Fire safety policy

Date: August 2024

Review date: June 2026

Version 1.0

Key points

The main principle of fire safety is that people working for or on behalf of the Trust are aware of the objectives to ensure persons are not exposed to the risks of fire. People are familiar with evacuation routes from a building in the event of a fire. Existing fire legislation requires suitable evacuation procedures to be in place for all people using the building. The Trust operates a full evacuation of a building with support for high-risk and vulnerable patients, and disabled people within the premises. Personal Emergency Evacuation Plans (PEEPs) should be prepared locally by teams for all persons, including staff and visitors, with mobility or cognitive restrictions. Where specific evacuation equipment is provided, trained staff will operate in order to evacuate mobility impaired patients/visitors/staff.

Introduction

The Tavistock and Portman NHS Trust is committed to maintaining the highest standards of fire safety to minimise the risk of fire, that has the potential to pose a threat of personal injury or loss of life.

The Trust recognises its statutory duties under the legislation detailed (but not limited to) in the statutory Obligations and the Board of Directors, supported by management are committed to the effective management of fire safety.

The Trust will ensure that robust procedures, clearly defined reporting and recording structures and mechanisms are in place and are appropriately resourced.

A clearly defined management structure in relation to fire safety, will promote the need for cooperation and collaboration from all employees to ensure that the Trust fulfils its statutory obligations.

Purpose

The Trust is committed to providing the highest levels of Fire Safety to ensure that all persons are not exposed to the risks posed by fire.

Scope

This Policy and associated procedures are relevant to all persons working for or on behalf of The Trust including contractors and external agencies and tenants working within trust premises.

All necessary resources will be made available to ensure the correct design, construction, supply and use of equipment and maintenance is carried out in line with The Trusts statutory Fire Safety obligations.

Definitions

Responsible Person

The Regulatory Reform (Fire Safety) Order 2005 states that every workplace must have a ‘responsible person’ who will put in place all necessary fire precautions to protect all persons in and around the Trusts premises. The Responsible Person for the purpose of this policy shall be Trust Board.

Risk

The potential of a fire occurring (likelihood) and the potential to cause harm, injury, or death (consequence)

Risk Assessment

The process of identifying hazards, the persons at risk and evaluation of the risks to persons, property, assets and the environment to reduce the risk of causing harm to as low as is reasonably practicable.

Detection and Warning

The provision and installation of a fire detection system to provide an early warning of fire to occupants of any building.

Means of Escape

Provision of safe and clear routes throughout the premises that remain unobstructed and are clearly identified to enable all occupants can escape to a place of safety.

Duties and responsibilities

Chief Executive

The Chief Executive will, on behalf of the Board of Directors ensure that the Regulatory Reform (Fire Safety) Order 2005 is complied with and where appropriate the NHS Firecode guidance is implemented in all premises owned, occupied or under the control of the Trust.

In conjunction with the Board Level Director the Chief Executive shall ensure that appropriate resources are allocated and planned as part of both the Trusts short and long-term business planning.

The Chief Executive shall provide appropriate information to assure the Trust Board that all requirements of fire safety legislation and the Department of Health’s Firecode are being met.

Day-to-day operational responsibility for fire safety will be discharged to the Deputy Chief Executive and Director of Finance.

Chief Financial Officer – (Board Level Director)

The Chief Financial Officer shall have designated responsibility for fire safety on behalf of the Chief Executive within the Trust and ensure that the Trust is compliant with current fire legislation.

The Chief Financial Officer shall be responsible for ensuring that all fire safety related issues are highlighted and be responsible for the proposal of works relating to Fire Safety to the Board.

