The Newcastle upon Tyne Hospitals NHS Foundation Trust
Fire Policy and Fire Evacuation Policy
Version No.:
Effective From:
Expiry Date:
Date Ratified:
Ratified By:
1
5.0
31 March 2015
31 March 2017
19 February 2015
Health and Safety Committee
Introduction
A fire in a hospital poses a major threat to the lives of everybody within it. Therefore
there must be the rapid means for detection, containment and control of fire, supported
by reliable and rehearsed procedures for removing patients and staff to a place of
safety. In a healthcare environment with very high dependency patients, it is unlikely
that any amount of physical fire precautions on their own can reduce fire risks to an
acceptable level. Adequate risk mitigation can only be achieved with the provision of a
sufficient number of suitably trained staff, an environment in which the fire precautions
are well maintained, and effective emergency action plans that have been sufficiently
rehearsed.
2
Policy Scope
This Policy covers all premises owned, occupied or managed by the Trust. It also
applies to the activities of the PFI service providers, other employers, contractors, and
volunteers, sharing or working on any of the organisation's sites.
3
Aim of the Policy
The Fire Safety Policy of the Trust aims to minimise the incidence of fire within Trust
Premises and also minimise the impact of a fire on life, safety, delivery of clinical
services, the environment and property.
4
Duties – Roles and Responsibilities
For the Fire Safety Management Structure see Appendix 1
4.1
Trust Board
 The Trust Board has overall accountability for the activities of the
organisation, which includes fire safety.
 The Trust Board delegates the responsibility for fire safety through the Chief
Executive.
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4.2
Chief Executive
 The Chief Executive will, on behalf of the Board, be responsible for ensuring
that The Regulatory Reform ( Fire Safety) Order 2005 is complied with and,
where appropriate, DoH’s guidance Firecode is implemented in all premises
owned, occupied or under control of the trust.
 The Chief Executive will ensure that all agreements for the provision of care
and other services by third parties include sufficient contractual agreements to
ensure compliance with the trust’s fire safety policy.
 The Chief Executive delegates the day-to-day operational responsibility for
fire safety to the Director of Estates and Facilities.
4.3
Board Level Director (with fire safety responsibility)
 The Director with fire safety responsibility (Appendix 1 Management
Structure) is responsible for ensuring that fire safety issues are highlighted at
Board level, this responsibility has been derogated to the Director of Estates
and Facilities/ Fire Safety Manager.
 This responsibility will extend to the proposal of programmes of work relating
to fire safety for consideration as part of the business planning process.
 Preparation and presentation of a quarterly report to the Health and Safety
Committee who will act as the Operational oversight Group, who will escalate
issues to the Trust Board via the Corporate Governance Committee.
 Assisting the Chief executive with Board level responsibilities for fire safety
matters
 Ensuring that the trust has in place a clearly defined fire safety policy and
relevant supporting protocols and procedures;
 Ensuring that all passive and active fire safety measures and equipment are
maintained and tested in accordance with the latest relevant
legislation/standards, and that comprehensive records are kept;
 Ensuring co-operation between other employers where two or more share
trust premises;
 Ensuring through senior management and line management structures that
full staff participation in fire training and fire evacuation drills and compliance
with the fire policy;
4.4
Assistant Fire Safety Manager
The Trust's designated Assistant Fire Safety Manager is the Deputy Director of
Estates, whose principal duties are:
 To appoint Personnel on all Trust sites to ensure that a designated person is
always available to take command of a fire emergency until the Fire Brigade
arrives.
 Delegates responsibility to the Lead Fire Advisor to disseminate the
processes within the Fire Policy
 To liaise with all organisations working on Trust premises to ensure that they
are aware of the Trust Policy and Procedures.
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4.5
To liaise with the Lead Fire Advisor for advice on developing a plan of action
for dealing with a fire emergency.
To ensure that agreed programmes of investment in fire precautions are
correctly accounted for in the Trust's annual Business Plan and prepare an
Annual Fire Report for submission to the Trust Board.
To co-ordinate all fire precautions within the Trust and have a working
knowledge of fire precautions and the fire alarm systems.
To consult with the Fire Advisors and Estates Management to ensure that fire
alarm systems are maintained and tested in accordance with NHS Guidance
(HTM 05-03 Part B) and British Standard 5839.
To investigate and remedy abuse of fire equipment.
Lead Fire Advisor
The Trust has statutory and other responsibilities in respect of fire safety for all its
premises. As a means of fulfilling its obligation, the Lead Fire Advisor manages a
team of specialist Fire Advisors. The team are responsible for advising
management on technical fire matters, monitoring the state of fire precautions in
the Trust's premises and for arranging sufficient training sessions for all staff.
The duties of the Lead Fire Advisor and his team are:
 To give advice on all fire precautions matters and to co-ordinate and monitor
fire precaution arrangements.
 To liaise and consult with the Home Office Inspectorate, Statutory Fire
Authorities, appropriate Building Control Officers, Health and Safety
Executive, Petroleum Officer and other bodies having advisory or mandatory
responsibilities over the whole range of fire precaution activities.
 To ensure the Trust's registration of premises is maintained under the
Regulatory Reform (Fire Safety) Order 2005 under the relevant part of the
Order and ensure that a regular inspection of Trust premises takes place in
compliance with Fire Certification, Health Technical Memorandum and
Workplace Regulations.
 To ensure that adequate means of escape from fire is available and that
suitable and sufficient fire fighting equipment is provided and maintained in
accordance with statutory requirements.
 To advise on the development, maintenance and review of fire safety policies,
procedures and systems.
 To monitor the testing of fire alarms and associated equipment in accordance
with current British Standards and advise Estates Management of any
defects.
 To prepare fire action notices, and ensure that they are displayed throughout
Trust premises.
 To prepare reports to the Trust Board for all serious incidents.
 To, where possible, attend all fire incidents, investigate false alarms and
maintain a permanent record of all fire incidents submitting monthly and
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4.6
annual returns to the Fire Safety Manager who will then forward the required
information to the Department of Health.
To liaise with the Estates Department to brief Contractors carrying out major
works and those providing a regular contract service, who may create fire
hazards, or where combustible materials may be involved (painting,
woodwork). Estates Management must ensure their staff and contractors are
trained to a high standard on fire prevention and use adequate safe systems
at work.
Role of Estates Management
In addition to responsibilities shared with other Managers, Trust's Estate
Managers are responsible for the following:
 Consulting with the Management Team, Building Control, Fire Advisors and
the Fire Service on any proposals to construct new premises, upgrade
existing buildings and/or equipment in order to maintain fire safety standards
in accordance with legislation and standards as contained in FIRE CODE Directory of Documents.
 The maintenance and testing of all fixed and portable fire alarm systems and
fixed fire fighting equipment in accordance with current British Standards.
The Estates Department will also be responsible for keeping up-to-date all
relevant maintenance and testing documentation.
 Ensuring that all Community/Leased properties have complied with this
Policy.
4.7
Heads of Department/Sister in Charge
 The monitoring of the fire safety within their respective departments.
 Ensuring all staff are aware of how to raise the alarm and contact switchboard
on ‘333’ if an incident is suspected.
 How to evacuate their part of the premises
 The location of fire-fighting equipment.
 Nominate sufficient members of staff to become fire wardens and be trained
in the use of fire-fighting equipment.
 Be prepared to make the decision if required to isolate medical oxygen
supplies, and the location of any isolating controls.
 Ensuring that new staff (on their first day of service) are given basic
familiarisation training that should include fire procedure, means of escape,
location of fire fighting equipment and designated assembly points.
 Ensuring that fire safety instructions are brought to the attention of their own
staff and that every member of staff participates in mandatory fire precautions
training and ensure training records are kept.
 Ensuring all textiles and furniture for use in patient areas conform to the
current Fire Code, Health Technical Memorandum and current British
Standard Specifications. Advice must be sought from Head of Housekeeping.
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4.8
Fire Response Team
The Fire response team will operate at RVI and Freeman sites
The key members who will attend every incident consist of:
 Duty Manager (PSC)
 Senior Craftsman of the Trust or Interserve
 Security Staff
Other members of the team who will attend if available are:
 Fire Advisor
 Estates Electrical/Engineering Manager
 For PFI buildings only - Interserve Manager
4.8.1 The roles and responsibilities of the team include:
 To attend fire incidents
 To contact Switchboard to 'stand down' if not required as per policy
 To take charge of the fire incident and delegate tasks as appropriate
 Implement the Major Incident Procedure if appropriate
 Remain available until the fire incident is resolved
 Communicate 'stand down' message at the end of a fire incident
4.9
Fire Wardens
The role and responsibility of the Fire Wardens include:
 Complete the organisation's Fire Warden Training
 Attend incidents within their area
 Control access until incident has resolved or situation has been taken over by
a more senior member of fire team
 Support evacuation process
 Act as contact point for local fire safety issues
4.10 All Employees and Volunteers
All employees and Volunteers have the following responsibilities:
 Complete mandatory fire training
 Ensure that fire hazards are removed or brought to the attention of local
managers
 Follow the Fire Procedure and assist in the reaction of fires and the prompt
continuation of patient care as required
 Familiarise themselves with fire risk assessments and ensure that controls
are followed and maintained
 Comply with this policy
 Complete incident forms via Datix as per this policy
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4.11 Service Providers and Site Sharers
All service providers and tenants must:
 Ensure that there is an equivalent and complimentary policy for the prevention
and management of fire incidents
 Inform the organisation of activities presenting a particular hazard before any
work commences and report any fire incidents arising from their activities.
This must be communicated to the Trusts Lead Fire Advisor
 Liaise with the organisation through the Health and Safety Committee
4.12 Telephone Switchboard Staff
 Are responsible for informing the Fire Response Team and where required
(as per the policy) the Fire Service on receipt of an alarm
 Record all fire alarm activations
4.13 Individual Members Responsibilities
4.13.1 Security Staff
 Meet and direct Fire Services
 Prevent entry to area of fire incident to unauthorised personnel
 Assist evacuation procedure
 Provide security and maintain access for Emergency Services and
other required personnel
4.13.2 Senior Porters
 To act upon instructions from the Fire Advisor and/or Duty Manager
(PSC)
4.13.3 Estates Electrical/Engineering Manager/ Senior Craftsman/ Interserve
Manager
 Reset Fire Alarm system if instructed by Fire Advisor/Duty
Manager(PSC) or Fire Service
 Act on the directions of the Fire Advisor/Duty Manager or Fire Services
5
Definitions
Arson
The deliberate starting of fires
CAD
Computer Aided Design
Datix
Electronic Incident Reporting System
IOT
Institute of Transplantation
PFI
Private Finance Initiative
PPM
Planned Preventative Maintenance
PSC
Patient Services Co-ordinator
Fire Response Team
 Estates Department (Engineers)
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Interserve in PFI buildings
Security/Portering Services
Patient Services Co-ordinator (PSC)
Fire Wardens from other areas may be requested to attend
6
Policy
6.1
Statutory Requirements and Guidance
The principal statutory requirements that have a direct bearing on fire safety and
must be observed by NHS Hospital Trusts at all times are:
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NHS Fire Code.
Building Regulations 2006 Approved Document B - Fire Safety.
Regulatory Reform (Fire Safety) Order 2005.
Health and Safety at Work Act,
The Management of Health and Safety at Work Regulations.
NHS Housing in the Community: Housing Act 1985.
Registration of Houses with Multiple Occupancy
Places of Work Regulation 1992 (as amended).
Occupiers Liability Act
These regulations are updated frequently and the Trust receives notification of
updates from the Department of Health.
The Lead Fire Advisor assesses these updates and produces a gap analysis with
an action plan to the Health and Safety Committee for discussion.
The Health and Safety committee will discuss the recommendations and
advise/approve the action plan. The Lead Fire Advisor will give regular reports
regarding the progress of the implementation of the actions detailed within the
plan.
The Health and Safety Committee will also decide as part of the Trusts Risk
Management Strategy and where appropriate, that any identified risks will be
included within the Trusts Risk Register.
6.2
Fire Drawings
Fire drawings of all premises on site showing fire compartment walls, water
supplies, fire alarm systems, fire extinguishing equipment, lighting systems and
fire signs and notices will be reviewed in accordance with the Risk assessment
process The electronic and hard copies are available from the CAD team at the
RVI, These must be available for use by the Fire Service. These are available to
the on-call Engineer or Builder via the shared drive in Estates.
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As part of the monitoring process of the Fire Drawings, these will be checked for
each area during the area's Risk Assessment.
6.3
Contractors
All contractors will be made aware of fire safety instructions and this Policy as
part of the induction prior to commencing work and documented on the
contractors induction form (Appendix 4), these are kept by the particular hospital
Workshop Manager.
6.3.1 Permits to Work and Hot Works
Under no circumstances should fire alarms be interfered with without
a permit to work, obtained from Estates or Interserve FM
Where any work is to be carried out by a contractor or works personnel,
where there is a planned disconnection of part of the fire alarm system, a
permit must be sought from either the Interserve FM service provider or
Trust Estates Department which must be issued prior to the time and date
required to carry out work. Whether this is a permit to work or a hot permit
is decided upon by the estates department when they review whether heat
or flame producing equipment is being used. In both cases the form is the
same, but the non-applicable sections are deleted (see Appendix 5 for the
form).
A member of the Fire Safety team in advance of the proposed work must
be contacted requesting authorisation to disconnect a section of the fire
alarm system and also giving information about the possible implications
of such a disconnection.
The capping of detectors will only be permitted if strictly managed by Trust
Estates/Interserve managers and following specific permission of a Fire
Advisor, if alternative provisions such as changing smoke detectors to heat
detectors, is not possible due to time or cost restrictions.
In all cases a Fire Safety Advisor and the Department/Ward Nurse in
Charge of the affected area must be informed of the work and the
implications of that work, prior to commencement. This must all be
documented on the Permit to Work.
Alternative methods of alerting persons in case of fire must be provided
(obligatory) during periods when the alarm is inoperable, although in most
cases the 'break glass' (core point) of the fire alarm will remain active. Air
horns will be provided to the areas where the alarms have been disabled.
These must be described on the permit. Copies of the permit to work/hot
work must be kept by the appropriate hospital Workshop Manager and the
Contractor (so it is available on request) and a copy sent to the Fire
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Advisor. A record of where the fire alarms are being isolated on any given
day must be kept by the Estates workshop manager of the relevant
hospital.
All staff in the area affected will be informed of the alternative method prior
to the alarm being incapacitated as documented on the permit.
Before commencing any hot work the area is to be cleared of as much
combustible material as possible with suitable and sufficient means of
attacking any outbreak of fire that may occur.
