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HTM 05-01 Managing healthcare fire safety

 
 
Health Technical Memorandum 05-01: Managing healthcare fire safety (Second Edition) 
 
 
 
 
 
Health Technical Memorandum
05-01:
Managing healthcare fire safety
Second edition
 
. Crown copyright 2013
You may re-use this information (not including logos) free of charge in any format or me-dium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives. gov.uk/doc/open-government-licence/ or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk.
This document is available from our website at www.gov.uk/government/organisations/department-of-health
 
Executive summary
This Health Technical Memorandum sets out recommendations and guidance for the management of fire safety in healthcare buildings. It should not be quoted as if it were a specification, and any claims of compliance should be carefully examined to ensure they are not misleading.
While Heath Technical Memoranda 05-02 and 05-03 provide guidance in respect of the fire precautions and protective measures appropriate for healthcare premises, this Health Technical Memorandum is intended to assist in determining the appropriate fire safety management system to be applied to healthcare organisations. 
Health Technical Memorandum 05-01 sets out guidance that recognises the nature of healthcare organisations and the need for a robust system of fire safety management. The guidance and recommendations contained in this Health Technical Memorandum should allow the current statutory regulations to be applied sensibly within a framework of understanding.
The primary remit of NHS organisations with regard to fire safety is the safety of patients, staff and visitors. For all premises under their control, NHS organisations will need to select and effectively implement a series of measures to achieve an acceptable level of fire safety, taking into account:
.
all relevant legislation and statutes; 
 
.
the guidance in this Health Technical Memorandum;
 
.
the relevant guidance contained in other parts of Firecode; and
 
.
the advice and approval of building control and fire and rescue authorities.
 
 
Acknowledgements
The Department of Health would like to thank the following for their help in developing this guidance:
BB7
Chief Fire Officers Association
Department for Communities & Local Government
Healthfire
National Association of Healthcare Fire Officers
NHS Wales Shared Services Partnership
Glossary of terms
For the purposes of this document the following terms are defined:
Assembly point: a pre-determined area of safety where persons should assemble in the event of an emergency.
Authorising Engineer (Fire): a chartered fire engineer, or a chartered member of an appropriate professional body, with extensive experience in healthcare fire safety.
Child: a person who is not over the compulsory school age.
Compartmentation: the fire-resisting elements including walls, floors, and where applicable, roofs and/or other structures used in the separation of one fire compartment from another.
Competence: where a person is required to be competent, he/she must be able to demonstrate through training and experience or knowledge and other qualities that they have the ability to properly assist in undertaking the preventative and protective measures.
Competent Person (Fire): a person who can provide skilled installation and/or maintenance of fire-related services (both passive and active fire safety systems).
Complex healthcare organisations: hospitals or other healthcare premises that perform invasive procedures and other treatments that place a dependence on staff for evacuation.
Fire emergency action plan: the pre-determined plan that describes the actions necessary in the event of a fire to protect relevant persons and facilitate their safe evacuation.
Fire engineering: the application of scientific and engineering principles to the protection of people, property and the environment from fire.
Fire-fighting equipment: the fire extinguishers, fire blankets and other equipment made available to trained personnel for the purpose of fighting fire.
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 risk assessment: the process of identifying fire hazards and evaluating the risks to people, property, assets and the environment arising from them, taking into account the adequacy of existing fire precautions, and deciding whether the fire risk is acceptable without further fire precautions.
Fire Safety Adviser (Authorised Person – Fire): a person who has sufficient training and experience or knowledge and other qualities to enable them to properly assist in undertaking preventative and protective measures.
Fire safety management system: a robust framework of protocols and processes used to ensure that an organisation can fulfil all tasks required to achieve the fire safety objectives set out in the fire safety policy.
Fire Safety Manager: the person within the organisation tasked with coordinating fire safety issues throughout the organisation’s activities.
Fire Safety Order: The Regulatory Reform (Fire Safety) Order 2005.
Fire safety policy: a high level statement of intent, as expressed by the board, partners, or equivalent controlling body, setting out clear fire safety objectives for the organisation.
Fire safety procedure: a detailed document setting out each step of a process intended to prevent fire, maintain fire precautions, minimise fire hazards or effectively respond to a fire incident.
Fire safety protocols: a set of organisation-specific guidelines that set the fire safety parameters of any activity that may impact on fire risk.
Healthcare building: a hospital, treatment centre, health centre, clinic, surgery, walk-in centre or other building where patients are provided with medical care, diagnostics or other associated treatment.
Hot works: Operations involving the use of open flames or the local application of heat or friction such as welding, soldering, cutting or brazing.
Material change: A change in arrangements or circumstances that may have an impact on the validity of fire risk assessments, fire precautions, fire emergency action plans etc.
Management level: standard or quality of the organisational fire risk management system.
Occupant dependency: the categorisation of occupants on the basis of their likely need for assistance to effect their safe evacuation in an emergency. The following categories are referred to in this Health Technical Memorandum:
.
Independent: occupants 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: all occupants except those classified as “independent” or “very high dependency”.
 
.
Very high dependency: those whose clinical treatment and/or condition creates a high dependency on staff. This will include those in critical care areas, operating theatres, coronary care etc and those for whom evacuation would prove potentially life-threatening.
 
 
Place of relative safety: an initial place away from the immediate danger of fire and from which further evacuation is possible to a place of safety.
Place of safety: a place where persons are in no danger from fire.
Premises: the land, building, or part of a building which is owned, occupied or managed by the organisation.
Preventative and protective measures: the measures which have been identified by the responsible person in consequence of a risk assessment as the general fire precautions necessary to comply with the requirements and prohibitions imposed by the Fire Safety Order.
Progressive horizontal evacuation: evacuation of patients away from a fire into an adjacent fire-free compartment on the same level.
Relevant person: any person who may be lawfully on, or in the immediate vicinity of, the premises and who is at risk from a fire on the premises.
Responsible person: the employer of persons working at the premises, a person who has control of the premises, or the owner of the premises.
Young person: any person who has not attained the age of 18.
1 Introduction and
scope 
1.1 Effective fire safety depends on a combination of physical fire precautions and a robust system of effective management. Fire safety in the healthcare environment is particularly challenging since many healthcare building occupants will require some degree of assistance from healthcare staff to ensure their safety in the event of a fire.
1.2 Even in primary care environments, the proportion of building occupants that may require some assistance to quickly escape the effects of a fire is likely to be greater than that which would be expected from a cross-section of the general population.
1.3 While physical fire precautions within a building are intended to provide protection to building occupants, effective fire safety management ensures that the incidence of fire is minimised, the physical fire precautions are maintained in an operational state, the organisation is able to respond effectively should a fire occur, and that the impact of a fire incident is minimised.
1.4 The current legislation in the form of the Regulatory Reform (Fire Safety) Order 2005 requires a managed risk approach to fire safety. The process of fire risk assessment, mitigation and review requires a robust system of management capable of identifying hazards, qualifying their impact, devising appropriate mitigation and continual monitoring. 
1.5 The presence of a robust system of fire safety management is a key influence in fire risk assessment and in many healthcare environments it is the determining factor in evaluating the level of fire risk.
1.6 The increasing prevalence of building fire strategies for healthcare premises which contain fire-engineered design solutions are likely to intensify the need for enhanced fire safety management. These solutions may require enhanced fire safety management to be applied holistically or simply as a specific component of a fire-engineered solution. 
1.7 In a healthcare environment with very high dependency patients (see Glossary), it is unlikely that any amount of physical fire precautions on their own can reduce fire risks to an acceptable level. Adequate risk mitigation can only be achieved with the provision of a sufficient number of suitably trained staff, an environment in which the fire precautions are well maintained, and effective emergency action plans that have been sufficiently rehearsed. It is the non-physical elements of these fire precautions that are provided as a function of fire safety management.
General application 
1.8 This Health Technical Memorandum provides guidance in respect of the management of fire safety in healthcare organisations. 
1.9 It is intended that this Health Technical Memorandum should be applied to all types of healthcare organisations, including those that only perform administrative functions.
1.10 While much of the content of this document draws on examples from more complex organisations such as an acute hospital trust, the principles are equally applicable to a small general practice or other healthcare organisation.
1.11 The guidance within this Health Technical Memorandum cannot take account of all the circumstances that may be found in any particular healthcare organisation, but are intended to highlight the fire safety management aspects that need to be considered.
1.12 The Department of Health recognizes that the range of healthcare providers is extensive, and therefore Firecode may not address specific issues for all organisations. Fire safety professionals are expected to use professional judgement when considering fire safety measures, taking particular account of:
.
the type of healthcare being provided;
 
.
the average age and dependency of patients;
 
.
planned staffing levels; and
 
.
the size of the premises.
 
 
2 Department of Health
fire safety policy
Purpose
2.1 To provide an unambiguous statement of fire safety policy applicable to the NHS in England, and to premises where patients receive NHS-funded treatment or care, excluding a single private dwelling.
Policy aims
2.2 This fire safety policy aims to minimise the incidence of fire throughout all activities provided by, or on behalf of, the NHS in England.
2.3 Where fire occurs, this policy aims to minimise the impact of such occurrence on life safety, the delivery of patient care, the environment and property.
Application 
2.4 This policy applies wherever NHS organisations in England owe a duty of care to service users, staff or other individuals.
Facilitation 
2.5 The Department of Health will:
.
ensure that appropriate advice and guidance on matters relating to fire safety will be available to NHS organisations in England through the provision of the Firecode suite of guidance;
 
.
facilitate the development of partnership initiatives with stakeholders and other appropriate bodies in the provision of fire safety where reasonably practicable. 
 
 
Implementation
2.6 All NHS organisations in England must:
.
comply with legislation relating to fire safety;
 
.
follow evidence-based best practice guidance where reasonably practicable;
 
.
ensure that suitable and sufficient governance and assurance arrangements are in place to manage fire-related matters and demonstrate due diligence;
 
.
have in place a clearly defined management structure for the delivery, control and monitoring of fire safety measures, which is shared across the organisation;
 
.
provide appropriate levels of investment in the estate and personnel to facilitate the implementation of suitable fire safety precautions;
 
.
facilitate the development of partnership initiatives with stakeholders and other appropriate bodies in the provision of fire safety where reasonably practicable.
 
 
Monitoring
2.7 The performance of the NHS in England against the aims of this policy will be monitored through:
.
the requirements for registration and continued compliance with the essential standards of quality and safety as monitored by the Care Quality Commission;
 
.
the annual ERIC return of fire reports and false alarm reports.
 
 
3 Statutory fire safety
duties 
3.1 While a number of statutes place duties in respect of fire safety on those controlling an organisation or its activities, the two primary pieces of legislation that impose statutory fire safety duties are the Building Regulations 2010 and the Regulatory Reform (Fire Safety) Order 2005. The former of these focuses on the minimum functional fire safety requirements that must be met in the provision of a new building or the material alteration or change of use of an existing building. The latter is concerned with the continued fire safety provisions to protect relevant persons.
Fire safety requirements of the Building Regulations 2010
3.2 The Regulations consider five aspects of fire safety in the construction of buildings as set out in Part B of Schedule 1:
.
B1 Means of warning and escape
That sufficient provision is made in the design of the building so that an early warning of fire can be given and the building occupants can escape to a place of safety. 
 
.
B2 Internal fire spread (linings)
That the internal linings of a building do not support a rapid spread of fire.
 
.
B3 Internal fire spread (structure)
That the stability of the building structure is maintained for a reasonable period and the spread of fire through the building and in unseen cavities and voids is inhibited by subdividing the building with fire-resisting construction or the installation of automatic fire suppression.
 
.
B4 External fire spread
That the spread of fire between buildings is discouraged by adequate separation between them and controlling the number and size of openings in the building envelope.
 
.
B5 Access and facilities for the fire service
That the building, the site layout and access roads are designed in such a way as to enable the fire and rescue service to fight fire and effect the rescue of persons caught in a fire.  
 
 
3.3 While the Building Regulations are predominantly focused on the physical fire precautions incorporated in a building, all such measures are complemented by, and often dependent on, adequate fire safety management activity to ensure their correct use, continued functioning and that such provisions remain appropriate throughout the life of the building.
3.4 In particular, Part 8 of the Building Regulations states a requirement under Regulation 38 for the person carrying out relevant work to provide the responsible person with information relating to the design and construction of the building, and the services, fittings and equipment provided which will assist the responsible person to operate and maintain the building with reasonable safety.
Fire safety requirements of the Regulatory Reform (Fire Safety) Order 2005
3.5 The Regulatory Reform (Fire Safety) Order 2005 came into force in October 2006 and replaced the the greater part of previous fire safety legislation. In this document it will be referred to as the Fire Safety Order.
3.6 Responsibility for complying with the Fire Safety Order rests with the responsible person. For the majority of cases in healthcare organisations the responsible person will be the employer. For example, in a hospital NHS trust the responsible person is likely be the Trust Board, whereas for a general practice, the responsible person may be the senior partner or an individual GP.
3.7 The Fire Safety Order requires that the responsible person puts in place all necessary fire precautions to protect relevant persons in the event of fire in and around the premises
3.8 In order to determine the necessary fire precautions, the responsible person is required to undertake a suitable and sufficient assessment of fire risk which takes into account those at special risk, such as disabled people, those that have special needs and children. In addition, consideration of any dangerous substance liable to be on the premises must be reflected in the fire risk assessment.
3.9 Any preventative and protective measures necessary to safeguard those potentially at risk from the effects of fire should be implemented to the extent that it is reasonable and practicable. Effective arrangements must be made for the planning, organisation, control monitoring and review of the preventative and protective measures.
3.10 Duties imposed on the responsible person include:
.
Taking measures to reduce the risk of fire on the premises and the risk of the spread of fire on the premises.
 
