Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Part 1: Sources of ignition

  • Are there procedures in place to control any smoking materials, e.g. Cigarettes, matches or lighters?

  • Are there procedures in place to monitor any cooking processes?

  • Are there procedures in place to monitor the use of any electrical, gas or oil fired heaters in the assessment area?

  • Are there procedures in place to control the use of any portable lighting equipment?

  • Are there procedures in place to report any faulty electrical or misused electrical equipment?

  • Are there procedures in place to control the use of extension leads or multi plug adapters being used within the assessment area?

  • Has all portable electrical equipment been PAT tested?

  • Are there procedures in place to monitor any hot surfaces, or any obstructions of ventilation equipment?

  • Are there procedures in place to control any hot works processes, e.g. welding by contractors, incineration or bitumen activities conducted within the assessment area?

  • Is all electrical wiring in good condition and regularly inspected by a competent person?

  • Are all light bulbs / shades and fittings clear of combustible materials?

  • Are all electrical sockets, plugs, appliances, and adapters in good condition?

  • Are there present, any lightening protection systems in place within the assessment area?

  • Are there procedures in place to minimise to a minimum any risks from Arson, and that a fire may be started by patients or public, either accidentally or deliberate, particularly by those who are elderly, suffer from mental illness, with learning difficulties, or young persons with difficulties?

  • Are there procedures in place to monitor and record any history or evidence of Arson?

  • Are there procedures in place to monitor and record any previous history of fire loss within the assessment area?

Part 2: Sources of fuel

  • Are all laundry supplies, e.g. bedding, towels, medical supplies etc within the assessment area stored correctly?

  • Are all toiletries, aerosols, wall and ceiling hangings and linings within the assessment area stored or fitted correctly within the assessment area?

  • Are all plastics or rubber materials e.g. soft play or restraint areas, video tapes, X-ray film, polyurethane foam- filled furniture, foam filled mats or polystyrene based materials stored correctly in the assessment area.

  • If there are any wood or wood-based furniture, textiles and, or soft furnishings e.g. spare clothing or hanging curtains within the assessment area, are they stored correctly?

  • If there are any waste products particularly finely divided items such as shredded paper, wood shavings, or off cuts and dust within the assessment area, are they stored and disposed of correctly?

  • Are all textiles and furnishings to the correct standard?

  • If there are any clothing or private belongings e.g. Seasonal and religious occasion decorations within the assessment area, are they stored correctly?

  • If there are any flammable products e.g. cleaning and decorating products, petrol, white spirit, methylated spirit, alcohol, cooking oils or disposable lighters within the assessment area, are they stored correctly?

  • Is there an up to date COSHH register within the assessment area?

  • If there any flammable liquids stored in plastic containers are they stored correctly within the assessment area?

  • If there are present, any flammable gases e.g. Liquefied petroleum gas (LPG) including aerosol canisters within they assessment area, are they stored correctly?

  • If present do any materials used to line walls and ceilings e.g. Carpet tiles, polystyrene ceiling tiles conform to current fire safety regulations?

  • Are all storage areas controlled and monitored according to their risk? Are all store doors either shut or locked shut depending on their use?

  • Is all office paperwork tidy and stored properly?

  • Are all means of escape routes including corridors, lobbies, and stairwells free from obstructions and storage of combustible materials?

  • Are all wheeled waste bins stored in designated areas away from any buildings? Are contractors skips controlled and placed in appropriate areas away from the sides of any buildings fitted with openable windows?

Part 3: Sources of Oxygen

  • Are all oxygen supplies from cylinder storage and piped systems e.g. medical oxygen and oxygen used by contractors e.g welding processes controlled within the assessment area?

  • Are all Oxygen/Medical Gases stored appropriately within the assessment area?

  • Are there present, shut off valves for piped Oxygen/Medical Gas Supplies within the assessment area? If yes are any such valves marked or labeled to identify as to which area they control?

Part 4: Persons at risk

  • If there any employees who work alone, either regularly or at specific times and/or in isolated areas, e.g. Domestics, pottering staff, security staff, maintenance staff, nursing or other staff especially at night, if yes is there a lone worker policy in place?

