Title Page
Add the document name in this format: Site, Building number and name, FRA, your initials, month year. For example: St Marks, B1 Admin, AW, March 2020
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Document name
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Site photograph
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Responsible Person for this premises is: Berkshire Healthcare NHS Foundation Trust, Fitzwilliam House, Skimped Hill Lane, Bracknell, RG12 1LH
- Yes
- No
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Are there other organisations with Responsible Person duties within the premises?
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NHS Property Services, 99 Gresham Street, London EC2R7HE
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ISS UK & Ireland, Velocity 1, Brooklands Drive, Brooklands, Weybridge, Surrey, KT13 0SL
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Bellrock Property & Facilities Management, Peat House, 1 Waterloo Way, Leicester LE1 6LP
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If other Responsible Persons add details here
Distribution List
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Service Managers
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Estates & Facilities
Risk rating
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Premises use
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Building risk
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Management risk
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Address of Premises:
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Postcode:
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Assessor:
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Date of Fire Risk Assessment:
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How often should this risk assessment be reviewed?
- Annually (All sleeping Accommodation, CHP buildings)
- Biennially (Health Centres, Clinics, Storage Units)
- Triennially (Offices)
This frequency may change, for example if there have been new building works, a change of building use or number and type of occupants. Reviews should also take place after fire related incidents.
Building size, construction and ownership
Significant findings
The Premises
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Who is the premises owned / leased by?
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Name of tenants:
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Number of floors in the building:
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Approximate floor area (m2 - per floor) (To include all floors of responsibility)
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Brief details of construction: (Date of construction, brick, timber, purpose built or converted)
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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
- 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
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If other:
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Primary Usage:
- Hospital with inpatients
- Hospital with no inpatients
- Health centre, clinic, surgery or walk-in centre
- Offices with no patient access
- Nursery
- Unoccupied
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Secondary Usage:
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Areas not included in the assessment: (Please provide a reason for exclusion from the assessment)
Occupancy Profile
Occupancy Profile
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Maximum number of employees at any one time:
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Is there more than one employer (eg other trusts, CCGs etc)
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Give details of employers within the building
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Maximum number of additional persons at any one time:
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Children attending nursery
Occupants especially at risk from fire
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Sleeping Occupants?
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How many beds?
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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.
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Are PEEPS or GEEPS in use, current and is a copy held in the fire safety information folder for the premises
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Occupants in remote areas?<br>(Lone working / Isolated Areas)
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Give details of Permit to Work systems or similar
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Young Person's?<br>(Individual Risk Assessment provided for any person who has not attained the age of 18)
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Others (Details of Elderly / Infirm / Mental Ability)
- 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
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Sources of Ignition:
- Fixed electrical heaters
- Portable electrical heaters
- Toaster
- Microwave
- Kettle
- Open flame sterilising equipment
- Dedicated staff smoking area outside of building which is managed and monitored
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Sources of Fuel:
- Alcohol
- Textiles
- Furniture
- Disposable products
- Stationery
- Domestic & Clinical Waste
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Sources of Oxygen:
- Medical Oxygen Cylinders
- Piped oxygen with isolation valves
- No oxygen on site
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Are patients a fire risk:
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Details of any further measures to reduce risk from patients setting fires be added here:
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
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Evaluate the risk of a fire occurring:
- Flammable materials too close to source of ignition
- Toaster or hob too close to cupboards or other combustible material
- Fixed wiring is not tested as per IEE Regulations (every 5 years with records kept centrally)
- Portable equipment is not all PAT tested
- Staff members not carrying out regular visual checks
- Damaged, or faulty electrical equipment found to be in use
- Risk of arson attacks with premises externally/internally not being managed by local staff
- Poor management of refuse e.g. wheelie bins not 8m from premises in locked storage area
- Poor management of contractors/ hot-works on site
- Poor management of electrical cables
- Combustibles being stored near high voltage electrical equpment
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Evaluate the risk to people from a fire starting on the premises :
- 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
- Staff managed area
- Escape routes have fire detection, which would quickly raise the alarm to make an escape
- Fire detection installed throughout premises, which would quickly raise the alarm for persons to make an escape
- Single staircase or dead-end condition increases risk
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Remove and reduce the hazards that may cause a fire:
- Separate combustibles from sources of ignition
- Re-position toaster or move items away from hob
- Designate a storage area for storage of waste materials to be agreed and inform staff
- Remove items that could be target for arsonists
- Improve cable management
- Improve management of portable appliance charging
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Remove and reduce the risks to people from fire:
- 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 addition: Upgrade fire resistance door to storeroom for waste storage with half-hour fire-resisting materials and 'keep locked shut' signage to be provided
- They will be considered with the following addition: Provide automatic fire detection to escape routes
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The following persons have been considered as part of the assessment within 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
Fire Hazards,Electrical
1. Electrical Sources of Ignition
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Reasonable measures taken to prevent fires of electrical origin
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a. Fixed electrical installations periodically inspected and tested? (Every 5 years)
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b. Portable appliance testing carried out (where appropriate) on a risk assessed basis?