The principle fire duties shall be:

To ensure the Trust has a clearly defined Fire Safety Policy that is communicated.
Be responsible for the relevant protocols and procedures are in place to support the Fire Safety Policy.
To communicate all Fire Safety related issues to the Board through preparation of reports and present an annual update on the Trusts status.
To ensure all work undertaken in both new and existing buildings is of a satisfactory technical standard on conforms to all statutory and mandatory fire safety requirements and that all proposals are referred to the Fire Safety Manager before building control approval.
To ensure all passive and active fire safety measures and equipment are maintained and tested in accordance with the appropriate schedules and legislation.
For a schedule and oversight of annual fire safety audit, including reports and findings to the Trust Board, through the Senior and Line Management, ensure that full participation in fire training and fire drills is maintained.
Appointment and support the function of the Fire Safety Manager.

The Board Level Director will delegate authority for day-to-day operational fire safety to the Fire Safety Manager and they shall liaise directly with the appointed Board Director on all fire related issues.

Director of Estates, Facilities Management & Capital Projects (Fire Safety Manager)

The duties of the Fire Safety Manager shall be clearly defined in relation to all matters relating to fire safety to avoid conflict with other potentially overlapping operational responsibilities. The role does not require fire safety competencies but should have sufficient access to competent advice.

The main duties shall be:

Direct liaison with the Board Level Director on all fire related issues.
Implementation of the fire safety policy and for all Directorates to adhere to Policy
Presentation of an annual report to the Trust Board detailing the status of Fire Safety within the Trust.
Obtaining expert and technical advice on fire legislation and application of guidelines (Fire Safety Advisor).
Implementation of requirements advised by the Fire Safety Advisor, as required under Statutory provisions and Codes of Practice.
Consideration and prioritisation of all further advice from the Fire Safety Advisor, making recommendations to the Board for a programme of investment and implementation.
Establishing and maintaining the Trust Fire Safety Committee, this is subsumed within the H&S meeting.
The development, implementation, monitoring and review of the organisation’s Fire Safety Management System including reporting of incidents, incident investigation and the undertaking of an annual Fire Safety Audit.
Ensuring that suitable fire risk assessments are undertaken, recorded and suitable action plans developed, adding any items to the Trusts Risk Register when appropriate.
Ensuring that a fire safety training regime is implemented, maintained and audited.
Responsibility for the inspection and maintenance of Fire Detection and Warning Systems, Emergency Lighting and Fire Fighting Equipment and obtaining timely reports.
Ensuring all new works and projects are fully compliant with statutory requirements and the Fire code.
Establishing and maintaining an integrated approach to fire safety to ensure a consistent and coordinated approach across all shared areas and projects.
Development and implementation Personal Emergency Evacuation plans in consultation with those that need them and ensuring they are kept up to date.
Liaison with all relevant enforcing authorities, managers, Fire Safety Advisor and Authorising Engineer (Fire)

Hard FM Manager – (Deputy Fire Safety Manager & Fire Safety Adviser Authorised Person – Fire)

The Fire Safety Manager will be accountable to the Designated Senior Operational Fire Safety Manager for matters of fire safety and will act as their deputy.

The main duties shall be:

Day to day implementation of the fire safety policy.
Assisting the Fire Safety Manager in the preparation of an annual report to the Trust Board detailing the status of Fire Safety within the Trust.
Obtaining expert and technical advice on fire legislation and application of guidelines (Fire Safety Advisor).
Implementation of requirements advised by the Fire Safety Advisor, as required under Statutory provisions and Codes of Practice.
Prioritisation of all further advice from the Fire Safety Advisor, making recommendations to the Fire Safety Manager on a prioritised programme of investment and implementation.
Supporting the implementation, monitoring and review of the organisation’s Fire Safety Management System including undertaking all investigations in relation to all fire related incidents and fire alarm activations.
Ensuring that suitable fire risk assessments are undertaken, recorded and suitable action plans developed, including identifying the hazards, assessing the risks and recording the findings.
Working with the Fire Safety Advisor to assist in the development and implementation of a fire safety training regime.
Responsibility for the inspection and maintenance of Fire Detection and Warning Systems, Emergency Lighting and Fire Fighting Equipment and obtaining timely reports.
Ensuring all new works and projects are fully compliant with statutory requirements and the Fire code.
Monitoring of all tenants within Trust owned properties to ensure compliance with statutory obligations and Trust policies and procedures, documenting concerns and formally raising non-compliance issues and concerns.
Maintaining an integrated approach to fire safety to ensure a consistent and coordinated approach across all shared areas and projects.
Liaison with all relevant enforcing authorities, managers, Fire Safety Advisor and Authorising Engineer (Fire).
Undertaking Risk assessments in relation to Fire Safety,

