Fire Policy – HSC003 - Northamptonshire Healthcare NHS

Fire Policy – HSC003
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Table of Contents
Fire Policy – HSC003................................................................................................................................ 1
Why we need this Policy ..................................................................................................................... 3
Regulatory Reform (Fire Safety) Order 2005 .................................................................................. 3
Fire Policy Statement ...................................................................................................................... 4
What the Policy is trying to do ............................................................................................................ 5
Which stakeholders have been involved in the creation of this Policy .............................................. 5
Any required definitions/explanations ............................................................................................... 5
Key duties ............................................................................................................................................ 5

Chief Executive ........................................................................................................................ 5

Trust Board.............................................................................................................................. 6

Board Level Director (Finance Director) ................................................................................. 6
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Fire Safety Manager (Head of Property Management) .......................................................... 6

Fire Officer .............................................................................................................................. 6

Nominated / Competent Person(s) ......................................................................................... 7

Capital Projects Manager ........................................................................................................ 7

All Managers – including Service Managers and Duty Managers ........................................... 7

All employees, visitors, contractors and temporary staff ....................................................... 7

Authorising Engineer (Fire) ..................................................................................................... 8

Fire Safety Committee (Health, Safety and Risk Committee) …………………………………………..…8

Premises with more than one Employer ................................................................................ 8
Policy detail ......................................................................................................................................... 8

Fire Statutory Standards Surveys - Risk Assessments ............................................................. 8

Fire Procedures, Procedures for Serious and Imminent Danger ............................................ 8

Operational Fire Risk Assessment ........................................................................................... 8

Fire Equipment Maintenance ................................................................................................. 9

Fire / Unwanted Fire Signals (Uwfs) Incident Reports ............................................................ 9

Purchase of Textiles and Furniture ......................................................................................... 9

Means of Escape ..................................................................................................................... 9
Training requirements associated with this Policy ........................................................................... 10

Mandatory Training .............................................................................................................. 10

Specific Training not covered by Mandatory Training .......................................................... 10
How this Policy will be monitored for compliance and effectiveness .............................................. 10
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For further information..................................................................................................................... 11
Equality considerations ..................................................................................................................... 12
Reference Guide ............................................................................................................................... 12
Document control details ................................................................................................................. 13
Appendix 1 - GENERAL FIRE PRECAUTIONS ...................................................................................... 14
Appendix 2 - OXYGEN CYLINDERS ..................................................................................................... 15
Appendix 3 - PERSONS TRAPPED IN LIFTS......................................................................................... 17
Appendix 4 - GAS SAFETY (CATERING) .............................................................................................. 19
Appendix 5 - FIRE DETECTION – I.T. SERVER ROOM ......................................................................... 21
Appendix 6 - PEEP ............................................................................................................................. 22
Why we need this Policy
A fire in a healthcare environment would pose a major threat to the lives of everyone within it, but
particularly to its patients. Therefore, hospitals and other healthcare premises, require a fire safety
policy based on avoidance of fire. In its event, there must be the means for rapid detection,
containment and staff supported by reliable and rehearsed procedures for removing patients to
places of safety. The policy needs a high level of management commitment and professional
competence. The whole policy must be supported by a procedure for appraising and re-appraising
fire precautions and for staff training and re-training. Fire code: ‘Policy and Principles’ provides the
framework for such a fire safety strategy.
Fire safety in the National Health Service is the concern of everyone. Every member of staff is
responsible for knowing the fire hazards within their working environment, practicing and promoting
fire prevention and knowing the right action to take in the event of a fire breaking out.
Regulatory Reform (Fire Safety) Order 2005
The policy document meets the requirements of the Regulatory Reform (Fire Safety) Order 2005.
The ‘Order’ replaces previous fire safety legislation. Any fire certificate issued under the Fire
Precautions Act 1971 will cease to have any effect. Therefore the organisation and staff must carry
out fire risk assessments and keep them up to date to ensure that all the fire precautions in the
premises remains current and adequate.
Responsibility for complying with the order rests with the responsible person. In a workplace, this is
the employer and any other person who may have control of any part of the premises, e.g. the
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occupier (tenant occupying a small area of the property or the sole tenant) or owner. In all other
premises, the person or people in control of the premises will be responsible. If there is more than
one responsible person in any type of premises (e.g. a multi-occupied complex) all must take
reasonable steps to co-operate and co-ordinate with each other.
The local Fire and Rescue authority will enforce the Order. The enforcing authority will have the
power to inspect Northamptonshire Healthcare NHS Foundation Trust premises to check that we are
complying with our duties under the Order. They will look for evidence that the Trust has carried
out a suitable fire risk assessment and acted upon the significant findings of that assessment. If the
enforcing authority is not satisfied with the outcome of the fire risk assessment or the action that
has been taken, they may issue an enforcement notice that requires certain improvements to be
made, or in extreme cases, a prohibition notice that restricts the use of all or part of Trust premises
until improvements are made.
Failure to comply with the order or any notice issued by the enforcing authority is an offence.
Note Responsible person can be the employer of persons working at the premises, a person who has
control of the premises or the owner of the premises
Fire Policy Statement
NHFT will meet its statutory duty under the Regulatory Reform (Fire Safety) Order 2005 (hereafter
referred to as the Fire Safety Order). The Trust will accept its responsibility as an employer under
the Department of Health Firecode and related European Commission / European Union Directives
(EC / EU), to provide a safe working environment for all of its employees, patients, visitors and
contractors with regard to fire safety in the workplace.
Additionally, the Trust will seek to promote fire safety awareness throughout its Healthcare
premises, through management initiatives, fire safety campaigns and mandatory fire training.
Without prejudice to the generality of that duty, the matters to which that duty extends will include,
for all premises:-





