Fire Safety

Standard Operating Procedure

Title:

Fire Safety Standard Operating Procedure

Date effective from: 09/03/2022 Review date: 08/03/2025

Author/s: Fire Safety Manager (NHSL) and Fire Safety Advisor(REAS)

Target Audience: All NHS Employees.

Supersedes: Fire Safety Standard Operating Procedure 19/11/2018

Fire, Fire Safety, Emergency Fire action Plans, EFAP, Firecode, Fire
Keywords (min. 5):
Regulations, Fire Guidance.

Version Control

Date Author Version/Page Reason for change

Fire Safety Manager (NHSL) and

09/03/22 1.1 Technical Update
Fire Safety Advisor(REAS)

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1. Introduction

1.1 - Introduction
1.2 - Definition/Abbreviations
1.3 - Responsibilities (General)
1.3.1 The Chief Executive.
1.3.2 The Nominated Officer (Fire).
1.3.3 The Fire Safety Manager ( Operations )
1.3.4 The Fire Safety Officers/Advisors.
1.3.5 FM Managers.
1.3.6 All Line Managers.
1.3.7 Fire Incident Responders.
1.3.8 Shared Premises.

2. Fire Safety Specific Responsibilities

2.1- 3i Studio “Fire Manager”.

2.2 - Fire Risk Assessments.
2.3 - The Reporting of Fire Incidents.
2.4 - The Reporting of Unwanted Fire Alarm Signals (UFAS).
2.5 - Liaison with Scottish Fire and Rescue Service.

3. Premises Specific Fire Safety

3.1 - Fire Control Centre (provided in all buildings designed for phased evacuation)
3.2 – Means of Escape
3.3 - Progressive Horizontal Evacuation.
3.4 – Structural Fire Precautions.
3.5 – Detection and Warning.
3.6 - Fire Alarm System
3.6.1- Detection and Warning
3.6.2 – Maintenance of Alarm System
3.6.3 Policy on Silencing Fire Alarms
3.7 - Emergency Lighting
3.8 - First Aid Fire Fighting Equipment
3.9 - Access for Fire Fighting Appliances.
3.10 – Surface Finishes, Furniture, Textiles.
3.11 - Fire Safety Checks to be carried out with Premises.

4. Staff Responsibilities
4.1 - Staff Responsibilities
4.2 - Premises Manager Responsibilities.
4.3 - Fire Drills and Exercises.

5 Electrical Equipment General Fire Safety.

5.1 – Electrical Equipment General.
5.2 – Electrical equipment checks before use.

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 5.3 – Personal Portable Electrical Equipment.
5.4 - NHS Owned Portable Electrical Equipment.

6 General Fire Safety

6.1 – Smoking.
6.2 - Chemical, Solvents, Medical Gases and X-Ray.
6.3 – Flammable Liquids.
6.4 - Fire Precautions in Specific Areas.
6.5 - Deliberate Fire Raising.
6.6 – The Equality act 2010.
6.7 – Fire Precautions for Notice Boards.
6.7.1 – General Guidance.
6.7.2 – Enclosed Notice Boards.
6.7.3 – Unenclosed Notice Boards.
6.8 – Batteries (Fire Risk).
6.8.1 – Storing New and Waste Batteries.
6.8.2 – Battery Recycle Bins / Disposal.
6.9 – Fire Procedures.

7. Summary

Fire Safety Standard Operating Procedure

• 1.1 – Introduction

Fire Safety is one of the Boards higher risk areas and therefore it is of utmost importance that we
manage and control this area effectively.

There are a number of mitigating measures and actions we take to achieve this and this standard
operating procedure aims to detail these.

This standard operating procedure applies to all persons occupying premises owned, occupied or
managed by NHS Lothian board.

This Operational Procedure should also be used in conjunction with the NHS Lothian Fire Safety
Policy (L1).

• 1.2 - Definition / Abbreviations

• EFAP – Emergency Fire Action Plan

• FRA – Fire Risk Assessment
• SHTM – Scottish Health Technical Memorandum
• NOF – Nominated Officer (Fire)
• SFRS- Scottish Fire and Rescue Service
• SOP – Fire Safety Operational Policy
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 • FSA’s – Fire Safety Advisers
• PHE - Progressive Horizontal Evacuation
• PPM’s- Planned Preventative Maintenance Schedule
• DDA – Disability Discrimination Act
• UFAS – Unwanted Fire Alarm Signal
• DSEAR – The Dangerous substance and Explosive Atmosphere Regulations 2002
• NHS Firecode – is a suite of documents which provide guidance to be applied throughout
healthcare premises, and will also advise where other more appropriate standards may
apply e.g. British or European standards (Bs, Bs:En)
• Fire Scotland Act – is an Act of the Scottish Parliament made to restate and amend the
law in relation to fire services
• 3i Fire Manager – is the NHS Scotland asset management system that is used as the main
recording tool by Fire Safety Departments to record all Fire Safety Data.
• Duty Holder – the Fire Scotland Act places a duty on those responsible for fire safety
within relevant premises to carry out a fire risk assessment. These people are defined in
the Fire (Scotland) Act 2005 as Duty Holders.
• Competent Person – Person, suitable trained and qualified by knowledge and practical
experience, and provided with the necessary instructions, to enable the required task(s) to
be carried out correctly.

• 1.3 – Responsibilities (General)

1.3.1 -The Chief Executive will be the “Duty Holder” for the purposes of the Fire (Scotland) Act 2005
as amended and the Fire Safety (Scotland) Regulations 2006. And will have overall responsibility to
manage the strategy through the Executive Board, in terms of command structure and ensure clear
guidelines for those tasked with the compliance of legislative guidance and statutory standards, The
Chief Executive has assigned the role of lead executive for fire safety to the Nominated Officer (Fire).

1.3.2 - The Nominated Officer (Fire) will have a working knowledge of Fire Safety matters. They will
provide a safe working environment in compliance with relevant Health and Safety legislation to all
those who work in or on its premises.
They must ensure that there are arrangements for identifying, evaluating and managing the risk of
fire.
They must ensure that any adverse events relating to fire are monitored and reported to Health and
Safety Committees and other local Health and Safety Groups where applicable. The person holding
this position will have sufficient responsibility and seniority to carry out a whole range of duties at the
highest level. He or she will be a senior officer from within either the Estates Department or Facilities
Management structure. He or she will have a global view of NHS Lothian in terms of the engineering
of firefighting equipment, automatic fire detection systems, and planned preventative maintenance.
He or she will also have responsibility for future development of equipment and buildings, as well as
being the head of any project team with regard to fire safety planning and development. The
Responsibilities of the Nominated Officer (Fire) as listed above does not replace the duty holder
responsibilities of others specified in the Fire (Scotland) Act 2005 as amended and additional
supporting regulations. The full duties of the Nominated Officer (Fire) are outlined in NHS in Scotland,
A Model Management Structure for Fire Safety (Current Edition). The Nominated Officer (Fire) will, for
this function, report directly to the Chief Executive and will be required to submit regular reports on
the general state of fire precautions within their area of responsibilities.

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1.3.3 - The Fire Safety Manager ( Operations ) will provide advice to the Nominated Officer (Fire) on
technical and specialised matters. The Head of Fire Safety will compile an annual report to the Health
and Safety committee which summarises the work of the previous year and make recommendations
for future years.

The responsibilities of the Fire Safety Manager ( Operations ) are multiple and include:

• The Fire Safety Manager is tasked with developing and managing the fire safety
management system, and will be responsible for (exemplar role/duties)

• The day-to-day implementation of the fire safety policy and SOP (Fire).

• Obtaining expert advice on fire legislation, and technical advice on the application and
interpretation of fire safety guidance, including SHTM Firecode.

• Raising awareness of all fire safety features and their purpose throughout the Board.

