LEEDS MENTAL HEALTH FIRE RISK ASSESSMENT Report for …...the existing fire safety arrangements...

LEEDS MENTAL HEALTH FIRE RISK ASSESSMENT Report for Newsam Centre Seacroft hospital York Road Leeds RA05159-S02-R01-Issue 1

RA05159-S02-R01-Issue 1

Issued 30 November 2006 Page 2 of 24

Executive summary

Tenos br ie f

Tenos were appointed to conduct fire risk assessments for Leeds Mental Health. This report relates to the fire risk assessment carried out at Newsam Centre Seacroft hospital, York Road, Leeds. The assessment was carried out by Dominic Vallely of Tenos Limited on 13th 15th and 21st September 2006.

Risk analys is

This fire risk assessment is intended to determine the adequacy, effectiveness and suitability of the fire safety measures within the Newsam Centre. Our overall assessment of the Newsam Centre is MODERATE FIRE RISK. This is typical of the expected level of risk in a building this type and occupancy. The term MODERATE represents a tolerable level of risk; however recommendations are included in the action plan to reduce the risk to “as low as reasonably practicable”.

S ign i f icant f indings

The significant findings from this risk assessment have identified that the arrangements for occasional access for maintenance staff within the roof void are compromised by the lack of effective procedures to ensure safe escape. The remedial action should not involve physical changes.

Overv iew

The Regulatory Reform (Fire Safety) Order 2005 places statutory duties for fire safety arrangements within a building on the “responsible person”. The people responsible for fire safety within the Newsam Centre should consider the recommendations contained in this report and implement them as they determine necessary. The headline results of the assessment are summarised in three strategic areas; management; active systems and passive systems:

The fire safety management arrangements are consistent with most buildings of this type, but would benefit from the provision of more detail to achieve full compliance with the Fire Safety Order.

The active fire safety systems are generally to a good standard: however some areas for improvement have been identified

The passive fire safety systems are generally to a good standard; however some areas for improved protection have been identified.

The need for continuing fire safety management by all users of the building is essential to ensure that the likelihood of a fire within the building is minimised and that in the event of a fire occurring the consequences of that fire is minimised to be as low as reasonably practicable. This report and the recommended action plan will assist with the ongoing management of the fire safety arrangements at the Newsam Centre, Alma Street, Leeds, LS9 7BE.

It is the joint responsibility of Leeds Mental Health Teaching NHS Trust and Accent to consider the recommended actions and review this risk assessment on a regular basis to ensure that it is maintained up to date. To demonstrate effective fire safety management to the enforcing authorities we recommend that the Leeds Mental Health Teaching NHS Trust and Accent document the actions taken within the action plan provided in this report.

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Issue and amendment record

Issue Date Author Checked by Amendment details

D1 26 Oct 06 Dominic Vallely John Barnfield Draft for client review

1 30 Nov 06 Dominic Vallely John Barnfield First Issue

Important information This fire risk assessment report has been prepared following a site inspection and is based on the observations made during that visit, together with information received from personnel on site and an examination of documents made available. It does not include any areas, activities or processes that the assessor was not made aware of whilst on site. The omission of any area of the building from this report should not be construed to assume compliance with the legislative requirements pertinent to that part of the building. We recommend that this report is kept within the building to which it relates and available for review by the enforcing authorities. This report relates only to statutory requirements and reducing unnecessary business interruption, Additional fire safety measures may be appropriate for insurance, loss prevention or environmental purposes. This fire risk assessment report is copyright of Tenos Limited and applies only to the Newsam Centre. It must not be used to manage fire safety risk in any other building. This report may only be forwarded to a third party if reproduced in full and without amendment to the content or presentation.

Contents: 1 Introduction 4

2 Details of assessment 5

3 General observations 9

4 Document review 10

5 Risk assessment analysis 11

6 Significant findings and action plan 12

7 References and bibliography 24

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1 Introduction

1.1 Employers, Building Managers and Owners are responsible for the fire safety provisions within buildings under their control. They are required to ensure that a suitable and sufficient fire risk assessment is carried out of their buildings by virtue of the provisions contained in the Regulatory Reform (Fire Safety) Order 2005.

1.2 The people responsible for fire safety are also required to take such general fire

precautions as will ensure, so far as reasonably practicable, the safety of any of their employees; and any other person who may be affected by a fire in the building.

1.3 This report documents the fire risk assessment carried out at Newsam Centre,

Seacroft hospital, York Road, Leeds by Dominic Vallely of Tenos Ltd on 13th 15th and 21st September 2006. The risk assessment was confined to the areas occupied exclusively by Leeds Mental Health and the means of escape therefrom.

1.4 The assessment was carried out to satisfy the requirements of the current fire

safety legislation utilising a semi-quantified approach. Fire hazards were identified, together with the identification of any persons at significant risk and the risk of fire was then evaluated.

1.5 The preventative and protective measures recommended within this report are

based on the principles of:

• risk removal, • evaluation of the risks which cannot be removed, • combating risks at source, • replacing dangerous products, process etc by non-dangerous or less

dangerous products, process etc, • a coherent holistic approach to fire safety policy and procedures throughout

the building, • provision of appropriate instruction, information, training and supervision.

1.6 This report documents the significant findings and records the results of that evaluation.

1.7 The assessment methodology used is a Modular Method, whereby the

assessment is considered under three principal areas;

Current Fire Safety Arrangements Ignition Hazards Propagation Hazards.

In addition to life safety issues consideration is given to Business Continuity and the effects a fire would have on the building assessed and whether or not it could affect neighbouring occupiers.

1.8 As part of the Fire Safety Management arrangements we recommend that an

audit be carried out in 12 months time to monitor and record progress on implementing the Fire Risk Assessment recommendations.

1.9 In order to demonstrate good Fire Safety Management practice to any enquiring party we recommend that the actions taken to reduce the hazards identified are documented in the action plan provided within this report.

1.10 All staff working in the building should be reminded of the need to follow laid

down procedures at all times. 1.11 We recommend that this report is kept on site and available for inspection by

the enforcing authorities.

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2 Details of assessment

2.1 The fire risk assessment was conducted in two parts; the first part involved a desktop audit of the existing fire safety management policies and procedures, a review of fire safety documentation and interviews with the people responsible for the day-to-day fire safety management within the building.