The provision of adequate means of escape.
Arrangements for detecting and giving warning in case of fire.
The provision of a means of fighting a fire appropriate to the risk and the maintenance of it.
Plans for serious and imminent danger in so far as it relates to the evacuation of premises.
Training for all staff in procedures to be followed in the event of fire appropriate to the risk,
fire drills and evacuation exercises as required by the Department of Health Firecode
guidance, with full accurate records to be maintained.
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

Fire risk assessments as required by the Fire Safety Order and EC / EU Directives.
In compliance with the Fire Safety Order, relevant guidance and related EC / EU Directives, the
Trust will conduct its activities in such a way as to ensure that people who may not be
employees, but who may be affected by those activities, are not exposed to risk to their health
and safety in relation to fire, e.g. the general public, contractors, employees of contractors,
patients and temporary workers.
All employees are reminded that they equally have a personal responsibility to safeguard themselves
and that their actions, either by instruction, example or behaviour; should not put other people,
plant or property in jeopardy or are to co-operate with the employer in regard to the Fire Safety
Policy
What the Policy is trying to do
To provide a safe working environment for all its employees, patients, visitors and contractors with
regard to fire safety in the workplace.
Which stakeholders have been involved in the creation of this Policy



Health, Safety and Risk Committee
Trust Policy Board
Fire Officer
Any required definitions/explanations
NHFT - Northamptonshire Healthcare NHS Foundation Trust
Key duties
Overall responsibility for fire safety will rest at the highest management level (The Chief Executive).
The Trust has also identified specific responsibilities to be discharged at various levels throughout
the organisation’s management structure.

Chief Executive
The Chief Executive is responsible for ensuring that current fire legislation is met and that,
where appropriate, Firecode guidance is implemented in all premises owned or occupied by
the NHS organisation. Chief Executives are required to have appropriate fire safety policies
and programmes of work in place, in order to improve and maintain fire precautions within
the organisation’s premises.
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
Trust Board
The Trust Board has corporate responsibility for the activities of the organisation, and should
ensure they have appropriate assurance that the requirements of the current fire safety
legislation are met and, where appropriate, that the objectives of Firecode are met.

Board Level Director (Chief Operating Officer)
The Director of Operations is the Trust Board level Director responsible for championing fire
safety issues at Board level. Part of this will include proposing programmes of work relating
to fire safety for consideration as part of the annual capital programme and business
planning.

Fire Safety Manager (Head of Property Management)
The Head of Property Management is the Trust Nominated Fire Safety Manager, within the
meaning set out in Department of Health, Firecode HTM 05-01 managing healthcare fire
safety, and will be responsible for ensuring the effectiveness of fire safety standards and
policy for all Trust premises.
The Fire Safety Manager will be the person within NHFT tasked with coordinating fire safety
issues throughout the organisations activities.
Duties and Responsibilities will include:
Fire safety features awareness and their purpose

Fire safety risks particular to the Trust

Requirements for disabled site users (staff, patients, visitors), related to fire
procedures

Ensuring appropriate levels of management are always available for decisions to be
made at all times during the day

Compliance with legislation

Review, development and implementation of the Trust’s Fire Safety Policy

Development of the Trust’s fire safety strategy

Development of an effective training programme

Co-operation between other employers, where two or more share the same premises

Fire incidents are reported in accordance with current practice

Monitoring review and mitigation of unwanted fire incidents

Liaison with enforcing authorities, and other managers as appropriate

Monitoring and inspection of fire safety systems
Fire Safety Manager will be responsible for informing the Fire Officer in respect of any new
properties and amendments to existing premises, and ensuring compliance with the means
of escape and fire provisions at all material times.
Fire Safety Manager will be responsible for the maintenance of fire precautions throughout
the Trust's premises.

