding of the risk assessment, including the preventive measures that have or will have been taken. In practice, it is very unlikely that a properly conducted fire risk assessment, which takes into account all the matters relevant for the safety of people in case of fire, will conclude that no fire precautions (including maintenance) are necessary.
 
Young person: any person who has not attained the age of 18.
 
 
 
 
 
 
 
 
3 Statutory requirements
 
 
 
 
 
 
 
Introduction
 
3.1 This chapter summarises the main statutory requirements of the Fire Safety Order. For more information, see the “FSO Green Guide”.
 
3.2 The Fire Safety Order replaces previous fire safety legislation. Any fire certificate issued under the Fire Precautions Act 1971 will cease to have any effect.
 
3.3 Fire risk assessments under the Fire Precautions (Workplace) Regulations 1997 (as amended 1999) using Health Technical Memorandum 86 will need to be reviewed taking account of the wider scope of the Fire Safety Order.
 
3.4 If the healthcare organisation employs five or more people, the premises are licensed, or an alterations notice requiring the organisation to do so is in force, the significant findings of a risk assessment and the actions taken should be recorded. (For a list of details that should be included in significant findings, see Chapter 5, ‘Step 4 Record, plan, inform, instruct and train’.)
 
3.5 These findings should be supported by a plan of the premises, indicating the general fire precautions.
 
3.6 Dedicated records (including details of significant findings, any action taken, a copy of the emergency plan, maintenance of fire protection equipment and training) should be kept. An example is provided in Chapter 7, ‘Example of recordings of significant findings’.
 
3.7 Healthcare organisations must be able to satisfy the enforcing authority, if called upon to do so, that they have carried out a suitable and sufficient fire risk assessment. Keeping records will help to achieve this and will also form the basis of subsequent reviews. If records are kept, only significant details and any necessary action taken should be recorded.
 
3.8 The Fire Safety Order requires fire precautions to be put in place “where necessary” and to the extent
 
that it is reasonable and practicable in the circumstances of the case.
 
3.9 Responsibility for complying with the Fire Safety Order rests with the “responsible person”. In a workplace, this is the employer and any other person who may have control of any part of the premises (for example the occupier or owner). In all other premises, the person or people in control of the premises will be responsible.
 
3.10 If there is more than one responsible person in any type of premises (for example a multi-occupied complex), all must take all reasonable steps to cooperate and coordinate with each other.
 
Compliance monitoring by fire authorities
 
3.11 All fire authorities (FAs) in England and Wales have a statutory duty to enforce the provisions of the  Fire Safety Order.
 
3.12 The Fire Safety Order has moved fire safety law from the prescriptive approach of fire certificates (whereby enforcing authorities directed requirements) to a risk-based regime where responsibility for ensuring compliance clearly rests with those generating and managing the risk – the responsible person. The FA’s principal role is to monitor compliance by ensuring that a suitable and sufficient fire risk assessment has been undertaken in the premises to which the Fire Safety Order applies.
 
3.13 The Department for Communities and Local Government (DCLG) has issued fire safety risk assessment guidance for responsible persons, which provides recommendations and guidance (benchmarks) for use when assessing the adequacy of fire precautions in premises subject to the Fire Safety Order (see ‘Fire safety law and guidance documents for business’).
 
3.14 This Health Technical Memorandum is considered by the Chief Fire Officers’ Association (CFOA) to be an equally valid method to comply with fire
 
 
 
 
 
 
safety law. However, it should be borne in mind that this is one of a suite of guidance documents and it should be read/ applied in conjunction with other relevant Health Technical Memoranda and operational manuals.
 
3.15 DCLG has published the Fire and Rescue Service National Framework, setting out priorities for FAs with the aim of promoting public safety and the economy, efficiency and effectiveness of authorities and their functions (see ‘The Fire and Rescue Service National Framework’). This framework indicates that authorities must have a fire safety audit and inspection programme forming part of its integrated risk management plan (IRMP).
 
3.16 FAs are expected to operate a risk-based enforcement programme directing resources to those places that pose a significant risk to life. Hospitals are in the highest risk category; consequently, they will attract regular audit and inspections.
 
3.17 Fire-and-rescue services in England and Wales have adopted a data-gathering and fire safety audit process that has been agreed with DCLG to ensure a consistent approach to risk categorisation and enforcement.
 
3.18 This process is supported by several fire safety directives published by CFOA for FAs to adapt or adopt.
 
3.19 These directives cover all aspects of enforcement, audit and administration, and were produced by the National CFOA Regulatory Reform Fire Safety Order Working Group prior to the introduction of the Fire Safety Order. Further information is available at the CFOA website.
 
Compliance code
 
3.20 The enforcement policy is based on the principles of the compliance code to which all FAs are signatories. The CFOA directive has adopted and adapted the enforcement management model (EMM) used by the Health and Safety Executive and local authority enforcers. The EMM provides a framework to help inspectors make enforcement decisions in line with best practice, promoting consistent application by fire safety enforcement officers. This is not a procedure in its own right but captures the issues that inspectors consider when exercising their professional judgement, and it reflects the process by which enforcement decisions are reached.
3.21 
The EMM is a key tool to determine appropriate enforcement action, be it formal or informal action. Where there is no excessive risk and the residual risk is being adequately managed (often by provision of agreed interim measures), a  partnership approach is encouraged.
 
Note
 
The compliance code is an agreement between business and government on good enforcement in respect to fire safety law. It encourages enforcing authorities to be helpful, to actively work with businesses, especially small and medium-sized businesses, to advise on and to assist with compliance where appropriate.
 
 
Unwanted fire signals (UwFS)
 
3.22 Many hospital premises have significant numbers of unwanted fire signals from automatic fire- detection systems. FAs are increasingly recognising that this may be evidence of non-compliance with the requirements of the Fire Safety Order in that it may be an indication that:
 
? the fire warning system is not fit for purpose (standard and design); or
 
? the premises and/or system are not being adequately managed and maintained.
 
3.23 Health Technical Memorandum 05-03 Part H – ‘Reducing false alarms in healthcare premises’ gives guidance on reducing UwFS and should be referred to in consultation with the FA.
 
3.24 Many FAs are taking a firmer line with regard to dealing with premises with high numbers of UwFS in terms of both fire safety enforcement and operational-response options. Consequently, this may be an additional reason for hospital premises to attract audit, inspection or even enforcement action by FAs.
 
3.25 These unwanted calls cause a significant impact  and burden on hospital services, the community and the FAs, and should therefore be minimised. If healthcare organisations fail to act to reduce UwFS, the FA may require local assessment of an actuation of the fire alarm before a call is placed to the FA.
 
“As low as reasonably practicable” (ALARP)
 
3.26 When assessing the adequacy of fire precautions in premises and compliance with the Fire Safety
 
 
 
 
 
 
Order, a key concept is ALARP. This is defined in the DCLG guides:
 
[ALARP] “Is a concept where risks should continue to be reduced until you reach a point where the cost and effort to reduce the risk further would be grossly disproportionate to the benefit achieved.”
 
3.27 This is in line with health and safety guidance, which is well-established and is generally based on “good practice”. Further information is available from the Health & Safety Executive.
 
3.28 Health Technical Memorandum 05-03 Part B – ‘Fire detection and alarm systems’ specifies an L1 standard (L2 for treatment centres) for automatic fire detection and alarms. The provision of automatic detection as a compensating feature for another deficiency in general fire precautions is unacceptable.
 
3.29 FAs accept that the provision of L1 systems is best practice, to be attained within a time period agreed with the FA, and in premises whose fire risk assessment has found a need for improved protection (for example in some older premises).
 
3.30 The benefits of automatic detection – in providing an early warning of fire to allow the early evacuation of patients, public and staff before being affected – is well-established and clearly outweighs the cost and inconvenience of retrofitting. When making a decision around ALARP, the benefits and whether the cost is grossly disproportionate should be considered.
 
3.31 When a significant fire risk is identified, an action plan with appropriate timescales must be put in place by the responsible person and be agreed with the FA. The onus is on the responsible person to demonstrate what is not “reasonably practicable” (Article 34 of the Fire Safety Order).
 
3.32 When FAs are assessing the adequacy of the proposed automatic fire detection and taking decisions as to the appropriate level of enforcement action and timescales, they will consider all relevant issues such as the standard of all other general fire precautions and management (for example sprinklers or subcompartmentation).
 
Detection of fire by observation and by automatic fire-detection systems
 
3.33 The early detection of fire by people is probably the best form of detection, and the design and layout  of many healthcare premises make a positive contribution to fire safety in this way. Healthcare
 
fire statistics indicate that almost 70% of fires in hospitals are detected by staff, patients or visitors.
 
3.34 In a hospital or treatment centre, the most important aspect is the number of beds/ trolleys visible from the staff base, which is the base from which all staff work and where information is stored and exchanged. Although it is unlikely that the staff base will be permanently staffed, a location that provides good observation will improve the likelihood of a fire being detected at an early stage and enable a more effective filtering out of obvious false alarms.
 
3.35 For most ward layouts, staff are normally in a position to detect a fire early in its development approximately 90% of the time. For some ward layouts, where all the patient accommodation is in single rooms, the probability that staff can detect a fire early in its development is reduced. In these cases, the installation of an automatic fire detection and alarm system should be given a high priority. In planning the installation of a fire-detection system, consideration will need to be given to the provision of care in other accommodation when the system is being installed.
 
3.36 Where a ward layout facilitates a high degree of observation, the installation of an automatic fire detection and alarm system may be a lower priority, but must be installed within a time-frame agreed with the FA.
 
Staircases
 
3.37 In some older hospital premises, the number of staircases may be inadequate or not as wide as current Health Technical Memoranda or Approved Document B – ‘Fire safety’ standards require. In these instances, the cost of providing new and/or additional staircases would often be disproportionate to the benefits. In such circumstances, a suitable and sufficient fire risk assessment may show that provision of additional subcompartmentation, additional staff and staff training provides an equivalent level of safety for the occupants (each will be treated on its own merits).
 
Enforcement action
 
3.38 The preferred form of enforcement action by FAs in hospital premises (providing the responsible person is cooperative and making reasonable efforts to comply) is by way of an agreed action plan (see the CFOA directive); however, if the residual risk is
 
 
 
 
 
 
excessive, a formal enforcement notice may be issued.
 
3.39 FAs will discuss enforcement action with responsible persons and consider their views and attitudes prior to doing so. Consequently, if an FA is considering serving a formal enforcement notice and the technical solution cannot be agreed, the responsible person with the agreement of the FA may seek a determination (judgement) from the Secretary of State.
 
3.40 See Article 36 of the Fire Safety Order, and Regulatory Reform (Fire Safety) Order 2005 Guidance Note 2 on “Determination of disputes by the Secretary of State”.
 
3.41 However, if the responsible person or the FA do  not think a determination is an appropriate route of appeal, a formal appeal should be made to a magistrate within 21 days of the issue of the notice.
 
3.42 Every effort should have been made by those involved with the audit process, prior to the issue of the enforcement notice, to agree on the works required within the notice to ensure fire safety is to the required standard(s). This may involve full discussion with senior managers of both organisations at an early stage, preferably before the issue of the enforcement notice. If such discussion takes place after the issue of the enforcement notice, it should take place as soon as possible and in time to allow the responsible person to have recourse to court should this informal approach fail.
 
3.43 If an agreed action plan with the responsible person by the FA is not complied with, formal action would normally be taken by the issue of an enforcement notice and ultimately – if the enforcement notice is not complied with – prosecution.
 
3.44 If the hospital is planned for replacement, timescales should be taken into account. In the case of relatively short periods, such as two years, interim measures may be acceptable to reduce significant expenditure, but where the time periods are longer, it is unlikely that interim measures will be acceptable.
 
Fire safety audit process
 
3.45 The initial data-gathering and audit process by FAs, particularly in the first instance, consists of a number of phases:
Audit arranged with the relevant responsible person (normally one month prior).
 
? Data-gathering  implemented.
 
? Audit of risk assessment, systems, procedures, records and responsible person compliance against each specific duty (Articles) under the Fire Safety Order.
 
? Validation of the above (by inspection) – this could be all of the premises or only key elements.
 
? Assessment of the compliance level and calculation of the risk rating.
 
? Audit and inspection outcome, and feedback (for example, whether it is satisfactory or it requires some form of enforcement action, which may be formal or informal (including education and advice)).
 
? Follow-up inspection, if necessary.
 
? Scheduling of the next fire safety audit, depending on the level of compliance and premises risk.
 
3.46 Hospitals seldom comprise only one building.
Consequently, the inspecting officer will normally first establish which buildings and premises are separate and will then determine which to audit and inspect.
 
3.47 Many premises on hospital sites contain support services that are comparatively lower-risk and may not attract the same attention as those premises providing patient care. Further information can be found on the CFOA website.
 
3.48 It should be noted that other types of audit and inspection may be undertaken by fire safety inspectors (for example in response to complaints, UwFS or specific inspections). Additionally, operational fire-fighters may visit hospitals primarily to gather operational intelligence to prepare and plan for incidents under the Fire and Rescue Services Act 2004. Some FAs use operational crews to undertake fire safety visits of lower-risk premises (such as offices) on hospital sites.
 
Note
 
Authorised fire authority fire safety inspectors will not undertake fire risk assessments on behalf of the responsible person.
 
 
 
 
 
 
 
 
4 Assessment areas
 
 
 
 
 
 
 
4.1 To assess the fire hazards and people at risk and to evaluate the fire risk, the healthcare premises under consideration should be divided into a series of assessment areas. The boundaries of these assessment areas could be determined by the functional layout of the healthcare premises; normally each nursing and/or other management unit will be an assessment area.
 
