HSPOLCORE17 Fire Safety Policy by Provide Community

Fire Safety Policy

Version: V7

Ratified by: Finance Investment Committee

Date ratified: 03/05/2023

Job Title of author:

Health, Safety, Fire and Security Manager –Estates and Facilities

Reviewed by Committee or Expert Group Property, Health and Safety Group Meeting

Equality Impact Assessed by:

1. Introduction

Fire is a potential hazard in all premises - hospitals, clinics, health/ social care centres and administration buildings. . Should a fire occur without suitable control measures in place the potential risk to life could be significant

The consequences of fire in hospitals and other health and social care premises can be especially serious because of the difficulties and dangers associated with the emergency evacuation of service users, many of whom may be highly dependent.

This policy has been developed in order to describe the management arrangements for fire safety and enable guidance to be produced to protect people from the hazards of fire.

The policy applies to all sites where Provide employees, contractors, volunteers, visitors, service users and others use

2. Purpose

Fire safety arrangements are a vital part of a business’s fire safety policy that detail the preventive and protective measures needed to keep relevant persons safe.

Provide considers fire safety to be of paramount importance and wishes to assure all service users, staff and visitors that it has appropriate policies and procedures in place to safeguard the occupants from the effects of fire.

The organisation is committed to comply with all statutory fire safety standards and will endeavour to attain the mandatory requirements identified in the Fire Regulatory Reform (Fire Safety) Order, where "reasonably practicable".

Provide aims to protect life above all else but will ensure suitable and sufficient infrastructure exists to protect property. The fire strategy is to control and contain the effects of fire to permit occupants to evacuate to a place of safety and where possible, to limit damage to essential services thus minimising the impact of disruption to continual health and social care within the organisation.

The organisation will train and educate all staff to a suitable and sufficient level commensurate with their role within Provide.

Working in conjunction with our Commissioners, Partner Trusts/Providers, NHS Property Services and other landlords, all fire-fighting or fire alerting systems and equipment shall be fit for purpose and inspected in accordance with the most up to date regulations as well as manufacturer’s instructions.

As part of the fire prevention initiative, the organisation operates a no smoking policy in all premises, both within its buildings and grounds

3. Definitions

Fire safety terms and definitions used in this policy;

• Combustible material – A substance that can be burned.

• Competent person – A person with enough training and experience or knowledge and other qualities to enable them to assist in undertaking the preventative and protective measures.

• Dangerous substance – A substance which because of its physico-chemical or chemical properties andthe way it is used or is present at the workplace creates a risk.

• Escape routes – Routes forming that part of the means of escape from any point in the premises to a final exit.

• Unwanted Fire Signal (UwFS) or false alarm – A fire signal, usually from a fire warning system, resulting from a cause other than a fire.

• Fire door – A door or shutter, together with its frame and furniture, provided for the passage of people, air or goods which, when closed, is intended to restrict the passage of fire and/or smoke to a predictable level of performance.

• Flammable material – Easily ignited and capable of burning rapidly.

• Means of escape – Routes provided to ensure safe egress from premises or other locations to a place of total safety.

• Responsible person – The person ultimately responsible for fire safety as defined in the Fire Safety Order.

• Fire Compartment -Is basically the division of a building into cells, using construction materials that will prevent the passage of fire from one cell to another for a given period of time.

This policy applies to all Provide premises and all Provides staff including agency staff and contractors, volunteers and bank staff. Some staff will be working in other buildings that are not owned by the Provide, the principles of this policy will still apply and the same standard of fire safety guarantees must be in place as per the Fire Safety Order and implemented by the landlord and/or the major employer in that premises this will be checked by the Head of Health, Safety and Compliance.

4. Duties

Provide recognises its responsibilities to implement in full their fire safety duties and to ensure all their employees understand the fire safety procedures and partake in fire evacuation drills.

The Board and Group Chief Executive

The overall responsibility for the performance of Provide in respect of fire precautions and fire safety rests with the Group Chief Executive.

The Chief Executive is therefore responsible for ensuring the implementation of the Policy and will nominate a Board Level Executive Director (Executive Director for Finance & Estates) to oversee this in all premises occupied by Provide ensuring:

• That Provide Community has in place a clearly defined Fire Safety Policy and relevant supporting protocols and procedures.

• That all work which has implications on fire precautions in new and existing Provide buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory fire safety requirements

• That all proposals for new buildings and alterations to existing buildings are referred to the Head of Health, Safety and Compliance before Building Control approval is sought.

• 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.

• Coordination and Co-operation between other Responsible Persons where two or more share premises

• Through senior management and line management structures that full staff participation in fire training and fire evacuation drills is maintained.

• Agreed programmes of investment in fire precautions are properly accounted for in Provides annual business plan.

Directors/Assistant Director’s

All Directors and Assistant Directors/Team Managers are responsible for:

• Assisting the Head of Health, Safety and Compliance in the day-to-day implementation of the fire safety strategy.

