http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/Risk_Management_Fire_Policy_August_09

Risk Management (Fire) Policy

Responsible Directorate:

CORPORATE SERVICES

Responsible Director:

HELENA CORDER

Date Approved: Committee:

Governance

Version:

.

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Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List: Web address: Restrictions:

Risk Management (Fire) Policy Chris Bedford Terry Service 02 01 April 2009 01 April 2011 Fire Safety Adviser

Standard for Better Health Map Domain: Core Standard Reference:

Performance Indicators:

Domain 6 (care environment and amenities) C20 Domain 3 (Gov) C7a C7c Standards for Better Healthcare C20: Health care services are provided in environments which promote effective care and optimise health outcomes by being a) a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation 1. No of fire related incidents reported.

2. Number of false fire alarms. .

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Contents

Section Policy Statement 1.

Introduction 2.

Associated Policies and Procedures.

3.

Aims and Objectives.

4.

Scope of the Policy 5.

Accountabilities and Responsibilities.

6.

General On-Site Information 7.

Equality Impact Assessment 8.

Training Needs Analysis 9.

Monitoring Compliance 10.

References Appendices A B C D

Definitions Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool

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Policy Statement NHS Kirklees attaches the highest importance to the health, safety and welfare of all our staff, patients and the general public and this includes all aspects of fire safety.

The aim is to provide and maintain safe and healthy working conditions, safe equipment and systems of work, and to provide such information, instruction, training and supervision as is needed for this purpose.

The Trust fully supports the Health and Safety Executive objective to ensure that the risks to health and safety of workers are properly controlled as well as NHS standards for fire safety (HTM Firecode) and related fire legislation.

This policy extends to healthcare premises owned, occupied or managed by the Trust.

1.

Introduction NHS Kirklees is responsible under current legislation for managing the risk from fire at all of our premises. In order to do this we must have a consistent approach to fire safety management whereby we ensure that our premises are safe by design, that there are adequate means of escape, adequate means to fight fire and that all staff are fully aware of their responsibilities.

It is also important that the Trust can assure patients, customers, partners, and stakeholders that we have a robust approach to managing fire risk.

2.

Associated Policies and Procedures This policy should be read in accordance with the following Trust policies, procedures and guidance: • • •

Risk Management (Health and Safety) Policy Risk Management (Arson) Policy Risk Management (Security) Policy The Secretary of State requires all NHS Trusts to comply with Firecode, the NHS code of practice for fire safety. This contains the Department of Health Fire Policy plus specialized technical guidance used to assess and achieve suitable standards in existing premises, new premises, upgrading of premises, or where a change of use or occupancy takes place.

3.

Aims and Objectives To maintain a uniform approach to fire safety management throughout the organization in order to protect lives, property and assets whilst complying with current legislation.

4.

Scope of the Policy This policy must be followed by all NHS Kirklees employees, including those on temporary or honorary contracts, bank staff, students and contractors (unless the contractors are working within their own controlled area and they have adequate arrangements in place to manage fire safety).

Breaches of this policy may lead to disciplinary action being taken against the individual, or other sanctions such as the individual being barred from the premises.

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5.

Accountabilities and Responsibilities

5.1: The Chief Executive The Chief Executive is the accountable-officer responsible for all aspects of Fire Safety but may delegate the day-to-day management of these responsibilities to other Directors and Managers within the organisation.

5.2: Trust Board The Trust Board is responsible for ensuring that the Trust complies with all aspects of Fire safety and associated regulations.

5.3: Lead Director (Health and Safety including Fire Safety) The Chief Executive will delegate fire safety to a lead director who will be responsible for ensuring that the Trust meets its obligations under NHS guidance and associated legislation.

5.4: Fire Safety Manager: To assist in this task the lead director will appoint a Manager who will act as the nominated officer for fire The Fire Safety Manager has the responsibility for the co-ordination of Trust policy, and to promote compliance with current regulations.

Duties include: • Arranging Fire Risk Assessments and annual reviews.

• Monitoring the effectiveness of the fire safety policy and local procedures in all premises (Fire Emergency Action Plans).