4.2 Assessment areas may consist of more than one fire compartment, but the boundaries of the assessment area should be compartment walls and floors or sub-compartments.
 
4.3 Assessment areas that contain “very high dependency” patients (see Chapter 5, ‘Step 2’) should always be enclosed by compartment walls.
 
4.4 Assessment areas will not normally cover more than one floor, but may do so where a single nursing or management unit incorporates two different functions on different floors (for example sleeping areas and day spaces on separate storeys).
 
4.5 Escape routes from the assessment area should be included in the assessment. The escape route may include circulation spaces, stairways, escape bed lifts, the potential for refuge in adjacent areas on
 
the same level, escape to ground level, and final escape to a place of safety.
 
4.6 Assessments should be made of the healthcare premises in operation. It is not possible for an assessment to be wholly complete before occupation.
 
4.7 An assessment is dependent on many factors, including fire hazards, people at risk, building layout, physical fire precautions, staffing and management. A change in any of these will require a review and revision of the fire risk assessment. Non?patient-access areas of healthcare premises (particularly hospitals) which can present a hazard due to fires starting outside the assessment area (see Chapter 5, ‘Step 1’) should not be in the same compartment as the assessment area.
 
4.8 Having divided the healthcare premises into a number of assessment areas, it is then possible to undertake the fire risk assessment.
 
4.9 Chapter 5 of this Health Technical Memorandum covers patient-access areas (for example wards, out- patient departments, A&E, theatres) and associated non-patient-access areas (for example laundry, main kitchens, offices).
 
 
 
 
 
5 Risk assessment in patient-access areas
 
 
 
 
 
 
 
Introduction
 
5.1 This guidance adopts the five-step fire risk assessment process used in the “FSO Green Guide”. The correlation table in Chapter 1 indicates where the worksheets contained in Health Technical
 
Figure 1 The five steps of a fire risk assessment
 
FIRE SAFETY RISK ASSESSMENT
 
 
Identify fire hazards
 
Identify:
 
Memorandum 86 most readily correspond to the five-step fire risk assessment process contained in this guidance. The results of each assessment area should be recorded on separate assessment forms.
 
Sources of ignition Sources of fuel Sources of oxygen
 
Identify people at risk
 
Identify:
People in and around the premises People especially at risk
 
Evaluate, remove, reduce and protect from risk
 
Evaluate the risk of a fire occurring
Evaluate the risk to people from fire Remove or reduce fire hazards Remove or reduce the risks to people
? Detection and warning
? Fire-fighting
? Escape routes
? Lighting
? Signs and notices
? Maintenance
 
Record, plan, inform, instruct and train
 
Record significant finding and action taken
Prepare an emergency plan
Inform and instruct relevant people; cooperate and coordinate with others Provide training
 
Review
 
Keep assessment under review
Revise where necessary
 
Remember to keep to your fire risk assessment under review
 
 
 
 
 
 
5.2 This chapter highlights which parts of the fire risk assessment process NHS organisations may have to undertake for the first time and which parts can, after review, build on existing fire risk assessments. For example, worksheets relating to the identification of hazards will now incorporate the philosophy used in the “FSO Green Guide”, which requires fire risks to be “as low as reasonably practicable” (ALARP) with a greater emphasis on the prevention of fires.
 
5.3 This chapter also highlights those tasks that NHS organisations should undertake after they have assessed their fire risks.
 
5.4 Patient-access areas are those areas of healthcare premises to which patients have access either with or without supervision and either as in-patients or as out-patients. They include all areas containing escape routes used by patients.
 
5.5 Commercial enterprises within hospital premises, which may be frequented by patients, are considered in Health Technical Memorandum 05- 03 Part D – ‘Commercial enterprises in healthcare premises’ and in the relevant guide to the Fire Safety Order (see ‘Communities – Fire safety law/ aboutguides’).
 
Managing fire safety
 
5.6 Good management of fire safety (see Health Technical Memorandum 05-01 – ‘Managing healthcare fire safety’) is essential to ensure that  fires are unlikely to occur. However, if they do occur, they must be rapidly detected and extinguished or contained. If a fire does develop, everyone in the premises should be able to escape  to a place of safety in accordance with the fire safety strategy outlined in Health Technical  Memorandum 05-01, Chapters 5–7. (See also the “FSO Green Guide”.)
 
5.7 Chief executives of trusts should develop an adequate fire strategy to:
 
? ensure that their management policies regarding fire safety comply with the relevant guidance in Health Technical Memorandum 05-01;
 
? ensure that sufficient and adequately trained staff are available at all material times (day and/ or night) to provide for the safe evacuation of patients from the assessment area, in accordance with the emergency evacuation plan (see
Step 4);
maintain an up-to-date set of drawings showing the assessment areas, which should indicate:
 
(i) alarm and detection systems;
 
(ii) means of escape;
 
(iii) compartmentation;
 
(iv) first-aid fire-fighting equipment; and
 
(v) access and facilities for fire-and-rescue services;
 
? keep up-to-date records for a minimum of three years of all maintenance work, instruction and training, and fire drills. Records should be included for:
 
(i) means for detecting and giving warning in the event of fire;
 
(ii) means for fighting fire;
 
(iii) automatic fire-suppression systems;
 
(iv) any smoke-management, smoke-control or smoke-venting systems;
 
(v) escape lighting systems;
 
(vi) fire doors and fire-exit doors;
 
(vii) instruction and training; and
 
(viii) fire drills.
 
5.8 Records should include:
 
? the date on which the testing and maintenance was carried out and by whom;
 
? the date on which any defects were reported and the action taken to remedy such defects; and
 
? the date on which the defect was remedied and by whom.
 
5.9 Further information on managing fire safety is available in Health Technical Memorandum 05-01.
 
Step 1: Identifying fire hazards
 
Introduction
 
5.10 For a fire to start, three elements are needed:
 
? a source of ignition;
 
? fuel; and
 
? oxygen.
 
Identify sources of ignition
 
5.11 Sources could include:
 
 
 
 
 
 
? arson (for example by patients who suffer from mental illness);
 
? smoking materials (for example cigarettes, matches and lighters);
 
? naked flames (for example matches, candles or gas- or liquid-fuelled open-flame equipment);
 
? electrical, gas- or oil-fired heaters (fixed or portable);
 
? cooking equipment;
 
? faulty or misused electrical equipment;
 
? lighting equipment;
 
? hot surfaces and obstruction of equipment ventilation;
 
? hot processes (for example welding by contractors);
 
? other work processes;
 
? lightning; and
 
? chemicals used for cleaning, laundering and some clinical processes.
 
5.12 Fires may be started by patients, either accidentally or deliberately, and particularly by:
 
? patients with mental health problems;
 
? older people;
 
? people with learning disabilities;
 
? young people with disabilities.
 
5.13 Indications of “near-misses”, such as scorch marks on furniture or fittings, discoloured or charred electrical plugs and sockets, cigarette burns etc can help to identify hazards that may not otherwise be noticed.
 
Fire hazard rooms
 
5.14 Certain rooms within patient-access areas of healthcare premises constitute a particular fire hazard. These are known as “fire hazard rooms” and may include:
 
? chemical stores;
 
? cleaners’ rooms;
 
? linen stores;
 
? clothes storage;
 
? dayrooms;
 
? disposal rooms;
laboratories;
 
? lift-motor rooms;
 
? patient bedrooms provided for:
 
(i) older people;
 
(ii) people with mental health problems;
 
(iii) people with learning disabilities;
 
? relatives’ overnight accommodation;
 
? staff changing rooms;
 
? storerooms;
 
? ward/residential/staff kitchens;
 
? X-ray film and record stores;
 
? all rooms within the main laundry in which delivery, sorting, processing and packing and storing are carried out.
 
Non-patient-access areas
 
5.15 Non-patient-access areas of healthcare premises (particularly hospitals) can present a hazard to patient-access areas due to fires starting outside the assessment area, for example:
 
? boilerhouses;
 
? sterile services departments;
 
? central staff changing;
 
? flammable stores;
 
? laundries;
 
? main electrical gear;
 
? main kitchens;
 
? main stores;
 
? medical gas stores;
 
? medical records;
 
? pathology departments;
 
? patient services;
 
? pharmaceutical (manufacturing) areas;
 
? waste collection/disposal areas, incineration works.
 
Identify sources of fuel
 
5.16 Some of the most common fuels found in premises providing healthcare are:
 
 
 
 
 
 
? laundry supplies (such as bedding and towels) and medical supplies (such as disposable aprons);
 
? toiletries, aerosols, wall and ceiling hangings, and linings;
 
? plastics, rubber (for example soft play or restraint areas), video tapes and polyurethane;
 
? foam-filled furniture, foam-filled mats and polystyrene-based display materials;
 
? wood or wood-based furniture, textiles and soft furnishings (such as spare clothes and hanging curtains);
 
? clothing, private belongings (such as toys), and seasonal and religious-occasion decorations (such as Christmas decorations);
 
? flammable products (such as cleaning and decorating products, petrol, white spirit, methylated spirit, cooking oils, disposable cigarette lighters, and hand-sanitising solutions);
 
? flammable gases such as liquefied petroleum gas (LPG), including aerosol canisters; and
 
? waste products, particularly finely divided items such as shredded paper and wood shavings, off- cuts and dust.
 
5.17 Physiotherapy departments and X-ray departments (particularly film storage) can present a significant source of flammable material.
 
5.18 Consideration should be given to the materials used to line walls and ceilings (for example murals, materials used for hospital art projects, and noticeboards) and how they might contribute to the spread of fire.
 
Identify sources of oxygen
 
5.19 In addition to medical gas pipeline systems and cylinders (see Health Technical Memorandum
02-01 – ‘Medical gas pipeline systems’), sources of oxygen can sometimes be found in materials used or stored at premises, such as:
 
? some chemicals (oxidising materials), which can provide a fire with additional oxygen and so help it to burn. These chemicals should be identified on their container (and Control of Substances Hazardous to Health (COSHH) data sheet) by the manufacturer or supplier, who can advise as to their safe use and storage; or
oxygen supplies from cylinder storage and piped systems (for example medical oxygen and oxygen used by contractors such as in welding processes).
 
Step 2: Identifying people at risk
 
Introduction
 
5.20 All people who are likely to use the premises should be considered, but particular attention should be paid to people who may be especially at risk, such as:
 
? employees who work alone, either regularly or  at specific times and/or in isolated areas – especially at night (for example cleaners, security staff, maintenance staff, nursing staff and care staff );
 
? people who are unfamiliar with the premises (for example agency or temporary staff, guests, visitors (including visiting medical or social care staff ) and contractors);
 
? patients who are unable to escape unaided (young children, babies, older people, physically disabled people (in particular people with mobility impairment), mentally disabled people, people with vision or hearing impairment, those with some other sensory impairment, and those whose ability to escape unassisted is impaired due to their medical condition or medication,  or who may be intoxicated);
 
? people who are not able to leave the premises quickly, but who do not require assistance (for example older patients or visitors who have limited disabilities);
 
? parents with children;
 
? people with language difficulties; or
 
? other persons in the immediate vicinity of the premises.
 
5.21 The risk assessment should take into account the patient’s medical conditions, sensory awareness and mobility. In complex healthcare premises providing services for patients with very high dependency (such as those in critical care areas, special care baby units, operating theatres or those suffering from mental illness) or disabled people, it may also be necessary to seek expert advice of another competent person (for example clinical staff ).
 
 
 
 
 
 
Dependency of patients
 
5.22 For the purposes of this document, occupants are classified as independent (including patients), dependent or very high dependency (these latter two terms refer to patients only), based upon a broad consideration of their anticipated mobility and/or dependence. The categories differentiate between the anticipated dependence of various occupants, either during an evacuation or as a consequence of the treatment they are receiving.
 
Independent
 
5.23 Patients will be defined as being independent if their mobility is not impaired in any way and they are able to physically leave the premises without staff assistance, or if they experience some mobility impairment and rely on another person to offer minimal assistance. This would include being sufficiently able to negotiate stairs unaided or with minimal assistance, as well as being able to comprehend the emergency wayfinding signage around the facility.
 
Dependent
 
5.24 Patients who are classed as neither “independent” nor “very high dependency” are classed as dependent  patients.
 
Very high dependency
 
5.25 Patients with very high dependency are those whose clinical treatment and/or condition creates a high dependency on staff. This will include those in critical care areas, operating theatres and those where evacuation would prove potentially life- threatening.
 
5.26 Assessment areas will include a mix of people with a range of dependencies. Some will be able to escape without assistance; others will require considerable extra help to do so.
 
5.27 Any assessment will need to be based on the clinical dependency/care needs of the majority, but it must also take into account any individuals at risk, such as those listed in paragraph 5.20.
 
Step 3: Evaluate, remove, reduce and protect from risk
 
Introduction
 
5.28 The management of the premises and the way people use them will have an effect on the evaluation of risk.
5.29 
To maintain a pleasant healing environment and non-institutional atmosphere, precautions should be introduced carefully, taking account of any possible adverse effects on the quality of service- users’ lives and the care they receive, without compromising the safety of the occupants in case of fire.
 
Evaluate the risk of a fire occurring
 
5.30 The chances of a fire starting will be low if the premises are well-managed and have limited ignition sources that are kept well away from combustible materials. In general, fires start in one of three ways:
 
? accidentally, such as when smoking materials are not properly extinguished or when lighting displays are knocked over;
 
? by defect, act or omission, such as when electrical office equipment is not properly maintained or when waste packaging is allowed to accumulate near a heat source; or
 
? deliberately, such as an arson attack where external waste receptacles placed too close to the building have been set on fire (see Health Technical Memorandum 05-03 Part F – ‘Arson prevention in NHS premises’ for further guidance).
 
