Fire Risk Assessment (Version 2)

Fire Risk Assessment

Responsible Person: NHS Property Services Ltd 415C Skipton House 80 London Road London SE1 6LH

• Address of Premises:

• Postcode:

• Assessor:

  Sign

• Date of Fire Risk Assessment:

  Date

• How often should this risk assessment be reviewed?<br>

  Annually (All sleeping Accommodation, CHP buildings)

  Biennially (Health Centres, Clinics, Storage Units)

  Triennially (Offices)

Examples of frequency of change: Complex building i.e. Height, layout, poor safety history, age Suspect it is no longer valid, significant changes to premises i.e. Post new works

Significant Findings

The Premises

• Who is the premises owned / leased by?

• Name of tenants:

• Number of floors in the building:

• Approximate floor area (m2 - per floor) (To include all floors of responsibility)

• Design Criteria Note: The building was designed and constructed using the listed guides, for further information on the building and design please refer to the Fire Strategy Design documents, plans and consultation process that compliment this fire risk assessment

  Select Firecode Guides Approved Document B BS9999 (not to be used for Hospital sites as per Note A in table 2) Other Building Standard - Please provide details

  • Firecode Guides
  • Approved Document B
  • BS9999 (not to be used for Hospital sites as per Note A in table 2)
  • Other Building Standard - Please provide details

• Primary Usage:

• Secondary Usage:

• Areas not included in the assessment: (Please provide a reason for exclusion from the assessment)

Occupancy Profile

• Maximum number of employees at any one time:

• Maximum number of additional persons at any one time:

Occupants especially at risk from fire

• Sleeping Occupants?

• How many beds?

• Disabled occupants? (Personal Emergency Evacuation Plans in use when necessary)<br>The Equality Act 2010 - in the case of disability, employers and service providers are under a duty to make reasonable adjustments to their workplaces to overcome barriers experienced by disabled people. Where necessary, measures will be put in place to ensure evacuation procedures include persons with disabilities.

  Yes

  No

• Occupants in remote areas?<br>(Lone working / Isolated Areas)

  Yes

  No

• Young Person's?<br>(Individual Risk Assessment provided for any person who has not attained the age of 18)

  Yes

  No

• Others (Details of Elderly / Infirm / Mental Ability)

  Select Elderly persons and persons with mental or physical issues are accepted as patients In-patients are assessed prior to admission by clinic staff

  • Elderly persons and persons with mental or physical issues are accepted as patients
  • In-patients are assessed prior to admission by clinic staff

Identified Fire Hazards

• Sources of Ignition:

  Select Fixed electrical heaters Toaster Microwave Kettle Open flame sterilising equipment Dedicated staff smoking area outside of building which is managed and monitored

  • Fixed electrical heaters
  • Toaster
  • Microwave
  • Kettle
  • Open flame sterilising equipment
  • Dedicated staff smoking area outside of building which is managed and monitored

• Sources of Fuel:

  Select Alcohol Textiles Furniture Disposable products Stationary Domestic & Clinical Waste

  • Alcohol
  • Textiles
  • Furniture
  • Disposable products
  • Stationary
  • Domestic & Clinical Waste

• Sources of Oxygen:

  Select Medical Oxygen Cylinders Piped oxygen with isolation valves

  • Medical Oxygen Cylinders
  • Piped oxygen with isolation valves

The following fire hazards have been considered as part of the assessment within the premises:- - Ignition sources (i.e. naked flames, sparks, portable heaters, smoking materials) - Sources of fuel (i.e. large quantities of paper, combustible fabrics, plastics, paints, thinners, chemicals, flammable gases). - Work processes, - Structural features that promote the spread of fire (large single uncompartmented buildings, open staircases, openings in walls and floors, large voids above ceilings and below floors.)

Evaluate, remove, reduce and protect from fire risk

• Evaluate the risk of a fire occurring:

  Select Flammable materials adjacent to open flame-producing equipment Toaster too close to cupboards Fixed wiring is tested as per IEE Regulations (every 5 years with records kept centrally) Portable equipment is PAT tested and staff members conduct regular visual checks on a monthly basis (records kept in fire safety folder on site). Damaged, illegal or faulty electrical equipment is reported and removed from use as per procedure Staff are diligent when patients and visitors are on premises for identifying risk on arson attacks with premises externally/internally covered by CCTV Wheelie bins are 8m from premises in locked storage area Hot work/contractors permit in place for contractors working on site

  • Flammable materials adjacent to open flame-producing equipment
  • Toaster too close to cupboards
  • Fixed wiring is tested as per IEE Regulations (every 5 years with records kept centrally)
  • Portable equipment is PAT tested and staff members conduct regular visual checks on a monthly basis (records kept in fire safety folder on site).
  • Damaged, illegal or faulty electrical equipment is reported and removed from use as per procedure
  • Staff are diligent when patients and visitors are on premises for identifying risk on arson attacks with premises externally/internally covered by CCTV
  • Wheelie bins are 8m from premises in locked storage area
  • Hot work/contractors permit in place for contractors working on site

• Evaluate the risk to people from a fire starting on the premises :

  Select Open plan layout with good visibility - fire quickly evident. Escape routes have fire detection, which would quickly raise the alarm for persons to make an escape Waste is being stored on escape routes, staff informed and removed on the day of risk to persons making an escape to a place of safety