• The development, implementation, monitoring and review of the organisation’s fire safety
management system.

• Ensuring that fire risk assessments are undertaken, recorded and suitable action plans
devised.

• Ensuring that risks identified in the fire risk assessments are included in the Boards risk
register as appropriate.

• The operational management of fire safety risks identified by the risk assessments.

• The development, implementation and review of the organisations emergency fire action
plans (EFAP).

• The development, delivery and audit of an effective fire safety training programme.

• The reporting of fire incidents in accordance with Board policy and external requirements.

• Monitoring, reporting and initiating measures to reduce false alarms and unwanted fire
signals.

• Liaison with External Enforcing Authorities, Board Managers and Authorising Engineer
(Fire).

• Providing a link to the relevant Executive committees.

• Ensuring an appropriate level of management is always available by the establishment of

Fire Response Teams for board sites or premises.

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1.3.4 - The Fire Safety Advisors will provide knowledge, training, guidance and advice relating to all
aspects of Fire Safety.

The responsibilities of the Fire Safety Advisor are multiple and include:

• To promote and support the implementation of NHS Lothian’s Fire Safety policy and procedures in
the designated sites

• To assist the Fire Safety Manager in devising, promoting and supporting improvements in Fire
safety management strategies (policy formulation, organisational structures, planning),

• Assist the Fire Safety Manager with the continuing development of the fire safety management
system which includes policies, procedures and guidance.

• liaising with, and supporting, the Nominated Officer (Fire), the Fire Safety Manager by providing
technical support in the interpretation of the statutory and mandatory requirements for NHS
Lothian, and ensuring that the Nominated Officer (Fire) is informed of all fire related activities
within the Board.

• Ensuring all areas have a current fire risk assessment and that this is reviewed once every year
(Hospitals), once every two year for other healthcare premises, or after a fire incident or
significant change of function or physical layout.

• Provide guidance, including recommending priorities for improvements identified as a result of the Fire
Risk Assessment non -compliance.

• Providing training advice and preparing and presenting training programmes as per the training
matrix.

• Providing specialist technical advice on the application and interpretation of fire safety guidance,
including SHTM Fire code.

• Assisting with the review of the content of the Board fire safety policy.

• The preparation of fire prevention education.

• Assist managers to compile emergency action plans.

• The investigation of all fire-related incidents and fire alarm actuations.

• Liaise with contractors on site via the Estates Department, and Heads of Service to ensure that all
work carried out on site has the appropriate risk assessments in place to prevent unnecessary
risks and to ensure contractors comply with the statutory and mandatory obligations of NHS
Lothian.

• Advising upon suitable and adequate provision of firefighting equipment, signs and notices, and
ensuring that all firefighting equipment is appropriately maintained in consultation with Estates
and Site Facilities Manager/Site Responsible Manager.

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• Liaison with External Enforcing Authorities, Board Managers and Authorising Engineer (Fire).

1.3.6 - FM Managers are responsible for the effective implementation of this procedure within their area of
responsibility including overall management of any potential risks and development of safe systems of work
to manage any identified risks.
They are answerable for the safety of their work force, and the activities in their charge, and are expected
to promote a high degree of Fire safety awareness amongst all work forces.

FM Managers should: -

• Consult with the Nominated Officer (Fire) and The Fire Safety Manager to ensure that the Fire Safety
Policy and SOP (Fire) is being applied and understood across all areas of NHSL.

• Formulate, with the assistance of the Nominated Officer (Fire) and the Fire Safety Manager a Fire
Strategy compliance programme for both active and passive measures in existing buildings and new
projects.

• Ensure that the interests of Fire Safety are represented at the NHSL Board. In particular that adequate
financial provision is made for the maintenance of Fire Safety Provisions, the repair and upgrade of Fire
Safety measures in buildings, staff training, including the continuous personal development (CPD)
training of specialist Fire Safety Staff and those with specific Fire Safety Duties.

• Support action to follow disciplinary procedures for staffs who continues to breach the Fire Safety Policy
or SOP (Fire), or their actions or omissions put themselves and/or others at risk from a real or potential
fire incident.

• The supervision of the day to day fire precautions and co-ordination of staff in a fire emergency
will be the responsibility of the NOMINATED OFFICER (FIRE) until an appropriate Senior Officer on
site takes command of the situation.

1.3.7 - All Line Managers will ensure that each member of their own staff: -

• Is made aware of fire safety instructions.

• Observes basic fire precautions.

• Participates in Fire Training at a frequency and Content set out in Scottish Health Technical
Memorandum (SHTM) 83 part 2 July 2017
http://www.hfs.scot.nhs.uk/publications-/guidance-publications/

Through practical instruction and theoretical training every member of staff will
be aware of their duties and responsibilities in respect of fire safety and fire precautions.

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 1.3.7 Cont. All Line Managers will ensure that: -

• Appropriate Daily Fire checks are carried out within their direct area of responsibility.
• Appropriate Monthly Fire checks are carried out within their direct area of
responsibility.
• Appropriate Quarterly Fire checks are carried out within their direct area of
responsibility.

See section 4.1 for further guidance.

1.3.8 Fire Incident Responders (where applicable) –

NHS Lothian must have a means of ensuring that appropriate emergency response
teams are established and that sufficient staff are available at all times to provide
assistance with evacuation in a fire emergency from those premises owned, occupied or
managed by NHS Lothian;
NB: in small premises a fire response team may not be necessary e.g. community
premises, health centres etc. however, arrangements must be made to ensure alarms of
fire are appropriately responded to and supervised, including arrangements for
evacuation, liaising with the fire and rescue service and, re-setting of alarms etc.
Fire Incident Responders where applicable, is a trained member of staff who responds
to an alarm of fire, attending the location of an incident when alerted.
Fire Incident Responders may be part of a team or a single nominated person in small
premises.

Fire Incident Responders should –

i. Attend a Fire Incident when alerted and assist in the Fire Evacuation, directing
staff and members of the public to a place of safety.

ii. Assisting in investigating the source of a fire alarm, providing information and
assistance to the fire service.

iii. Reporting to the incident controller and acting on their instruction or that of
another authorised person e.g. police or fire officer: acting on own authority to
prevent harm or help those who require immediate assistance.

iv. Reporting fire safety issues to relevant person in the course of their normal
duties e.g. obstructed exit routes; damaged doors or self-closers.

1.3.9 Shared Premises a number of buildings or areas are occupied by tenants from other
organisations.

• These tenants should comply with the broader principles of the Fire Safety Policy
And SOP (Fire).

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 • As tenants they are required to comply with all statutory obligations, including the
Fire (Scotland) Act 2005.

• The Chief Executive should ensure that tenants from other organisations comply
with the broader principles of this policy and its associated procedure. Those
tenants from other organisations will manage Fire Safety in their own areas, carry
out their own Fire Risk Assessments and introduce fire safety procedures in their
occupied premises. Any significant findings must be shared with NHS Lothian board
and joint measures should be put in place to minimise harm caused by fire.

• 2.1 3i Studio “FIRE MANAGER”

NHS Lothian must use the 3i studio “Fire Manager” module of the NHS Scotland Asset
management system as the primary means of meeting the aims of this procedure in the
context of strategic and operational management of fire safety matters and the statutory
requirement to conduct fire risk assessments.

Fire Manager must be used to –

• Record data on actual fire safety performance outcomes such as alarm incidents,
unwanted fire alarm signals, primary and secondary fire incidents. This will ensure
consistency in the general reporting of fire-related incidents throughout NHS
Scotland.
• As a means of ensuring that procedures are in place to undertake and review fire
safety risk assessments and record outcomes in accordance with the fire (Scotland)
Act 2005 and related subordinate legislation within parts of all premises owned,
occupied or managed by NHS Lothian.
• To record all reports of all fire incidents within parts of all premises owned,
occupied or managed by NHS Lothian,
• To record all reports of Unwanted Fire Alarm Signals (UFAS) within parts of all
premises owned, occupied or managed by NHS.