Fire Officer
Fire Officer role will be provided by External Consultancy for all specialist matters, supported
by the Estates Technical Compliance Officer.
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Duties and Responsibilities will include:
Provide expert advice on the application and interpretation of fire legislation,
guidance, and Firecode

Advise on the content of the Trust’s Fire Safety Policy

Assist with the development of the Trust’s fire strategy

Aiding the development and delivery of a suitable training programme

Liaison with enforcing authorities on technical issues

Liaison with managers and staff on fire safety matters

Liaison with the Authorising Engineer (Fire)

Undertake / Risk Assessments Review

Advise Managers in the interpretation and application of relevant statutory
provisions, Department of Health Firecode and other guidance
The Fire Officer will prepare an annual fire safety report, the details of which will assist the
Chief Executive to sign the ’Annual Certificate of Fire Safety Management’.

Nominated / Competent Person(s)
All Premises and Departments will have a Nominated / Competent Person(s) and Deputy
who must be of sufficient seniority and proficiency, who must attend Responsible Person’s
Fire Training provided by the Trust, to enable existing Fire Precautions to be followed, and
ensure any relevant action plans are implemented with accurate records maintained.
Duties and Responsibilities will include:
Nominate Fire Wardens as appropriate

Act as focal point on fire safety issues for local staff

Assist in the fire safety regime within local areas

Support and raise local fire safety issues with line management

Assist in co-ordination of the response to a fire incident in the locality

Responsible for roll-call during a fire incident

Where appropriate, trained to tackle a fire with first aid fire fighting aids

Ensuring all fire related incidents are reported in a timely manner

Capital Projects Manager
The Capital Projects Manager, on behalf of the Trust, is responsible for liaison with the Fire
Officer in respect of the Trust’s new properties and amendments to existing stock, thus
ensuring compliance with the means of escape and provisions at all times.

All Managers – including Service Managers and Duty Managers
Managers will have a responsibility to ensure that their staff (and as appropriate, visitors,
contractors and temporary staff etc.,) adhere to relevant fire safety policies and procedures
within their respective areas of responsibility.

All employees, visitors, contractors and temporary staff
All individuals must co-operate with the NHFT to ensure the workplace is safe from fire and
its effects and must not do anything that will place themselves or other people at risk. ;
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
Authorising Engineer (Fire)
An external Fire Engineer / Consultant will only be engaged if necessary, where the in-house
resources have only limited expert knowledge. The role in all other cases will be carried out
by the Maintenance Manager.

Health, Safety and Risk Committee
The Health, Safety and Risk Committee will meet bi-monthly to monitor and review all fire
safety issues.

Premises with more than one Employer
Where shared premises exist, each employer shall be responsible for managing fire safety in
their respective area. Formal arrangements must be made to share information regarding
potential risks, emergency procedures, staff training, and full co-operation given by each
Employer to ensure that fire safety measures are not compromised.
Where shared common areas exist, (e.g. stairways, corridors) the host employer will have
the responsibility for managing fire safety. Full details of the responsibilities for shared
premises are given in ‘HSC007 - Shared Occupancy Policy’.
Policy detail
In carrying out the arrangements for implementing this policy, the Chief Executive, through the
Trust’s management structure, will address the following issues:
Fire Statutory Standards Surveys - Risk Assessments
Surveys and risk assessments and / or reviews, will be carried out annually by the Trust Fire
Officer.
Further advice and guidance is contained within the NHS Firecode suite of documents and
Guidance notes.

Fire Procedures, Procedures for Serious and Imminent Danger
The Fire Safety Manager (see key duties above) must ensure that fire procedures are in
place throughout the whole of the Trust’s premises, and the procedures include
arrangements for serious or imminent danger as set out in the Management of Health and
Safety at Work Regulations 1999 and as required by Emergency Planning.

Operational Fire Risk Assessment
The Nominated / Competent Person for each Ward / Department, in conjunction with the
Fire Officer, will ensure that there is a current Fire Risk Assessment which takes account of
all the risks relating to the premises and the operational issues of the service.
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The Nominated / Competent Person for each Ward / Department will ensure that The
Operational Plan / Fire Risk Assessment and all its records must be readily available at all
times, both for recording and inspection purposes.
A regular review will be carried out to ensure that all fire precautions are maintained.

Fire Equipment Maintenance
The Estates Department will ensure that fire equipment maintenance is carried out by an
approved contractor services (see key duties above), in accordance with the appropriate
British Standard.