  • Are all people who are unfamiliar with the premises, e.g. agency or temporary staff, guests, visitiors (including visiting medical or social care staff) contractors in the assessment area, made aware of the fire safety procedures for the area.

  • Are there procedures in place to ensure that any patients who are unable to escape unaided (young children, babies, the elderly, physically disabled people (in particular people with mobility impairment) are evacuated safely in the event of a fire alarm activation.

  • Are there procedures in place in regards the evacuation of any people who are not able to leave the premises quickly (but do not require assistance), e.g. patients or visitors who are elderly or with limited disabilities and parents with children?

  • Are there procedures in place in regards the evacuation of any mentally disabled people, people with vision or hearing impairment, people with some other sensory impairment?

  • Are there procedures in place in regards the evacuation of people with language difficulties in the assessment area?

  • Are there people in the immediate vicinity of the premises?

  • Are there procedures in place in regards the evacuation of any people who's ability to escape unassisted is impaired due to their medical condition, medication, or who may be intoxicated?

  • Are there procedures in place to minimise the risk of a fire starting in a non-patient access areas that could affect adjacent patient access areas?

  • Has the maximum and minimum number of patients been considered within the assessment area?

  • Has the maximum and minimum number of staff on duty been considered within the assessment area?

  • Has the maximum and minimum number of any disabled staff been considered within the assessment area?

  • Has the maximum and minimum number of patients requiring assistance to evacuate been assessed within the assessment area?

  • Has the maximum and minimum number of visitors been assessed within the assessment area?

  • Has the maximum and minimum number of visitors with disabilities or impairments been considered within the assessment area?

Part 5 Fire Protection Measures

  • Has the total travel distance to the nearest emergency exit been considered within the assessment area?

  • Has any travel distances in excess of 60 metres been considered within the assessment area?

  • If any travel distances in excess of 60 metres have been identified in assessment area, have measures been put in place to ensure that the distance is either reduced, layout of area has been revised, number of persons in the assessment area has been reviewed, staff training has been increased for staff working in assessment area?

Part 6: Escape Routes & Strategies

  • Have you considered the type, number and dependency of people using the premises, when determining whether your premises have adequate means of escape?

  • Patient Dependency (Independent): have you considered the mobility of patients classed as independent in regards the patient is not impaired in any way and that they are able to physically leave the premises without the assistance of staff?

  • Patient Dependency (Very High Dependency): have you considered those patients whose conditions create a high dependency on staff. This includes those in intensive care, intensive therapy units, and operating theatres, and for those patients where evacuation could prove to be life threatening?

  • Patient Dependency (Dependent): have you considered all patients except those defined as independent or very high dependent. This category also includes children and any patients with mental health issues, regardless of their independent mobility?

  • Have you considered assisted means of escape, when determining whether your premises have adequate means of escape?

  • Have you considered the evacuation strategy when determining whether your premises have adequate means of escape, ie, size of doors for bed evacuation; size of corridors; rails outside of external fire exits for bed; wheelchair; mattress or slide sheet evacuation, also the location and number on each ward?

  • Have you considered the implications on the area of relative safety when using Progressive Horizontal Evacuation?

  • Have you considered the necessary equipment you have to take with you to keep the "care package" going?

  • Are beds and furniture stored correctly and not on escape routes?

Part 7: Emergency Evacuation of Persons with Mobility Impairment

  • Have you made provision for the emergency evacuation of disabled persons via:- Staircases, Horizontal Evacuation, Refuges; Rails; Evacuation Lifts, and other suitable Evacuation Aids?

Part 8: Signs and Notices

  • Are there instructions on how to use any first aid fire fighting equipment such as: fire extinguishers, hose reels, fire blankets?

  • Have provisions been made for patients or visitors with impaired vision?

  • Are all fire escape signs correctly positioned?

  • Does all escape signage have a pictograph on them?

  • Are designated fire doors indicated with appropriate signs ie, "Fire Door Keep Shut"

  • Are designated fire doors fitted with appropriate signage indicating how to use the door mechanism ie, "Push Bar To Open"?

  • Where necessary have "Fire Exit" doors got "Fire Exit Keep Clear " signs fitted?