.
Taking measures to eliminate or reduce risks resulting from the presence and/or use of dangerous substances.
 
.
Providing appropriate means of detecting fire and raising the alarm including communication with the external emergency services.
 
.
Providing appropriate fire-fighting equipment.
 
.
Providing and ensuring the availability of appropriate escape routes and exits.
 
.
Planning, implementing and rehearsing appropriate procedures for serious and imminent danger and for areas of danger.
 
.
Maintaining the facilities, equipment and devices necessary to safeguard the safety of relevant persons.
 
.
Appointing sufficient competent persons to assist in undertaking the preventative and protective measures.
 
.
Providing employees, and the parents of employed children, with comprehensible and relevant information on risks identified in the fire risk assessments, the preventative and protective measures taken, and the appropriate procedures.
 
.
Providing similar information to persons working in or on the premises who are not employed by the responsible person.
 
.
Providing adequate safety training to employees.
 
.
Cooperating and coordinating with other responsible persons that have duties in respect of the premises.
 
.
Maintaining provisions deemed necessary for safeguarding the safety of fire-fighters.
 
 
3.11 The duties imposed by the Fire Safety Order on the responsible person are also imposed on every person, other than the responsible person, who has to any extent control of the premises. The extent of such duties is determined by the extent of control exercised by that person. In essence, the person in charge of a ward at any given time is subject to the same responsibilities under the Fire Safety Order as the responsible person in respect of the ward, in so far as the elements they control. 
3.12 Every employee, while at work, must take reasonable care for themselves and other relevant persons who may be affected by their acts or omissions at work. In addition, all employees must inform their employer or nominated representative of any work situation or matter that represents a serious or imminent danger or any shortcomings in safety arrangements. 
4 NHS trust fire safety
policies
4.1 The effective management of fire safety in any organisation requires the board, partners or equivalent controlling body to clearly set out the fire safety priorities and objectives for the organisation. This is achieved by the preparation and dissemination of a fire safety policy. The Department of Health’s fire safety policy should be used as the model on which a trust should base its fire safety policy. An exemplar trust fire safety policy is provided in Appendix A.
4.2 The fire safety policy should, by necessity, be brief and avoid such detail as would require the policy to be regularly updated to reflect changes in legislation, guidance or personnel. Such detail should be confined to the fire safety protocols and management procedures.
4.3 There is an important distinction between the fire safety policy that is prepared by the board and sets out clear objectives and instructions for the management team to fulfil, and the fire safety procedures that are prepared by the management team and detail the processes by which the organisation delivers the fire safety outcomes to meet the objectives of the fire safety policy. This distinction has a significant influence on the efficacy of fire safety management in NHS organisations. Where the distinction is effective, the board, partners or equivalent controlling body are in a position to govern, while management are free to effectively control the organisational resources to deliver the desired fire safety outcomes through the production and implementation of appropriate procedures.
4.4 The fire safety policy should clearly state the policy aims and the scope of its application such that there is an unambiguous statement of the organisational fire safety objectives applicable throughout the organisation’s activities. Details of the arrangements to facilitate fire safety that will be provided by the board, partners or equivalent controlling body should be included together with details of the expectations for management in the delivery of the policy objectives.
4.5 Arrangements for monitoring the performance of management procedures and measures are an important element of any policy.  It is through appropriate monitoring and assurance systems that the board, partners or equivalent controlling body measures delivery against the objectives set out in the fire policy and demonstrates due diligence and effective governance.
4.6 The fire safety policy should be signed by the chief executive or equivalent officer on behalf of the board, partners or equivalent controlling body, disseminated to all staff and made freely available to all parties that are stakeholders in the organisation’s delivery of a fire-safe environment.
4.7 It is important that the fire safety policy is reviewed regularly to ensure that it meets the organisation’s needs, includes sufficient facilities and management instruction to deliver the policy aims, and describes appropriate arrangements for the monitoring of fire safety performance throughout the organisation.
5 Effective fire safety
management
5.1 In less complex organisations, or those with few staff and/or premises, it may be possible for the Fire Safety Manager to adequately manage and control potential fire hazards, planning and training needs throughout the organisation. However, in large and/or complex organisations, such as an acute hospital trust, it is unlikely that a single person could exercise sufficient control to ensure that all aspects of the fire safety regime were satisfactorily delivered throughout the organisation.
5.2 In all but the smallest of healthcare organisations it will be necessary to develop a fire safety management system to ensure that an appropriate fire-safe environment is maintained. A fire safety management system should ensure that:
.
fire safety objectives are set and clearly communicated throughout the organisation;
 
.
a suitable fire safety management structure is developed along with clearly defined roles and responsibilities;
 
.
appropriate guidance is produced and disseminated throughout the organisation to ensure that all of the organisation’s activities support the fire safety objectives;
 
.
a suitable and sufficient assessment of fire risks is undertaken throughout the relevant areas of all premises owned, occupied and/or managed by the organisation;
 
.
appropriate action plans for improvement to fire precautions are recorded and actioned;
 
.
fire risk assessments are maintained up-to-date and are reviewed as appropriate;
 
.
a suitable programme of fire safety training is developed and implemented;
 
.
a robust system for the monitoring and reporting of fire incidents, false alarms, unwanted fire signals and other fire safety issues is developed and implemented;
 
.
the performance of the fire safety management system is periodically audited and assessed against the organisation’s fire safety objectives.
 
 
5.3 An exemplar fire safety management system is shown diagrammatically in Appendix B. In this system, the board, partners or equivalent controlling body are responsible for setting out the fire safety policy, which includes the organisation’s fire safety objectives. The remainder of the fire safety management system is developed and implemented by the various levels of operational management. The outcomes delivered by the fire safety management system are communicated to the board, partners or equivalent controlling body through incident reports, periodic internal reporting and an annual audit. In this way, the board, partners or equivalent controlling body hold the organisation’s management to account for their performance against the fire safety objectives set out in the fire safety policy.
5.4 The implementation of the fire safety policy requires a management structure with clearly defined roles and responsibilities, reporting channels and parallel pathways that ensure the communication of fire safety information to the board, partners or equivalent controlling body.
5.5 To successfully implement the fire safety policy, all staff need to be provided with sufficient information and delegated authority to facilitate their undertaking of the duties required to effect the fire safety management system and deliver the fire safety objectives of the organisation. To this end, the Fire Safety Manager should develop a framework of robust fire safety protocols that provide clear guidance to those performing a fire safety role and to those whose activities may indirectly affect fire safety within the organisation. For example, without sufficient guidance, the purchasing department may procure upholstered furniture that does not meet the minimum standard for use in a public area of medium hazard. Further information in respect of fire safety protocols is provided in Chapter 8. 
5.6 While fire risk assessments are a statutory duty placed on the responsible person, it is recognised that in all but the smallest of healthcare premises, a person competent in healthcare fire safety and risk assessment, such as the Fire Safety Adviser, should undertake them. The ownership of the fire risk assessment and its findings should be vested in the person in control of the area that has been assessed. Hence, in the case of a ward, it is the ward manager or equivalent that has ownership of the fire risk assessment and its findings, albeit that there may be significant findings and actions that are outside the ward manager’s control which are collated and managed centrally. The local ownership of fire safety issues ensures that the person with control over individual departments or areas of the premises can discharge the duties imposed on them by the Fire Safety Order.
5.7 The outcomes, and especially the significant findings, of the fire risk assessment should be communicated to all employees. This can be readily achieved by:
.
staff briefings carried out by local managers; and
 
.
the compilation of a fire safety information manual for each ward, department or area that contains:––
specific and detailed information in respect of the findings of the fire risk assessment, and
 
––
the protective and preventative measures in place.
 
 
 
 
 
5.8 The review of the fire risk assessment can be more easily performed where the local manager is provided with details of the parameters that may invalidate the fire risk assessment, and is instructed to request a review if any material changes occur. In such a regime, the fire risk assessment may be reviewed by the competent fire risk assessor undertaking a physical check of the area, primarily in response to a request from the local manager. However, it is recommended that the competent fire risk assessor periodically visits each area to review the fire risk assessment, albeit that such a review would be less frequent with the local management monitoring and controlling the fire risks in their area.
5.9 Fire emergency action plans will need to be developed to ensure that in the event of a fire the organisation and its staff:
.
respond appropriately to ensure the safety of all relevant persons; and
 
.
meet the objectives of minimising disruption to the provision of services, and damage to the environment and property.
 
 
The organisation as a whole will need to develop appropriate action plans to coordinate resources to ensure that central functions are delivered and local actions are adequately supported. Local emergency action plans will also need to be developed that detail the specific actions to be taken relevant to the fire hazards, precautions, occupancy staff availability etc within the area concerned. 
5.10 Such action plans will need to be regularly reviewed to ensure that they are appropriate and capable of delivering the desired outcomes. All fire emergency action plans need to be regularly rehearsed either through fire drills, walkthroughs, table-top exercises or through other appropriate means. Rehearsal of the fire emergency action plans should ensure that staff are familiar with:
.
the necessary actions that are to be taken including raising the alarm;
 
.
the location of fire equipment including manual call points, fire alarm panels, fire extinguishers and evacuation aids; 
 
.
the location of fire escape routes and exits;
 
.
the location of suitable areas of relative and ultimate safety including, where appropriate, refuges and assembly points;
 
.
the process of evacuation including, where appropriate, techniques for the evacuation of dependent and very high dependency patients horizontally and, where necessary, vertically using stairs or evacuation lifts where provided.
 
 
5.11 The rehearsal of fire emergency action plans should be used as an opportunity to fine-tune each element of the action plan to form a robust process. To facilitate identifying areas of potential weakness in the organisation’s response to a fire emergency, the rehearsal of fire emergency action plans should periodically involve a broad range of stakeholders including staff from adjacent wards and departments, estates and engineering personnel, the fire and rescue service and others whose interaction may be influential in providing a full response to a fire emergency.
5.12 The Fire Safety Manager should ensure a training needs analysis is undertaken for all employees and other staff working within the organisation and provide an appropriate programme of fire safety training. Local managers are responsible for ensuring that the staff working within their ward, department or area have received an appropriate level of fire safety training and at the required frequency as identified in the training needs analysis.
5.13 While recognising the operational difficulties of releasing staff for training, and instances where it may be necessary to utilise temporary nursing and other staff, whose fire safety training may have lapsed, the local manager should ensure that the number of staff members on duty in the ward, department or area at any one time that have not received up-to-date fire safety training compared with those that have does not exceed 1-in-3.
5.14 The local manager should ensure that staff members on duty at any time who are not up-to-date in respect of fire safety training are kept to an absolute minimum and programmed to receive the training as a matter of priority.
5.15 An essential element of the fire safety management system is the audit process. The performance of key elements of the fire safety management system should be periodically audited. The outcomes should be communicated to the board, partners or equivalent controlling body as part of their monitoring function and validation against the fire safety objectives stated in the policy. To provide adequate assurance and robust governance, the fire safety management system should be periodically reviewed by parties independent of those responsible for the delivery of the fire safety outcomes.
5.16 The development of a robust fire safety management system requires a broad spectrum of skills and should be undertaken by a multidisciplinary team, led by the Fire Safety Manager, with wide consultation prior to its adoption. Each element of the fire safety management system should be considered individually and collectively to ensure that it will not result in inadvertent consequences.
5.17 The Equality Act 2010 sets out the different ways in which it is unlawful to treat someone, such as direct and indirect discrimination, harassment, victimisation and failing to make a reasonable adjustment for a disabled person. The act prohibits unfair treatment in the workplace, when providing goods, facilities and services, when exercising public functions, and in the disposal and management of premises.
5.18 Section 149 (1) of the Equality Act 2010 sets out the three main aims of the public sector Equality Duty:
a.
eliminate unlawful discrimination, harassment and victimisation; 
 
b.
advance equality of opportunity between people who share a protected characteristic and people who do not;
 
c.
promote good relations between people who share a protected characteristic and those who do not.
 
