Fire Safety Policy & Fire Safety Management System
Version 01.04 22 October 2013
Emergency Evacuation Procedures
Contents
1.
Raising the fire alarm
2.
Schedule of patient evacuation
3.
3.1
3.2
3.3
3.4
3.5
Designated fire officer roles
The Fire Team Leader
Security personnel
Shift Technicians
Fire Point Co-ordinator
Porter – Meets and accompanies the Fire Brigade to the Fire Team Leader
4.
Evacuation equipment placement
5.
Use of lifts in fire emergencies
6.
Fire fighting lobby telephone numbers
7.
Fire assembly points
8.
Fire incident procedures flow chart
9.
Action in the event of fire (Patient Areas)
10. Action in the event of fire (Non- Patient Areas)
11.
The Fire Team
11.1
11.2
11.3
11.4
11.5
11.6
11.7
Fire Team Action Card 1 - Telephone Switchboard
Fire Team Action Card 2 - Fire Team Leader
Fire Team Action Card 3 - Porter
Fire Team Action Card 4 - Senior Security Officer
Fire Team Action Card 5 - Shift Technician
Fire Team Action Card 6 - Fire Point Co-ordinator
Fire Action Card Log
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Fire Safety Policy & Fire Safety Management System
Version 01.04 22 October 2013
GENERAL INFORMATION
1.
Raising the fire alarm
Operate the nearest safe fire alarm call point and dial x5555
NOTE: During 0830-1600 on normal weekdays if the fire alarm activation has been via a
single detector head (only) there will be a delay of up to 8 minutes before the Fire Brigade
are called. This is to allow for a local assessment to be made by the hospitals Fire
Wardens and Fire Team. If the Fire Brigade are needed to help with the incident the Fire
Team Leader will make this decision – if the Fire Team Leader has not contacted the
Switchboard within 8 minutes of the fire alarm activation the Fire Brigade will be contacted
automatically by the Switchboard Operator. In the event of a fire alarm being activated, the
following two-stage alarm will be heard:


2.
A continuous alarm in the zone where the incident is located;
An intermittent alarm in adjacent zones (horizontally only)
Schedule of patient evacuation
If evacuation is necessary ensure that patients and other persons who may be in immediate
danger are quickly moved away from the effects of combustion. The evacuation priority
should be:
3.
a.
Patients in immediate danger first, then:
b.
Ambulant patients
Patients that need little or no assistance
c.
Semi-ambulant patients
Patients that need some assistance
d.
Non-ambulant patients
Patients furthest from the safe area
e.
Non-ambulant patients
Patients nearest to the safe area
Designated fire officer roles
The following are key personnel during a fire incident. All staff must act upon
instructions given to them by designated persons undertaking any of these roles
3.1
The Fire Team Leader – Initially take charge of the incident at the actuated fire
alarm panel
3.2
Security personnel - Assist the Fire Team Leader and attend the fire zone affected
to assist with evacuation and fire fighting
3.3
Shift Technicians – Provide technical advice
3.4
Fire Point Co-ordinator – Co-ordinates Trust response; delegated by the Fire
Team Leader
3.5
Porter – Meets and accompanies the Fire Brigade to the Fire Team Leader
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4.
Evacuation equipment placement
There are two evacuation ‘Ski Pads’ in the external stair lobbies each of the Tower Block
wards; and…….
There are two evacuation stretchers in each of the following locations: 4 S/W/E (external
stair lobby)
5.
Use of lifts in fire emergencies
Only wards and departments that have agreed the use of lifts (for patient evacuation) as
part of their fire evacuation plans with the Trusts Fire safety Adviser can use them in a fire
emergency. If fire incidents escalate into major incidents the Silver Commander can
authorise the use of lifts for patient evacuation under the control of the Fire Team Leader
Key operated override switches on lifts 7-10 and 11-14 have been provided to give
emergency control of the lifts to the Fire Team Leader
6.
Fire fighting lobby telephone numbers
13th (Q) floor
a phone is required for this area
12th floor
74110
11th floor
74111
10th floor
74112
9th floor
74113
8th floor
74114
7th floor
74115
6th floor
74116
5th floor
74117
4th floor
74118
3rd floor
74119
2nd floor
74120
1st floor
74121
Ground floor
74122
Fireman’s entrance
74500
Lower ground floor
74123
Service level floor
74124
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7.
Fire assembly points
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8.
Fire incident procedures flow chart
Fire Team (8.30 a.m. – 4 p.m. weekdays)