2.2 The second part involved a physical inspection of the premises and fire escape

routes. The survey was a non-destructive visual inspection of the premises. Where false ceilings have been installed, the assessor carried out random sampling to visually inspect the effectiveness of fire compartmentation.

2.3 The information in this section is based on the answers provided during the

desktop audits with people responsible for fire safety; the assessor interviewed the following Trust staff: Teri Wadsworth and Ward Clinical Team Managers and Suzanne Horsfall and Deborah Bradley from Accent Group.

Genera l

Date: • 13 September 2006

Consultant:: • Dominic Vallely

Company Name: • Leeds Mental Health Teaching NHS Trust

Address: • Newsam Centre • Seacroft hospital • York Road • Leeds

Respons ib i l i ty

Client Contact

• Mrs Teri Wadsworth

Position in Company • Directorate Support Manager

Responsibility • The person interviewed is not responsible for fire safety throughout the entire premises.

• Other Managers have responsibility for fire safety within their departments, e.g. CTMs in Wards.

Other Employers • Other employers Accent Group provide

services to this business with employees within the building

Co-ordination and Co-operation

• Regular meetings are held with the other employers. There was no documentary evidence to support that fire safety within the building is a regular agenda item, although it is discussed.

Other Responsible Persons • There are no other persons with fire safety

responsibilities within the building.

Other Responsible Persons • There are other persons with fire safety responsibilities within the building.

On-site Representative • Mrs Deborah Bradley

Position in Company • House Services Manager – Accent

Co-ordination and Co-operation

• Regular meetings are held with the other responsible persons. There was no documentary evidence to support that fire safety within the building is a regular agenda item, although it is discussed.

• The fire safety arrangements within the building, provided by others and relevant to this building have been made known to the employer.

Pol icy and procedure

Organisation • The employer operates on more than one site in the UK

Fire Safety Management • A Corporate fire safety policy has been defined and published setting out the principles for fire safety management.

• A fire safety management plan was available on site, setting out the roles and responsibilities of employees with fire safety responsibilities.

• The fire safety management plan has been implemented throughout the building

• There was no documentary evidence to support knowledge of the fire safety management plan by all employees.

• The fire safety management plan has been issued to other employers within the building.

• The fire safety management plan has been tested by the employer.

• The fire safety management plan was reviewed by the employer in May 2005

• Nominated members of staff are delegated to deliver specific fire safety management activities.

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Emergency Plan • The company has produced a Corporate Emergency Plan for all its buildings.

• The emergency plan for the building was available.

• There was no documentary evidence to support the testing or review of the emergency plan by the employer.

• The adequacy of the emergency plan was not reviewed by the Tenos assessor.

Business Continuity Plan • The company has produced a Corporate

Business Continuity Plan to minimise business disruption.

• Contingency plans are in place to minimise business disruption, the adequacy of the plan was not reviewed by the Tenos assessor.

Fire Safety Training • The company has a published staff fire safety

training policy. • The company's fire safety training policy

includes direction on staff fighting fires. • Staff are directed to fight fires only if they

consider it is safe to do so and they have received appropriate training in how to choose and use an extinguisher.

Smoking Policy • The company has a policy on smoking

within the building. • Staff are not permitted to smoke within the

building,, service users are permitted to smoke in designated areas inside the building.

Control of Contractors • The company has a policy for the control of

contractors. All contractors are briefed on the existing fire safety arrangements before they start work.

Insurance Requirements • The company's insurance company have not

imposed additional fire safety requirements on the building.

Previous Risk Assessment • A fire risk assessment has been carried out

previously, however there was no documentary evidence available on site to support the previous risk assessment having been carried out.

Maintenance: • The company has a policy for the pre-

planned preventative maintenance of all fire safety plant and equipment.

Record Keeping: • A fire safety logbook was available for review. See Document Review.

Imported Risks • The employer has not been notified of any

risks by neighbours. • Highly flammable materials (Alcohol

impregnated cleaning wipes) are used on all floors

• Highly flammable materials (Alcohol impregnated cleaning wipes) are stored on all floors.

Fire Statistics • The building has had a number of small fires

in the last five years. Details are collated centrally off site and were not available for review.

• It is understood that there is an arson or fire raising issue in the immediate locality.

• Fires in neighbouring property have been attributed as of doubtful origin

• Arson and fire raising have been considered as a potential ignition source by the local management.

• The local fire service is West Yorkshire Fire Service.

• There was no documentary evidence to suggest that the enforcing authority have raised any concerns regarding the fire safety arrangements at the current time.

Bui ld ing

Activity: • Provision of treatment and care for people who have mental health problems

• The processes and procedures carried out do not involve or produce dangerous substances.

• The assessor was made aware of the following hazards to himself whilst in the building; the assessor is not to work alone in patient areas and was issued with a staff alarm.

Operating Hours • The building is occupied 24 hours a day 7

days a week. .

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Characteristics: • The building comprises a building of 3 floors the height of the top floor is greater than 5m, but less than 18m.

• The external walls are of brick construction with concrete floors and a pitched slate roof.

• The internal arrangements are of traditional corridor with rooms off.

• The workplace was not designed with a documented fire safety strategy; however fire safety design drawings were available for review.

• The workplace is of a simple arrangement, without complex routes or sub-division.

Dimensions: • The building is approximately 93m long and

110m wide with a footprint of 5100m² and a gross floor area of 11200m².

Security • The building is situated within a partially

fenced enclosure. • Entry and exit doors are provided with

electronic security systems. • Security is provided 24 hours a day by on-site

security. • Car parking is provided on site.

Other Legislation • N/A

Utilities: • The building is provided with mains electricity. • The building is provided with town’s mains

gas. • LPG is not used in the building • Heating is provided by a low pressure hot

water system from a gas burning appliance

Occupancy

Number of Employees: • Trust – 140 + • Accent – 32 •

Number of Other Persons: • 101 beds for service users. • Up to approx 200 other people.

Occupant Density: • The occupant density is considered to be Medium.

Occupant Characteristics: • There were no employees under the age of

18 years at the time of the assessment. • The users of the building are predominantly

between 18 - 65 years of age.

Familiarity: • The employees are familiar with the layout of the building.