  • Open plan layout with good visibility - fire quickly evident. Escape routes have fire detection, which would quickly raise the alarm for persons to make an escape
  • Waste is being stored on escape routes, staff informed and removed on the day of risk to persons making an escape to a place of safety

• Remove and reduce the hazards that may cause a fire:

  Select Use a safer alternative to open flame equipment Re-position toaster Designate a storage area for storage of waste materials to be agreed and inform staff

  • Use a safer alternative to open flame equipment
  • Re-position toaster
  • Designate a storage area for storage of waste materials to be agreed and inform staff

• Remove and reduce the risks to people from fire:

  Select Current fire precautions, including fire separation and compartmentation, fire warning/emergency lighting system and firefighting equipment are indicated on attached plan and have been assessed as part of the risk assessment They will be considered with the following additions: Provide automatic fire detection to escape routes, Upgrade fire resistance door to storeroom for waste storage with half-hour fire-resisting materials and 'keep locked shut' signage to be provided

  • Current fire precautions, including fire separation and compartmentation, fire warning/emergency lighting system and firefighting equipment are indicated on attached plan and have been assessed as part of the risk assessment
  • They will be considered with the following additions: Provide automatic fire detection to escape routes, Upgrade fire resistance door to storeroom for waste storage with half-hour fire-resisting materials and 'keep locked shut' signage to be provided

• The following persons have been considered as part of the assessment within the premises:

  Select Employees Employees, visitors, and other persons whose mobility, hearing or eyesight is impaired Other persons in the premises if the premises are multi-occupied Varied working practices (i.e. areas of your premises occupied when others are not) Areas where employees/others are isolated Visitors Persons who may be asleep in the premises

  • Employees
  • Employees, visitors, and other persons whose mobility, hearing or eyesight is impaired
  • Other persons in the premises if the premises are multi-occupied
  • Varied working practices (i.e. areas of your premises occupied when others are not)
  • Areas where employees/others are isolated
  • Visitors
  • Persons who may be asleep in the premises

1. Electrical Sources of Ignition

• Reasonable measures taken to prevent fires of electrical origin

  Yes

  No

• a. Fixed electrical installations periodically inspected and tested? (Every 5 years)

  Yes

  No

• b. Portable appliance testing carried out (where appropriate) on a risk assessed basis?

  Yes

  No

• c. Suitable policy in place regarding the use of personal electrical appliances? <br>This should be subject to a Trust policy from the user organisation

  Yes

  No

• d. Suitable limitation and management of trailing leads and adaptors?

  Yes

  No

• e. Charging and storage of batteries undertaken on site?

  Yes

  No
Electrical Hazards

• Identified Hazards

  a. Fixed Electrical Installation

  b. Portable appliances

  d. Trailing leads and Adaptors

  e. Charging and storage of batteries

  Other

• If other, please state:

• Existing Control Measures:

  Select Inspected within last 5 years Evidence of testing routine, cable leads and plugs in good condition Cable leads and plugs in good condition. Cables do not pose a trip hazard or run in such a way as to cause cable wear Trained staff undertake this task, wearing suitable personal protective equipment and following a safe system of work Well-ventilated area provided for charging Safe storage area for spare power batteries Charging units maintained Charging procedure displayed The use and charging of E-Cigarettes on NHS PS premises is prohibited due to number of fires involving these devices

  • Inspected within last 5 years
  • Evidence of testing routine, cable leads and plugs in good condition
  • Cable leads and plugs in good condition. Cables do not pose a trip hazard or run in such a way as to cause cable wear
  • Trained staff undertake this task, wearing suitable personal protective equipment and following a safe system of work
  • Well-ventilated area provided for charging
  • Safe storage area for spare power batteries
  • Charging units maintained
  • Charging procedure displayed
  • The use and charging of E-Cigarettes on NHS PS premises is prohibited due to number of fires involving these devices

• Additional Control Measures Required:

  Select Fixed electrical wire test required to current industry standards Cable leads and plugs in good/poor condition. A testing routine of these items is required Trailing leads and adaptors that supply power to fixed electrical equipment such as IT should be replaced with wall mounted sockets Staff training required to carry out this task Suitable PPE and a safe system of work required Well-ventilated area required for charging Safe storage area for spare power batteries to be provided Charging units to be maintained by competent person Charging procedure required at charging point Circular to NHS PS staff and tenants informing them of the ban on E-Cigarettes circulated and refreshed on a regular basis

  • Fixed electrical wire test required to current industry standards
  • Cable leads and plugs in good/poor condition. A testing routine of these items is required
  • Trailing leads and adaptors that supply power to fixed electrical equipment such as IT should be replaced with wall mounted sockets
  • Staff training required to carry out this task
  • Suitable PPE and a safe system of work required
  • Well-ventilated area required for charging
  • Safe storage area for spare power batteries to be provided
  • Charging units to be maintained by competent person
  • Charging procedure required at charging point
  • Circular to NHS PS staff and tenants informing them of the ban on E-Cigarettes circulated and refreshed on a regular basis

Deficiencies and Comments:

• Last fixed wire inspection:

  Date

• Last portable appliance testing:

  Date

Fixed Wire Installation Testing Note: The legislation of specific relevance to electrical maintenance and Fixed Installation Testing is the Health & Safety at Work Act 1974, the Management of Health & Safety at Work Regulations 1999, the Electricity at Work Regulations 1989 and the Workplace (Health, Safety and Welfare) Regulations 1992. Maximum period between inspection and testing 5 years for Hospitals, Offices, Residential accommodation, Commercial premises.