  • Are all red Break Glass Call Points identified with appropriate signage?

  • Is there an "Action In case of Fire" notice beside each red Break Glass Call Point within the assessment area?

  • Does all "Action in case ofFire" notices have appropriate assembly point suitable for both Clinical and Non-Clinical personnel?

Part 9: Lightning

  • Is the building large enough to require lightning protection?

  • If lightning protection is required, does it meet the requirements of BS6651: 1992?

  • If fitted are lightning protection systems visually inspected every 12 months?

Part 10: Access for Fire Engines and Fire Fighters

  • Are all access roads to the building hard standing areas for fire engines and access roads into the building for fire-fighters, kept free from obstructions?

  • In taller buildings, is the rising fire main free from obstruction and secure?

  • Are there periodic maintenance checks carried out on any or all wet/dry risers within the assessment area?

  • Are there any other fire-fighting facilities to assist fire-fighters?

  • Are firefighters switches fitted to luminous discharge tubes where applicable?

Part 11: Fire-fighting Equipment

  • Is all fire-fighting equipment in the correct position and in satisfactory and serviceable condition? Are they within 12 month service date?

  • Are all fire extinguishers positioned on escape routes?

  • Are the extinguishers suitable, sufficient and well sited?

  • Are the extinguishers visible or does their position need indicating?

  • Are fire blankets provided where required ie in kitchens or beverage bays where cooking equipment such as ovens, cookers, microwave ovens, toasters etc are situated?

  • Has the use of any automatic fire extinguishing or suppressant systems been considered within the assessment area?

Part 12: Means of Escape - Single Direction of Escape

  • Is the premises provided with such a means of escape in case of fire, and such a means for securing that the means of escape can be safely and effectively used at all material times, as may be reasonably required in the circumstances of the case? (Minimum escape widths of 800mm from offices)

  • Has an evacuation strategy been provided?

  • Are there sufficient fire exits for the occupancy of the building?

  • Where provided, has the means of escape been designed as a series of stages?

  • Stage One - Horizontal Escape - Does this stage also include any horizontal travel outside the room of origin if there is still only one direction of travel?

  • Stage Two - Reaching Safety of Another Sub-Compartment - Does this stage involve such things as passing through a fire resisting barrier?

  • Stage Two - Reaching Safety of Another Sub-Compartment - is an alternative provided so that it is possible to turn your back on the fire and move away from it?

  • Stage Three - Vertical Escape - Is vertical escape down to the ground floor or access level possible should it be necessary?

  • Stage Four - Safe Exit - Is safe exit from the foot of the stairway to a place of safety away from the building possible?

  • Is the maximum distance for a single direction no more than 15m in patient areas or more than 18m in non-patient areas, before there is a choice of escape routes?

  • Is the maximum distance for escape no more than 15m (can include escape from an inner room providing access room is not a fire hazard room)?

  • Is the maximum distance for escape no more than 30m from any point to an adjoining sub-compartment, compartment or staircase?

Part 13: Means of Escape - Travel Distance

  • Is an emergency plan for the premises, stating the preferred methods of evacuation prepared, in order to assess the suitability of circulation spaces?

  • All Premises: Are doors on the escape route side-hung or pivoted?

  • All Premises: if sliding doors are found on the escape route, do they open outward when subjected to reasonable pressure from any direction?o

  • All Premises: if powered sliding doors are provided, do they have a monitoring system to ensure they fail safe to the fully open position in the event of a power failure?

  • All Premises: are all doors non-obstructive of escape corridor widths?

  • All Premises: if any doors to cupboards are located along corridors on the escape route, do such doors open through 180 degrees to avoid obstruction?

  • All Premises: Do doors across circulation spaces providing single direction of escape open in the direction of escape (doors to bedrooms do not have to open in the direction of escape)?

  • Are doors across circulation spaces fitted with glazed observation panels?

  • Can you confirm that the route is not prejudiced by smoke and flame issuing from openings in the buildings in the buildings envelope e.g. Windows and doors?

  • Will the structural elements resist the spread of heat and smoke for at least 30 minutes?

  • Is the escape route clearly defined?

  • Is the route installed with anti-slip surface?

  • Are adequate handrails provided?