The above is mandated by virtue of the Fire Safety Policy NHS Scotland ( 2021-08-
04 )

• 2.2 Fire Risk Assessments

A Fire Risk Assessment is a legal requirement in the workplace.
A Fire Risk Assessment is an organised, methodical look at your premises, the activities
carried on there, and the likelihood that a fire could start and cause harm to those in the
vicinity of the premises, it should identify steps to be taken to reduce hazards as low as
reasonably practicable, and recommend what fire precautions and management
arrangements can be put in place to ensure a fire does not take place.
The Fire Safety Manager will be overall responsible for ensuring that Risk Assessment
inspections are carried out in all premises using the 3i Studio Fire Manager web based
system mandated by virtue of the Fire Safety Policy NHS Scotland ( 2021-08-04 )
In Buildings Jointly occupied by NHS Lothian, the statutory obligation to conduct a fire risk
assessment applies equally to all the occupiers and/or owners who are identified as duty
holders in sections 53 and 54 of the Fire Scotland Act. NHS Lothian Fire Safety must
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therefore conduct a fire risk assessment in the part(s) of the building occupied by NHS,
including any communally occupied parts that form part of an escape route(s) leading to
final exits.

Fire Risk Assessment Activity should be prioritised by identifying areas on a risk basis, each
Fire Safety Advisor will organise a programme to ensure that Fire Risk Assessments are
current, regularly reviewed and recorded onto 3i Studio Fire Manager web based system
using the standard 3i Template.
It is recommended that a Fire Officer/Advisor is accompanied by the buildings manager or
someone in a similar position who knows the building and the people who work in that
building during the audit.

Any problems/Concerns will be referred to the Fire Safety Advisor who will take action and
report back to the Fire Safety Manager and/or Site Manager.
The Chief Executive will be informed of any assessments which put the NHS Lothian Staff,
premises/facilities, or patients at Risk.

The Fire Risk Assessment programme should be carried out in line with the below organise,
control and monitor measures.

• ORGANISE – NHS Lothian has been divided into Four Areas, East and
Midlothian, Edinburgh Acute, Edinburgh Community and West Lothian, each
area will have a Fire Safety Officer/Advisor assigned, the FSO will organise a
programme to ensure that all areas have a current Fire Risk Assessment and
that this is reviewed once every year (Hospitals), once every two year for
other healthcare premises, or after a fire incident or significant change of
function or physical layout.
NHS Fire Safety Officers/Advisors carrying out the FRA will be able to identify
the Fire hazards, identify the people at risk, and evaluate fire safety measures
provided and/or required to protect people (e.g. escape routes and fire alarm
systems).

• Control – Appropriate action must be taken to control risks, the Most

effective control measure involves avoiding a risk altogether or, if this is not
possible, how you can reduce the risks and manage them, it may not be
possible to eliminate a hazard if doing so means that you cannot make the
end product or deliver the service.
A Fire Risk Assessment will identify which fire risk can be removed, and will
identify how to eliminate as many of the risks associated with fire as possible.
Once a fire risk is initially identified and recorded an action plan will be
formulated, the action plan owner/author shall deliver to the relevant
responsible person to ensure that action is taken.
The Chief Executive will be informed of any Assessments which put the NHS
Lothian Staff, Premises/Facilities, or Patients at Risk.
All staff must be aware of the fire hazards in their workplace and take
reasonable steps to
eliminate or reduce the risk of fire.

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 Control measures for serious risks should be reviewed more frequently.

• Monitor – Accountability for fire safety should be clearly allocated to ensure

that all fire risks procedures are followed and maintained, Managers and
persons with control of premises should be provided with the authority and
resources to implement and maintain control measures effectively.

• Fire Safety Advisors will review the control measures to make sure they are
working effectively, this should –
Provide a monitoring regime to ensure the ongoing effectiveness of the control measures
Identify if the control measures have introduced any new problems and to ascertain if any new
hazards are identified?

• Demonstrate that the correct Fire Safety Procedures are being followed?

• Identify that Staff is actively involved in identifying fire hazards and possible control
measures? And that they are openly raising fire safety concerns and reporting problems
promptly?

• Identify that the frequency and severity of fire safety risks are reducing over time.

• If new legislation or new information becomes available, does it indicate current controls
may no longer be the most effective?

The above measures should assist in demonstrating that risk is reduced as far as is reasonably
practicable in the Fire Risk Assessment Process.

2.3 The Reporting of Fire Incidents.

NHS Lothian must report fires involving death or serious injury to the Health and Safety
Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
1995.
In addition all fires involving death, injury, or damage which results in significant
disruption to patient services must be notified immediately by telephone, fax or email to:

Health Finance and Infrastructure

Scottish Government Health and Social Care Directorates
St. Andrew's House, Regent Road
Edinburgh
EH1 3DG
Email: [email protected]
(Tel: 0131 244 2383)
(Fax: 0131 244 2371)
(Note: Minor fire incidents and alarm incidents are not required to be reported to SGHD)

All Fire Incidents will be investigated by NHS Lothian FSA’s to identify any action(s) required
to ensure that all possible lessons are learned in order to mitigate the risk of reoccurrence.
All Fire Incidents within the respective areas will be investigated by the FSO’s and supported
by the responsible department.
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 This will be recorded using the standard format report form on the 3i Studio Fire Manager
and Datix system.

2.4 The Reporting of Unwanted Fire Alarm Signals (UFAS).

Each FSA will investigate and record all UFAS incidents onto 3i Studio Fire Manager using
the standard template within their respective area.

Each FSA will work actively to reduce UFAS within their area of responsibility, they will
engage with staff to identify reasons for continual actuations and agree action plans and
monitor future UFAS activity.

2.5 Liaison with Scottish Fire and Rescue Service (SFRS).

NHS Lothian recognises the importance of liaison with the SFRS in respect of fire
precautions and possible firef ighting in all NHS Lothian premises, The Concordat will
be followed to ensure a joint partnership agreement is met.
The Concordat is available at -
http://intranet.lothian.scot.nhs.uk/Directory/FireSafety/Pages/default.aspx
Liaison will be co-coordinated by the Fire Safety O f f i c e r s / Advisors, to
include visits, familiarisation, periodic exercises and consultation regarding
matters including structural fire precautions, current legislation and code of
practice.
Visits and exercises conducted by SFRS at NHS Lothian premises
will be monitored by the Fire Safety Advisors.

3.1 - Fire Control Centre (where applicable).

A fire control centre should be provided in all buildings designed for phased evacuation, and in
large or complex buildings, to enable the fire and rescue service to assist the premises
management control an incident immediately on arrival.

The fire control centre should be either:

a) A room dedicated solely as a fire control centre; or

b) Combined with the management central control room.

The fire control centre should be adjacent to a fire and rescue service access point, or other
location agreed with the fire and rescue service, and it should be readily accessible, preferably
directly from the open air.
If this is not practicable, the route to the fire control centre should be protected.
Because of the possible need for the fire control centre to be operational over an extended
period of time, it should be separated from the remainder of the building by a 2 hour fire-
resisting construction and should incorporate facilities to enable it to function as normal during

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an emergency.
The fire control centre should be provided with a 3 hour non-maintained system of emergency
lighting supplied from a source independent of the normal lighting, to enable the control
centre to operate satisfactorily in the absence of the normal lighting supply throughout the
building, a reliable means of communication with the fire control centre, either a fire telephone
system or a radio telecommunication system acceptable to the fire authority, should be
provided for use by the management of the building in conjunction with the fire control system
and control of evacuation, and for communications between fire and rescue service personnel.

NOTE Recommendations for fire performance and protection of telecommunications equipment

and telecommunications cabling are given in BS 8492.