Portable electrical appliance Testing Note: The Electricity at Work Regulations 1989 requires that any electrical equipment that has the potential to cause an injury is maintained in a safe condition. However, the Regulations do not specify what needs to be done, by whom or how frequently (i.e. they don't make inspection or testing of electrical appliances a legal requirement, nor do they make it a legal requirement to undertake this annually) Further guidance can be sought from the HSE website.

2. Smoking

• Reasonable measures taken to prevent fires as a result of smoking?

  Yes

  No

• a. Smoking prohibited in the building?

  Yes

  No

• b. Smoking permitted in appropriate areas?

  Yes

  No

• c. Suitable arrangements for those who wish to smoke?

  Yes

  No

• d. This policy appeared to be observed at the time of the inspection?

  Yes

  No
Smoking Hazard

• Identified Hazards

  Smoking within and around the premises

  Other

• If other, please state:

• Existing Control Measures:

  Select Not allowed and enforced Patients who wish to smoke have a care plan in place Patients smoking materials are kept in safe custody by staff Designated smoking materials for staff

  • Not allowed and enforced
  • Patients who wish to smoke have a care plan in place
  • Patients smoking materials are kept in safe custody by staff
  • Designated smoking materials for staff

• Additional Control Measures Required:

  Select Patients who wish to smoke should have a care plan in place Patients smoking materials are/are not kept in safe custody by staff Designated smoking areas are away from the immediate vicinity of the premises, smoking dispensers to be emptied on a regular basis by the tenant/occupier

  • Patients who wish to smoke should have a care plan in place
  • Patients smoking materials are/are not kept in safe custody by staff
  • Designated smoking areas are away from the immediate vicinity of the premises, smoking dispensers to be emptied on a regular basis by the tenant/occupier

Deficiencies and Comments: No smoking policy applies to all staff, patients and visitors on all NHS premises - both inside and outside. Smoking is not permitted in any NHS buildings which includes E-Cigarettes and the charging of such devices (see advice note to all NHS PS staff and tenants) The policy complies with NHS national guidance on smoke-free environments

3. Arson / Deliberate Ignition

• Basic security against arson by outsiders or other persons appears reasonable?

  Yes

  No

• a. Is there close proximity to the premises available for ignition by outsiders?

  Yes

  No
Arson Hazards

• Identified Hazards

  External Fire Load

  Other

• If other, please state:

• Existing Control Measures:

  Select Waste materials within locked compound away from premises No reported incidents in the last year External lighting sufficient to negate dark areas around the premises CCTV in operation

  • Waste materials within locked compound away from premises
  • No reported incidents in the last year
  • External lighting sufficient to negate dark areas around the premises CCTV in operation

• Additional Control Measures Required:

  Select Waste materials to be located within locked compound away from premises External lighting should be improved subject to lighting survey to negate dark areas around the premises

  • Waste materials to be located within locked compound away from premises
  • External lighting should be improved subject to lighting survey to negate dark areas around the premises

Deficiencies and Comments: Combustible waste should not be stored against the building

• CCTV Present?

  Yes

  No

• External Lighting?

  Yes

  No

• Security Fence?

  Yes

  No

• Physical Security

  Yes

  No

4. Portable Heaters

• The use of portable heaters avoided as far as practicable?

  Yes

  No

• a. Is the use of portable heaters avoided as far as practicable? Note: Portable gas cylinder heaters and paraffin heaters are NOT to be used in NHS premises

  Yes

  No

• b. (i) If the portable heaters are used, is the use of the more hazardous type (e.g. radiant bar fires of lpg appliances) avoided?

  Yes

  No

• b. (ii) If the portable heaters are used, are suitable measures taken to minimise the hazard of ignition of combustible materials?

  Yes

  No

• c. Are fixed heating installations subject to regular maintenance?

  Yes

  No

Considerations to minimise the hazard of ignition of combustible materials due to these heaters: - Always position heaters so the heater back is against a wall and the heating element is facing into the room - Switch heaters off if you are not in the room. Unplug electric heaters at cease work - Always follow the manufacturers' operating and maintenance instructions - Ensure the electrical power lead does not create a trip hazard - Do not use flammable materials, aerosols or cleaning fluids near heaters - Do not place heaters close to furniture, curtains or bedding. 1 metre in all directions - Do not stand or sit too close to heaters, some clothes may ignite easily - Do not place heaters on uneven surfaces or where they can be knocked over easily

Portable Heaters Hazards

• Identified Hazards

  Portable Heater(s)

  Other

• If other, please state:

• Existing Control Measures:

  Select Electrical tested Site away from combustible/flammable items by at least 1 metre in all directions

  • Electrical tested
  • Site away from combustible/flammable items by at least 1 metre in all directions

• Additional Control Measures Required:

  Select Electrical test required To be sited away from combustible/flammable items by at least 1 metre in all directions

  • Electrical test required
  • To be sited away from combustible/flammable items by at least 1 metre in all directions

Deficiencies and Comments:

• Appropriate use of the portable heater has been passed to staff/tenants at the premises informing them of the risks? (Please state type and manufacturer)

  Yes

  No

• Heaters are not PAT certified, issue to be raised with the occupier/tenant?