• Ensuring that, within their area of responsibility, any fire safety control measures determined within the fire risk assessment and by the fire safety strategy are upheld

• Ensuring vulnerable persons (i.e. those with disabilities, the young, the elderly etc.) are considered within local fire risk assessment and personal emergency evacuation plans

• Ensuring provision is made for all their staff to participate at least annually in fire safety training and any organised fire evacuation drills

• Ensure sufficient staff are nominated to carry out the role of Fire Marshall

Estates and Facilities Managers

Estates and Facilities Managers, (including Compliance Manager) These will be responsible for all sites and premises within sites where Provide staff operate in accordance with the The Fire Safety (England) Regulations 2022 and Department of Health Fire code HTM05-01 “Managing Healthcare Fire Safety”.

• Development of onsite fire procedure in consultation with all staff and Responsible Persons

• Ensuring the activities of contractors working on site are safe and free from risk of fire and taking effective steps to ensure that their activities do not subvert fire precautions in existing premises

• Ensuring that fire drills are undertaken as a minimum annually and any findings implemented

• Ensuring the regular checks are undertaken to ensure risks do not develop between the undertakings of risk assessments and if they do are appropriately managed

• Ensuring that local fire procedures are brought to the attention of all their own staff, contractors working on site and visitors as appropriate

• Developing local fire procedures detailing the action to be taken on discovering a fire or on hearing the fire alarm and agreeing them with the Head of Health, Safety and Compliance including the use of any fire panels

• Ensuring all incidents involving fire and false alarms are reported according to the organisation’s Incident Reporting Policy, Datix.

• Ensuring coordination and cooperation on sites where there is more than one Responsible Person.

Fire Marshall’s

Fire Marshals are responsible for:

• Familiarising themselves with the fire risk assessment for the site

• Co-ordinating the overall site fire evacuation process

• Communicating with fire and emergency services as they arrive on site

• Ensuring that buildings are not re-occupied until the all clear is given

• Liaising with Estates and Facilities teams to ensure that day to day fire safety issues or concerns are resolved

• Escalating any concerns to the Provide Manager on call / Head of Health, Safety and Complaince.

• Attend appropriate training to enable them to fulfil the role of the Fire Marshal

• Act as a focal point for local staff with regard to fire safety issues

• Observe and ensure (on a day to day basis) that escape routes are clear and available for use

• Ensure that fire action notices are clear and readable

• Ensure that equipment like fire extinguishers are visible and stored ready for use on the hook or red floor box provided for the purpose

• Carry out a fire safety inspection of the workplace on a regular basis (monthly) and record and report their observations to the Estates and Facilities Teams

• Take appropriate and effective action, according to their training and instruction, if a fire does occur

• Participate in practised fire drills

Employees

Individuals, other than fire marshals, may have specific roles to fulfil during a fire emergency e.g. Porters and Receptionists. It must be clear within local procedures what their duties are and sufficient training and instruction must be given to enable them to fulfil these duties.

The principle duties of employees and individuals are:

• On discovering a fire, operate the nearest manual call point without delay and dial (9-) 999

• Evacuate from the building

• Report to the designated assembly point

• Report the extent and location of the fire to fire marshall’s

• Not to interfere with or misuse anything provided in the interest of safety

Report any general concerns about fire safety, equipment or procedures to their manager and the fire Marshall.

Organisation

Provide will make the following arrangements to comply with the above:

• Provide for the training of all employees. The training should relate to fire hazards, precautions and fire evacuation drills. Specific training will be provided for people with special responsibilities, i.e. Fire Marshall’s,

• Manage safe escape routes including, where appropriate, emergency escape lighting

• Report all fire related concerns to the relevant landlords so that they can investigate the matter

• Undertaken fire risk assessments, remedials and reviews

5. Consultation and Communication

Managers will be responsible for ensuring all fire related hazards are identified and risk assessed as part of an ongoing process and that all staff within the service receives adequate training commensurate with their role. All staff shall receive support if required in line with this policy and procedure.

6. Monitoring

Ongoing audit to ensure review or

• Fire risk assessment action plans

• Fire safety and maintenance procedures

• Use of premises

• Communication systems (including detection and alarms)

• Local policies

• Training

• Records

• Carrying out 6 monthly fire drills and/or regular fire walk and talks.

7. Principle Legislation and Guidance

• The Health and Safety at Work Act 1974

• The Management of Health and Safety at Work Regulations 1999

• The Building Regulations Act 2010

• The National Health Service and Community Care Act 1990

• Regulatory Reform (Fire Safety) Order 2022

• Furniture and Furnishings (Fire Safety) Regulations 1988

• Fire Code HTM 05-02 2006 Managing Healthcare Fire Safety

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

• Fire Safety Risk Assessment for Healthcare Premises Guidance

• Fire Safety in Specialised Housing

8. Training

Fire safety instruction will be provided via the approved e-learning packages or face to face training packages. Training of fire marshals will be provided by Provide to all staff identified to carry out this function. Fire marshal training shall be refreshed on a regularly basis.

Every new member of staff will be given basic fire precaution instructions relating to their own workplace by their line manager during their first days of work and also at Corporate Induction.