 
5.19 As part of developing a fire safety management system, providers of NHS-funded healthcare must show they have considered their duty under section 149 (1) and can demonstrate evidence to support compliance.
5.20 A specification for fire risk management systems is available in PAS 7 – ‘Fire risk management systems’ (2013 edition) and this Health Technical Memorandum can be considered as healthcare-specific guidance supporting such a specification to identify the basic requirements of a fire safety management system.
5.21 Users of this Health Technical Memorandum are advised to consider the benefit of third-party certification of conformity with PAS 7 (2013). Appropriate conformity attestation arrangements are described in BS EN ISO/IEC 17021. Users seeking assistance in identifying appropriate conformity assessment bodies or schemes should contact UKAS for advice and further information.
6 Appropriate
management levels
6.1 In healthcare organisations the delivery of an appropriate level of fire safety will be largely influenced by the development of a robust fire safety management system and the capabilities of those that bring the system into effect. 
6.2 In large and more complex healthcare organisations and/or those that cater for dependent or very high dependency patients, the quality of management and their proactive approach to fire safety is fundamental to the mitigation of fire risks.
6.3 In smaller, less complex healthcare organisations where patients that require assistance to escape from fire are uncommon, the reliance on proactive fire safety management is less pronounced. In such circumstances the resources required to achieve a similar level of fire safety management to that of a more complex organisation may be disproportionate to the level of risk present.
6.4 The appropriate level of fire safety management should be determined from Table.1 and the corresponding features of the management level should be incorporated into the fire safety management system and processes. The level of management knowledge should not be reduced from that given in the table; however, based on a higher risk identified by assessment, it can be increased to the more appropriate level.
6.5 The Department of Health acknowledges the diverse nature of healthcare providers, for example those providing community based care, where the organisation may be responsible for a range of healthcare premises of varying complexity. In such circumstances the local management of each premises should conform to the management level appropriate for that type of premises as shown in Table 1. However, the management of central functions should conform to the management level appropriate for the most complex premises and/or highest dependency of patients in the organisation’s portfolio.
Level 1 fire safety management
6.6 Level 1 fire safety management exhibits the following attributes:
.
Anticipates and proactively identifies the impact of any proposed changes to risk profile including changes to the occupancy, periods of abnormal occupancy, and fire hazards, identifying and implementing alternative protection and management measures that will be required to mitigate the change.
 
.
The manager(s) with responsibility for fire safety are empowered to initiate maintenance or repair in order to ensure that legislative requirements are met.
 
.
The staffing level provided is specifically appropriate to the building concerned, including the use of the building, the nature of the occupants, the management systems in place, and the active and passive systems provided. Staff are suitably trained to assist occupants effectively in a fire emergency, and sufficient arrangements are in place to provide contingencies for staff absences.
 
.
The arrangements for training ensure that there are sufficient staff trained in all aspects of fire prevention, fire protection and evacuation procedures, and where necessary, they are able to use the appropriate extinguishing equipment so as to provide full coverage of the building, with provision for contingencies, sickness or holiday absences.
 
.
The system for work control is developed proactively with clear lines of responsibility, a robust permit system, logging and audit processes, and routine checking and supervision. The permit system considers not only the risks inherent with the works activity, but also the potential implications for other departments and activities. 
 
.
The system of communications is able to ensure that all of those involved, or potentially involved, in an incident are rapidly and effectively given relevant information. The system makes use of alternative formats as necessary and has predetermined contingency plans for when systems fail.
 
.
The maintenance system exhibits dynamic monitoring of the fire safety systems, and the equipment is kept fully functional at all material times. Alternative procedures and arrangements have been devised for those times when systems, equipment and other arrangements are not available or not functioning correctly.
 
.
Liaison with the fire and rescue service is proactive including effective arrangements for notifying the fire and rescue service of changes to the occupancy, periods of abnormal occupancy and other relevant factors. Arrangements are in place for routine meetings with the fire and rescue service, and additional meetings where a change in the building or its occupancy is proposed.
 
.
Contingency planning is proactive, taking into account a wide range of possible emergencies and incidents. These will include logistical planning comprising such issues as the provision of shelter, communications, transport, the weather, time of day, time of week, time of year (holidays etc) and traffic-related issues, as well as scenarios such as power failures or floods.
 
 
Level 2 fire safety management
6.7 Level 2 fire safety management exhibits the following attributes:
.
Identifies the impact of changes to risk profile including changes to the occupancy, periods of abnormal occupancy and fire hazards, and reacts to those changes by identifying and implementing alternative protection and management measures to mitigate the change.
 
.
The responsibility for fire safety, and the necessary supporting staff and resources, is likely to be divided over a number of different individuals, departments or even companies. It is likely that the implementation of any necessary changes will require approval of those not directly responsible for the routine management of fire safety within the premises.
 
.
The staffing level provided is specifically appropriate to the building concerned, including the use of the building, the nature of the occupants, the management systems in place, and the active and passive systems provided. Staff are suitably trained to assist occupants effectively in a fire emergency; however, there is no contingency provision.
 
.
The arrangements for training ensure that there are sufficient staff trained in all aspects of fire prevention, fire protection and evacuation procedures, and, where necessary, they are able to use the appropriate extinguishing equipment so as to provide full coverage of the building; however, there is no contingency provision.
 
.
The system for work control provides clear lines of responsibility but is reactive to works activity. A robust permit system is in place which includes logging and audit processes. 
 
.
The system of communications provides information to all involved in an incident. The system makes use of alternative formats as necessary; however there is no contingency provision.
 
.
The maintenance system exhibits periodic monitoring of the fire safety systems, and the equipment is kept fully functional at all material times. Alternative procedures and arrangements are devised reactively when systems, equipment and other arrangements are not available or not functioning correctly.
 
.
Liaison with the fire and rescue service includes arrangements for notifying the fire and rescue service of changes to the occupancy, periods of abnormal occupancy and other relevant factors. There are no arrangements for routine meetings with the fire and rescue service or where a change in the building or its occupancy is proposed.
 
.
Contingency planning takes into account a narrow range of possible emergencies and incidents. These will include logistical planning including issues such as the provision of shelter, communications, transport, the weather, time of day, time of week, time of year (holidays etc) and traffic-related issues, as well as scenarios such as power failures or floods.
 
 
Level 3 fire safety management
6.8 Level 3 fire safety management exhibits the following attributes:
.
Reviews the impact of changes periodically, identifying and implementing alternative protection and management measures to mitigate those changes.
 
.
Managers responsible for fire safety are likely to have limited or no power or resources, and are thus unlikely to be able to ensure that the fire safety systems are kept fully functional without reference to a third party.
 
.
The staffing levels provided do not routinely and specifically address the building concerned or its use, the nature of the occupants, or the active and passive systems provided. 
 
.
General fire safety training is provided on a periodic basis.
 
.
The system for work control is reactive to any work required on site. 
 
.
The system of communications provides information to all involved in an incident but there is no provision for the use of alternative formats or contingency arrangements.
 
.
The system of planned maintenance and testing is likely to be controlled by others.
 
.
There is no system of communication with the fire and rescue service. Any communications are likely to be reactive.
 
.
Contingency planning is minimal.
 
 
7 Fire safety
management roles
and responsibilities
7.1 The following paragraphs detail roles and responsibilities that are likely to be required to adequately address fire safety management in a complex healthcare organisation such as an acute hospital trust.  While not all roles will be required for smaller and less complex organisations, the responsibilities described here will need to be discharged in any organisation through a management structure appropriate to that organisation. (See Appendix C for an exemplar fire safety management structure.)
7.2 The fire safety management structure and lines of responsibility and reporting should be clearly set out in a format similar to the exemplar Appendix C. The structure should clearly identify each post holder, the fire safety role that they assume and their job title. 
7.3 In some organisations, the role of Fire Safety Adviser may be fulfilled by an external contractor. Where this is the case, details of the contractor and the contractual arrangements should be specified in the fire safety management structure.
7.4 In many organisations some of the roles described here may be combined. For example, it may be possible to combine the roles of Fire Safety Manager and Fire Safety Adviser where the post holder possesses suitable managerial skills and fire safety competency. (See Appendix D for exemplar person specifications for these roles.)
Trust Board
7.5 The Trust Board has overall accountability for the activities of the organisation, which includes fire safety. 
7.6 The Trust Board should ensure that it receives appropriate assurance that the requirements of current fire safety legislation and the objectives of DH’s Firecode are being met.
7.7 The Trust Board discharges the responsibility for fire safety through the Chief Executive.
Chief Executive
7.8 The Chief Executive will, on behalf of the Board, be responsible for ensuring that current fire legislation is complied with and, where appropriate, DH’s Firecode guidance is implemented in all premises owned, occupied or under the control of the trust. 
7.9 The Chief Executive will ensure that all agreements for the provision of care and other services by third parties include sufficient contractual arrangements to ensure compliance with the trust’s fire safety policy.
7.10 The Chief Executive discharges the day-to-day operational responsibility for fire safety through the Director with fire safety responsibility.
Board Level Director (with fire safety responsibility)
7.11 The Director with fire safety responsibility is responsible for ensuring that fire safety issues are highlighted at Board level. 
7.12 This responsibility will extend to the proposal of programmes of work relating to fire safety for consideration as part of the business planning process. 
7.13 This will include the management of the fire-related components of the capital programme and future allocation of funding.
7.14 At an operational level the Director with fire safety responsibility should be:
.
assisting the Chief Executive with Board level responsibilities for fire safety matters;
 
.
ensuring that the trust has in place a clearly defined fire safety policy and relevant supporting protocols and procedures;
 
.
ensuring that all work that has implications for fire precautions in new and existing trust buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory fire safety requirements (including DH’s Firecode);
 
.
ensuring that all proposals for new buildings and alterations to existing buildings are referred to the Fire Safety Manager before building control approval is sought;
 
.
ensuring that all passive and active fire safety measures and equipment are maintained and tested in accordance with the latest relevant legislation/standards, and that comprehensive records are kept;
 
.
ensuring cooperation between other employers where two or more share trust premises;
 
.
ensuring through senior management and line management structures that full staff participation in fire training and fire evacuation drills is maintained;
 
.
ensuring that agreed programmes of investment in fire precautions are properly accounted for in the trust’s annual business plan;
 
.
ensuring that an annual audit of fire safety and fire safety management is undertaken, and the outcomes communicated to the Trust Board;
 
.
fully support the Fire Safety Manager function.
 
 
7.15 In line with delegated authority, the Director with fire safety responsibility devolves day-to-day fire safety duties to the Fire Safety Manager.
Fire Safety Manager
7.16 The role of Fire Safety Manager is primarily a managerial role suitable for a senior operating manager. The role does not necessitate the duty holder to possess fire safety competencies provided that they have sufficient access to competent fire safety advice provided either from an internal Fire Safety Adviser or an external source.
7.17 The Fire Safety Manager acts as a focus for all fire safety matters in the organisation, and therefore the role should be carried out by one person. While the Fire Safety Manager may have a different line manager, accountability for fire safety matters should always be through the board level director.
7.18 The role of Fire Safety Manager may be combined with other operational roles such as health and safety, risk management, local security management specialist, emergency planning etc. However, when nominating the Fire Safety Manager, it will be necessary to ensure that there are clearly defined areas of responsibility and an integrated approach to avoid conflict with any overlapping responsibilities.
7.19 The Fire Safety Manager is tasked with developing and managing the fire safety management system, and will be responsible for (exemplar role/duties):
.
the day-to-day implementation of the fire safety policy;
 
.
reporting of non-compliance with legislation, policies and procedures to the Director with fire safety responsibility;
 
.
obtaining expert advice on fire legislation;
 
.
obtaining expert technical advice on the application and interpretation of fire safety guidance, including DH’s Firecode;
 
.
raising awareness of all fire safety features and their purpose throughout the trust;
 
.
the development, implementation, monitoring and review of the organisation’s fire safety management system;
 
.
the development, implementation and review of the organisation’s fire safety policy and protocols; 
 
.
ensuring that fire risk assessments are undertaken, recorded and suitable action plans devised;
 
.
ensuring that risks identified in the fire risk assessments are included in the trust’s risk register as appropriate;
 
.
the operational management of fire safety risks identified by the risk assessments;
 
.
 the development, implementation and review of the organisation’s fire emergency action plan;
 
.
ensuring that requirements related to fire procedures for less-able staff, patients and visitors are in place;
 
.
the development, delivery and audit of an effective fire safety training programme;
 
.
the reporting of fire incidents in accordance with trust policy and external requirements;
 
.
monitoring, reporting and initiating measures to reduce false alarms and unwanted fire signals;
 
.
liaison with external enforcing authorities;
 
.
liaison with trust managers;
 
.
liaison with the Authorising Engineer (Fire);
 
.
monitoring the inspection and maintenance of fire safety systems to ensure it is carried out;
 
.
ensuring that suitable fire safety audits are undertaken, recorded and the outcomes suitably reported;
 
.
providing a link to the relevant trust committees; 
 
.
ensuring an appropriate level of management is always available by the establishment of Fire Response Teams for trust sites or premises.
 
 
Fire Safety Adviser [Authorised Person (Fire)]
7.20 The Fire Safety Adviser will be accountable to the Fire Safety Manager for matters of fire safety. They provide competent fire safety advice and will be responsible for (exemplar role/duties):
.
undertaking, recording and reporting fire risk assessments;
 
.
providing expert advice on fire legislation;
 
.
providing expert technical advice on the application and interpretation of fire safety guidance, including DH’s Firecode;
 
.
assisting with the review of the content of the trust’s fire safety policy;
 
.
assisting with the development and delivery of a suitable and sufficient training programme for staff;
 
.
the assessment of fire risks within premises owned, occupied or under the control of the trust;
 
.
the preparation of fire prevention and emergency action plans;
 
.
the investigation of all fire-related incidents and fire alarm actuations;
 
.
liaison with the enforcing authorities on technical issues;
 
.
liaison with managers and staff on fire safety issues;
 
.
liaison with the Authorising Engineer (Fire).
 