5.31 It is important to:
 
? look critically at the premises and try to identify any incident waiting to happen and any acts or omissions which might allow a fire to start;
 
? investigate previous fire history and reported near misses;
 
? look for any situation that may present an opportunity for an arsonist.
 
Evaluate the risk to people
 
5.32 It is essential that the means of escape and other fire precautions are adequate to ensure that everyone can make their escape to a place of total safety before the fire and its effects can trap them in the building.
 
5.33 In evaluating this risk to people, situations such as the following should be considered:
 
? Fire starting on a lower floor affecting the escape routes for people on upper floors or the only escape route for people with disabilities.
 
 
 
 
 
 
? Fire developing in an unoccupied space that people have to pass by to escape from the building.
 
? Fire or smoke spreading through a building – affecting people in remote areas – via routes such as vertical shafts, service ducts, ventilation systems, poorly installed, poorly maintained or damaged walls, and partitions and ceilings.
 
? Where ventilation systems might assist the spread of flames, smoke and hot gases from a fire, it will be necessary to take steps to safeguard the means of escape against this hazard. Ventilation ducts should be fitted with fire dampers (which close on actuation of the fire alarm) where they cross compartment boundaries (walls or floors). In subcompartment walls, dampers which operate on fusible links may be used. (Further information can be found in Health Technical Memorandum 05-02.) In some premises, the dirty extract may continue  to operate after the activation of the alarm, where it flows directly out of the building.
 
? Fire and smoke spreading through a building due to poor installation of fire precautions (for example incorrectly installed fire doors or incorrectly installed services penetrating fire walls).
 
? Fire and smoke spreading through the building due to poorly maintained and damaged fire doors or fire doors being wedged open.
 
5.34 Particular consideration should be given to fires that may start in non-patient?access areas, which affect adjacent patient-access areas.
 
5.35 With the exception of fire doors to mental health patients’ bedrooms, all fire-resisting doors – other than those to locked cupboards and service ducts
– should normally be fitted with:
 
? an appropriately controlled self-closing device (with an automatic hold-open device if necessary); or
 
? a free-swing controlled door-closing device that will close the door from any angle on operation of the fire alarm or automatic fire-detection system.
 
5.36 Any other variation must be justified within the fire risk assessment.
 
 
Note
 
Additional nursing arrangements may be necessary in mental health accommodation (for example constant observation for mental health patients with high-risk emotional and behavioural difficulties such as self- harm, arson etc); within these arrangements, control measures might include higher levels of training, staff etc.
 
5.37 Where self-closing devices are not fitted to fire doors, this should be taken into account in the ward’s fire safety management procedures. Further guidance can be found in Health Technical Memorandum 05-01 and Appendix B2 of the “FSO Green Guide”.
 
5.38 For occupants with very high dependency (see  Step 2), the provision of additional fire precautions should be considered, such as:
 
? visual observation;
 
? lower travel distance;
 
? increased refuge;
 
? lower height above ground;
 
? higher numbers of staff;
 
? escape bed lifts; and
 
? automatic suppression systems (for example sprinklers).
 
Remove or reduce the hazards
 
5.39 Having identified the fire hazards in Step 1, healthcare organisations should remove those hazards if it is reasonably practicable to do so. If they cannot be removed, reasonable steps should be taken to reduce them. This is an essential part of fire risk assessment and, as a priority, this must take place before any other actions. It is important to make sure that any actions taken to remove or reduce fire hazards or risk are not substituted by other hazards or risks.
 
Remove or reduce sources of ignition
 
5.40 The first option should always be the removal of the ignition source; however, if that is not feasible, there are various ways to reduce the risk caused by potential sources of ignition, for example:
 
? Wherever possible, replace a potential source by a safer alternative.
 
 
 
 
 
 
? Replace naked-flame and radiant heaters with fixed convector heaters or a central heating system. Restrict the movement of, and guard, portable heating appliances.
 
? Ensure that electrical, mechanical and gas equipment is installed, used, maintained and protected in accordance with the manufacturer’s instructions.
 
? Safe systems of work should be established, adhered to and periodically re-evaluated (see also Health Technical Memorandum 05-03 Part A – ‘General fire safety’ for more information on the reduction of fire hazards and general fire precautions).
 
? Take precautions to avoid arson. Arson should be addressed in the fire safety and waste management policies for the healthcare premises (see Health Technical Memorandum 05-01). Guidance on the prevention of arson is available in Health Technical Memorandum 05-03 Part F
– ‘Arson prevention in NHS premises’ and includes:
 
(i) site access;
 
(ii) building access;
 
(iii) design of staff circulation routes to increase passive surveillance;
 
(iv) the reduction of unfrequented areas;
 
(v) use of CCTV and specialist staff;
 
(vi) restricted access to sensitive areas (stores, plantrooms etc) and to disused (or derelict) buildings.
 
? A permit-to-work system should be in place to ensure that:
 
(i) all areas where hot work (for example welding) has been carried out are checked to confirm that no ignition has taken place and no smouldering materials remain;
 
(ii) sources of ignition such as blow-lamps or hot-air guns are not used when work is carried out on gas fittings, which involves exposing pipes that contain or have contained flammable gas.
 
? Healthcare premises should have adequate protection from lightning. BS EN 62305-1–4 give guidance on the design of systems for the protection of structures against lightning. Specialist advice from a suitably qualified person
 
or installer should be sought. All lightning protection systems should be visually inspected once in every 12-month period by a suitably qualified person, and a record of inspections kept.
 
Remove or reduce sources of fuel
 
5.41 The first option should always be the removal of the fuel; however, if that is not feasible, there are various ways to reduce the risks caused by materials and substances that burn, for example:
 
? Remove or treat large areas of highly combustible wall and ceiling linings (for example polystyrene or carpet tiles) to reduce the rate of flame spread across the surface.
 
? Reduce waste and flammable materials, liquids and gases in all areas to a minimum. Keep remaining stock in dedicated storerooms or storage areas – preferably outside, where only authorised staff are allowed – and only store the minimum required for the operation of the premises.
 
? Ensure that flammable materials, liquids and gases are kept to a minimum and are stored properly with adequate separation distances between them.
 
? Do not keep incompatible flammable materials together.
 
? Develop a formal system for the control of combustible waste (including toxic and contaminated waste) by ensuring that waste materials and rubbish are not allowed to build up and are carefully stored until properly disposed of, particularly at the end of the day.
 
? Main medical gas stores should always be located in separate buildings (see Health Technical Memorandum 02-01 for more guidance).
 
? Take action to avoid any parts of the premises, and in particular storage areas, being vulnerable to arson or vandalism.
 
? Textiles and furniture can present a significant fire hazard. In patient-access areas, textiles and furniture should comply with the guidance in Health Technical Memorandum 05-03 Part C
– ‘Textiles and furnishings’.
 
 
 
 
 
 
Other materials
 
5.42 Further guidance on the reduction of fire hazards from other materials can be found in Health Technical Memorandum 05-03 Part A – ‘General fire safety’. Other materials can include:
 
? aerosol sprays;
 
? flammable liquids;
 
? medical gases;
 
? LPGs;
 
? disposable goods and packaging made from paper, plastic and expanded foam;
 
? combustible waste.
 
5.43 This list is not definitive, and other combustible materials may be present in patient/resident access areas of healthcare premises.
 
Remove or reduce sources of oxygen
 
5.44 Reduce the potential source of oxygen supplied to a fire by:
 
? closing all doors, windows and other openings not required for ventilation;
 
? shutting down ventilation systems that are not essential to the function of the premises;
 
? not storing oxidising materials near, or with, any heat source or flammable materials;
 
? controlling the use and storage of oxygen cylinders and/or piped oxygen, ensuring that they are not leaking;
 
? maintaining piped oxygen supplies in accordance with the manufacturer’s instructions; and
 
? ensuring that shut-off valves for use in an emergency are available and located such that they are easily accessible in the event of a fire and that staff are trained in their use (cross- reference should be made to the healthcare organisation’s medical gases policy).
 
Flexibility of fire protection measures
 
5.45 Flexibility will be required when applying this guidance; the level of fire protection should be proportional to the risk posed to the safety of the people in the premises. Therefore, the objective should be to reduce the remaining risk to a level as low as reasonably practicable. The higher the risk of fire and risk to life, the higher the standards of fire
 
protection will need to be. However, the risk  should be reduced to as low as possible before putting in place additional fire protection measures.
 
Fire detection and warning systems
 
5.46 All complex healthcare premises will need some form of system for detecting fire and warning the occupants. Staff and/or automatic fire-detection and warning systems can provide detection and warning of fire. Current guidance for new hospitals recommends an L1 detection and alarm system. Treatment centres should be protected to an L2 standard. Older hospitals may not achieve this standard of detection and alarm. Therefore, as part of future refurbishment or upgrading of fire precautions, this lower standard should be improved within a time period agreed with the FA.
 
Fire detection and alarm systems
 
5.47 Any fire detection and alarm systems should comply with Health Technical Memorandum
05-03 Part B – ‘Fire detection and alarm systems’, which provides general principles and technology guidance on the design, specification, installation, commissioning, testing, operation and maintenance of fire-alarm systems in healthcare premises. It should be read in conjunction with BS 5839-1.
 
5.48 False alarms from fire warning systems are a major problem and result in many unwanted calls to the fire-and-rescue service every year. To help reduce the number of false alarms, the design and location of activation devices should be reviewed against the way the premises are currently used (see Health Technical Memorandum 05-03 Part H – ‘Reducing false alarms in healthcare premises’).
 
Fire-fighting equipment and facilities
 
5.49 Extinguishers should primarily be used to protect life and facilitate safe escape.
 
5.50 People with no training (for example visitors and members of the public) should not be expected to attempt to extinguish a fire. However, all staff should be familiar with the location and basic operating procedures for the equipment provided, in case they need to use it. If the fire strategy means that certain people, for example fire marshals, will be expected to take a more active role, they should be provided with more comprehensive training.
 
5.51 Other fixed installations and facilities, such as dry rising mains, access for fire-and-rescue-service vehicles or automatically-operated fixed fire-
 
 
 
 
 
 
suppression systems (for example sprinklers and gas or foam flooding systems), may also have been provided. Where provided, such equipment and facilities must be maintained.
 
Manual fire-fighting equipment
 
5.52 Hand-held extinguishers, fire blankets and hose reels should be provided as necessary. Portable extinguishers should comply with BS EN 3 parts 3, 6 and 7 and should be inspected and maintained in accordance with BS 5306-3. Hose-reel installations should conform to the relevant section of
BS 5306-1.
 
5.53 Generally, there should be one 13A-rated extinguisher for every 200 m?, or part thereof, or at least two extinguishers per floor. Extinguishers using carbon dioxide or other media should be provided as required. Fire blankets should be provided in all cooking and pantry areas. Guidance on the means of extinguishing various classes of fire is provided in Health Technical Memorandum
05-03 Part A – ‘General fire safety’.
 
Sprinklers
 
5.54 Fire safety in healthcare premises does not normally require the installation of any form of automatic suppression system such as sprinklers; however, it may be present for a range of reasons including:
 
? the facilitation of delayed evacuation;
 
? property protection;
 
? business/service continuity where the facility provides specialist services (for example a regional cancer centre); and
 
? part of a fire-engineered solution.
 
5.55 Automatic fire-suppression systems will normally form part of a fire-engineering solution and may mitigate some of the risks associated with:
 
? dependent and very high dependency patients;
 
? lack of fire-resisting construction around fire hazard rooms;
 
? poor levels of observation;
 
? reduced fire protection to elements of structure; or
 
? insufficient external-envelope protection.
 
5.56 The installation of life-safety automatic fire- suppression systems (normally sprinklers) should be considered in all new healthcare premises (see
 
paragraph 6.94 of Health Technical Memorandum 05-02). Where the premises provide specialist care, for example a regional cancer centre, the impact of fire, however small, could have a devastating effect on patient care. In existing healthcare premises, consideration should be given to the fitting of fire- suppression systems where the fire risk assessment justifies such a provision.
 
Escape routes and strategies
 
5.57 Once a fire has started, has been detected and a warning has been given, occupants should be able to escape safely, either unaided or with assistance, but without the help of the fire-and-rescue service. The escape routes and their evacuation strategy should form part of a fire safety strategy for the premises, which should also include the procedures for operating and maintaining any fire protection measures necessary for the safe operation of the building. Appendix G of Health Technical Memorandum 05-02, and Health Technical Memorandum 05-01, provide further guidance on the development and documentation of fire safety strategies and procedures.
 
Evacuation
 
5.58 In all cases, escape routes should be designed to ensure, as far as possible, that any person confronted by fire anywhere in the building should be able to turn away from it and escape (or be evacuated), either direct to a place of total safety (single-stage evacuation) or initially to a place of reasonable safety (progressive horizontal evacuation), depending on the escape strategy adopted.
 
5.59 A place of reasonable safety can be an adjacent subcompartment or compartment on the same level. From there, further escape will be possible either to another adjacent compartment or to a protected stairway or direct to final exit.
 
Means of escape and security
 
5.60 Exit doors on escape routes and final-exit doors should normally open in the direction of travel and be quickly and easily openable without the need for a key or special knowledge (for more information, see Chapter 8, ‘Provision and use of electronic locks on doors’).
 
 
 
 
 
 
Powered sliding doors
 
5.61 Sliding doors are acceptable on escape routes in healthcare premises, provided they convert to outward-opening doors when subjected to reasonable pressure from any direction. In the case of powered sliding doors, they should be installed to ensure that they fail-safe to the fully open position in the event of a power failure. For further information on actuation of release mechanisms, see BS 7273-4.
 
