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Health TechnicalMemorandum 05-01:Managing healthcare fre saety

Second edition

April 2013

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Health Technical Memorandum

05-01:Managing healthcare ire saety

Second edition

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Health Technical Memorandum 05-01: Managing healthcare fre saety (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: [email protected].

gov.uk.

This document is available from our website at www.gov.uk/government/organisations/

department-of-health

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Executive summary

This Health Technical Memorandum sets outrecommendations and guidance or themanagement o ire saety in healthcare

buildings. It should not be quoted as i it were aspeciication, and any claims o complianceshould be careully examined to ensure they arenot misleading.

While Heath Technical Memoranda 05-02 and05-03 provide guidance in respect o the ireprecautions and protective measuresappropriate or healthcare premises, this Health

Technical Memorandum is intended to assist indetermining the appropriate ire saety

management system to be applied tohealthcare organisations.

Health Technical Memorandum 05-01 sets outguidance that recognises the nature ohealthcare organisations and the need or arobust system o ire saety management. Theguidance and recommendations contained in

this Health Technical Memorandum shouldallow the current statutory regulations to beapplied sensibly within a ramework o

understanding.

The primary remit o NHS organisations withregard to ire saety is the saety o patients,sta and visitors. For all premises under theircontrol, NHS organisations will need to selectand eectively implement a series o measuresto achieve an acceptable level o ire saety,taking into account:

all relevant legislation and statutes;

the guidance in this Health TechnicalMemorandum;

the relevant guidance contained in otherparts o Firecode; and

the advice and approval o buildingcontrol and ire and rescue authorities.

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Acknowledgements

The Department o Health would

like to thank the ollowing or their

help in developing this guidance:BB7

Chief Fire Officers Association

Department for Communities & LocalGovernment

Healthfire

National Association of Healthcare Fire

Officers

NHS Wales Shared Services Partnership

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Contents

Executive summary ...................................................................................................................iii

Acknowledgements iv

Glossary of terms vi

1 Introduction and scope 1

2 Department of Health re safety policy3

3 Statutory re safety duties 4

4 NHS trust re safety policies 7

5 Effective re safety management 8

6 Appropriate management levels 12

7 Fire safety management roles and responsibilities 16

8 Fire safety protocols22

9 Fire safety information manuals23

10 Planning and responding to a re emergency25

11 Training28

12 Reporting and audit 33

Appendix A Exemplar trust re safety policy 35

Appendix B Exemplar re safety management system 37

Appendix C Exemplar re safety management structure 39

Appendix D Exemplar person specication 40

Appendix E Developing re safety protocols 44

Appendix F Developing the training needs analysis 50

Appendix G Exemplar annual statement of re safety55

References 57

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Glossary o terms

For the purposes of this document thefollowing terms are defined:

Assembly point: a pre-determined area o

saety where persons should assemble in theevent o an emergency.

Authorising Engineer (Fire): a chartered ireengineer, or a chartered member o anappropriate proessional body, with extensiveexperience in healthcare ire saety.

Child: a person who is not over the compulsoryschool age.

Compartmentation: the ire-resisting elementsincluding walls, loors, and where applicable,roos and/or other structures used in theseparation o one ire compartment romanother.

Competence: where a person is required to becompetent, he/she must be able todemonstrate through training and experience orknowledge and other qualities that they havethe ability to properly assist in undertaking the

preventative and protective measures.

Competent Person (Fire): a person who canprovide skilled installation and/or maintenanceo ire-related services (both passive and activeire saety systems).

Complex healthcare organisations: hospitalsor other healthcare premises that perorminvasive procedures and other treatments thatplace a dependence on sta or evacuation.

Fire emergency action plan: the pre-determined plan that describes the actionsnecessary in the event o a ire to protectrelevant persons and acilitate their saeevacuation.

Fire engineering: the application o scientiicand engineering principles to the protection opeople, property and the environment rom ire.

Fire-fighting equipment: the ire extinguishers,ire blankets and other equipment madeavailable to trained personnel or the purpose oighting ire.

Fire resistance: the ability o an element obuilding construction, component or structureto ulil, or a stated period o time, the requiredload-bearing capacity, ire integrity and/orthermal insulation and/or other expected duty ina standard ire resistance test.

Fire risk assessment: the process oidentiying ire hazards and evaluating the risksto people, property, assets and the environmentarising rom them, taking into account theadequacy o existing ire precautions, anddeciding whether the ire risk is acceptablewithout urther ire precautions.

Fire Safety Adviser (Authorised Person Fire): a person who has suicient training and

experience or knowledge and other qualities toenable them to properly assist in undertakingpreventative and protective measures.

Fire safety management system: a robustramework o protocols and processes used toensure that an organisation can ulil all tasksrequired to achieve the ire saety objectives setout in the ire saety policy.

Fire Safety Manager: the person within the

organisation tasked with coordinating ire saetyissues throughout the organisations activities.

Fire Safety Order: The Regulatory Reorm (FireSaety) Order 2005.

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vii

Glossary o terms

Fire safety policy: a high level statement ointent, as expressed by the board, partners, orequivalent controlling body, setting out clear ire

saety objectives or the organisation.Fire safety procedure: a detailed documentsetting out each step o a process intended toprevent ire, maintain ire precautions, minimiseire hazards or eectively respond to a ireincident.

Fire safety protocols: a set o organisation-speciic guidelines that set the ire saetyparameters o any activity that may impact onire risk.

Healthcare building: a hospital, treatmentcentre, health centre, clinic, surgery, walk-incentre or other building where patients areprovided with medical care, diagnostics or otherassociated treatment.

Hot works: Operations involving the use oopen lames or the local application o heat orriction such as welding, soldering, cutting orbrazing.

Material change: A change in arrangements orcircumstances that may have an impact on thevalidity o ire risk assessments, ire precautions,ire emergency action plans etc.

Management level: standard or quality o theorganisational ire risk management system.

Occupant dependency: the categorisation ooccupants on the basis o their likely need orassistance to eect their sae evacuation in anemergency. The ollowing categories arereerred to in this Health TechnicalMemorandum:

Independent: occupants will be deinedas being independent:

i their mobility is not impaired in anyway and they are able to physicallyleave the premises without staassistance; or

i they experience some mobilityimpairment and rely on anotherperson to oer minimal assistance.

This would include being suiciently

able to negotiate stairs unaided or withminimal assistance, as well as beingable to comprehend the emergencywayinding signage around the acility.

Dependent: all occupants except thoseclassiied as independent or very highdependency.

Very high dependency: those whoseclinical treatment and/or condition createsa high dependency on sta. This willinclude those in critical care areas,operating theatres, coronary care etc andthose or whom evacuation would prove

potentially lie-threatening.

Place of relative safety: an initial place awayrom the immediate danger o ire and romwhich urther evacuation is possible to a placeo saety.

Place of safety: a place where persons are inno danger rom ire.

Premises: the land, building, or part o a

building which is owned, occupied or managedby the organisation.

Preventative and protective measures: themeasures which have been identiied by theresponsible person in consequence o a riskassessment as the general ire precautionsnecessary to comply with the requirements andprohibitions imposed by the Fire Saety Order.

Progressive horizontal evacuation:evacuation o patients away rom a ire into an

adjacent ire-ree compartment on the samelevel.

Relevant person: any person who may belawully on, or in the immediate vicinity o, thepremises and who is at risk rom a ire on thepremises.

Responsible person: the employer o personsworking at the premises, a person who hascontrol o the premises, or the owner o the

premises.

Young person: any person who has notattained the age o 18.

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1 Introduction and scope

1 Introduction andscope

1.1 Eective ire saety depends on acombination o physical ire precautions and arobust system o eective management. Firesaety in the healthcare environment isparticularly challenging since many healthcarebuilding occupants will require some degree oassistance rom healthcare sta to ensure theirsaety in the event o a ire.

1.2 Even in primary care environments, theproportion o building occupants that mayrequire some assistance to quickly escape the

eects o a ire is likely to be greater than thatwhich would be expected rom a cross-sectiono the general population.

1.3 While physical ire precautions within abuilding are intended to provide protection tobuilding occupants, eective ire saetymanagement ensures that the incidence o ireis minimised, the physical ire precautions aremaintained in an operational state, theorganisation is able to respond eectively

should a ire occur, and that the impact o a ireincident is minimised.