In the case of tar or bitumen boilers a bund must be provided to contain
any leakage or spillage equal to the total contents plus 10%.
In any case the hot work must cease at least 1 hour prior to the end of the
working shift and examination of the area for any signs of fire or hot spots
to be carried out before leaving the site.
All LPG cylinders must be returned to a safe and secure storage area
and not left in situ.
Acetylene gas should not be used where there are suitable alternatives.
Fires involving acetylene cylinders directly or indirectly will have very
serious implications to the safe running of the hospital.
6.4
Fire Prevention
The Trust operates a No Smoking Policy throughout all Trust sites.
6.4.1 Environment
Environmental factors must be taken in to account when looking at fire
prevention. The following must be ensured to maintain good fire
prevention practices:
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Fire doors must not be wedged open
No furniture must block fire escapes or fire doors
Rubbish must be placed in the designated area
Faulty electrical equipment must be reported immediately
Faulty gas appliances must be reported immediately
All textiles and furniture for use in patient areas should conform to current
Fire Code, Health Technical Memorandum 05-03 Part C and current
relevant British Standard Specifications.
All new patient areas created within existing hospitals and those with new
extensions and major alterations/upgrading must be equipped at their
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commissioning stage with textiles and furnishings in accordance with the
previously mentioned standards, advice should be sought from either the
Supplies Department or the Fire Advisors to ensure that they conform to
current standards.
Maintenance of Trust premises should include fire resistance ratings of
structures, rate of surface spread of flame, especially on routes of escape,
and compartmentation to allow safe progressive horizontal evacuation of
patient areas. This information is held within the Fire Drawings.
6.4.2 Fire Risk Assessments
In accordance with Health Technical memorandum 05-03 part K the Lead
Fire Advisor and his team will maintain the database which contains Fire
Risk Assessments for all areas throughout the Trust. Where Trust Staff are
based in non-Trust premises it is the responsibility of the landlord of that
property to ensure that a Fire Risk assessment have been carried out and
is reviewed using the risk based approach below.
It is the Lead Fire Advisors responsibility to ensure that every area within
the Trusts premises has an up to date Fire risk assessment and that they
will include the identifying of the general fire precautions that the Trust has
to implement to comply with the requirements of the Regulatory Reform
(Fire Safety) Order 2005.
Every Fire Risk assessment, as per the sample in Appendix 2, has a
summary and a Risk level attributed to it, this risk level will determine their
review periods.
The review periods of the individual risk assessments will be carried out in
accordance with the following criteria. If an area has been assessed as
low risk it will be reviewed 3 yearly, an area assessed as medium will be 2
yearly and any area that has been assessed as high risk will be reviewed
on an annual basis, unless,
a) There is reason to suspect it is no longer valid; or
b) There has been a significant change in the matters to which it
relates including premises, special, technical and organisational
measures, or organisation of the work undergo significant changes,
extensions, or conversions.
The Lead Fire Advisor and his team are the only authorised personnel to
carry out reviews of the Fire Risk assessments.
Personal Risk Assessments for individuals with specific needs, (see
Appendix 3) upon a request, are carried out by the Lead Fire Advisor or
his team and these are retained by the Fire Team and a copy kept in the
staff member's personnel file.
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6.5
Fire Alarms and Fire Fighting Equipment
6.5.1 Fire Alarm and Equipment Testing
The maintenance and testing of all fixed and portable fire alarm systems
and fixed fire fighting equipment is in accordance with current British
Standards. The Estates Department is responsible for keeping up-to-date
all relevant maintenance and testing documentation. The testing consists
of an annual rolling programme and all Fire alarms and equipment will be
tested annually
Non-scheduled testing of alarms must not be carried out without first
informing the Fire team. In addition, the Fire team should be informed of
any faults in the alarm equipment or of any repairs being undertaken.
Maintenance and testing of the system will be in accordance with the
current BS 5839-1:2002 and HTM (Firecode) 05-03 Part B.
Testing of the Fire Alarm system is carried out as below:
 RVI
o Leazes Wing Wednesday 0900-1000.
o Rest of site Monday 0900-1000
o New Victoria Wing Monday 1030
o Dental Hospital Tuesday 0800-0900
 FRH Tuesday 0830-1030
 NCCC Tuesday 1030
 CAV, blocks A,B and C Tuesday 1100-1200
Fire Equipment to be tested is:
 Fire Blankets – A visual check by the Fire Wardens in their area
once a month and annually by the Fire Extinguisher Engineers and
recorded in their assessment record and then sent to the Fire team
annually (in December). It is the Ward Manager or the Area
Manager's responsibility to ensure this is completed
 Fire Extinguishers – A visual check by the Fire Wardens in their
area once a month and annually by the Fire Extinguisher Engineer
and recorded in their assessment record and then sent to the Fire
advisor yearly (in December)
Departmental Fire Equipment is checked on a monthly basis as above and
the form (Appendix 6) is completed. These are returned to the Fire
Advisor (Estates, RVI) annually in December. It is the Ward Manager or
the Area Manager's responsibility to ensure this is completed. New check
lists are available on the Fire Advisors web site on the Trust intranet
 Fire Hydrants and Mains - by Estates Dept. tested annually
 Fixed CO2/ Drenching Installation Dry and Wet Rising Mains - by
Estates Dept., and/or Outside Contractor 6 monthly
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Sprinkler System within the IOT basement - private contractor
arranged six monthly by estates. A PPM checklist is completed
each time and a copy is stored in the Estates Department
6.5.2 Fire Alarm Failure
Staff should contact Estates Helpdesk (Ext 21000) if they suspect the
system is not working correctly.
In the event that the fire alarm system develops a fault which renders it
inoperable for any length of time, alternative methods of raising the alarm
within wards and departments must be implemented.
The Fire Advisor or Duty Manager must be contacted as soon as the fault
is recognised and a system of alternative instructions must be
implemented by:
 Additional patrols will be done by one of the following, Fire Safety
Advisors, security Staff, Duty Manager or Fire Wardens;
 Extra vigilance by all staff;
 The issuing of air horns to staff at strategic locations;
 All staff to be briefed on alternative methods of alarm raising
A record of all failures is kept in the estates department by the Head of
Electrical Engineering.
A Datix incident report must be completed which must include the
measures taken. This should be completed by either a member of the Fire
team or the Head of Electrical Engineering (if a Fire Advisor is present and
informed then it is completed by them, if not it is the Head of Electrical
Engineering's responsibility).
6.5.3 Fire Drills
The Fire drill procedure will comply with the recommendations set out in
Health Technical memorandum 05-03
Practice fire drills will be done as a simulated exercise in conjunction with
the ward/department’s risk assessment. The frequency of the drills will be
annually and simulate actual site conditions. In the event of an inability to
carry out an evacuation due to the clinical needs of the patients the Fire
Advisors will ensure that all staff are walked through the procedure
Once the decision has been made as to the level of the Fire drill to be
carried a member of the Fire team will arrive unannounced and start the
drill. This is recorded on the Fire Drill form (Appendix 7). From this,
recommendations will be made and will be taken to the next meeting of the
Directorate Governance group where an action plan will be agreed. The
action plan will be reviewed at each governance group until completion of
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the action plan. The completed action plan will then be sent to the Fire
team to store with the Fire Drill form. A record of all fire drills undertaken
is held within the Fire team.
6.5.4 Fire Alarm System
The Trust’s fire alarm system comprises of automatic heat and smoke
detectors, manual glass call points, with audible siren or bell type
sounders. Visual indicators incorporated with a sounder are located in
areas to assist visual and audible impairment of individuals.
Fire detectors are actuated by either a rise in temperature as with heat
detectors and by the detection of particles as in smoke detection.
An alarm of fire can be raised by actuation of a break glass release call
point or detection by automatic detectors as indicated above.
The system is a two stage fire alarm in that it operates in the following
way:
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Continuous sounding of the fire alarm
This indicates a fire event in the immediate zone or
compartment
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Intermittent sounding of the fire alarm
This indicates that the system has detected a fire event in the
adjacent zone or compartment
Zone and Compartment fire alarm sounds vary (as detailed above) but
usually indicate relationship to a particular ward or department. Zones
remote to the fire may remain silent.
Information with regard to the fire zone is shown on the fire panels which
are situated throughout the Hospitals.
6.6
On the Sounding of the Fire Alarm
On receipt of the location of the incident via DECT system, the Fire Response
Team must proceed to the incident and assume charge. The Fire Advisor or
Deputy must confirm fire or false alarms to the Switchboard - (Telephone
333), who will then inform the fire assembly point controllers via the DECT
phone.
The instruction to silence and reset followed by the instruction ‘Stand Down’ if it is
false alarm must be relayed through the Switchboard.
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If it is an incident await the arrival of the Fire Service to carry out further
investigations
On arrival of the Local Authority Fire & Rescue Service, the Fire Response Team
will relay any information to the Officer In-Charge i.e. action already taken and if
there is anyone at risk. They must be prepared to offer their expertise especially
in regard to patients and co-ordinating Hospital staff.
The Fire Response Team will liaise with the Duty Engineer and other Fire
Response Team members. Out of normal working hours the Duty Engineer can
be contacted via the Switchboard. (Telephone 333)
If it is necessary to evacuate, the Lead Fire Advisor or one of his team should
organise the evacuation. This will include making arrangements to receive
patients in a safe section of the Hospital and the organisation of assistance as
required.
Additional staff may be required from other areas; these staff will be accessed via
Switchboard, who can be contacted on 333, who in turn will contact other
departments and request staff to attend to support any evacuation.
On completion of the incident, the Lead Fire Advisor or one of his team should
contact the Switchboard who will communicate with the assembly points and
instruct staff to stand-down, information to be passed to all Fire Wardens on
control points.
The fire alarm can only be silenced on the instructions of the PSC, Lead
Fire Advisor, Fire Advisor or the Fire Service if they are in attendance.
All areas within the organisation should have local evacuation procedures.
These should be made in conjunction with the Fire Advisor and the local
Fire Warden. An area specific risk assessment must be undertaken prior to
the procedures being made, so that they can inform the most appropriate
evacuation route and procedure.
The local evacuation procedures should be based on the following
sections.
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6.6.1 Local Actions on discovering a fire
If a fire is suspected and following a quick
search, you still suspect there to be a possible
fire, operate the fire alarm via a break glass call
point
If trained to do so tackle fire if safe to do so
using equipment provided and ensuring that
the exit is clear and reachable
DO NOT
Use lifts in the zone or department where the alarm is
sounding.
Enter the building, zone or department when the
alarm is sounding
DO
Go to the assembly point if this is within
your evacuation procedure i.e. non-clinical
areas and stay there until told to return to
the building.
Allow others to enter even if they insist
Remember the basic procedure:
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Raise the alarm
Always your first action
 Move person(s) from immediate danger where appropriate
Usually through two sets of fire doors (Progressive Horizontal Procedure)
 Evacuate the ward or department
Instigate, decide, evaluate
 Close all doors and windows behind you
But don’t delay or put lives at risk
 If safe to do so, tackle the fire
If you are trained and have the correct extinguisher for the incident
 Get out and stay out
Assist in evacuation of patients and visitors, remember your part in the
evacuation plan – if in doubt ask!
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6.6.2 Local Action for a continuous alarm
Staff who are not
undertaking patient care
gather at Nurses station
or Department Heads
office/desk
Department Head/ Nurse
in Charge designates a
member of staff to go to
investigate where fire is
(preferably a fire warden)
Tackle fire if safe to do and
you have been trained,
using equipment provided
and ensuring that the exit
is clear and reachable
Department Head/
Nurse in Charge
designates a member of
staff to close windows
and doors without
putting themselves at
risk
Department Head/ Nurse in
Charge designates a member
of staff to reassure patients
and visitors
If the alarm sounds between the hours of 0800-1700 at
either RVI, FRH or Dental Hospital, then the
switchboard will only inform the Fire Response Team
who will have five minutes to get to the incident
location and confirm if the Fire Service are required or
not, however if the switchboard are alerted to a second
activation within that area or receive a call stating that
it is a confirmed incident, then the switchboard
operator will contact the Fire Service via the ‘999’
system
Fire Response Team arrive and the lead
person will coordinate any evacuation and
fire control until Fire Service arrive
Fire Service arrive and take over control
of the incident including evacuation and
fire fighting and liaise between
Emergency services and hospital
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6.6.3 Local Action for Intermittent Alarm
This indicates that you are not in the fire area, but are receiving a prewarning of the need to start an evacuation or other actions required should
the need arise. The actions required within the intermittent zone are as
follows:
Staff who are not undertaking
patient care gather at Nurses station
or Department Heads office/desk
No new procedures which could
incapacitate patients should be
commenced until incident is
resolved
Department Head/ Nurse in Charge
designates a member of staff to go
to the nearest fire alarm repeater
panel to determine location of fire
incident - feed back to Department
Head/ Nurse in Charge
Staff should be prepared to assist
with evacuation from fire area and
prepare to receive patients from fire
area, switchboard may ring and
request assistance with evacuation
in other areas.
Page 17 of 70
6.6.4 Phased Horizontal Evacuation
The Hospital Evacuation Plan involves Progressive Horizontal Evacuation
for in-patient areas via a compartment barrier into a separate fire
compartment on the same level. Movement will be horizontally via two fire
doors should the need arise. Vertical movement should only be
considered as a last resort.
Specific considerations based on patient dependency
The Firecode has three classifications for patient dependency:
Independent – patients are considered to be independent if:
 Their mobility is not impaired in any way and they are able to
physically leave the premises without staff assistance; or
 They experience some mobility impairment and rely on another person
to offer minimal assistance. This would include being sufficiently able
to negotiate stairs unaided or with minimal assistance, as well as
being able to comprehend the emergency way finding signage around
the facility.
Dependent – all patients except those classified as “independent” or “very
high dependency”.
Very high dependency – Are those whose clinical treatment and/or
condition creates a high dependency on staff. This will include those in
critical care areas, operating theatres, coronary care etc. and those for
whom evacuation would prove potentially life-threatening.
A Place of Relative Safety Could Be:
 Through one or more sets of fire doors on the same floor.
 To another Ward/Department on the same level.
 To a lower floor.
 Ultimate safety to outside.
Manual techniques for emergency evacuation are methods of a last resort
as they are extremely stressful and exhausting.
There are four basic methods of emergency evacuation. These are in
order of priority:
1. Walking.
2. Wheeled transport.
3. Sliding along the floor.
4. Lifting.
NB: Sliding is less stressful than lifting a patient.
Evacuating Patients
 Walk patient whenever possible.
 Slide rather than lift.
Page 18 of 70