Single-direction escape
 
5.62 The maximum distance to be travelled before there is a choice of escape route or a protected escape route is 15 m (see Figure 2).
 
5.63 The risks from an increased single-direction-escape travel distance could be mitigated by:
 
? a high degree of observation;
 
? adequately trained staff and use only by independent patients; or
 
? a reduced overall travel distance.
 
5.64 Single-direction escape may include escape from an inner room (a room only accessible through an access room), provided that:
 
? the total distance to be travelled before there is a choice of escape route is carefully considered;
 
? the access room is not a fire hazard room; and
 
? the access room is fitted with automatic fire detection.
 
Overall travel distance
 
5.65 Travel distance is the maximum horizontal distance to be travelled between any point to one of the following:
 
? an adjoining compartment;
 
? a subcompartment;
 
? an escape stairway; or
 
? the outside.
 
5.66 The first part of this may be escape in a single direction before there is a choice of escape routes (see Figure 3).
 
5.67 The maximum overall distance to be travelled within a subcompartment is 30 m.
 
5.68 The design of circulation spaces (corridors or defined routes in open-plan areas) should ensure
 
that it is possible to evacuate patients from the assessment area by the most appropriate method. In order to assess the suitability of circulation spaces, there should be an emergency evacuation plan for the assessment area, stating the preferred methods of evacuation (see Step 4).
 
5.69 A flat roof may form part of an escape route in older hospitals, provided that:
 
? there are an adequate number of staff available to assist with the evacuation;
 
? the patients are not categorised as “dependent” and “very high dependency” (see Health Technical Memorandum 05-02, Appendix H);
 
? the use of the route would not be prejudiced by smoke and flame issuing from openings in the building envelope;
 
? the roof construction will provide a period of fire resistance of at least 60 minutes;
 
? the route is defined, has a non-slip surface and has adequate handrails;
 
? escape lighting is provided for the route.
 
Subdivision of corridors
 
5.70 In healthcare premises (other than those accommodating dependent or very high dependency patients) where the corridors are more than 30 m long, the corridors should be subdivided near their centre by fire doors and, where necessary, fire-resisting construction so as to limit the spread of fire and smoke and to protect escape routes if there is a fire. Very often this can be achieved through the use of subcompartmentation.
 
5.71 In premises where there are dependent or very high dependency patients, hospital streets (where used) should be subdivided at 30 m intervals.
 
5.72 Where other corridors form part of the circulation routes, subdivision with fire doors and fire-resisting construction should be in line with the travel distances for subcompartmentation.
 
Note
 
Hospital design – even those with a hospital street – is based on the principle of protected areas (or subcompartments and compartments) rather than protecting corridors, which would be functionally restrictive.
 
 
 
 
 
Figure 2 Measurement of single-direction travel distance
 
 
 
The maximum travel distance in a single direction of escape, before there is a choice of escape routes, should be no more than 15 m
 
 
 
 
 
Inner room
 
 
 
Outer room (this should not be a fire hazard room)
 
Single direction escape in this instance includes:
? travel within the inner room; and
? travel within the outer room.
 
 
 
 
 
 
 
 
 
 
 
 
Single direction escape in this instance includes only travel within the room
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Single direction escape in this instance includes:
? travel within the room; and
? travel within the circulation space until there is a choice of escape routes.
 
 
 
 
 
Figure 3  Measurement of overall escape distance
 
 
Adjoining compartment
or subcompartment
 
 
 
Circulation space
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note:
Travel distance includes single-direction escape
 
 
 
 
5.73 Where a corridor serves two exits from a floor,  these corridors should be subdivided with fire doors to separate the two exits.
 
5.74 Doors that are provided solely for the purpose of restricting the travel of smoke need not be fire doors, but will be suitable as long as they are:
 
? of substantial construction;
 
? capable of resisting the passage of smoke; and
 
? self-closing.
 
5.75 Doors on circulation routes fitted with a self- closing device should incorporate an electromagnetic hold-open device that is activated by the operation of the fire-detection and alarm system (see Health Technical Memorandum 05-03 Part B). Smoke should not be able to bypass these doors (for example above a false ceiling, or via alternative doors from a room or adjoining rooms that open on either side of the subdivision).
 
Protected stairways
 
5.76 The positioning and design of stairways should ensure that it is possible to evacuate all patients from the assessment area by the most appropriate method. To assess the suitability of stairways, there should be an emergency evacuation plan for the
 
assessment area, stating the preferred methods of evacuation (see Step 4 and Health Technical Memorandum  05-01).
 
5.77 A protected stairway can be considered suitable (see paragraph 5.116, ‘Compartmentation’) if it is in a protected shaft and has direct access, or protected access, to the outside at ground or access level. Such access should be suitable for the evacuation of patients and lead to a place of total safety away from the building.
 
5.78 A stairway may serve more than one assessment area, but the aggregate width of the stairways provided should be sufficient for the number of people likely to be evacuated, taking into account the evacuation policy of the healthcare premises.
 
5.79 External stairways should not be prejudiced by smoke and flames issuing from openings in the building envelope (for example windows, doors – see Figure 4), and may not be appropriate for some patients with very high dependency.
 
5.80 For dependent or very high dependency patients, their accommodation, and therefore the assessment area, should be on a floor no more than 12 m above ground-floor level (typically three floors – see Figure 5).
 
 
 
 
 
 
Figure 4  Fire resistance of areas around external stairways
 
 
 
 
1.8 m
 
 
1.8 m
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Defined zone for fire-resisting walls, doors and windows on an external stairway. Windows within this area should provide a period of resistance of at least 30 minutes
 
 
Figure 5  Height above ground
5.81 
Where assessment areas are higher than the third storey (that is, higher than three storey heights above ground level), increased risk to dependent or very high dependency patients can typically be mitigated by combinations of:
 
? increased number of compartments;
 
? additional staircases;
 
? provision of escape lifts; and
 
? small compartment sizes.
 
5.82 If an assessment area is on two floors, the position of the higher floor should be considered in determining the height above ground level (see Chapter 4, ‘Assessment areas’).
 
5.83 For guidance regarding basements, see the ‘FSO Green Guide’.
 
Staff-assisted evacuation
 
5.84 For dependent and very high dependency patients, it is the responsibility of the local management to devise suitable arrangements to ensure that adequate numbers of staff are on duty and available at all times (during meal breaks etc).
 
5.85 A minimum of two staff present at all times (three if there are over 30 patients) should be available to evacuate patients. These staff members should have received training in the methods of patient evacuation appropriate to the dependency of the
 
 
 
Third floor
 
 
 
 
 
 
Second floor
 
 
 
 
 
First floor
 
 
 
 
 
Ground floor
 
 
 
 
 
 
patient and should be familiar with the evacuation procedures of their place of work. It is essential that the agreed evacuation strategies and procedures (see paragraph 5.6 ‘Managing fire safety’) recognise that an effective evacuation will depend on assistance given by staff from adjacent, and other, compartments in accordance with the hospital’s emergency response procedures.
 
Escape bed lifts
 
5.86 If very high dependency patients are present in the assessment area, escape bed lifts can be used to partly reduce the fire risk they experience due to their dependency.
 
5.87 Where escape lifts are installed, there should be a minimum of two and they should comply with the guidance in Health Technical Memorandum 05-03 Part E – ‘Escape bed lifts’. The lift lobby at ground or access level should provide access, or protected access, to the outside.
 
Emergency escape lighting
 
5.88 If there is a fire, occupants must be able to find their way to a place of safety by using escape routes that have enough lighting. Where any escape routes are internal and without windows or the premises are used during periods of darkness (including early darkness on winter days), some form of back-up to the normal escape-route lighting should be provided.
 
5.89 In most healthcare premises, a comprehensive system of automatic emergency escape lighting should be in place to illuminate all the escape routes. In addition, where people have difficulty seeing conventional signs, a “way guidance” system may need to be considered.
 
5.90 Escape lighting is required to illuminate the circulation spaces in the event of a fire and to guard against a failure of electrical supply. Health Technical Memorandum 06-01 – ‘Electrical services: supply and distribution’ gives guidance on escape lighting and details of the electrical supply required to ensure that sufficient normal lighting is on a maintained essential supply circuit (for healthcare and fire safety purposes).
 
Signs and notices
 
5.91 In some premises, it is important to avoid an institutional environment. However, signs must be used, where necessary, to help people to identify escape routes and fire-fighting equipment. These
 
signs are required under the Health and Safety (Safety Signs and Signals) Regulations 1996 and must comply with the provisions of these regulations.
 
5.92 Where the locations of escape routes and fire- fighting equipment are readily apparent and visible at all times, signs are not necessary.
 
5.93 Notices must be used, where necessary, to provide the following:
 
? instructions on how to use any fire safety equipment;
 
? the actions to be taken in the event of a fire; and
 
? information for the fire-and-rescue service (for example location of sprinkler valves or electrical cut-off switches).
 
5.94 All signs and notices should be positioned so that they can be easily seen and understood.
 
Fire signs and notices
 
5.95 Fire signs should be provided where appropriate in conspicuous positions. Fire signs should be recognisable, readable and informative. They should convey essential information to regular and infrequent users of the premises and the fire-and- rescue services. The visibility, illumination and height of display should be carefully considered.
 
5.96 Fire action notices should be permanently displayed in conspicuous positions throughout the assessment area and should be specific to it. Additional fire action notices giving further instruction should be displayed on staff noticeboards, in staff rooms and in residential accommodation. The purpose of fire action notices is to give concise instructions on the actions to be taken on discovering a fire and on hearing the alarm. Details of the emergency evacuation plan relevant to the assessment area should be included.
 
Surface finishes
 
5.97 The finish applied to walls and ceilings can contribute to the spread of fire. Some finishes will transfer fire from one area to another very quickly by surface spread of flame. This not only makes the fire difficult to control, but provides additional fuel, which will increase the severity of the fire.
 
5.98 Class 0 is the highest product performance classification but is not a classification identified in any British Standard test. Class 0 is defined in
 
 
 
 
 
 
Approved Document B of the Building Regulations.
 
5.99 Surface finishes that can be effectively tested for surface spread of flame are rated for performance by reference to the method specified in BS 476-7. Under this standard, materials or products are classified 1, 2, 3 or 4, with Class 1 being the highest.
 
5.100 The classes normally used in healthcare premises are Class 0 or Class 1 (or their corresponding BS EN classifications), and the following table gives guidance on classifications for use in specific areas:
 
Location
Walls
Ceiling
Circulation spaces
Class 0
Class 0
Other rooms
Class 0
Class 1
Small rooms (up to 4 m?)
Class 1
Class 1
5.101 The following generic materials and products all achieve a Class 0 rating:
 
? products classified as non-combustible when tested to BS 476-4;
 
? brickwork, blockwork, concrete and ceramic tiles;
 
? plasterboard (painted or not, or with a PVC facing not more than 0.5 mm thick) with or without an air-gap, or fibrous or cellular insulating material behind;
 
? wood-wool cement slabs; and
 
? mineral-fibre tiles or sheets with cement or resin binding.
 
5.102 The following materials may also achieve Class 0 but, as the properties of different products with the same generic description vary, the ratings of these materials/products should be substantiated by test evidence:
 
? aluminium-faced fibre-insulating boards;
 
? flame-retardant decorative laminates on calcium-silicate board;
 
? thick polycarbonate sheet;
 
? phenolic sheet; and
 
? unplasticised polyvinyl chloride (uPVC).
 
5.103 The following generic materials and products all achieve a Class 1 rating – all Class 0 materials referred to above plus:
 
? timber;
hardboard;
 
? blockboard;
 
? particle board;
 
? heavy flock wallpapers; and
 
? thermosetting plastics – if flame-retardant- treated to achieve a Class 1 standard.
 
5.104 The following materials may also achieve Class 1 but, as the properties of different products with the same generic description vary, the ratings of these materials/ products should be substantiated by test evidence:
 
? phenolic or melamine laminates on a calcium- silicate substrate; and
 
? flame-retardant decorative laminates on a combustible core.
 
Additional finishes
 
5.105 Where walls are covered by temporary surfaces (such as posters, fabrics, prints and decorations), the significance of these needs to be considered.
 
5.106 Small, adequately separated areas with surface finishes of a lower classification than specified may be acceptable provided they do not amount to more than 5% of the total wall area (for example noticeboards).
 
5.107 Where walls have been subject to repeated painting over a number of years with gloss paints, the accumulated thickness of paint film may present a high fire hazard and provide for rapid transfer of fire over its surface. Where this situation exists, specialist technical advice should be obtained.
 
5.108 The use of anti-graffiti and intumescent paints requires careful consideration, especially when they are applied over existing painted surfaces. Full technical guidance should always be obtained from the manufacturer.
 
Floor coverings
 
5.109 The finish applied to a floor may also contribute to the spread of fire. (Health Technical Memorandum 61 – ‘Flooring’ gives guidance on the selection of floor finishes for hospitals.)
 
5.110 Although hardwood flooring is not considered a fire hazard, the finish applied to certain flooring materials may, over a period of time, accumulate and constitute a fire hazard.
 
 
 
 
 
 
5.111 The accumulation, over a number of years, of wax polish applied to a timber floor will pose a significant fire hazard.
 
Fire-resisting structures
 
Fire hazard rooms
 
5.112 These rooms should be enclosed in fire-resisting construction to ensure that they do not represent a serious fire hazard (fire hazard rooms are listed in Step 1).
 
5.113 Alternatively, an automatic fire-suppression system, such as sprinklers, could be used to ensure that fire hazard rooms do not represent a serious fire hazard.
 