• The service users of the building are not familiar with the layout of the building.

Alertness: • The building provides sleeping

accommodation for service users and a small number of Trust staff..

Mobility: • There are no mobility impaired persons

employed within the building at the present time.

• There was one mobility impaired service user at the time of the assessment.

Sensory: • There are no sensory impaired persons

employed within the building at the present time.

• There were no sensory impaired service users at the time of the assessment.

Refuge Points • Refuges for mobility impaired persons are

provided in separate fire resisting compartments at the same level due to the use of progressive horizontal evacuation.

• Refuge points are not signed to indicate their location and are not considered necessary in this building.

Fire Safety Training • The company has a published staff fire safety

training policy. • The company's fire safety training policy

includes direction on staff fighting fires. • Staff are directed to fight fires if safe to do

so and they have received enhanced fire safety training.

Evacuation: • The building adopts a progressive horizontal

evacuation strategy. • The evacuation of less able-bodied persons

has been considered and arrangements put in place for their effective evacuation.

• Evacuation wardens are considered necessary to assist with the safe evacuation of all persons from the premises. and are utilised to ensure total safe evacuation of the building.

• There was no documentary evidence available to indicate enhanced training for evacuation wardens.

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Evacuation Drills: • There was no documentary evidence produced to support proactive fire evacuation drills.

• There was no documentary evidence available to support the existence of a building re-entry protocol.

• There was no documentary evidence available to support the existence of a briefing following re-entry to the building.

Assembly Point • The assembly point is situated within the car

park at the side of the building.

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3 General obser vations

Fire safety arrangements

Fire Detection and Warning:

• The building is provided with a fire alarm system.

• The fire alarm system has not been enhanced for business continuity purposes.

• The insurers have not specified an increased specification for the fire alarm system.

• Special warning arrangements have not been provided for the hearing impaired and are not considered necessary due to a staff led evacuation strategy..

Fire Fighting Equipment: • The building is provided with portable fire

fighting equipment

Emergency Routes and Exits

• The escape arrangements provide adequate means of escape from the building

• The escape routes were generally clear and available; however they were obstructed by storage in a few areas at the time of the assessment.

Escape Lighting • Emergency escape lighting is provided within

the building • The building is used during the hours of

darkness.

Escape Signage: • The exit routes are generally provided with adequate directional exit signage to clearly and un-ambiguously indicate the route to be taken, some additional signage may be beneficial.

Assembly Point • The assembly point is situated within the car

park at the side of the building and provides adequate safety for persons evacuating.

• All persons can disperse from the assembly point without returning to the building

• The assembly point is provided with adequate signage.

Addit ional Observat ions

3.1 The fire stopping to the service risers has been carried out to provide horizontal separation on a floor by floor basis without improvements to the separation of the risers from the corridors. The fire separation between the risers and the corridors is incomplete as the door frames are not effectively sealed to the walls. At the current time this does not present a problem due to the horizontal fire stopping, however the management of the introduction of additional services into these risers must be carefully managed to ensure that the horizontal separation is maintained in the future.

3.2 The majority of the office doors in the administration area are provided with self

closing devices and signed as fire door keep shut. A number of doors are held in the open position to facilitate ease of working and improve air flow. The doors are not required to be fire resisting or self closing where escape is available in two directions from an office environment. Consideration should be given to removing the self closing devices from those doors that are held open to facilitate ease of working.

3.3 Fire evacuation drills are not carried out due to number of fire alarms within the

building. Notwithstanding this the majority of fire alarms are actuated in Ward areas and therefore the Administrative function receives an intermittent alarm and no action is taken. The staff in the administration area should participate in prearranged fire drills to reinforce the fire safety training they receive. Consideration should be given to nominating staff whose roll means they remain in the building for the majority of their working time as fire evacuation wardens to ensure the effective evacuation of the Administration function.

3.4 All clinical staff are issued with a key to operate the manual fire alarm call points,

however they have only received limited training in their use. It is recommended that subject to the operational needs prevailing at the time of the weekly fire alarm test, clinical staff should be invited to activate the alarm on their ward.

3.5 The AZO wipes used in clinical areas are classified as Highly Flammable. They

should be stored in accordance with the manufacturer’s instructions. Consideration should also be given to where the containers are situated for immediate use in view of their flammable nature and the characteristics of the service users.

3.6 A further inspection was carried out on Tuesday 24th October to look at the fire

stopping provisions in the ceiling void of Ward 3. The findings revealed that the areas inspected are visually provided with fire stopping that should perform its desired function in the event of fire.

Bus iness Cont inui ty

3.7 The recommendations contained within this report should be acted upon to reduce the likelihood of a fire occurring and mitigate the potential damage to this building, neighbouring employers, adjacent property and the core business.

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4 Document review

4.1 A review was carried out as part of the assessment to determine the documentary evidence available to validate the existing fire safety management policies and procedures within the building.

4.2 Where records were not available the associated hazard is included in the record

of hazards identified below, together with a recommended remedial action.

Documentation Available Availability

Fire safety logbook Yes

Company fire safety policy Yes

Local fire safety management plan Yes

Fire safety strategy for building Yes

Plans of the building Yes

Previous fire risk assessment No

Fire Certificate Yes

Emergency Plan Yes

Business Continuity Plan Yes

Insurance Company Requirements No

Liaison meetings with other employers No

Document Audit Staff fire safety training records Yes Staff fire evacuation drill records There was no documentary evidence

produced to support proactive fire evacuation drills.

Fire alarm testing records The fire alarm is tested regularly.

Fire alarm maintenance records The fire alarm system is subjected to

regular inspection and maintenance in accordance with BS5839 Part 1 2002.

Fire alarm contractors worksheets Fire alarm engineers maintenance

certificates were available on site

Fire alarm fault reporting Faults to the fire alarm system are recorded in the fire safety log book and reported to the maintenance contractor.

Emergency escape lighting testing The escape lighting is tested monthly

for functionality.

Emergency escape lighting maintenance

No documentary evidence was produced to support inspection, maintenance and discharging of the escape lighting system.

Emergency escape lighting contractors worksheets

Emergency lighting engineers maintenance certificates were not available on site

Emergency escape lighting fault reporting

There was no documentary evidence produced to support the recording of defects to the emergency escape lighting system.