  Yes

  No

  N/A

5. Fixed Heating Installations

• Are there fixed heating installations such as boilers used within the premises?

  Yes

  No

• a. Are fixed heating installations subject to regular maintenance?

  Yes

  No

• b. Are suitable measures taken to minimise the hazard of ignition of combustible materials due to these heaters?

  Yes

  No
Fixed Heating Hazards

• Identified Hazards

  Fixed Heating Installations

  Ignition from heaters

  Other

• If other, please state:

• Existing Control Measures:

  Select Automatic fire detection in place Fire extinguishers in place Gas/Electrical cut off in place Suitable ventilation Maintenance of boiler is undertaken Control of entry to plant room Minimal combustible sources within plant room other than essential items

  • Automatic fire detection in place
  • Fire extinguishers in place
  • Gas/Electrical cut off in place
  • Suitable ventilation
  • Maintenance of boiler is undertaken
  • Control of entry to plant room
  • Minimal combustible sources within plant room other than essential items

• Additional Control Measures Required:

  Select All combustible materials to be removed from front boiler room Breaches to be made good in boiler room Rubbish and old building materials to be removed from rear boiler room area

  • All combustible materials to be removed from front boiler room
  • Breaches to be made good in boiler room
  • Rubbish and old building materials to be removed from rear boiler room area

Deficiencies and Comments:

• Boiler Fuel Supply:

  Main Gas

  Fuel Oil via tank

  Electric

  Other

6. Cooking

• Reasonable measures taken to prevent fires as a result of cooking?

  Yes

  No

  N/A

• a. Filters cleaned or changed and ductwork cleaned regularly?

  Yes

  No

  N/A

• b. Suitable extinguishing appliances available? (e.g. fire blanket, wet chemical etc)

  Yes

  No

  N/A

• c. Suitable Shut Down Procedures in place?

  Yes

  No

  N/A
Cooking Hazards

• Identified Hazards

  Select Filters and duct work Fire Equipment Shut down procedures Electrical catering equipment Gas appliances and supply Other

  • Filters and duct work
  • Fire Equipment
  • Shut down procedures
  • Electrical catering equipment
  • Gas appliances and supply
  • Other

• If other, please state:

• Existing Control Measures:

  Select Cleaned routinely under contract In place and suitable for the equipment and cooking processes undertaken Satisfactory procedures in place but not documented Electrical items except fridge(s) are switched off at cease work Electrical testing undertaken Regular cleaning of catering items Cable management satisfactory Annual servicing of gas appliances in place

  • Cleaned routinely under contract
  • In place and suitable for the equipment and cooking processes undertaken
  • Satisfactory procedures in place but not documented
  • Electrical items except fridge(s) are switched off at cease work
  • Electrical testing undertaken
  • Regular cleaning of catering items
  • Cable management satisfactory
  • Annual servicing of gas appliances in place

• Additional Control Measures Required:

  Select To be cleaned and maintained under contract Not in place. Not suitable for the equipment and cooking processes undertaken No satisfactory procedures in place Electrical testing should be carried out Regular cleaning routines should be undertaken Cable management required i.e. single plug to socket, short cable runs, avoid use of extension blocks without RCD Annual servicing of gas appliances required

  • To be cleaned and maintained under contract
  • Not in place. Not suitable for the equipment and cooking processes undertaken
  • No satisfactory procedures in place
  • Electrical testing should be carried out
  • Regular cleaning routines should be undertaken
  • Cable management required i.e. single plug to socket, short cable runs, avoid use of extension blocks without RCD
  • Annual servicing of gas appliances required

Deficiencies and Comments:

• Type of Catering:

  Commercial catering

  Domestic catering

  Beverage Room / bay only

• Correct fire detection installed?

  Yes

  No

  N/A

7. Lightning

• Does the building have a lightning protection system?

  Yes

  No

  None Installed

• a. Is the lightning protection system subject to a suitable maintenance regime?

  Yes

  No

  N/A
Lightning Hazards

• Identified Hazards

  Lightning protection system

  Other

• If other, please state:

• Existing Control Measures:

  Maintained and tested to current standards

• Additional Control Measures Required:

  To be maintained and tested to current standards

Deficiencies and Comments: Lightning Protection Systems Annual Test and Inspection to comply with BSEN 62305. Lightning protection systems are required to be tested and certified annually, including testing of individual earth electrodes, continuity testing and overall system testing.

8. Dangerous Substances

• Dangerous substances are, or could be used or stored, within the premises?<br>(a substance or preparation that because of its chemical and sometimes physical properties and the way it is present and/or used at work creates a fire or explosion risk to people)

  Yes

  No

• Are the general fire precautions adequate to address the hazards associated with dangerous substances used or stored within the premises?

  Yes

  No

  N/A

• If dangerous substances are present, has a risk assessment been carried out as required by the Dangerous Substances and Explosive Atmospheres Regulations 2002?<br>(Medical treatment areas e.g. operating theatres and treatment rooms excluded from DSEAR)

  Yes

  No

  N/A
Dangerous Substances Hazards

• Identified Hazards

  Sterilising Materials

  Other

• If other, please state:

• Existing Control Measures:

  Stored in suitable areas and containers away from potential sources of ignition, to include issues of chemical reactivity and compatibility

• Additional Control Measures Required:

  Staff awareness and training

Deficiencies and Comments: The general fire precautions are adequate for the identified processes involved with the storage and use of dangerous substances. Dangerous substances should be reduced to the lowest reasonable quantity necessary to deliver the service. All flammable liquids and gases should be locked away except in use items. Highly flammable liquids are to be carefully managed including the disposal of contaminated materials. Up to 50 litres may be stored in a fire resisting cabinet or bin that will contain any leaks.