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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
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d. Suitable limitation and management of trailing leads and adaptors?
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e. Charging and storage of batteries undertaken on site?
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f. Are USB ports provided to reduce use of chargers by patients
Electrical Hazards
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Identified Hazards
- a. Fixed Electrical Installation
- b. Portable appliances
- d. Trailing leads and Adaptors
- e. Charging and storage of batteries
- f. Personal rechargeable appliances used by patients
- g. Other
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If other, please state:
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Existing Control Measures:
- 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
- Portable equipment charging units maintained
- Charging procedure displayed
- Management of single use E-Cigarettes where permitted
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Additional Control Measures Required:
- 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:
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1. Electrical source of ignition Deficiencies and comments:
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Last fixed wire inspection:
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Last portable appliance testing:
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.
Fire Hazards Smoking
2. Smoking
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Reasonable measures taken to prevent fires as a result of smoking?
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a. Smoking prohibited in the building?
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b. Smoking permitted in appropriate areas?
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c. Suitable arrangements for those who wish to smoke?
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d. This policy appeared to be observed at the time of the inspection?
Smoking Hazard
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Identified Hazards
- Illicit smoking by patients within the hospital site
- Illicit smoking still taking place on the ward
- Other
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If other, please state:
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Existing Control Measures:
- No smoking policy effectively being enforced
- Use of E-cigarettes by patients is suitably controlled
- Patients smoking materials are kept in safe custody by staff
- Other
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Additional Control Measures Required:
- Patients smoking materials are/are not kept in safe custody by staff
- Other
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
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2. Smoking Deficiencies and comments:
Fire Hazards Arson
3. Arson / Deliberate Ignition
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Basic security against arson by outsiders or other persons appears reasonable?
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Have there been previous cases or threats of arson at this premises?
Arson Hazards
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Identified Hazards
- Refuse storage is poor; bins unlocked, overfull and/ or near buildings
- Build up of dry vegetation near buildings
- Other possible fuel allowed to build up near buildings
- Other
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If other, please state:
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Existing Control Measures:
- 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
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Additional Control Measures Required:
- 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
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3. Arson/Deliberate ignition Deficiencies and comments:
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CCTV Present?
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External Lighting?
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Security Fence?
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Physical Security
Fire Hazards Portable Heaters
4. Portable Heaters
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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
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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?
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b. (ii) If the portable heaters are used, are suitable measures taken to minimise the hazard of ignition of combustible materials?
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c. Are fixed heating installations subject to regular maintenance?
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
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Portable Heaters Hazards
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Identified Hazards
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If other, please state:
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Existing Control Measures:
- Electrical tested
- Only oil-filled radiators in use
- Site away from combustible/flammable items by at least 1 metre in all directions
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Additional Control Measures Required:
- Electrical test required
- Current heaters to be removed or replaced with a lower risk type
- To be sited away from combustible/flammable items by at least 1 metre in all directions
Deficiencies and Comments:
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Heater use
- Advice on the appropriate use of portable heaters given to staff/tenants at the premises highlighting risks
- Heaters are not PAT certified, issue to be raised with occupier/tenant
- Other
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4. Portable heaters Deficiencies and comments:
Fire Hazards Fixed Heating Installations
5. Fixed Heating Installations
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Are there fixed heating installations such as boilers used within the premises?
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a. Are fixed heating installations subject to regular maintenance?
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b. Are suitable measures taken to minimise the hazard of ignition of combustible materials due to these heaters?
Fixed Heating Hazards
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Identified Hazards
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If other, please state:
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Existing Control Measures:
- 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
- Boiler room has 60 minute compartment barrier surrounding it
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Additional Control Measures Required:
- 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:
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Boiler Fuel Supply:
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5. Fixed Heating Installations Deficiencies and comments:
Fire Hazards Cooking
6. Cooking
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Type of catering within this premises
- Commercial catering including deep-fat fryers
- Commercial catering but no deep-fat fryers
- Servery with regen machine, toaster, etc but no hot cooking
- Staff kitchen with hob and oven
- Patient training kitchen
- Staff beverage room with no hot cooking
- Staff beverage area in open space
- No cooking or beverage preparation takes place
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a. Reasonable measures taken to prevent fires as a result of cooking?