  • Is escape lighting provided for the route?

Part 14: Means of Escape - Refuge

  • All Premises: Are there at least 2 separate (sub) compartments on each floor level?

  • All Premises: Does each (sub) compartment have a minimum of 2 fire exits either to the adjoining sub compartment or to another compartment, escape stair or outside?

Part 15: Means of Escape - Stairways

  • Medium Size Premises: Are there sufficient number of stairways to ensure that from each sub-compartment there are alternative means of escape to the ground floor?

  • Medium Size Premises: Is there a stairway within 40 metres of any room on an upper floor?

  • Medium Size Premises: Are all stairways in protected shafts , (except in the case of existing buildings where they may be external, provided they are not prejudiced by smoke or flames issuing from openings in the buildings envelope e.g. Windows))?

  • Do all protected shafts enclosing stairways have direct access to the outside at ground level, which leads to a place of safety away from the building, or access to the outside via a route which is free of combustible materials and is enclosed in 30 minute fire resisting construction?

  • Where any protected shafts descend to a basement level is there suitable physical separation at ground level to prevent those escaping from upper floors continuing to descend below ground floor level?

  • Where a stairway is the only stairway in a building, or where it is external , is it constructed of materials which are non- combustible or of limited combustibility?

  • Are escape stairways maintained in safe and sound condition?

Part 16: Means of Escape - Escape Lighting

  • Is escape lighting installed?

  • Is escape lighting provided to cover the following areas? Each exit door, intersections in corridors, outside each final exit and external escape routes, emergency escape signs , stairways so that flight receives adequate light, changes in floor levels, windowless rooms and toilet accommodation exceeding 8m2, fire fighting equipment, fire alarm call points, equipment that would need to be shut down in an emergency, lifts, areas greater than 60m2?

  • Is primary lighting provided to all internal and external escape routes?

  • Large Premises: is escape lighting provided within the following spaces: External routes to a place of safety?

Part 17: Means of Escape: - Escape Lifts

  • Are Escape Lifts present within the assessment area?

  • If lifts are not usable in event of fire are there alternative means to enable disabled and ambulance persons to escape in safety?

  • Is the building designed and constructed so that in the event of a fire, it's fire resistance will be retained for a reasonable period?

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Buildings with less than 4 storeys above ground - 30 minutes.

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time? Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Buildings with 4 storeys above ground - 60 minutes.

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Buildings with more than 4 storeys above ground - 60 minutes.

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Building basements with 2 or more storeys deep - 60 minutes.

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Column, beam or other member forming part of a structural frame

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Load bearing walls.

  • All elements of the structure should be able to resist the effects of heat for a reasonable period of time. Do the following elements meet this standard? (The minimum fire resistance of all elements of structure should be): Floor.

  • If the premises has a wall common to two or more buildings is it so designed and constructed that it provides adequate resistance to the spread of fire between those buildings.

  • If the premises is semi-detached or forms part of a terrace, does that wall between the different occupancies have a fire resistance of 60 minutes?

Part 19: Containment - Compartmentation

  • Is the building adequately sub-divided with fire-resisting construction into compartments and sub-compartments, to inhibit the spread of fire within it?

  • Medium & Large Premises: Is each floor a compartment floor, with the same fire resistance as the elements of structure?

  • Are all openings adequately fire stopped and limited to doors which are FD30 or FD30S?

  • Are all openings adequately fire stopped and limited to openings for cast iron or steel pipes of not more than 160mm diameter?

  • Are all openings adequately fire stopped and limited to openings for pipes of other materials of not more than 40mm diameter?

  • Are all openings adequately fire stopped and limited to ventilation ducts which comply with the requirements of BS5588: Part 9?

  • Are all openings adequately fire stopped and limited to refuse and laundry chutes of non-combustible construction which are accessed through fire resisting doors?

  • Are all openings adequately fire stopped and limited to protected shafts?

  • Do all protected shafts have the same period of fire resistance as the compartment structure?

  • Is the access to any protected shafts only permitted from circulation spaces and sanitary accommodation?

  • Is any access through circulation spaces through doors which are FD30s?

  • Are all protected shafts ventilated in the form of an openable window of 1m2, or similar, at the top of the shaft?