 
7.21 Where specialist solutions are required to resolve fire safety issues, the Fire Safety Adviser would not necessarily be expected to have the level of skill required but would know the limits of their capabilities and, when necessary, seek specialist advice from an Authorising Engineer (Fire).
Authorising Engineer (Fire) [External Specialist]
7.22 The Authorising Engineer (Fire) will act as an independent professional adviser to the healthcare organisation. The Authorising Engineer (Fire) will act as assessor and make recommendations for the appointment of Authorised Persons (Fire), monitor the performance of fire safety management, and provide an annual audit to the Board Level Director (with fire safety responsibility). 
7.23 This guidance does not require any organisation to directly employ an Authorising Engineer (Fire). Indeed, to effectively carry out this role, particularly with regard to audit, it is preferable that the Authorising Engineer (Fire) remains independent of the operational structure of the trust. 
7.24 When commissioning an Authorising Engineer (Fire), the trust will ensure that the appointed Authorising Engineer (Fire) is a chartered engineer and member of the Institution of Fire Engineers or a chartered member of a similar professional body or that these specialist organisations are contacted for further guidance and/or information.
7.25 The Authorising Engineer (Fire) will be required to demonstrate competence in their particular field of expertise.
Competent Person (Fire)
7.26 Installers and maintainers of fire safety equipment will be commissioned by the trust and must be able to demonstrate a sound knowledge and specific skills in the specialist service being provided. This may include the installation and/or maintenance of related fire safety equipment/services such as:
.
fire alarm and detection systems;
 
.
portable fire fighting equipment;
 
.
fire suppression systems;
 
.
fire dampers;
 
.
fire-fighting hydrants etc.
 
 
7.27 In cases where external parties provide services, the party concerned should be registered with an appropriate fire industry accreditation scheme. 
Local Management
7.28 Matrons, heads of service and departmental managers have responsibility for:
.
monitoring fire safety within their respective workplaces and ensuring that contraventions of fire safety precautions do not take place;
 
.
ensuring local fire risk assessments are undertaken and maintained up-to-date;
 
.
notifying the Fire Safety Adviser of any proposals for “change of use”, including temporary works that may impact on the risk assessment, within their area;
 
.
reporting any defects in the fire precautions and equipment in their area and ensuring that appropriate remedial action is taken; 
 
.
ensuring that local fire emergency action plans are developed, brought to the attention of staff and adequately rehearsed to ensure sufficient emergency preparedness;
 
.
ensuring that local fire emergency action plan is revised in response to changes, including temporary works, which may affect response procedures; 
 
.
ensuring the availability of a sufficient number of appropriately trained staff at all times to implement the local fire emergency action plan;
 
.
ensuring that the duties outlined in this document and relevant fire safety instructions are brought to the attention of staff through local induction and ongoing staff briefings; 
 
.
ensuring that every member of their staff attends fire safety training as set out in the trust’s fire safety training matrix; 
 
.
ensuring that all new staff, on their first day in the ward/department, are given basic familiarisation training within their workplace, to include:––
local fire procedures and evacuation plan
 
––
means of escape
 
––
location of fire alarm manual call points
 
––
fire-fighting equipment
 
––
any fire risks identified;
 
 
 
 
.
keeping a record of staff induction and attendance at fire safety training;
 
.
ensuring staff at all levels understand the need to report all fire alarm actuations and fire incidents as detailed in the fire safety protocols;
 
.
ensuring that the staff record is completed and returned denoting how this document has been brought to the attention of staff;
 
.
where appropriate, ensuring that sufficient Fire Wardens are identified and appointed for their specific areas of responsibility.
 
 
Fire Warden
7.29 The size and complexity of the trust’s buildings and activities may necessitate the appointment of local Fire Wardens to ensure there is a focal point for local staff.
7.30 The Fire Wardens essentially will be the “eyes and ears” within that local area but will not have an enforcing role. They will report any issues identified to their matron and/or head of service or departmental managers and if necessary to the Fire Safety Adviser or Fire Safety Manager.
7.31 The Fire Warden should:
.
act as the focal point on fire safety issues for the local staff;
 
.
organise and assist in the fire safety regime within local areas;
 
.
raise issues regarding local fire safety with their line management;
 
.
support line managers in their fire safety issues.
 
 
Fire Incident Manager
7.32 The most senior person in charge of an area and present at the time that an incident occurs should assume the role of the Fire Incident Manager.
7.33 The Fire Incident Manager is required to:
.
take control of the incident;
 
.
direct the local response;
 
.
ensure that the fire alarm system has been activated and that staff in the area are aware of the incident;
 
.
initiate the local fire emergency action plan;
 
.
determine whether evacuation is necessary and commence the evacuation if appropriate;
 
.
liaise with the Fire Response Team and the Fire Response Team Leader on their arrival.
 
 
Fire Response Team Leader
7.34 A senior manager will be nominated as the Fire Response Team Leader to ensure initial control of an emergency. 
7.35 The Fire Response Team Leader is required to:
.
respond to confirmed fire events;
 
.
take responsibility for direction of the Fire Response Team;
 
.
liaise with the Fire Incident Manager;
 
.
liaise with the attending fire and rescue service;
 
.
instigate the internal major incident plan (if required).
 
 
Fire Response Teams
7.36 The Fire Safety Manager should establish Fire Response Teams on all trust sites. Local site circumstances will best determine the quantity of people and skill profile required. 
7.37 The Fire Response Team procedures should reflect and where necessary integrate with the trust’s major incident policy and procedures.
All staff, contract staff and volunteers
7.38 All staff, contractors and volunteers should:
.
comply with the trust’s fire safety protocols and fire procedures;
 
.
participate in fire safety training and fire evacuation exercises where applicable;
 
.
report deficiencies in fire precautions to line managers and Fire Wardens;
 
.
report fire incidents and false alarm signals in accordance with trust’s protocols and procedures;
 
.
ensure the promotion of fire safety at all times to help reduce the occurrence of fire and unwanted fire alarm signals;
 
.
set a high standard of fire safety by personal example so that members of the public, visitors and students when leaving trust premises take with them an attitude of mind that accepts good fire safety practice as normal.
 
 
Fire Safety Committee
7.39 In NHS organisations, it is recommended that a Fire Safety Committee be formed. The committee should be responsible for the review of all fire safety matters. Standard agenda items might include fire incidents, false alarms, enforcement action, and staff training.
7.40 In exceptional circumstances, fire safety matters could be dealt with by another committee such as a health and safety or risk management committee. However, where fire safety is part of another committee’s remit, fire safety should be a standing agenda item.
7.41 The relevant committee will act as a parallel conduit for reporting on fire safety issues to the trust Board, and for conveying exception reporting of issues for which the Fire Safety Manager/Adviser may consider themselves to be professionally compromised.
8 Fire safety protocols
8.1 A comprehensive set of fire safety protocols is fundamental to the successful management of fire safety in all but the smallest of healthcare organisations. Each organisation should develop and disseminate a set of comprehensive protocols (reflecting the size, nature and risks present in the organisation) that provide guidance on all issues relating to fire safety within the organisation. It is important to ensure that sufficient guidance is provided to all areas of the organisation’s activities and particularly to those that could significantly impact the level of fire safety within the organisation despite the activity appearing on initial examination to be unrelated to the management of fire safety. For example, without sufficient guidance the activities of the laundry may result in inappropriate processes that deteriorate the flame retardancy of textiles used within the organisation.
8.2 The fire safety protocols should be bespoke to each organisation and be sufficiently detailed as to provide clear instruction on fire safety matters. For example, where an organisation uses a particular manufacturer of fire alarm equipment the fire safety protocols should provide details of the manufacturer and the equipment that should be used for future developments as necessary to ensure compatibility with existing systems.
8.3 The contents of the fire safety protocols manual should include a broad range of topics and should provide information and procedures for all fire-safety-related issues. The following contents list is not exhaustive, and local arrangements will dictate the necessary detail. All organisations should consider the following list and develop fire safety protocols that address the relevant issues: 
.
fire prevention;
 
.
risk assessments;
 
.
fire strategies;
 
.
emergency planning and procedures;
 
.
fire safety training;
 
.
fire safety information manuals;
 
.
construction and refurbishments;
 
.
fire detection and alarm systems;
 
.
false alarms and unwanted fire signals;
 
.
fire extinguishers;
 
.
security;
 
.
arson;
 
.
hot works;
 
.
maintenance of fire equipment;
 
.
fire stopping;
 
.
portable appliance testing;
 
.
medical gases;
 
.
purchasing;
 
.
laundry;
 
.
information for the fire and rescue service;
 
.
salvage and continuity planning.
 
 
Further detail and information prompts that may assist in developing appropriate fire safety protocols are provided in Appendix E.
8.4 To facilitate the compilation of such a comprehensive set of fire safety protocols, it is essential that the Fire Safety Manager coordinates input from an array of disciplines relevant to the organisation.
9 Fire safety information
manuals
9.1 While fire safety protocols provide detailed procedures and information applicable to the whole organisation, in larger and more complex healthcare organisations, specific information pertinent to each ward, department or area should be provided to staff that work within that area. An effective form of communicating such information is the provision of a local fire safety information manual.
9.2 Consideration should be given to providing each ward, department and/or area with a bespoke fire safety information manual. This manual may be provided as a physical file located in the area to which it relates, or stored electronically in such a way that it can be readily accessed in the area to which it relates. In either case, the information contained within the fire safety information manual should be freely available to be reviewed by any member of staff, patient or patient’s representative. 
9.3 The following items should be included in the fire safety information manual:
.
A description of the ward/department/area.
A brief description of the area, its extent, location and use.
 
.
A fire safety plan of the ward/department/area. 
A plan drawing showing the extent of the area and the location of relevant fire safety features including the locations of:––
fire compartmentation and sub-compartmentation;
 
––
fire detection and alarm system devices;
 
––
fire hazard rooms;
 
––
fire doors and those that should be kept shut;
 
––
fire extinguishers;
 
––
fire escape routes;
 
––
evacuation equipment;
 
 
 
 
.
A fire safety checklist.
A schedule of the fire safety checks that should be undertaken on commencement of work by the person in charge of the area during that work period, including for example:––
check that the nearest fire alarm repeat panel displays a healthy condition;
 
––
check that the manual call points are unobstructed;
 
––
check that the fire extinguishers are in place and readily accessible;
 
––
check that escape routes are clear and unobstructed;
 
––
check that the fire doors that should be kept shut are fully closed;
 
 
 
 
.
A copy of the emergency action plan specific to the ward/department/area.
The detailed local fire emergency action plan including:––
actions to be take on discovering a fire;
 
––
actions to be taken on hearing the fire alarm;
 
––
detailed procedures for evacuation;
 
––
the location of fire exits and evacuation equipment;
 
––
the location of fire extinguishers.
 
 
 
 
.
A copy of the fire risk assessment specific to the ward/department/area.
Include any specific hazard items that have been identified and the protective and preventative measures in place to mitigate the resultant risk.
 
.
Guidance in respect of the parameters of the fire risk assessment.
Specific guidance intended to inform the local manager of the parameters of the fire risk assessment. This guidance sets the constraints of operating the area and the boundaries beyond which the fire risk assessment may be invalidated. It is this guidance that will allow the local manager to maintain a safe environment and prompt a request for the fire risk assessment review in response to material changes within the ward/department/area concerned.
 
.
Staff fire safety training records.
 
.
Records of fire drills and emergency fire action plan rehearsals.
 
.
Records of fires, false alarms and unwanted fire signals.
 
.
Local fire salvage plan (where applicable).
A plan that provides details of items and their locations specific to the area that will assist the fire and rescue service to plan their fire-fighting, and where possible recovery, activities to best protect the continuity of care, delivery of service and high value property. The local salvage plan may include details of:––
service-critical items;
 
––
items required to support the continuation of care such as patient notes, specialist drugs or equipment;
 
––
high value equipment.
 
 
 
 
 
9.4 The fire safety information manual should be maintained by the local manager. Staff training records and records of fire drills/fire emergency action plan rehearsals should be updated as appropriate. Changes to the fire risk assessments, fire emergency action plans, salvage plans etc should be reflected in the fire safety information manual following discussion with the Fire Safety Manager or Fire Safety Adviser.
10 Planning and
responding to a
fire emergency
10.1 An effective response to any fire emergency depends on the preparedness of all those involved and a detailed knowledge and understanding of the fire emergency action plan and the arrangements in place to safeguard building occupants. To achieve such a level of preparation, a considerable effort should be made in the form of planning, training,
practising and testing the arrangements in place.
10.2 Every organisation must put in place robust fire emergency action plans for each area it is responsible for, with the intention
of safeguarding all relevant persons should
a fire occur. In larger or more complex healthcare organisations, the fire emergency action plan may comprise a number of elements such as:
.
the immediate response by staff in the ward/department/area affected;
 
.
the swift response and assistance of those in adjacent areas;
 
.
the immediate deployment of Fire Response Team;
 
.
summoning the fire and rescue service as necessary;
 
.
the coordination of additional resources as necessary.
 