9. Housekeeping

• Is the standard of housekeeping adequate?

  Yes

  No

• a. Combustible materials appear to be separated from ignition sources?

  Yes

  No

• b. Appropriate storage of hazardous materials?

  Yes

  No

• c. Avoidance of inappropriate storage of combustible materials? (Escape routes and final exits are kept clear of any combustibles including storage materials and/or waste?

  Yes

  No

• d. Avoidance of unnecessary accumulation of combustible materials and/or waste?

  Yes

  No
Housekeeping Hazards

• Identified Hazard:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

Deficiencies and Comments: Excessive combustible waste within rooms and corridors produce a high fire loading which if ignited will cause greater damage and potentially reduce the ability to carry on business delivery. Regular housekeeping routines can reduce this fire loading of excessive and surplus combustible materials such as leaflets, packaging, papers etc.

10. Hazards Introduced by Contractors and Building Works

• Fire safety conditions have been imposed on both external contractors and in-house maintenance staff?

  Yes

  No

• Is there a satisfactory control over works, including use of hot work permits, where appropriate, carried out in the building by external contractor?

  Yes

  No

• Give details: (e.g. Building maintenance is carried out under a Service Level Agreement)

• This process is a Contractual agreement between NHS Property Services LTD and the Facilities Maintenance body. In this premises, the work is undertaken by: (Insert name of company)

Contractors / Building Works Hazards

• Identified Hazard:

• Existing Control Measures

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

11. Other Significant Fire Hazards that warrant consideration:

• Are there any other fire hazards that warrant consideration within the premises?<br>(This to include any fire hazards from any process; heat producing, spark or friction generating, chemical or other process which has the capacity to ignite, create excessive or rapid heat or generate oxidising or flammable gas that impact on the general fire precautions)

  Yes

  No
Other Significant Hazards:

• Identified Hazards:

  Compressed Medical Gas Cylinders

  IT Rooms

  MRI Scanners

  X-Ray Machines

  Other

• If other, please state:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

12. Evacuation Strategy The evacuation strategy for this premises is detailed below: (Please tick appropriate strategy)

• Single Stage Evacuation The fire alarm system is a single stage evacuation system, which means that when the alarm sounds, the building is evacuated in an orderly manner. The requirement for means of escape is that everyone within a building may reach either a place of safety or, in certain circumstances, a protected zone within a reasonable travel distance. Primary Construction for this Building- Applies to the main fabric of a building, walls, floors, roof and internal dividing walls Buildings are categorised into 3 classes: Class A - complete non-combustible construction, i.e. elements of structure, floors, and walls, supporting structure of brick or concrete Class B - traditional construction, i.e. non-combustible walls with combustible floors Class C - combustible construction, i.e. timber floors and walls The evacuation times that are generally accepted as: Class A - 3 minutes Class B - 2 and a half minutes Class C - 2 minutes These are not hard and fast times, and can be extended or reduced according to the particular circumstances of the case, but they do form a reasonable basis for most situations.

• Progressive Horizontal Evacuation Relevant persons are dependant on staff to assist with their escape. Provisions have been made to move such persons from an area affected by fire, through a fire resisting barrier to an adjoining fire protected area on the same level, where they can wait in a place of safety whilst the fire is dealt with, or await further evacuation down a protected route to total safety. NOTE - Progressive Horizontal Evacuation is subject to the following: Protected areas should be designed to provide: - Sufficient capacity to accommodate the number of occupants who will need to use them. For this purpose a protected area should be sufficient capacity to accommodate its normal occupants and the occupants of the largest adjoining protected area. - Progressive movement away from a fire via sequential adjoining protected areas. - Means for escape via stairway(s) should this become necessary The number and size of the protected areas depends on a number of factors: - the time it will take to evacuate people from the area of a fire to an adjacent protected area; - the number of people to be evacuated; - the level of any mobility impairment; - the number of staff to assist in evacuation; - the fire protection arrangements; - layout of the premises; and - location and number of staircases;

• Delayed Evacuation Relevant persons are dependant on staff to assist with their escape however it is not desirable or practical to evacuate persons (e.g. due to medical conditions or treatments). Such persons may remain within their rooms whilst the fire is dealt with and the danger has passed. NOTE - Delayed Evacuation is subject to the following: Bedrooms to be enclosed in an enhanced level of fire-resisting construction (protected bedrooms). A protected bedroom should be of 60 minute fire-resisting construction and the door should be fire-resisting and fitted with a self-closing device. In addition the escape route from the protected bedroom(s) to the adjoining protected areas, refuge or final exit (including any stairway) will also require an increased level of fire protection to allow access for staff to assist with subsequent evacuation from the protected bedroom(s). If necessary the door may be fitted with electromechanical hold-open or free swing devices that operate immediately the fire alarm actuates. If provision of such fire resistance is not possible, you may be able to show through your risk assessment that alternative measures to limit the growth and spread of the fire are appropriate, such as an automatic fire suppression system supported by robust staff response procedures. Any resident who is initially left in a fire protected bedroom should be accompanied by a carer. As such, the total number of residents awaiting evacuation in protected bedrooms should be less than the number of staff on duty. It is imperative that if some less able residents are left in protected bedrooms to await evacuation, then other staff know which rooms have been evacuated and those which still contain residents and where necessary are able to notify the fire and rescue service when they arrive. Arrangements for delayed evacuation should only be based on a pre-planned basis.