Soft FM Manager – Operational

The Fire Safety Adviser will be accountable to the Designated Senior Operational Fire Safety Manager for matters of fire safety.

The main duties shall be:

Day to day implementation of the fire safety policy
Assisting the Fire Safety Manager in their duties.
Assisting with the development, maintenance and audit of a Fire Safety training regime for all personnel including seeking feedback from personnel on all training to ensure gaps are identified.
Providing expert advice and interpretation of relevant statutory provisions, Including technical advice and guidance on all fire safety related codes of practice and standards.
Preparation of fire prevention and emergency action plans.
Preparation of the annual fire safety audit with the Fire Safety Manager and deputies.
Liaison with managers and other personnel as required on fire safety related issues.
To seek advice from the Authorising Engineer (Fire) to resolve fire safety issues where specialist advice and guidance is needed.
Liaising with all relevant enforcing authorities (minimum annually) for advice and support and Authorised Engineer (Fire) for all technical issues.
Consultation with individuals to develop Personal Emergency Evacuation plans and ensuring they are kept up to date.
Preparing reports as required by the Fire Safety Manager.
Reporting of all fire related incidents through the agreed procedure. (Appendix)

Authorising Engineer (Fire)

The Trust will ensure that a competent, independent Authorising Engineer (Fire) is appointed, who will act as an independent professional adviser. The Trust will ensure that the Authorising Engineer (Fire) can demonstrate their competence and expertise in their particular field, is a Chartered Engineer and is a member of a professional body (Institution of Fire Engineers of similar).

The main duties shall be:

To act as an assessor and make recommendations for the appointment of Authorised Persons (Fire).
To monitor the performance of Fire Safety Management and provide an annual audit to the Board Level Director.

Competent Persons (Fire)

Installers and maintainers of fire safety equipment will be commissioned or appointed by the Trust and must be able to demonstrate the relevant competence, skills and knowledge for the specialist service being provided.

This may include the installation/maintenance or enhancement of systems or equipment related to fire safety, such as:

Fire alarm/detection systems
Fire Fighting equipment

Other Fire Safety systems including, but not limited to fire dampers, suppression systems and hydrants. If the service is provided by an external source, they must also be registered with an appropriate industry accreditation scheme.

Managers – Responsible Persons

All managers, heads of department and heads of service will be responsible for ensuring that the Trust’s Fire Safety Policy is implemented within their area.

Their main duties will be:

Monitoring fire safety within their respective workplaces and ensuring that contraventions of fire safety precautions do not take place.
Ensuring local risk assessments are undertaken and maintained up to date and notifying the Fire Safety Adviser of any changes of use/temporary works which may impact on their area and the existing risk assessment.
Reporting any defects in the fire precautions and equipment in their areas, through the Estates helpdesk, and ensuring that appropriate remedial action is taken.
Ensure local fire emergency plans are developed and brought to the attention of staff, including adequate rehearsal.
Ensure local fire emergency action plans are devised in response to any changes including temporary works.
Ensure availability of a sufficient number of trained staff to implement the emergency action plan and fire wardens are trained and are on site when a team member is on TPFT premises.
Ensure that all staff receive fire safety training, documents and understand their duties as outlined in this policy.
For all staff, visitor, student, patients’ occupational health needs to be assessed to ensure the local risk assessment support and respectfully meet the needs of the team.
As part of their local induction ensure that all staff are familiarised with relevant fire safety information and training including:
Local fire procedures and evacuation plan
Means of escape
Fire Alarm call points
Fire Fighting Equipment
Fire Risks specific to the local workplace

Managers will ensure that all staff are fully aware of their duties in relation to fire safety, the need to report incidents and false activation and will ensure that all Fire Safety Training is recorded on their staff record. Where appropriate managers will identify and appoint Fire Wardens for specific areas.

