Docstoc

Annual Report Fire Safety

Document Sample
Annual Report Fire Safety Powered By Docstoc
					Annual Report
   Fire Safety
               2008/2009




            Prepared by: GP Tibbs
 Fire Safety and Security Manager
Contents

Introduction                                                                     3
Staff Training                                                                   3
Fire Safety Policy/Procedures                                                    3
Unwanted Fire Signals (UwFS)                                                     3
   Unwanted fire Signals from NUH sites                                          4
   Queen’s campus breakdown of UWfs & fire sources                               4
   City Campus breakdown of UWfs & fire sources:                                 5
   Unwanted Fire Signals Statistics                                              5
Fire Risk Assessments                                                            5
Fire Safety Capital Investment for 2008/2009                                     6
The year ahead and priorities for Fire Safety in 2009/2010                       6
   Fire Risk Assessments                                                         6
   Training                                                                      6
   Training Objectives 2009/10                                                   6
   Unwanted Fire Signals                                                         7
   Unwanted Fire Alarm Reduction Targets for 2009/2010                           7
   Fire Safety Management                                                        7
   Fire Safety Capital Investment                                                8
Appendix A                                                                       9
2008/09 Action/Implementation Progress Plan and Revised Completion Targets       9
Appendix B                                                                      12
2009/10 Action/Implementation Plan and target setting                           12




Annual Fire Safety Report 2008/09                                       Page 2 of 13
Introduction
Nottingham University Hospitals NHS Trust has a statutory responsibility to ensure that
all of the premises owned and operated by the Trust comply with current fire safety
legislation, and Department of Health guidance. The Trust must ensure that effective
arrangements are in place for the management of fire safety and implement any
necessary improvements or adjustments required which relate to an increased fire risk
potential.

The purpose of this report is to inform the Trust Board of the current state of fire safety
provision in all Trust premises, and indicates where further fire safety related
improvements are necessary.

Staff Training
During 2008/09, fire safety training was delivered through mandatory training days. To
further assist managers to meet their statutory/mandatory obligations it was supported
by specialist ward/departmental specific training delivered directly in the workplace.

A total of 6261 staff (49.2%) were trained in fire safety during 2008/09.

Fire Safety Policy/Procedures
The Trust Board approved a revised and updated fire safety policy on 2nd April 2009;
this is available on the Trust Intranet. There are some further supporting procedures
which were developed in 08/09 which will be implemented through 09/10:-

   •   Workplace Fire Safety Guidelines
   •   Guidelines on the reduction of unwanted fire signals
   •   Arson Management Policy

Unwanted Fire Signals (UwFS)
The Trust continues to make strenuous efforts to reduce the number of unwanted fire
signals (UwFS) generated from its three sites. Ropewalk House, by its nature of being a
small site, causes few problems with UwFS.
The City campus and QMC campus generated between them 539 fire signals to the
Nottinghamshire Fire and Rescue Service during 2008/09. This is an overall increase of
8% on the 2007/08 figure of 496.
Whilst the number of calls generated may have risen it is reassuring to see that the
number of unwanted fire signals is showing an overall reduction of 4% across the Trust
by comparison to 2007/08. Whilst a contradiction to the former paragraphs it is a clear
indication that the message delivered through fire safety training of the need to reduce
unwanted fire alarm signals is being acted upon. In addition, the QMC campus has
seen the opening of the new Nations Treatment Centre in the last twelve months which
has had an impact (see table page 3) on the number of fire alarm calls generated from
the QMC campus.
Investigation into the root cause of unwanted signals has revealed that a significant
number result from inadequate local practices. It is estimated these are in the region of
10 – 16% per quarter.



Annual Fire Safety Report 2008/09                                               Page 3 of 13
Unwanted fire signals are not solely the responsibility of NUH (see table 2 below) and
are also produced by organisations occupying NUH premises as detailed in the
following tables.