1.4 The current legislation in the orm o theRegulatory Reorm (Fire Saety) Order 2005requires a managed risk approach to ire saety.

The process o ire risk assessment, mitigationand review requires a robust system omanagement capable o identiying hazards,qualiying their impact, devising appropriatemitigation and continual monitoring.

1.5 The presence o a robust system o iresaety management is a key inluence in ire riskassessment and in many healthcare

environments it is the determining actor inevaluating the level o ire risk.

1.6 The increasing prevalence o building irestrategies or healthcare premises whichcontain ire-engineered design solutions arelikely to intensiy the need or enhanced iresaety management. These solutions mayrequire enhanced ire saety management to beapplied holistically or simply as a speciiccomponent o a ire-engineered solution.

1.7 In a healthcare environment with very highdependency patients (see Glossary), it is unlikelythat any amount o physical ire precautions ontheir own can reduce ire risks to an acceptablelevel. Adequate risk mitigation can only beachieved with the provision o a suicientnumber o suitably trained sta, an environmentin which the ire precautions are wellmaintained, and eective emergency actionplans that have been suiciently rehearsed. It isthe non-physical elements o these ire

precautions that are provided as a unction oire saety management.

General application

1.8 This Health Technical Memorandumprovides guidance in respect o themanagement o ire saety in healthcareorganisations.

1.9 It is intended that this Health Technical

Memorandum should be applied to all types ohealthcare organisations, including those thatonly perorm administrative unctions.

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1.10 While much o the content o thisdocument draws on examples rom morecomplex organisations such as an acute

hospital trust, the principles are equallyapplicable to a small general practice or otherhealthcare organisation.

1.11 The guidance within this Health TechnicalMemorandum cannot take account o all thecircumstances that may be ound in anyparticular healthcare organisation, but areintended to highlight the ire saety managementaspects that need to be considered.

1.12 The Department o Health recognizes thatthe range o healthcare providers is extensive,

and thereore Firecode may not addressspeciic issues or all organisations. Fire saetyproessionals are expected to use proessional

judgement when considering ire saetymeasures, taking particular account o:

the type o healthcare being provided;

the average age and dependency opatients;

planned staing levels; and

the size o the premises.

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2 Department o Health fre saety policy

2 Department o Healthire saety policy

Purpose

2.1 To provide an unambiguous statement o

ire saety policy applicable to the NHS inEngland, and to premises where patientsreceive NHS-unded treatment or care,excluding a single private dwelling.

Policy aims

2.2 This ire saety policy aims to minimise theincidence o ire throughout all activitiesprovided by, or on behal o, the NHS inEngland.

2.3 Where ire occurs, this policy aims tominimise the impact o such occurrence on liesaety, the delivery o patient care, theenvironment and property.

Application

2.4 This policy applies wherever NHSorganisations in England owe a duty o care to

service users, sta or other individuals.

Facilitation

2.5 The Department o Health will:

ensure that appropriate advice andguidance on matters relating to ire saetywill be available to NHS organisations inEngland through the provision o theFirecode suite o guidance;

acilitate the development o partnershipinitiatives with stakeholders and otherappropriate bodies in the provision o iresaety where reasonably practicable.

Implementation

2.6 All NHS organisations in England must:

comply with legislation relating to iresaety;

ollow evidence-based best practiceguidance where reasonably practicable;

ensure that suitable and suicientgovernance and assurance arrangementsare in place to manage ire-relatedmatters and demonstrate due diligence;

have in place a clearly deined

management structure or the delivery,control and monitoring o ire saetymeasures, which is shared across theorganisation;

provide appropriate levels o investment inthe estate and personnel to acilitate theimplementation o suitable ire saetyprecautions;

acilitate the development o partnershipinitiatives with stakeholders and otherappropriate bodies in the provision o iresaety where reasonably practicable.

Monitoring

2.7 The perormance o the NHS in Englandagainst the aims o this policy will be monitoredthrough:

the requirements or registration andcontinued compliance with the essential

standards o quality and saety asmonitored by the Care QualityCommission;

the annual ERIC return o ire reports andalse alarm reports.

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3 Statutory ire saetyduties

3.1 While a number o statutes place duties inrespect o ire saety on those controlling anorganisation or its activities, the two primarypieces o legislation that impose statutory iresaety duties are the Building Regulations 2010and the Regulatory Reorm (Fire Saety) Order2005. The ormer o these ocuses on theminimum unctional ire saety requirements thatmust be met in the provision o a new buildingor the material alteration or change o use o anexisting building. The latter is concerned withthe continued ire saety provisions to protect

relevant persons.

Fire saety requirements o the

Building Regulations 2010

3.2 The Regulations consider ive aspects o iresaety in the construction o buildings as set outin Part B o Schedule 1:

B1 Means of warning and escapeThat suicient provision is made in the

design o the building so that an earlywarning o ire can be given and thebuilding occupants can escape to a placeo saety.

B2 Internal fire spread (linings)That the internal linings o a building donot support a rapid spread o ire.

B3 Internal fire spread (structure)That the stability o the building structure

is maintained or a reasonable period andthe spread o ire through the building andin unseen cavities and voids is inhibited

by subdividing the building with ire-resisting construction or the installation oautomatic ire suppression.

B4 External fire spreadThat the spread o ire between buildingsis discouraged by adequate separationbetween them and controlling the numberand size o openings in the buildingenvelope.

B5 Access and facilities for the fireservice

That the building, the site layout andaccess roads are designed in such a wayas to enable the ire and rescue service toight ire and eect the rescue o personscaught in a ire.

3.3 While the Building Regulations arepredominantly ocused on the physical ireprecautions incorporated in a building, all suchmeasures are complemented by, and otendependent on, adequate ire saety

management activity to ensure their correctuse, continued unctioning and that suchprovisions remain appropriate throughout thelie o the building.

3.4 In particular, Part 8 o the BuildingRegulations states a requirement underRegulation 38 or the person carrying outrelevant work to provide the responsible personwith inormation relating to the design and

construction o the building, and the services,ittings and equipment provided which willassist the responsible person to operate andmaintain the building with reasonable saety.

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3 Statutory fre saety duties

Fire saety requirements o the

Regulatory Reorm (Fire Saety)

Order 2005

3.5 The Regulatory Reorm (Fire Saety) Order2005 came into orce in October 2006 andreplaced the the greater part o previous iresaety legislation. In this document it will bereerred to as the Fire Saety Order.

3.6 Responsibility or complying with the FireSaety Order rests with the responsible person.For the majority o cases in healthcareorganisations the responsible person will be the

employer. For example, in a hospital NHS trustthe responsible person is likely be the TrustBoard, whereas or a general practice, theresponsible person may be the senior partneror an individual GP.

3.7 The Fire Saety Order requires that theresponsible person puts in place all necessaryire precautions to protect relevant persons inthe event o ire in and around the premises

3.8 In order to determine the necessary ireprecautions, the responsible person is requiredto undertake a suitable and suicientassessment o ire risk which takes into accountthose at special risk, such as disabled people,those that have special needs and children. Inaddition, consideration o any dangeroussubstance liable to be on the premises must berelected in the ire risk assessment.

3.9 Any preventative and protective measures

necessary to saeguard those potentially at riskrom the eects o ire should be implementedto the extent that it is reasonable andpracticable. Eective arrangements must bemade or the planning, organisation, controlmonitoring and review o the preventative andprotective measures.

3.10 Duties imposed on the responsible personinclude:

Taking measures to reduce the risk o ireon the premises and the risk o thespread o ire on the premises.

Taking measures to eliminate or reducerisks resulting rom the presence and/oruse o dangerous substances.

Providing appropriate means o detectingire and raising the alarm includingcommunication with the externalemergency services.

Providing appropriate ire-ightingequipment.

Providing and ensuring the availability oappropriate escape routes and exits.

Planning, implementing and rehearsing

appropriate procedures or serious andimminent danger and or areas o danger.

Maintaining the acilities, equipment anddevices necessary to saeguard thesaety o relevant persons.

Appointing suicient competent personsto assist in undertaking the preventativeand protective measures.