Portable fire fighting equipment inventory

An inventory of portable fire fighting equipment is not maintained.

Portable fire fighting equipment maintenance

Portable fire extinguishers are serviced annually by a competent fire extinguisher service engineer.

Portable fire fighting contractors worksheets

Portable extinguisher engineers maintenance certificates were not available on site

Are Fitted fire fighting systems fitted None Fitted

Fire damper maintenance No documentary evidence was

produced to support inspection, and maintenance of the fire dampers fitted in ductwork.

Fire fighting systems fault reporting & rectification

Faults to fixed and portable fire-fighting equipment are identified, reported and rectified.

Evidence to support maintenance by others Yes

Electrical BS7671 periodic inspection certificate Yes

Electrical BS7671 alterations certificate No Portable appliance testing records No Lightning conductor maintenance No Gas soundness and combustibility certificates Yes

Space heating maintenance engineers certificates Yes

Evidence of control of Hot Work No Fire Service correspondence There was no documentary evidence

to suggest that the enforcing authority have raised any concerns regarding the fire safety arrangements at the current time.

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5 Risk assessment analysis

5.1 The next pages contain: • significant findings • evaluation of the active, passive and fire safety management systems in

place; • analysis of risk; • hazards identified within the workplace assessed; • prioritised action plan.

5.2 The ranking numbers have the following meanings in the Risk Analysis for the

areas assessed:

L ike l ihood of ign i t ion occurr ing

1 Low likelihood of ignition 2 Medium likelihood of ignition 3 High likelihood of ignition 4 Very High likelihood of ignition

L ike l ihood of f i re development

1 Low likelihood of fire development 2 Medium likelihood of fire development 3 High likelihood of fire development 4 Very High likelihood of fire development

F ire Hazard Index

1 Very low possibility of established burning 2 Low possibility of established burning 3 Medium possibility of established burning 4 High possibility of established burning 5 Very High possibility of established burning

Potent ia l consequence to l i fe (LR)

1 No injury or minor injury – no time off work 2 Minor injury – < 3 days off work 3 Major injury – > 3 days off work 4 Single fatality 5 Multiple fatalities

Potent ia l consequence to bus iness (BR)

1 Minimal impact in specific area - no effect on core business 2 Some impact in specific area - minimal impact on core business

3 Loss of area - minimal impact on core business 4 Loss of number of areas - major impact on core business 5 Loss of workplace - stoppage of core business > 6 months

5.3 The risk categorisation is mathematically calculated to produce an overall risk ranking for the building. The consequences are numerically weighted against likelihood. The risk rankings range from Very High Risk (RED) through to Low Risk (GREEN) as depicted in the table below.

VERY HIGH The overall level of risk is very high. It is considered that immediate remedial action should be taken.

HIGH The overall level of risk is high. Remedial measures should be instigated as soon as practical and interim management procedures introduced to control the risk until the remedial measures have been completed.

MODERATE The overall level of risk is considered to be moderate. The overall level of risk is considered to be tolerable but recommendations are included in the action plan to reduce the risk to “as low as reasonably practicable”.

LOW The overall level of risk is low. Existing risk control measures should be maintained. Any recommendations highlighted in the action plan should implemented when practical.

5.4 The prioritisation of recommended actions ranges from Very High Priority (RED)

through to Low Priority (GREEN) as depicted in the table below.

The highest priority, immediate urgent action is recommended to reduce the risk

High Priority, action recommended to reduce the risk as soon as practicable.

Medium priority, action recommended to reduce the risk

Low priority, action may be necessary to further reduce the risk or maintain the arrangements at the current level.

5.5 Any action taken to remove or reduce the risk identified should be recorded on

the following pages in the “Action taken” column, dated and signed. When the item is completely closed the final column should be marked as complete.

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6 Significant findings and action plan

Persons especia l ly at r i sk

The following persons have been identified as being potentially at significant risk. Contractors and staff in the roof void.

S igni f icant f indings

Ref Location Hazards Identified Action Required

1.16 Roof void -. The distance of travel exceeds the maximum recommended where escape routes are available in more than one direction

The means of escape arrangements should be reviewed to provide alternative escape points and reduce the distance of travel from the roof void.. A number of roof access points are provided however they are not openable from within the roof void, albeit that they are provided with steps within the roof void they cannot be manipulated from within the roof void.

Consideration should be given to preparing and implementing a management procedure for roof void entry whereby an alternative access point is identified, opened and provided with steps prior to entering the void to work.

1.31 Roof void - The compartment walls do not continue through the roof void to the underside of the roof

The compartment wall should continue to the underside of the roof and the junction be sealed with a fire resisting material to prevent the spread of fire and smoke from one compartment to another. The roof is subdivided by foil backed mineral wool barriers. The installer should be requested to provide confirmation that the walls are capable of providing a minimum of 60 minutes fire resistance, have been installed to the manufacturers recommendations and that they are vertically aligned with the compartment walls below.

2.02 Roof Void - Above 1st floor.

Ground floor - 1DG 08.

Discarded smoking materials were observed Increase awareness of the smoking policy amongst all users of the building to discourage illicit smoking

Risk analys is

Risk Analysis for the building

Likelihood of Ignition occurring

Likelihood of Fire Development Fire Hazard Index Consequences to

life Consequences to

business Life Risk Business Risk

2.3 2.3 3.0 2.4 1.9 MODERATE MODERATE

The above ranking relates to the findings at the time of the on-site assessment.

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L ist of Hazards Ident i f ied / Pr ior i t i sed Act ion Plan

Priority Ref. Hazards Identified Location Consequence

L B Action Required Action Taken Date Name Item

Closed?

Fire Safety Arrangements

1.01 Inadequately documented arrangements for the co-operation and co-ordination of fire safety management

Throughout the building - The absence of a co-ordinated approach could result in the responsible person failing to make adequate arrangements for fire safety within the building due to other risks present in the building under the control of other responsible persons.

The people responsible for fire safety within the premises should co-operate with each other to ensure that the fire safety arrangements within the premises are suitable, sufficient and co-ordinated. It is recommended that these meetings are documented to demonstrate effective co-operation to the enforcing authorities.