A full description on what a control centre should contain is available within BS 9999 current
edition

Communications systems for fire and rescue -service use

In large or complex buildings a reliable means should be provided of communicating from the
fire and rescue service access level to all fire-fighting lobbies.
Full discussions on the specific requirements for the building should be undertaken with the
appropriate fire and rescue service.
Any fire telephone system should be in accordance with BS 5839-9 current edition

NOTE this is not the same as the lift communications system described
In BS EN 81-72.

Drawings for fire and rescue service use

In large or complex buildings and those having extensive accommodation below ground level,
the fire and rescue service should have available to them suitable and sufficient information on
the building layout, escape routes, special hazards and special procedures that might be in
operation.
Much of this should be available in the emergency pack but some additional information might
also be of assistance.

NOTE for example, plans of basement accommodation could be displayed at the Fire and rescue
service access storey in any stairway (or lobby) leading to the basement and more detailed
drawings could be made available at the fire control centre.

Before assembling this additional information, the issue should be discussed with the fire and
rescue service.
Where this information is to be made available, it should be located such as it can be readily
referred to in an emergency – not necessarily in the same place as the emergency pack.
Additional copies should be available in any fire control centre and at any other locations
agreed with the fire and rescue service.
All drawings and plans should be to a scale agreed with the enforcing authorities, and should
comply with the recommendations in BS 9999 Current Edition.

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3.2 Means of Escape.

The Fire Safety Advisors will advise on adequate means of escape in all NHS Lothian premises,
established according to the following principles:

• The occupants of a building should be able to turn their backs on fire wherever it
occurs and travel away from it directly through circulation spaces and stairways
to a place of safety.

• As far as practicable, there should be an alternative means of escape from any

point in a building, should the normally accepted escape route become blocked
or dangerous to use.

• The most satisfactory evacuation procedure for Hospital and Residential Care
premises is Progressive Horizontal Evacuation whereby, in the first instance,
persons can move horizontally away from the affected area into an unaffected
area on the same level, where they can remain in relative safety for a time

• As far as practicable, distance of travel should conform to the appropriate

guidelines

• Access and egress areas MUST remain unimpeded at all times.

• Instructions in respect of Fire Doors, Emergency Exits, P r o t e c t e d Stairwells

and Landings remain sterile must be strictly enforced at all times.

• Building and engineering work in progress must not prejudice the means of
escape. Where work impinges on means of escape routes alternative
arrangements must, in conjunction with the Fire Safety Advisers and Estates, be
identified and maintained as an approved alternative means of escape.

• Escape Routes and Emergency Exits in premises will be signposted on the

recommendation of the Fire Safety Officer/Advisers, with all signs conforming to
the requirements of BS 5499 Part 1 & Part 4 Current Edition, and the Health and
Safety (Safety, Signs, and Signals) Regulations Current Edition.

• Every member of staff will be made aware of their responsibility to ensure that
escape routes are kept clear at all times.

• Heads of Departments are responsible for ensuring that means of escape is

maintained to a high level, i.e. kept free from combustible materials and
obstructions at all times.

3.3- Progressive Horizontal Evacuation (where applicable).

• Evacuation

The principle of escape design for hospitals is that in an emergency, patients should be able to
move, or be moved, to a place of relative safety on the same level, with assistance in the first
12
instance from staff, from which further escape to a place of safety is possible. This principle is
termed ‘progressive horizontal evacuation’ and is dependent on there being available at all
times, amongst other things, sufficient structural fire compartments on each floor of the
building.

Evacuation aids must not be considered as a first option for escape design, but escape routes
should be designed to permit mattress evacuation or equivalent should it become necessary.
The guidance and standards specified in this document assume that escape design follows
these principles. Escape route widths and the width of escape stairs serving patient sleeping
accommodation, including the specification for stairway landings, are contained in the ‘Non-
domestic technical handbook’ Annex B; 2.B.3.

• Progressive Horizontal Evacuation

The primary aims of Progressive Horizontal Evacuation are:

1. To remove patients, staff and others from immediate danger.

2. To keep the distance of any movement as short as possible.
3. To avoid routes which in the particular circumstances may need to be used by fire-
fighters and others involved in firefighting.
4. To remove patients to a reception area remote from the fire and suitable for their
comfort and continued treatment, possibly for some hours, and to take a role call. (Be
prepared – always have a dedicated clipboard and pen immediately available.)

These aims are broad guidelines, fire is unpredictable and no two fires may be the same.
Initiative, common sense, a sound knowledge of emergency procedures and a calm approach
to an emergency will do much to ensure a satisfactory outcome.

• EFAP for Areas Using Progressive Horizontal Evacuation

The knowledge which managers have of the physical constraints of the parts of the health
premises for which they are responsible, the capabilities of their staff, and the characteristics of
the patients in their charge are essential to the formulation of evacuation plans.
Plans will need to be reviewed and modified as necessary to take account of changed
circumstances.
EFAP should be drafted by the clinical lead under consultation with the Fire Safety Advisor.

The below points will need to be considered when devising a plan.

1. Estimate the number of patients and staff who will need to be moved from the fire
compartment or premises in a fire emergency and the time available for such an
evacuation.
2. Consider the degree of dependency of patients and estimate the degree of surveillance
and assistance they will require.
3. Estimate the number of staff available both during the day and at night to cope with an
emergency in each ward or part of the premises.

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 4. When estimating the number of staff available, consider their capabilities to cope with
evacuation, that is, physical fitness, training and their likely performance under stress
(especially part time, agency or night staff).
5. Consider the patient handling methods which would be appropriate in an evacuation,
bearing in mind building constraints on the escape route and the types of patients,
discuss and agree these with the area Fire Safety Advisor.
6. Identify and note the location of any equipment which could be used to aid evacuation.
7. In the light of the preceding factors, estimate the number of extra helpers and their
locations required to achieve the safe and speedy removal of all patients.
8. Estimate the number of staff available within your premises who could give assistance
in an emergency elsewhere.
9. Know how to deal with patients on life-support equipment during an emergency.
10. Know how to deal with patients whose behaviour is likely to be obstructive during an
evacuation.
11. Practice aspects of the escape plan regularly, including patient handling techniques, and
involve all members of staff.

The design of means of escape from hospitals must not place reliance on, nor assume that
evacuation will be undertaken by, or is the responsibility of, the Fire and Rescue Service.

Evacuation is the explicit responsibility of the occupiers of the premises who must put in place
management arrangements and procedures, including the provision of sufficient properly
trained staff at all times, to facilitate the evacuation of all occupants in the event of a fire
emergency. See also Scottish Government Health Directorates Fire Safety Policy for NHS
SCOTLAND; CEL 25 (2008); Annex B. Mandatory Requirements (1)

As a fire situation develops and the remaining safe egress time for escape reduces, the Fire
and Rescue Service may assist in patient evacuation to the extent they consider necessary; or
in the most extreme circumstances, where assisted evacuation by staff is no longer viable,
undertake rescues from fire.

3.4 - Structural Fire Precautions.

• NHS Lothian recognises the importance of incorporating structural fire precautions

within the buildings for which it is responsible, utilising COMPARTMENTATION
wherever practicable and fire resisting materials and methods of construction (NHS
in Scotland Fire Code SHTM 85).

• All building schemes, including alterations to existing premises, will comply with the
requirements of building legislation and with all other relevant standards and code
of practice.

• The Fire Precautions aspect of existing NHS Lothian premises will be regularly
inspected by the Fire Safety Ad viso r s accompanied by the Estate Manager or his
representative as appropriate. NHS in Scotland Fire Code SHTM 86 (Fire Risk
Assessment) will be followed.

14
 3.5 - Detection and Warning.