Providing employees, and the parents o

employed children, with comprehensibleand relevant inormation on risks identiiedin the ire risk assessments, thepreventative and protective measurestaken, and the appropriate procedures.

Providing similar inormation to personsworking in or on the premises who arenot employed by the responsible person.

Providing adequate saety training to

employees.

Cooperating and coordinating with otherresponsible persons that have duties inrespect o the premises.

Maintaining provisions deemed necessaryor saeguarding the saety o ire-ighters.

3.11 The duties imposed by the Fire SaetyOrder on the responsible person are alsoimposed on every person, other than theresponsible person, who has to any extentcontrol o the premises. The extent o suchduties is determined by the extent o control

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4 NHS trust fre saety policies

4 NHS trust ire saetypolicies

4.1 The eective management o ire saety inany organisation requires the board, partners orequivalent controlling body to clearly set out theire saety priorities and objectives or theorganisation. This is achieved by the preparationand dissemination o a ire saety policy. TheDepartment o Healths ire saety policy shouldbe used as the model on which a trust shouldbase its ire saety policy. An exemplar trust iresaety policy is provided in Appendix A.

4.2 The ire saety policy should, by necessity,

be brie and avoid such detail as would requirethe policy to be regularly updated to relectchanges in legislation, guidance or personnel.Such detail should be conined to the ire saetyprotocols and management procedures.

4.3 There is an important distinction betweenthe ire saety policy that is prepared by theboard and sets out clear objectives andinstructions or the management team to ulil,and the ire saety procedures that are prepared

by the management team and detail theprocesses by which the organisation deliversthe ire saety outcomes to meet the objectiveso the ire saety policy. This distinction has asigniicant inluence on the eicacy o ire saetymanagement in NHS organisations. Where thedistinction is eective, the board, partners orequivalent controlling body are in a position togovern, while management are ree toeectively control the organisational resourcesto deliver the desired ire saety outcomesthrough the production and implementation oappropriate procedures.

4.4 The ire saety policy should clearly state thepolicy aims and the scope o its applicationsuch that there is an unambiguous statement othe organisational ire saety objectivesapplicable throughout the organisationsactivities. Details o the arrangements toacilitate ire saety that will be provided by theboard, partners or equivalent controlling bodyshould be included together with details o theexpectations or management in the delivery othe policy objectives.

4.5 Arrangements or monitoring theperormance o management procedures andmeasures are an important element o anypolicy. It is through appropriate monitoring andassurance systems that the board, partners orequivalent controlling body measures deliveryagainst the objectives set out in the ire policyand demonstrates due diligence and eectivegovernance.

4.6 The ire saety policy should be signed by

the chie executive or equivalent oicer onbehal o the board, partners or equivalentcontrolling body, disseminated to all sta andmade reely available to all parties that arestakeholders in the organisations delivery o aire-sae environment.

4.7 It is important that the ire saety policy isreviewed regularly to ensure that it meets theorganisations needs, includes suicient acilitiesand management instruction to deliver the

policy aims, and describes appropriatearrangements or the monitoring o ire saetyperormance throughout the organisation.

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5 Eective ire saetymanagement

5.1 In less complex organisations, or those withew sta and/or premises, it may be possible orthe Fire Saety Manager to adequately manageand control potential ire hazards, planning andtraining needs throughout the organisation.However, in large and/or complex organisations,such as an acute hospital trust, it is unlikely thata single person could exercise suicient controlto ensure that all aspects o the ire saetyregime were satisactorily delivered throughoutthe organisation.

5.2 In all but the smallest o healthcareorganisations it will be necessary to develop aire saety management system to ensure thatan appropriate ire-sae environment ismaintained. A ire saety management systemshould ensure that:

ire saety objectives are set and clearlycommunicated throughout theorganisation;

a suitable ire saety management

structure is developed along with clearlydeined roles and responsibilities;

appropriate guidance is produced anddisseminated throughout the organisationto ensure that all o the organisationsactivities support the ire saetyobjectives;

a suitable and suicient assessment oire risks is undertaken throughout the

relevant areas o all premises owned,occupied and/or managed by theorganisation;

appropriate action plans or improvementto ire precautions are recorded andactioned;

ire risk assessments are maintained up-to-date and are reviewed as appropriate;

a suitable programme o ire saetytraining is developed and implemented;

a robust system or the monitoring andreporting o ire incidents, alse alarms,unwanted ire signals and other ire saety

issues is developed and implemented; the perormance o the ire saety

management system is periodicallyaudited and assessed against theorganisations ire saety objectives.

5.3 An exemplar ire saety managementsystem is shown diagrammatically in AppendixB. In this system, the board, partners orequivalent controlling body are responsible orsetting out the ire saety policy, which includesthe organisations ire saety objectives. Theremainder o the ire saety managementsystem is developed and implemented by thevarious levels o operational management. Theoutcomes delivered by the ire saetymanagement system are communicated to theboard, partners or equivalent controlling bodythrough incident reports, periodic internalreporting and an annual audit. In this way, theboard, partners or equivalent controlling body

hold the organisations management to accountor their perormance against the ire saetyobjectives set out in the ire saety policy.

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5 Eective fre saety management

5.4 The implementation o the ire saety policyrequires a management structure with clearlydeined roles and responsibilities, reporting

channels and parallel pathways that ensure thecommunication o ire saety inormation to theboard, partners or equivalent controlling body.

5.5 To successully implement the ire saetypolicy, all sta need to be provided withsuicient inormation and delegated authority toacilitate their undertaking o the duties requiredto eect the ire saety management systemand deliver the ire saety objectives o theorganisation. To this end, the Fire Saety

Manager should develop a ramework o robustire saety protocols that provide clear guidanceto those perorming a ire saety role and tothose whose activities may indirectly aect iresaety within the organisation. For example,without suicient guidance, the purchasingdepartment may procure upholstered urniturethat does not meet the minimum standard oruse in a public area o medium hazard. Furtherinormation in respect o ire saety protocols isprovided in Chapter 8.

5.6 While ire risk assessments are a statutoryduty placed on the responsible person, it isrecognised that in all but the smallest ohealthcare premises, a person competent inhealthcare ire saety and risk assessment, suchas the Fire Saety Adviser, should undertakethem. The ownership o the ire risk assessmentand its indings should be vested in the personin control o the area that has been assessed.Hence, in the case o a ward, it is the wardmanager or equivalent that has ownership othe ire risk assessment and its indings, albeitthat there may be signiicant indings andactions that are outside the ward managerscontrol which are collated and managedcentrally. The local ownership o ire saetyissues ensures that the person with control overindividual departments or areas o the premisescan discharge the duties imposed on them bythe Fire Saety Order.

5.7 The outcomes, and especially the signiicantindings, o the ire risk assessment should be

communicated to all employees. This can bereadily achieved by:

sta brieings carried out by local

managers; and

the compilation o a ire saety inormationmanual or each ward, department orarea that contains:

speciic and detailed inormation inrespect o the indings o the ire riskassessment, and

the protective and preventativemeasures in place.

5.8 The review o the ire risk assessment canbe more easily perormed where the localmanager is provided with details o theparameters that may invalidate the ire riskassessment, and is instructed to request areview i any material changes occur. In such aregime, the ire risk assessment may bereviewed by the competent ire risk assessorundertaking a physical check o the area,primarily in response to a request rom the localmanager. However, it is recommended that thecompetent ire risk assessor periodically visitseach area to review the ire risk assessment,albeit that such a review would be less requentwith the local management monitoring andcontrolling the ire risks in their area.

5.9 Fire emergency action plans will need to bedeveloped to ensure that in the event o a irethe organisation and its sta:

respond appropriately to ensure thesaety o all relevant persons; and

meet the objectives o minimisingdisruption to the provision o services,and damage to the environment andproperty.

The organisation as a whole will need todevelop appropriate action plans to coordinateresources to ensure that central unctions are

delivered and local actions are adequatelysupported. Local emergency action plans willalso need to be developed that detail thespeciic actions to be taken relevant to the ire

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5 Eective fre saety management

5.17 The Equality Act 2010 sets out the dierentways in which it is unlawul to treat someone,such as direct and indirect discrimination,

harassment, victimisation and ailing to make areasonable adjustment or a disabled person.The act prohibits unair treatment in theworkplace, when providing goods, acilities andservices, when exercising public unctions, andin the disposal and management o premises.