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b. Filters cleaned or changed and ductwork cleaned regularly?
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c. Suitable extinguishing appliances available? (e.g. fire blanket, wet chemical etc)
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d. Kitchen staff trained to use extinguishing appliances provided?
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e. Suitable Shut Down Procedures in place?
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f. Fire detection is suitable for the type of cooking?
Cooking Hazards
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Identified Hazards
- Filters and duct work not cleaned
- Fire equipment missing or unmaintained
- Shut down procedures not in place
- Electrical catering equipment faulty or not tested
- Gas appliances and supply faulty or not maintained
- Poor staff training or procedures
- Other
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If other, please state:
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Existing Control Measures:
- Cleaned routinely under contract
- Measures in place and suitable for the equipment and cooking processes undertaken
- Satisfactory procedures in place and 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
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Additional Control Measures Required:
- Hoods, filters etc be cleaned and maintained under contract.
- Suitable control measures are not in place for the 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
- Procedures in place but not properly documented
Deficiencies and Comments:
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6. Cooking Deficiencies and comments:
Fire Hazards Lightning
7. Lightning
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Does the building have a lightning protection system?
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a. Is the lightning protection system subject to a suitable maintenance regime?
Lightning Hazards
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Identified Hazards
- Building is not protected from lightning
- Other
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If other, please state:
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Existing Control Measures:
- Lightning control is fitted, maintained and tested to current standards
- Other
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Additional Control Measures Required:
- Lightning control is required on this building
- Existing system requires testing 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.
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7. Lightning Deficiencies and comments:
Fire Hazards Dangerous Substances
8. Dangerous Substances
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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)
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Are the general fire precautions adequate to address the hazards associated with dangerous substances used or stored within the premises?
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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)
Dangerous Substances Hazards
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Identified Hazards
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If other, please state:
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Existing Control Measures:
- Stored in suitable areas and containers away from potential sources of ignition, to include issues of chemical reactivity and compatibility
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Additional Control Measures Required:
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.
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8. Dangerous Substances Deficiencies and comments:
Fire Hazards Housekeeping
9. Housekeeping
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Is the standard of housekeeping adequate?
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a. Combustible materials appear to be separated from ignition sources?
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b. Appropriate storage of hazardous materials?
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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?
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d. Avoidance of unnecessary accumulation of combustible materials and/or waste?
Housekeeping Hazards
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Identified Hazard:
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Existing Control Measures:
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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.
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9. Housekeeping Deficiencies and comments:
Fire Hazards Contractors/Buildingworks
10. Hazards Introduced by Contractors and Building Works
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Fire safety conditions have been imposed on both external contractors and in-house maintenance staff?
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Is there a satisfactory control over works, including use of hot work permits, where appropriate, carried out in the building by external contractor?
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Building maintenance is carried out under a SLA. The maintenance provider can sub contract work as required and issue permits, monitor safe system of work etc. This process is a Contractual agreement between NHS Property Services LTD and the Facilities Maintenance body. In this premises, the work is undertaken by:
Contractors / Building Works Hazards
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Identified Hazard:
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Existing Control Measures
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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10. Hazards Introduced by Contractors and Building Works Deficiencies and Comments:
Fire Hazards Other
11. Other Significant Fire Hazards that warrant consideration:
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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)
Other Significant Hazards:
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Identified Hazards:
- Compressed Medical Gas Cylinders
- IT Rooms
- MRI Scanners
- X-Ray Machines
- Other
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If other, please state:
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Existing Control Measures:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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11. Other significant fire hazards that warrant consideration Deficiencies and Comments:
Evacuation Strategy
12. Evacuation Strategy The evacuation strategy for this premises is detailed below: (Please tick appropriate strategy)
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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.
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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;
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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.
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Written copies of Evacuation Procedures are located as follows:
Evacuation Hazards
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Identified hazards:
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Existing Control Measures:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments
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12. Evacuation Strategy Deficiencies and Comments:
Fire Safety Provisions Means of Escape
13. Means of Escape from Fire
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It is considered that premises are provided with reasonable means of escape in case of fire?
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a. Adequate design of escape routes?
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b. (i) Reasonable distances of travel when there is escape in a single direction?
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b. (ii) Reasonable distances of travel when there are alternative means of escape?
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c. Suitable protection of escape routes? (Fire resisting construction)
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d. Adequate provision of exits?
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e. Exits easily and immediately open-able where necessary?