• Ensuring that all staff members have the opportunity to participate in fire safety talks.

• Ensuring reports of all fire incidents are reported in accordance with NHS procedures.

• Providing an annual report to the Trust Board on all aspects of fire compliance.

• Attending suitable fire safety training and refreshing training at least every five years.

• Keeping updated on changes in fire safety management and regulation.

• Ensuring all staff members are aware of and understand their responsibilities within the framework of the fire safety policy.

5.5: Incident Control Officer (ICO) On any large site (as defined in the fire risk assessment) a senior manager will take on the role of Incident Control Officer in accordance with their legal obligations to manage health and safety. If there are no clear person for this role the person will be appointed by the Lead Director. The ICO will be responsible for appointing suitable deputies to take on their role in their absence.

An ICO will take charge in the event of a fire (or any other emergencies at their site including Bomb or Terrorist threats). Their role will be to co-ordinate and they will be supported by deputies and fire wardens. In the event of an emergency they will liaise directly with the emergency services. They will give the or the all-clear usually on instruction from the emergency services and the order to evacuate in the instance of bomb or other threat (following assessment).

Other site specific duties for ICOs include: • Attending site safety committees.

• Checking that any areas of concern identified in the Fire Risk Assessment have been addressed and following-up any concerns through normal management channels.

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• •

• • • • • •

Writing the Fire Emergency Action Plan for the site.

Encouraging local managers to identify staff or frequent visitors who may through disability have difficulty evacuating the building. and that they complete a Personal Emergency Evacuation Plans (PEEPS).

Appointing adequate numbers of Fire Wardens.

Ensuring that Fire Wardens are suitably trained and equipped in order to respond to any emergency.

Supporting Fire Wardens on issues of fire risk (e.g., when reporting inappropriate storage, or blocked fire exits).

Arranging Fire Drills as stipulated in the Fire Risk Assessment.

Ensuring that all incidents that relate to fire including any false alarms, fires or risk of fires (including suspected arson) are reported in line with the trust incident reporting procedure.

Attending training on appointment and refresher training at least every two years.

5.6: Estates Manager Duties Include: • Ensuring that buildings are provided with adequate fire protection, detection, fire fighting equipment and means of escape (including emergency lighting), and that all such provisions are adequately managed and maintained.

• Managing all records of testing, maintenance and defect in the on-site Fire Log Books.

• Providing adequate signage.

• Managing Hot Work Permits.

• Liaising with the Fire Safety Adviser and Incident Control Officer before commencing significant works to any site.

5.7: Trust Managers Duties Include: • Implementation of fire safety procedures within their workplace.

• Ensuring the workplace is free from risks associated with fire safety.

• Ensuring members of their staff members receive initial information on fire safety and evacuation procedures immediately following appointment (local and company induction).

• Conducting Personal Emergency Evacuation Plans for any vulnerable staff members or frequent visitors who may have difficulty during emergency evacuation due to disability or other relevant factors.

• Ensuring that their staff members attend annual fire safety talks.

• Encouraging and supporting staff members to volunteer as Fire Wardens when opportunities arise.

• Cooperating with Fire Wardens on fire safety matters.

• Ensuring that all incidents relating to fire including any false alarms, fires or risk of fires (including suspected arson) are reported in line with the trust incident reporting procedure.

5.8: Fire Wardens: Duties include: • Assisting the Incident Control Officer with routine fire safety management.

• Assisting the ICO in the event of an emergency.

• Conducting periodic site inspections to identify fire related risks, where upon they are empowered to direct action where fire hazards are identified. They are fully supported by their ICO and will have access to advice from the Fire Safety Adviser.

• Attending training on appointment and refresher training at least every two years.

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5.9: All Staff Members Everyone’s’ duties include: • Complying with all relevant policies and procedures.

• Attending the Trusts Fire Safety Talks at least annually.

• Cooperating with the ICO and Fire Wardens on all matters relating to fire safety.

• Ensuring that all incidents that relate to fire including any false alarms, fires or risk of fires (including suspected arson) are reported in line with the trust incident reporting procedure.