Do not attempt to singly lift anyone except very ‘light’ patients or
children and then only when no other option is available.
Keep patient at floor level whenever possible.
When Evacuating Patients the Least Strenuous Method Should Be
Used:
It may be necessary to evacuate some patients bodily, or in bed covers, or
as a last resort being dragged in sheets or on a mattress.
Ensure that escape routes and exits are never obstructed by beds and
wheelchairs, and external exit routes are not obstructed by vehicles or
deliveries.
Patients, who can walk well with, or without an aid, should be supervised
by a member of staff and not allowed to wander.
Where there is sufficient space, wheeled evacuation is less tiring and
much quicker. e.g. use of beds (one or more patients in a bed),
wheelchairs and wheeled commodes or trolleys.
Arrangements should be made immediately for a safe, warm section of the
Hospital not involved in the fire incident to be made available to receive
evacuees.
The Senior Nurse should take the records of patients and staff with them
and undertaken a ‘roll call’. Report this action to the PSC/Deputy and
Officer In-Charge of the Fire Service ie, the result of the ‘roll call’, areas
not checked.
On evacuation, consideration should be given to upgrading the situation to
a disaster and mobilising more staff to assist, as appropriate.
The Ambulance Service should be informed if it is considered that
ambulance assistance will be required to assist in the movement of
patients.
Please note: the point beyond two fire doors would be considered
the safe assembly point.
6.6.5 Simultaneous (Total) Evacuation Strategy
Where the procedure is for total evacuation, on activation of the fire alarm,
all persons are to report to the fire assembly point indicated on the fire
action notices.
Fire evacuation assembly points where total evacuation is considered
appropriate are areas in a place of ultimate safety, where persons can
assemble until permitted to re-enter the building.
Page 19 of 70
Assembly points are indicated by signs with a green background and white
lettering, usually in the open air away from the building
On arrival at the fire assembly point the P.S.C./Deputy will check to ensure
all persons are accounted for. Any person reported as missing will be
reported to the Senior Fire Service Officer upon their arrival.
Action in Unoccupied Area
The Fire Response Team will investigate these areas using the utmost
care and without putting themselves or others at any risk, If anyone is
unsure or not confident to look in these areas then the Fire Service should
be called
To gain entry into secure areas, the senior person present will arrange for
the entry keys from the Nominated Key Holder, Department Head or
Portering & Security Officer as appropriate.
Senior Person at Incident Initially will:
 Determine location and extent of the fire.
 Take charge of the situation until the arrival of the PSC
 Implement the Fire Procedure and Evacuation Procedure as required.
 Ensure reassurance is given to patients in ward or patient area.
 Prevent fire spread by closing all doors and windows, without putting
persons at risk.
 Organise fire fighting attempt, but only if safe to do so and someone
has been trained.
 Hand over control to the PSC and give further assistance as required.
6.7
Incident on Raised Helipad
There is a raised helipad located on level 7 New Victoria Wing, this is staffed with
three trained fire fighters from 0800-2000 hours 365 days per year, if an incident
occurs then the following procedure should be adopted.
In the event of an Emergency
The Helipad Fire Fighting Team will:
 Immediately call the switchboard using the helipad emergency Dect phone
 Carry out Fire Fighting duties strictly in accordance with the Fire Fighting
Procedures.
The Switchboard will carry out the duties as depicted on the Helipad Action Card
(located in the helipad operational procedure) held by the Fire Advisor/Helipad
Manager
 Immediately put a call out to the Fire Service
 Inform the in house Fire Response Team via Dect Phone
 Notify A&E Department of the incident
 Follow the standard Fire/Business Continuity Plan procedures.
A&E Department will:
Page 20 of 70