Fire Wardens

The Trust will ensure Fire Wardens will be in place for each area of the Trusts premises to ensure that there is a local workplace point of contact for staff to report any concerns or issues. They will act as the eyes and ears for all Fire Safety related matters, reporting and concerns raised or issues to their manager, head of department or service.

Their main duties will be:

Organise and assist with 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
Support in evacuation of premises for fire drills or in the event of an incident

Fire wardens will be required to attend training and to undertake refresher training every three years.

Fire Safety Committee – included within H&S meeting

The Fire Safety Manager will establish and maintain a Fire Safety in line with NHS guidance. The committee’s main duties shall be:

Responsibility for the review of all Fire Safety Matters (incidents/false alarms/training etc)
Reporting of fire safety issues as a parallel conduit to the Trust Board.
Reporting of issues where the Fire Safety Manager or Adviser may consider themselves to be professionally compromised.

Statutory obligations

Rhe Trust will ensure, as far as is reasonably practicable that it does not expose any persons to the risks posed by fire and will achieve this by ensuring that it complies with all relevant legislation and statutory requirements in respect of fire safety, following appropriate guidance in the undertaking of its duties. The primary legislation (but not limited to) and guidance are:

Mandatory legislation

Regulatory Reform (Fire Safety) Order 2005

In addition the following legislation and relevant sections relating to fire safety:

Health & Safety at Work Act 1974

The Management of Health and Safety at Work Regulations 1999

The Dangerous Substances and Explosive Atmospheres Regulations 2002

Building Regulations

Building Regulations 2010

Guidance & Best Practice

HTM 05-01 Managing Healthcare Fire Safety – Fire code

HTM 05-02 Guidance to Support Functional Provisions (Fire safety in the design of healthcare premises)

HTM 05-03 Operational Provisions (Parts A-K)

Procedures/Process

Evacuation Procedure

Emergency evacuation procedures will be in place to ensure that all staff understand the Fire Evacuation Procedure for each area/building and that all evacuations, including false activations take place in an organised and controlled manner.

Fire Risk Assessment

Fire Risk Assessments shall be undertaken by a competent person (Fire Safety Adviser) and fire safety issues shall be understood and managed by the person/s in control of each area enabling them to discharge their duties imposed on them by the Fire Safety Order, where those elements are within their control.

Fire Risk Assessments should follow the industry recognised standard as defined within PAS 79. A recording structure shall be in place that provides actions for individual departments to complete outstanding actions or action work/s via other departments.

Fire Drills

The Trust will develop appropriate systems to periodically undertake Fire Drills as required as part of their Statutory Duty. These should be organised by the Responsible Person locally and in conjunction with the Fire Safety Adviser.

The Fire Drill should be used to test the robustness of the evacuation plan and identify any potential weaknesses in The Trusts response to an emergency.

Fire Detection & Warning Systems, Emergency Lighting and Fire Fighting Equipment

The Trust will ensure that suitable and sufficient Fire Detection and Warning systems will be in place throughout the Trust buildings and that they will be subject to a regular testing programme, with any required maintenance prioritised. All testing and maintenance will be monitored via the Compliance Dashboard and shall always be accessible for inspection and checks by enforcing authorities. The Compliance Dashboard will be reviewed regularly to ensure its ongoing effectiveness and that it is covering all relevant areas of fire safety.