Fire / Unwanted Fire Signals (Uwfs) Incident Reports
All incidents must be recorded in the Trust Datix web electronic incident reporting system, in
accordance with Trust Policy.
All actual fire incidents must also be reported by telephone to the Fire Officer at the earliest
opportunity.
All false alarms and near misses, should be only recorded on Datix.
All fire incidents and false alarms are the subject of a report using the NHS Estates Fire Data
System. This will be undertaken by the Trust’s Estates Department using the information on
Datix.

Purchase of Textiles and Furniture
Textiles and furniture used throughout Trust premises are only to be purchased in
accordance with the guidance set out in HTM 05-03 Operational Provisions Part C Textiles
and Furnishings. Where ‘safety ratings criteria’ cannot be met, i.e.; Community Homes,
items must fully comply with the Consumer Protection Act 1987, with all labels securely
fixed to the underside of the items purchased for future reference.
Budget holders must purchase items through the Trust’s Purchasing Department, with
companies who are recognised by the Trust for holding such approved contracts.
Note:
The flammability of all goods must be considered when purchasing all textiles and furniture
for use within the Trust. If there is any doubt then seek advice from the Trust’s Officer.

Means of Escape
Lifts must not be used when a fire alarm is activated or in the event of a fire situation. Each
premises Risk Assessment will have an individual procedure for those premises that have
lifts.
PEEPS (Personal Emergency Evacuation Plans) should be completed for these personnel who
require assistance during an evacuation: these plans should be completed at the earliest
opportunity in consultation with the Fire Officer and / or Health and Safety Advisor.
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Training requirements associated with this Policy

Mandatory Training
Training required to fulfil this policy will be provided in accordance with the Trust’s Training
Needs Analysis. Management of training will be in accordance with the Trust’s Statutory and
Mandatory Training Policy’
As detailed within HTM 05-01 AND HTM 05-03 the appropriate training of staff is deemed as
essential. The Trust policy dictates that all staff within an in-patient area will be required to
undertake face to face training annually. All other staff may undertake e-learning twice
within a three year period and face to face training once within the three year period.
Clearly as detailed within the training needs analysis all staff, particularly within higher risk
environments should discuss fire on a regular basis ensuring staff are fully aware of their
local duties and responsibilities and are familiar with the fire safety issues in their workplace.

Specific Training not covered by Mandatory Training
Ad hoc and refresher training sessions based on an individual’s training needs as defined
within their annual appraisal or job description.
How this Policy will be monitored for compliance and effectiveness
The table below outlines the Trusts’ monitoring arrangements for this document. The Trust reserves
the right to commission additional work or change the monitoring arrangements to meet
organisational needs.
Aspect of compliance
or effectiveness being
monitored
Duties
Review of:
 Current fire safety
management and
maintenance
procedures
 Changes in use of
premises
 Effectiveness of
communication
systems,
including fire
alarm and
detection systems
Method of
monitoring
Individual
responsible
for the
monitoring
Monitoring
frequency
Group or
committee
who receive
the findings or
report
To be addressed by the monitoring activities below.
Group or committee
or individual
responsible for
completing any
actions
Audit and
inspections
Fire Officer
Bi-monthly
Fire Officer
Health, Safety
and Risk
Committee
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 Local fire safety
policies
 Training and
incident
management, and
maintaining
accurate records
 Actions following
risk assessment
There can be more
than one aspect to be
monitored so list each
separately
If there is mandatory
Training will be monitored in line with the Statutory and Mandatory Training Policy.
training associated
with this document
state the mandatory
training here
Where a lack of compliance is found, the identified group, committee or individual will identify required
actions, allocate responsible leads, target completion dates and ensure an assurance report is represented
showing how any gaps have been addressed.
For further information
For any further advice, contact:Technical Compliance Officer.
Address:
Northamptonshire Healthcare NHS Foundation Trust
Estates Department
Manfield Court
Manfield Hospital
Kettering Road
Northampton
NN3 6NP
E-mail:
Tel:
Mobile:
Fax:
Vincent.penny@nhft.nhs.uk
01604 678034
07917 889350
01604 678194
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Equality considerations
The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact
of Policy changes for different groups within the community. In particular, the Trust is required to
assess the impact (both positive and negative) for a number of ‘protected characteristics’ including:









Age;
Disability;
Gender reassignment;
Marriage and civil partnership;
Race;
Religion or belief;
Sexual orientation;
Pregnancy and maternity; and
Other excluded groups and/or those with multiple and social deprivation (for example
carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless
people).
The author has considered the above and this is incorporated into the overarching health and safety
equality analysis.
Reference Guide
Regulatory Reform Act (Fire Safety Order) 2005
Disability Discrimination Act (2005)
Health and Safety at Work Act .1974
Management of Health and Safety at Work Regulations 1999
Department of Health Firecode suite of documents
Firecode Fire Safety in the NHS 05-01 Managing Healthcare Fire Safety
Firecode HTM 83 General Fire Precautions in Healthcare Premises
Firecode HTM 82 Fire Alarm Detection Systems
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Firecode HTM 87 Textiles and Furniture
BS 5306 – 1:2006 Specifications for Fire Hydrants
BS 5306 – 9: 2015 Code of Practice Portable Fire Fighting Equipment
BS 5839 – 1: 2013 Fire Alarm Systems
BS 5266 - 1988 Escape Lighting Systems
Document control details
Author:
Approved by and date:
Responsible Committee:
Any other linked Policies:
Policy number:
Version control:
Version
No.
Fire consultant
Trust Policy Board – November 2017
Health, Safety and Risk Committee
HSC001 - Health & Safety Policy
HSC002 - Policy and Guidance for the Use of Risk Register
HSC005 - Workplace Policy
HSCg003 - Shared Occupancy Guidelines
HSC003
Version 1:1
Date of
Next
Implementation Review
Date
06.07.2016
01.07.2019
Reason for Change (eg. full rewrite,
1.0
Date
Ratified/
Amended
06.07.2016
1.1
21.09.2017
22.09.2017
Updates to training section, change title
from fire safety advisor to fire officer,
update responsible committee to health,
safety and risk committee
21.09.2020
amendment to reflect new legislation,
updated flowchart, minor amendments, etc.)
New governance of trust policies
template.
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Appendix 1 - GENERAL FIRE PRECAUTIONS
All Managers and Fire Marshalls will have a responsibility for monitoring general fire precautions
within their respective areas and this will include the following:

Avoidance of the use of highly flammable materials or liquids whenever practicable.

Orderly methods of stacking in Stores where linen, paper or plastic packaging are used, to
reduce the risk of fire spreading and to assist fire fighting.

Storage of equipment and packages in designated areas only; not in Plant rooms, service voids
and shafts, corridors, lobbies and under stairs.

Regular checks to ensure that storage is never permitted in hospital corridors, escape routes, fire
exists or near fire-fighting equipment.

Positively discourage the drying of items over heaters having radiant heat sources, which can
lead to high temperatures and possible ignition.

Regular checks for the accumulation of rubbish in out-of-sight spaces, such as lift wells, behind
radiators, basements, dead-end corridors etc., Waste and unauthorised storage must be dealt
with promptly.

Correct storage of cleaning rags and materials in non-combustible containers after use.

When leaving places of work, checking for possible causes of fire e.g. unnecessary electrical
equipment left on or plugged in, gas appliances and other heat sources left on. Vulnerable doors
and windows should be secured against intruders.

When a television is not in use, check that the equipment is switched off, unplugged from socket
outlets and not left on stand-by.

Removal of unfused multiple point adaptors found in socket outlets and warning generally of
their use. Do not connect extension leads to extension leads.

Regular checking of electrical cables and cords for signs of wear and the immediate withdrawal
from service of any suspect electrical equipment, which must be reported to the Estates
Department for inspection and repair.

To ensure that the ‘No Smoking’ policy is enforced at all times.
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Appendix 2 - OXYGEN CYLINDERS

Oxygen cylinders are in everyday use in a healthcare environment and great care should be
taken when using and storing oxygen cylinders. Oxygen behaves differently to air, compressed
air, nitrogen and other inert gases. At high pressure, such as from a cylinder, pure oxygen can
react violently with some common materials, particularly oils and greases. Other materials may
catch fire spontaneously. Nearly all materials, including textiles, rubber and even metals will
burn vigorously in oxygen.

Even a small increase in the oxygen level in the air can create a dangerous situation. It becomes
easier to start a fire, which will then burn hotter and more fiercely than in normal air. It may be
almost impossible to put the fire out. A leaking valve or hose in a poorly ventilated room, or
confined space, can quickly increase the oxygen concentration to a dangerous level.

The main causes of fires and explosions when using oxygen are:




Oxygen enrichment from leaking equipment
Use of materials not compatible with oxygen
Use of oxygen in equipment not designed for oxygen service
Incorrect or careless operation of oxygen equipment

Oxygen enrichment is the term often used to describe situations where the oxygen level is
greater than in air. Oxygen is colourless, odourless and tasteless. The presence of an oxygenenriched atmosphere could not be easily detected by the human senses.

The main danger to people from an oxygen-enriched atmosphere, is that clothing and hair can
catch fire, causing serious or even fatal burns.