  • Are all doors in sub-compartment walls FD30 or FD30S?

  • Are all doors leading to protected shafts from circulation spaces, or in sub-compartment walls, fitted with an automatic self-closing device?

  • Confirm no hold-open devices present?

  • Are self closing devices on fire doors operating correctly, including door selectors?

  • Are fire doors maintained in an effective working (damage to door, frame, smoke seals etc)?

  • Are doors fitted with magnetic locks provided with green emergency door release break glass manual override switch?

  • Where fire doors are fitted with electronic hold open devices, do the doors close correctly on activation of the fire alarm?

  • Where automatic sliding doors are fitted, do these doors fail safe to the open position on activation of the fire alarm?

  • Where the answers to the above are yes, are they linked to an L1 alarm and detection system, which also has safeguards on night-time closing?

Part 29: Containment - Sub-division of Cavities

  • Are there concealed cavities in roofs, ceilings or walls sub-divided, so as to prevent the unseen spread of fire & smoke?

  • Medium & Large Premises: Are all cavities in walls sealed where they meet compartment floors or sub-compartment walls, or where they meet fire resisting ceilings?

  • Medium & Large Premises: Are sub compartments 30 minute FR with no distance between sub divisions greater than 20 meters?

Part 21: Containment - External Envelope Protection

  • New Buildings: Are the external walls and roofs designed and constructed so that they can afford adequate resistance to the spread of fire over them, and from one building to another, having regard to the position of the building?

  • New Buildings: Do junctions of walls and low level roofs provide at least 60 minute FR?

  • New Buildings: Do junctions of walls and low level roofs provide at least 60 minute FR?

  • New Buildings: Do junctions of compartment walls and external walls provide at least 1m FR equal to the compartment walls?

  • New Buildings: No openings within 1.8m of external wall providing less than 30 minute FR?

Part 22: Fire Alarm Automatic Detection

  • Is there an automatic fire detection system installed?

  • Is there automatic detection installed in all areas?

  • If fitted is the fire alarm "Conventional"?

  • If fitted is the fire alarm "Addressable"?

  • If fitted is the fire alarm "a life protection system"?

  • If fitted is fire alarm "a property protection system"?

  • Is fire alarm linked to an "Alarm Receiving Centre"?

  • Are there break glass call points provided at each final exit, storey exit, nurse station?

  • Can the fire alarm be clearly heard throughout the building?

  • Is the fire alarm visual and audible?

  • Is the fire alarm tested weekly within the assessment area?

  • Are records kept in regards all testing and maintenance of the fire alarm system?

Part 23: Fire Training

  • Do all staff receive fire safety training during a staff induction programme prior to commencing work within their ward or department?

  • Do all staff receive mandatory fire safety training annually, or sooner if a risk assessment identifies a higher risk of fire?

  • Have you trained your staff in using the means of escape, fire warning system and fire routine procedures?

  • Are there records of all fire training drills, tests and examinations carried out?

  • Are fire drills carried out? Date of last evacuation drill?

  • Is there a system in place for logging staff in and out of the assessment area?

  • Have you considered all the people likely to be present in your work place and others that may share the building with you?

  • Is there a system in place for recording visitors and guests present in the assessment area?

  • Are there procedures in place to account for all persons in the assessment area should evacuation be necessary?

Part 24: Fire Hazard Rooms

  • Are Fire Hazard Rooms separated from the remainder of the building by materials affording at least half hour fire resistance?

Part 25: Control of Contractors

  • Are there arrangements in place to control the works carried out by contractors?

  • Are there arrangements in place for the safe storage of any hazardous materials brought on site by contractors?

  • Do contractors receive H&S and Fire Safety instructions either on site or prior to commencing work on site?

Part 26: RRO Audits

  • Has the assessment had any previous RRO Audits conducted by local Fire and Rescue Service?

Part 27: Recommendations / Action Plan

  • Place all recommendations within this section and label either urgent or non - urgent.

Part 28: Overall Risk Rating

  • Risk Rating:

Part 29: Review Date

  • Date of review:

Part 30: Signature of Auditor

  • Auditor to Sign Here:

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