6.8
Take appropriate action based on the nature of the incident
Community Buildings
There is no Fire Response Team or investigation period in community buildings
nor is there a requirement for one. Evacuation principals in Community buildings
require, total evacuation from the building to the designated assembly point, and
investigation should not be made into the reason for activation prior to
evacuation. If NUTH staff are working in a building that is not owned by the
Trust, then they should follow the evacuation principles of that building, if unsure
either contact a line-manager or follow the instruction on a fire evacuation notice
that should be displayed throughout the building.
6.9
Residences
All residents who occupy accommodation within the Trust must be informed of
the fire precaution measures relating to their own particular block or home and
any abuse of the regulations may subject them to disciplinary action and
termination of accommodation tenancy. These premises include Cheviot Court
and Beechwood House at the Freeman Hospital, Doctors Residences and
Crawford House at the RVI and the Doctors Residences and Family
accommodation on Grainger Park Road Newcastle. A pack should be issued to
residents from Housekeeping when they take up their residence, which has a
section on Fire Safety and also there are fire action notices throughout the
premises detailing actions to take in the event of a fire, or any alarm activation.
Housekeeping will keep a record of the packs given out and who is in the
resident at any one time.
6.10 Procedure for Reporting Incidents of Fire
Notification of fire incidents as laid down in Firecode HTM 05-01 which is the
responsibility of the Fire Safety Manager. The Fire Safety Manager delegates
this responsibility to the Lead Fire Advisor but will meet regularly to review.
Following a fire incident, the Management team for the area affected or the PSC
via Datix will report the matter as soon as possible to the Lead Fire Advisor. This
will ensure that an inspection is carried out and that the Lead Fire Advisor
prepares a technical analysis and report, forwarded to the Fire Safety Manager
and the Health and Safety Committee (or other body nominated by the
Department of Health).
An Incident Report (Datix) must be completed for each incident of fire or false
alarm no matter how trivial; the Lead Fire Advisor or a member of his team has
the responsibility to investigate this incident. Where an incident of fire involves
the movement of patients, loss of life or property damage, the Fire Safety Advisor
must be immediately informed and a report forwarded to the Department of
Health.
Page 21 of 70
For incidents out of normal hours, it is expected that the Duty Manager (PSC) will
notify the senior management team for the affected area, who will in turn inform
the Lead Fire Advisor.
Where the incident involves death or serious injury a report must also be
forwarded to the Health and Safety Executive in accordance with the Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).
This must also be reported in line with the Trust processes for the management
and investigation of incidents.
Further advice can be obtained from the Trust Health and Safety Department.
7
Training
In accordance with Health Technical memorandum 05-03 Healthcare organisations are
required, both under Law and under the provisions of Firecode, to provide effective
annual training in fire safety and how to respond to an outbreak of fire. This applies to
all staff without exception.
The Trust will offer 2 types of training, Face to face and an E-learning module.
Clinical staff must attend face to face training at least once every 2 years and nonclinical staff must attend face to face training every 3 years.
Specific local induction training must be carried out within the local induction
procedures. This includes local evacuation procedures and the location of fire fighting
equipment and arrangements for fire equipment and alarm testing.
To support the development of plans to fire fight and evacuate the organisation's
premises, the organisation allows the Tyne and Wear Fire Service to carry out training
exercises within the organisation's premises.
8
Equality and Diversity
The Trust is committed to ensuring that, as far as is reasonably practicable, the way we
provide services to the public and the way we treat our staff reflects their individual
needs and does not discriminate against individuals or groups on any grounds. This
document has been appropriately assessed
9
Monitoring Compliance
Standard /
process /
issue
6.1 Statutory
requirements
and guidance
Monitoring and audit
Method
By
Committee
Frequency
The details of all DoH regulation
alerts with a progress report on
implementation
Fire
Safety
Manager
Governance
and Health and
Safety
Committees
Quarterly
6.2 CAD
drawings
Percentage Level of compliance
with a progress report of noncompliance
Page 22 of 70
6.3.1 Permits to
work
6.4.2 Fire risk
assessments
6.5.1 Fire alarm
and equipment
testing
6.5.2 Fire alarm
failure
6.5.3 Fire drills
7 Training
10
The number of permits to work
issued to Contractors, details of
any occurrences when
contractors have been working
without permits and details of
actions taken
The level of compliance, in that,
all areas of the Trusts property
have an up to date Assessment,
all non-compliance will be
reported and will include a
remedial plan to ensure future
compliance
A pre-planned maintenance
percentage compliance report of
all statutory testing carried out by
the Estates Dept
The number of fire alarm
activations within the last quarter,
detailing the number of actual
incidents and false alarms
caused by contractors, faulty
equipment or staff
The percentage level of
compliance that fire drills have
been carried out in accordance
with the HTM 05-03, giving
details for non-compliance and
the remedial action to be taken
Percentage of compliance with
mandatory training, annual on
line and face to face will be
reported
Consultation and review
In writing this policy the regulations which govern all healthcare premises have been
followed and included. To ensure that the needs of all staff have been considered the
following stakeholders have been consulted prior to ratification of this policy:
 Fire Advisors
 Health and Safety Committee members
 Director of Estates
 Clinical Governance and Risk Department
 Tyne and Wear Fire Service
11
Implementation
The policy will be available for all staff and contractors working for the organisation
within the policy library on the intranet. To ensure that all staff are aware of their
responsibilities and the procedures within the policy an email is sent to all staff informing
them of the policy update and where they can access it.
Page 23 of 70
The changes to the policy will be highlighted through mandatory training and specific
training where a need is identified.
As the policy is reviewed and updated this will be highlighted on the Fire Advisors
section of the intranet and an alert notice displayed on the home page for a short period
highlighting the need to review the policy to all staff.
The policy is also reinforced through the Fire Warden training and through the Fire
Advisors stand at the organisation's open day.
12
References