Rostered Facilities Manager, or
Estates Officer
 Shift Technician
 Security
 Portering Services
 Senior Manager/Nurse on Duty in
area affected
Fire Team (All times outside of the hours
listed above)





Duty Site Manager
Shift Technician
Security
Portering Services
Senior Manager/Nurse on Duty
Managers & Senior Nurses
are to ensure
Departmental/Ward Fire
Procedures are put into
operation immediately on
hearing any Continuous Fire
Alarm
Fire Team
Leader to
establish
Control Point
and organise
initial search
Isolate all non essential
equipment and prepare to
implement Departmental
Emergency Plan on hearing
any Intermittent Fire Alarm
Plans of
Location to be
made available
to Fire Brigade
THE PERSON DISCOVERING THE FIRE
OPERATES THE FIRE ALARM CALL
POINT & DIALS x5555
The Switchboard identifies the location of the
fire from the fire alarm panel and informs LFB
via ‘999’ call
Switchboard to send ‘voice over’ to Fire Team
over the group bleep system advising of the
fire incident location
Fire Team to report to
designated assembly
point for fire in that
location
Porters to
monitor traffic
& meet Fire
Brigade @
Designated
Rendezvous
Point
Fire Team to
assess situation
and advise Fire
Team Leader
FIRE
Fire Team Leader to declare ALL CLEAR (on
authorisation of Fire Brigade). Collate reports
and recommendations e-mail to Trust
Specialist Fire Safety Advisor
YES
NO
YES
Fire
Extingu
ished
Silver Commander
to assess action
required under
Business Continuity
Plan
NO
Is the fire
Fire Team to:
Extinguish Fire (if
safe & possible)
Evacuate &
secure area
Extinguished?
Assist Fire Brigade
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9.
Action in the event of fire (Patient Areas)
DETECTION OF FIRES
1
Raise the alarm immediately by operating the nearest fire alarm call point and
telephone x5555
2
Fight the fire if it is safe to do so
3
Close doors and windows in the vicinity if it is safe to do so
4
Prepare to evacuate patients horizontally following the local evacuation procedure
ON HEARING THE FIRE ALARM (continuous bells)
1
Seek and search for signs of fire
2
Move patients in immediate danger first
3
Fight the fire if it is safe to do so
4
Close doors and windows in the vicinity if it is safe to do so
5
Prepare to evacuate patients horizontally following the local evacuation procedure
ON HEARING THE FIRE ALARM (intermittent bells)
1
Send a member of staff to the fire alarm panel to liaise with the Fire Team Leader re:
the incident, then go back to their department/ward and brief the person in charge
2
Close doors and windows in the vicinity if it is safe to do so
3
Prepare to evacuate patients horizontally following the local evacuation procedure
EVACUATION PROCEDURE
1
Move patients in immediate danger first
2
Evacuate patients horizontally to the nearest safe area
3
If necessary continue to evacuate patients horizontally following the local evacuation
procedure
4
Immediately report to the senior member of staff or Fire Team anyone that is not
accounted for
DO NOT:

Take any undue risks

Stop to collect personal belongings

Use lifts unless you are instructed it is safe to do so by the Fire Team or Fire Brigade
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10.
Action in the event of fire (Non- Patient Areas)
DETECTION OF FIRES
1
Raise the alarm immediately by operating the nearest fire alarm call point and
telephone x5555
2
Fight the fire if it is safe to do so
3
Close doors and windows in the vicinity if it is safe to do so
4
Evacuate to your assembly point
ON HEARING THE FIRE ALARM (continuous bells)
1
Close doors and windows in the vicinity if it is safe to do so
2
Evacuate to your assembly point
ON HEARING THE FIRE ALARM (intermittent bells)
1
Send a member of staff to the fire alarm panel to liaise with the Fire Team Leader re:
the incident, then go back to their department/ward and brief the person in charge
2
Close doors and windows in the vicinity if it is safe to do so
3
Prepare for evacuation
DO NOT:

Take any undue risks

Stop to collect personal belongings

Use lifts unless you are instructed it is safe to do so by the Fire Team or Fire Brigade

Return to the building until told it is safe to do so
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11.
The Fire Team
The Fire Team consists of:
A Team Leader; Two Security Officers; One Porter; One Shift Engineer
The Fire Team will be alerted to fire incidents by the Telephonist via the Group Alert Bleep
System – The Switchboard will state the incident location, floor number and fire zone. The
Fire Team are to:
1
Proceed to the fire alarm panel on the relevant floor and investigate the incident with
the assistance of the departmental manager concerned (if available)
2
Ensure that they have all necessary keys/codes etc to allow access to locked areas
3
Provide the main bleep holder e.g. the Fire Team Leader, with all relevant information
necessary to assist the Fire Brigade
Fire calls will be sent via the Group Alert Bleep System, the telephonist will advise the
location, floor number and fire zone
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11.1 Fire Team Action Card 1 - Telephone Switchboard
Who:
All Switchboard staff
Accountable to:
The Fire Team Leader
Purpose:
To alert Fire Team and broadcast fire incident details, and provide ongoing communications
Actions:
1
Contact the Fire Brigade via the 999 system stating the location of the incident
2
Broadcast fire incident details to the Fire Team. Using the voice facility give the floor
number and display the floor number on the pagers (if a second operator is available, both
these tasks should be carried out simultaneously)
3
Provide ongoing communications
4
Call in staff as requested by the Fire Team Leader or Silver Commander
5
Record incident details in the Log Book
Major Incidents
1
Should a Major Incident be declared - make further telephone calls and call in staff as per
the Major Incident Policy
2
In the event of a Major Incident, the Fire Team Leader may require Switchboard to
establish a link with the Communications Officer who will establish a Communications
Centre
Note
Between 09.00-17.00 on normal working days the designated Communications Officer is the Head
of Operational Services. At all other times the Site Manager will undertake this role or nominate a
senior member of staff on site
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11.2 Fire Team Action Card 2 - Fire Team Leader
Who: Senior Porter Mon- Fri 8.30 am - 4.00 pm
Senior Nurse, Site Bed/Site management - all other times
Purpose:
1
Lead the Trust Fire Team
2
Liaise with the senior Fire Brigade Officer and co-ordinate the actions of the Trust
Fire Team
3
Debrief and the Team down
4
Record the incident details
Actions:
1
Proceed to the fire alarm panel identified by the Telephonist; don the high visibility jacket to
identify yourself. Commence a log of the incident
2
Organise two members of the Fire Team to carry out a search of the fire zone in alarm –
these staff should remain in radio contact with the Fire Team Leader at all times. If there
are insufficient staff available to carry out a search, (e.g. the Fire Team Leader and 2
others) then no search is to be undertaken - searches should only be undertaken if it is safe
to do so. Ensure that all staff deployed on any search and/or fire-fighting duties have
returned safely to Assembly Point and can be accounted for using the Fire Action Log
(10.7)
3
It is the responsibility of the Fire Team Leader to ensure that as far as is reasonably
practicable all areas have been adequately searched.
4
Brief senior Fire Brigade staff and the Silver Commander on information received from the
Fire Team at the fire zone
5
If a fire is confirmed appoint and brief a Fire Point Co-ordinator to carry out the duties
outlined on Action Card 6
6
Inform switchboard of the Fire Entry Assembly Point
7
If appropriate organise first aid fire fighting operations but place no one at personal risk
Incidents will fall into one of the following three categories:
1
Alarm without any fire e.g. detector activated by dust
2
Minor situation e.g. can be dealt with prior to the arrival of the Fire Brigade, or
3
Major situation (stage II), possible large-scale evacuation, all emergency services
involved – Silver Commander to assess action required under the Business Continuity Plan
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Personnel assessing an incident should consider, whether it will involve:

The initial treatment, rescue and transport of a large number of casualties?

Directly or indirectly, large numbers of people?