 
10.3 In larger or more complex organisations it is unlikely that the fire emergency action plan will involve the full and immediate evacuation of all building occupants. The response is likely to be multi-level, combining an organisational response with a local response. For example, in hospital trusts it is common for the fire service to be summoned by a central switchboard and a Fire Response Team to be mobilised to the area of the reported incident, while the fire scene manager initiates the local fire emergency action plan. Appropriate fire emergency action plans should be developed for each level of the organisation and for each area it is responsible for. 
10.4 It is not possible to give precise guidance on every conceivable situation that could arise in a fire emergency. However, the following items should be considered when developing fire emergency action plans:
.
action on discovery of a fire.
 
 
Fire alarm:
.
raising the alarm;
 
.
action on hearing the fire alarm;
 
.
the meaning of warning and alarm signals;
 
.
arrangements for degradation of the fire detection and alarm system;
 
.
arrangements for declaring a false alarm.
 
 
Evacuation:
.
arranging and coordinating evacuation;
 
.
methods of evacuation for dependent and very high dependency patients;
 
.
arrangements for the evacuation of bariatric patients;
 
.
availability of appropriate evacuation aids;
 
.
risk assessment findings (risk to occupants while evacuating).
 
 
Incident response:
.
fire-fighting (prior to the arrival of the fire and rescue service);
 
.
Fire Response Team actions;
 
.
availability of staff as an additional resource;
 
.
internal management control systems;
 
.
declaring a major incident and initiating the major incident plan.
 
 
Communication:
.
arrangements for calling the fire and rescue service;
 
.
arrangements for notifying the fire and rescue service of a false alarm;
 
.
arrangements for communication between those responding to the fire emergency;
 
.
arrangements for communication and coordination with other building occupiers and responsible persons.
 
 
Continuity of care
.
availability of additional specialist equipment for continuing care;
 
.
facilities for the continuation of care;
 
.
caring for high-risk and vulnerable patients;
 
.
information for the fire and rescue service;
 
.
contingency planning;
 
.
disabled people;
 
.
visitors and relatives;
 
.
information, instruction and training.
 
 
Recording information and reporting:
.
recording response activities;
 
.
press/media liaison;
 
.
debriefing after the incident;
 
.
arrangements for incident recording and reporting.
 
 
Recovery:
.
salvage planning;
 
.
returning the building to normal service
 
.
site and building security.
 
 
10.5 It is essential that any fire emergency action plan is thoroughly tested and rehearsed to ensure that the contents are feasible and the intended outcomes are satisfactorily delivered. To this end, each fire emergency action plan should be rehearsed by the staff that are intended to implement them in the event of a fire incident. 
10.6 Ideally, such rehearsals should involve an unannounced fire drill that includes the full evacuation of occupants, and this should be the aim wherever possible. In circumstances where the full evacuation of occupants is not possible, alternative arrangements should be made to rehearse the fire emergency action plan such as walkthroughs and/or desktop exercises combined with practical training sessions in the evacuation of dependent patients and other occupants.
10.7 Wherever possible, the fire and rescue service should be invited to take part in the rehearsal of the fire emergency action plan. This approach helps to ensure that the organisations work together effectively and supports the ethos of joint working and familiarisation through the Fire and Rescue Services Act 2004.
10.8 Details of emergency fire action plan rehearsals should be recorded, together with outcomes and any actions that require the amendment of any parts of the emergency fire action plan.
10.9 The fire emergency action plan should be regularly reviewed and amended where necessary in response to any material changes including changes to:
.
the layout of the area concerned;
 
.
escape routes;
 
.
staffing levels;
 
.
any of the fire safety equipment;
 
.
occupancy profile;
 
.
the fire service response.
 
 
10.10 The organisation must be able to demonstrate that the fire emergency action plans in place are appropriate and sufficiently robust so as not to rely on any other agencies for evacuation.
10.11 To facilitate the effective deployment of fire-fighting resources, it is necessary to provide the fire and rescue service with sufficient information. The information should be compiled in a usable format and made readily available to the attending fire and rescue service on their arrival. The information required by fire and rescue services about premises, their 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, the fire and rescue service and, potentially, the premises.
10.12 Information that should be provided includes:
.
plans of the premises;
 
.
the location of valuable equipment (for example CT and MRI scanners); and
 
.
information about:––
fire and safety systems;
 
––
utilities and environmental systems;
 
––
hazardous contents of the premises.
 
 
 
 
 
10.13 This list is not exhaustive, but provides a valuable starting point. The local fire and rescue service should be consulted regarding other information they may require, furthering the concept of joint working and familiarisation and the development of the joint operational tactical plan.
10.14 The information made available to the fire and rescue service should be regularly reviewed and maintained up-to-date.
11 Training
11.1 Adequate fire safety training is essential to ensuring that fire prevention and emergency action plans can be put into practice. In many healthcare environments, the safe evacuation of patients in the event of a fire will rely on the effective action of staff in implementing the emergency plan.
11.2 The provision of adequate fire safety training is a legal duty placed on the responsible person by the Fire Safety Order.
11.3 In order to satisfy the legal requirements for training, staff need to have an understanding of the fire risks to which they may be exposed and know what to do in the event of a fire so that fire safety procedures can be applied effectively. This requirement applies to all staff irrespective of their seniority or professional discipline. All staff training should take place during the normal working hours of those being trained. 
11.4 The Fire Safety Manager is responsible for ensuring that an appropriate programme of fire safety training is developed and suitable arrangements are in place for the delivery of that training to all employees and other relevant staff. It is the responsibility of matrons, heads of service and departmental managers to ensure that all of their staff have attended the appropriate fire safety training as detailed in the training needs analysis matrix.
Fire safety induction training
11.5 All staff, including part-time and agency staff, should receive local fire safety induction training on or before their first day of employment, or on their relocating to a new work area. This may be delivered by the staff member’s line manager or the person in charge of the area in which they are to work. Where a member of staff is to work in a number of areas, it will be necessary to provide local fire safety induction training for each workplace. The local fire safety induction training should include:
.
details of the risk identified in the fire risk assessments for the area(s) concerned;
 
.
details of the protective and preventative measures in place;
 
.
any specific instruction necessary to prevent fire in the area as a result of hazardous processes, substances and/or equipment;
 
.
details of the local fire emergency action plan including:––
the action to be taken on discovery of a fire 
 
––
means of raising the fire alarm
 
––
the actions to take on hearing the fire alarm
 
––
staff responsibilities during a fire incident
 
––
procedures for evacuation
 
––
the location of fire exits and evacuation equipment
 
––
the location of fire extinguishers
 
––
other relevant equipment etc.
 
 
 
 
.
a physical tour of the escape routes and assembly points, if appropriate, or places of relative safety.
 
 
11.6 The details of this local fire safety induction training, including the contents of the training, should be recorded and maintained as part of the local management’s training records and made available to the Fire Safety Manager.
11.7 In all but the smallest healthcare organisations, either prior to their commencement of work or as soon as practicable thereafter – and in any case within one month of their appointment – all new members of staff should attend corporate fire safety induction training. While this induction is likely to take the form of generic training, its purpose is to provide a greater understanding of the fire safety processes and issues throughout the wider organisation. This induction training should include:
.
basic fire safety and the fire safety protocols;
 
.
fire safety responsibilities and reporting structures;
 
.
actions to take on discovering a fire;
 
.
actions to take on hearing the fire alarm;
 
.
procedures for evacuation;
 
.
staff responsibilities during a fire incident;
 
.
specialist roles (switchboard staff, estates staff, Fire Wardens, local security management specialist etc);
 
.
the organisation’s fire and false alarm incident records.
 
 
11.8 This induction training should be conducted by a person competent in fire safety matters in the healthcare environment. The attendance of each staff member, together with the contents of the training provided, should be recorded and those records made available to each staff member’s manager. The duration of this training should reflect the nature of the training and instruction being provided.
Periodic fire safety training
11.9 All staff should receive regular updated fire safety training and instruction. The duration and frequency of the training should be determined by a training needs analysis. This should take account of the fire risks present in the premises, the numbers and dependency of people at risk, and the responsibilities of staff in a fire emergency. The outcomes of the fire risk assessment and the resulting determination of training requirements should be formally recorded and periodically reviewed. It is expected that staff involved in the direct care of patients, who may need to help evacuate others, should receive instruction more frequently than those who may only be required to evacuate themselves from the building on the sounding of the fire alarm.
11.10 The training needs analysis should take into account each member of staff’s general duties, their role in preventing fire and their potential role in executing the fire emergency action plan. An exemplar approach to developing a training needs analysis is included in Appendix F.
11.11 Staff should understand the action to take in the event of fire, which will include some or all of the following:
.
raise the alarm, inform the main telephone switchboard and request assistance;
 
.
remove patients (and others) in immediate danger to a place of safety;
 
.
fight the fire with approved equipment, but only if it is safe to do so and staff have been trained in their use;
 
.
evacuate the area in accordance with the emergency evacuation plan;
 
.
close all doors, windows, hatches etc to prevent further spread of fire, smoke and toxic fumes;
 
 
11.12 An effective programme of fire safety training will enable staff to learn about and practise basic actions and to appreciate the wider implications of the fire safety strategy, including:
.
the reasons for fire and smoke compartmentation of buildings and for protected escape routes to the open air;
 
.
the importance of ensuring that the intended functions of fire/smoke doors are not prejudiced by the dangerous practice of wedging them in the open position;
 
.
the significant findings of relevant fire risk assessments;
 
.
the dangers of locking fire-exit doors – no fire-exit door on any escape route to be secured by a means requiring the use of a key or digital keypad for egress;
 
.
the need for a clear procedure for allowing contractors to work within healthcare premises;
 
.
the need to be familiar with escape routes, site layout, and the internal layout of the premises in which they work and reside, and to recognise the need to keep escape routes free of obstruction and rubbish;
 
.
the potentially fatal consequences of the spread of fire, smoke and toxic gases;
 
.
the importance and benefits of reducing false alarms and unwanted fire signals;
 
 
11.13 Additional training should be provided to meet the special needs of particular locations and for those staff who have special responsibilities. Some examples are:
.
Nursing staff and any others who may have to assist in the evacuation of patients should receive instruction and training in appropriate methods of evacuation – that is, techniques for moving and assisting patients (and others) to evacuate quickly in an emergency. The special problems of moving patients from critical care areas and similar locations where very high dependency patients are cared for should be well-rehearsed.
 
.
Telephone switchboard operators should be instructed and trained in the actions they should take in the event of fire in the healthcare premises including:––
interpreting the information displayed on the fire detection and alarm system control panel;
 
––
communicating with the Fire Response Team; 
 
––
communicating with the fire and rescue service.
 
 
 
 
.
Estates staff require precise instructions for dealing with the safe control and isolation of services such as gas, water, electricity, ventilation, piped medical gases etc, which they may need to control during a fire. 
 
.
Cleaning and housekeeping staff should be instructed in the appropriate controls for flammable substances that they may use in their duties and the need to clear escape routes of cleaning equipment in the event of a fire.
 
 
11.14 The training needs analysis should be developed by the Fire Safety Manager in conjunction with the Fire Safety Adviser and should determine the appropriate training, both in terms of content and frequency, for each group of staff whose activities, responsibilities and actions in the event of a fire are similar.
11.15 In some cases the training needs analysis is likely to identify staff groups whose fire safety training requirement is minimal. For example, administration staff that work in offices remote from patient care areas, and whose duties do not bring them into patient or public areas, are likely to need to respond to a fire alarm activation by leaving the building and assembling at a predetermined assembly point. For these staff, annual fire safety training may comprise participation in a successful unannounced fire drill. This would be supplemented with attendance at a formal fire safety training session every three years. In other cases, some groups may require more frequent training with considerable instruction. For example, staff that work in operating theatres are likely to require some training in the characteristics of fire and fire growth to equip them with the information necessary to decide whether to continue with a procedure or seek to evacuate, as well as the evacuation techniques necessary to evacuate a very high dependency patient.
11.16 The fire safety training programme should include practical sessions and fire drills to supplement classroom instruction. Training sessions should be well-publicised and arrangements made in good time for the release of staff. The training programme needs to make reasonable provision to facilitate staff working patterns, including those on permanent night duty and those that work part-time, to ensure that sufficient training opportunity is available to all staff members.
11.17 The use of e-learning may offer a number of benefits to an organisation. However, in all but the smallest healthcare organisations such as a small GP’s practice with a single-stage evacuation plan, e-learning is not acceptable as the sole means of training staff. E-learning can only be used to support training delivered by a person competent in fire safety in the healthcare environment.
11.18 E-learning is not acceptable as the sole means of training for the following reasons:
.
it does not take account of significant findings from fire risk assessments;
 
.
it does not take account of changes in working practice;
 
.
it cannot adequately train staff in evacuation techniques, particularly those involving patient evacuation;
 
.
it is unlikely to provide for job-specific training;
 
.
there is little opportunity for direct feedback to trainees’ questions.
 