The Regulatory reform (Fire Safety) Order 2005. SI 2005 No.541. HMSO 2005.
www.opsi.gov.uk/si/si2005/20051541.htm
Building Regualtions2000.SI 2000No 2531. HMSO,2000.
www.opsi.gov.uk/si/si2000/20002531.htm
Building Regulations 2000: Approved Document B: Fire Safety -Volume 1.
Department for Communities and Government, 2006.
Building Regulations 2000: Approved Document B: Fire Safety- Volume 2.
Department for Communities and Local Government, 2006.
Health and Safety at Work etc Act 1974. HMSO, 1974.
12.1 Firecode publications
 Health Technical Memorandum 05-01: Managing healthcare fire safety. The
Stationery Office, 2013
 Health Technical Memorandum 05-02: Guidance in support of functional
provisions for healthcare premises. The Stationery Office, 2007.
 Health Technical memorandum 05-03: Part B. Fire detection and alarm
systems. The Stationery Office, 2006.
 Health Technical Memorandum 05-03: Part C. textiles and furnishings. The
Stationery Office, 2007.
 Health and Technical memorandum 05-03: Part D. Commercial enterprises
on healthcare premises. The Stationery office, 2006.
 Health Technical Memorandum 05-03: Part F. Arson control in healthcare
premises. The Stationery Office, 2006.
 Health Technical Memorandum 05-03: Part G. Laboratories. The Stationery
Office 2006.
 Health Technical Memorandum 05-03: Part H. reducing unwanted fire signals.
The Stationery Office, 2006.
 Health Technical Memorandum 05-03: Part J. Guidance on fire engineering of
healthcare premises. The Stationery Office, 2008.
 Health Technical Memorandum 05-03: Part L Fire statistics 1994-2005. The
Stationery Office, 2007.
Page 24 of 70
13
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


