All Fire detection & Warning Systems, Emergency Lighting and Firefighting Equipment will, as a minimum, be tested and maintained in accordance with the Relevant Standards/good practice (see table below).

Fire Detection & Warning Systems

BS 5839 Part 1 provides recommendations for the planning, design, installation, commissioning and maintenance of fire detection and fire alarm systems for non-domestic premises.

Daily check of Fire Panel

Weekly check of Sensor/call point

Regular Servicing by competent contractor

6 monthly Inspection and testing carried out by a competent contractor

All checks must be recorded

Emergency Lighting

BS EN 50172 (BS 5266-8) Emergency Escape Lighting Systems

Monthly Manual simulated failure test and visual check for illumination*.

Visual check post simulated failure to check batteries are charging

*Test should be sufficient in length for checks to be undertaken but should aim to minimise damage to the system by being tested for too long.

Annual Full discharge test

Fire Fighting Equipment

BS EN3 – Portable fire extinguishers

BS 5306-3 Fire extinguishing installations and equipment on premises – Commissioning of portable fire extinguishers. Code of Practice

Weekly Correctly located, Clearly Visible

Monthly Visual check by a competent person to ensure pins are in place, exterior not damaged

Additional Checks

Annual service by competent contractor to include:

Test discharge

Pressure testing

Refilling

Safety Signs

BS 5499 Safety Signs, including Fire Safety Signs

Weekly Signs are in place and not obstructed

Annual Checks and replacements to ensure full compliance.

Means of Escape

All means of escape are to be always kept clear of obstructions and other hazards, this includes any location that forms part of the dedicated escape routes including exit fire doors. Regular checks are to be undertaken of all areas that form part of the dedicated escape routes and emergency exit doors checked regularly to ensure they can open freely without obstruction and that any external areas are clear of further hazards/obstructions.

Fire Prevention

To minimise the risk of fire, the Trust shall encourage all staff and visitors to adhere to the highest standards of housekeeping and will do so in the following ways:

Visible signage displayed to encourage all staff and visitors to deposit waste in the correct receptacle.

Combustible waste to be placed in designated bins and not stored next to electrical equipment or heaters.

Bins where possible should be metal or fire retardant with self-closing lids to minimise the risk of fire, particularly in more enclosed areas such as wards/offices.

Electrical sockets must not be overloaded and all electrical equipment and circuits will be regularly tested.

All incidents including fires, false alarms and other related incidents shall be recorded through the agreed procedure to enable the Fire Safety Manager to evaluate and identify lessons to be learnt.

The Fire Safety Manager shall review and report on all fire related incidents to the Trust Board through the agreed process

Personal Emergency Evacuation Plans (PEEP)

In the planning of evacuation procedures, adequate consideration should be given to the individual needs and requirements of people with disabilities and so far as is reasonably practicable, should be discussed with them. Where possible, minor modifications should be made to existing procedures, recognising that in some cases individual Personal Emergency Evacuation Plans (PEEP’s) may need to be developed.

Information Instruction Training Advice

The Trust shall ensure that all personnel have access to appropriate training resources to ensure they are able to undertake the training as required, this may include access to:

Induction Sessions/Training
Online e-learning
In person training delivered by Manager/Fire officer/Fire Safety Advisor

In addition the Trust will ensure that each department has access to a Fire Safety Manual where the department is able to as a minimum will include:

A brief description of the department, its location and use.
A plan detailing the area and the location of fire safety features including the location of:
- Fire detection and alarms
- Fire doors that should remain closed
- Fire Extinguishers
- Means of Escape
- Evacuation equipment
- Fire compartmentation information

A safety checklist should be available as part of the manual to enable fire safety checks to be undertaken by those in charge of an individual area.

In addition a copy of the emergency plan should be available in each area to ensure all staff are aware of:

The actions they should take on discovery of a fire
Procedures for evacuation
The location of fire exits and evacuation equipment
The location of Fire Fighting equipment.