 
11.19 In exceptional circumstances where a member of staff cannot be made available for training delivered by the Fire Safety Adviser (due, for example, to long-term sickness absence), the use of e-learning may be considered as a temporary alternative. However, no member of staff should be permitted to continue their duties with a gap in their record of training longer than twice the interval identified in the training needs analysis.
11.20 It is recommended that any training delivered by e-learning should be completed within one month of the session commencing. Any session not completed within the month should result in the e-learning programme being recommenced.
11.21 In addition to the periodic fire safety training identified in the training needs analysis, additional training should be provided in response to any material changes including:
.
the risk assessment findings;
 
.
the physical layout of the workplace;
 
.
the number and/or nature of patients;
 
.
the number of staff;
 
.
the emergency action plan;
 
.
following a report by the enforcing fire authority highlighting training;
 
.
following a fire or near miss.
 
 
11.22 Fire safety training should only be delivered by persons competent in fire safety in the healthcare environment.
11.23 In order to verify that appropriate training has been completed in accordance with the training needs analysis by each member of staff, records should be kept which include:
.
the names of those attending; 
 
.
the dates and duration of the instruction;
 
.
the nature and content of training given; and
 
.
details of those providing instruction
 
 
Those records should be made available to each staff member’s manager to facilitate them discharging their duty to ensure that all their staff attend fire safety training.
Fire safety training audit
11.24 It is necessary to ensure that the programme of fire safety training is delivering the desired outcomes and ensuring that staff are aware of their fire safety responsibilities and their role in fire prevention and implementing the fire emergency action plan.
11.25 Assessing the effectiveness of training schemes is important but often difficult to carry out with certainty. The Fire Safety Manager in conjunction with healthcare Fire Safety Advisers should, on a regular basis (but normally no less than every two years), devise methods of testing staff.
11.26 It is likely that the practical performance of staff at training sessions and during rehearsals of the fire emergency action plan will offer the best indication of the effectiveness of a programme and the degree to which staff have assimilated instruction.
11.27 The recording system should enable the Fire Safety Manager to oversee training programmes effectively and check that training goals have been met, including those for part-time, agency and night-duty staff. 
11.28 The efficacy of the fire safety training programme should also be included in the annual fire safety audit.
12 Reporting and
audit
12.1 An essential element of any fire safety management system is a robust reporting and audit process. This process provides feedback to the monitoring function of the board, partners or equivalent controlling body and provides the necessary assurance to demonstrate good governance.
Reporting
12.2 Aside from the usual reporting of adverse incidents such as fires or notices issued by the fire service, there is a need to facilitate the periodic review of fire safety matters by the board, partners or equivalent controlling body. To this end, the board should consider receiving regular reports containing:
.
the number of fires and any associated incident reports together with running totals for the annual reporting period;
 
.
the number of false alarms and any associated incident reports together with running totals for the annual reporting period;
 
.
the number of unwanted fire signals and any associated incident reports together with running totals for the annual reporting period;
 
.
the percentage of staff that have received fire safety training in accordance with the training needs analysis;
 
.
the outcome on any audits undertaken by the fire and rescue service together with any associated reports and communications.
 
 
12.3 At the end of each annual reporting period, the trust is required to report details in respect of the number of fires and false alarms to DH via the ERIC data return.
Audit
12.4 To provide the board, partners or equivalent controlling body with sufficient assurance it is necessary to undertake an audit of the fire safety management system and the outcomes delivered and to assess these against the objectives set in the fire safety policy. While such a process should enable the organisation to demonstrate due diligence, it also serves as the means by which the board, partners or equivalent controlling body holds the management to account for the delivery of an appropriate level of fire safety.
12.5 Audits are performed to ascertain the validity and reliability of information as well as to provide an assessment of the fire safety management system’s internal control. In order to ensure the integrity of the audit process and provide the necessary assurance to the board, partners or equivalent controlling body within a structure of sound governance, the audit should be undertaken by parties independent of the fire safety management structure.
12.6 Those undertaking the fire safety audit should be able to demonstrate sufficient competence in fire safety matters in the healthcare environment.
12.7 A fire safety audit should be carried out on a regular basis (ideally annually for larger and more complex premises) and should include a review of the following issues:
.
Does the fire safety policy contain clear fire safety objectives and appropriate commitment to facilitate the management of fire safety in the organisation?
 
.
Are management roles and responsibilities clearly described and are post holders aware and accepting of the roles they are required to fulfil?
 
.
Do the fire safety protocols provide sufficient and clear instruction on important fire safety matters, and in particular to those whose role may not immediately appear to significantly impact upon fire safety?
 
.
Are adequate fire risk assessments in place for all areas under the organisation’s ownership, occupation and/or control?
 
.
Have suitable fire safety improvement action plans been developed to mitigate the risks identified in the fire risk assessments?
 
.
Have the significant findings from fire risk assessments been communicated to the board, partners or equivalent controlling body and has appropriate action been implemented?
 
.
Has an appropriate training needs analysis been undertaken and a suitable fire safety training programme been implemented?
 
.
Has the fire safety training activity been effective in ensuring that staff are aware of their fire safety responsibilities and their role in fire prevention and implementing the fire emergency action plan? 
 
.
Have sufficient robust fire emergency action plans been developed, disseminated and suitably rehearsed for all parts of the organisation?
 
.
Is a suitable programme of maintenance activity by sufficiently competent persons in place to adequately maintain the fire precautions, systems and equipment?
 
.
Is sufficient information in respect of the emergency procedures, fire precautions, systems and equipment readily available in an appropriate form to facilitate fire-fighting activities?
 
.
Where applicable, has a detailed plan of action plan been implemented to reduce false alarms and unwanted fire signals?
 
.
Have any notices been issued by the fire and rescue services in respect of the organisation’s compliance with statutory fire safety duties?
 
.
Is the fire safety management system delivering the appropriate outcomes to meet the fire safety objectives set by the organisation’s fire safety policy?
 
 
This list is not exhaustive but reflects many of the key questions that the audit should seek to answer.
12.8 It is recommended that the organisation should produce an annual statement of fire safety to provide a clear indication in respect of the status of fire safety management within the organisation and a statement of assurance that adequate fire safety measures are in place. This statement should reflect the information historically provided to DH and it would be appropriate to use a similar format. See Appendix G for an exemplar annual statement of fire safety. This annual statement would not need to be submitted to DH.
12.9 The outcome of any fire safety audit and internal reports should be used as the basis on which to formulate the annual statement of fire safety.
12.10 The annual statement of fire safety is to be retained by the organisation and may be presented to the Care Quality Commission along with supporting documentation as evidence of performance against Outcome 10 of the ‘Essential standards of quality and safety’. 
12.11 Local fire and rescue authorities may also wish to have sight of the internal annual statement of fire safety.
Appendix A – Exemplar
trust fire safety policy
Purpose
To provide an unambiguous statement of fire safety policy applicable to Anytown NHS Trust and to premises where patients of Anytown NHS Trust receive treatment or care, excluding a single private dwelling.
Policy aims
This fire safety policy aims to minimise the incidence of fire throughout all activities provided by, or on behalf of, Anytown NHS Trust.
Where fire occurs, this policy aims to minimise the impact of such occurrence on life safety, the delivery of patient care, the environment and property. 
Application
This policy applies wherever Anytown NHS Trust owes a duty of care to service users, staff or other individuals.
Facilitation
The Trust Board will:
.
discharge its responsibilities as a provider of healthcare to ensure that suitable and sufficient governance arrangements are in place to manage fire-related matters;
 
.
provide appropriate levels of investment in the estate and personnel to facilitate the implementation of suitable fire safety precautions;
 
.
facilitate the development of partnership initiatives with stakeholders and other appropriate bodies in the provision of fire safety where reasonably practicable.
 
 
Implementation
The Trust Board expects those tasked with managing aspects of fire safety to:
.
diligently discharge their fire safety responsibilities as befits their position;
 
.
have in place a clearly defined management structure for the delivery, control and monitoring of fire safety measures;
 
.
have in place a programme for the assessment and review of fire risks;
 
.
develop and implement appropriate protocols, procedures, action plans and control measures to mitigate fire risks, comply with relevant legislation and, where practicable, codes of practice and guidance;
 
.
develop and disseminate appropriate fire emergency action plans pertinent to each department/building/area to ensure the safety of occupants, protect the delivery of service and, as far as reasonably practicable, defend the property and environment;
 
.
develop and implement a programme of appropriate fire safety training for all relevant staff;
 
.
develop and implement monitoring and reporting mechanisms appropriate to the management of fire safety.
 
 
Monitoring
The Trust Board will monitor the implementation of this policy through:
.
periodic review of fire and false alarm incident reports;
 
.
periodic review of fire safety training records;
 
.
periodic review of fire service notices and communications;
 
.
fire safety audit reports;
 
.
periodic third-party fire safety audit.
 
 
Appendix B – Exemplar fire safety management system
PLAN (Establish)
 Establish fire safety policy, objectives, targets, controls, protocols and procedures relevant to improving fire safety management in order to deliver results that align with the organisation’s overall policies and objectives. 
 
DO (Implement and operate)
 Implement and operate the fire safety policy, controls, processes and procedures.
 
CHECK (Monitor and review)
 Monitor and review performance against fire safety policy and objectives. Report results to management for review, and determine and authorise actions for remediation and improvement.
 
ACT (Maintain and improve)
 Maintain and improve the fire safety management system by taking corrective action based on the results of the management review and fire safety audit. Reappraise the scope of the fire safety management system, the fire safety policy and objectives. 
 
 
 
 
 
 
Appendix C – Exemplar fire safety management structure
.
 
 
Appendix D – Exemplar person specification
The essential requirements are not intended to prevent suitable applicants from being appointed. Criteria may not be met at the time of potential appointment, but both essential and desirable criteria should form the basis of a continuing professional development process.
Fire Safety Manager
Criteria
 Essential
 Desirable
 
 
Training & qualifications
 Science or engineering-based education; or extensive experience of fire safety.
Fire engineering/fire safety degree or other relevant engineering/science degree
Membership of professional organisation (Institution of Fire Engineers; Institution of Occupational Safety and Health)
Professional qualification in a fire-related subject.
Training in healthcare fire safety.
 
Experience
 A number of years’ experience of operating in a senior management role.
Awareness of fire safety and other risk issues.
Experience of working across organisational boundaries to improve standards.
Experience of working with external agencies and influencing internal change.
 Knowledge and experience in the application of Firecode.
Knowledge of risk management techniques.
Awareness of the Regulatory Reform (Fire Safety) Order 2005, its practical implications and application.
Practical knowledge and interpretation of the Building Regulations 2010.
Experience and knowledge of undertaking fire risk assessment.
Knowledge of:
. fire safety
. fire risk management
. fire legislation and codes of practice
. fire safety training.
Ability to undertake fire safety audits.
(Continued)
 
 
 
 
 
Criteria
 Essential
 Desirable
 
 
Communication and relationship skills 
 Highly developed and effective negotiating and influencing skills and ability to develop and maintain constructive relationships with professional and managerial disciplines.
Highly developed management skills and the ability to maximise resource utilisation.
Highly developed and effective verbal and written communication skills.
Ability to assimilate, analyse and present complex problems, identify necessary action, make recommendations and ensure actions are implemented.
 
Analytical and judgement skills
 Ability to assimilate, analyse and present complex problems, identify necessary action, make recommendations and ensure actions are implemented.
Understanding of the principles of risk assessment.
 Good organisational skills with practical and methodical project planning and ability to manage a number of concurrent schemes.
 
Planning and organisation skills
 General computer literacy skills and ability to use Microsoft Office applications.
Ability to devise and manage the delivery of training programmes.
The ability to concentrate for long periods of time and prioritise and manage a varied and unpredictable work pattern.
 
Physical skills 
 Able to satisfy the physical demands of the job.
Occasional moderate physical effort required as duties dictate e.g. evacuation of patients.
Occasional moving of heavy equipment
e.g. extinguishers, training equipment.
 Occasional working at heights and in confined spaces e.g. scaffold or roof voids.
 
Other 
 Highly motivated and resourceful with a proactive approach to problem-solving.
Innovator with a positive attitude and willingness to take responsibility.
Self-motivated and has the ability to use own initiative.
The ability to motivate others to deliver sometimes challenging outcomes.
Good team player.
Ability to work within a changing environment.
Willingness to participate in continued professional development.
 Active interest in own self-development.
 
 
 
 
 
 
Fire Safety Adviser
Criteria
 Essential
 Desirable
 
 
Training & qualifications
 Science- or engineering-based education; or extensive experience of fire safety.
Certificate in Training Practice or extensive experience of preparing and delivering training.
Membership of a professional organisation (e.g. the Institution of Fire Engineers (IFE); the Institute of Fire Prevention Officers (IFPO))
 Fire engineering/fire safety degree or other relevant academic qualification.
Corporate membership of professional organisation (Institution of Fire Engineers; Institution of Occupational Safety and Health)
Professional qualification in a fire-related subject.
Training in healthcare fire safety.
Registered as a fire risk assessor with a recognised accreditation body.
 