Associated documentation
Business Continuity Management policy
Contractors-Guidance in the use of
Control of Substances Hazardous to Health
Disabled Persons
Health and Safety Operational Policy
Induction Policy
Information Governance Policy
Information Security Policy
Major Incident plan
Mandatory Training Policy
Medical Gas Pipeline Systems
Moving and Handling of the Bariatric Patient
Moving and Handling Policy
Oxygen Management Policy
Risk Management Strategy
Risk Register-Management and Use
Security Policy
Serious Incident (Sls) Reporting and Management Policy
Smokefree Trust Policy
Transportation and Storage of Medical Gases
Page 25 of 70
Appendix 1: Fire safety management structure
14 Trust Board
15
Corporate
Governance
Committee
Chief Executive
Board member with
Fire safety
responsibility
Derogation of
authority (4.3 of
Policy)
Health and Safety
Committee
Director of
Estates & Facilities/
Fire Safety Manager
(4.3 of Policy)
Fire Design
Engineer
(External contractor if
required for projects)
Assistant Fire Safety
Manager
(4.4 of Policy)
Lead Fire
Advisor
(4.5 of Policy)
Assistant Fire
Advisors
Departmental Managers
(4.6 & 4.7 of Policy)
Fire Wardens
(4.9 of Policy)
Staff
(4.10 & 4.11 of Policy)
Direct accountability for fire safety
Fire safety reporting
Exception reporting
Page 26 of 70
(Operational
oversight group)
Appendix: 2 Risk Assessment
Annex B (informative)
Model pro-forma for documentation of a fire risk assessment for premises in
England and Wales
B.1 This annex contains a model pro-forma for documentation of a fire risk assessment for premises in
England and Wales. If the pro-forma is completed by a competent person, the format and scope of
the fire risk assessment will be suitable and sufficient to satisfy the recommendations of this PAS.
Modifications to this format will be necessary in the case of premises in multiple occupation, for which
information about the building and about the premises of the occupier, for whom the fire risk
assessment is being carried out, both need to be recorded. NOTE Enforcement of fire safety
legislation is the prerogative of the enforcing authority charged by legislation with the responsibility to
do so. Each enforcing authority is autonomous. There remains debate as to the legal interpretation of
what constitutes the significant findings of a fire risk assessment. However, the format of the proforma contained in this annex, being part of a BSI PAS, is considered by the Chief Fire Officers’
Association to be one suitable format for recording the significant findings of a suitable and sufficient
fire risk assessment, although many other formats would also be acceptable.
NOTE Enforcement of fire safety legislation is the prerogative of the enforcing authority charged by legislation with
the responsibility to do so. Each enforcing authority is autonomous. There remains debate as to the legal
interpretation of what constitutes the significant findings of a fire risk assessment. However, the format of the proforma contained in this annex, being part of a BSI PAS, is considered by the Chief Fire Officers' Association to be one
suitable format for recording the significant findings of a suitable and sufficient fire risk assessment, although many
other formats would also be acceptable.
B.2 The format of a documented fire risk assessment may vary from that shown in this Annex, provided
that the recommendations of each clause of this PAS are satisfied. For example, in the case of means
of escape, compliance with Annex D necessitates that the key factors in Table D.1 are explicitly
addressed in the documented fire risk assessment, but not all the specific issues
shown in Table D.1 and in the pro-forma contained in this Annex need necessarily be included
in all documented fire risk assessments conforming to the recommendations of this PAS, as they might
not all constitute “significant findings”. It is, however, necessary for compliance with this PAS, that the
specific issues have, at least, been considered by the fire risk assessor while carrying out the fire risk
assessment.
B.3 Equally, the prompt-list of fire hazards shown in the pro-forma may be expanded. This might be
appropriate, for example, if there are significant fire hazards for which no headings are included in
the pro-forma.
B.4 Where description of any fire hazards or fire precautions is considered appropriate, this can
be recorded under the relevant “Comments” heading in the pro-forma. The comments sections
can also be used to set out justification for acceptance of standards of any fire protection measures
that depart significantly from a prescriptive norm (see 10.3).
B.5 While it might not be essential to record further information in every comments section, care
needs to be taken to ensure that the pro-forma does not become a mere tick-list with inadequate
supporting information. Such a fire risk assessment is unlikely to satisfy fire safety legislation, nor would
it conform to the recommendations of this PAS.
Page 27 of 70
REGULATORY REFORM (FIRE SAFETY) ORDER 2005
FIRE RISK ASSESSMENT
Responsible person (e.g. employer) or
person having control of the premises:
Address of premises:
Assessor:
Date of fire risk assessment:
Date of previous fire risk assessment:
Suggested date for review: 1)
The purpose of this report is to provide an assessment of the risk to life from fire in these premises, and,
where appropriate, to make recommendations to ensure compliance with fire safety legislation. The
report does not address the risk to property or business continuity from fire.
[Date]
1)
This fire risk assessment should be reviewed by a competent person by the date indicated above or at such earlier time
as there is reason to suspect that it is no longer valid, or if there has been a significant change in the matters to which it
relates, or if a fire occurs.
Page 28 of 70
GENERAL INFORMATION
1.
THE PREMISES
1.1
Number of floors:
1.2
Approximate floor area:
m2 per floor
m2 gross
m2 on ground floor
[enter units as appropriate]
1.3
Brief details of construction
1.4
Use of premises
2.
THE OCCUPANTS
2.1
Approximate maximum number:
2.2
Approximate number of employees at any one time:
2.3
Maximum number of members of public at any one time:
2.4
Associated times/hours of occupation:
Page 29 of 70
3.
OCCUPANTS ESPECIALLY AT RISK FROM FIRE
3.1
Sleeping occupants:
3.2
Disabled occupants:
3.3
Occupants in remote areas and lone workers:
3.4
Young persons:
3.5
Others:
4.
FIRE LOSS EXPERIENCE
5.
OTHER RELEVANT INFORMATION
Page 30 of 70
6.
RELEVANT FIRE SAFETY LEGISLATION
6.1
The following fire safety legislation applies to these premises:
6.2
The above legislation is enforced by:
6.3
Other legislation that makes significant requirements for fire precautions in these premises (other
than the Building Regulations 2010):
6.4
The legislation to which 6.3 makes reference is enforced by:
6.5
Comments:
Page 31 of 70
FIRE HAZARDS AND THEIR ELIMINATION OR CONTROL
7.
ELECTRICAL SOURCES OF IGNITION
7.1
Reasonable measures taken to prevent fires of electrical origin?
7.2
More specifically:
Yes
No
Fixed installation periodically inspected and tested?
Yes
No
Portable appliance testing (where appropriate) carried out?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Suitable arrangements for those who wish to smoke?
Yes
No
This policy appeared to be observed at time of inspection?
Yes
No
Yes
No
Suitable policy regarding the use of personal electrical
appliances?
Suitable limitation of trailing leads and adapters?
7.3
Comments and hazards observed:
8.
SMOKING
8.1
Reasonable measures taken to prevent fires as a result of smoking?
8.2
More specifically:
Smoking prohibited on the premises?
Smoking prohibited in appropriate areas?
N/A
8.3
Comments and hazards observed:
9.
ARSON
9.1
Does basic security against arson by outsiders appear reasonable? 2)
Page 32 of 70
9.2
Is there an absence of unnecessary fire load in close proximity to the
premises or available for ignition by outsiders?
9.3
Comments and hazards observed:
Yes
No
2)
Reasonable only in the context of this fire risk assessment. If specific advice on security (including security against
arson) is required, the advice of a security specialist should be obtained.
10.
PORTABLE HEATERS AND HEATING INSTALLATIONS
10.1
Is the use of portable heaters avoided as far as practicable?
10.2
If portable heaters are used:
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
Filters changed and ductwork cleaned regularly?
N/A
Yes
No
Suitable extinguishing appliances available?
N/A
Yes
No
Is the use of the more hazardous type (e.g. radiant
bar
fires or lpg appliances) avoided?
Are suitable measures taken to minimize the hazard of
ignition of combustible materials?
10.3
Are fixed heating installations subject to regular
maintenance?
10.4
Comments and hazards observed:
11.
COOKING
11.1
Are reasonable measures taken to prevent fires as a
result of cooking?
11.2
More specifically:
11.3
Comments and hazards observed:
Page 33 of 70
12.
LIGHTNING
12.1
Do the premises have a lightning protection system?
12.2
Comments and hazards observed:
13.
HOUSEKEEPING
13.1
Is the standard of housekeeping adequate?
13.2
More specifically:
N/A
Combustible materials appear to be separated from ignition
sources?
Avoidance of unnecessary accumulation of combustible materials
or waste?
Appropriate storage of hazardous materials?
N/A
Avoidance of inappropriate storage of combustible materials?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
13.3
Comments and hazards observed:
14.
HAZARDS INTRODUCED BY OUTSIDE CONTRACTORS AND BUILDING WORKS
14.1
Are fire safety conditions imposed on outside contractors?
Yes
No
14.2
Is there satisfactory control over works carried out on the premises
by outside contractors (including “hot work” permits)?
Yes
No
14.3
If there are in-house maintenance personnel, are
suitable precautions taken during “hot work”, including
use of “hot work” permits?
Yes
No
Page 34 of 70
N/A
14.4
Comments:
15.
DANGEROUS SUBSTANCES
15.1
Are the general fire precautions adequate to address the
hazards associated with dangerous substances used or
stored within the premises?
N/A
Yes
No
If 15.1 applies, has a specific risk assessment been carried
out, as required by the Dangerous Substances and
Explosive Atmospheres Regulations 2002?
N/A
Yes
No
15.2
15.3
Comments:
16.
OTHER SIGNIFICANT FIRE HAZARDS THAT WARRANT CONSIDERATION INCLUDING
PROCESS HAZARDS THAT IMPACT ON GENERAL FIRE PRECAUTIONS
16.1
Hazards:
16.2
Comments and deficiencies observed:
Page 35 of 70
FIRE PROTECTION MEASURES
17.
MEANS OF ESCAPE FROM FIRE
17.1
It is considered that the premises are provided with reasonable
means of escape in case of fire.
17.2
More specifically:
Yes
No
Adequate design of escape routes?
Yes
No
Adequate provision of exits?
Yes
No
Exits easily and immediately openable where necessary?
Yes
No
Fire exits open in direction of escape where necessary?
Yes
No
Yes
No
Yes
No
Avoidance of sliding or revolving doors as fire exits
where necessary?
N/A
Satisfactory means for securing exits?
Reasonable distances of travel:
Where there is a single direction of travel?
N/A
Yes
No
Where there are alternative means of escape?
N/A
Yes
No
N/A
Yes
No
Yes
No
Yes
No
Suitable protection of escape routes?
Escape routes unobstructed?
17.3
It is considered that the premises are provided with
reasonable arrangements for means of escape for
disabled people.
17.4
Comments and deficiencies observed:
18.
MEASURES TO LIMIT FIRE SPREAD AND DEVELOPMENT
18.1
It is considered that there is:
Page 36 of 70
N/A
compartmentation of a reasonable standard 3)
Yes
No
reasonable limitation of linings that might promote fire spread.
Yes
No
Yes
No
18.2
As far as can reasonably be ascertained, fire dampers
are
provided as necessary to protect critical means of
escape against passage of fire, smoke and combustion
products
in the early stages of a fire? 3), 4)
18.3
Comments and deficiencies observed:
N/A
3)
Based on visual inspection of readily accessible areas, with a degree of sampling where appropriate.
4)
A full investigation of the design of HVAC systems is outside the scope of this fire risk assessment.
19.
EMERGENCY ESCAPE LIGHTING
19.1
Reasonable standard of emergency escape lighting
system provided? 5)
19.2
Comments and deficiencies observed:
N/A
Yes
No
5)
Based on visual inspection, but no test of illuminance levels or verification of full compliance with relevant British
Standards carried out.
20.
FIRE SAFETY SIGNS AND NOTICES
20.1
Reasonable standard of fire safety signs and notices?
Page 37 of 70
N/A
Yes
No
20.2
Comments and deficiencies observed:
21.
MEANS OF GIVING WARNING IN CASE OF FIRE
21.1
Reasonable manually operated electrical fire alarm
system provided? 6)
21.2
Automatic fire detection provided?
21.3
Extent of automatic fire detection generally appropriate
for the occupancy and fire risk?
N/A
Yes
No
21.4
Remote transmission of alarm signals?
N/A
Yes
No
21.5
Comments and deficiencies observed:
N/A
Yes
No
Yes
Yes (part of
No
(throughout
premises)
premises only)
6)
Based on visual inspection, but no audibility tests or verification of full compliance with relevant British Standard
carried out.
22.
MANUAL FIRE EXTINGUISHING APPLIANCES
22.1
Reasonable provision of portable fire extinguishers?
22.2
Hose reels provided?
22.3
Are all fire extinguishing appliances readily accessible?
Page 38 of 70
N/A
N/A
Yes
No
Yes
No
Yes
No
22.4
Comments and deficiencies observed:
23.
RELEVANT AUTOMATIC FIRE EXTINGUISHING SYSTEMS
23.1
Type of system:
23.2
Comments:
24.
OTHER RELEVANT FIXED SYSTEMS AND EQUIPMENT
24.1
Type of fixed system:
Page 39 of 70
24.2
Comments:
24.3
Suitable provision of fire-fighters switch(es) for
high voltage luminous tube signs, etc.
24.4
Comments:
N/A
Yes
No
Yes
No
MANAGEMENT OF FIRE SAFETY
25.
PROCEDURES AND ARRANGEMENTS
25.1
Fire safety is managed by: 7)
25.2
Competent person(s) appointed to assist in undertaking the
preventive and protective measures (i.e. relevant general fire
precautions)?
Page 40 of 70
Comments:
25.3
Is there a suitable record of the fire safety arrangements?
Yes
No
Yes
No
Yes
No
Yes
No
Comments:
25.4
Appropriate fire procedures in place?
More specifically:
Are procedures in the event of fire appropriate and
properly documented?
N/A
Are there suitable arrangements for summoning the fire
and rescue service?
Are there suitable arrangements to meet the fire and
rescue service on arrival and provide relevant information,
including that relating to hazards to fire-fighters?
N/A
Yes
No
Are there suitable arrangements for ensuring that the
premises have been evacuated?
N/A
Yes
No
Is there a suitable fire assembly point(s)?
N/A
Yes
No
Are there adequate procedures for evacuation of any
disabled people who are likely to be present?
N/A
Yes
No
N/A
Yes
No
Comments:
25.5
Persons nominated and trained to use fire extinguishing
Page 41 of 70
appliances?
Comments:
25.6
Persons nominated and trained to assist with evacuation,
including evacuation of disabled people?
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
Comments:
25.7
Appropriate liaison with fire and rescue service (e.g. by fire
and rescue service crews visiting for familiarization visits)?
Comments:
25.8
Routine in-house inspections of fire precautions
(e.g. in the course of health and safety inspections)?
Comments:
7)
This is not intended to represent a legal interpretation of responsibility, but merely reflects the managerial
arrangement in place at the time of this risk assessment.
Page 42 of 70
26.
TRAINING AND DRILLS
26.1
Are all staff given adequate fire safety instruction and
training on induction?
N/A
Yes
No
N/A
Yes
No
Comments:
26.2
Are all staff given adequate periodic “refresher training”
at suitable intervals?
Comments:
26.3
Does all staff training provide information, instruction or training on the following:
Fire risks in the premises?
N/A
Yes
No
The fire safety measures on the premises?
N/A
Yes
No
Action in the event of fire?
N/A
Yes
No
Action on hearing the fire alarm signal?
N/A
Yes
No
Method of operation of manual call points?
N/A
Yes
No
Location and use of fire extinguishers?
N/A
Yes
No
Means for summoning the fire and rescue service?
N/A
Yes
No
Identity of persons nominated to assist with evacuation?
N/A
Yes
No
Identity of persons nominated to use fire extinguishing
appliances?
N/A
Yes
No
Page 43 of 70
Comments:
26.4
Are staff with special responsibilities (e.g. fire wardens)
given additional training?
N/A
Yes
No
N/A
Yes
No
Is their employer given appropriate information
(e.g. on fire risks and general fire precautions)?
N/A
Yes
No
Is it ensured that the employees are provided with
adequate instructions and information?
N/A
Yes
No
Comments:
26.5
Are fire drills carried out at appropriate intervals?
Comments:
26.6
When the employees of another employer work in the premises:
Comments:
Page 44 of 70
27.
TESTING AND MAINTENANCE
27.1
Adequate maintenance of premises?
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
Comments and deficiencies observed:
27.2
Weekly testing and periodic servicing of fire detection
and alarm system?
Comments and deficiencies observed:
27.3
Monthly and annual testing routines for emergency
escape lighting?
Comments and deficiencies observed:
27.4
Annual maintenance of fire extinguishing appliances?
Comments and deficiencies observed:
27.5
Periodic inspection of external escape staircases
and gangways?
Page 45 of 70
Comments and deficiencies observed:
27.6
Six-monthly inspection and annual testing of rising mains?
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
Comments and deficiencies observed:
27.7
Weekly and monthly testing, six-monthly inspection and
annual testing of fire-fighting lifts?
Comments and deficiencies observed:
27.8
Weekly testing and periodic inspection of sprinkler
installations?
Comments:
27.9
Routine checks of final exit doors and/or security
fastenings?
Page 46 of 70
Comments:
27.10
Annual inspection and test of lightning protection
system?
N/A
Yes
No
Yes
No
Comments:
27.11
Are suitable systems in place for reporting and subsequent
restoration of safety measures that have fallen below standard?
Comments:
27.12
Other relevant inspections or tests:
Page 47 of 70
Comments:
28.
RECORDS
28.1
Appropriate records of:
Fire drills?
N/A
Yes
No
Fire training?
N/A
Yes
No
Fire alarm tests?
N/A
Yes
No
Emergency escape lighting tests?
N/A
Yes
No
Maintenance and testing of other fire protection systems?
N/A
Yes
No
.
28.2
Comments:
Page 48 of 70
FIRE RISK ASSESSMENT
The following simple fire risk level estimator is based on a commonly used health and safety risk
level estimator.
Likelihood of fire
Potential consequences of fire
Slight harm
Moderate harm
Extreme harm
Low
Trivial risk
Tolerable risk
Moderate risk
Medium
Tolerable risk
Moderate risk
Substantial risk
High
Moderate risk
Substantial risk
Intolerable risk
Taking into account the fire prevention measures observed at the time of this risk assessment, it
is considered that the hazard from fire (likelihood of fire) at these premises is:
Low
Medium
High
In this context, a definition of the above terms is as follows:
Low
Unusually low likelihood of fire as a result of negligible potential sources of ignition.
Medium
Normal fire hazards (e.g. potential ignition sources) for this type of occupancy,
with fire hazards generally subject to appropriate controls (other than minor
shortcomings).
High
Lack of adequate controls applied to one or more significant fire hazards, such as
to result in significant increase in likelihood of fire.
Taking into account the nature of the premises and the occupants, as well as the fire