1.02 Inadequately documented arrangements for the management of fire safety

Throughout the building - The absence of a clear documented fire safety management plan results in disparate measures being taken to manage the risk. These are generally not co-ordinated or complete, with individuals believing that somebody else is taking care of a particular facet of fire safety management

A fire safety management plan should be documented for the building. The management plan should include the organisation for delivery of the fire safety arrangements, including the roles and responsibilities of responsible persons, the controls, monitoring and review arrangements for the preventative and protective measures provided to ensure adequate fire safety arrangements throughout the building. The fire safety management plan should be brought to the attention of all employees and other persons who work in the premises and made available to other users of the premises as appropriate.

1.03 Inadequately documented arrangements for the management of emergency situations

Throughout the building - The emergency plan may not be suited to the existing risks within the building following changes to working practices and process or personnel changes. This could result in personnel taking action that could make the situation worse than the initiating event.

The emergency plan should be tested by practicing scenarios to ensure that all staff are aware of their assembly points and responsibilities under the plan and that the plan is effective. The plan should be reviewed at frequent intervals to ensure that it is still pertinent to the building and takes account of changing personnel and processes

1.04 Ineffective documented arrangements for the management of building re-entry procedures

Throughout the building - Early re-occupation could lead to the need to evacuate again before the all clear has been confirmed

Establish a building re-entry protocol, whereby the building is only reoccupied after the all clear has been given by the fire service officer in charge, or the nominated person following and evacuation drill

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Closed?

1.05 Ineffective documented management of evacuation procedures

Throughout the building - The lack of a review meeting could lead to the evacuation plan becoming unsuitable and put building occupants at risk.

A review of each evacuation should be carried out following re-occupation of the building, involving evacuation wardens, to ensure that the processes and procedures in place worked effectively. If necessary the evacuation plan should be revised to take account of any lessons learnt and a further evacuation drill carried out to test the amended plan. The meeting should be recorded, with a lead entry in the fire logbook.

1.06 Inadequate documentation of fire safety equipment

Throughout the building - The lack of documentary evidence could result in fire fighting equipment not being regularly checked and potentially missing maintenance inspections

Provide an inventory of fire fighting equipment within the building.

1.07 Inadequately documented fire safety related record keeping

Throughout the building - The lack of documentary evidence would make it difficult to prove that the fire safety measures in the building are appropriate and maintained to provide a safe environment for all persons resorting to the building

The fire safety logbook should be used to record all matters relating to fire safety management within the building. Records should include but not necessarily be limited to details of; the fire safety equipment provided within the premises; the testing and maintenance arrangements for the equipment and the fire safety training delivered to staff and nominated persons. The log book should be kept on site, available for use by fire safety suppliers and inspection by the enforcing authorities

1.08 Inadequately documented fire safety training

Throughout the building - The lack of training could result in serious injury to staff members or other building users due to the incorrect action being taken

All staff should take part in a fire evacuation drill at least annually to ensure that they remain familiar with the fire safety arrangements within the building. Evacuation of an area following an unwanted fire alarm should be treated as a fire drill.

Arrangements should be put in place to carry out pre-planned evacuation drills in the administration section of the building. The evacuation drills should be recorded in the fire safety logbook.

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Closed?

1.09 Inadequately documented fire safety refresher training

Throughout the building - The lack of training could result in serious injury to staff members or other building users due to the incorrect action being taken

All staff should receive refresher training periodically to ensure that they remain familiar with the fire safety arrangements within the building, the actions they are required to take to safeguard themselves and others. The training should be delivered locally and should include the participation of staff in an evacuation drill to test the evacuation procedures. The training should be recorded in the fire safety logbook

1.10 Inadequately documented training for staff in evacuation techniques

Throughout the building - The lack of additional training for evacuation wardens results in disparate measures being taken to manage the evacuation and could lead to areas of the building not being checked as the evacuation occurs, resulting in persons being unaccounted for

Staff should receive enhanced training to enable them to assist with the evacuation of the building. The training should be delivered locally and be based on written instructions prepared by the responsible person for the building concerned

1.11 Inadequately documented training in fire safety for the responsible person

Throughout the building - The lack of training in fire safety results in disparate measures being taken to manage the risk. These are generally not co-ordinated or complete, with individuals believing that the actions taken are correct, albeit that they may increase the risk and not mitigate it

The nominated staff should receive enhanced instruction and training in fire safety to enable them to discharge their responsibilities. The training should include fire safety legislation and the systems provided to deliver effective fire safety within the building, including but not limited to; fire detection and warning systems, means of escape, fire fighting equipment, fire risk assessment, testing and maintenance procedures, emergency procedures, evacuation techniques, record keeping etc.

1.12 No documentary evidence to support maintenance of equipment interfaced with the fire alarm system, e.g. door hold open devices, magnetic locks, gas solenoid valves.

Throughout the building The fire alarm system could fail to operate the interfaced equipment in a fire situation, resulting in the fire safety measures failing to carry out the desired function and compromising the ability of people to make their escape unaided

The fire alarm system and all interfaced equipment, e.g. magnetic hold opens, free swing devices, power isolators fire dampers etc. should be subjected to a pre-planned preventative maintenance regime in accordance with BS 5839 Part 1 and records kept on site.

From the records available there is no evidence to support maintenance of the automatic detection fitted in the roof voids. The maintainer should be requested to ensure that all devices are included in the maintenance programme.

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1.13 Incomplete documentary evidence to support effect fault reporting procedures for the fire detection and warning system

Throughout the workplace The fire alarm system could fail to operate in a fire situation allowing a fire to become established before it is discovered. People would be unaware of a fire during the early stages and their ability to escape unaided could be compromised

Faults to the fire alarm system should be reported to the approved maintenance contractor for immediate repair in accordance with the recommendations of BS 5839 Part 1 and records kept on site of the defect, request for repair and rectification of the fault

1.14 Inappropriate positioning of automatic smoke detector

Roof void - throughout roof void.

1st floor - Corridor by Junior Doctors bed-sit. Administration corridor

Fire could become established before the detector operates. People would be unaware of a fire during the early stages. Their ability to escape unaided could be compromised

Consideration should be given to relocating the smoke detectors so that they are a minimum of 500mm from a wall or vertical down stand over 250mm in depth, The smoke detectors should also be a maximum of 7.5 metres from a wall and a maximum of 15m apart. It may be necessary to install additional detectors to provide adequate coverage.