Experience
 Several years’ experience in fire safety 
Experience of preparing and delivering training courses.
Experience of working across organisational boundaries to improve standards.
Experience of working with external agencies and influencing internal change.
Experience and knowledge of undertaking fire risk assessment.
Knowledge of:
. fire safety
. fire risk management
. fire legislation and codes of practice
. fire safety training.
Ability to undertake fire safety audits.
 Knowledge and experience in the application of Firecode.
Understanding of fire modelling techniques.
Knowledge of risk management techniques.
Practical knowledge and interpretation of the Regulatory Reform (Fire Safety) Order 2005.
Practical knowledge and interpretation of the Building Regulations 2010.
 
Communication and relationship skills 
 Highly developed and effective negotiating and influencing skills and ability to develop and maintain constructive relationships with professional and managerial disciplines.
Highly developed and effective verbal and written communication skills.
 Ability to assimilate, analyse and present complex problems, identify necessary action, make recommendations and ensure actions are implemented.
 
Analytical and judgement skills
 Ability to devise and deliver training programmes.
Understanding the principles of risk assessment
Good organisational skills with practical and methodical project planning and ability to manage a number of concurrent schemes.
 Ability to assimilate, analyse and present complex problems, identify necessary action, make recommendations and ensure actions are implemented.
 
 
 
 
 
Criteria
 Essential
 Desirable
 
 
Planning and organisation skills
 General computer literacy skills and ability to use Microsoft Office applications.
Ability to devise and deliver training programmes.
The ability to concentrate for long periods of time and prioritise and manage a varied and unpredictable work pattern.
 Ability to use AutoCAD.
 
Physical skills 
 Able to satisfy the physical demands of the job.
Occasional working at heights and in confined spaces e.g. scaffold or roof voids.
Occasional moderate physical effort required as duties dictate
e.g. evacuation of patients etc.
Occasional moving of heavy equipment e.g. extinguishers, training equipment.
 
Other 
 Highly motivated and resourceful with a proactive approach to problem-solving.
Innovator with a positive attitude and willingness to take responsibility.
Self-motivated and has the ability to use own initiative.
Good team player.
Ability to work within a changing environment.
Willingness to participate in continued professional development.
 Active interest in own self-development.
 
 
 
 
 
 
Appendix E – Developing
fire safety protocols
The following information prompts are intended to assist in developing a comprehensive set of fire safety protocols. The list of items included should not be considered to be exhaustive. Local arrangements will dictate the necessary detail.
Fire strategy concepts
What should be the fire strategy approach to each new building?
.
What guidance should the design reference?
 
.
Where elements are fire-engineered, how are they to be assessed?
 
.
Should the building be provided with sprinklers?
 
 
What should be the arrangements for fire detection and alarm?
.
Should automatic fire detection be provided? If so, to what standard?
 
.
Should any fire detection and alarm system interface with existing systems? If so, what is the nature of the interface? 
 
 
What should be the evacuation strategy?
.
Should all building occupants evacuate immediately?
 
.
Should the evacuation strategy support phased evacuation or progressive horizontal evacuation? 
 
 
What arrangements are necessary to facilitate future development?
.
Should arrangements to limit external fire spread take account of potential future development?
 
.
Should the arrangements for fire-fighting access and/or water supplies consider future development potential?
 
 
Fire risk assessments
Who is responsible for providing fire risk assessments?
Who carries out the risk assessment?
How does the organisation ensure the competency of the fire risk assessor?
What is the scope and what are the limitations of the risk assessment programme?
Is a survey of compartmentation included?
Will the risk assessment be limited by issues of access, asbestos etc?
Who takes ownership of the fire risk assessment?
Who initiates a review of the fire risk assessment?
.
Are reviews undertaken periodically? If so, at what period?
 
.
Are reviews undertaken in response to material changes? If so, how are these initiated?
 
.
How are changes to adjacent areas and departments considered?
 
 
Are temporary changes to be reflected in the fire risk assessments?
.
How is the introduction of hot works to an area that may invalidate the fire risk assessment during the period of the works considered?
 
.
How is the degradation of the fire detection and alarm system considered?
 
.
How are temporary changes to adjacent areas and departments considered?
 
 
How are the findings of the fire risk assessment communicated?
.
How are findings communicated to employees?
 
.
How are findings communicated to the parents or guardians of any young persons employed in the organisation?
 
.
How are findings communicated to other employers that share the premises?
 
 
How are the findings of other employers’ risk assessments communicated to the organisation and accounted for in their risk assessments?
Fire prevention
What steps should staff take to prevent the occurrence of fire?
.
How are sources of ignition controlled?
 
.
How are combustible materials and flammables controlled?
 
.
How are sources of oxygen and oxidising agents controlled?
 
 
What facilities are in place to assist in the prevention of fire?
What action should staff take to prevent arson?
Fire detection and alarm systems
Is there a standard type used in the organisations? If so, what are the details of the system used?
What arrangements are there for the system maintenance and testing?
Is annual functional testing undertaken?
What arrangements are there for a degradation of the system’s performance? How are building occupants notified? How do the fire risk assessments reflect the potential impact?
What arrangements are there for disabling part or all of the system to facilitate works, cleaning activity etc? How are building occupants notified? How do the fire risk assessments reflect the potential impact?
What arrangements are there for undertaking work on the system?
False alarms and unwanted fire signals
What actions should staff take to avoid false alarms?
What actions should staff take to prevent false alarms becoming unwanted fire signals?
What actions should staff take to minimise the disruption caused by false alarms and unwanted fire signals?
How should false alarms and unwanted fire signals be recorded and reported?
Fire extinguishers
What type of fire extinguishers are used in the organisation?
How should they be used?
Are there typical locations? If so, where are fire extinguishers likely to be located?
What are the arrangements for their servicing and maintenance?
Who should be trained in their use?
Portable appliance testing
What equipment needs to be subject to portable appliance testing?
Does new equipment require testing in its first year of use?
What frequency should appliances be subject to testing?
How should portable appliance testing be indicated on the equipment?
How should portable appliance testing be recorded?
Medical gases
What procedures are necessary for the safe use of medical gases?
How should medical gas cylinders be stored?
Where should medical gas cylinders be stored?
How many medical gas cylinders should be stored in any central location?
How many medical gas cylinders should be stored in any local location?
Purchasing
What fire safety standards should apply to upholstered furniture being procured?
What fire safety standards should apply to textiles and furnishings being procured?
Is there a list of items that should not be purchased without first consulting with the Fire Safety Manager or Fire Safety Adviser?
What procedure should be followed to obtain advice for the purchase of items that may pose a fire hazard?
Laundry
What laundry processes should be used to preserve the fire retardancy of textiles?
What labelling should be used on textiles to identify their fire retardancy properties?
Security
Does the fire risk assessment take account of the lockdown policy and process?
Does the emergency evacuation plan work during a lockdown?.
What are the procedures for lockdown which can assist with the management of a fire incident?
Maintenance of fire precautions and systems
What procedures should be followed for the maintenance of fire precautions and systems?
What should be the maintenance intervals for each system or element of the fire precautions?
What arrangements are there for a degradation of the fire precautions or system during maintenance activity? How are building occupants notified? How do the fire risk assessments reflect the potential impact?
Construction, refurbishment and other works
What are the procedures for ensuring that project works do not compromise fire safety?
Is there a process of consultation with the Fire Safety Manager and/or Fire Safety Adviser?
Is there a permit-to-work system in place for any works that may penetrate a fire-resisting structure?
Is there a permit-to-work system in place for any works that may obstruct access or a fire escape route?
Is there a permit-to-work system in place for any works that may affect facilities for the fire and rescue service such as access routes, fire appliance hardstanding, fire hydrants, fire mains etc?
How do the fire risk assessments reflect the potential impact both for the area concerned and for adjacent or associated areas?
How are building occupants notified and the potential impact reflected in the fire emergency action plan?
How are project records collated and changes reflected in the information provided to the fire and rescue service?
Fire stopping
What are the procedures for fire stopping?
What is the specification for fire stopping?
What are the requirements for product certification?
What are the requirements for fire stopping contractor certification?
How are the details of fire stopping recorded?
.
Are details of location, product type and quantity, date of installation, contractor’s details and batch numbers recorded?
 
.
Are details identified locally on the fire-resisting element to which the fire stopping is applied and records collated centrally?
 
 
Is the application of fire stopping inspected prior to the completion of works and the closing of ceilings etc? If so, who carries out the inspection? How is the inspection recorded?
Hot works
What are the procedures for hot works?
Who is responsible for undertaking the risk assessment associated with the hot works?
How do the fire risk assessments reflect the potential impact particularly for adjacent or associated areas?
How are building occupants notified and how is the potential impact reflected in the fire emergency action plan?
Security
What procedures should be followed to ensure that security arrangements do not compromise means of escape?
Where electronic or magnetic locking devices are in use, what are the arrangements for overriding the locking mechanisms in the event of a fire?
What are the arrangements for avoiding the unintentional operation of manual call points by persons intending to activate the door lock controls?
How do the security measures for protecting vulnerable patients interact with the means of escape? Is the escape from some areas reliant on the staff to unlock doors?
How do security arrangements external to the building impact on the ability of those evacuating to move away from the building to a place of safety?
Fire emergency action plans
Who is responsible for developing the fire emergency action plans?
How are action plans coordinated between different departments and different organisational levels?
How are the fire emergency action plans communicated to staff and other relevant persons?
Who initiates a review of the fire emergency action plan?
.
Are reviews undertaken periodically? If so, at what period?
 
.
Are reviews undertaken in response to material changes? If so, how are these initiated?
 
.
How are changes to adjacent areas and departments considered?
 
 
Are temporary changes to be reflected in the fire emergency action plans?
.
How is the degradation of the fire detection and alarm system considered?
 
.
How are temporary changes to adjacent areas and departments considered?
 
.
How are these temporary changes communicated to staff?
 
 
How should the fire emergency action plans be rehearsed? 
How often should the rehearsal take place?
Salvage and continuity planning
Who is responsible for developing the salvage plans and continuity plan?
How are salvage and continuity plans coordinated between different departments and different organisational levels?
How is the salvage and continuity plan made available to the fire and rescue service when they attend?
Who initiates a review of the salvage plan and continuity plan?
.
Are reviews undertaken periodically? If so, at what period?
 
.
Are reviews undertaken in response to material changes? If so, how are these initiated?
 
 
Fire safety information manual
What arrangements are in place to provide fire safety information manuals?
What form should the fire safety information manual take and what should it contain?
Who is responsible for ensuring that the fire safety information manual is maintained up-to-date?
What are the arrangements for ensuring that the fire safety information manual is available to staff members, patients and patient representatives?
Who initiates a review of the fire safety information manual?
.
Are reviews undertaken periodically? If so, at what period?
 
.
Are reviews undertaken in response to material changes? If so, how are these initiated?
 
 
Fire safety training
What arrangements are in place to provide fire safety training? Do these arrangements include training for volunteers and/or employees of other organisations that work within the premises?
How is the training needs analysis communicated to staff?
How do those requiring training arrange to receive the appropriate fire safety training?
What are the training arrangements for temporary, agency and/or bank staff?
What are the arrangements for recording
(i) attendances at fire safety training sessions and
(ii) the content of each training session attended?
How is the responsibility for ensuring staff members are made available for fire safety training communicated to line managers?
How is the effectiveness of fire safety training audited?
Information for the fire and rescue service
What arrangements are in place to collate the relevant information?
How is the fire and rescue service engaged in the process to ensure that sufficient information is available in a usable format?
Where is the package of information located, and how is it delivered to the attending fire and rescue service?
What process is in place for reviewing and updating the information available to the fire and rescue service?
Appendix F – Developing
the training needs
analysis
The following exemplar is not exhaustive and is intended to highlight the process of training needs analysis and the arrangements for recording the analysis outcomes in a format that permits staff and their line managers to identify their training needs.
1. Determine staff fire safety responsibilities
Consider the fire safety responsibilities of each staff member in terms of their role in preventing a fire, managing fire safety and their response as part of the emergency action plan. The following examples are used to illustrate the process:
.
An administrator that works in an office and does not enter patient or public access areas as part of their role.
Has a general role for fire safety with no specific fire hazards and their fire emergency action plan is to evacuate themselves and attend the assembly point.
 
.
An administrator that is ward-based or often enters ward areas.
Has a general role for fire safety with no specific fire hazards and their fire emergency action plan may require them to assist in the evacuation of visitors and/or ambulant patients.
 
.
A member of ward housekeeping staff.
Has a general role for fire safety but may have to manage specific fire hazards associated with cleaning fluids, storage of waste and other combustibles. Their fire emergency action plan may require them to clear escape routes of service and cleaning equipment and to assist in the evacuation of visitors and/or ambulant patients.
 
.
A member of the food delivery catering staff.
Has a general role for fire safety but may have to manage specific fire hazards associated with catering equipment. Their fire emergency action plan may require them to clear escape routes of equipment, ensure the safe storage of potentially hot equipment, and to assist in the evacuation of visitors and/or ambulant patients.
 
.
A member of the nursing staff on a general ward.
Has a general role for fire safety but may have to manage specific fire hazards associated with medical gases. Their fire emergency action plan may require them to evacuate dependent patients both horizontally and vertically using evacuation equipment.
 
.
A member of nursing staff on a critical care unit.
Has a general role for fire safety but may have to manage specific fire hazards associated with medical gases. Their fire emergency action plan may require them to avoid patient evacuation where possible and to evacuate very high dependency patients both horizontally and vertically using evacuation equipment if necessary.
 
