worcestershire acute hospitals nhs trust PAPER L – APPENDIX

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worcestershire acute hospitals nhs trust PAPER L – APPENDIX Powered By Docstoc

Subject: Report by: Purpose:

Annual Fire Safety Report Peter Male – Director of Facilities, Estates and PFI To provide assurance to the Board that appropriate fire safety measures have been in place during 2006/07

Recommendation: The Committee is asked to note the contents of this report 1. 1.1 Introduction The year under review has seen steady progress within the Trust against a backcloth of significant changes in legislation. A major reform of fire safety legislation occurred with the introduction of the Fire Safety Order on 1st October 2006. The Trust’s current fire safety arrangements are in line with the new statutory requirements. During the year there have been no RIDDOR reportable fire incidents. However there have been 6 fires of a minor nature, in Acute Trust areas, together with 4 others in Mental Health Trust and PCT occupied areas on Acute sites. Fire Policy and Procedure Document The introduction of the new Fire Safety Order has been the most radical overhaul of fire safety legislation in the UK for over 30 years. All existing legislation was repealed and consolidated in the new Order. This included the 1971 Fire Precautions Act and the associated issue of fire certificates, and the 1997 Workplace Regulations. However the risk assessment rather than prescriptive approach to fire precautions introduced in the Workplace Regulations is adopted in the new legislation. This also introduced the concept of the Responsible Person who is responsible for ensuring compliance with the legislation. In addition to the named individuals notified to the Fire Brigade as the lead and liaison persons on each site, the Fire Safety Order also makes it clear that the body corporate i.e. “the Trust” can also be regarded as the Responsible Person, as indeed can anyone whom it can be shown is responsible (via consent and neglect) for committing an offence under the Order. Furthermore punishment takes the form of a criminal rather than a civil action which can result in either a fine or imprisonment for up to 2 years. 1




2. 2.1




The Responsible Person in a workplace is usually the employer and in multi-occupied premises there is a duty placed upon all parties to cooperate and co-ordinate with one another. 2.4 The Government has issued a series of specialist guides to assist the implementation of the Order including one entitled “Fire Safety Risk Assessment in Healthcare Buildings”. In addition, the Department of Health has reissued the Firecode suite of guidance documents for existing and new build healthcare accommodation which now reflects the requirements of the Fire Safety Order. The Building Regulations have also been revised. Linked to the introduction of this new legislation, the Fire Brigade are now taking a more proactive approach to the major sources of call-outs as part of their Integrated Risk Management Plans – a risk based approach to managing fire risks within their area. In view of both the level of risk and high number of incidents (mainly false alarms), hospital premises feature as top priority premises in the Brigade’s plans. Brigade representatives have held meetings on each site with designated Responsible Persons and the Trust Fire Safety Adviser to review risk assessments, maintenance and training records and discuss steps being taken to reduce repeated sources of false alarms. The Brigade are also required to visit the site of a real fire within 5 days and make a report. At the same time they discuss with managers the steps being taken to prevent a recurrence. Internally an amendment was made to the Worcester Site Fire Incident Action Plan from 4/9/06. From this date the Bed Manager replaced the Trust Duty Manager as the Assembly Point Co-ordinator in both WRH and the Aconbury buildings. They would however contact the Duty Manager if an incident proved to be a real fire. Fire Incidents The number, type and location of all fire incidents are regularly reviewed at the quarterly Trust Fire Safety Group meetings and trends analysed. In addition, as noted above, a routine visit from the Fire Brigade is also now received following any real incidents whether major or minor. During 2006/07 there were 10 real incidents of which 3 related to deliberate patient action in Mental Health Trust accommodation on the Newtown and Kidderminster sites and one related to a PCT managed area – smoking battery charger on a patient hoist in the GP ward at Kidderminster Hospital. Of the remaining 6 incidents in Acute Trust areas these were equally divided between the Worcester, (1Newtown, 2 WRH) and Redditch sites, and can be summarised as follows:



3. 3.1




3.3 Worcester A/E Department -Patient smoking in disabled toilet then put cigarette into waste bin causing some small degree of smoke -Smoke from fan motor -Smoking nurse call system power supply

Catalyst security control room Maple Ward Alexandra Estates car park Residences General Management 3.5


Spontaneous combustion of contractor's car due to electrical fault Grilled chicken caught fire Microwave in kitchen produced smoke

The largest fire was that relating to the spontaneous combustion of the contractor's car at the Alexandra Hospital. The incident relating to the smoking nurse call system on Maple Ward caused concern and was followed by a full debrief meeting including representatives from all relevant Trust and Catalyst departments. The outcome was the immediate introduction of a loaned radio operated nurse call system followed by installation of a new system. In line with Firecode both real and false alarm incidents are required to be reported online to NHS Estates. The table below shows the total number of false alarm and real fire incidents by site during 2005/6 and 2006/7. False Alarms 2005/6 2006/7 27 20
(mainly MHP)



Worcester Kidderminster

Real Fires 2005/6 2006/7 0 5
(2 MHP)


(mainly MHP)

(Mental Health Accommodation)

(1 PCT and 1 MHP)

Alexandra Totals 4. 4.1 Fire Training

61 117

53 102

0 3

3 10

The Trust’s Fire Safety Adviser continued to provide a full training programme on all three sites including induction and refresher training and bi-monthly fire warden and fire team training sessions. Dedicated fire training sessions were also provided for all staff working for our PFI partners in Worcester. The overall level of fire training achieved was 43%. In addition the monthly programme of unannounced fire drills provided a further practical fire training component – see below.



4.2 The Fire Adviser also prepared new diagrammatic handouts for fire team members showing the functioning of the fire team radios used on each particular site. The handouts also summarised the designated locations on each site of the differing members of the fire team during an incident. Fire Drills The monthly programme of unannounced fire drills continued on the Alexandra and Kidderminster sites and commenced at Worcester during 2007. These drills provide practical training for both fire team members and ward/departmental staff and fire wardens. Any training and maintenance deficiencies are also highlighted. A verbal debrief with attending staff occurs at the end of each drill. The written fire drill reports subsequently prepared incorporate an action list and are distributed to relevant managers. They are also routinely reviewed at the quarterly Trust Fire Safety Group. Risk Assessments The Trust’s Fire Safety Adviser undertook annual fire risk assessments on all sites in line with the requirements of the new Fire Safety Order and prepared prioritised action lists of matters requiring attention. These were costed by the Facilities Directorate and business case submissions made for funding essential works. Work will shortly commence on the fitting of new fire alarm panels on the Alexandra site – the first phase of a major scheme to replace all the fire alarm system which is now nearly 20 years old. During the latter part of the year Vita commenced a scheme at Worcester to effect repairs to all the fire doors in the New Hospital, in line with recommendations in the fire risk assessments. A separate fire stopping repairs scheme in the roof spaces has also been carried out during the year. Annual Firecode Certificate and Firecode Compliance This was signed by the Chief Executive and submitted to the DoH in January 2007 following receipt of a report by the Trust’s Fire Safety Adviser confirming compliance with Firecode and the new Fire Safety Order requirements. Construction Projects All major capital schemes completed during the year received the requisite building regulations approvals which incorporate fire safety provisions. Fire precautions advice is obtained from the Trust’s Fire Safety Adviser during the detailed planning stage for all major projects.

5. 5.1

6. 6.1


7. 7.1

8. 8.1




9. 9.1 Trust Fire Safety Group In line with the requirements of Firecode, the Trust has a Fire Safety Group which meets quarterly to review fire policy and procedures and monitor fire incidents/false alarms, fire drill reports and risk assessments. Trends are analysed and actions monitored. The Group is chaired by the Director of Facilities, Estates and PFI and includes representation from Catalyst, Vita, ISS and the Mental Health Partnership Trust Risk Manager. The Fire Brigade’s Fire Safety Manager (Northern District) attended one meeting during the year. Recommendation


10.1 The Committee is asked to note the content of this report.

Peter Male Director of Facilities, Estates and PFI