• Generally within NHS Lothian premises there will be an automatic fire alarm system in
accordance with BS 5839 Part 1 current edition, a Category complying with a L2 or
system should be provided for Healthcare premises other than Hospitals. A category
complying with a L1 system should be provided through all parts of Hospital premises.

• Where the Premises will be used solely as office accommodation or contain no Patient
access (including as part of the means of escape for patients), the fire detection and
alarm systems should follow the recommendation of the relevant parts of BS 5839
Current Edition.

• The maintenance and servicing will be the responsibility of the Estates Manager
according to a Planned Preventative Maintenance Schedule. All tests and faults will be
recorded.

3.6 - Fire Alarm System.

Within all NHS Lothian Premises a Single(Competent Person), Named Member of the premises
management should be appointed to supervise all matters pertaining to the Fire Alarm System
(This person should have received suitable and sufficient training to hold this position ) this
person should ensure that all relevant occupants of the protected premises are instructed in
the proper use of the system, particular care should be taken to ensure that relevant occupants
are able to interpret Fire, Pre-alarm and fault indications, and that they are adequately familiar
with the appropriate controls, including those associated with initiation of fire alarm signals,
and silencing of unwanted fire alarm signals, in premises in multiple occupation, it should be
ensured that sufficient representatives of each occupier are instructed.

Whenever a Fire Alarm activates, always ensure that the local Fire Evacuation Procedure is
followed in accordance with your Emergency Fire Action Plan (EFAP)

3.6.1 - Maintenance of Fire Alarm System.

• Fire Alarm systems will be tested on a weekly basis by the appropriate Staff according to
a Planned Preventative Maintenance Schedule. Defects will be reported, repaired and
records updated.

• In addition to the weekly test, an inspection and test of the system should be carried
out over a 12 month period by a specialist contractor, on completion of the work, any
outstanding defects should be reported to the responsible person and a record of the
inspection and test should be made on the servicing certificate.

o NOTE 1 - The work described may be carried out over the course of two or more
service visits during each twelve month period.

• Any work that involves isolation or part isolation of the Alarm must only be carried out
after the responsible person has completed a “Permit to work” to state that isolation is
necessary and that the operation can be completed safely in accordance with a Risk
15
 Assessment and Method Statement, and once the permitted work is completed the
system will return to a full operational condition.

3.6.2 – Policy on silencing alarms

• Health Care Premises excluding Ward/Sleeping Areas – The Fire Alarm should only be silenced on
instruction from the Scottish Fire and Rescue Service, the Single Named Member of the premises
management (Competent Person) will be responsible for resetting of the alarm at all times, they
must not reset the alarm until Scottish Fire and Rescue Service personnel have inspected and
confirmed the cause of the alarm activation.

Scottish Fire and Rescue Service will not silence or reset the fire alarm, it is the responsibility of NHS
Lothian to provide a responsible person who is trained and competent to supervise all matters
pertaining to the Fire Alarm System.

• Ward / Sleeping Areas – The Fire Alarm must only be silenced (if there is a clinical need) if you are
certain that it is a False alarm activation/UFAS, and that there is no risk to Patients/Staff or other
building occupants.
The alarm must not be reset, the Single Named Member of the premises management (Competent
Person) will be responsible for resetting of the alarm at all times, they must not reset the alarm until
Scottish Fire and Rescue Service personnel have inspected and confirmed the cause of the alarm
activation.
It is good practice to allow the evacuation to complete (interrupting an evacuation is confusing and
leads to a false sense of security that every alarm is false).

In the Event of Discovering a Fire Staff must not attempt to silence the alarm.

On Activation of Fire Alarm within Ward /Sleeping Areas – Person in Charge may check for
signs of a Fire, using the below steps, remember that you are looking for signs of a Fire and not
a Fire itself.
If there is an obvious Fire a further call should be made 999/2222 to confirm that it is a Fire
Incident and not just an alarm sounding, Give as much detail as possible to Fire and Rescue
Service.

Investigation /action steps

• Do not search for signs alone, always check in pairs.

• Check the Fire Alarm Panel to find out where the alarm has activated, it is vital that
you have a Full Zone Plan adjacent to the panel.
• Have another member of staff remain at the panel and remain in contact at all times
using appropriate communications i.e. Mobile Telephone or Radios.
• When investigating look, listen and smell for signs of Fire, it might be smoke, heat or
unusual noises and could be any one, some or all of those signs.
• Never open a door unless you are certain that there is not a fire behind the door,
use vision panels to assess, if it is a solid door you can feel the door with the back of
16
 your hand for signs of heat, however, if in doubt keep the door closed and advise Fire
and Rescue Service that this area has not been checked.

Confirmation of Fire – The Fire Alarm must remain sounding to alert persons not to enter
the affected area,
Attempt to fight fire if it is safe to do so and you do not put yourself at risk

No Evidence of Fire - The Fire Alarm may be silenced

In the Event of Discovering a Fire Staff must not attempt to silence the alarms

3.7 – Emergency Lighting.

• In all NHS Lothian Hospitals and as far as practicable in other NHS Lothian premises,
emergency lighting will be provided in accordance with the appropriate
recommendations of BS 5266 Part 1 current edition.

• Emergency lighting systems will be tested on a regular basis by the appropriate

Estates Staff according to a Planned Preventative Maintenance Schedule. Defects will
be reported, repaired and records updated.

3.8 - First Aid Fire Fighting Equipment

In all NHS Lothian premises first aid firef ighting equipment will be provided and
positioned according to: -

• The relevant section of NHS in Scotland Firecode (SHTM 83, Current Edition
and other relevant publications.

• The Fire Risk Assessment.

• The recommendation of the Fire Safety Officer/Advisors.

With all new building schemes the requirements for firefighting equipment will be
determined at the planning stage by consultation with the Fire Safety Advisors.

A specialist contractor will provide a maintenance service and a yearly inspection of firefighting
appliances of various manufactures, all in accordance with the recommendations of the BS
6643 part 1 and BS5306 Part 3. All appliances inspected will have a label attached with date of
inspection and/or test and signature of inspector and sealing strip or tag.

Through training and instruction every member of staff will be made aware of: -

• The location and use of firefighting equipment.

• The need to keep firefighting equipment accessible and free from
obstruction at all times.
17
 Please also refer to Staff Training Document. (SHTM 83) available at
– http://www.hfs.scot.nhs.uk/publications-/guidance-publications/

3.9 - Access for Fire Fighting Appliances.

• As far as practicable, the Nominated Officer (FIRE), and/or Site Manager, Fire Safety
Manager and representatives of the Local Fire and Rescue Authority will agree access
routes for firefighting appliances in respect of all NHS Lothian premises.

• The Nominated Officer (FIRE), and/or Site Manager as appropriate, will make the
necessary arrangements for these routes to be kept clear of parked vehicles and other
obstructions.

• All members of staff will, during annual training, be made aware and reminded that
they have a responsibility for ensuring that access routes are kept clear .

3.10 - Surface Finishes, Furniture, Furnishings, Textiles.

• The Procurement Manager in conjunction with the Fire Safety Advisers will ensure that
all items conform to (SHTM87 – Textiles and Furniture), Furnishings, Bed Assemblies,
Apparel must comply with appropriate British or other Standards at the time they are
purchased. It will be the responsibility of the user to ensure that the manufacturer’s
instructions, in respect of fire precautions, retention of fire retardancy etc., are
followed.

• Estates Officers and others responsible for construction and decoration in NHS Lothian
premises will ensure that, apart from small areas which may be exempt, the surface
finish of wall and ceilings corresponds to a standard no lower than that specified in the
appropriate guidelines (SHTM85 Current Edition)

• The premises Manager must ensure that all curtains and other items of flame retardant
linen sent for laundering or repair are treated as necessary to maintain fire retardancy
to the appropriate standard. Guidelines contained in NHS in Scotland Fire Code SHTM
87, Textiles and Furniture.