Due to the sub-division of the roof void with cavity barriers it may be feasible to relocate smoke detectors into the central area of each divided space to provide adequate coverage.

Each area within the roof void including the small voids at the extremities of the building should be provided with automatic detection.

1.15 Lack of a manual call points at exits from roof voids in secure areas.

Roof void - The warning of fire could be delayed whilst persons leaving the building attempt to locate a call point resulting in failure to inform others of the situation immediately

Consideration should be given to providing and installing manual fire alarm break glass call points in close proximity to designated access and egress points to the roof voids, The call points should be installed by a competent engineer and linked to the premises fire alarm system. A commissioning certificate should be obtained from the installer to show compliance with BS 5839 Part 1 2002.

Alternatively consideration should be given to preparing and implementing a management procedure for communications between persons working in the roof void and the facilities management team.

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1.16 The distance of travel exceeds the maximum recommended where escape is only available in one direction

Roof void - Excessive travel distances increase the time required for escape. The increased time could be greater than the maximum available safe egress time, and endanger life

The means of escape arrangements should be reviewed to provide alternative escape points and reduce the distance of travel from the roof void.. A number of roof access points are provided however they are not openable from within the roof void, albeit that they are provided with steps within the roof void they cannot be manipulated from within the roof void..

Consideration should be given to preparing and implementing a management procedure for roof void entry whereby an alternative access point is identified, opened and provided with steps prior to entering the void to work.

1.17 No documentary evidence available or permanent label to confirm the fire resisting rating of the roller shutters

Second floor - Kitchen roller shutter.

First floor - Roller shutters to Kitchens.

Ground floor - Roller shutters to kitchens. Roller shutter Pharmacy.

The area of higher fire risk may not be adequately separated from the remainder of the building by effective fire resisting construction. Fire and smoke could affect a large part of the building entering escape routes and rendering the route unusable, therefore preventing persons from escaping

Fire resisting roller shutters should be clearly identifiable as shutters which meet the testing requirements of BS476 for a stated period of time by use of a UKAS certified marking scheme.

The supplier should be requested to provide documentary evidence that the shutters are to the required standard. If it is not possible to ascertain that they provide a minimum of 30 minutes fire resistance consideration should be given to replacing them with certified clearly marked 30 minute fire resisting shutters.

1.18 Doors shown as 60 minute fire resisting on fire strategy drawings not installed. – Doors fitted are nominally of 30 minute fire resistance.

2nd Floor - corridor sub-division bedrooms 12 - 17, corridor bedrooms 1 - 11, plant room to lift lobby.

The escape route could be compromised by fire and smoke entering it via the door opening, rendering the route unusable, therefore preventing persons from escaping

Consider providing a fire resisting door to FD60 standard. The door should be certificated as meeting the minimum standard of testing to BS476 for a 60 minute fire resisting door.

1.19 Inadequate provision of self closing fire resisting door

2nd Floor - Staff locker room, Waiting room.


The fire resisting door should be provided with a positive action self closing device. The device should be capable of closing the door from any angle of opening and overcome any latch fitted to the door.

1.20 Disconnected self closing mechanism

2nd Floor - IDS 91.

Ground floor - IDG 72.


The self closing device should be reconnected to the door and every effort taken to ensure that the door is maintained effectively self closing

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1.21 Poorly fitting fire resisting self closing door

2nd Floor - Laundry., 1DS 82

1st floor - 3DF 56, 1DF 31. Laundry.



The doors should be repaired to provide a good fit in their frame. With double doors every effort should be made to maintain a small gap to the centre. The gap at the centre of the door should be restricted to a maximum of 3mm.make it effectively self-closing into its frame

1.22 Fire resisting doors held in the open position

2nd Floor – Dining Room, IDS 75.

1st floor - 1DF 18, 1DF 08, 1DF 03.



The holding of fire doors in the open position should cease immediately and the practice be discouraged amongst employees

1.23 Intumescent strips and cold smoke seals missing from door or frame

Ground floor - 1DG 73. The escape route could be compromised by fire and smoke entering it via the door opening, rendering the route unusable, therefore preventing persons from escaping

Consider providing intumescent strips and cold smoke seals and fit to the top and the edges of the door or within the frame

1.24 Doors fitted with electronic locks are not provided with a manual override to unlock the door in the event of an emergency

2nd Floor - Accent offices-fire escape, Ward 6 entry door, IDS 28.

1st floor - 1DF 103.

People escaping from the building could be trapped by a locked door in front of them and the fire behind them, preventing them from escaping

Consideration should be given to providing and installing an emergency manual override mechanism, to enable persons to unlock the door by one simple operation in the event of the need to evacuate the building

1.25 The escape route was compromised by stored materials.

2nd Floor – Accent -corridor.

1st floor - Therapy corridor.

Ground floor - corridor back door.

The escape provision from the premises is reduced to a sub-standard level, which could delay or prevent persons from escaping

The stored materials should be removed immediately and the escape route maintained free from storage and combustible materials at all times

1.26 No documentary evidence to support maintenance to the emergency escape lighting by competent persons

Throughout the building - The escape lighting could fail to operate when required resulting in inadequate luminance an delaying the escape of persons within the building

The escape lighting should be subjected to a pre-planned preventative maintenance regime in accordance with BS5266 Part 1 and records kept on site The emergency escape lighting engineers' worksheets should be obtained from the maintainer to provide documentary evidence that maintenance is carried out by competent persons.

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1.27 No documentary evidence to support reporting of faults to the emergency escape lighting

Throughout the building - The escape lighting could fail to operate when required resulting in inadequate luminance an delaying the escape of persons within the building

Faults to the emergency escape lighting system should be reported to the approved maintenance contractor for immediate repair in accordance with the recommendations of BS 5266 Part 1 and records kept on site of the defect, request for repair and rectification of the fault

1.28 Inadequate fire procedure information displayed

Throughout the building - Statutory compliance is not achieved within the building

Consider providing fire procedure notices in prominent positions and on Health & Safety notice boards, correctly completed with local information.