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f. Escape routes unobstructed?
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g. Fire exits open in the direction of escape where necessary?
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h. Avoidance of sliding or revolving doors as fire exits where necessary?
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i. Satisfactory means for securing exits?
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j. Satisfactory fire precautions for all inner rooms and dead ends?
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k. It is considered that the premises are provided with reasonable arrangements for means of escape for disabled people?
Means of Escape Hazards
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Identified Hazards:
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If other, please state:
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Existing Control Measures:
- Sterile lobby
- Occupation does not exceed 60 persons
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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13. Means of Escape from Fire Deficiencies and Comments:
Measures to limit fire spread
14. Measures to limit Fire Spread and Development
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a. It is considered that there is compartmentation of a reasonable standard. (Fire resistant to collapse, fire penetration and transfer of excessive heat
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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)
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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?
Fire Spread Hazards
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Identified hazards:
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Existing Control Measures:
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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.
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14. Measures to Limit Fire Spread and Development Deficiencies and comments:
Escape Lighting
15. Emergency Escape Lighting
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Reasonable standard of emergency escape lighting system provided?
Emergency Escape Lighting Hazards
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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
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If other, please state:
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Existing Control Measures:
- Emergency lighting units fitted internally
- Emergency lighting units fitted externally
- Flicked tested monthly undertaken
- Annual discharge undertaken
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Additional Control Measures:
- 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
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Type:
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15. Emergency Escape Lighting deficiencies and comments:
Fire Safety Signs and Notices
16. Fire Safety Signs and Notices
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Reasonable standard of fire safety signs and notices?<br>This includes fire exit, fire escape signage, fire resisting door and hazard signage.
Signs and Notices Hazards
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Identified Hazards
- Alternative routes and final exits in the premises which could be difficult for persons to navigate to a place of safety
- Other
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If other, please state:
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Existing Control Measures: The following signage and notices have been provided:
- Fire Action Notices
- Directional Escape Signage
- Hazard room signage
- Fire door signage
- Equipment hazard signage
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Additional Control Measures Required:
- 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.
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16. Fire Safety Signs and Notices Deficiencies and comments:
Means of giving warning in case of Fire
17. Means of Giving Warning in case of Fire
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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.
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If yes, give details: (e.g. Break glass call points, fire bell, air horn, klaxon etc.)
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a. Automatic fire detection provided? <br>
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If yes, to what Standard? (e.g. BS 5839 Part 1)
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If yes, what grade of system?
- L1
- L2
- L3
- L4
- L5
- Not known
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Has the L1, L2, L3, L4, L5 system design and installation certificate been available?
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Approximate age of system:
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Throughout premises?
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Part of Premises Only?
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b. Extent of automatic fire detection generally appropriate for the occupancy and fire risk?
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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.)
Means of giving warning Hazards
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Identified Hazards
- Providing persons with appropriate warning of a fire
- Other
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If other, please state:
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Existing Control Measures: Fire detection systems with the following devices:
- Manual Call Points at each final emergency exit
- Smoke and Heat detection
- Sounders
- Fire Alarm Panel
- Repeater Panel
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Additional Control Measures Required:
- 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.
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17. Means of Giving Warning in Case of Fire Deficiencies and comments:
Manual Fire Extingushing Appliances
18. Manual Fire Extinguishing Appliances
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a. Reasonable provision of portable fire extinguishers?
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b. Are all fire extinguishing appliances readily accessible and unobstructed? <br>(i.e. mounted on walls or on appropriate bases)
Manual Fire Extinguishing Hazards
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Identified Hazards
- Control of small fires in the premises
- Other
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If other, please state:
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Existing Control Measures:
- 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
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Date of last annual service:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and Comments:
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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 the premise
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18. Manual Fire Extinguishing Appliances Deficiencies and comments:
Automatic Extinguishing Systems
19. Relevant Automatic Fire Extinguishing Systems
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Does the property have a fixed system?
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State type of system and location: (inert gas suppression systems, sprinklers/misting systems etc.)
Automatic Fire Extinguishing Hazards
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Identified Hazards:
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Existing Control Measures:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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19. Relevant Automatic Fire Extinguishing Systems Deficiencies and Comments:
Fire-fighters Switch- Luminous Tubes
21. Firefighter Switch - High Voltage Luminous Tube Signs etc
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Suitable provision of fire fighters switche(s) for high voltage luminous tube signs, etc.
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State location:
Firefighter Switch Hazards
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Identified Hazards:
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Existing Control Measures:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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21. Firefighters Switch Deficiencies and Comments:
Other Fixed Systems & Equipment
20. Other Relevant Fixed Systems and Equipment
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Does the property have a fixed system?