 
2. Group staff with similar fire safety responsibilities 
Using the staff responsibilities identified in step 1, group together those members of staff that have similar fire safety responsibilities even though their usual functions may not be similar. For example:
.
A dietician that regularly visits the ward areas may have similar fire safety responsibilities to an administrator that is ward-based or often enters ward areas.
 
.
A physiotherapist, doctor or consultant that is ward-based or regularly visits the ward areas may have similar fire safety responsibilities to ward staff and may be able to assist in implementing the emergency action plan.
 
.
A consultant surgeon or member of the operating theatre staff may have similar fire safety responsibilities to a member of nursing staff on a critical care unit.
 
 
3. Determine the training requirement for each fire safety responsibility
For staff to meet their fire safety responsibilities, it will be necessary for them to receive adequate training. From the examples given in step 1, there are some discrete training requirements applicable to each group of staff represented. This would require the development of the following training packages:
.
General fire safety and fire prevention.
 
.
General fire safety and fire prevention and the safe storage and use of equipment, combustibles and flammable solvents.
 
.
General fire safety and fire prevention and the safe storage and use of potentially hot equipment.
 
.
General fire safety and fire prevention and the safe storage and use of medical gases.
 
.
The evacuation process – self-evacuation.
 
.
The evacuation process – assisting independent patients and visitors.
 
.
The evacuation process – evacuating dependent patients.
 
.
The evacuation process – evacuating very high dependency patients.
 
 
In some cases it may be appropriate to combine training packages to provide training sessions with a broader relevance where there are sufficient common elements; for example, it may be appropriate to combine the training packages aimed at domestic staff with those aimed at catering staff where much of the training is common to both groups.
4. Determine the nature, duration and number of training sessions required to deliver the appropriate level of training for the fire safety responsibilities
For some groups the training syllabus will be relatively small whereas others may require significant training input. Some fire safety training elements may be adequately delivered using alternative methods to face-to-face training. For example, general fire safety awareness and basic fire prevention may be adequately delivered to some groups through the use of e-learning, intranets or printed media.
 The duration of any fire safety training session should be determined mainly by the content of the training syllabus that needs to be delivered. For some groups, the fire safety training syllabus is modest and will not require an extensive training session to deliver its content. 
However, for other groups it may not be practical to deliver the entire training syllabus to a training group in a single session; therefore, a number of shorter duration training sessions, each presenting a different part of the training syllabus, may be preferable.
5. Determine the frequency at which each training element should be repeated
The frequency of fire safety training should reflect the complexity of the information that needs to be imparted. The greater the degree of complexity of the fire safety training, the more frequently such training should be refreshed. The following examples illustrate a flexible approach determined by the training needs of each group:
.
For some groups, such as those whose fire emergency action plan consists of self-evacuation, the frequency of face-to-face fire safety training may be extended to as little as once every three years, provided that:––
in each intervening year, basic fire safety awareness is delivered through e-learning, an interactive website or recorded printed media; and
 
––
an unannounced fire drill takes place, providing that the fire drill is considered successful.
 
 
 
 
.
For other groups, such as those working in operating theatres, the fire safety training syllabus is likely to be extensive, requiring training in a broad range of fire safety topics including: ––
fire prevention;
 
––
characteristics of fire and smoke;
 
––
reducing fire spread;
 
––
use of fire extinguishers;
 
––
deciding when to evacuate;
 
––
evacuating very high dependency patients.
 
 
 
 
 
Effective fire safety training for such groups is likely to require practical sessions in the use of fire extinguishers and the evacuation of very high dependency patients. Facilitating these practical exercises will not be easily achieved if combined with other fire safety training elements in a single session. It may be more appropriate to provide training in the form of a number of shorter sessions, each concentrating on a particular aspect of the fire safety training syllabus. For example:
––
Session 1:
one-hour practical session on the use of fire extinguishers.
 
––
Session 2:
30-minute classroom session on fire prevention, fire and smoke spread etc.
 
––
Session 3:
30-minute department-based session on the theory of evacuating very high dependency patients, including a walkthrough of the fire emergency action plan.
 
––
Session 4:
one-hour practical session on evacuating very high dependency patients.
 
 
A rolling training programme may comprise, for example, the delivery of each training session in turn with an interval between training sessions of eight months.
The information developed in the training needs analysis can be readily displayed in a matrix format that identifies each staff group, each fire safety training package, and the frequency with which each group should receive each training package that is appropriate for their fire safety and fire emergency action plan roles. Table F1 provides an example of a training needs matrix.
The examples shown in Table F1 are intended to be indicative and to illustrate a flexible approach to determining the provision of fire safety training. The format, content, frequency and duration of training sessions indicated should not be used as a normative reference. The specific nature, duration and frequency of fire safety training should be determined by the Fire Safety Manager, reviewed periodically and adjusted as necessary to deliver the desired training outcomes. 
The provision of training should be determined on the basis of that required to facilitate staff undertaking their roles in fire safety and implementing the fire emergency action plan. Limitations in the availability of training resources or the ability of staff to be released from their duties to attend training are not considered an appropriate basis on which to develop a programme of training.
Using the approach described in Table F1, each staff group will receive refresher fire safety training at least once in every 12-month period, even though the nature of such training may vary from a successful unannounced fire drill (for those whose actions during a fire incident require self-evacuation only) to practical training in techniques for evacuating very high dependency patients (for those in critical care environments).
The training needs analysis should be reviewed periodically and in response to:
.
relevant changes including staffing, the number and dependency of patients, the nature of evacuation equipment provided and changes to the premises;
 
.
the fire safety training audit identifying that the level of understanding and awareness among staff of their fire safety responsibilities and their role in fire prevention and implementing the fire emergency action plan is unsatisfactory;
 
.
a report by the enforcing fire authority highlighting training.
 
 
Key:
a = upon commencement of work in an area
x = upon commencement of work for the organisation
12 = 12-month interval between training
24 = 24-month interval between training
36 = 36-month interval between training
Note: Where a member of staff has attended a fire lecture in the previous 12-month period, the use of e-learning is not required.
The use of e-learning for fire safety training is described in
Chapter 11; it should not be used as the sole method of delivering
fire safety training. 
 Fire safety induction (Local) 
 Fire safety induction (Corporate)
 (45 minutes)
 General fire safety (e-learning)
 General fire safety (classroom session)
(30 minutes)
 Combustibles, flammables & equipment
(15 minutes)
 Fire safety including medical gases 
(30 minutes)
 Fire & smoke spread etc
(30 minutes)
 Using fire extinguishers (Practical)
(1 hour)
 Fire evacuation drill
 Assisting independent patients & visitors.
(15 minutes)
 Evacuating dependent patients (Theory)
(30 minutes)
 Evacuating dependent patients (Practical)
(1 hour)
 Evacuating very high dependency patients (Theory)
(30 minutes)
 Evacuating very high dependency patients (Practical) (1 hour)
 
An administrator that works in an office and does not enter patient or public access areas as part of their role
 a
 x
 12
 36
 12
 
An administrator that is ward-based or often enters ward areas
 a
 x
 12
 12
 
A member of ward housekeeping staff
 a
 x
 12
 12
 12
 
A member of the food delivery catering staff.
 a
 x
 12
 12
 12
 
A member of the nursing staff on a general ward.
 a
 x
 12
 12
 12
 24
 
A member of nursing staff on a critical care unit.
 a
 x
 24
 24
 24
 24
 24
 24
 
A member of working in an operating theatre
 a
 x
 24
 24
 24
 24
 24
 24
 
 
 
 
Table F1 Exemplar training needs matrix
Appendix G – Exemplar annual statement of fire safety
Annual statement of fire safety 20XX
NHS organisation:
 
I confirm that for the period 1 January 20XX to 31 December 20XX, all premises which the organisation owns, occupies or manages have had fire risk assessments undertaken in compliance with the Regulatory Reform (Fire Safety) Order 2005, and (please tick the appropriate boxes):
 
1
 There are no significant risks arising from the fire risk assessments.
 
2
 The organisation has developed a programme of work to eliminate or reduce to a reasonably practicable level the significant risks identified by the risk assessment.
 
3
 The organisation has identified significant risks, but does not have a programme of work to mitigate those significant risks.
 
4
 Where a programme to mitigate significant risks has not been developed, please insert the date by which such a programme will be available, taking account of the degree of risk.
 
5
 During the period covered by this statement, the organisation has/has not* been subject to any enforcement action by the fire and rescue authority.
Please outline details of enforcement action in Annex A Part 1.
 
6
 The organisation has/has not* any ongoing enforcement action pre-dating this Statement. Please outline details of ongoing enforcement action in Annex A Part 2.
 
7
 The organisation achieves compliance with the Department of Health’s fire safety policy by the application of Firecode or some other suitable method.
 
Chief Executive:
 
Fire Safety Manager:
 
Contact details:
 E-mail:
 
Telephone:
 
Mobile:
 
Signature of Chief Executive
 
Date:
 
Completed statement to be retained for future audit.
 
 
 
 
* Delete as appropriate
ANNEX A
Part 1 – Outline any enforcement action taken during the past 12 months and the action taken or intended by the organisation. Include, where possible, an indication of the cost to comply.
 
 
Part 2 – Outline any enforcement action ongoing from previous years and the action the organisation has taken so far. Include any proposed action needed. Include an indication of the cost incurred so far and, where possible, an indication of costs to fully comply.
 
 
NHS Organisation:
 
Date:
 
 
 
 
 
 
References 
Legislation
Building Regulations 2010. SI 2010 No 2214.
http://www.legislation.gov.uk/uksi/2010/2214/contents/made
Equality Act 2010.
http://www.legislation.gov.uk/ukpga/2010/15/contents
Fire and Rescue Services Act 2004.
http://www.legislation.gov.uk/ukpga/2004/21/contents
Regulatory Reform (Fire Safety) Order 2005. SI 2005 No 1541.
http://www.legislation.gov.uk/uksi/2005/1541/contents/made
Firecode publications
Health Technical Memorandum 05-02. – Guidance in support of functional provisions for healthcare premises.
https://www.gov.uk/government/publications/guidance-in-support-of-functional-provisions-for-healthcare-premises
Health Technical Memorandum 05-03 – Operational provisions.
https://www.gov.uk/government/publications/suite-of-guidance-on-fire-safety-throughout-healthcare-premises-parts-a-to-m
Other publications
Care Quality Commission (2010). Guidance about compliance: Essential standards of quality and safety.
http://www.cqc.org.uk/sites/default/files/media/documents/gac_-_dec_2011_update.pdf
BS EN ISO/IEC 17021. Conformity assessment. Requirements for bodies providing audit and certification of management systems. British Standards Institution, London, 2011.
PAS 7:2013. Fire risk management systems specification. British Standards Institution, London, 2013.
 
Contents
Executive summary...................................................................................................................iii
Acknowledgements..................................................................................................................iv
Glossary of terms.....................................................................................................................vi
1 Introduction and scope .........................................................................................................1
2 Department of Health fire safety policy.................................................................................3
3 Statutory fire safety duties ....................................................................................................4
4 NHS trust fire safety policies.................................................................................................7
5 Effective fire safety management..........................................................................................8
6 Appropriate management levels..........................................................................................12
7 Fire safety management roles and responsibilities............................................................16
8 Fire safety protocols.............................................................................................................22
9 Fire safety information manuals...........................................................................................23
10 Planning and responding to a fire emergency...................................................................25
11 Training................................................................................................................................28
12 Reporting and audit............................................................................................................33
Appendix A – Exemplar trust fire safety policy......................................................................35
Appendix B – Exemplar fire safety management system......................................................37
Appendix C – Exemplar fire safety management structure...................................................39
Appendix D – Exemplar person specification........................................................................40
Appendix E – Developing fire safety protocols......................................................................44
Appendix F – Developing the training needs analysis...........................................................50
Appendix G – Exemplar annual statement of fire safety........................................................55
References ..............................................................................................................................57
 
Indicative examples of premises type
 Patient & occupant characteristics
 Management level
 
Acute hospital
 Dependent & very high dependency patients
Occupants may be asleep
Potentially large numbers of occupants in out-patient facilities
 1
 
Mental health hospital
 Dependent patients with potentially challenging behaviour
Potential for fire setting
Occupants may be asleep
 1
 
Diagnostic & treatment centre
 Dependent & very high dependency patients
Patients anaesthetised or sedated
 1
 
Minor injuries unit
 Patients predominantly independent
Occupants able to escape from fire with minimal assistance
Occupants awake
 2
 
Primary care centre – multiple GPs, minor treatment and/or dental provisions
 Majority of patients independent
Small numbers of patients may be sedated
 2
 
Small GP practice
 Majority of patients independent
Small numbers of occupants at any one time
Occupants awake
Premises small and easily navigated
 3
 
 
 
 
 
Table 1 Appropriate levels of fire safety management for indicative examples
 
 
Table B1 Explanation of PLAN DO CHECK ACT model
 
 
 
 
 
Health Technical
Memorandum 05-01:
Managing healthcare fire safety
Second edition
 
April 2013
 
 
 


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