5.18 Section 149 (1) o the Equality Act 2010sets out the three main aims o the publicsector Equality Duty:

a. eliminate unlawul discrimination,harassment and victimisation;

b. advance equality o opportunity betweenpeople who share a protectedcharacteristic and people who do not;

c. promote good relations between peoplewho share a protected characteristicand those who do not.

5.19 As part o developing a ire saetymanagement system, providers o NHS-undedhealthcare must show they have considered

their duty under section 149 (1) and candemonstrate evidence to support compliance.

5.20 A speciication or ire risk managementsystems is available in PAS 7 Fire riskmanagement systems (2013 edition) and thisHealth Technical Memorandum can beconsidered as healthcare-speciic guidancesupporting such a speciication to identiy thebasic requirements o a ire saety managementsystem.

5.21 Users o this Health TechnicalMemorandum are advised to consider thebeneit o third-party certiication o conormitywith PAS 7 (2013). Appropriate conormityattestation arrangements are described in BSEN ISO/IEC 17021. Users seeking assistance inidentiying appropriate conormity assessmentbodies or schemes should contact UKAS oradvice and urther inormation.

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6 Appropriatemanagement levels

6.1 In healthcare organisations the delivery oan appropriate level o ire saety will be largelyinluenced by the development o a robust iresaety management system and the capabilitieso those that bring the system into eect.

6.2 In large and more complex healthcareorganisations and/or those that cater ordependent or very high dependency patients,the quality o management and their proactiveapproach to ire saety is undamental to themitigation o ire risks.

6.3 In smaller, less complex healthcareorganisations where patients that requireassistance to escape rom ire are uncommon,the reliance on proactive ire saetymanagement is less pronounced. In suchcircumstances the resources required toachieve a similar level o ire saety managementto that o a more complex organisation may bedisproportionate to the level o risk present.

6.4 The appropriate level o ire saetymanagement should be determined rom

Table 1 and the corresponding eatures o themanagement level should be incorporated intothe ire saety management system andprocesses. The level o managementknowledge should not be reduced rom thatgiven in the table; however, based on a higherrisk identiied by assessment, it can beincreased to the more appropriate level.

6.5 The Department o Health acknowledgesthe diverse nature o healthcare providers, orexample those providing community basedcare, where the organisation may be

responsible or a range o healthcare premiseso varying complexity. In such circumstancesthe local management o each premises shouldconorm to the management level appropriateor that type o premises as shown in Table 1.However, the management o central unctionsshould conorm to the management levelappropriate or the most complex premisesand/or highest dependency o patients in theorganisations portolio.

Level 1 ire saety management6.6 Level 1 ire saety management exhibits theollowing attributes:

Anticipates and proactively identiies theimpact o any proposed changes to riskproile including changes to theoccupancy, periods o abnormaloccupancy, and ire hazards, identiyingand implementing alternative protectionand management measures that will be

required to mitigate the change.

The manager(s) with responsibility or iresaety are empowered to initiatemaintenance or repair in order to ensurethat legislative requirements are met.

The staing level provided is speciicallyappropriate to the building concerned,including the use o the building, thenature o the occupants, the managementsystems in place, and the active andpassive systems provided. Sta aresuitably trained to assist occupantseectively in a ire emergency, and

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6 Appropriate management levels

suicient arrangements are in place toprovide contingencies or sta absences.

The arrangements or training ensure thatthere are suicient sta trained in allaspects o ire prevention, ire protectionand evacuation procedures, and wherenecessary, they are able to use theappropriate extinguishing equipment soas to provide ull coverage o the building,with provision or contingencies, sicknessor holiday absences.

The system or work control is developedproactively with clear lines oresponsibility, a robust permit system,logging and audit processes, and routinechecking and supervision. The permitsystem considers not only the risksinherent with the works activity, but alsothe potential implications or otherdepartments and activities.

The system o communications is able toensure that all o those involved, or

potentially involved, in an incident arerapidly and eectively given relevantinormation. The system makes use oalternative ormats as necessary and haspredetermined contingency plans orwhen systems ail.

The maintenance system exhibitsdynamic monitoring o the ire saetysystems, and the equipment is kept ullyunctional at all material times. Alternativeprocedures and arrangements have beendevised or those times when systems,equipment and other arrangements arenot available or not unctioning correctly.

Liaison with the ire and rescue service isproactive including eective arrangementsor notiying the ire and rescue service ochanges to the occupancy, periods oabnormal occupancy and other relevantactors. Arrangements are in place orroutine meetings with the ire and rescueservice, and additional meetings where a

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 injur ies unit Pat ients predominant ly 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

Smal l 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

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change in the building or its occupancy isproposed.

Contingency planning is proactive, taking

into account a wide range o possibleemergencies and incidents. These willinclude logistical planning comprisingsuch issues as the provision o shelter,communications, transport, the weather,time o day, time o week, time o year(holidays etc) and traic-related issues, aswell as scenarios such as power ailuresor loods.

Level 2 ire saety management6.7 Level 2 ire saety management exhibits theollowing attributes:

Identiies the impact o changes to riskproile including changes to theoccupancy, periods o abnormaloccupancy and ire hazards, and reactsto those changes by identiying andimplementing alternative protection andmanagement measures to mitigate thechange.

The responsibility or ire saety, and thenecessary supporting sta andresources, is likely to be divided over anumber o dierent individuals,departments or even companies. It islikely that the implementation o anynecessary changes will require approvalo those not directly responsible or theroutine management o ire saety withinthe premises.

The staing level provided is speciicallyappropriate to the building concerned,including the use o the building, thenature o the occupants, the managementsystems in place, and the active andpassive systems provided. Sta aresuitably trained to assist occupantseectively in a ire emergency; however,there is no contingency provision.

The arrangements or training ensure thatthere are suicient sta trained in allaspects o ire prevention, ire protection

and evacuation procedures, and, wherenecessary, they are able to use theappropriate extinguishing equipment soas to provide ull coverage o the building;however, there is no contingencyprovision.

The system or work control providesclear lines o responsibility but is reactiveto works activity. A robust permit systemis in place which includes logging andaudit processes.

The system o communications providesinormation to all involved in an incident.

The system makes use o alternativeormats as necessary; however there isno contingency provision.

The maintenance system exhibits periodicmonitoring o the ire saety systems, andthe equipment is kept ully unctional at allmaterial times. Alternative procedures andarrangements are devised reactivelywhen systems, equipment and otherarrangements are not available or not

unctioning correctly.

Liaison with the ire and rescue serviceincludes arrangements or notiying theire and rescue service o changes to theoccupancy, periods o abnormaloccupancy and other relevant actors.

There are no arrangements or routinemeetings with the ire and rescue serviceor where a change in the building or itsoccupancy is proposed.

Contingency planning takes into accounta narrow range o possible emergenciesand incidents. These will include logisticalplanning including issues such as theprovision o shelter, communications,transport, the weather, time o day, timeo week, time o year (holidays etc) andtraic-related issues, as well as scenariossuch as power ailures or loods.

Level 3 ire saety management

6.8 Level 3 ire saety management exhibits theollowing attributes:

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6 Appropriate management levels

Reviews the impact o changesperiodically, identiying and implementingalternative protection and managementmeasures to mitigate those changes.

Managers responsible or ire saety arelikely to have limited or no power orresources, and are thus unlikely to beable to ensure that the ire saety systemsare kept ully unctional without reerenceto a third party.

The staing levels provided do notroutinely and speciically address thebuilding concerned or its use, the nature

o the occupants, or the active andpassive systems provided.

General ire saety training is provided ona periodic basis.

The system or work control is reactive to

any work required on site.

The system o communications providesinormation to all involved in an incidentbut there is no provision or the use oalternative ormats or contingencyarrangements.

The system o planned maintenance andtesting is likely to be controlled by others.

There is no system o communication

with the ire and rescue service. Anycommunications are likely to be reactive.

Contingency planning is minimal.

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7 Fire saetymanagement rolesand responsibilities

7.1 The ollowing paragraphs detail roles andresponsibilities that are likely to be required toadequately address ire saety management in acomplex healthcare organisation such as anacute hospital trust. While not all roles will berequired or smaller and less complexorganisations, the responsibilities describedhere will need to be discharged in anyorganisation through a management structureappropriate to that organisation. (See Appendix

C or an exemplar ire saety managementstructure.)