Unwanted fire Signals from NUH sites
Table 1
                   Number           Overall           Number       Trend        2008/09
                   of UWfS          Trust             of UWfS
                                                                                 Target
                                    Percentage
                   2008/09                            2007 / 08
Ropewalk                 2              1%                2         No        No target set
House                                                             change
City campus            177             37%              185          4%          25%
                                                                  reduction    reduction
Queen’s                297             62%              311          5%          10%
campus                                                            reduction    reduction
Total                  476                              498         4%            35%
                                                                  reduction    reduction


Queen’s campus breakdown of UWfs & fire sources

Table 2                             Number of UWfS                  Overall Percentage
             NUH                                 167                            56%
 Nottingham Healthcare                           84                             28%
University of Nottingham                         23                              8%
    Medical School
    Nations Healthcare                           23                              8%
Total UWfs                                       297
Other Calls
Good Intent                                      18                             49%
(smell of burning etc.)
Special Services                                  8                             22%
(Cutting off jewellry for
ED – Chemical spills –
floods etc)
Minor Fires                                      11                             29%
Total fire signals                               37




Annual Fire Safety Report 2008/09                                                       Page 4 of 13
City Campus breakdown of UWfs & fire sources:

Table 3                             Number of UWfS              Overall Percentage
NUH                                            177                            100%
Total UWfs                                     177
Other Calls
Good Intent                                    18                             64%
(smell of burning etc.)
Minor Fires                                    10                             36%
Total fire signals                             28


Action is underway to improve the level of detailed information on UwFS at the City
campus. There remains a reporting deficit against Trust policy in relation to fire alarm
actuations at this time which the fire safety training programme will assist in addressing.
This level of unwanted fire alarm actuation, whilst reducing, continues to have an impact
on the reaction of building occupants. This in turn causes a potential disregard of the
fire alarm. This not only increases the potential risk of harm but also gives the wrong
impression to members of the public, patients and visitors that frequent Trust premises.


Unwanted Fire Signals Statistics
Table 4
 Site     UwFS          Trigger       Number of      Firecode   Comment
                        devices       Actuations      Grade
                                       per 1000
                                       Devices
 QMC       297          30,000           <12            A       Continue to manage as we
                                                                are.
 City      177           7,000           >23            D       Must aim to reduce the number
                                                                of unwanted fire signals over the
                                                                next twelve months.
                                                                On this basis the City is 150%
                                                                worse for UWFS than the QMC
                                                                campus.




Unwanted fire signals from Trust premises are decreasing and are heading toward
levels that will be acceptable under NHS guidance [Firecode HTM 05/03 Part H]. The
ongoing aim is to reduce, to as low as practically possible, all unwanted fire signals from
Trust premises.

Fire Risk Assessments
Fire risk assessments and follow up reviews are being carried out on a rolling
programme across all Trust premises. The main issues were identified at the City
campus and will require capital investment. The Fire Safety and Security Manager has
been tasked to write a business plan for submission to the IGC for funding to improve
the standard of fire safety and detection within the Trust’s premises.

Annual Fire Safety Report 2008/09                                                     Page 5 of 13
Fire Safety Capital Investment for 2008/2009
The following table shows the fire safety improvements made within the Trust during the
2008/2009 financial year.

Table 5

 Campus           Fire Safety Improvement                                        Cost
 City             Partial upgrade of fire alarm system at St Francis.            £8 000
 City             Upgrade of fire precautions on Edward 2 and Harvey 2           £25 000
                  ward areas.
 City             Fire alarm upgrade in Physiotherapy outpatients’ area.         £76 000
 City             Replacement of obsolete fire alarm control panels that         £38 000
                  are no longer supported by the manufacturer.
 QMC              Survey and outline of fire damper provision within South       £10 000
                  and East Blocks.
 City             Installation of fire alarm detection in electrical sub- £58 000
                  stations.
 City             Completion of fire doors upgrade along the South £11 770
                  Corridor.
 Capital Fire Safety Budget 2008/2009                           Investment £226 770



The year ahead and priorities for Fire Safety in 2009/2010

Fire Risk Assessments

The financial year 2009/2010 will see the start of the risk assessment review process.
At this time it is anticipated that the review process will last for four consecutive years
up to 2012/2013 with a full fire risk re-assessment taking place in year five (2013/2014).

Training

The remaining fire safety courses that have been developed will be delivered in
2009/2010 to bring the Trust’s fire training into line with the requirements of the current
fire safety legislation.

Fire Wardens have been identified by their respective line managers for most areas
within the Trust as required under article 13 of the Fire Safety Order 2005. By the end
of March 2010 it is anticipated that the Trust will have trained sufficient numbers of Fire
Wardens to carry out the appropriate local duties within Trust’s premises, enabling the
Trust to comply fully with article 13.

Training Objectives 2009/10

 1      Roll out practical evacuation training across the Trust
 2      Roll out lecture theatre based delivery program for evacuation theory
 3      Roll out program for fire evacuation exercises
 4      Carry out an environmental Risk Assessment for practical fire training
 5      Deliver practical fire training module


Annual Fire Safety Report 2008/09                                                 Page 6 of 13
Unwanted Fire Signals

2009/2010 will see the introduction of Trust developed guidelines for the reduction of
unwanted fire signals. The guidelines will assist local managers to ensure that all
reasonably practical measures are implemented to reduce the number of unwanted fire
signals generated from their areas.