• Members of staff will be made aware by instruction from line management, that they
must not introduce furniture and furnishings which do not conform to the appropriate
standards of fire retardancy in any premises.

3.11 - Fire Safety Checks to be carried out with Premises.

Each area will have nominated person(s) with specific fire safety duties, however, everyone is
expected to take reasonable steps to prevent and mitigate the effects of fire.

For specific duties please see section 4.2 Premises Manager Responsibilities

18
 4.1 Staff Responsibilities.

All NHS Lothian employees are responsible for, and have a legal duty in respect of, fire safety,
under The Fire Scotland act 2005.
All employees must practice good fire prevention, part of which is good housekeeping, and are
expected to take reasonable steps to prevent and mitigate the effects of fire.
They are also personally responsible for complying with the fire safety policy and their local fire
procedures and the requirements of the Health and Safety at Work Act 1974.
Fire Safety roles must be integrated with all other aspects of work as part of, rather than an
addition to, the care of patients, staff, and visitors.

Duties should include but not limited to –

• You must co-operate with the board, so far as is necessary, to allow them to comply with their
fire safety responsibilities.
• You must inform the NHS Fire Safety Department (or a fellow employee with specific
fire safety responsibilities), of anything relating to the premises which could represent a
serious and immediate fire safety danger; or anything which you reasonably consider
represents a shortcoming in the boards fire safety protection arrangements.
• You must observe all instructions, information and training/drills intended to secure fire
safety.
• You must NOT interfere with any buildings fabric or equipment provided with assuring
fire safety.

Compliance with this procedure and the NHSL Fire Policy is likely to satisfy the provision of the
law.

4.2 – Premises Manager Responsibilities.

Premises managers should ensure that sufficient fire checks are carried out or deputised to a
responsible person to be carried out and recorded in a fire management Logbook as evidence.
The below checks/inspections are applicable.

Daily Fire Check.

The below checks require to be carried out on a daily basis by the premises manager or a
deputy.
These checks do not require to be documented.

Escape Routes.
• Are all Corridors and Escape routes clear of obstructions and any combustible
materials?
• Are all Fire Escape Doors easily opened and clear of obstruction both inside and outside
of premises?
• Are all Fire Action notices and Fire Directional Signage clearly visible and accurate?

Fire Doors and Exit Doors.

19
 • Are all Fire Escape Doors easily opened and clear of obstruction both inside and outside
of premises?
• Do Push bars/pads operate easily (where fitted)?
• Are fire doors kept closed or locked shut where applicable?
• Are all self-closing doors kept closed and self-closers working?
• Are hold open devices or swing free arms working?

Fire Fighting Equipment.

• Is all the Fire Fighting equipment stored within the correct location?
• Do all Fire Extinguishers have anti-tamper tags in place?
• (Where Applicable) Do all Fire Extinguisher Storage boxes have Keys and Anti Tamper
indicators Present?
• Are all Fire Blankets in the correct storage boxes and anti-tamper tags in place?
• (Where Applicable) is all the Evacuation Equipment present and has not been tampered
with in any way?

Emergency Light Units.

• Are all Emergency Light units showing a LED indicator (Tell Tale Lights Illuminated)?
• Are all Emergency Light units in place and undamaged?

Emergency Fire Action Plan (EFAP).

• Do you have a written EFAP, and does all staff have access to this?
• Do your staffs know what to do if a fire occurs, and are aware of the Fire and
Emergency Procedures?

In addition to the above daily checks, the below should be checked on a weekly basis.
Fire Warning System (Fire Alarm).
• Is the system tested weekly using a different call point each week and the results
recorded?
• Can the Fire Alarm be heard throughout the premises?
Note * It is important that all staff are instructed to report any instance of poor
audibility of the Fire Alarm through communication with line management or to the
Estates Helpdesk

Any defects that are identified during the check/inspection should be reported via the Estates
Helpdesk – 33333 or email see below

Please include in the email the following information;

• Name & telephone number of the person making the request.

• Identify the site/building/room/area/department where the problem is.
• Clearly define the nature of the request. Emphasise if it is a health and safety matter or
patient care related.
• Any other relevant information e.g. priority, restricted or limited access

email: [email protected]

20
If you have an emergency out with the above hours please implement call-out procedures for
your area.

Monthly Fire Extinguisher Check

The below Visual Inspection must be carried out by the premises manager or a deputy at least
once per month.
When circumstances require, inspections should be carried out more frequently.

This inspection requires to be documented.

When carrying out these visual inspections, it should be ensured that:

1. Each extinguisher is correctly located in its designated place;
2. Each extinguisher is unobstructed and visible;
3. The operating instructions of each extinguisher are clean and legible and face outwards;
4. Each extinguisher has not been operated and is not obviously damaged or has any
missing parts;
5. The reading of any pressure gauge is within the green zone;
6. The tamper indicators of each extinguisher are not broken or missing;

The responsible person should record the results of these visual inspections in Fire Safety
Management logbook.
If any corrective action is required the responsible person must contact the Fire Safety
Department, who will then ensure that the extinguishing equipment is maintained in an
efficient state, in good working order and good repair.

Quarterly Fire Safety Checks.

All Fire Safety Questions should be answered within the quarterly health and safety checklist
(where applicable)
Please see example below.

2. Fire Safety (*Any queries contact the Fire Safety Department

Yes No N/A
direct)

a) Do staff have access to an Emergency Fire Action Plan, and are

they all aware of the Fire and Emergency Procedures.

b) Do you have a copy of your annual Fire Risk Assessment for your
department completed by your local Fire Officer?

c) Are all your staff aware of the fire evacuation plan for your
department?

d) How many staff up to date on Fire Safety training?

How many staff are outstanding?
e) Whether you have stated ‘no’ or n/a to any question, please expand here on the
reasons for this.

21
4.3 - Fire Drills and Exercises.

All staffs are required to take part in at least one fire drill per year.
The emergency plan needs to be tested and you can do this by running a fire drill.

A fire drill should be organised by the person who is in control of the premises, this may fall
under the remit of more than one person in areas where various different users and shift
patterns are present.

The typical aims of a Fire Drill can include –

• Reinforce procedures to new employees.

• Find potential weaknesses relating to the evacuation strategy.
• If any practices or procedures have occurred this will test them.
• Test Procedures for people with impaired mobility.

More detailed information on Fire Drills and Test Evacuations is given within SHTM 83: Part 2
General fire precautions Fire safety training, this document is available at -
http://www.hfs.scot.nhs.uk/publications-/guidance-publications/

5.1 - Electrical Equipment (General)

Fire precautions associated with electrical equipment in all NHS Lothian premises will be based
on the principles outlined in NHS in Scotland Fire Code (SHTM83 part 7.96 - Fire Safety in
Health Care Premises), installations must be maintained in accordance with good practice, and
a Planned Preventative Maintenance Schedule should be applied as necessary.

All new electrical equipment, including items introduced by patients and resident staff, will be
checked by Estates staff prior to initial use.
Electrical engineering services associated with fire detection and alarm systems require
particular attention. Periodic testing and servicing of electrical installations must include
electrical resistance and earth continuity tests as prescribed in the Regulations for Electrical
Equipment of Buildings published by the Institution of Electrical Engineers (identical to
BS7671:2001)

Note * There is no legal definition of portable equipment. However, in this guidance it

means equipment that is intended to be connected to a generator or a fixed installation
by means of a flexible cable and either a plug and socket or a spur box, or similar
means. This includes equipment that is either hand-held or hand-operated while
connected to the supply, intended to be moved while connected to the supply, or likely
to be moved while connected to the supply.
Extension leads, plugs and sockets, and cord sets that supply portable equipment are
classified as portable equipment because they operate in the same environment and
are subject to the same use as the equipment they serve.