7.2 The ire saety management structure andlines o responsibility and reporting should beclearly set out in a ormat similar to theexemplar Appendix C. The structure shouldclearly identiy each post holder, the ire saetyrole that they assume and their job title.

7.3 In some organisations, the role o Fire Saety

Adviser may be ulilled by an externalcontractor. Where this is the case, details o thecontractor and the contractual arrangementsshould be speciied in the ire saetymanagement structure.

7.4 In many organisations some o the rolesdescribed here may be combined. For example,it may be possible to combine the roles o FireSaety Manager and Fire Saety Adviser wherethe post holder possesses suitable managerial

skills and ire saety competency. (SeeAppendix D or exemplar person speciicationsor these roles.)

Trust Board

7.5 The Trust Board has overall accountabilityor the activities o the organisation, whichincludes ire saety.

7.6 The Trust Board should ensure that itreceives appropriate assurance that therequirements o current ire saety legislationand the objectives o DHs Firecode are beingmet.

7.7 The Trust Board discharges theresponsibility or ire saety through the ChieExecutive.

Chie Executive

7.8 The Chie Executive will, on behal o theBoard, be responsible or ensuring that currentire legislation is complied with and, where

appropriate, DHs Firecode guidance isimplemented in all premises owned, occupiedor under the control o the trust.

7.9 The Chie Executive will ensure that allagreements or the provision o care and otherservices by third parties include suicientcontractual arrangements to ensure compliancewith the trusts ire saety policy.

7.10 The Chie Executive discharges the day-to-

day operational responsibility or ire saetythrough the Director with ire saetyresponsibility.

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7 Fire saety management roles and responsibilities

Board Level Director (with ire saety

responsibility)

7.11 The Director with ire saety responsibility isresponsible or ensuring that ire saety issuesare highlighted at Board level.

7.12 This responsibility will extend to theproposal o programmes o work relating to iresaety or consideration as part o the businessplanning process.

7.13 This will include the management o theire-related components o the capitalprogramme and uture allocation o unding.

7.14 At an operational level the Director with iresaety responsibility should be:

assisting the Chie Executive with Boardlevel responsibilities or ire saety matters;

ensuring that the trust has in place aclearly deined ire saety policy andrelevant supporting protocols andprocedures;

ensuring that all work that hasimplications or ire precautions in newand existing trust buildings is carried outto a satisactory technical standard andconorms to all prevailing statutory andmandatory ire saety requirements(including DHs Firecode);

ensuring that all proposals or newbuildings and alterations to existingbuildings are reerred to the Fire SaetyManager beore building control approvalis sought;

ensuring that all passive and active iresaety measures and equipment aremaintained and tested in accordance withthe latest relevant legislation/standards,and that comprehensive records are kept;

ensuring cooperation between otheremployers where two or more share trust

premises;

ensuring through senior managementand line management structures that ull

sta participation in ire training and ireevacuation drills is maintained;

ensuring that agreed programmes o

investment in ire precautions are properlyaccounted or in the trusts annualbusiness plan;

ensuring that an annual audit o ire saetyand ire saety management isundertaken, and the outcomescommunicated to the Trust Board;

ully support the Fire Saety Managerunction.

7.15 In line with delegated authority, the Directorwith ire saety responsibility devolves day-to-day ire saety duties to the Fire Saety Manager.

Fire Saety Manager

7.16 The role o Fire Saety Manager is primarilya managerial role suitable or a senior operatingmanager. The role does not necessitate theduty holder to possess ire saety competencies

provided that they have suicient access tocompetent ire saety advice provided eitherrom an internal Fire Saety Adviser or anexternal source.

7.17 The Fire Saety Manager acts as a ocusor all ire saety matters in the organisation, andthereore the role should be carried out by oneperson. While the Fire Saety Manager mayhave a dierent line manager, accountability orire saety matters should always be through the

board level director.

7.18 The role o Fire Saety Manager may becombined with other operational roles such ashealth and saety, risk management, localsecurity management specialist, emergencyplanning etc. However, when nominating theFire Saety Manager, it will be necessary toensure that there are clearly deined areas oresponsibility and an integrated approach toavoid conlict with any overlappingresponsibilities.

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7.19 The Fire Saety Manager is tasked withdeveloping and managing the ire saetymanagement system, and will be responsible

or (exemplar role/duties): the day-to-day implementation o the ire

saety policy;

reporting o non-compliance withlegislation, policies and procedures to theDirector with ire saety responsibility;

obtaining expert advice on ire legislation;

obtaining expert technical advice on theapplication and interpretation o ire saetyguidance, including DHs Firecode;

raising awareness o all ire saety eaturesand their purpose throughout the trust;

the development, implementation,monitoring and review o theorganisations ire saety managementsystem;

the development, implementation andreview o the organisations ire saetypolicy and protocols;

ensuring that ire risk assessments areundertaken, recorded and suitable actionplans devised;

ensuring that risks identiied in the ire riskassessments are included in the trustsrisk register as appropriate;

the operational management o ire saety

risks identiied by the risk assessments; the development, implementation and

review o the organisations ireemergency action plan;

ensuring that requirements related to ireprocedures or less-able sta, patientsand visitors are in place;

the development, delivery and audit o aneective ire saety training programme;

the reporting o ire incidents inaccordance with trust policy and externalrequirements;

monitoring, reporting and initiatingmeasures to reduce alse alarms andunwanted ire signals;

liaison with external enorcing authorities;

liaison with trust managers;

liaison with the Authorising Engineer (Fire);

monitoring the inspection andmaintenance o ire saety systems toensure it is carried out;

ensuring that suitable ire saety auditsare undertaken, recorded and the

outcomes suitably reported;providing a link to the relevant trust

committees;

ensuring an appropriate level omanagement is always available by theestablishment o Fire Response Teams ortrust sites or premises.

Fire Saety Adviser [Authorised

Person (Fire)]7.20 The Fire Saety Adviser will be accountableto the Fire Saety Manager or matters o iresaety. They provide competent ire saetyadvice and will be responsible or (exemplarrole/duties):

undertaking, recording and reporting irerisk assessments;

providing expert advice on ire legislation;

providing expert technical advice on theapplication and interpretation o ire saetyguidance, including DHs Firecode;

assisting with the review o the content othe trusts ire saety policy;

assisting with the development anddelivery o a suitable and suicienttraining programme or sta;

the assessment o ire risks withinpremises owned, occupied or under thecontrol o the trust;

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the preparation o ire prevention andemergency action plans;

the investigation o all ire-related

incidents and ire alarm actuations;

liaison with the enorcing authorities ontechnical issues;

liaison with managers and sta on iresaety issues;

liaison with the Authorising Engineer (Fire).

7.21 Where specialist solutions are required toresolve ire saety issues, the Fire Saety Adviser

would not necessarily be expected to have thelevel o skill required but would know the limitso their capabilities and, when necessary, seekspecialist advice rom an Authorising Engineer(Fire).

Authorising Engineer (Fire) [External

Specialist]

7.22 The Authorising Engineer (Fire) will act as

an independent proessional adviser to thehealthcare organisation. The AuthorisingEngineer (Fire) will act as assessor and makerecommendations or the appointment o

Authorised Persons (Fire), monitor theperormance o ire saety management, andprovide an annual audit to the Board LevelDirector (with ire saety responsibility).

7.23 This guidance does not require anyorganisation to directly employ an Authorising

Engineer (Fire). Indeed, to eectively carry outthis role, particularly with regard to audit, it ispreerable that the Authorising Engineer (Fire)remains independent o the operationalstructure o the trust.

7.24 When commissioning an AuthorisingEngineer (Fire), the trust will ensure that theappointed Authorising Engineer (Fire) is achartered engineer and member o theInstitution o Fire Engineers or a chartered

member o a similar proessional body or thatthese specialist organisations are contacted orurther guidance and/or inormation.

7.25 The Authorising Engineer (Fire) will berequired to demonstrate competence in theirparticular ield o expertise.

Competent Person (Fire)

7.26 Installers and maintainers o ire saetyequipment will be commissioned by the trustand must be able to demonstrate a soundknowledge and speciic skills in the specialistservice being provided. This may include theinstallation and/or maintenance o related iresaety equipment/services such as:

ire alarm and detection systems;portable ire ighting equipment;

ire suppression systems;

ire dampers;

ire-ighting hydrants etc.