Oxygen enrichment is often the result of:






Leaks from damaged or poorly maintained hoses, pipes and valves
Leaks from poor connections
Opening valves deliberately or accidentally
Not closing valves properly after use
Poor ventilation when oxygen is being used
The following points should be taken into account for the continuing safety of staff and patients:
 Keep away from all flammable materials
 Keep all naked flames away from cylinders
 When not in use, place in store, keep the store locked shut and, if possible, the store
should have ventilation
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 If a store is not available, keep the cylinders in the same location and ensure good staff
discipline
 If a cylinder should leak, it must be taken outside immediately and Estates Department
informed. If this type of incident occurs on a hospital site, Porters will assist
 Ensure new members of staff are aware of the location of oxygen cylinders
 Staff are to be deemed competent in the use of oxygen

If oxygen cylinders or equipment are used carelessly or incorrectly, then a fire may result. All
users of oxygen should know and understand the dangers and should receive training in the use
of oxygen equipment.

There are a number of precautions to follow when using oxygen equipment:
 Handle oxygen cylinders carefully; use a purpose built trolley to move them
 Keep cylinders chained or clamped to prevent them falling over
 Store oxygen cylinders, when not in use, in a well ventilated storage area or
compound, away from combustible materials and separated from cylinders of
flammable gas
 Keep oxygen equipment clean. Contamination by particulate matter; dust, sand,
oils, greases or general atmospheric debris, are a potential fire hazard. Portable
equipment is particularly susceptible to contamination and precautions should be
taken to keep it clean
 Use clean hands or gloves when assembling oxygen equipment e.g. attaching the
pressure regulator or making connections
 Wear suitable clean clothing, free from oil and easily combustible contaminants
 Check that fire extinguishers are in good condition and ready for use
 Check that escape routes are clear
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Appendix 3 - PERSONS TRAPPED IN LIFTS
Many people each year are involved in lift incidents and the Fire Service is frequently called in for
assistance with this type of ‘Special Service’. Because of this, the Trust has introduced a procedure
to deal with the possibility of lift incidents occurring within Trust premises.
Lift rescues can be divided into two principle classes:
1. Those where people are shut in a lift car because of malfunction
Actions to be taken:
 In the event of a lift failure, telephone (9) 999 for the Fire Service. This will mean you
have an instant response, as engineers may not always be readily available
 Inform the Trust Duty Engineer by contacting the Berrywood Hospital Switchboard,
telephone 01604 682682.
 Ensure you have someone to meet the Fire Service and to take them to the Lift Motor
room.
 Communication is paramount – if someone can talk to the people trapped inside the lift
and keep them informed of the action you are taking, this will help any person,
particularly of a nervous disposition, to remain calm. All lifts are fitted with a ‘Fall Safe’
device and cannot ‘free-fall’ even with a damaged cable.
 Do not allow anyone to attempt to use the lift; cordon off all lift doors and if possible,
have someone in attendance to prevent others from using the lift.
 Information that the Fire Service will require:
-
the number of persons trapped in the lift
what type of persons / patients they are
how are they reacting to the emergency
 After the rescue, some people may be suffering from stress and may require medical
attention. If possible, have a trained First-Aider available to assist
2. Those where someone has been trapped in the lift mechanism
(The above is only likely to occur when Lift Maintenance Engineers are testing or repairing
lifts)
Actions to be taken:
 In the event of someone being trapped in the lift mechanism, telephone (9) 999 and
inform the Fire Service. Give the Fire Service as much information as possible and
emphasise that persons are trapped in the mechanism. The correct information will
mean the Fire Service immobilising an emergency tender. This appliance carries
equipment to deal with this situation and the Fire Service Control will alert an
ambulance.
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 Inform the Trust Duty Engineer by contacting the Berrywood Hospital Switchboard,
telephone 01604 682682.
 Ensure a member of staff meets the Fire Service and directs them to the Lift Motor
Room
 Before the arrival of the Fire Service, inform the person/s trapped, what action has been
taken and tell them that help is on the way
 Do not allow anyone to attempt to use the lift. Cordon off all lift doors and if possible,
have someone in attendance to prevent others form using the lift
It is obvious that the second situation is the more serious; however, it can be very stressful
for the person/s trapped in the lift, as some of our patients may be elderly, infirm and
some may have a mental disorder.
INFORMATION THAT WILL ASSIST THE FIRE SERVICE

Attempt to find out who is trapped e.g. the Lift Maintenance Engineer, as they may be able
to advise or assist the Fire Service

Action to take after the rescue: Assist the Fire Service if requested and keep people away
from the incident

No untrained staff should attempt to release trapped people – this could cause further
problems
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Appendix 4 - GAS SAFETY (CATERING)
1.
2.
3.
Procedure in the event of a fire or fire alarm activation

Ensure that all gas supplies are shut off using the mains valves

Ensure that all cooking appliances are turned off and any hot pots and pans removed to
a safe location

Evacuate the kitchen if required
Ventilation

Kitchen ventilation is required to create a safe and comfortable working environment.
Catering and cooking can produce significant quantities of fumes and vapours, as well as
large amounts of heart. Ventilation is necessary to remove theses and discharge them
to a safe external location

It is particularly important to provide adequate ‘make-up’ air for gas-fire appliances. The
term ‘make-up’ air, relates to the provision of an adequate supply of air via a ventilation
system, or by using a flueing system. Inadequate ventilation or flueing arrangements,
can lead to incomplete combustion and the accumulation of combustion products, such
as carbon monoxide.
Manually ignited gas-fire catering equipment
In order to comply with guidance and legislation, the Trust should:
4.