The QMC campus continues with a performance grading of ‘A’ for the management of
unwanted fire signals. (As defined in Firecode HTM 05/03 Part H Reducing Unwanted
Fire Signals in Healthcare Premises ) This means our current management processes
are adequate as we produce less than 12 actuations per 1000 devices.
The City campus has a performance grading of ‘D’ for the management of unwanted fire
signals. To attain an ‘A’ grading equivalent to the QMC’s performance all organisations
based on the City campus (NUH and its third party occupiers) must aim to reduce the
number of unwanted fire signals by at least 40% during 2009/2010.
All areas should continually review and monitor their working practices and
environments in line with the automatic detection provided; paying particular attention
to, the sighting and use of, cooking equipment [Toasters, Kettles, Microwaves, etc.] and
the practice of wedging open kitchen doors. By taking these simple actions it is
possible to gain a reduction of up-to 13% per quarter in the number of unwanted fire
signals generated.


Unwanted Fire Alarm Reduction Targets for 2009/2010
Queen’s campus                         10% reduction – maximum of 267
City Campus                            40% reduction – maximum of 106
Ropewalk House                         100% reduction - 0

Fire Safety Management

The final parts of the Trust’s fire safety strategy will be put into place with the
introduction of fire wardens across the Trust in 2009/2010. The campus fire safety
officers will hold meetings with the fire wardens on a regular basis to ensure that there
is effective communication throughout the Trust. A system of Fire Forums is to be put
into place and Directorates will be asked to identify individuals to take a directorate lead
for fire safety. Fire Forums will allow issues to be addressed quickly to share information
on good practice across the Trust.

The campus fire safety officers will identify specific localised shortfalls in the reduction
of unwanted fire signals; and will engage all staff to actively assist in reducing the
number of unwanted signals.

The fire safety team will identify areas where there are no evacuation plans in place and
assist managers of those areas to formalise their local evacuation plans. The objective
is that all areas will have an evacuation plan in place by the end of March 2010.

Work will be completed with the Emergency Planning/Business Continuity Team to
ensure the Trust is well prepared should the need arise to totally evacuate any of its
buildings.
The review and development of policy for responding to chemical incidents to ensure
that the appropriate Trust and local plans and procedures are in place and
implemented. This work will be carried out in conjunction with the Trust’s Health and
Safety Team.
Annual Fire Safety Report 2008/09                                                Page 7 of 13
A Fire Safety Web site is in development to provide detailed technical information,
training resources and general advice and information to all staff, patients and visitors at
the Trust.

The merger of the Fire Safety and Security management responsibilities in 2009/2010
will be a year with new challenges for both teams. The transition between the two
departments at present has been smooth and well received throughout the Trust and
the Organisations that work with us. The result has been renewed motivation amongst
the contracted security staff to deliver a high standard of service to the Trust. There is
considerable work still to be done over the next twelve months in improving further the
service quality.

Fire Safety Capital Investment

Further capital investment will be required through 09/10 and beyond with a risk based
approach being adopted to provide a schedule of investment. This will form part of the
wider, condition and statutory business case being developed from the results of the six
facet survey.




Annual Fire Safety Report 2008/09                                                Page 8 of 13
Appendix A
2008/09 Action/Implementation Progress Plan and Revised Completion Targets

Key Theme               Action                                                                       Due Date          Responsible   Completed
Fire Safety Team        In line with the Regulatory Reform (Fire Safety) Order and Department of End                   MB            Completed
                        Health Guidance a new fire safety team structure is currently out to advert. May/June 08                     June 2008
                        This will provide the management structure as outlined in the recently
                        adopted Fire Safety Policy.

Fire Risk Assessments   Continue the fire risk assessment process started by the Building Research August 08           FSM           85%
                        Establishment and to extend the process to the Queen’s Medical Centre                                        completed
                        Campus by reviewing existing risk assessments in the new format of
                        Firecode HTM 05/03 Part K and the Regulatory Reform Fire Safety Order
                        2005 bringing the Trust into line with fire safety legislation.