7.27 In cases where external parties provideservices, the party concerned should beregistered with an appropriate ire industry

accreditation scheme.

Local Management

7.28 Matrons, heads o service anddepartmental managers have responsibility or:

monitoring ire saety within theirrespective workplaces and ensuring thatcontraventions o ire saety precautionsdo not take place;

ensuring local ire risk assessments areundertaken and maintained up-to-date;

notiying the Fire Saety Adviser o anyproposals or change o use, includingtemporary works that may impact on therisk assessment, within their area;

reporting any deects in the ireprecautions and equipment in their areaand ensuring that appropriate remedialaction is taken;

ensuring that local ire emergency actionplans are developed, brought to the

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determine whether evacuation isnecessary and commence the evacuationi appropriate;

liaise with the Fire Response Team andthe Fire Response Team Leader on theirarrival.

Fire Response Team Leader

7.34 A senior manager will be nominated as theFire Response Team Leader to ensure initialcontrol o an emergency.

7.35 The Fire Response Team Leader is

required to:

respond to conirmed ire events;

take responsibility or direction o the FireResponse Team;

liaise with the Fire Incident Manager;

liaise with the attending ire and rescueservice;

instigate the internal major incident plan (irequired).

Fire Response Teams

7.36 The Fire Saety Manager should establishFire Response Teams on all trust sites. Localsite circumstances will best determine thequantity o people and skill proile required.

7.37 The Fire Response Team procedures

should relect and where necessary integratewith the trusts major incident policy andprocedures.

All sta, contract sta and

volunteers

7.38 All sta, contractors and volunteers should:

comply with the trusts ire saetyprotocols and ire procedures;

participate in ire saety training and ireevacuation exercises where applicable;

report deiciencies in ire precautions to

line managers and Fire Wardens;

report ire incidents and alse alarmsignals in accordance with trustsprotocols and procedures;

ensure the promotion o ire saety at alltimes to help reduce the occurrence oire and unwanted ire alarm signals;

set a high standard o ire saety bypersonal example so that members o the

public, visitors and students when leavingtrust premises take with them an attitudeo mind that accepts good ire saetypractice as normal.

Fire Saety Committee

7.39 In NHS organisations, it is recommendedthat a Fire Saety Committee be ormed. Thecommittee should be responsible or the review

o all ire saety matters. Standard agenda itemsmight include ire incidents, alse alarms,enorcement action, and sta training.

7.40 In exceptional circumstances, ire saetymatters could be dealt with by anothercommittee such as a health and saety or riskmanagement committee. However, where iresaety is part o another committees remit, iresaety should be a standing agenda item.

7.41 The relevant committee will act as aparallel conduit or reporting on ire saetyissues to the trust Board, and or conveyingexception reporting o issues or which the FireSaety Manager/Adviser may considerthemselves to be proessionally compromised.

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8 Fire saety protocols

8.1 A comprehensive set o ire saety protocolsis undamental to the successul managemento ire saety in all but the smallest o healthcareorganisations. Each organisation should

develop and disseminate a set ocomprehensive protocols (relecting the size,nature and risks present in the organisation) thatprovide guidance on all issues relating to iresaety within the organisation. It is important toensure that suicient guidance is provided to allareas o the organisations activities andparticularly to those that could signiicantlyimpact the level o ire saety within theorganisation despite the activity appearing oninitial examination to be unrelated to themanagement o ire saety. For example, withoutsuicient guidance the activities o the laundrymay result in inappropriate processes thatdeteriorate the lame retardancy o textiles usedwithin the organisation.

8.2 The ire saety protocols should be bespoketo each organisation and be suiciently detailedas to provide clear instruction on ire saetymatters. For example, where an organisation

uses a particular manuacturer o ire alarmequipment the ire saety protocols shouldprovide details o the manuacturer and theequipment that should be used or uturedevelopments as necessary to ensurecompatibility with existing systems.

8.3 The contents o the ire saety protocolsmanual should include a broad range o topicsand should provide inormation and proceduresor all ire-saety-related issues. The ollowing

contents list is not exhaustive, and localarrangements will dictate the necessary detail.

All organisations should consider the ollowinglist and develop ire saety protocols thataddress the relevant issues:

ire prevention;

risk assessments;

ire strategies;

emergency planning and procedures;

ire saety training;

ire saety inormation manuals;

construction and reurbishments;

ire detection and alarm systems;

alse alarms and unwanted ire signals;

ire extinguishers;

security;

arson;

hot works;

maintenance o ire equipment;

ire stopping;

portable appliance testing;

medical gases;

purchasing;

laundry;

inormation or the ire and rescue service;

salvage and continuity planning.

Further detail and inormation prompts that mayassist in developing appropriate ire saetyprotocols are provided in Appendix E.

8.4 To acilitate the compilation o such acomprehensive set o ire saety protocols, it isessential that the Fire Saety Managercoordinates input rom an array o disciplinesrelevant to the organisation.

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9 Fire saety inormation manuals

9 Fire saety inormationmanuals

9.1 While ire saety protocols provide detailedprocedures and inormation applicable to thewhole organisation, in larger and more complexhealthcare organisations, speciic inormationpertinent to each ward, department or areashould be provided to sta that work within thatarea. An eective orm o communicating suchinormation is the provision o a local ire saetyinormation manual.

9.2 Consideration should be given to providingeach ward, department and/or area with a

bespoke ire saety inormation manual. Thismanual may be provided as a physical ilelocated in the area to which it relates, or storedelectronically in such a way that it can be readilyaccessed in the area to which it relates. Ineither case, the inormation contained within theire saety inormation manual should be reelyavailable to be reviewed by any member o sta,patient or patients representative.

9.3 The ollowing items should be included in

the ire saety inormation manual:

A description o the ward/department/area.A brief description of the area, its extent,location and use.

A ire saety plan o the ward/department/area.A plan drawing showing the extent of thearea and the location of relevant fire

safety features including the locations of: ire compartmentation and sub-

compartmentation;

ire detection and alarm systemdevices;

ire hazard rooms;

ire doors and those that should bekept shut;

ire extinguishers;

ire escape routes;

evacuation equipment;

A ire saety checklist.A schedule of the fire safety checks thatshould be undertaken oncommencement of work by the person incharge of the area during that workperiod, including for example:

check that the nearest ire alarmrepeat panel displays a healthycondition;

check that the manual call points are

unobstructed;

check that the ire extinguishers are inplace and readily accessible;

check that escape routes are clearand unobstructed;

check that the ire doors that shouldbe kept shut are ully closed;

A copy o the emergency action plan

speciic to the ward/department/area.The detailed local fire emergency actionplan including:

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actions to be take on discovering aire;

actions to be taken on hearing the ire

alarm;

detailed procedures or evacuation;

the location o ire exits and evacuationequipment;

the location o ire extinguishers.

A copy o the ire risk assessment speciicto the ward/department/area.Include any specific hazard items that

have been identified and the protectiveand preventative measures in place tomitigate the resultant risk.

Guidance in respect o the parameters othe ire risk assessment.Specific guidance intended to inform thelocal manager of the parameters of thefire risk assessment. This guidance setsthe constraints of operating the area andthe boundaries beyond which the fire risk

assessment may be invalidated. It is thisguidance that will allow the local managerto maintain a safe environment andprompt a request for the fire riskassessment review in response tomaterial changes within the ward/

department/area concerned.

Sta ire saety training records.

Records o ire drills and emergency ireaction plan rehearsals.

Records o ires, alse alarms and

unwanted ire signals.

Local ire salvage plan (where applicable).A plan that provides details of items and

their locations specific to the area that willassist the fire and rescue service to plantheir fire-fighting, and where possiblerecovery, activities to best protect thecontinuity of care, delivery of service andhigh value property. The local salvageplan may include details of:

service-critical items;

items required to support thecontinuation o care such as patientnotes, specialist drugs or equipment;

high value equipment.