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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
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Identified Hazards:
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Existing Control Measures:
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Additional Control Measures Required? (See appendix A of NHS PS Fire Management Plan)
Deficiencies and comments:
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20. Other Relevant Fixed Systems and Equipment Deficiencies and Comments:
Procedures & Arrangements
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.)
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Fire Safety Managed in this Premises by:
Note: Responsible Persons at the premises must cooperate and coordinate their fire safety measures and activities.
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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)
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Is there a suitable record of the fire safety arrangements?
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Appropriate fire procedures in place?
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Are procedures in the event of a fire appropriate and properly documented?
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Are there suitable arrangements for summoning the Fire and Rescue Service?
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Are there suitable arrangements to meet the F&RS on arrival and provide relevant information, including that relating to hazards to fire fighters?
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Is there a plan of the building available indicating basic layout and any areas of significant risk?
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Are there suitable arrangements for ensuring that the premises have been evacuated?
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Is there a suitable fire assembly point(s)?
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Are there adequate procedures for evacuation of any disabled people who are likely to be present?
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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.
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Appropriate liaison (if necessary) (e.g. F&RS crews visiting for familiarisation visits)?
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Routine in-house inspections of fire precautions (e.g. in the course of health and safety inspections)?
Deficiencies and comments:
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22. Procedures and arrangements Deficiencies and Comments:
Training and Drills
23. Training and Drills Fire safety training is managed by A nominated Fire Safety Manager for each occupier / tenant organisation
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Fire Safety Training is managed by:
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Are arrangements in place to ensure that all new staff and visitors (where necessary) provided with fire safety induction and local building familiarisation?
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Is this induction training recorded?
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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?
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Are staff with special responsibilities (e.g. fire wardens and fire evacuation marshals) been appointed and provided with additional training?
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Are fire drills carried out at appropriate intervals and a record of such drills recorded? (6 monthly)
When the employees of another employer work in the premises:
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Is the employer given appropriate information (e.g. on fire risks and general fire precautions)?
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Is it ensured that the employees are provided with adequate instructions and information?
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Is there adequate co-operation and co-ordination between different Responsible Persons (Multi-Occupancy) to ensure compliance with the Fire Safety Order?
Does all staff training provide information, instruction or training on the following:
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Fire risk in the premises?
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The fire safety measures in the premises?
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Action in the event of fire?
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Action on hearing the fire alarm signal?
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Method of operation of manual call points?
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Location and use of fire extinguishers?
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Means for summoning the Fire and Rescue Service?
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Identify of persons nominated to assist with evacuation?
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Identify of persons nominated to use fire extinguishing appliances?
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.
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23. Training and Drills Deficiencies and comments:
Testing & Maintenance
24. Testing and Maintenance
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Testing and Maintenance is carried out by:
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Adequate maintenance of premises?
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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?
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Monthly and annual testing routines for emergency escape lighting?<br>Function test monthly with annual discharge or PPM in place
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Monthly visual check and annual maintenance of fire extinguishing appliances?
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Last Annual fire appliance service?
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Periodic inspection of external escape staircases and gangways?
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Six monthly inspection and annual testing of rising mains?
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Weekly and monthly testing, six monthly inspection and annual testing of fire-fighting lifts?
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Weekly testing and periodic inspection of sprinkler installations?
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Routine checks of final exit doors and/or security fastenings?
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Annual inspection and testing of lightning protection system?
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Are suitable systems in place for reporting and subsequent restoration of safety measures that have fallen below the required standard?
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Other relevant inspections or tests: (Give details)
Deficiencies and comments: The Regulatory Reform (Fire Safety) Order 2005 - Article 17 - Maintenance The responsible person must ensure, where necessary in order to safeguard the safety of relevant persons, that the fire precautions are maintained in good working order.
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24. Testing and Maintenance Deficiencies and Comments:
Recording
25. Recording
Appropriate records held for:
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Is there a local fire safety information folder?
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Fire drills?<br>6 monthly, but at least once every 12 months
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Fire Training?
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Fire alarm tests?
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Emergency escape lighting tests?
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Maintenance and testing of other fire precaution systems?
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Location of Records: (Available for inspection by Fire Authority if required)
Deficiencies and comments:
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25. Recording Deficiencies and Comments:
Internal Audit Checks
Internal Audit Checks
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Document Prepared by:
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Date:
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Checked by:
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Date:
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File Location:
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Copy to SSM:
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Date:
Building plans
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Add plans of the building here if it will assist with understanding this FRA