protection and procedural arrangements observed at the time of this fire risk assessment, it is
considered that the consequences for life safety in the event of fire would be:
Slight harm
Moderate harm
Extreme harm
In this context, a definition of the above terms is as follows:
Slight harm
Outbreak of fire unlikely to result in serious injury or death of any occupant
(other than an occupant sleeping in a room in which a fire occurs).
Moderate harm
Outbreak of fire could foreseeably result in injury (including serious injury) of
one or more occupants, but it is unlikely to involve multiple fatalities.
Extreme harm
Significant potential for serious injury or death of one or more occupants.
Accordingly, it is considered that the risk to life from fire at these premises is:
Trivial
Tolerable
Moderate
Page 49 of 70
Substantial
Intolerable
Comments:
A suitable risk-based control plan should involve effort and urgency that is proportional to risk.
The following risk-based control plan is based on one that has been advocated for general
health and safety risks:
Risk level
Trivial
Action and timescale
No action is required and no detailed records need be kept.
Tolerable
No major additional fire precautions required. However, there might be a need for
reasonably practicable improvements that involve minor or limited cost.
Moderate
It is essential that efforts are made to reduce the risk. Risk reduction measures,
which should take cost into account, should be implemented within a defined
time period. Where moderate risk is associated with consequences that constitute
extreme harm, further assessment might be required to establish more precisely
the likelihood of harm as a basis for determining the priority for improved control
measures.
Substantial
Considerable resources might have to be allocated to reduce the risk. If the
premises are unoccupied, it should not be occupied until the risk has been
reduced. If the premises are occupied, urgent action should be taken.
Intolerable
Premises (or relevant area) should not be occupied until the risk is reduced.
(Note that, although the purpose of this section is to place the fire risk in context, the
above approach to fire risk assessment is subjective and for guidance only. All hazards
and deficiencies identified in this report should be addressed by implementing all recommendations
contained in the following action plan. The fire risk assessment
should be reviewed regularly.)
Page 50 of 70
ACTION PLAN
It is considered that the following recommendations should be implemented in order to reduce
fire risk to, or maintain it at, the following level:
Trivial
Tolerable
Definition of priorities (where applicable):
Priority (where
applicable)
1.
Page 51 of 70
Action by
whom
Date
action
undertaken
Appendix 3: Personal Emergency Evacuation Plan Checklist
Fire Safety 2014
Newcastle upon Tyne Hospitals NHS Foundation Trust
PEEP 1 - Personal Emergency Evacuation Plan Checklist
Section 1 - General information
Name of Assessor:
Name of Person Plan Prepared For:
Assessed Person’s Ward/ Department:
Date of Assessment:
Nature of Impairment(s)/Disability:
Area(s)
(1)
Covered By The Assessment:
(2)
What times / days are covered by this
assessment?
Does the building Fire Risk Assessment
denote that the proposed building has
suitable access/egress.
(3)
YES
NO
NOTES
(1) The PEEP should, as far as practicable, be specific to individual areas of study / work / residence. However, if, for
example, a number of activities are proposed to take place in adjacent areas from which escape will be affected using the
same emergency provisions then it may be possible to assess the provisions on one form. Hearing impaired persons will
normally be able to be assessed on one form since the provisions are likely to be the same regardless of location.
(2) It is important to distinguish in the PEEP whether the area to be accessed will be used inside or outside of “normal”
working areas. It is likely that certain areas of buildings will be inaccessible outside of normal working hours e.g. to assure
security. The PEEP needs to demonstrate that this has been adequately considered.
(3) If a building assessment deems that a particular area does not meet the general access requirements for person being
assessed then alternative management arrangements will need to be identified. Once these arrangements have been
identified then a new PEEP will need to be undertaken to ensure that the new location(s) is / are adequate.
Please indicate which other NUTH Buildings you will be using and whether a PEEP has been completed for them:
Additional NUTH buildings which may be used
PEEP Completed?
YES / NO
YES / NO
Page 52 of 70
YES / NO
YES / NO
YES / NO
One of the following forms should be completed by the assessor and the assessed person.
Form A – Mobility Impairment
Form B – Visual Impairment
Form C – Hearing Impairment
Form D – General – For all other disabilities not falling within Forms A – C.
In order that an effective PEEP can be prepared for you it may be necessary to share some of the information
provided with other relevant members of NUTH staff.
I understand that these details will only be disclosed if they are required to meet the needs of my Personal
Emergency Egress Plan.
Signature: ………………………………………
Date: ………………………………..
Page 53 of 70
FORM A - MOBILITY IMPAIRED PERSONS
Name:
Name of Ward/Department:
Building to which this PEEP applies:
Floors used:
Personal Emergency Evacuation Plan Checklists
1
2
3
4
5
6
7
8
yes
no
Have the general emergency procedures been explained to you?
Could you raise the alarm if you discovered a fire (operate the call point)?
Can you open the fire escape door on the floor(s) you will be using?
Could you use a telephone in the area to call the emergency services?
Are you able to and have you been shown how to use the refuge
communications equipment?
If you are (or will you be) resident in a Trust owned property has a PEEP
been prepared for your accommodation? (If not please ask for one to be
prepared)
Do you use a manual wheelchair?
What is the approximate width of your wheelchair
mm
9
10
11
12
If you use another type of mobility aid, what is it? (insert details)
b) Activities on the Ground Floor
At the intended time of use, how many fire exits are available for disabled
use?
If only 1 emergency exit is available, how far, approximately, is the exit
from the area where you are starting to escape?
How long, approximately, would it take you to evacuate, unaided, from the
building? (please record a time for each of your available exits up to a mins
maximum of 4)
Mins
Mins
Mins
13
14
15
Are the escape routes free from any structural features that will present
either a hazard or a barrier to you using any of the available fire exits?
c) The following questions need to be answered by all “ground floor
based” mobility impaired persons that will be assisted by full time
“helpers”.
Who will be providing this assistance? (insert names)
Who will cover this “help” role when your normal helper is absent e.g. due to sickness,
leave etc? (insert names)
Page 54 of 70
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
d) Activities based above the Ground Floor (or in a basement with
access by stairs)
Have all possibilities for relocating the activity or service provision on the
ground floor (of this or any other building) been exhausted?
Is the area to be used above the 5th floor?
Is there an “Evacuation Lift”?
At the intended time of use, how many fire exits from the floor to be used
are available for use? (Insert number in column)
Do any of the escape routes involve escape into an adjoining building or
fire-compartment - allowing horizontal evacuation?
Have refuges been provided on, or adjacent to, each fire escape route
(where applicable)?
Where refuges have been provided, are these appropriate for use at the
intended time of occupancy?
Where refuges are not provided on all escape routes, does the existing fire
escape signage clearly lead you to other refuges that are available?
Are the refuge doors of the self-closing type and operating correctly?
Do refuges have communication points that are accessible for you to use
i.e. telephone or speaker connected to building fire control point or
Security?
Are you able to use an “evac” chair?
Can you transfer to an “evac” chair without assistance?
Is there an evacuation chair provided in the building?
Where are the nearest alternative chairs kept?
How long, approximately, would it take you, unaided, to reach a place of
safety in an emergency?
(Please record a time for each of your available exits up to a maximum of
4.)
min
min
min
min
31
32
e) The following questions need to be answered by all “non-ground
floor based” mobility impaired persons that will be using / provided
with full time “helpers”.
Who will be providing this assistance?
Who will cover this “help” role when your normal helper is absent e.g. due to sickness,
leave etc.?
ASSESSMENT SIGN-OFF:
Signed (Assessor)
Signed (PEEP User)
Page 55 of 70
FORM B - VISUALLY IMPAIRED PERSONS
Name
Name of Ward /Department
Building to which this PEEP applies:
Floors used:
Personal Emergency Evacuation Plan Checklists
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
AWARENESS OF EMERGENCY EGRESS PROCEDURES
Have the general emergency procedures been explained to you?
Could you raise the alarm if you discovered a fire (operate the call point)?
Can you open the fire escape door on the floor(s) you will be using?
Could you use a telephone in the area to call the emergency services?
If you are (or will you be) resident in a Trust owned property has a PEEP
been prepared for your accommodation? (If not please ask for one to be
prepared)
Do you require the emergency escape procedure to be on tape?
Do you require the emergency escape procedures to be in Braille?
Do you require the emergency escape procedures to be in large print?
Can you read the fire escape signs?
How long would you estimate that it would take to evacuate the building
under assessment, unaided (other than with the help of any items identified
above), in the event of an emergency?
How many escape routes are available to you in the event of an
emergency?
Have any hazardous “projections” or other structural components been
identified on your escape routes?
b) The following questions need only be answered by those visually
impaired persons possessing some degree of visual capacity
Are all escape routes clearly sign posted to meet YOUR requirements?
Where applicable, are all escape corridors designed so as to prevent visual
confusion in YOUR circumstances?
Where applicable, are all escape staircases fitted with adequate colour
contrasting nosing and a suitable handrail?
c)The following questions need to be answered by all visually
impaired persons that will be using / provided with full time “helpers”
while in the building for which this peep is being prepared.
Who will be providing this assistance?
17
Who will cover this “help” role when your normal helper is absent e.g. due
to sickness, leave etc. (insert names)
18
ARE YOU AWARE OF ANY OTHER MEASURES THAT COULD BE
INTRODUCED IN THE BUILDING UNDER ASSESSMENT THAT COULD
FURTHER AID YOUR EVACUATION IN CASE OF AN EMERGENCY
ASSESSMENT SIGN-OFF:
Signed (Assessor)
Signed (PEEP User)
Page 56 of 70
yes
no
min
FORM C - HEARING IMPAIRED PERSONS
Name:
Name of Ward /Department:
Building to which this PEEP applies:
Floors used:
Personal Emergency Evacuation Plan Checklists
1
AWARENESS OF EMERGENCY EGRESS PROCEDURES
Have the general emergency procedures been explained to you?
2
Could you raise the alarm if you discovered a fire (operate the call point)?
3
Can you open the fire escape door on the floor(s) you will be using?
4
Could you use a telephone in the area to call the emergency services?
5
If you are (or will you be) resident in non Trust property, has a PEEP been
prepared for you, (If not please ask for one to be prepared)
6
Can you hear the fire alarm in normal circumstances?
7
Do you require the building emergency procedures to be provided to you in
an alternative format to the standard written instructions?
8
Do you require written emergency procedures to be supported by BSL
(British Sign Language) interpretation
9
Is your work room fitted with a flashing beacon, linked to the fire alarm?
10
Is your toilet () fitted with a flashing beacon linked to the fire alarm?
11
ARE YOU AWARE OF ANY OTHER MEASURES THAT COULD BE
INTRODUCED IN THE BUILDING UNDER ASSESSMENT THAT COULD
FURTHER AID YOUR EVACUATION IN CASE OF AN EMERGENCY
yes
no
ASSESSMENT SIGN-OFF:
Signed (Assessor)
Signed (PEEP User)
Thank you for completing this form the information provided will be used to help produce a
Personal Evacuation Escape plan to meet your needs.
Page 57 of 70
FORM D - GENERAL
Name:
Name Ward/Department:
Building to which this PEEP applies:
Floors used:
Personal Emergency Evacuation Plan Checklists
AWARENESS OF EMERGENCY EGRESS PROCEDURES
1
Have the general emergency procedures been explained to you?
2
Could you raise the alarm if you discovered a fire (operate the call point)?
3
Can you open the fire escape door on the floor(s) you will be using?
4
Could you use a telephone in the area to call the emergency services?
5
If you are (or will you be) resident in a Trust owned property has a PEEP
been prepared? (If not please ask for one to be prepared)
6
Can you hear the fire alarm in normal circumstances?
7
8
Do you need assistance to get out of your place of work/study in an
emergency?
Is anyone designated to assist you to get out in an emergency?
9
Is the arrangement with your assistant a formal arrangement?
10
In an emergency could you contact the person in charge of evacuating the
building in which you work and tell him where you were located?
11
Do you require the building emergency procedures to be provided to you in
an alternative format to the standard written instructions?
12
Can you move quickly in the event of an emergency?
13
ARE YOU AWARE OF ANY OTHER MEASURES THAT COULD BE
INTRODUCED IN THE BUILDING UNDER ASSESSMENT THAT COULD
FURTHER AID YOUR EVACUATION IN CASE OF AN EMERGENCY
yes
no
ASSESSMENT SIGN-OFF:
Signed (Assessor)
Signed (PEEP User)
Thank you for completing this form the information provided will be used to help produce a
Personal Evacuation Escape plan to meet your needs.
Page 58 of 70
Appendix 4: Contractors Induction Form
Contractors Quick Site Induction Checklist (Estates)
Given By: ___________________ Position Held __________________
1
Company
2
Employees Working and Job Titles (First
name to indicate supervisor/ point of
contact)
3
Contact Details
4
5
6
7
Expected Duration of Work/ Hours of Work
Method Statement(s)
Risk Assessment(s)
Working for (Company/ Name/ Contact
Details)
Site Contact Details
Location of Work
Location of Domestic Facilities/ Eating
Areas/ Site Plan
Obtaining Door Keys/ Access Codes/
Passes
Telephone policy
Fire Alarm Activation
Emergency Evacuation Procedure
Emergency Telephone Numbers
Car Parking/ Permits
Deliveries/ Access
Set Up Areas
Work Permits - Electrical/ Hot Work/
Confined Spaces
Asbestos Policy
Security Issues
No smoking policy
Site/ Contractor Tidiness
Tool Box Talks/ Supervisors responsibilities
to devolve information downwards
Any Other Issues
8
9
10
11
12
13
14
15
15
16
17
18
19
20
21
22
23
24
1.
2.
3.
4.
No mobile phones operated on site.
Continuous alarm.
2222 – Cardiac Arrest, 0 - Operator
Estates Workshop
No smoking on premises
I have been instructed in the items listed above and understand my responsibilities
Signed:
Dated:
_______________________________________________________
Page 59 of 70
Appendix 5: Permit to Work/ Hot Permit
ESTATES DEPARTMENT
FIRE ALARM ISOLATION/HOT WORK* PERMIT
*Delete if Hot Work is not applicable
Hot Work applicable to: Cutting, welding, soldering, brazing and the use of
equipment producing heat or naked flames.
Permit No.
Requisition No.
Commencement Date & Time: ___________________________________
Expiry Date & Time:
___________________________________
Location of Work: ___________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Description of Work: _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
NO WORK MUST BE CARRIED OUT IF:
1.
2.
3.
The sprinkler system is out of service.
There is a flammable or dusty atmosphere.
Any vessels have previously contained flammable liquids or gases.
SITE: Dental / Leazes Wing / Victoria Wing / Claremont Wing / Catering
The following Fire Alarm Zones / Devices need to be isolated:
Page 60 of 70
Authorising Person:
I have authorised the work to proceed, informed the Competent Person of the Hospital Fire Procedure and instructed
him on the means of safe escape from the work location.
Date
Date
Personnel in the zone have been informed of the isolation and briefed on the alternative
method of raising the Alarm, i.e. 333 Call to Telephone Exchange.
Time
Time
ANNEX 1
(to Estates Procedures
Hot Work Permit)
Name
Signature
THE NEWCASTLE UPON TYNE HOSPITALS FOUNDATION TRUST
Date
ROYAL VICTORIA INFIRMARY
ESTATES DEPARTMENT
Time
HOT WORK FIRE PRECAUTIONS
_______________________________________________________________
Competent Person:
1.
I accept responsibility for carrying out the work indicated above and I am conversant with the relevant Fire & Safety
Precautions required of me, as stated in Annexe 1 Hot Work Precautions.
Name
The area must be personally examined and approved by an authorised individual to confirm
that the following necessary safeguards have been arranged prior to issuing this permit.
(a)
Floors and surrounds must be swept clean and wet down.
(b)
All combustible stock, plant, insulations, etc. must be relocated 40 ft away from
the operation or the remainder must be protected with non-combustible curtains,
metal guards or flame proofed covers (not ordinary tarpaulins).
(c)
Any floor or wall opening or open mesh flooring within 40 ft of the cutting and
welding operations must be covered over tightly.
(d)
A responsible individual having authority to stop the work must be assigned to
watch for dangerous sparks in the area as well as in floors above and below and
in adjacent areas.
(e)
Ample fire protection equipment – hose reels, extinguishers, water buckets, etc.
must be provided and a responsible individual trained in their use must be
available.
(f)
Warning notices must be posted adjacent to and, where necessary, below the
work area.
Signature
Date
Time
___________________________________________________________________________
Authorising Person:
The work has been completed and the work area checked, the Fire Alarm Zone/Detectors can now be reinstated.
Name
2.
Appoint a trained responsible employee, with authority to stop the work, to regularly check the area,
particularly during lunch and rest periods, on completion of the work and 30 minutes after completion.
3.
Ensure that all gas cylinders are safely secured in upright positions, and gas pipes and
cables are in good condition, properly secured and kept as short as possible.
___________________________________________________________________________
4.
Provide suitable ancillary equipment to ensure safety of workmen and method of
operation.
Craftsman
5.
Ensure the workmen know where the fire alarm is situated.
6.
Ensure the area is kept clean and tidy.
7.
The area must be personally examined
Signature
Date
Time
Zone/Device Isolated
Name
Zone/Device Reinstated
Name
Page 61 of 70
Appendix 6: Fire Equipment Checklist
FIRE SAFETY 2014
FIRE EQUIPMENT MONTHLY CHECKLIST
HOSPITAL / SITE
BUILDING /
BLOCK
FLOOR LEVEL
WARD /DEPT
Carryout monthly check of fire fighting equipment to ensure :