9.4 The ire saety inormation manual shouldbe maintained by the local manager. Statraining records and records o ire drills/ire

emergency action plan rehearsals should beupdated as appropriate. Changes to the ire riskassessments, ire emergency action plans,salvage plans etc should be relected in the iresaety inormation manual ollowing discussionwith the Fire Saety Manager or Fire Saety

Adviser.

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10 Planning and responding to a fre emergency

10 Planning andresponding to aire emergency

10.1 An eective response to any ireemergency depends on the preparedness o allthose involved and a detailed knowledge andunderstanding o the ire emergency action planand the arrangements in place to saeguardbuilding occupants. To achieve such a level opreparation, a considerable eort should bemade in the orm o planning, training,practising and testing the arrangements inplace.

10.2 Every organisation must put in placerobust ire emergency action plans or eacharea it is responsible or, with the intentiono saeguarding all relevant persons shoulda ire occur. In larger or more complexhealthcare organisations, the ire emergencyaction plan may comprise a number oelements such as:

the immediate response by sta in the

ward/department/area aected; the swit response and assistance o

those in adjacent areas;

the immediate deployment o FireResponse Team;

summoning the ire and rescue service asnecessary;

the coordination o additional resourcesas necessary.

10.3 In larger or more complex organisations itis unlikely that the ire emergency action plan

will involve the ull and immediate evacuation oall building occupants. The response is likely tobe multi-level, combining an organisationalresponse with a local response. For example, inhospital trusts it is common or the ire serviceto be summoned by a central switchboard anda Fire Response Team to be mobilised to thearea o the reported incident, while the irescene manager initiates the local ire emergencyaction plan. Appropriate ire emergency action

plans should be developed or each level o theorganisation and or each area it is responsibleor.

10.4 It is not possible to give precise guidanceon every conceivable situation that could arisein a ire emergency. However, the ollowingitems should be considered when developingire emergency action plans:

action on discovery o a ire.

Fire alarm: raising the alarm;

action on hearing the ire alarm;

the meaning o warning and alarmsignals;

arrangements or degradation o the iredetection and alarm system;

arrangements or declaring a alse alarm.

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Evacuation: arranging and coordinating evacuation;

methods o evacuation or dependent andvery high dependency patients;

arrangements or the evacuation obariatric patients;

availability o appropriate evacuation aids;

risk assessment indings (risk tooccupants while evacuating).

Incident response: ire-ighting (prior to the arrival o the ire

and rescue service);

Fire Response Team actions;

availability o sta as an additionalresource;

internal management control systems;

declaring a major incident and initiatingthe major incident plan.

Communication: arrangements or calling the ire and

rescue service;

arrangements or notiying the ire andrescue service o a alse alarm;

arrangements or communicationbetween those responding to the ireemergency;

arrangements or communication andcoordination with other building occupiersand responsible persons.

Continuity o care availability o additional specialist

equipment or continuing care;

acilities or the continuation o care;

caring or high-risk and vulnerablepatients;

inormation or the ire and rescue service;

contingency planning;

disabled people;

visitors and relatives; inormation, instruction and training.

Recording inormation and

reporting: recording response activities;

press/media liaison;

debrieing ater the incident;

arrangements or incident recording andreporting.

Recovery: salvage planning;

returning the building to normal service

site and building security.

10.5 It is essential that any ire emergencyaction plan is thoroughly tested and rehearsedto ensure that the contents are easible and theintended outcomes are satisactorily delivered.

To this end, each ire emergency action planshould be rehearsed by the sta that areintended to implement them in the event o aire incident.

10.6 Ideally, such rehearsals should involve anunannounced ire drill that includes the ull

evacuation o occupants, and this should be theaim wherever possible. In circumstances wherethe ull evacuation o occupants is not possible,alternative arrangements should be made torehearse the ire emergency action plan such aswalkthroughs and/or desktop exercisescombined with practical training sessions in theevacuation o dependent patients and otheroccupants.

10.7 Wherever possible, the ire and rescue

service should be invited to take part in therehearsal o the ire emergency action plan. Thisapproach helps to ensure that the organisations

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10 Planning and responding to a fre emergency

work together eectively and supports theethos o joint working and amiliarisationthrough the Fire and Rescue Services Act2004.

10.8 Details o emergency ire action planrehearsals should be recorded, together withoutcomes and any actions that require theamendment o any parts o the emergency ireaction plan.

10.9 The ire emergency action plan should beregularly reviewed and amended wherenecessary in response to any material changesincluding changes to:

the layout o the area concerned;

escape routes;

staing levels;

any o the ire saety equipment;

occupancy proile;

the ire service response.

10.10 The organisation must be able todemonstrate that the ire emergency actionplans in place are appropriate and suicientlyrobust so as not to rely on any other agenciesor evacuation.

10.11 To acilitate the eective deployment oire-ighting resources, it is necessary to providethe ire and rescue service with suicientinormation. The inormation should be

compiled in a usable ormat and made readilyavailable to the attending ire and rescue serviceon their arrival. The inormation required by ireand rescue services about premises, theirconstruction, contents, hazards and built-in ireprotection measures is becoming increasinglycomplex; the more inormation that can bemade available, the lower the risk to occupants,the ire and rescue service and, potentially, thepremises.

10.12 Inormation that should be providedincludes:

plans o the premises;

the location o valuable equipment (orexample CT and MRI scanners); and

inormation about:

ire and saety systems;

utilities and environmental systems;

hazardous contents o the premises.

10.13 This list is not exhaustive, but provides avaluable starting point. The local ire and rescueservice should be consulted regarding otherinormation they may require, urthering theconcept o joint working and amiliarisation andthe development o the joint operational tacticalplan.

10.14 The inormation made available to the ireand rescue service should be regularly reviewedand maintained up-to-date.

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11 Training

11.1 Adequate ire saety training is essential toensuring that ire prevention and emergencyaction plans can be put into practice. In many

healthcare environments, the sae evacuation opatients in the event o a ire will rely on theeective action o sta in implementing theemergency plan.

11.2 The provision o adequate ire saetytraining is a legal duty placed on theresponsible person by the Fire Saety Order.

11.3 In order to satisy the legal requirementsor training, sta need to have an understanding

o the ire risks to which they may be exposedand know what to do in the event o a ire sothat ire saety procedures can be appliedeectively. This requirement applies to all stairrespective o their seniority or proessionaldiscipline. All sta training should take placeduring the normal working hours o those beingtrained.

11.4 The Fire Saety Manager is responsible orensuring that an appropriate programme o ire

saety training is developed and suitablearrangements are in place or the delivery othat training to all employees and other relevantsta. It is the responsibility o matrons, heads oservice and departmental managers to ensurethat all o their sta have attended theappropriate ire saety training as detailed in thetraining needs analysis matrix.

Fire saety induction training

11.5 All sta, including part-time and agencysta, should receive local ire saety inductiontraining on or beore their irst day o

employment, or on their relocating to a newwork area. This may be delivered by the stamembers line manager or the person in charge

o the area in which they are to work. Where amember o sta is to work in a number o areas,it will be necessary to provide local ire saetyinduction training or each workplace. The localire saety induction training should include:

details o the risk identiied in the ire riskassessments or the area(s) concerned;

details o the protective and preventativemeasures in place;

any speciic instruction necessary toprevent ire in the area as a result ohazardous processes, substances and/orequipment;

details o the local ire emergency actionplan including:

the action to be taken on discovery oa ire

means o raising the ire alarm

the actions to take on hearing the irealarm

sta responsibilities during a ireincident

procedures or evacuation

the location o ire exits and evacuationequipment

the location o ire extinguishers

other relevant equipment etc.

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11 Training

a physical tour o the escape routes andassembly points, i appropriate, or placeso relative saety.

11.6 The details o this local ire saety inductiontraining, including the contents o the training,should be recorded and maintained as part othe local managements training records andmade available to the Fire Saety Manager.

11.7 In all but the smallest healthcareorganisations, either prior to theircommencement o work or as soon aspracticable thereater and in any case withinone month o their appointment all newmembers o sta should attend corporate iresaety induction training. While this induction islikely to take the orm o generic training, itspurpose is to provide a greater understandingo the ire saety processes and issuesthroughout the wider organisation. Thisinduction training should include:

basic ire saety and the ire saetyprotocols;

ire saety responsibilities and reportingstructures;

actions to take on discovering a ire;

actions to take on hearing the ire alarm;

procedures or evacuation;

sta responsibilities during a ire incident;

specialist roles (switchboard sta, estatessta, Fire Wardens, local securitymanagement specialist etc);

the organisations ire and alse alarmincident records.