5.2

22
5.3 Electrical Equipment Checks before use.
NHS Lothian requires that all staff carryout the following simple basic inspection of portable
electrical equipment (source HSG 107 User checks (visual) each time that the equipment is
taken into use and as felt necessary during use.

Check For -:

• Damage (apart from light scuffing) to the cable sheath;

• Damage to the plug, for example the casing is cracked or the pins are bent;
• Inadequate joints, including taped joints in the cable;
• The outer sheath of cable not being effectively secured where it enters the plug or the
equipment, obvious evidence would be if the coloured insulation of internal cable cores
were showing;
• The equipment has been subject to conditions for which it is not suitable, e.g. it is wet
or excessively contaminated;
• Damage to the external casing of the equipment, or there are loose parts or screws;
• Evidence of overheating (burn marks or discolouration);
• Physical damage i.e. cracks to light switches, sockets or any other item of the fixed
electrical installation visible to employees.

These checks also apply to extension leads and their associated plugs and sockets.

The local management / staff shall take effective steps to ensure that the equipment is not
used again until it has been repaired by a Competent Person. (E.g. the defective equipment
must be labelled as “Faulty” by the department manager and repaired by the Estates
Maintenance Team).

Any faults that are identified during the check/inspection should be reported via the Estates
Helpdesk – 33333 or email see below

Please include in the email the following information;

• Name & telephone number of the person making the request.

• Identify the site/building/room/area/department where the problem is.
• Clearly define the nature of the request. Emphasise if it is a health and safety matter or
patient care related.
• Any other relevant information e.g. priority, restricted or limited access

email: [email protected]

5.4 Personal Portable Electrical Equipment.

Where Personal Electrical Equipment is permitted, it is essential it is used and charged in a

safe manner.
Staff should be aware of the risk of fire as a result of faulty charging devices particularly
those using
Lithium batteries.

23
The following guidelines outline the precautionary measures which should be taken –

• Personal Electrical equipment belonging to staff, patients or others should not be used in
healthcare premises unless it has been tested and approved for use by a properly
qualified person to carry out such tests.
• Equipment including chargers must comply with all safety regulations including BS EN
62133 current edition (safety requirements for portable sealed secondary cells and
batteries for use in portable devices.) and display the CE mark of conformity.
• The charger must be correct type for use with the device.
• Devices should not be used where water or other liquids spills are likely.
• Devices must not be used in an oxygen rich environment.
• Safety advice should be given to patients receiving oxygen at Home.
• If a charger begins to overheat, it should immediately be switched off at mains and
unplugged, the charger must then be checked before re-use.
• All staff should be made aware of the fire hazards associated with the use and recharging
of personal electrical equipment through training and instruction.

5.5 NHS Owned Portable Electrical Equipment.

NHS Owned Portable Electrical Equipment.

NHS Owned Portable Electrical Equipment must be tested and serviced under the above
procedure requirements 5.2 (Electrical equipment checks before use)

The below guidelines should be applied by everyone using Portable Electrical

Equipment -:

• Check your sockets, plugs and cables regularly. Do these before you plug anything in –
look for signs of fraying, general wear and tear, or a loose plug, if you see burn marks or
they feel hot, report to Estates Department Immediately using the correct reporting
procedure and the equipment should be taken out of use immediately.
• Turn off any electrical equipment you are not using, never leave electrical items
switched on while unattended, within Clinical Areas do not switch off or un-plug any
equipment without seeking the permission of the person in charge.
• Be careful when using hand-held electrical equipment – make sure you switch off and
unplug when you have finished. This is important with items that get hot, for instance
hairdryers or curling tongs, as they may come into contact with materials that can catch
fire (like curtains).
• Check the current rating of an electrical adaptor before you plug appliances in – make
sure that the total current used does not exceed the adaptor’s rating, if in doubt seek
advice from Estates Department.
• In the event that during any use or inspection a Portable Appliance Test Label (PAT) is
observed to be out of date this should be reported immediately by the appropriate
management system. (there is no legal requirement to label equipment that has been
inspected or tested, nor is there a requirement to keep records of these activities,
however, NHS Lothian do maintain a record of activity)
• NEVER overload a socket by using in-appropriate adapters, NHSL premises should have
sufficient sockets to avoid the use of adapters and trailing leads, however, if the use of
trailing leads and adapters are required advice and consent should be agreed with NHSL
Estates Department.

24
 • Electrical switch rooms, sub stations, electrical cupboards MUST not be used as a
general store cupboard and shall be maintained free of obstruction and combustible
material at all times. (For further advice consult NHSL Fire Safety Department.)

6.1 - Smoking

• In line with the NHS Lothian’s No Smoking Policy, smoking is prohibited in all areas.

• Health Education and Fire Training will be utilised in conjunction with the regulation and
prohibition signs to effect control of smoking.

6.2- Chemicals, Solvents, Medical Gases and X-Ray

• All persons using Chemicals, solvents, Medical Gas and X-Ray equipment must adhere to
the below guidelines.

• Fire precautions associated with the use and storage of chemical solvents and medical
gases in NHS Lothian premises will be implemented according to the guidelines set out
in the relevant sections of NHS in Scotland Fire Code (SHTM83 Current edition) – Use
and Storage of Flammable Substances.

• In all NHS Lothian X-ray Departments the storage and use of all radioactive substances,
materials and equipment must comply with: -

a) -Area Radiation Protection Committee rules and guidelines.

b) -Ionising Radiation regulations Current Edition and all other relevant Codes of
Practice.

These departments will have a Planned Preventative Maintenance Contract on all equipment
used in x-ray duties.

6.3- Flammable Liquids

All persons using Flammable Liquids must adhere to the below guidelines.

In this guidance, flammable liquid means a liquid with a flashpoint of 60°C or below
This reflects the EU Classification, Labelling and Packaging of Substances and Mixtures
Regulation (no 1272/2008) (the CLP Regulation), which sets the criterion for substances and
mixtures to be classified as flammable to be those with a flashpoint of up to 60°C
This guidance does not apply to flammable liquids which present special hazards requiring
specific precautions, e.g. ethylene oxide, peroxides, and other liquids which carry a risk of rapid
decomposition, polymerisation or spontaneous combustion.
* Please seek the advice of Fire Safety Department if in doubt

25
 • Storage of Flammable Liquid.

The safe storage of flammable liquids in healthcare premises is dealt with in Health and Safety
series booklet HS (G) 51 ‘The storage of flammable liquids in Containers’.
The quantities of flammable and highly-flammable liquids kept in departments should be as
small as is reasonably practicable for the day-to-day purposes of the department.
Where flammable liquids are intentionally present at the workplace, there is a specific
requirement under DSEAR for you to identify the potential risks such activity may pose to your
employees and others whose health and safety may be affected.
The outcome of this risk assessment will determine the measures to be taken to eliminate or
reduce these risks so far as reasonably practicable.

• Risk Assessment Requirements

The risk assessment required under DSEAR may be carried out as part of the risk assessment
requirements of the Management Regulations and general fire safety legislation, which follows
the same approach as that used in health and safety legislation. In particular, given the need to
take account of the presence of flammable liquids in the general fire safety risk assessment,
you may find it of benefit to carry out the required risk assessments as a consolidated exercise.
A risk assessment should be carried out regardless of the quantity of flammable liquid present
at the workplace, as it will enable you to decide whether existing measures are sufficient or
whether any additional controls or precautions are necessary.
As well as assessing the normal activities within the workplace, you will also need to assess
non-routine activities, such as maintenance work, where there is often a higher potential for
fire and explosion incidents to occur. If there is no risk to safety from fires and explosions, or
the risk is trivial, no further action is needed.
If there are risks, then you must consider what you need to do to comply fully with the
requirements of DSEAR.
Where you have, through your DSEAR risk assessment, concluded that the storage of
flammable liquids in containers is appropriate at your workplace, DSEAR requires the following
safety measures and procedures to be considered:

• Control Measures
• Mitigation Measures
• General Safety Measures
• Emergency procedures to be implemented in the event of an incident

Control measures are those measures taken to prevent an incident from occurring. Mitigation
measures are those measures taken should an incident occur to limit its extent and effect.
General safety measures are those measures intended to ensure the workplace and facilities
within this – along with the work processes – are designed, constructed and maintained to
reduce the risks arising from the dangerous substance so far as reasonably practicable.
The purpose of emergency procedures is to enable control or containment of an incident to
allow sufficient time for people to escape or be evacuated to a place of safety; and following
the incident, make the situation safe.