The Fire Fighting Equipment is within scheduled servicing dates

Cleanliness and general upkeep of equipment

Location of equipment is correct

There are identifying labels placed above each Fire Extinguisher

There are no visual defects … dents or corrosion

Safety pins and security seal tags are in place

There is no sign of discharge from any Fire Extinguisher

The Fire Blanket has not been used and returned to casing
REPORT ANY DEFECTS PROMPTLY TO THE FIRE TEAM DEPARTMENT
(Dect 24333) ( Dect 23703) ( Dect 20611) or via e mail
RECORD OF DEPARTMENT CHECK
MONTH
JANUARY
DATE
NAME
FEBRUARY
MARCH
APRIL
MAY
Page 62 of 70
SIGNATURE
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
AUDIT
NB : CHECKLIST IS TO BE FORWARDED UPON COMPLETION TO :TRUST FIRE ADVISOR, ESTATES DEPT, RVI FOR AUDIT
Page 63 of 70
Appendix 7: Fire Drill Form
FIRE EVACUATION DRILL REPORT
NHS Building Name:
Fire Evacuation Drill Report
Bldg No:
Building Address:
The Newcastle Upon Tyne
Hospitals NHS Foundation Trust
Name /Department:
Address:
Date of Drill:
Location of Drill:
Weather Conditions:
Time Alarm Activated:
Time – All persons
Accounted for:
Person(s) in
Attendance:
e.g. Slightly wet , Overcast with Clouds
00 hrs : 00 mins : 00secs
hrs :
mins :
secs
*(time from activation of the Fire Alarm to all persons safely clear of safely clear of the building)
(names of Drill Supervisors)
Overall Standard of
Drill:
Tick ()
Comments
Unsatisfactory
Satisfactory
Action Required / Responsibility
Good
Very Good

Action Cleared
SIGNATURE OF DRILL SUPERVISORS IN ATTENDANCE
PRINT NAME
POSITION
Page 64 of 70
SIGNATURE
Appendix 8: Audit Proforma
Standard / process / issue
The organisation is meeting
all the statutory requirements
Fire Drawings for all
premises are in place,
available and within review
period
Monitoring and audit
Method
By
Audit
Fire
Health and
Advisors Safety
Committee
All Contractors have
completed induction prior to
commencing work
All Contractors have a permit
or hot permit to work
All textiles and furniture
conform to the current fire
code
All organisation premises
have fire resistance ratings
and rate of surface spread of
flame
All areas within the
organisation have an up to
date Risk Assessment
The Fire Alarm system is
checked as per policy
If the Fire Alarm system fails
the procedure as per policy
is followed
Fire Drills are held twice
yearly per hospital as per
policy
All Fire incidents will be
reviewed as per policy
All organisation residences
receive fire safety
information
All areas have a trained and
up to date Fire Warden
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Committee
Frequency
Annual
Standard
Question
The organisation is meeting all statutory requirements
Fire Drawings for all premises are in place, available and within review
period
Has any new
Has a gap analysis If there were any Was the action plan Are there Fire
If no what's
requirements/regul been completed? recommendations, completed
Drawings for all the missing?
ations been
was an action plan
organistion
released since the
made?
premises?
last audit?
All Contractors
have completed
induction prior to
commencing
work
Are the drawings Are the drawings All contractors on
within the two year available on the site have a
review period? shared drive?
completed
induction form?
All organisation
premises have
fire resistance All areas within the organisation have an up to date Risk
All textiles and furniture confirm to the current fire code
Assessment
ratings and rate of
surface spread of
flame
All Contractors have a permit or hot permit to work
All contractors can Workshop manager
produce a work has a record of all
permit or hot permit contractors on site
on asking
at the current time
Workshop manager
has a record of all
isolated fire alarms
at the current time
Area where Fire
alarm is isolated is
aware and has
been given other
methods to raise
alarm if required
The area in which Work was stopped
hot works are
an hour prior to
undertaken is
finishing time
cleared prior to
commencing
Has there been any Have these been Do they meet the
new furnishings purchased through current fire code?
purchased
the Supplies dept?
following last
audit?
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Do the Fire
drawings have the
following on them:
Fire resistance
ratings of
structures
Rate of surface
spread of flame
The Fire Alarm system is checked as per policy
All areas within the is the risk
If it isn't how far The Fire alarms are The Fire equipment Fire hydrants and
organisation have a assessment within outside of the
checked weekly in each area is
mains are checked
completed risk
it's review period review period is it?
checked monthly yearly
assessment
(as per the risk
rating)?
If the Fire Alarm system fails the procedure as per policy is followed
Fixed CO2/
Sprinkler system is Has the Fire alarm Were extra patrols Were air horns
Drenching
checked six
failed since the last instigated?
issued to the
Instillation/ Dry and monthly
audit?
affected areas?
Wet rising mains
are checked
monthly
Were staff briefed Was a datix form
on alternative
completed?
methods of raising
the alarm?
Fire Drills are held twice yearly p
Was a fire drill
If no which sites
carried out on each were not covered?
Hospital site in the
last year?
Equality Analysis Form A
This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration
and approval.
PART 1
1.
Assessment Date: 25/04/2013
2.
Name of policy / strategy / service:
Fire Policy
3.
Name and designation of Responsible Officer:
Mr Steve Holland
4.
Names & Designations of those involved in the impact analysis screening process:
Mr Steve Holland Trust lead Fire Advisor Lucy Hall Equality and Diversity Lead
5.
Is this a:
Policy
X
Is this:
New

Who is affected:
Employees
X
6.
Strategy 
Revised
Service 
X
Service Users 
Wider Community

What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and
pasted from your policy)
The purpose of this document is to:
Explain the structure of the organisation and how fire safety will be managed.
Identify those personnel with specific duties and responsibilities and to indicate what those duties and responsibilities are.
Ensure that all staff are aware of their roles in ensuring a fire safe environment.
Give guidance and instruction to all members of staff
Page 67 of 70
7.
Summary of evidence related to protected characteristics and the policy, strategy, or service that you are analysing?
Protected
Characteristic
Evidence. Within the embedded
document highlight or add
evidence relevant to the policy,
strategy, or service that you are
analyzing. Highlight or add
relevant evidence about how the
Trust is meeting the needs of
people in various protected
Groups
Race / Ethnic origin
(including gypsies
and travellers)
Evidence around
communication needs. Some
H:\17-01-13\Hosp
patients and staff may not be
Trust\EDS\grades\2013 regrading\Race.ppt
able to understand the fire
action notices.
Steps to be taken to add
H:\17-01-13\Hosp
Trust\EDS\grades\2013 regrading\Refugees andpeople seeking
asylum.ppt to notices. ( Steve
pictograms
Holland) 6 months.
No evidence of any difference
for men and women.
No
Religion and Belief
No evidence of any difference
in relation to religion and
H:\17-01-13\Hosp
beliefs..
Trust\EDS\grades\2013 regrading\Religion and Belief.ppt
No.
Sexual orientation
including lesbian,
gay and bisexual
people
No evidence of any difference
in relation to Lesbian Gay and
H:\17-01-13\Hosp
Bisexual People.
Trust\EDS\grades\2013 regrading\Sexual orientation.ppt
No.
Age
No evidence of any difference
in relation to Young people.
H:\17-01-13\Hosp
H:\17-01-13\Hosp
Actions already taken in
Trust\EDS\grades\2013 regrading\Younger
Trust\EDS\grades\2013
Age.ppt
regrading\Older age.ppt
realtion to older people within
the policy
No.
Sex (male/ female)
Does evidence/engagement
highlight areas of direct or
indirect discrimination? If yes
describe steps to be taken to
address (by whom, completion
date and review date)
Does the evidence highlight
any areas to advance
opportunities or foster good
relations? If yes what steps will
be taken? (by whom,
completion date and review
date)
No.
H:\17-01-13\Hosp
Trust\EDS\grades\2013 regrading\Men and Women.ppt
Page 68 of 70
Disability – learning
difficulties, physical
disability, sensory
impairment and
mental health.
Consider the needs
of carers in this
section
Gender Reassignment
Marriage and Civil
Partnership
Evidence of communication
needs for disabled people, staff
training addresses this, PEEPS
to be included in the policy (
Steve Holland) GEEPS to be
discussed with ENT Opthalmic
and Older Peoples Services (12
months)
No evidence of any difference
in relation to Gender Reassignment
No.
No evidence of any difference
in relation to Marriage and Civil
H:\17-01-13\Hosp
Partnership
Trust\EDS\grades\2013 regrading\Marriage and civil Partnership.ppt
No.
Need to consider evacuation of
women giving birth and
undergoing caesarian section
Maternity Department
No.
H:\17-01-13\Hosp
Trust\EDS\grades\2013 regrading\Disability.ppt
H:\17-01-13\Hosp
Trust\EDS\grades\2013 regrading\GenderIdentity.ppt
Maternity /
Pregnancy
8.
No.
Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?
No
9.
Engagement has taken place with people who have protected characteristics and will continue through the Equality
Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement
in respect of any significant changes to policies, new developments and or changes to service delivery. In such
circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.
Do you require further engagement
10.
Yes
No
Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to life, respect for private
and family life, the right not to be treated in a degrading way, and the right to education?)
No
Page 69 of 70
PART 2
Print name
Steve Holland
Date of completion
25/04/2013
(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the
Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)
Page 70 of 70