Fire Risk Assessments   Complete the City Hospital Risk Assessments                                     May 2008       FSM           Completed
                                                                                                                                     May 2008
Fire Risk Assessments   A risk treatment schedule will be developed from both City and QMC risk         City June 08   FSM           City
                        assessments which will identify priority and cost. These will be fed into the   and QMC                      Campus
                        capital programme and revenue budget allocations.                               Sept 08.                     Completed
                                                                                                                                     September
                                                                                                                                     2008
Fire Training           Increase in the fire safety team resource will allow a radical change in the    End            MB/FSM        Completed
                        delivery of fire safety training across the Trust.                              May/June 08                  June 2008

Fire Training           Rolling out the new fire safety training program to enable the Trust to fulfil  March 2009     FSM/FSO       Started
                        it’s responsibilities under fire safety legislation and also those under NHS                                 August
                        Firecode. The programme is aimed at helping the Trust to meet mandatory                                      2008
                        training requirements and reach 100% of staff trained.
Fire Training           The introduction of a ‘Booking System’ for fire safety training so as to assist March 2009     FSM           Deferred to
                        in ensuring maximum attendance                                                                               2010/11

Fire Training           The introduction of specific training such as evacuation training to allow      March 2009     FSM/FSO       Completed
                        staff to practice their local plans.                                                                         April 2009
Key Theme                           Action                                                                              Due Date      Responsible   Completed
Fire Training                       Specific training sessions dealing with response, risk assessment etc. to           March 2009    FSM/FSO       Completed
                                    enable all those who have a responsibility are sufficiently and appropriately                                   April 2009
                                    trained to assist in ensuring the safety of patients, staff and visitors to Trust
                                    premises.

Fire Training                       Additional fire safety courses are being developed for staff, covering              August 2008   FSM/SFO       Completed
                                    specialist topics such as ward evacuation, practical fire fighting, incident                                    November
                                    response and in line with the new fire safety legislation fire warden and fire                                  2008
                                    risk assessment training.

Unwanted Fire Signals               The introduction of the ‘Guidelines for the reduction of unwanted fire              June 2008     FSM           Deferred
                                    signals’                                                                                                        on to 2009
                                                                                                                                                    / 2010
Unwanted Fire Signals               A new guidance document due for release late summer will assist         September                 FSM           Deferred
                                    managers with the actions they should be taking to reduce the number of 2008                                    on to 2009
                                    unwanted calls that are generated from their areas, and also help in                                            / 2010
                                    creating accurate records for fire alarm actuations,
Unwanted Fire Signals               Reduce unwanted fire signals at QMC by 10% of the 2007 figures and March 2009                     FSM/          Deferred
                                    sustain the ‘A’ Rating.                                                                           Managers      on to 2009
                                                                                                                                                    / 2010
Unwanted Fire Signals               Reduce unwanted fire signals at CITY by at least 25% of the 2007 figures March 2009               FSM/          Deferred
                                    and attain the ‘A’ Rating.                                                                        Managers      on to 2009
                                                                                                                                                    / 2010
Fire Safety Management              During 2008/2009 the new format of fire safety management will be rolled March 2009               FSM/FSO       Deferred
                                    out across the Trust, with supporting seminars for management to assist in                                      on to 2009
                                    understanding the responsibilities they have in regard to fire safety within                                    / 2010
                                    the workplace. Introducing the fire risk assessment process and what is
                                    expected of managers in relation to this.

Fire Safety Management              Undertake a full review of the response to fire alarms to ensure that any March 2009              FSM           On going
                                    changes that may have taken place have not compromised the safety of
                                    the patients, staff or visitors.


Annual Fire Safety Report 2008/09                                                     Page 10 of 13
Key Theme                           Action                                                                      Due Date     Responsible   Completed
Fire Safety Management              The Duty Nurse Managers role in responding to fire alarm calls will also be March 2009   FSM/BCO       On going
                                    reviewed, and where necessary any additional training requirement will be
                                    undertaken.

Fire Safety Management              Work with the Emergency Planning / Business Continuity Team to review March 2009         FSM/BCO       On going
                                    the ‘Evacuation Plans’ for both campuses.

Fire Safety Management              Carry out a review of the procedures for responding to chemical incidents March 2009     FSM/HSA       Deferred
                                    to be undertaken and appropriate plans and procedures implemented                                      on to 2009
                                    across the whole of the Trust encompassing both campus’s, in conjunction                               / 2010
                                    with the Trust Health and Safety Team.