Non-patient-access areas
 
5.114 Non-patient-access areas of complex healthcare premises (particularly hospitals) that can present a hazard due to fires starting outside the assessment area (see Step 1) should not be in the same compartment as the assessment area.
 
5.115 If dependent or very high dependency patients (see Step 2) are in a compartment adjoining a non- patient-access area listed in Step 1 (either horizontally or vertically), additional fire precautions may be necessary. In certain cases, the adjacency should not be permitted (see Table 1 in Health Technical Memorandum 05-02).
 
Compartmentation
 
5.116 In preparing the assessment area, it is important to check that the boundaries of the assessment area are either compartment or subcompartment walls. A compartment should have a fire-resisting floor that is used to separate one fire compartment from another and should have a minimum period of fire resistance of 60 minutes (see Chapter 4, ‘Assessment areas’).
 
5.117 For healthcare premises containing dependent or very high dependency patients, the maximum compartment size within the assessment area should be 900–2000 m? (900–3000 m? in single- storey buildings).
 
5.118 To maintain the integrity of compartmentation, openings should be adequately fire-stopped and limited to:
 
? doors which have a period of fire resistance not less than that of the compartment structure;
the following pipes and their diameters:
 
(i) cast-iron or steel pipes – not more than 160 mm diameter;
 
(ii) pipes of other materials – not more than 40 mm diameter;
 
(iii) pipes such as those supporting vacuum operated tissue-sample pod transport systems, with a proprietary seal which has been shown by test to maintain the fire resistance of the compartment structure
– any diameter;
 
? ventilation ducts that comply with the requirements of BS 9999;
 
? waste and laundry chutes of non-combustible construction which are accessed through fire- resisting doors; and
 
? protected shafts.
 
5.119 Openings in compartment floors for stairways, lifts and escalators, and pipes and ducts not complying with the previous paragraph, should be enclosed in a protected shaft that has the same period of fire resistance (integrity, insulation and, where applicable, load-bearing capacity) as the compartment floor.
 
5.120 The protected shaft/stairway should form a complete barrier to fire between different compartments to which the shaft connects.
 
5.121 Access to a protected shaft from a circulation space should be through doors and doorsets that provide a period of fire resistance of at least 60 minutes.
 
5.122 Access to a protected shaft from a room should be through a lobby. The combined fire resistance of the two sets of doors or doorsets to the lobby should be at least 60 minutes.
 
5.123 Means of ventilating protected shafts in the event of fire should be provided as follows:
 
? for a protected shaft containing a stairway – at the top of the stairway, an openable window, or similar, providing an area of 1 m?;
 
? for a protected shaft containing a lift or lifts, a permanent opening of 0.1 m? for each lift.
 
Subdivision of roof and ceiling voids
 
5.124 Any roof or ceiling void above an assessment area should be subdivided by 30-minute fire-resisting barriers such that the maximum undivided area
 
 
 
 
 
 
does not exceed 400 m?. Openings should be limited to:
 
? doors which have at least 30 minutes’ fire resistance;
 
? pipes that satisfy the guidance given at
paragraph 5.116.
 
Elements of structure
 
5.125 For the safety of dependent and very high dependency patients, staff and fire-fighters, elements of structure (such as a column or other parts of a structural frame, a load-bearing wall or a floor) should possess the following minimum levels of fire resistance:
 
? single-storey healthcare premises – 30 minutes;
 
? healthcare premises with floors between one and four storey heights above ground –
60 minutes;
 
? healthcare premises with floors above four storey heights above ground – 90 minutes;
 
? healthcare premises with basements two or more storeys deep – 90 minutes.
 
5.126 A level of fire resistance 30 minutes lower than the levels given in the paragraph above (with a minimum fire resistance of 30 minutes) can only be mitigated by an automatic suppression system (such as sprinklers).
 
Sandwich panels
 
5.127 Some buildings used as healthcare premises, or as part of a healthcare facility, have insulated core panels as exterior cladding or for internal structures and partitions.
 
5.128 Insulated core panels are easily constructed, which enables alterations and additional internal partitions to be erected with minimum disruption.
 
5.129 They normally consist of a central insulated core that is sandwiched between an inner and outer metal skin with no air-gap. The external surface is then normally coated with a PVC covering to improve weather resistance or the aesthetic appeal of the panel. The central core can be made of various insulating materials, ranging from virtually non-combustible through to highly combustible.
 
5.130 As it is difficult to identify the material that makes up a panel’s central core, best practice can help to reduce any additional risk:
Do not store highly combustible materials or install heating appliances such as baking ovens against the panels.
 
? Control ignition sources that are adjacent to, or penetrating, the panels.
 
? Have damaged panels or sealed joints repaired immediately and make sure that jointing compounds or gaskets used around the edges of the panels are in good order.
 
? Where openings have been made for doors, windows, cables and ducts, check that these have been effectively sealed and the inner core has not been exposed.
 
? Ensure that there has been no mechanical damage (for example caused by mobile equipment such as wheelchairs) – if so, repair any that has occurred.
 
? Ensure that any loads, such as storage and equipment, are only supported by panels that have been designed and installed to perform this function.
 
5.131 The panels should be installed by a competent person in accordance with industry guidance.
 
5.132 The use of combustible panels in healthcare premises should be carefully considered. The fire risk assessment may need to be revised to ensure that any increased risk resulting from this type of construction is considered. Wherever possible, panels with a non-combustible core should be used.
 
5.133 Further guidance on insulated core panels and the panel-labelling scheme can be found in Health Technical Memorandum 05-02.
 
External-envelope  protection
 
5.134 The external wall or roof should provide sufficient fire resistance to prevent external fire spread from adjacent buildings or part of the same building in different compartments.
 
5.135 The importance of external-envelope protection for existing buildings depends on the proximity of adjacent buildings or compartments within the same building. In an isolated building surrounded by parkland, for example, the external-envelope protection may not be important. However, where the building is surrounded by similar buildings on a compact urban site, external-envelope protection becomes important.
 
 
 
 
 
 
Junction of walls and low-level roofs
 
5.136 Where a roof abuts an external wall, the roof should provide a period of fire resistance of at least 60 minutes for a distance of 3 m from the wall (see Figure 6). However, where the area below the low- level roof is protected by automatic fire  suppression (for example sprinklers), the fire resistance requirement could be reduced.
 
 
 
 
Figure 6 Fire resistance at junction of external walls and low-level roofs
 
3 m
 
Junction of compartment walls and external walls
 
5.137 When a compartment (or subcompartment) wall meets an external wall, there should be a 1 m wide storey-height strip of external wall that has a period of fire resistance at least equal to that of the compartment (or subcompartment) wall, to prevent fire spread between compartments (or subcompartments) (see Figure 7).
 
Unprotected area
 
5.138 The maximum percentage of unprotected area in an external wall should be determined from the graph in Figure 8.
 
5.139 Other methods of determining space separation are described in Building Research Establishment (BRE) Report 187 – ‘External fire spread: building separation and boundary distances’.
 
 
 
 
 
 
 
External wall –
   no fire resistance
 
 
Shaded area of low-level roof (including any rooflights) to provide
60 minutes’ resistance to fire and smoke
 
 
 
Low-level roof (flat or pitched) – no fire resistance
 
Smoke control
 
5.140 Fire safety in healthcare premises does not normally require the installation of any form of mechanical smoke control; however, it may be present for a range of reasons including:
 
? an atrium smoke-control/extract system;
 
? a pressurised stairway in accordance with BS EN 12101-6; or
 
 
 
 
 
 
 
Figure 7 Junction of compartment walls and external walls
 
Figure 8  Unprotected areas
 
Distance from building/site boundary (m)
 
 
 
 
 
 
 
Compartment or subcompartment wall
 
 
External wall minimum 1 m in length
 
12.5
 
10
 
7.5
 
5
 
2.5
 
0
100   90
 
Percentage of unprotected area
 
 
 
 
 
 
 
Compartment or subcompartment wall
 
External wall minimum 1 m in length
 
 
Notes:
1. A relevant boundary may also be a notional boundary between two buildings on the same site.
 
2. Where the building is fitted with sprinklers throughout, the distance to the relevant boundary may be halved, subject to a minimum distance of 1 m being maintained.
 
 
 
 
 
 
? a Nucleus or other hospital with smoke extraction from the hospital street.
 
5.141 Smoke control will normally form part of a fire- engineering solution and may mitigate some of the risks associated with extended single and/or overall travel distance (see Health Technical  Memorandum 05-03 Part J – ‘Guidance on fire engineering of healthcare premises’).
 
Installation testing and maintenance
 
5.142 The following are examples of checks and tests that should be considered.
 
Daily checks
 
5.143 The following checks should be carried out daily:
 
? Remove bolts, padlocks and security devices from fire exits.
 
? Ensure that doors on escape routes swing freely and close fully.
 
? Check exits and escape routes to ensure that they are clear from obstructions and combustible materials, and are in a good state of repair.
 
? Check the fire-alarm panel to ensure that the system is active and fully operational.
 
? Where practicable, visually check that emergency-lighting units are in good repair and apparently working.
 
? Check that all safety signs and notices are legible.
 
Weekly tests and checks
 
5.144 The following checks should be carried out weekly:
 
? Test fire-detection and warning systems, manually-operated warning devices, door hold- open devices, and electronically-controlled locking mechanisms and other devices interfaced with the fire-alarm control panel, following the manufacturer’s or installer’s instructions.
 
? Check that fire extinguishers and hose reels are correctly located and in apparent working order.
 
Monthly tests and checks
 
5.145 The following checks should be carried out monthly:
Test all emergency lighting systems to make sure they have enough charge and illumination according to the manufacturer’s or supplier’s instructions.
 
? Check that all fire doors are in good working order and closing correctly, and that the frames and seals are intact.
 
Six-monthly tests and checks
 
5.146 A competent person should test and maintain the fire-detection and warning system.
 
Annual tests and checks
 
5.147 The emergency lighting and all fire-fighting equipment, fire alarms and other installed systems should be tested and maintained by a competent person. All structural fire protection and elements of fire compartmentation should be inspected and any remedial action carried out.
 
5.148 Equipment can cause a fire hazard in an assessment area. Therefore:
 
? an effective programme of planned preventive maintenance should be in operation throughout the healthcare premises;
 
? there should be an agreed procedure for reporting faults;
 
? action should be taken to repair faults once reported, or otherwise to ensure that the equipment is made safe;
 
? there should be an adequate number of electrical sockets for the equipment used in each room;
 
? there should be clear user instructions for complex electrical equipment;
 
? extension leads, two-way adaptors etc should be used only under the direction of a suitably qualified member of staff/other person;
 
? the wiring of plugs should not be carried out by untrained members of staff; and
 
? personal electrical equipment should only be used after it has been checked by a suitably qualified member of staff/other person.
 
 
 
 
 
 
Step 4: Record, plan, inform, instruct and train
 
Record the significant findings and action taken
 
5.149 Significant findings should include details of:
 
? the fire hazards identified;
 
? the actions that have been taken or that will be taken to remove or reduce the chance of a fire occurring (preventive measures);
 
? persons who may be at risk, particularly those at greatest risk;
 
? the actions that have been taken or that will be taken to reduce the risk to people from the spread of fire and smoke (protective measures);
 
? the actions people need to take in case of fire, including details of any persons nominated to carry out a particular function (the emergency plan);
 
? the information, instruction and training identified that people need and how it will be given;
 
? evidence of cooperation and coordination with other occupants;
 
? evidence of significant findings of risk assessments conducted under regulations relating to DSEAR (Dangerous Substances and Explosive Atmospheres Regulations 2002) and Article 16 of the Fire Safety Order.
 
5.150 For further information see Chapter 7, ‘Example of recordings of significant findings’.
 
5.151 Healthcare organisations must be able to satisfy  the enforcing authority, if called upon to do so, that a suitable and sufficient fire risk assessment has been undertaken. Keeping records will assist with this and will also form the basis of subsequent reviews. Where records are kept, not all details will be necessary for the enforcing authority – only those that are significant and those recording any action that has been taken (see Chapter 3, ‘Statutory requirements’).
 
5.152 The fire risk assessment report should include a simple line drawing to illustrate the fire precautions (see Figure 9). This can help to monitor precautions as part of any ongoing review.
 
Emergency  plans
 
5.153 An emergency plan for dealing with any fire situation should be in place.
 
5.154 The purpose of an emergency plan is to ensure that:
 
? where practicable, all staff know what to do if there is a fire; and
 
? the premises can be safely evacuated.
 
5.155 The emergency plan should be based on the fire safety strategy (see ‘Risk assessment in patient- access areas’) (which may be revised based on the outcome of the fire risk assessment) and be available for employees, their representatives (where appointed), patients (if they request it) and the enforcing authority.
 
5.156 In most premises providing healthcare, the emergency plan will need to be detailed and, where necessary, compiled only after consultation with the other occupiers of the premises and the responsible people (for example other occupiers in a multi-occupied building or those who have control over any part). In most cases, this means a single emergency plan covering the whole  building. One person should be designated to coordinate this task.
 
5.157 The guidance on emergency plans in Health Technical Memorandum 05-03 Part – ‘General fire safety’ and Chapters 6 and 7 of Health Technical Memorandum 05-01 should be followed.
 
Inform, instruct, cooperate and coordinate
 
5.158 Clear and relevant information and appropriate instructions should be given to staff and the employers of other people working in the premises, such as contractors, about how to prevent fires and what they should do if there is a fire. In some premises it may also be prudent to give  information to patients and regular visitors.
 
5.159 All relevant persons (for example contractors) should give and receive information about the fire safety arrangements and the findings of their and the healthcare organisation’s fire risk assessments; both risk assessments should be amended accordingly, if necessary, before they start work.
 