Give training and instructions on safe systems of work on catering equipment and
provide adequate supervision

Where it is reasonably practicable, fit flame failure devices to older equipment that does
not have such components

Have appliances serviced regularly in accordance with the manufacturer’s instructions
and with due regard to safe working procedures
Safety during emptying and cleaning of fryers
Hazards connected with emptying and cleaning fryers include fire, burns from hot oil,
contact with hot surfaces and fumes from boiling cleaning chemicals and the danger of the
chemicals overflowing.
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Manual emptying and filtering of fryers should only be carried out when the oil has been
cooled to 40 degrees Celsius.
It is essential that:

Staff are trained in safe procedures for emptying and cleaning

Staff are provided with suitable protective equipment, where required by the risk
assessment, e.g. eye protection and heat-resistant gloves etc.,

The dryer must be well maintained and any attachments used must be suitable for their
purpose, as recommended by the manufacturer

Any oil spillages must be cleaned up immediately, ensuring floor areas around
equipment are completely clean and dry to avoid slip risks

Most catering establishments are closed overnight for at least eight hours. For fire
safety and economy, fat fryers must be switched off when unattended. It is best
practice for manual oil filtering and cleaning to be carried out as a first task of the day,
rather than as part of the closing-down procedure
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Appendix 5 - FIRE DETECTION – I.T. SERVER ROOM
Fire detection and prevention arrangements in I.T. Server rooms
The Fire Officer will liaise with IM&T to ensure that all Server rooms are provided with adequate fire
detection and compartmentalisation as necessary. Additional detection and fire fighting equipment
may be required, but will be subject to a fire risk assessment to ensure that the correct level of cover
is provided. IM&T should contact the Fire Officer for advice when new Server rooms are required, or
if any structural changes are made to existing facilities.
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Appendix 6 - PEEP
Emergency Evacuation Arrangements (for people with disabilities or requiring additional
assistance)
General
Arrangements for safe egress to evacuate a building must be matched with the arrangements for
building accessibility. An evacuation plan must not rely upon the intervention of the Fire and
Rescue Service to make it work.
There are two areas of emergency evacuation which must be considered for people with disabilities
or who require additional assistance:
1.
A personal emergency evacuation plan (PEEP) for staff and regular visitors
2.
A general emergency evacuation plan (GEEP) for visitors or casual users of the building who
may be present infrequently, or on only one occasion. The groups of people who should be
considered include; staff, contractors, visitors and patients.
Responsible person
Depending upon the layout and occupancy within premises, the following responsibilities may rest
with either the direct line manager or person in control of the premises. (Where plans are required
for employees, the line manager is normally responsible for the development, implementation of
the PEEP and communicating information to other relevant parties).

Ensure that appropriate training required by employees who are involved in the evacuation
process is provided, for example, evacuation chair for use by mobility impaired persons training
(please note – Fire Marshal Training is provided by the Trust for Trust Managed Property).

Ensure that PEEP’s and GEEP’s (see above) within their areas of control, are kept up to date,
reviewed and changes are communicated to relevant parties.

Ensure that there is no conflict between plans in buildings. For example, ensuring that there are
adequate evacuation chairs for use by mobility impaired persons
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in a communal area if a ‘One off’ event is taking place.

Work co-operatively and communicate with landlords / others who are on the premises
(including where ‘One off’ and regular events are taking place, which people may assemble at).

Ensure that any identified roles are re-allocated for periods of absence when needs are initially
assessed.

Ensure that equipment (e.g. evacuation chair for use by mobility impaired persons ) are provided
and stored in an appropriate location.

Ensure that any equipment provided is adequately maintained and inspected.

Ensure that Personal Emergency Evacuation Plans described in this document, are put in place as
soon as possible, for example, prior to employment commencing where possible.