Fire Safety Management              Develop a Fire Safety Web site to provide detailed technical information, Sept 08        MB/ICT/FSM Deferred
                                    training resources and general advice and information to all staff, patients                        on to 2009
                                    and visitors at the Trust.                                                                          / 2010


MB: Mark Braden: Deputy Director Estates and Facilities Management
FSM: Fire Safety and Security Manager
SFO: Specialist Fire Officer (existing position)
FSO: Fire Safety Officer
BCO: Business Continuity Officer
HAS: Health and Safety Adviser




Annual Fire Safety Report 2008/09                                               Page 11 of 13
Appendix B
2009/10 Action/Implementation Plan and target setting

Key Theme                           Action                                                                  Due Date                 Responsible   Completed
Fire Risk Assessments               Complete all fire risk assessments and commence review and audit of March 2012                   FSM / Fire
                                    existing Fire Risk Assessments (125 per year) in line with Firecode HTM                          Safety Team
                                    05/03 Part K and the Regulatory Reform Fire Safety Order 2005 bringing
                                    the Trust into line with fire safety legislation.

Fire Risk Assessments               Draft business cases against the risk treatment schedule for consideration          March 2010   FSM
                                    of the IGC for funding to improve levels of fire safety across the Trust’s
                                    premises

Fire Training                       Continue to progress training across the Trust to enable managers to                March 2009   FSM/FSO
                                    access the right level of training for their staff, building on the progress from
                                    2008/2009 attempt to take the attendance from 49% to 100% of staff
                                    trained.
Fire Training                       The introduction of a ‘Booking System’ for fire safety training so as to assist     Review       FSM
                                    in ensuring maximum attendance (on hold to see if changes made to allow             Monthly
                                    better access to Fire Safety Training achieve the necessary attendance)
Fire Training                       Continue to deliver and develop specific training for evacuation to increase        March 2010   FSM/FSO
                                    level of knowledge and confidence in staff and raise the level of safety in all
                                    areas.
Fire Training                       Specific training sessions dealing with response, risk assessment etc. to           March 2010   FSM/FSO
                                    enable all those who have a responsibility are sufficiently and appropriately
                                    trained to assist in ensuring the safety of patients, staff and visitors to Trust
                                    premises.

Unwanted Fire Signals               Introduce the ‘Guidelines for the reduction of unwanted fire signals’               June 2009    FSM


Unwanted Fire Signals               the guidance document will assist managers with the actions they should             October      FSM
                                    be taking to reduce the number of unwanted calls that are generated from            2009
                                    their areas, and also help in creating accurate records for fire alarm
                                    actuations,
Annual Fire Safety Report 2008/09                                                    Page 12 of 13
Key Theme                           Action                                                             Due Date             Responsible   Completed
Unwanted Fire Signals               Reduce unwanted fire signals at QMC by 10% of the 2008 figures and March 2010           FSM/ Fire
                                    sustain the ‘A’ Rating.                                                                 Safety Team
                                                                                                                            and
                                                                                                                            Managers
Unwanted Fire Signals               Reduce unwanted fire signals at CITY by at least 40% of the 2008 figures March 2010     FSM/ Fire
                                    and attain the ‘A’ Rating.                                                              Safety Team
                                                                                                                            and
                                                                                                                            Managers
Fire Safety Management              During 2009/2010 fire safety management training for management to March 2010           FSM/FSO
                                    assist in understanding the responsibilities they have in regard to fire safety
                                    within the workplace. Introducing the fire risk assessment process and
                                    what is expected of managers in relation to this.

Fire Safety Management              Continue to monitor the response to fire alarms to ensure that any changes March 2010   FSM
                                    that take place do not compromised the safety of the patients, staff or
                                    visitors.

Fire Safety Management              Deliver training to the Duty Nurse Manager role on both campuses and the November       FSM/Fire
                                    Hospital at night co-ordinator to give them the skills required to respond to 2009      Safety Team
                                    fire alarm actuations.

Fire Safety Management              Carry out a review of the procedures for responding to chemical incidents March 2010    FSM/HSM
                                    to be undertaken and appropriate plans and procedures implemented
                                    across the whole of the Trust encompassing both campus’s, in conjunction
                                    with the Trust Health and Safety Team.

Fire Safety Management              Develop a Fire Safety Web site to provide detailed technical information, March 2010    MB/ICT/FSM
                                    training resources and general advice and information to all staff, patients
                                    and visitors at the Trust.


MB: Mark Braden Deputy: Director Estates and Facilities Management BCO: Business Continuity Officer
HSM: Health and Safety Manager FSM: Fire Safety and Security Manager
FSO: Fire Safety Officer

Annual Fire Safety Report 2008/09                                               Page 13 of 13

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:10
posted:8/27/2011
language:English
pages:13