They should be made aware of the siting of fire procedure notices, fire alarms, fire exit routes, firefighting equipment and fire assembly points. They should also be aware of what constitutes a fire hazard as well as the means for reporting concerns.

It is mandatory for all staff to attend or receive fire training bi-annually. This consists of the following:

• The action to take in the event of fire, and on discovering a fire

• Fire hazards

• Use of fire equipment

• Evacuation procedure

• Fire Drills

Managers are responsible for the accurate recording of staff attendance at fire lectures

and fire training sessions in partnership with the Learning and Development Department. This information may be called for at any time when reviewing fire precautions. The training record should be completed at each fire training session and retained by the Learning and Development Department

9. Smoke Free Policy

The organisation operates a smoke free policy, implemented primarily to ensure that staffs, visitors, service users and the general public are not exposed to tobacco smoke on premises.

The implementation of this policy will also in effect reduce fire hazard on site and help to reduce overall risk to occupants and users from fire incidents. Staff, contractors, visitors and service users should all be made aware of the smoke free policy.

This also applies to E-cigarettes. These are unregulated nicotine products for which there is insufficient evidence of safety. In view of this the use of E-cigarettes are not permitted on any Provide occupied site. There has been numerous cases reported in the media of E-cigarettes causing fires due to an explosion and subsequent harm to people

10.Home Visits

In accordance with the Provide No Smoking Policy, an employee has the right to ask a service user, and others present in their home or workplace, not to smoke within the room(s) they need to go into to perform and complete their duties. That includes young people and foster carers who smoke.

If the service users, or others on the premises, refuse to stop smoking in the relevant rooms of their home, the Provide employee must decide whether it is necessary to enter the premises on that occasion, or whether some alternative arrangement can be made

11.Contractors Working on Site

Contractors working on site must be informed of the fire safety procedure as part of their induction to site. A means of recording contractors onto and off site must also be implemented so that they can be accounted for during an emergency or evacuation. Contractors often introduce additional hazards to site by virtue of the works undertaken e.g. hot working. Hot working must not be allowed without the issue of a Hot Work Permit by the Head of Health, Safety and Compliance. See Hot Works Procedure.

The relevant Estates and Facilities Manager shall maintain records of all correspondence with contractors ensuring that appropriate controls have been implemented and that this fire safety policy/procedure is adhered to.

The Facilities Manager will where required liaise with services based on site to inform of any significant fire risks that may posed by planned works from contractors.

12.Use of Toasters

In accordance with the Provide No Smoking Policy toasters are prohibited in nonclinical areas, except in Provide Headquarters (Ground Floor Kitchen). The improper use of electrical appliances including toasters can cause unwanted fire alarm signals. Provide recognises the needs of service users and the supply of toast both in and out of hours to service users as being appropriate and meeting the needs of service users. It is therefore acceptable to use toasters in patient areas in accordance with the guidance in Appendix 1.

13.Monitoring, Recording and Reporting Arrangements

Systems will be put in place by our landlords for the inspection and maintenance of fire detection, fire suppressant, fire safety and firefighting equipment. This will, for the most part, be included in service level agreements external facilities management organisations as instructed by the relevant Estates Department.

However internally Provide will undertake both an annual and quarterly review of sites where staff are based. Where Provide are landlords or have landlord responsibilities they will ensure that all necessary fire inspections and maintenance arrangements are put in place to help ensure legal compliance.

Fire incidents will be reported internally in accordance with the Provide Incident Reporting Policy and the Head of Health, Safety and Compliance is notified. All outbreaks of fire to which the Fire and Rescue Service have been called must be investigated and findings implemented as appropriate

Appendix 1 Toaster Guidance

The improper use of electrical appliances including toasters can cause unwanted fire alarm signals and as such it is the policy to prohibit the use of toasters in non-clinical areas. The organisation recognises the needs of service users and the supply of toast both in but in particular out of hours to service users as being appropriate and meeting the needs of service users.

It is therefore acceptable to use toasters in patient areas in accordance with the following points which must be adhered to by all staff and services working within premises occupied by Provide staff.

• Conveyor toasters should be used in patient areas to minimise the risk of smoke occurring and triggering the alarms

• Toasters should only be used in appropriate kitchens and only on open work surface areas. They should not be moved to other areas within the premises

• All toasters must be cleaned regularly to prevent build-up of crumbs

• Toasters should be subjected to regular PA tests

• When in use, toasters must not be left unattended. However, if staff have to leave the kitchen are for some unforeseen circumstance, then the toaster should be turned off

• The kitchen door should be closed and appropriate intumescent strip installed on the fire door (kitchen doors should be closed and not wedged open during normal operations)

• Any extraction fans etc. should be in operation. In the absence of any extraction, windows should be opened

If the toaster is fitted with a timing device then it should not be set to more than three minutes or as advised by the manufacturer’s instructions

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Fire Safety Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

This policy is designed to give a corporate framework for management of fire safety within the workplaces.

Project/Policy Manager: Head of Health, Safety and Compliance Date: April 2023

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’