Large numbers of enquiries from public and media?

Large scale combined resources of the three emergency services?

Mobilisation and organisation of emergency services and support organisations?

Large scale hospital medical resources
If the answer to most or all of the above questions is ‘yes’ then call the switchboard and
declare ‘internal major incident’ standby and follow procedures outlined in the major incident
policy. If the answer is ‘no’ proceed with instructions set out below:
Fire Alarms with no fire:
If a smoke or fire detector has been activated e.g. by dust the Fire Team Leader must satisfy
themselves that no fire exists; the fire alarm sounders may be silenced if there is no fire, but
cannot be reset until the Senior Fire Brigade officer has established that the area is safe. The Fire
Team Leader must brief the Senior Fire Brigade officer of the findings of the Fire Teams
investigation/search
Fire Alarms with a confirmed fire:
Direct the Fire Team members and Senior Staff as appropriate. If safe to do so, direct the Fire
Team to fight the fire and assist in the evacuation of patients from immediate danger. The Fire
Team Leader must brief the Senior Fire Brigade officer of the findings of the Fire Teams
investigation/search. On the authority of the Senior Fire Brigade Officer silence the fire alarm
sounders; once stood down by the senior Fire Brigade officer carry out the following actions:
•
Instruct the shift engineer to reset the fire alarm panel
•
Inform staff that have evacuated that they may return to the area
•
Inform Switchboard of stand down
•
Replace all used and part used fire fighting equipment from stock held adjacent to the
Security/Porters offices on the lower ground floor
•
Immediately complete the online Fire/UwFS form
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11.3
Fire Team Action Card 3 - Porter
Who:
Porter
Reports to:
Fire Team Leader
Purpose:
Meet and accompany fire brigade to the fire alarm panel identified by the Telephonist. Take the
Fire Bag to the fire alarm panel identified by the Telephonist. Provide assistance under the
direction of the Fire Team Leader.
Actions:
1
On receipt of a fire call open the fireman’s entrance door
2
Proceed to the Central Fire Fighting Stair Case (fireman’s lift lobby) at ground floor level,
switch on the fireman’s lift at ground floor level and secure it at that level for Fire Brigade
use
3
Open the gate to South Car Park
4
Note time of arrival of the Fire Brigade and report this to the Fire Team Leader
5
Escort the Fire Brigade to the affected floor. Remain at that floor; return to the ground floor
to collect further fire fighters as directed by the Senior Fire Brigade Officer.
6
Provide assistance under the direction of the Fire Team Leader
When the stand down has been announced
1
The fireman’s lift should be switched off with the lift at ground floor level and door closed
2
Secure the gate to South Car Park the Fire Brigade entrance
3
Replace any used fire fighting equipment from stock to the fire bag
Note: The fire fighting equipment bag must be checked on a weekly basis by Senior Porter
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11.4
Fire Team Action Card 4 - Senior Security Officer
Who:
Senior Security Officer
Reports to:
Fire Team Leader
Purpose:
Provide access to areas if required and provide assistance under the direction of the Fire Team
Leader
Actions:
1
Proceed to the fire alarm panel identified by the Telephonist
2
Provide access to secured areas
3
Assist with evacuation and fire fighting under the direction of the Fire Team Leader
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11.5
Fire Team Action Card 5 - Shift Technician
Who:
Shift Technician
Reports to:
Fire Team Leader
Purpose:
Give technical advice and support to the Fire Team Leader and the Fire Brigade, and provide
assistance under the direction of the Fire Team Leader
Actions:
1
Proceed to the fire alarm panel identified by the Telephonist
2
Establish which fire zone/address has the incident. Under the direction of the Fire Team
Leader proceed to, and investigate the incident with a Security Officer
3
Assist with evacuation and fire fighting under the direction of the Fire Team Leader
4
Provide advice on the layout and contents of the boiler house, plant rooms and other
Estates areas
5
Provide advice and technical support on the systems listed below to the Fire Team
Leader/Fire Brigade:

Fire Alarm System

Water Supplies

Fixed Fire Suppression systems

Medical Gases (including liquid oxygen supply and vacuum systems) NOTE: All
operation of this equipment is to be carried out on the specific instructions of the Fire
Team Leader - details regarding any operation of this equipment, including
emergency procedure, must be relayed as soon as possible to the authorised
officer. (Senior Engineer who normally authorises the shut down of these systems)

Lifts and associated equipment, including the procedure for rescue from lift
cars/machinery

Control of gas, electricity, heating, ventilation and air conditioning
systems as requested by the Fire Team Leader or Senior Fire Brigade Officer

Steam Systems

Refrigeration Plant

Emergency Generators and associated lighting equipment

Fuel Oil (bulk storage)

Pneumatic Systems
6
Silence the fire alarm when instructed by the Fire Team Leader
7
Reset the fire alarm panel when instructed by the Fire Team Leader
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11.6
Fire Team Action Card 6 - Fire Point Co-ordinator
Who:
Appointee by Fire Team Leader
Reports to:
Fire Team Leader
Purpose:
To co-ordinate Trust response to the incident as instructed by the Fire Team Leader
Actions:
1
On being delegated by the Fire Team Leader don the co-ordinators arm-band
2
Stay at the Assembly Point and liaise with the Fire Team Leader and other team members
3
Ensure that all staff report to you before being sent to the scene of the fire
4
Record the time and names of staff sent to the scene of the incident in the fire action log
(s10.7)
5
Instruct staff to return to you after completion of work or on stand down
6
Make arrangements to obtain equipment or assistance as instructed by the Fire Team
Leader
7
When the Fire Team is ‘stood down’ collate all entry forms and pass to the Fire Team
Leader along with a written report of your observations of the incident
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11.7
Fire Action Log
Name of Fire Point Co-ordinator……………………………………………
Date, time and location of incident…………………………………………………
Name
Time Sent
Time of
Return
Location/Comments
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Appendix G
G
Fire Safety Training and Competency Procedures
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G
FIRE TRAINING
Introduction
G.1
The provision of adequate fire safety training is a legal duty placed on the
responsible person by the Regulatory Reform (Fire Safety) Order 2005. The
Royal Free NHS Foundation Trust is committed to excellence in patient care and
recognises that the training and development of its staff is a contributory factor
in achieving this; fire safety training is essential to ensuring that fire prevention
and emergency action plans can be put into practice. In many healthcare
environments, the safe evacuation of patients in the event of a fire will rely on
the effective action of staff in implementing the emergency plan. Training is
provided in accordance with the training needs matrix - additional training will
be provided if a need is identified.
Trust Specialist Fire Safety Advisor
G.2
The Trust Specialist Fire Safety Advisor is responsible for ensuring that an
appropriate programme of fire safety training is developed and ensuring that
suitable arrangements are in place for the delivery of that training.
Clinical Directors, Directorate Managers and Heads of Departments
G.3
The Clinical Directors, Directorate Managers and Heads of Departments are
responsible for ensuring that staff attend fire training as detailed in the training
needs analysis matrix.
G.4
The Organisational Development and Learning Department will manage and
keep a database of staff attendance.
Staff responsibilities
G.5
All staff, whether employed whole or part time or in a voluntary capacity will be
responsible for keeping their fire training up to date and alerting their line
manager when fire training is due to expire.
G.6
Staff that fail to attend fire training for any reason must report this to their line
manager.
Induction Training
G.7
Fire training is a part of the Trust Induction training programme. General
induction training for all staff groups is managed by the Trust Organisation
Development and Learning Department (ODLD). Linked nursing induction
programmes are managed by the Directorate of Nursing, and induction
programmes for all medical staff are managed by the Postgraduate Education
Department, which is a sub-section of the ODLD.
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G.8
The ODLD organises and delivers a staff induction programme on a twice
monthly basis. All new staff are expected to attend the first induction
programme available to them after joining the Trust. Induction training will
include instruction on:








Basic fire safety and the fire safety protocols;
How to raise the fire alarm;
Actions to be taken on discovering a fire;
Actions to take on hearing the fire alarm;
Procedures for evacuation (horizontal and vertical);
The importance of fire doors and their correct use;
Staff responsibilities during a fire incident;
Use of first aid fire fighting equipment
Local induction training
G.9
The corporate induction programme is supplemented by a local induction,
which will be specific to the individual roles and responsibilities of staff within
departments.
G.10
All staff, including bank, part-time and agency staff, should receive local fire
safety induction training on or before their first day of employment, or on their
relocating to a new work area. This may be delivered by the staff member’s line
manager or the person in charge of the area in which they are to work. Where a
member of staff is to work in a number of areas, it will be necessary to provide
local fire safety induction training for each workplace. The local fire safety
induction training must include:








Any specific instruction necessary to prevent fire in the area as a result of
hazardous processes, substances and/or equipment;
Details of the local fire emergency action plan including: the action to be
taken on discovery of a fire
The means of raising the fire alarm
The actions to take on hearing the fire alarm
Staff responsibilities during a fire incident
Procedures for evacuation
The location of fire exits and evacuation equipment
The location of fire extinguishers
Update Training
G.11
To ensure that staff are up to date with current legislation and Trust
requirements, staff must receive fire training on an annual basis; topics covered
are the same as those covered in Induction Training. This training is provided
for two broad categories of staff:
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G.12
Staff with patient contact (all types of contact both clinical and non clinical):
staff must attend face to face training annually
G.13
Staff without patient contact (all grades of manager, admin and support staff
without direct patient contact): staff must attend face to face training annually
Ward evacuation training
G.14
Covers the topics provided in Induction Training but also includes a walk
through fire drill and practical use of evacuation training. The practical use of
evacuation equipment is also part of clinical manual handling training sessions
Fire Wardens
G.15
Current fire safety legislation requires a “fire safe” environment for patients,
visitors and staff 24 hours a day – the provision of Fire Wardens can provide an
assurance that local day to day fire safety issues are being effectively managed.
G.16
Fire wardens have two recognised fire safety roles: a day-to-day role and a
role when the fire alarm sounds; to achieve this training will be provided on the
following topics:












The action to be taken on discovering or suspecting a Fire
The action to be taken on hearing an alarm of Fire
Fighting fires
Assembly points
Evacuation routes
How to manage an evacuation of a non-clinical area
How to manage an evacuation of a clinical area
Practical use of evacuation equipment (where relevant)
Hospital Fire and Emergency Procedures
Hospital Fire Alarm System
European Extinguisher Colour Coding
Practical use of Fire Extinguishers
Fire Team
G.17
Training will be provided to ensure that the fire team can take initial control of
a fire emergency; this training will include:




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How to manage an evacuation of a non-clinical area
How to manage an evacuation of a clinical area
Practical use of evacuation equipment
Hospital Fire and Emergency Procedures
Fire Team Roles and Procedures
Practical use of Evacuation and Fire Fighting Equipment
HAMSON Partnership Limited, Hayworthe House, Market Place, Haywards Heath, West Sussex RH16 1DB - 01444 453364
Royal Free FSMS : 22 October 2013 : 01.04
20
Fire Safety Policy & Fire Safety Management System
Version 01.04 22 October 2013
Training needs matrix
Staff with patient
contact (all types of
contact both clinical
and non clinical)
Staff without patient
contact (all grades of
manager, admin and
support staff without
direct patient contact)
Trust induction (30
minutes)
Before or immediately
upon joining the Trust
Before or immediately
upon joining the Trust
Local induction
Immediately upon
joining the Trust
Immediately upon
joining the Trust
General fire training (30
minutes)
Yearly
General e-learning fire
training (30 minutes)
Not available
Staff are to attend
general fire training
within 12 months of
joining the Trust; after
this session general elearning fire training
can be alternated with
general fire training
Evacuating very high
dependency patients
Yearly
Not required
Yearly
Not required
3 Yearly
3 Yearly
Yearly
Yearly
(1 x hour) – provided for
staff working with high
dependency patients
only e.g.
ICU/SCBU/THEATRES
Ward evacuation
training
(1 hour)
Fire Warden training
(2 hours)
Fire Team training (2
hours)
HAMSON Partnership Limited, Hayworthe House, Market Place, Haywards Heath, West Sussex RH16 1DB - 01444 453364
Royal Free FSMS : 22 October 2013 : 01.04
21