6.0: General On-Site Information Owned Sites: On sites owned by NHS Kirklees, and where we are the major or controlling occupier we will: • Ensure that signage and instruction are available to all occupants and visitors in a format that they can understand.

• Ensure that our fire evacuation procedures are available to all occupants and invite them to attend any site specific fire safety talks or to participate in any site specific safety groups.

• Provide sufficient notification of any safety procedures relating to specific fire hazards (e.g.

Bottled Gas, flammable liquids).

Rented Sites: Where we occupy parts of sites owned or managed by others the senior manager will ensure that we: • Comply with their fire safety procedures.

• Attend any site specific fire talks run by the host.

• Raise any concerns about site specific fire safety both locally and through management.

• Delegate representation to any site specific safety groups.

• Notify the host if we introduce any fire hazard onto the site.

Client’s Place of Residence: When visiting clients’ homes we will: • Assess the risk to ourselves from any uncontrolled fire risks.

• Assess the risks to any vulnerable persons.

• Assess any hazard that we may introduce (eg equipment blocking exits, oxygen etc) • Report any significant concerns to the appropriate authority in a timely manner and complete an Incident report.

Special Events: When using a venue for any event the senior manager will: • Comply with any existing on-site fire arrangements.

• Make a suitable risk assessment taking in to account the amount of visitors and their mobility.

• Make an assessment of any fire hazards we may be introducing to the venue.

• Put into place any additional safeguards with the co-operation of the host.

7.0: Equality Impact Assessment All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.”

This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

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In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This Policy has been assessed and there is an impact identified where particular additional care is required to ensure that people with a range of disabilities are able to respond to a fire (see appendix C).

8.0: Training Needs Analysis All staff will receive induction training on fire safety as a part of their induction process.

All staff will attend an annual fire safety talk.

Incident Control Officers will receive training on appointment and refresher training every two years.

Fire Wardens will receive training on appointment and refresher training every two years.

The Nominated Fire Officer will receive any suitable training to keep them up to date with changes in fire safety management or changes in legislation. They will also receive suitable refresher training every five years (at least to NEBOSH Fire Certificate standard).

9.0: Monitoring Compliance with this policy The Fire Risk Assessments for each site will be reviewed at least annually.

Fire and false alarm incident reports from each site will be monitored at the Risk Management Group.

Fire Performance and training will be subject to periodic audit.

Those conducting fire training must keep a record of attendance to pass on to the training manager Line managers will be required to monitor staff training and non attendance at training must be notified to line managers to enable them to discharge their responsibility.

10.

References Statutory Instrument 2005 No. 1541: The Regulatory Reform (Fire Safety) Order 2005 NHS Fire Code 11.

Appendices

A. Definitions ICO – Incident Control Officer B. Key stakeholders consulted/involved in the development of the policy/procedure

Stakeholders name and designation Chris Bedford – Risk Manager (Fire) Keith Geldard – Estates Manager Terry Service – Assistant Director Risk Helena Corder – Lead Director (Fire) Liz Butterfield – Training and Development Manager Pat Patrice – Corporate Services Manager

Key Participant Yes/No Yes Yes Yes Yes

Feedback requested Yes/No yes yes yes yes

Feedback incorporated Yes/No No changes yes No changes yes

Yes

yes

No changes

Yes

yes

No changes

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C. Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure Yes/No 1.

Comments

Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race

No

• Ethnic origins (including gypsies and travellers)

No

• Nationality

No

• Gender

No

• Culture

No

• Religion or belief

No

• Sexual orientation including lesbian, gay and bisexual people

No

• Age

No

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

Yes

Extra duty of care – accounted for in Fire Risk Assessment and Personal Emergency Evacuation Plans.

2.

Is there any evidence that some groups are affected differently?

Yes

As above

3.

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

Yes

As above

4.

Is the impact of the policy/guidance likely to be negative?

No

5.

If so can the impact be avoided?

6.

What alternatives are there to achieving the policy/guidance without the impact?

7.

Can we reduce the impact by taking different action?

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