Information and instruction
 
5.160 All staff, including agency and bank staff, should be given information and instruction relevant to
 
 
 
 
 
Figure 9  Example of a line drawing showing general fire safety precautions
 
 
 
Six-bed room
 
Five-bed room
WC
 
 
 
WC
 
 
WCS ingleWC
bed roomFD
30
FDWC
 
 
S ingle bed room
 
 
S ingle bed room
 
30FD
30
 
FD 30
                                   FE FD
30
 
 
Glazing
 
 
FD 60
S taff base
 
 
 
 
Five-bed room
FD 30
 
ADL
kitchen
 
ADL
bath-
room
 
 
 
 
 
Sister’s
 
WCWC
 
 
FD 30
S taff
 
Assisted bathroom
 
 
Dirty utility
 
 
Clean utility
 
 
W W
 
 
 
 
FDSingle bed room
30
 
 
BFD
30
 
office
 
c hangeClothing s tore
 
 
Assisted
s howerWC
 
 
FD
FD30
30FD
FEW30
 
 
FD
30FD
60FE
 
 
 
 
FDLift
30
 
Staff
restWCFD
room 30
E quipment s tore
 
P antryTreatment room
FD 30
 
 
 
FD
30Four-bed room
 
WC
 
 
P atients utility
 
 
Day room/dining room
FDFD
3060
 
 
FD
Therapy30
FD 30
WC
Quiet room
FE
FD 60
 
 
 
60-minute fire-resisting wall 30-minute fire-resisting wall
FD      60-minute fire-door
FD         30-minute fire-door (S denotes smoke seal
D denotes hold-open device) Push-button break-glass fire alarm
Audible fire alarm
 
Smoke detector
 
 
 
Heat detector
 
Portable fire extinguisher
 
C        Fire extinguisher – carbon dioxide
 
F        Fire extinguisher – foam
 
W     Fire extinguisher – water
 
P         Fire extinguisher – dry powder
 
B         Fire blanket
 
  Hose reel
 
 
 
W        Visual alarm
 
M      Mimic fire alarm
FE       Illuminated fire exit Emergency lighting
FE      Escape chair FE       Smoke hood FE       Fire exit sign PAlarm panel
 
NI     Fire action notice
 
 
 
the overall fire safety strategy and their specific area of work, as soon as they start work and regularly after that. Specific consideration should be given to staff who work outside normal working hours, such as contract cleaners or maintenance staff.
5.161 
The information and instruction given should be based on the emergency plan and must include:
 
? the fire safety strategy;
 
? the significant findings from the fire risk assessment;
 
 
 
 
 
 
? the measures that have been put in place to reduce the risk;
 
? what staff should do if there is a fire;
 
? the identity of people nominated with responsibilities for fire safety; and
 
? any special arrangements for serious and imminent danger to persons from fire.
 
5.162 Fire action notices can complement this information and, where used, should be posted in prominent locations.
 
5.163 Information about the premises should be readily available for the attending fire-and-rescue services. The information should be located at a pre-agreed location (usually the main entrance area). Information needed by fire crews about premises’ construction, contents, hazards and built-in fire protection measures is becoming increasingly complex; the more information that can be made available, the lower the risk to occupants, fire crews and, potentially, the premises.
 
5.164 Further guidance on information and instruction to staff and on working with dangerous substances is given in Health Technical Memorandum 05-01 and Health Technical Memorandum 05-03 Part A
– ‘General fire safety’.
 
Cooperation and coordination
 
5.165 In non-NHS-owned premises (for example PFI), or where there is more than one occupier and where others are responsible for different parts of the building, it is important that:
take account of the findings of the fire risk assessment;
 
? explain the emergency procedures;
 
? take account of the work activity and explain the duties and responsibilities of staff.
 
5.168 Health Technical Memorandum 05-03 Part A – ‘General fire safety’ offers more guidance on staff training.
 
5.169 Training should not be reliant solely on computer- based instruction and/or the use of video, but should include face-to-face training delivered by a person competent to do so and, where appropriate, should include practical demonstrations and/or exercise.
 
Step 5: Review
 
5.170 The fire risk assessment should be a dynamic document that is maintained under constant review. The following are typical examples of reasons to review the validity of the current fire risk assessment:
 
? changes to the work process, the way work is organised or the introduction of new equipment;
 
? alterations to the premises;
 
? changes in use or occupation of the premises;
 
? substantial changes to furnishings and fixings that may affect fire safety;
 
? the failure of fire precautions/fire protection systems.
 
 
? liaison takes place between the various parties;
5.171
The fire risk assessment does not need to be
? they are made aware of any significant risks
 
amended for every trivial change. However, should
that have been identified; and
 
a change introduce new hazards, these hazards
 
? any significant findings of their fire risk assessments are taken into account.
 
5.166 Employees have a responsibility to cooperate with their employer so far as it is necessary to help the employer to comply with any legal duty.
 
Fire safety training
 
5.167 Adequate fire safety training for staff should be provided. The type of training should be based on the particular features of the premises and should:
 
must be considered. If they are significant,
necessary action should be taken to eliminate the risk or reduce ALARP.
 
 
 
 
 
6 Examples of alternative solutions
 
 
 
 
 
 
 
Introduction
 
6.1 The following examples (see the table below) demonstrate generally acceptable layouts showing appropriate fire protection measures to ensure the safety of people using the premises. These are not intended to be prescriptive or exhaustive but merely to help understand how the principles of means of escape may be applied in practice (see also Figure 5 for clarity on floor levels).
 
6.2 They are illustrative of the key features of the fire protection arrangements and not intended to be typical layouts. It may not be necessary to read all of this section, but only to consider those examples which most closely resemble the assessment areas.
 
Typical building examples
Example number
 
Example title
A
Ground to second floor with very high dependency patients
B
Ground to second floor with patients with a high propensity to start fires
C
Ground to second floor with poor observation of patients’ beds
D
Floors on or above the third-floor level accommodating patient-care areas
E
Dependent patients with highly infectious diseases
F
Delayed evacuation of very high dependency patients
6.3 In all these examples, the following basic principles apply:
 
? The furthest point on any floor to the final exit or storey exit to a protected stairway is within the overall suggested travel distance (see
Figure 3).
 
? The area near the exit is kept clear of combustibles and obstructions.
 
? There are sufficient protected stairways that are kept clear of combustibles and obstructions.
The escape route leads to a final exit.
 
? Where the stairway is not protected (for example atria), the final exit is visible and accessible from the discharge point of the stairway at ground-floor level.
 
? High-risk rooms do not generally open directly into a protected stairway.
 
? If the fire risk assessment shows that people using any floor would be unaware of a fire, it may require additional fire-protection measures.
 
? Combustible materials such as surface finishes, textiles and furnishings, and other materials comply with Health Technical Memorandum 05-03 Part C – ‘Textiles and furnishings’.
 
? Ignition sources comply with Health Technical Memorandum 05-03 Part A – ‘General fire safety’.
 
? Fire safety management complies with Health Technical Memorandum 05-01.
 
? Staff numbers are appropriate for progressive horizontal evacuation of the type and number of patients.
 
? Elements of structure, compartmentation and external fire spread comply with Health Technical Memorandum 05-02.
 
? Fire extinguishing such as manual fire-fighting equipment and access and facilities for the fire- and-rescue service comply with Health Technical Memorandum 05-03 Part A and Health Technical Memorandum 05-02.
 
A. Ground to second floor with very high dependency patients
 
6.4 Patients whose clinical treatment and/or condition creates a very high dependency on clinical staff (for example those in critical care areas, special care baby units or operating theatres) require additional fire precautions.
 
 
 
 
 
 
6.5 The additional protection for very high dependency patients can include a combination of:
 
? a high level of observation (more than 75% of beds from the staff base);
 
? a high number of staff (at least four staff members present at all times, six if there are over 30 patients on a ward);
 
? a high degree of refuge;
 
? more subcompartmentation around fire hazard rooms where it would not dilute levels of observation of beds;
 
? the installation of auto-suppression in key areas.
 
6.6 The above combination of measures is intended to:
 
? enable first-aid fire-fighting;
 
? increase the time available for escape by way of early detection of the fire; and
 
? reduce evacuation time by way of staff numbers and refuge.
 
B. Ground to second floor with patients with a high propensity to start fires
 
6.7 Patients who may have a high propensity to start fires either accidentally or deliberately include:
 
? older people;
 
? patients suffering from mental illness;
 
? patients with drug or alcohol dependency.
 
6.8 The additional protection for areas containing these patients can include:
 
? a high level of observation (more than 75% of beds from the staff base); or
 
? a very high standard of automatic detection (including air-sampling systems in addition to the standard L1 to ensure that any fire is detected early in its development).
 
6.9 The above measures are intended to increase the time available for escape by way of early detection of the fire.
 
C. Ground to second floor with poor observation of patients’ beds
 
6.10 On wards, most fires are detected by staff observing smoke at an early stage of the fire’s development.
6.11 
However, many wards have single rooms, which means that fewer patient beds are visually observable from the staff base.
 
6.12 Where observation is poor, additional protection can include:
 
? a high number of staff (at least four staff members present at all times, six if there are over 30 patients in a ward);
 
? an automatic suppression system such as a water sprinkler system; or
 
? a combination of: -short travel distances, and -a high degree of refuge.
 
6.13 The above measures are intended to:
 
? enable first-aid fire-fighting;
 
? increase the time available for escape by way of early detection of the fire;
 
? reduce evacuation time by way of staff numbers or a combination of fire precautions; or
 
? reduce fire severity due to suppression.
 
6.14 Of course it is also possible to increase the observation, but this may be undesirable for nursing or clinical reasons.
 
D. Floors on or above the third-floor level accommodating patient-care areas
 
6.15 The greater the height that patients are located at, the more difficult it is for them to receive assistance in the event of a fire or use vertical egress should that become necessary. Therefore, use of the third or higher floor for the care of very high dependency patients should only be considered where these restrictions are negated.
 
6.16 The additional protection for patients on or above a third floor can include a combination of:
 
? an increase in the number of compartments and/or  subcompartments;
 
? installation of escape bed lifts; and
 
? small compartments (that is, less than 900 m?).
 
6.17 The above measures are intended to enhance facilities for progressive horizontal evacuation and vertical evacuation should that become necessary.
 
6.18 Of course it may be possible to relocate in-patient accommodation in the future.
 
6  Examples of alternative solutions
 
 
 
 
 
E. Dependent patients with highly infectious diseases
 
6.19 These are likely to be specialised locations in a limited number of hospitals. The clinical condition of the patient requires them to be isolated from all other patients/ wards.
 
6.20 A higher standard of fire protection should be applied to minimise the need for evacuation. The following should be considered:
 
? additional fire-resisting construction/ compartmentation;
 
? double-door protection (although provided for infection control, it provides an additional bonus for fire protection);
 
? a high level of observation;
 
? a higher level of fire training for staff;
 
? pre-planned communications (to inform ward staff of location and development of the incident in order to allow for risk assessment with regard to when to evacuate the isolation area);
 
? pre-planned evacuation route to minimise the effects of infection.
 
F. Delayed evacuation of very high dependency patients
 
6.21 Very high dependency patients in operating theatres or critical care areas may not be able to be moved until they have been stabilised and prepared for evacuation.
 
6.22 Full evacuation is usually only undertaken as a last resort. This delay will require additional fire precautions irrespective of patients’ location and height above ground level.
 
6.23 The additional protection for very high dependency patients can include a combination of:
 
? a very high level of observation;
 
? a very high staff-to-patient ratio;
 
? a high degree of refuge;
 
? additional  subcompartmentation;
 
? a higher level of fire training for staff, appropriate to their specific location;
good communications (both within the department and between the coordinator and the fire service);
 
? additional zoning of the fire alarm.
 
6.24 The provision of sprinklers should also be considered, if appropriate.
 
Hospitals designed to the Nucleus standards
 
6.25 Nucleus hospitals are those that were designated as conforming to the “Nucleus” concept by submission to the Department of Health. Such hospitals generally used standard departmental designs with minor modifications agreed locally with the fire authority. In addition to complete hospitals, Nucleus extensions were built to a number of existing hospitals; they were also classified as conforming to the Nucleus principles in the same way.
 
6.26 Some hospitals were not designed to Health Technical Memorandum 05-02 (formerly Health Technical Memorandum 81) but were designed to conform to the principles of Nucleus fire precautions. The objective of the Nucleus fire- precaution strategy is to provide life safety, not property protection.
 
6.27 There are seven main areas where Nucleus hospitals differ from other hospitals:
 
? management;
 
? detection and alarm;
 
? means of escape;
 
? fire and smoke containment;
 
? smoke dispersal;
 
? separation of fire hazards;
 
? fire-fighting provisions.
 
6.28 Nucleus fire precautions were an integral part of  the Nucleus hospital design system. The design strategy provided for the control and containment of a fire as well as for the safe evacuation of patients and other personnel. In common with Approved Document B of the Building Regulations and Health Technical Memorandum 05-02, it is assumed that there will only be one fire at a time within the hospital complex.
 
6.29 The Nucleus design provides a high standard of fire safety and, provided all the fire safety measures that
 
 
 
 
 
 
were part of the original Nucleus design are maintained and the management aspects of fire safety are acceptable, the overall level of fire safety should be acceptable. For this reason, it is important that the original as-built fire plans are available.
 
6.30 NHS trusts with hospitals that have incorporated Nucleus fire precautions should maintain their records and drawings to inform the fire risk assessment of these premises.
 
“Nucleus-related”
 
6.31 Some hospitals were loosely termed “Nucleus- related”. These hospitals used the cruciform template as the basis for planning, but did not fully adopt the Nucleus principles and were not designated by the Department of Health as Nucleus. The fire precautions in these hospitals were designed to comply with Health Technical Memorandum 81. Nucleus fire precautions recommendations should not be used in these hospitals.
 