For Public Access Buildings – ensure that reception staff are aware of action to take if they are
asked about assisted escape for visitors.
Co-ordinating roles may be necessary, in order to ensure that plans provided are understood
throughout the building / working areas. Responsibility for ensuring this is carried out rests with the
manager.
Employees

Notify their line manager of any circumstances which give rise to the requirement to have a
PEEP as soon as possible, OR, as soon as they are aware of any circumstances that might affect
their ability to evacuate the premises, using the existing standard evacuation arrangements
which are in place

Work co-operatively with management to ensure that PEEP’s and GEEP’s are implement

Attend relevant training as required
Patients / Clients
Patients, who are deemed as in-patients, should be assessed to determine their requirements for
safe evacuation if appropriate. This should be included as part of their care plan whilst they are on
Trust premises.
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Consideration should be given, based on their impairment and could include room location within
the ward that provides safe evacuation if kept within their bed.
The provision of additional evacuation aids, for example, evacuation sheets or wheelchairs.
Visitors

In buildings, visitors are encouraged to identify where they require additional assistance in line
with notices provided at the entrance, reception area or in meeting rooms.

Visitors are required to provide specific information where requested on event booking forms.
Ensure that fire risk assessments carried out for the Trust, consider the requirement to provide
GEEP’s as part of the assessment process.
Planning for the evacuation of people who require assistance
The findings contained in the fire risk assessment should be used for reference with this guidance.
PEEP
Most people have a very clear idea of what it will take to get out of the building. In some instances,
the person will be able to facilitate escape if suitable aids and adaption’s have been provided. The
person who is writing the plan should not make assumptions about the abilities of a person and
ensure that the plan is written with the person involved. The workplace(s) and evacuation routes
should be visited with the person the plan is being written for, this will ensure that individual needs
are taken into account.
Where third party premises are visited during the course of work, information should be sought
from the employer to establish the general arrangements in place.
All parties who are involved in ensuring that the PEEP is effective, should be given all relevant and
appropriate information, instruction and training.
A record of the PEEP must be made and be provided in an accessible format for the employee.
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GEEP
GEEP’s are written general procedures that can be used as options for people to choose from who
casually visit the building, or visit on a ‘One off’ basis. An assessment of the types of escape that can
be provided within the building should be carried out. GEEP’s should be held at reception points
within the building, advertised and offered to people as part of the entry / booking / reception
procedure. A person requiring assistance should be offered options and suitable instructions.
Where a person who requires assistance makes their needs known to a member of staff on their
arrival, then the choice of plan can be made at that time.
Where there are visitors who do not pass reception (for example, within a library) it is more difficult
to discuss and arrange a GEEP with that person. Information can be posted around the building and
staff training carried out on the basis that a plan may need to be put into action without prior
notification. An assessment will identify where equipment will be needed, for example, the
provision of evacuation chairs at suitable points.
Information for Plan Development
Both PEEP’s and GEEP’s should consider and communicate the following information:

The Fire Risk Assessment for the premises and activities (building features and fire protection)
including the means of raising alarm, fire compartments, escape routes, numbers of visitors and
site users who will be using escape routes.

Individual requirements including; unaided movement levels, if assistance is required, what rest
periods may be needed, can a disability be made worse e.g. by smoke, time needed for
evacuation, how will the individual be made aware that the alarm is sounding.

Management and staffing levels needed to implement the plan

Existing emergency evacuation arrangements and means of escape available including;
compartmentation, location of the fire compartments, evacuation chair for use by mobility
impaired persons provision, if there is an opportunity to use lifts and their locations, orientation
information, step markings, appropriate handrails.

What adjustments need to be made, for example, contrasting colours.
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
Information required including; how the alarm is raised, accessible formats of fire instruction
required, routes to be taken, hazards when moving around premises.
Additionally a PEEP should consider:

The job / tasks undertaken by the individual, for example; lone working, places of work, team
members.
Training and Information
Staff who provide assistance to users of the building during an evacuation, must receive training. An
assessment of training needs may include the following:

Technical building information, for example, if the building has fire compartmentation to allow
for horizontal evacuation as part of the plan, then those involved must understand why this is
possible.

The contents of emergency evacuation plans that they are involved in.

Evacuation chair for use by mobility impaired persons training and the full evacuation procedure
for the building.

Moving, handling and lifting techniques

How to respond to visitor requests for assisted evacuation.
Practice
Generally, all escape plans should be practiced at least every six months. Some evacuation plans will
need testing more frequently (and may also be recommended by a supplier or specialist). Practicing
a plan should not include the disabled person where there is a risk of their injury when being
assisted and should be discussed with the member of staff. People with learning difficulties may
need to practice on a monthly basis. The practice interval should be included in the written plan.
Review
Review must take place where there are any changes in circumstances that may affect the plan. This
includes changes to the location of the work, changes to the building or its fire safety features and
also changes in the individual’s condition. Otherwise, PEEP’s and GEEP’s must be reviewed for
overall effectiveness after twelve months.
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