1.29 Inadequate fire exit directional signage

Roof void - Persons using the building may become lost or disorientated resulting in them failing to make their escape without assistance

Consider providing additional directional fire exit signage to clearly and conspicuously identify the route to the nearest fire exit. Exit signage should meet the requirements of the Health and Safety (Safety Signs and Signals) Regulations 1996 or BS5499. The signs should be white graphics on a green background and incorporate pictograms and directional arrows. The pictograms used should meet one standard, mixed pictograms should not be used

1.30 No documentary evidence to support maintenance of fire dampers fitted in ventilation ductwork.

Throughout the building -

Fire and smoke could travel undetected from one compartment into another and prejudice the means of escape from the area

The position of all fire dampers should be identified and a pre-planned preventative maintenance regime commenced to ensure that all dampers are maintained in accordance with the manufacturer’s instructions and at least once every two years. Records of testing and maintenance should be held on site.

1.31 The compartment walls do not continue through the roof void to the underside of the roof

Roof void - Fire could spread to a large part of the premises without being checked by fire resisting construction, resulting in extensive fire damage and premature loss of the building

The compartment wall should continue to the underside of the roof and the junction be sealed with a fire resisting material to prevent the spread of fire and smoke from one compartment to another. The roof is subdivided by foil backed mineral wool barriers. The installer should be requested to provide confirmation that the walls are capable of providing a minimum of 60 minutes fire resistance, have been installed to the manufacturers recommendations and that they are vertically aligned with the compartment walls below.

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1.32 Inadequate provision of fire fighting equipment in an area of higher fire risk

1st floor - IT Room, 3DF34- Switchgear room.

Fire fighting equipment should be provided in buildings to assist persons in making their escape, without the intervention of other persons

Action should be taken to provide additional fire fighting equipment as follows:

IT Room provide 1 x 2kg CO2 extinguisher

Switchgear room provide 1 x 2kg CO2 extinguisher.

The extinguishers should be positioned close to the normal entry exit door

1.33 Inadequate testing and maintenance of fire fighting equipment

Ground Floor – Therapy suite, Fire equipment cupboard on approach to Ward 2, 3DG15

The extinguisher could malfunction if an attempt is made to use it in a fire situation, resulting in injury to the person attempting to use the extinguisher

Extinguishers should be serviced by a competent engineer as soon as practicable and arrangements made to ensure that they are serviced annually

1.34 Insufficient emergency shut off information in close proximity to gas burning appliances and main switchgear

1st floor - 1DF 18, Therapy lichen.


A fire involving the equipment could continue to feed the fire despite attempts to extinguish it if the isolator cannot be located

Consider providing signs/notices depicting the location of the emergency isolation switch or valve to identify the position of the device from all angles of approach. The signs should include a pictogram

1.35 Inadequate access to isolation points

1st floor - 1DF 18, Therapy lichen.


A fire involving the equipment could continue to feed the fire despite attempts to extinguish it if the isolator cannot be located or accessed

Access to the isolators should be improved to ensure that they are easily accessible in an emergency

1.36 Inadequate business continuity planning arrangements

Throughout the building Failure to develop a holistic business continuity management plan may lead to catastrophic business losses and damage to the organisations reputation following an event

A business continuity plan should be formulated which includes identification of alternative accommodation, arrangements for the continued delivery of the core activity, and maintenance of records and information systems. The plan should be brought to the attention of all the service delivery stakeholders

Ignition Hazards

2.01 Insufficient "No smoking" signs displayed in prominent places throughout the building

2nd Floor - Entry to Roof void. The lack of prohibition signs could lead to illicit smoking in areas with higher fire load, seriously increasing the risk of fire in the building

Consider providing additional " No smoking" signs and display throughout the building to remind persons of the prohibition in place

2.02 Discarded smoking materials were observed

2nd Floor - Roof void above 1st floor.


Illicit smoking could seriously increase the risk of fire in the building

Increase awareness of the smoking policy amongst all users of the building to discourage illicit smoking

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2.03 No documentary evidence to support procedures are in place to control contractor working

Throughout the building Contractor working can import a significant ignition risk into the building, failure to control it significantly increases the risk of fire

Procedures to control contractor working within the building should be determined and implemented to minimise the risk of fire due to contractor working

2.04 No documentary evidence to support procedures in place to control hot work

Throughout the building - Hot work imports a significant ignition risk into the building, failure to control it significantly increases the risk of fire

A permit to work system should be implemented to control the hot work within the building

2.05 No documentary evidence to support alterations and extensions to the electrical installation is only carried out by qualified electricians

Throughout the building - Inappropriate work on the electrical installation by a non-qualified person could give rise to an increased risk of ignition, leading to a fire within the building

All alterations and additions to the electrical installation should be carried out by a competent electrical contractor to meet BS 7671:2001 Requirements for Electrical Installations IEE Wiring Regulations Sixteenth Edition, normally referred to as the IEE (Institute of Electrical engineers') Wiring Regulations 16th Edition

2.06 No documentary evidence to support repairs to electrical appliances are only carried out by qualified electricians

Throughout the building - Failure to test and maintain the electrical appliances could give rise to an increased risk of ignition, leading to a fire within the building

All repairs to electrical appliances should be carried out by a competent electrical contractor

2.07 No documentary evidence to support a robust Portable Appliance Testing regime.

Throughout the building - Failure to test and maintain the electrical appliances could give rise to an increased risk of ignition, leading to a fire within the building

All portable electrical appliances, including short fused extension leads should be subjected to inspection and testing in accordance with The Electricity at Work Regulations 1989, the Provision and Use of Work Equipment Regulations 1998 and the associated guidance.

2.08 Inadequate controls to minimise the introduction of additional electrical appliances

Throughout the building - The introduction of additional appliances could give rise to overloading of the electrical circuits which presents an increased risk of ignition

A procedure for controlling the introduction of electrical appliances should be formulated and brought to the attention of all users of the building

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2.09 A cable reel extension was in use

1st floor - 3DF 18. The overloading of electrical sockets gives rise to an increased risk of ignition, leading to a fire within the building

The use of cable reel extensions on a permanent basis to provide extra sockets should cease immediately and the practice be discouraged. Additional permanent sockets or short fused extension leads should be considered to prevent the use of cable reels. Fused short extension leads should be included in the portable appliance testing regime.