 
 
 
 
7 Example of recording of significant findings
 
 
 
 
 
 
 
 
Ref
no.LocationFindings
 
 
 Variation/ justification or action required
 
 
 
Interim control measures
 
 
 
 Final control measures & date
 
 
Initial/ final risk rating
 
 
 
 Person responsible
 
Date completed/ Competent Person initials
 
 
 
 
 
 
 
 
8 Provision and use of electronic locks on doors
 
 
 
 
 
 
 
Introduction
 
8.1 The use of electronic locks on doors throughout healthcare premises is common practice. In order to use these devices effectively, reference should be made to BS 7273-4 and to Health Technical Memorandum 05-03 Part B.
 
8.2 Before deciding on the use of electronic locks, other methods of providing security should be considered. Advice should be sought from the trust local security management specialist as well as the trust fire safety adviser.
 
8.3 Where the use of an electronic lock is the only suitable solution, variations from the British Standard and Health Technical Memoranda will need to be justified on an individual risk assessment basis.
 
Escape routes and security
 
8.4 All doors on escape routes and final exit doors should normally open in the direction of travel and be quickly and easily openable without the need for a key. This is the starting point for all securing devices.
 
8.5 Exceptionally, there are specific life-safety protection reasons for additional security. If this is the case, each circumstance should be assessed individually. Such circumstances may include:
 
? maternity areas, where there is demonstrable evidence of abduction risks;
 
? mental health units, where the safety of patients, staff and members of the public could be at risk and where security of drugs is particularly important.
 
8.6 Additional security measures put in place simply to secure areas from theft or to manage the movement of people are not appropriate.
 
8.7 The need for extensive escape routes through sensitive areas should be addressed at design stage.
8.8 
However, it is accepted that in certain situations issues may arise, particularly in premises that provide accommodation for people with mental illness, where it may be essential to maintain a high level of supervision during an evacuation. In these situations, doors that open automatically on the activation of the fire-alarm system may not be acceptable, since patients would be able to leave and not necessarily follow the safest evacuation route, or could abscond, possibly placing themselves or others at risk. It would also be more difficult to establish that everyone had been safely removed from the fire-affected area.
 
8.9 In areas where this type of security is important, the staffing levels should be sufficient to allow the operation of a key-operated, or other staff- controlled, evacuation system. Any slight delay in opening doors compared with an automatic system should be compensated for by the ability of a well- trained staff team to organise a controlled evacuation more quickly.
 
8.10 The relationship between the securing of doors against unwanted entry and the ability to escape through them easily in an emergency has often proved problematical. Careful planning and the use of quality materials remain the most effective means of satisfying both of these objectives. Any device that impedes people making good their escape, either by being unnecessarily complicated to manipulate or not being readily openable, is not acceptable. It is at this stage where close cooperation between fire safety and security personnel is essential.
 
8.11 Acceptable securing devices that deny unauthorised access can take many forms, but in most premises where there are members of the public present or where users are not familiar with the building, panic exit bars (that is, push bars or touch bars) should be used. For further information, see BS EN 1125.
 
8.12 Premises that have limited numbers of staff or where most users are familiar with the building and
 
8 Provision and use of electronic locks on doors
 
 
 
 
 
where panic is not likely may use alternative devices (that is, push pads or lever handles). For further information, see BS EN 179.
 
Electrical locking devices
 
8.13 Electrically-operated entry-control devices have been developed and adapted for use as securing devices on fire exits. They fall into two main categories – electromechanical and electromagnetic:
 
? Electromechanical devices comprise electromechanical lock-keeps and draw-bolts, which can be controlled by people inside the premises by entering a code or by using smart cards, which have been adapted to control the exit from certain areas. Electromechanical locking devices are not acceptable on escape doors, unless:
 
(i) they are fitted with a manual means of overriding the locking mechanism such as a push bar, push pad or lever handle; or
 
(ii) they do not rely on a spring mechanism, they fail-safe open and they are not affected by pressure, in which case the criteria for electromagnetic devices should be applied.
 
? Electromagnetic devices comprise an electromagnet and a simple fixed retaining plate with no moving parts, and are therefore generally considered to be more reliable. Correctly designed and installed, they should “fail-safe unlocked” in operation. The release of this type of device is controlled by the interruption of electrical current to the electromagnet, either manually via a switch, or by a break-glass point (typically coloured green, often with an alarm to alert operation), or by linking via a relay to the fire-warning and detection system of the premises.
 
Time-delay devices on escape routes
 
8.14 A further development is the fitting of a time-delay system to the electronic door-locking device. This delays the actual opening of an exit door for a variable period following operation of the panic bar or other exit device. Periods of between 5 and 60 seconds can be pre-set at the manufacturing stage or can be adjusted when fitted.
 
8.15 These are not normally acceptable for use by members of the public. However, they may be acceptable for use by staff who are familiar with their operation and are suitably trained in their use.
8.16 
The use of a time-delay system that prevents the opening of emergency exits for a pre-set time is primarily used to improve security. These add a further layer of complexity to the fire strategy and should only be used in non-public areas when all other options, such as relocating valuable equipment or exterior boundary management, have been addressed.
 
8.17 A time-delay arrangement may be acceptable in areas such as mental health and baby units, but the implications of panic for escapees finding their escape apparently blocked should be fully considered.
 
Design, installation and management of electronic exit-door control devices
 
8.18 Access control should not be confused with exit control. Many devices are available which control the access to the premises but retain the immediate escape facility from the premises.
 
8.19 The use of any such devices (that is, other than those complying to BS EN 1125 or BS EN 179) may be accepted by enforcing authorities if the responsible person can demonstrate, through a suitable risk assessment for each individual door, both the need and the adequate management controls to ensure that people can escape safely from the premises. In particular:
 
? All other alternatives should have been explored and evaluated prior to considering the use of these devices.
 
? The requirement for additional exit control systems should be carefully assessed and should not be seen as a substitute for good management of the employees and occupants.
 
? All such devices, if fitted, must be in accordance with BS 7273-4 and fully meet the requirements for category A actuation:
 
(i) There should be an additional means of manually overriding the locking device at each such exit (typically a green break-glass point) and any variation must be justified by an individual risk assessment (for example the fitting of a remote override at a continually-staffed nurse station).
 
(ii) The device should be connected to the fire- warning and/or detection system.
 
(iii) In premises where there may be large numbers of people, the devices should only
 
 
 
 
 
 
be considered when linked to a comprehensive automatic fire-detection and warning system in accordance with BS 5839- 1 (for example L1, L2).
 
? The emergency exit doors should be clearly labelled with instructions on how to operate them.
 
? In public areas, when push bars are fitted on escape doors, they should release the electromagnetic locks immediately and allow the exit doors to open.
 
? Each emergency exit door should be fitted with a single securing device when the premises are occupied.
 
8.20 The use of electronic door-locking devices should be considered with particular care in premises with a number of different occupancies. The management of a complicated system of evacuation
 
for many different groups is unlikely to be practicable.
 
8.21 The technical standards in respect of sourcing, maintaining and testing must be extremely high. When part of the management control system involves trained personnel helping others at these doors, it is vital to ensure these people are available at all times.
 
8.22 The use of electronic exit-door control devices should not be considered where the number of trained staff is low or where members of the public would be expected to operate the devices without help.
 
8.23 BS 8220 gives further advice on security in buildings and, while this standard does refer to electronic locking devices, it also acknowledges that the balance must remain on the side of emergency escape rather than security.
 
 
 
 
 
 
 
 
9.1 In all buildings with basements (other than very small basements), stairways serving upper floors should preferably not extend to the basement, and in any case should not do so where there is only one stairway serving the building.
 
9.2 Any stairway that extends from the basement to upper floors should be separated at basement level by a fire-resisting lobby or corridor between the basement and the stairway.
 
9.3 All basements where there are more than 60 people likely to be present or where there are no fire exits direct to a place of safety should be provided with at least two stairways.
 
9.4 Where patients who are not fully ambulant have access to the basement, their escape should not necessitate travelling vertically up a stairway to a final exit (see Health Technical Memorandum 05-02 for further information).
9.5 
Wherever possible, all stairways to basements should be entered at ground or access level from the open air, and should be positioned so that smoke from any fire in the basement would not obstruct any exit serving the other floors of the building.
 
9.6 Where any stairway links a basement with the ground floor, the basement should be separated from the ground floor by two 30-minute fire- resisting doors, one at basement level and one at ground-floor level.
 
9.7 Any floor over a basement should provide 60 minutes’ fire resistance. Where this is
impractical, provided no smoke can pass through the floor, automatic smoke detection linked to a fire-alarm system that is audible throughout the premises could be provided as an alternative in the basement area.
 
 
 
 
 
 
10 Access and facilities for fire-and-rescue services
 
 
 
 
 
 
 
10.1 Access and facilities should be provided for the fire- and-rescue services to respond to a fire, including:
 
? adequate site access should be provided for fire- fighting appliances, which may need to attend in significant numbers, points of access having been agreed with the local fire authority;
 
? access should be provided for fire-and-rescue- service appliances to within 45 m of 25% of the building perimeter;
 
? access points into the building for fire-fighting personnel should be provided at suitable locations around the building; and
 
? at least one staircase suitable for use by fire- fighting personnel should be provided, which can be entered at ground level from a suitable access for fire-and-rescue-service appliances.
10.2 
Hospitals built since 1978 should comply with the provisions of the relevant version of Health Technical Memorandum 81 or Health Technical Memorandum 05-02 (depending on which was applicable at the time of Building Regulations application). The fire-fighting facilities outlined in section 3.3 of the “FSO Green Guide” should be taken into consideration during the risk assessment process.
 
10.3 Hospital roads used by fire-fighting appliances should be kept clear of obstructions at all times.
 
10.4 If parking is allowed, sufficient safe clearance should be provided and maintained to allow fire- fighting appliances clear passage at all times.
 
10.5 Fire-and-rescue-service access should be indicated on site plans and any associated mimic displays.
 
 
 
 
 
 
 
 
Health Technical Memorandum 86 – ‘Fire risk assessment in hospitals’.
‘Fire risk assessments in Nucleus hospitals’.  Regulatory Reform (Fire Safety) Order 2005. Department for Communities and Local Government
– Fire Safety Guides.
 
Health Technical Memorandum 81 – ‘Fire precautions in new hospitals’.
 
Health Technical Memorandum 05-02 – ‘Guidance to support functional provisions in healthcare premises’.
 
Education Act 1996.
 
Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 (the CHIP Regulations).
 
Control of Substances Hazardous to Health Regulations 2002.
 
Fire safety law and guidance documents for business. The Fire and Rescue Service National Framework. CFOA.
Health & Safety Executive (HSE).
 
Regulatory Reform (Fire Safety) Order 2005 Guidance Note 2, ‘Determination of disputes by the Secretary of State’.
 
Fire and Rescue Services Act 2004.
 
Health Technical Memorandum 05-01 – ‘Managing healthcare fire safety’.
 
FSO Green Guide.
 
Health Technical Memorandum 02-01 – ‘Medical gas pipeline systems’.
 
Fire risk assessments.
 
Health Technical Memorandum 05-03 Part A – ‘General fire safety’.
 
Health Technical Memorandum 05-03 Part B – ‘Fire detection and alarm systems’.
 
Health Technical Memorandum 05-03 Part C – ‘Textiles and furnishings’.
 
Health Technical Memorandum 05-03 Part D – ‘Commercial enterprises on healthcare premises’.
 
Health Technical Memorandum 05-03 Part E – ‘Escape bed lifts’.
 
Health Technical Memorandum 05-03 Part F – ‘Arson prevention in NHS premises’.
 
Health Technical Memorandum 05-03 Part H – ‘Reducing false alarms in healthcare premises’.
 
Health Technical Memorandum 05-03 Part J – ‘Guidance on fire engineering of healthcare premises’.
 
Health Technical Memorandum 06-01 – ‘Electrical services supply and distribution’.
 
Health and Safety (Safety Signs and Signals) Regulations 1996.
 
Building Regulations.
 
Health Technical Memorandum 61 – ‘Flooring’.
 
Dangerous Substances and Explosive Atmospheres Regulations 2002.
 
 
EXEMPLAR FIRE RISK  ASSESSMENT (FRA)
REGULATORY REFORM (FIRE SAFETY) ORDER 2005
 
This fire risk assessment should be undertaken by referring to Firecode – HTM 05-03: Part K
 
This exemplar fire risk assessment form is only to give a guide as to what to cover during the risk assessment process. It is not a mandatory fire risk assessment template and NHS organisations are free to use any format they wish. This particular template has been discussed and agreed with the Chief Fire Officers Association.
 
 
 
 
Premises full address (inc. Postcode):
 
 
 
 
Occupier:
 
Owner (if different to Occupier):
 
General description of building/premises:
 
 
 
 
Date of construction: No. of floors in building: No. of basements:
 
Name of the person conducting the FRA:
Note: Is the person conducting the assessment deemed to be competent?
 
I certify that to the best of my knowledge, the information contained in this fire risk assessment is correct, based on information provided at the time the assessment was undertaken.
 
Signature of Assessor: …………………………………………………………………….
 