• Written copies of Evacuation Procedures are located as follows:

Evacuation Hazards

• Identified hazards:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

13. Means of Escape from Fire

• It is considered that premises are provided with reasonable means of escape in case of fire?

  Yes

  No

• a. Adequate design of escape routes?

  Yes

  No

• b. (i) Reasonable distances of travel when there is escape in a single direction?

  Yes

  No

• b. (ii) Reasonable distances of travel when there are alternative means of escape?

  Yes

  No

• c. Suitable protection of escape routes? (Fire resisting construction)

  Yes

  No

• d. Adequate provision of exits?

  Yes

  No

• e. Exits easily and immediately open-able where necessary?

  Yes

  No

• f. Escape routes unobstructed?

  Yes

  No

• g. Fire exits open in the direction of escape where necessary?

  Yes

  No

• h. Avoidance of sliding or revolving doors as fire exits where necessary?

  Yes

  No

  N/A

• i. Satisfactory means for securing exits?

  Yes

  No

• j. Satisfactory fire precautions for all inner rooms and dead ends?

  Yes

  No

  N/A

• k. It is considered that the premises are provided with reasonable arrangements for means of escape for disabled people?

  Yes

  No
Means of Escape Hazards

• Identified Hazards:

  Single Staircase

  Other

• If other, please state:

• Existing Control Measures:

  Select Sterile lobby Occupation does not exceed 60 persons

  • Sterile lobby
  • Occupation does not exceed 60 persons

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

14. Measures to limit Fire Spread and Development

• a. It is considered that there is compartmentation of a reasonable standard. (Fire resistant to collapse, fire penetration and transfer of excessive heat

  Yes

  No

• b. It is considered that there is reasonable limitation of linings that may promote fire spread. (Flame spread across surfaces including walls, ceilings and other internal structures)

  Yes

  No

• c. It is considered that there is, as far as can be reasonably ascertained, fire dampers provided in ducts or vents as necessary to protect critical means of escape against passage of fire, smoke and combustion products in the early stages of a fire?

  Yes

  No

  N/A
Fire Spread Hazards

• Identified hazards:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

Deficiencies and Comments: The observations and assessment with regards to compartmentation are made from a visual inspection only. Fire linings are from a visual observation only.

15. Emergency Escape Lighting

• Reasonable standard of emergency escape lighting system provided?

  Yes

  No
Emergency Escape Lighting Hazards

• Identified Hazards:

  Internal areas require lighting in the event of a power failure

  External areas require lighting in the event of a power failure

  Other

• If other, please state:

• Existing Control Measures:

  Select Emergency lighting units fitted internally Emergency lighting units fitted externally Flicked tested monthly undertaken Annual discharge undertaken

  • Emergency lighting units fitted internally
  • Emergency lighting units fitted externally
  • Flicked tested monthly undertaken
  • Annual discharge undertaken

• Additional Control Measures:

  Select Monthly flick testing required Annual discharge required

  • Monthly flick testing required
  • Annual discharge required

Deficiencies and Comments: The existing emergency escape lighting system will not conform in full to current recommendations (e.g. in respect of luminance levels), particularly if the system was installed some years prior to 1999. This might be perfectly acceptable, but it is appropriate for new systems, and new work associated with upgrading of existing systems to conform to the current recommendations. Attention is drawn to current recommendations in BS 5266-1 and to the requirements of BS 5266-7 and BS 5266-8

• Type:

  3 hour Non Maintained

  3 hour Maintained

16. Fire Safety Signs and Notices

• Reasonable standard of fire safety signs and notices?<br>This includes fire exit, fire escape signage, fire resisting door and hazard signage.

  Yes

  No
Signs and Notices Hazards

• Identified Hazards

  Alternative routes and final exits in the premises which could be difficult for persons to navigate to a place of safety

  Other

• If other, please state:

• Existing Control Measures: The following signage and notices have been provided:

  Select Fire Action Notices Directional Escape Signage Hazard room signage Fire door signage Equipment hazard signage

  • Fire Action Notices
  • Directional Escape Signage
  • Hazard room signage
  • Fire door signage
  • Equipment hazard signage

• Additional Control Measures Required:

  Select Periodic checks are made and defective signage is replaced where necessary

  • Periodic checks are made and defective signage is replaced where necessary

Deficiencies and Comments: It is a requirement of the Health and Safety (Safety Signs and Signals) Regulations 1996 that these signs incorporate the appropriate pictogram. BS 5499-5:2002 Graphical symbols and signs. Safety signs, including fire safety signs. Signs with specific safety meanings. Superseded by BS ISO 7010:2011 - Prescribes safety signs used for accident prevention, fire protection, health hazard information and emergency evacuation.

17. Means of Giving Warning in case of Fire

• Reasonable manually operated fire warning system provided?<br><br>Based on visual inspection, but no audibility tests or verification of full compliance with relevant British Standard carried out. Compliance with this will be carried out by a competent person who will provide certification on compliance or recommend works to comply with the standard.

  Yes

  No

• If yes, give details: (e.g. Break glass call points, fire bell, air horn, klaxon etc.)