2.10 Multipoint adapters were in use

1st floor - 3DF 06, 3DF 31. The overloading of electrical sockets gives rise to an increased risk of ignition, leading to a fire within the building

The use of non fused multi-point adapters should be discouraged. Consideration should be given to providing additional permanent sockets or replacement of the multi point adapters with fused short extension leads. Fused short extension leads should be included in the portable appliance testing regime.

Propagation Hazards

3.01 No documentary evidence to support deep cleaning of the kitchen extract ducting system

Ground floor - Kitchen extract systems present an increased propagation hazard if not maintained to industry standards. Any fire in extract ducting could spread to involve large areas of the building very quickly

The extract ducting should be subject to pre-planned preventative maintenance and cleaning to meet industry standards

3.02 The upholstered furniture is in a poor state of repair with exposed foam filling material

2nd Floor - Waiting room.

1st floor - 3DF 65 Bed-sit.

The furniture could significantly contribute to fire growth within the area and produce large volumes of smoke which could affect the ability of people to escape in a short time scale

The furniture should be repaired or replaced with furniture which meets the requirements of The Furniture and Furnishings (Fire) (Safety) Regulation 1988, HTM 87 and the standards of BS 5852 with ignition sources 0 and 5, loose covers should be capable of meeting BS 5852 ignition source 1.

3.03 Areas where Oxygen cylinders are stored were untidy with readily available combustible materials in close proximity to cylinders, and not consistently signed as rooms containing Oxygen.

2nd Floor - Clinical store 1Ds 74.

1st floor - 1DF98.


The oxygen cylinders could be involved in a fire and significantly contribute to fire growth within the area.

Oxygen cylinders should be stored in accordance with the recommendations of HTM 2022-2, the manufacturers’ instructions and industry standards.

All rooms where Oxygen is stored should be clearly signed to meet the Health and Safety (Safety Signs and Signals) Regulations 1996.

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3.04 The general housekeeping arrangements were considered inadequate, due to an excessive fire load and disorganised storage.

1st floor - IT Room, Lift lobby 3DF 59, 1DF 15 storage against heater, IDF 17, IDF 89.


The combustibles could significantly contribute to fire growth within the area and produce large volumes of smoke which could affect the ability of people to escape in a short time scale

The housekeeping should be improved and every effort taken to ensure that it is maintained to acceptable standards

3.05 The upholstered furniture is not identified as meeting current standards

1st floor - 1DF 51- throws on chairs, I DF 96 Wraps.

Ground floor - Dining room, IDG 29, 1DG 41.

The furniture could significantly contribute to fire growth within the area and produce large volumes of smoke which could affect the ability of people to escape in a short time scale

The supplier should be requested to provide documentary evidence that the upholstered furniture meets the requirements of The Furniture and Furnishings (Fire) (Safety) Regulation 1988, HTM 87 and the recommendations of BS 5852 for materials when tested with ignition sources 0 and 5, loose covers should be capable of meeting BS 5852 ignition source 1. In the event that the

In the event that the supplier cannot provide documentary evidence to support compliance consideration should be given to replacing the soft furnishings with clearly marked compliant items.

3.06 Inappropriate wall and ceiling linings in circulation spaces

1st floor - Therapy corridor. Fire could become established very quickly and spread to include the whole space compromising the occupants escape route

The surface finishes to walls and ceilings should achieve a minimum of Class 0 surface spread of flame when tested in accordance with BS 476 Parts 6 and 7

3.07 No fire resistance to artificial foliage in circulation spaces

Ground Floor – Café Society and entrance foyer

Fire could become established very quickly and spread to include the whole space compromising the occupants escape route

The plants should be treated with a flame retardant chemical or removed from the building. If treated a certificate of conformity should be obtained from the supplier to demonstrate the standard of protection afforded and the recommended life span of the treatment.

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7 References and bibliography

7.1 Regulatory Reform (Fire Safety) Order 2005, SI 2005 No 1541, the Stationery Office 2005 7.2 Fire Safety - An employers Guide to Fire Precautions (Workplace) Regulations. HMSO 1999 7.3 Fire Safety Risk Assessment – Offices and Shops. HM Government 2006 7.4 Fire Safety Risk Assessment – Sleeping accommodation, HM Government 2006 7.5 Fire Safety Risk Assessment – Healthcare premises, HM Government 2006 7.6 Firecode HTM 87 – Textiles and Furniture NHS Estates 1999 7.7 Health Technical Memorandum 2022 – 2 Medical Gas Pipeline Systems Operational

Management NHS Estates 1997 7.8 BS 5839: Part 1: 2002. Fire detection and alarm systems for buildings, Code of practice for

system design, installation, commissioning and maintenance 7.9 BS 5266: Part 1: 2005, Emergency lighting, Code of practice for the emergency lighting of

premises. 7.10 BS 5266: Part 8: 2004, Emergency escape lighting systems. 7.11 BS 5588: Part 8: 1999, Fire precautions in the design construction and use of buildings, Code

of practice for means of escape for disabled people. 7.12 BS 5588: Part 12: 2004, Fire precautions in the design, construction and use of buildings,

Managing fire safety. 7.13 BS 5306: Part 2: 1990, Fire extinguishing installations and equipment on premises. Specification

for sprinkler systems. 7.14 BS 5852: 2006, Methods of test for assessment of the ignitability of upholstered seating by

smouldering and flaming ignition sources. 7.15 BS 476: Part 6: 1989, Fire tests on building materials and structures. Method of test for fire

propagation for products. 7.16 BS 476: Part 7: 1997, Fire tests on building materials and structures. Method of test to

determine the classification of the surface spread of flame of products. 7.17 BS 7671: 2001, Requirements for electrical installations. IEE Wiring Regulations. Sixteenth

edition. 7.18 Health and Safety (Safety, Signs & Signals) Regulations 1996. 7.19 BS 5499 Part 1: 2002 Graphic symbols and signs – Safety signs, including fire safety signs. 7.20 BS 5499 Part 4: 2000S Safety signs, including fire safety signs, Code of practice for escape

route signage. 7.21 The Health and Safety at Work etc. Act 1974.

7.22 The storage of flammable liquids in containers HSG 51 HSE Books 7.23 Electricity at Work Regulations 1989. 7.24 The Provision and Use of Work Equipment Regulations 1998.

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