 
Assessment Area:
 
Premises:
Original design guidance (if known) or guidance at last upgrade: (please tick)
 
 Red Fire Engine Book HTM 81 (grey) Nucleus
HTM 81 (yellow)
HTM 05-02
Other (state)
 
 
 
Use of Assessment Area: Hours premises in use:
Details of other employers in the building:
 
 
 
 
Name/position of the responsible person(s): Name of the person(s) providing the information: Contact details:
 
Maximum number of persons: Staff
 
Patients Others
Minimum number of staff on duty at any time:
 
Typical occupant dependency: (please tick) Independent
Dependent
Very High dependency
 
CONTENTS
 
 
 
ASSESSMENT REVIEW ASSESSMENT AREA PLAN FIRE RISK ASSESSMENT
SIGNIFICANT FINDINGS & ACTION PLANS
 
Fire Risk Assessment Review
 
Assessments should be kept under constant review, and in any case reviewed whenever circumstance change which affect the validity of the current assessment. Whilst there is no maximum period between assessments, it is recommended that the review period should not exceed 12 months.
 
 
 
Revision
Date
Name of assessor
Signature
Initial assessment
 
 
 
Revision 1
 
 
 
Revision 2
 
 
 
Revision 3
 
 
 
Revision 4
 
 
 
Revision 5
 
 
 
Revision 6
 
 
 
Revision 7
 
 
 
Revision 8
 
 
 
Revision 9
 
 
 
Revision 10
 
 
 
 
Assessment Area Plan
 
 
 
INSERT AN ASSESSMENT AREA PLAN DETAILING MEANS OF ESCAPE AND OTHER EXISTING PREVENTATIVE AND PROTECTIVE MEASURES
 
Fire Safety Risk Assessment
 
 
 
 
 
Step 1 Identify the hazards
 
 
1.1 Examples of sources of fuel that might be present (Tick those identified) Paper and card
Wood
Furniture including fixtures and fittings (window blinds etc) Flammable liquids
Waste materials Other (specify)
 
1.2 Examples of sources of ignition that might be present (Tick those identified) Portable and fixed electric heaters
Cooking
Electrical equipment Overloaded electrical sockets Static electricity
Arson
Smoking materials Hot work
Other (specify)
 
 
 
Sources of ignition
Sources of fuel
Sources of oxygen
YNY  NY  N
1.3 Does the
activity involve Processes such as cooking, Welding or frictional heat?
 
 
1.10 Are highly
flammable materials stored or used?
 
 
1.16 Is there piped
oxygen in use?
 
 
1.4 Is there gas
or burning oil equipment?
 
 
1.11 Is
combustible waste allowed to accumulate?
 
 
1.17 Are there
oxygen cylinders used/stored?
 
 
1.5 Are there light
bulbs etc. near flammable materials?
 
 
1.12 Are
excessive quantities of combustible materials used/stored?
 
 
1.18 Are Nitrous
oxygen cylinders used/stored?
 
 
1.6 Does
electrical equipment have current PAT test?
 
 
1.13 Are
substantial areas of walls or ceilings covered with flammable linings or materials?
 
 
1.19 Is storage and
use of cylinders in accordance with legislation/guidance?
 
 
 
 
1.7 Are there wander or
extension leads/multi point
adapters in sockets?
 
 
1.14 Are there any other
combustible materials that
represent a hazard i.e.
aerosols?
 
 
1.20 Are medical gas shut off switches
identifiable and suitably located?
 
 
1.8Are portable
heaters in use? Are they unobstructed and secured?
 
 
1.15 Is smoking
permitted or smoking materials present?
 
 
1.21 Is there an
operational procedure for isolation?
 
 
1.9 Is arson a potential
problem?
 
 
 
 
 
1.22 Are oxidising materials used or
stored?
 
 
 
Description of hazard
Identify necessary measures to eliminate (or reduce
ALARP) hazards
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Step 2  Identify people at risk
 
2.1 People in and around the premises (Tick those identified) Medical staff (including agency or temporary staff)
Non medical staff incl. cleaners/security/maintenance staff etc Member of the public – both visitors and patients
Others, including contractors
2.2 Also consider (Tick those identified)
Lone workers (including cleaners/security/maintenance staff esp. at night) Those with language difficulties
Non patients with disability
Other people in the immediate vicinity of the premises
2.3 Special considerations for young persons (Tick those identified)
 Have young people been given special consideration, due to their immaturity and inexperience, the nature and duration of work, the physical properties of
materials used and the training they require?
2.4 Other considerations (Tick those identified)
Are Personal Emergency Evacuation Plans (PEEPs) required/in place?
Are there specific risks that might affect fire-fighter safety? Are they controlled?
 
2.5 People at riskIndependent / dependent / very high dependency
 
Staff
No.
Dependency category / times at risk
Days
 
 
Nights
 
 
Lone workers
 
 
Patients - is the
assessment area:
Y/ N
Dependency category / number / times at risk
A sleeping area
 
 
A patient access area (e.g.
OPD, Physiotherapy, Radiology etc.)
 
 
A non patient area
 
 
Others in the immediate
vicinity who may be affected
No.
Control measures
Visitors
 
 
Contractors
 
 
Others (details)
 
 
 
General comments &
observations
Existing control measures
Further control measures
required
 
 
 
 
 
 
 
 
 
 
 
 
 
Step 3 – Evaluate, Remove or Reduce and protect from Risk
 
 
Principles of Prevention Applied (article 10 & schedule 1, part 3) Areas for Consideration (hierarchy)
 
* Avoid risks
* Remove risks
* Evaluate risks which cannot be avoided
* Combat risks at source
* Adapt to technical progress
* Replace dangerous substances by non dangerous or less dangerous substances (refer to DSEAR Regulations)
* Develop a coherent overall prevention policy which covers technology, organisation of work and the influencing factors relating to the work environment
* Give collective protective measures priority over individual protective measures and;
* Give appropriate instruction to employees
 
 
3.1Evaluate the risk of a fire occurring
Cause and ignition source
Observations inc High, Med or Low risk
3.1.1Smoking
 
3.1.2Fire started by patient
 
3.1.3Arson
 
3.1.4Work processes
 
3.1.5Fire hazard rooms
 
3.1.6Equipment
 
3.1.7Non patient areas (e.g. examples from Table 1 in HTM 05-02)
 
3.1.8Lightning
 
3.1.9Electrical
 
3.1.10 Toasters and portable equipment
 
3.1.11 Cooking
 
3.1.12 Contractors
 
 
 
 
3.1.13 General comments
& observations
3.1.14 Existing control measures
3.1.15 Further control measures required
 
 
3.2Evaluate the risk to people from fire.
 
Means of Escape
Comment
3.2.1  Is there an alternative direction of escape?
 
3.2.2  Is the travel distance acceptable?
 
3.2.3  Are escape routes free from obstruction and combustible materials?
 
3.2.4 Are escape routes clearly indicated with correct signage?
 
3.2.5  Is escape lighting provided and adequate?
 
3.2.6  Are fire/smoke dampers and control
systems maintained and tested?
 
3.2.7  Are elements of structure adequate?
 
3.2.8  Is (sub)compartmentation integrity
adequately maintained?
 
3.2.9  Are suitable refuge areas provided?
 
3.2.10 If refuge areas are provided, are communications provided and tested?
 
3.2.11 Are all internal fire doors clearly marked?
 
3.2.12 Is fire door integrity/strips/seals and all
furniture adequately maintained?
 
3.2.13 Are fire doors wedged open?
 
3.2.14 Is patient observation adequate for risk?
 
3.2.15 Are staff numbers adequate for the risk?
 
3.2.16 Are staff trained in correct evacuation
procedures?
 
3.2.17 Do staff carry out evacuation drills yearly?
 
3.2.18 Are staff/visitor fire notices adequate?
 
3.2.19 Are high risk rooms adequately protected?
 
3.2.20 Are there rooms utilised as fire hazard rooms, which do not meet current standards?
Identify the rooms and the strategy to upgrade.
 
3.2.21 Are there security devices on doors that are suitable & acceptable? Do they comply with
Appendix C in HTM 05-03: Part K?
 
3.2.22 Detail facilities provided for fire fighters. Is
the maintenance appropriate & are records kept?
 
3.2.23 If vertical evacuation is necessary (internal
or external), are stairways suitable in size & width? (Table 1 – HBN 40-02: Part C)
 
 
3.2.24 Detail any necessary action to eliminate or reduce ALARP identified risk
 
 
 
 
 
 
 
3.3Remove or reduce the fire hazards
Controls in place
Comment / Action taken to remove/reduce hazard
3.3.1 Are stock levels kept to a minimum?
 
3.3.2 Are flammable liquids stored correctly?
 
3.3.3 Is an effective waste management system in place and observed?
 
3.3.4 Is housekeeping to a high standard?
 
3.3.5 Is electrical, mechanical and gas
equipment used and maintained correctly?
 
3.3.6 Are extension, wander leads or socket
adaptors used?
 
3.3.7 Are portable heaters in temporary
use? If so, can they be replaced with fixed heaters or secured?
 
3.3.8 Are the recommendations of HTM 05-
03 Pt F on arson being adopted?
 
3.3.9 Are combustible materials / surface
finishes and notice boards etc to appropriate standards?
 
3.3.10 Are contractors ‘work’ and ‘hot work’ permits issued and monitored?
 
3.3.11 Can any hazardous substance be removed or replaced with a less dangerous
substance
 
 
 
 
3.3.12 General comments
& observations
3.3.13 Existing control
measures
3.3.14 Further control
measures required
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.4Remove and reduce the risks to people from fire
Means of escape
Comment / Action required
3.4.1  Is an AFD system installed, tested and maintained to HTM 05-03 Pt B?
 
3.4.2  If the AFD system does not conform to HTM 05-03: Part B what is the standard?
 
3.4.3  Are call points clear and available?
 
 
 
3.4.4  Is the fire alarm /AFD linked to an alarm centre?
 
3.4.5  Are appropriate fire action notices at all call points?
 
3.4.6  Are fixed suppression systems
adequately maintained and tested?
 
3.4.7  Are hose reels provided and
maintained?
 
3.4.8  Are appropriate portable
extinguishers provided?
 
3.4.9  Are the extinguishers suitably
located, indicated and readily available?
 
3.4.10 Has all fire fighting equipment been
serviced / recorded in the last 12 months?
 
3.4.11 Are smoke control systems
adequately maintained and tested?
 
3.4.12 Are staff trained to the required level?
(see HTM 05-03: Part A)
 
3.4.13 Is there clear access for Fire Service vehicles/personnel?
 
3.4.14 Are all textiles and furniture to
HTM 05-03 Pt C?
 
3.4.15 Do all commercial enterprises conform to HTM 05-03 Pt D?
 
 
3.4.16 Detail additional measures to eliminate or reduce ALARP identified risk
 
 
 
 
 
 
 
 
 
 
 
3.5 Management issues
Issue
Comment / Action required
3.5.1  Is a suitable emergency plan in place? Has it been practiced within the
past 12 months?
 
3.5.2  Have all staff received all
appropriate training in the last 12 months?
 
3.5.3  Are these Trust policies available
and do staff know where and how to access the Trust Fire/arson/security policy?
 
 
 
3.5.4  Were sufficient fire wardens present on the day of audit?
 
3.5.5  Are fire wardens completing and recording their routine checks?
 
3.5.6  Are maintenance records available
for AFD, /emergency lighting/FFE?
 
3.5.7  Are test records available for AFD?
 
3.5.8  Is co-ordination/co-operation with other Trusts working and recorded?
 
3.5.9  Has a Disability Discrimination Act (DDA) assessment been completed?
 
3.5.10 Are the requirements of the DDA being met?
 
3.5.11 Is this area subject of an action plan or enforcement notice from the Fire
Service?
 
3.5.12 Are staff proactive in the avoidance
of unwanted fire signals?
 
3.5.13 Detail the number of fires and unwanted signals in this area in the last 24
months. Include action taken to reduce UwFS.
 
3.5.14 Which HTM 05–03 Pt H category is achieved?
 
3.5.15 Are there any special evacuation aids present? If so, are staff trained in their
use?
 
3.5.16 Is there a plan on the wall indicating
fire safety measures?
 
3.5.17 Have employees, contractors etc.
been made aware of all relevant factors relating to the Trust’s fire safety arrangements?
 
 
 
 
3.5.18 Detail additional measures to eliminate or reduce ALARP identified risk
 
 
 
 
 
 
 
 
 
 
 
 
STEP 4Significant Findings & Action Plans
 
RISK VALUE MATRIX
 
LIKELIHOOD (L)
 
VALUE
SEVERITY OF OUTCOME (S)
Negligible
 
1
Negligible
Low
2
Slight damage to property
Minor injury to occupants, first aid required
 
 
Moderate
 
 
3
Moderate damage to property Partial evacuation required
Injury to occupants, medical attention required
 
 
High
 
Li
 
kelihood
Large scale damage to property Complete evacuation required Occupants require hospitalisation
Extreme
5
Major loss of property Major loss of life
 
 
 
 
1
2
3
4
5
2
4
6
8
10
3
6
9
12
15
4
8
12
16
20
5
10
15
20
25
 
Note: Beware of low likelihood but high severity
 
 
Risk Rating
 
Action
 
1 - 3
 
Record findings and review in twelve months
 
4 - 6
 
Moderate risk – Implement additional controls within 12 months
 
8 - 12
 
High risk – Implement interim measures immediately and full controls within 3 months
 
15 - 25
 
Extreme  risk  –  Cease  use  of  area  until  additional  controls  have  been applied.
 
 
FIRE RISK ASSESSMENT-SIGNIFICANT FINDINGS & ACTION PLAN
 
 
Variation /
Interim
Final Control
Initial/Final
Person
Date
Ref
No.
Location
Findings
justification or
Action
control
measures
Measures &
Date
risk rating
responsible
completed
/Competent
 
 
 
required.
 
 
 
 
Person
Initials
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


感动 同情 无聊 愤怒 搞笑 难过 高兴 路过
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