• a. Automatic fire detection provided? <br>

  Yes

  No

  N/A

• If yes, to what Standard? (e.g. BS 5839 Part 1 Grade L1/L2 etc.)

• Has the L1, L2, L3, L4, L5 system design and installation certificate been available?

  Yes

  No

  N/A

• Approximate age of system:

• Throughout premises?

  Yes

  No

• Part of Premises Only?

  Yes

  No

• b. Extent of automatic fire detection generally appropriate for the occupancy and fire risk?

  Yes

  No

• c. Remote transmission of alarm signals to an Alarm Receiving Centre?<br>(continuously manned premises, remote from those in which a fire alarm system is fitted, where the information concerning the state of the fire alarm system is displayed and/or recorded, so that the fire and rescue service can be summoned where necessary.)

  Yes

  No
Means of giving warning Hazards

• Identified Hazards

  Providing persons with appropriate warning of a fire

  Other

• If other, please state:

• Existing Control Measures: Fire detection systems with the following devices:

  Select Manual Call Points at each final emergency exit Smoke and Heat detection Sounders Fire Alarm Panel Repeater Panel

  • Manual Call Points at each final emergency exit
  • Smoke and Heat detection
  • Sounders
  • Fire Alarm Panel
  • Repeater Panel

• Additional Control Measures Required:

  Select Tested and maintained under PPM routine Manual call points are tested weekly Quarterly system check undertaken Six monthly system check undertaken Building and fire zone plan in place Maintain a clear area of 500mm around Fire Detection

  • Tested and maintained under PPM routine
  • Manual call points are tested weekly
  • Quarterly system check undertaken
  • Six monthly system check undertaken
  • Building and fire zone plan in place
  • Maintain a clear area of 500mm around Fire Detection

Deficiencies and Comments: Systems installed prior to 2002 might not conform in full to current standards, particularly in respect of certain aspects of engineering design. In many cases, this is perfectly acceptable, but it is expected that new systems and new work associated with the modification of existing systems, recommended in the action plan, will conform to current standards.

18. Manual Fire Extinguishing Appliances

• a. Reasonable provision of portable fire extinguishers?

  Yes

  No

• b. Are all fire extinguishing appliances readily accessible and unobstructed? <br>(i.e. mounted on walls or on appropriate bases)

  Yes

  No

• c. Are hose reels provided?

  Yes

  No
Manual Fire Extinguishing Hazards

• Identified Hazards

  Control of small fires in the premises

  Other

• If other, please state:

• Existing Control Measures:

  Select Provision of suitable and sufficient Fire Extinguishers for use on revel ant Class of fire Monthly user checks carried out Correct signage in place Extinguishers located satisfactorily

  • Provision of suitable and sufficient Fire Extinguishers for use on revel ant Class of fire
  • Monthly user checks carried out
  • Correct signage in place
  • Extinguishers located satisfactorily

• Date of last annual service:

  Date

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

Deficiencies and Comments: Portable fire extinguishers are regarded as the basic provision, while hose reels tend to be regarded as optional supplementary protection. Ensure that the presence of hose reels does not encourage occupants of the premises to remain within the premises carrying out fire-fighting beyond the time available for safe escape. Hose reels left by retreating employees can obstruct fire doors, allowing smoke and fire to spread throughout the premises. Monthly user checks to be carried out and recorded and Annual servicing undertaken by a competent company. Extinguishers are to be wall hung or placed on floor stands to current guidance.

• Fire blankets are provided in the kitchen of this premise.

  Yes

  No

19. Relevant Automatic Fire Extinguishing Systems

• Does the property have a fixed system?

  Yes

  No

  N/A

• State type of system and location: (inert gas suppression systems, sprinklers/misting systems etc.)

Automatic Fire Extinguishing Hazards

• Identified Hazards:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

20. Other Relevant Fixed Systems and Equipment

• Does the property have a fixed system?

  Yes

  No

  N/A

• If yes, stated type and location: (i.e. Dry/wet risers, fireman's lift control, smoke and ventilation, smoke curtains etc)

Other Relevant Fixed Systems Hazards

• Identified Hazards:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

21. Firefighter Switch - High Voltage Luminous Tube Signs etc

• Suitable provision of fire fighters switche(s) for high voltage luminous tube signs, etc.

  Yes

  No

  N/A

• State location:

Firefighter Switch Hazards

• Identified Hazards:

• Existing Control Measures:

• Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)

• Deficiencies and Comments:

22. Procedures and Arrangements Fire safety is managed by the Responsible Person for the Relevant Persons, which includes, employees, members of the public, visitors, contractors from other organisations and the self employed.

• Chief Executive Officer: (For each occupier / tenant organisation)

• Fire Safety Manager: (A nominated person with responsibility for carrying out day-to-day management of fire safety. (This may or may not be the same as the Responsible Person.)

• Duty Holders: (Nominated persons who are responsible for fire safety measures in the premises to ensure the safety of persons in case of fire.)

Note: Responsible Persons at the premises must cooperate and coordinate their fire safety measures and activities.

• Fire Safety Managed in this Premises by: NHS PS Services Ltd

• Are competent person(s) appointed to assist in undertaking the preventative and protective measures (i.e. relevant general fire precautions)? <br><br>Person(s) appointed with fire safety roles include - Fire Warden(s). Fire Evacuation Marshall(s) (Taking into consideration the Fire Safety (Employees Capabilities) (England) Regulations 2010 (S1 2010/471)

  Yes

  No

• Is there a suitable record of the fire safety arrangements?