11.8 This induction training should beconducted by a person competent in ire saetymatters in the healthcare environment. Theattendance o each sta member, together withthe contents o the training provided, should berecorded and those records made available to

each sta members manager. The duration othis training should relect the nature o thetraining and instruction being provided.

Periodic ire saety training

11.9 All sta should receive regular updated iresaety training and instruction. The duration and

requency o the training should be determinedby a training needs analysis. This should takeaccount o the ire risks present in the premises,the numbers and dependency o people at risk,and the responsibilities o sta in a ireemergency. The outcomes o the ire riskassessment and the resulting determination otraining requirements should be ormallyrecorded and periodically reviewed. It isexpected that sta involved in the direct care opatients, who may need to help evacuateothers, should receive instruction morerequently than those who may only be requiredto evacuate themselves rom the building on thesounding o the ire alarm.

11.10 The training needs analysis should takeinto account each member o stas generalduties, their role in preventing ire and theirpotential role in executing the ire emergencyaction plan. An exemplar approach to

developing a training needs analysis is includedin Appendix F.

11.11 Sta should understand the action to takein the event o ire, which will include some or allo the ollowing:

raise the alarm, inorm the main telephoneswitchboard and request assistance;

remove patients (and others) in immediatedanger to a place o saety;

ight the ire with approved equipment,but only i it is sae to do so and stahave been trained in their use;

evacuate the area in accordance with theemergency evacuation plan;

close all doors, windows, hatches etc toprevent urther spread o ire, smoke andtoxic umes;

11.12 An eective programme o ire saetytraining will enable sta to learn about andpractise basic actions and to appreciate the

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wider implications o the ire saety strategy,including:

the reasons or ire and smoke

compartmentation o buildings and orprotected escape routes to the open air;

the importance o ensuring that theintended unctions o ire/smoke doorsare not prejudiced by the dangerouspractice o wedging them in the openposition;

the signiicant indings o relevant ire riskassessments;

the dangers o locking ire-exit doors noire-exit door on any escape route to besecured by a means requiring the use oa key or digital keypad or egress;

the need or a clear procedure orallowing contractors to work withinhealthcare premises;

the need to be amiliar with escaperoutes, site layout, and the internal layout

o the premises in which they work andreside, and to recognise the need to keepescape routes ree o obstruction andrubbish;

the potentially atal consequences o thespread o ire, smoke and toxic gases;

the importance and beneits o reducingalse alarms and unwanted ire signals;

11.13 Additional training should be provided to

meet the special needs o particular locationsand or those sta who have specialresponsibilities. Some examples are:

Nursing sta and any others who mayhave to assist in the evacuation opatients should receive instruction andtraining in appropriate methods oevacuation that is, techniques ormoving and assisting patients (and others)to evacuate quickly in an emergency. The

special problems o moving patients romcritical care areas and similar locations

where very high dependency patients arecared or should be well-rehearsed.

Telephone switchboard operators should

be instructed and trained in the actionsthey should take in the event o ire in thehealthcare premises including:

interpreting the inormation displayedon the ire detection and alarm systemcontrol panel;

communicating with the FireResponse Team;

communicating with the ire and

rescue service.

Estates sta require precise instructionsor dealing with the sae control andisolation o services such as gas, water,electricity, ventilation, piped medicalgases etc, which they may need tocontrol during a ire.

Cleaning and housekeeping sta shouldbe instructed in the appropriate controls

or lammable substances that they mayuse in their duties and the need to clearescape routes o cleaning equipment inthe event o a ire.

11.14 The training needs analysis should bedeveloped by the Fire Saety Manager inconjunction with the Fire Saety Adviser andshould determine the appropriate training, bothin terms o content and requency, or eachgroup o sta whose activities, responsibilities

and actions in the event o a ire are similar.

11.15 In some cases the training needs analysisis likely to identiy sta groups whose ire saetytraining requirement is minimal. For example,administration sta that work in oices remoterom patient care areas, and whose duties donot bring them into patient or public areas, arelikely to need to respond to a ire alarmactivation by leaving the building andassembling at a predetermined assembly point.

For these sta, annual ire saety training maycomprise participation in a successulunannounced ire drill. This would be

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11 Training

supplemented with attendance at a ormal iresaety training session every three years. Inother cases, some groups may require morerequent training with considerable instruction.For example, sta that work in operatingtheatres are likely to require some training in thecharacteristics o ire and ire growth to equipthem with the inormation necessary to decidewhether to continue with a procedure or seek toevacuate, as well as the evacuation techniquesnecessary to evacuate a very high dependencypatient.

11.16 The ire saety training programme should

include practical sessions and ire drills tosupplement classroom instruction. Trainingsessions should be well-publicised andarrangements made in good time or therelease o sta. The training programme needsto make reasonable provision to acilitate staworking patterns, including those on permanentnight duty and those that work part-time, toensure that suicient training opportunity isavailable to all sta members.

11.17 The use o e-learning may oer a numbero beneits to an organisation. However, in allbut the smallest healthcare organisations suchas a small GPs practice with a single-stageevacuation plan, e-learning is not acceptable asthe sole means o training sta. E-learning canonly be used to support training delivered by aperson competent in ire saety in the healthcareenvironment.

11.18 E-learning is not acceptable as the sole

means o training or the ollowing reasons:

it does not take account o signiicantindings rom ire risk assessments;

it does not take account o changes inworking practice;

it cannot adequately train sta inevacuation techniques, particularly thoseinvolving patient evacuation;

it is unlikely to provide or job-speciictraining;

there is little opportunity or directeedback to trainees questions.

11.19 In exceptional circumstances where amember o sta cannot be made available ortraining delivered by the Fire Saety Adviser

(due, or example, to long-term sicknessabsence), the use o e-learning may beconsidered as a temporary alternative. However,no member o sta should be permitted tocontinue their duties with a gap in their recordo training longer than twice the intervalidentiied in the training needs analysis.

11.20 It is recommended that any trainingdelivered by e-learning should be completedwithin one month o the session commencing.

Any session not completed within the monthshould result in the e-learning programme beingrecommenced.

11.21 In addition to the periodic ire saetytraining identiied in the training needs analysis,additional training should be provided inresponse to any material changes including:

the risk assessment indings;

the physical layout o the workplace;

the number and/or nature o patients;

the number o sta;

the emergency action plan;

ollowing a report by the enorcing ireauthority highlighting training;

ollowing a ire or near miss.

11.22 Fire saety training should only bedelivered by persons competent in ire saety inthe healthcare environment.

11.23 In order to veriy that appropriate traininghas been completed in accordance with thetraining needs analysis by each member osta, records should be kept which include:

the names o those attending;

the dates and duration o the instruction;

the nature and content o training given;and

details o those providing instruction

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Those records should be made available toeach sta members manager to acilitate themdischarging their duty to ensure that all theirsta attend ire saety training.

Fire saety training audit

11.24 It is necessary to ensure that theprogramme o ire saety training is deliveringthe desired outcomes and ensuring that staare aware o their ire saety responsibilities andtheir role in ire prevention and implementing theire emergency action plan.

11.25 Assessing the eectiveness o trainingschemes is important but oten diicult to carryout with certainty. The Fire Saety Manager inconjunction with healthcare Fire Saety Advisersshould, on a regular basis (but normally no less

than every two years), devise methods o testingsta.

11.26 It is likely that the practical perormance

o sta at training sessions and duringrehearsals o the ire emergency action plan willoer the best indication o the eectiveness o aprogramme and the degree to which sta haveassimilated instruction.

11.27 The recording system should enable theFire Saety Manager to oversee trainingprogrammes eectively and check that traininggoals have been met, including those or part-time, agency and night-duty sta.

11.28 The eicacy o the ire saety trainingprogramme should also be included in theannual ire saety audit.

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12 Reporting and audit

12 Reporting andaudit

12.1 An essential element o any ire saetymanagement system is a robust reporting andaudit process. This process provides eedbackto the monitoring unction o the board, partnersor equivalent controlling body and provides thenecessar

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