The Trust shall continually review and update its training needs analysis/matrix to identify the minimum level of training required for each role as detailed below:

Mandatory Fire Safety Training (Induction)

Fire Training as a legal requirement will be included in the induction of all personnel (paid & voluntary), as a minimum this will include:

Information and instruction relating to fire precautions at The Trust.
Trust wide Evacuation procedures.
Awareness of the location office alarms, firefighting equipment, exit routes and assembly points.
Information on their role in an evacuation.

In addition further training will be given to all personnel in the event of a change to the fire risk or any of the above.

Workplace Training

All personnel will receive additional workplace training on their first shift and it will be the responsibility of the line manager to ensure that all personnel are given detailed information on:

Specific fire precautions for local workplace.
Detail risks/hazards relevant to the workplace.
Awareness of the location of fire alarms, firefighting equipment, exit routes and assembly points.
Information on their role in an evacuation.

Annual Training

Managers/department heads shall ensure that all personnel receive annual fire safety training to ensure that awareness of the following are maintained and that they continue to have the skills and knowledge to undertake the tasks required.

Workplace fire precautions and updates.
Identification of workplace risks/hazards.
Identification and use of Fire Fighting Equipment

Evacuation Training

Periodic Fire Drills will be undertaken by the Trust, at least annually, which will act as a rehearsal/training exercise to ensure that in the event of a fire all personnel are aware and able to undertake their duties to ensure the safety of all. The Fire Safety Advisor will provide advice and support on the options available to undertake the fire drill to minimise the impact on the level of care and distress it may cause to patients.

The Trust will record details of the evacuation in the Fire Log Book and in conjunction with the Fire Safety Adviser, will ensure that areas of concern are highlighted and lessons are learnt.

Contractors

Contractors working on-site will be required to undertake and induction prior to commencing work. The Induction will include information and training in relation to the Trusts Fire Safety, Evacuation Procedure and any further information relating to specific precautions and hazards including any relevant permits e.g. Hot Works Permits.

Advice

Any employee with concerns about any aspect of Fire Safety Management within The Trust should raise their concern in the first instance with their line manager. Should this not be possible, personnel are advised to raise their concerns through the Fire Safety Manager.

Process for monitoring compliance with this policy review monitor audit

Review

The overall performance of this policy and associated requirements will be reviewed quarterly as part of the Fire Safety Committee and is included in the H&S meeting

Monitoring ( KPI’s) & Audit

The Fire Safety Committee will monitor the implementation of the Fire Safety Policy and its requirements including the monitoring of any set KPI’s, which will include:

Review of all fire incident/investigation reports, including any recommendations/guidance received from enforcing authorities.
Review of all false activations, their cause and any identifiable patterns that may result in additional training.
Fire Safety Audit Reports
Fire Safety Training records review
Periodic external fire safety report

Compliance

Regular performance, progress and the overall effectiveness of the Fire Safety Policy will be presented to the Trusts Board.

Smoking

Smoking is prohibited on Trust premises. All of personnel have a duty to prohibit smoking so it does not present any undue fire Risk and follows the Trusts Policy

Arson

Trust premises due to easy access may be subject to arson attempts which have the potential to cause injury, damage to the fabric of the building and death. The Trust will ensure it has an awareness, through its networks of any deliberately started fires in the locality and raise awareness to personnel where appropriate.

All accidental fires on the premises will be fully investigated and recorded and any patterns or repeat incidents highlighted and escalated. The Trust will also ensure that where possible, access to trust buildings will be restricted (e.g. overnight/out of hours) and that an awareness of the potential of an Arson attempt is Risk Assessed and updated.

Implementation

Following PAG approval, it is anticipated that the Policy will be disseminated and embedded across the Trust

References

Regulatory Reform (Fire Safety) Order 2005
HTM 05-01
HTM 05-03
BS 9999 Guidance
The Health & Safety at Work Act 1974