  Yes

  No

• Appropriate fire procedures in place?

  Yes

  No

• Are procedures in the event of a fire appropriate and properly documented?

  Yes

  No

• Are there suitable arrangements for summoning the Fire and Rescue Service?

  Yes

  No

• Are there suitable arrangements to meet the F&RS on arrival and provide relevant information, including that relating to hazards to fire fighters?

  Yes

  No

• Is there a plan of the building available indicating basic layout and any areas of significant risk?

  Yes

  No

• Are there suitable arrangements for ensuring that the premises have been evacuated?

  Yes

  No

• Is there a suitable fire assembly point(s)?

  Yes

  No

• Are there adequate procedures for evacuation of any disabled people who are likely to be present?

  Yes

  No

• Persons nominated and trained to assist with evacuation, including evacuation of disabled people?<br>A Disabled person(s) evacuation strategy must not rely on rescue of disabled people by the fire and rescue service. Assistance with their evacuation is provided by nominated persons within the premises.

  Yes

  No

• Appropriate liaison (if necessary) (e.g. F&RS crews visiting for familiarisation visits)?

  Yes

  No

• Routine in-house inspections of fire precautions (e.g. in the course of health and safety inspections)?

  Yes

  No

• Deficiencies and Comments:

23. Training and Drills Fire safety training is managed by: -A nominated Fire Safety Manager for each occupier / tenant organisation -Senior GP of Practice

• Are arrangements in place to ensure that all new staff and visitors (where necessary) provided with fire safety induction and local building familiarisation?

  Yes

  No

• Is this induction training recorded?

  Yes

  No

• Are arrangements in place to ensure that all staff undertake annual fire safety refresher training and familiarisation where necessary, and to ensure that it is recorded?

  Yes

  No

• Are staff with special responsibilities (e.g. fire wardens and fire evacuation marshals) been appointed and provided with additional training?

  Yes

  No

• Are fire drills carried out at appropriate intervals and a record of such drills recorded? (6 monthly)

  Yes

  No

When the employees of another employer work in the premises:

• Is the employer given appropriate information (e.g. on fire risks and general fire precautions)?

  Yes

  No

• Is it ensured that the employees are provided with adequate instructions and information?

  Yes

  No

• Is there adequate co-operation and co-ordination between different Responsible Persons (Multi-Occupancy) to ensure compliance with the Fire Safety Order?

  Yes

  No

  N/A

Does all staff training provide information, instruction or training on the following:

• Fire risk in the premises?

  Yes

  No

• The fire safety measures in the premises?

  Yes

  No

• Action in the event of fire?

  Yes

  No

• Action on hearing the fire alarm signal?

  Yes

  No

• Method of operation of manual call points?

  Yes

  No

• Location and use of fire extinguishers?

  Yes

  No

• Means for summoning the F&Rs?

  Yes

  No

• Identify of persons nominated to assist with evacuation?

  Yes

  No

• Identify of persons nominated to use fire extinguishing appliances?

  Yes

  No

Deficiencies and Comments: Where two or more organisations share a premise, adequate fire safety for all occupants will only be achieved if the organisations co-operate with one another to co-ordinate their fire safety measures. For example, there needs to be co-ordination of fire procedures, fire drills and fire management strategy. It needs to be ensured that one occupier's activities and practices do not create a risk to those in another occupier's part of the premises.

24. Testing and Maintenance

• Testing and Maintenance is carried out by:

• Adequate maintenance of premises?

  Yes

  No

• Weekly testing and periodic servicing of fire detection and alarm system to include ancillary equipment (e.g. door hold open devices, door locks etc.)<br>Manual call point(s) tested weekly on a rotational basis?

  Yes

  No

• Monthly and annual testing routines for emergency escape lighting?<br>Function test monthly with annual discharge or PPM in place

  Yes

  No

  N/A

• Periodic inspection of external escape staircases and gangways?

  Yes

  No

  N/A

• Six monthly inspection and annual testing of rising mains?

  Yes

  No

  N/A

• Weekly and monthly testing, six monthly inspection and annual testing of fire-fighting lifts?

  Yes

  No

  N/A

• Weekly testing and periodic inspection of sprinkler installations?

  Yes

  No

  N/A

• Routine checks of final exit doors and/or security fastenings?

  Yes

  No

• Annual inspection and testing of lightning protection system?

  Yes

  No

  N/A

• Are suitable systems in place for reporting and subsequent restoration of safety measures that have fallen below the required standard?

  Yes

  No

• Other relevant inspections or tests: (Give details)

• Deficiencies and Comments:

25. Recording

Appropriate records held for:

• Fire drills?<br>6 monthly, but at least once every 12 months

  Yes

  No

• Fire Training?

  Yes

  No

• Fire alarm tests?

  Yes

  No

  N/A

• Emergency escape lighting tests?

  Yes

  No

  N/A

• Maintenance and testing of other fire precaution systems?

  Yes

  No

  N/A

• Location of Records: (Available for inspection by Fire Authority if required)

• Deficiencies and Comments:

Internal Audit Checks

• Document Prepared by:

• Date:

  Date

• Checked by:

• Date:

  Date

• File Location:

• Copy to SSM:

• Date:

  Date