• Safe Disposal of unwanted small quantities of Flammable Liquids

The safe disposal of unwanted small quantities of flammable or highly flammable liquids should
be entrusted to competent persons acting with the knowledge of the hospital fire safety
26
officer/adviser.
It may be possible to achieve disposal by safely burning highly-flammable liquids in suitable
shallow metal trays in the open air, at safe locations remote from buildings, flammable storage
areas and drains.
Highly-flammable liquids and many solutions and reagents used in pathology laboratories must
never be disposed of down sinks; gulley’s and drains, as this practice can cause explosions,
injury and damage.

• Incineration

Certain items, such as paraffin wax and spent aerosol canisters, are not suitable for disposal
within incinerators because they can cause explosions and thereby jeopardise the safety of
operators and equipment. Some aerosol canisters use flammable gases as propellants, and
these can explode with great force. “Ozone-friendly” spraying substances are available; some in
non-pressurised containers, and the use of these should be encouraged.

Advice on the handling of Aerosol Cans

• Healthcare departments should hold only a number of cans required for
immediate use. Additional quantities should be kept in a cool store,
preferably one reserved for the storage of highly flammable substances and
having adequate low-level ventilation
• Cans should not be exposed to excessive heat, for example direct sunlight or radiators
• Cans should be handled and stored carefully to avoid damage
• Aerosols should not be sprayed near naked flames or other sources of ignition
• An aerosol can should not be operated when the can is inverted
• Manufacturers’ warnings printed on the container must always be observed

Under no circumstances may aerosol cans be disposed of by incineration- the

resultant explosion may cause injury and considerable damage, NHS Lothian
will ensure that users do not place cans in refuse bins, but keep them
separately for eventual collection and disposal.

6.4 - Fire Precautions in Specific Areas

• NHS Lothian recognises the importance of enhancing fire precautions in specific areas of
high fire risk, e.g. laundries, kitchens and laboratories.

• The staff working in these areas will be made aware of the specific risks and
precautionary measures as outlined in the appropriate (SHTM) documents

• The Fire Safety Officers/Advisers will make regular visits and inspections of high fire risk
areas within all NHS Lothian premises to ensure that fire precautions are being
maintained to a high standard

27
 6.5 Deliberate Fire-Raising

Introduction

Deliberate fire-raising is a significant cause of fire in all types of premises, including hospitals
and other healthcare premises. It is a cause for concern especially in Health Boards because of
the inherent life risk in most of the premises they occupy, and the impact fire damage may
have on the wider provision of healthcare.

For the purpose of this document the term deliberate fire-raising is used generically to describe
all acts of fire-raising

Wilful fire-raising is a common law offence under Scots law applicable to deliberately starting
fires with intent to cause damage to property.

In particular the Scots Law offence has to be "wilful"; if a fire is the result of an act of
recklessness then the offence of Culpable and Reckless Conduct applies.

It is common to find both offences charged together where criminal events involve fire and
both offences carry a maximum sentence of life imprisonment

Scottish Government have categorised the cause of fire under the following –

• Accidental - caused by accident (not thought to be deliberate or malicious).

• Malicious - where malicious ignition is established beyond reasonable doubt.

• Deliberate - where a fire is started deliberately (but not necessarily with malicious
intent) such as some fires started by children, psychiatric patients, suicides and
attempted suicides. Deliberate fires do not include those fires that accidentally got out
of control, e.g. a fire in a grate or a bonfire. In these cases the cause should be classed as
"accidental".

• Doubtful - where malicious or deliberate ignition is merely suspected but not established
beyond reasonable doubt. This description should not be used to indicate general
uncertainty about the cause of the fire.

• Not known - where there is general uncertainty about the cause of the fire. The "not
known" category should only be used if absolutely necessary, but where possible the
most likely cause on the evidence available should be given.

Wilful Fire Raising Prevention

The prevention, control and detection of deliberate fire-raising should form a routine part of
the training given to staff in accordance with the training requirements of the ’Fire Safety
Policy’

Simple ‘good housekeeping’ measures and the improved management of security

arrangements may be implemented quickly and easily and these measures themselves may
have a significant impact on the potential for deliberate fire raising e.g. Waste material should
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not be allowed to accumulate.

A deliberate fire-raiser is in many cases likely to start a fire whenever they are presented with a
casual opportunity.

The below guidance should help towards preventing deliberate fires:

• Frequent but irregularly timed patrols by staff both during and outside normal hours to
vulnerable parts of premises will help to deter deliberate fire-raising and may even lead
to the discovery of preparations for an attack.

• All NHS Staff should ensure that all reasonable and practical measures are taken to
make certain that all areas are secured from unauthorised persons at all times
(especially during noncore hours of operation) and any periods that a building, or parts
of a building are unoccupied, Staff awareness to Deliberate Fires should be achieved
through training, staff should be familiar with the security arrangements for open
access areas, access to other areas should be limited and supervised, staff should be
trained and encouraged to challenge those who have no visible ID, are in a restricted
area or who appear to be unfamiliar with the premises, or otherwise exhibit suspicious
behaviour

• Staff should promote good housekeeping, in particular waste material should not be
allowed to accumulate anywhere in the premises and waste bins with lockable lids
should be located in safe areas. Waste should be collected regularly and should ideally
be stored in a safe location outside the building, prior to its disposal.

• Any waste bins and skips stored outside the building should be covered and kept locked,
sited away from any other building or structure that a fire could impact upon, and
where possible should be in areas with good surveillance, further advise can be sought
from the “Waste Management Policy”

• All cupboard and storage areas should be kept locked shut at all times

• The security of premises with regard to fire safety should be assessed, where premises
are identified as particularly vulnerable, security arrangements must be carefully
considered in consultation with the Police and any other relevant parties

Further advise can be found within SFPN Note 6 Version 3 “The

prevention and control of deliberate fire-raising in NHS Scotland
healthcare premises” available at -
http://www.hfs.scot.nhs.uk/publications-/guidance-publications/
6.6 - The Equality Act 2010

NHS Lothian recognises its responsibility for ensuring compliance in respect of

The Equality Act 2010.

Heads of Departments will be responsible for ensuring that the development of fire
Strategies take into account the requirements of The Equality Act 2010.

The Head of Fire Safety / Fire Safety Advisors will provide information and advice
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 Designed to assist Heads of Departments formulate these strategies.

6.7 - Fire Precautions for Notice Boards

6.7.1 -General Guidance

Wall mounted notice boards; display boards and bulletin boards are used
Throughout the NHSL as a simple and convenient way of communicating information
To Occupants.
The boards are mounted predominantly in corridors but also in rooms within a
Building.
All NHSL buildings fall under the requirements of The Fire Scotland Act and relevant
Scottish Health Technical Memorandums, and therefore must meet specific standards
relating to means of escape in the event of fire.
The use of fire doors, fire compartmentation and appropriate fire resistant building
materials within a building are essential components of a fire prevention management
strategy.
In the event of fire, open notice boards which have substantial amounts of
paper-attached can significantly reduce the protection provided by fire resistant
building
materials and compartmentation.
Therefore it is incumbent on NHSL Fire Safety to ensure that there are appropriate rules
in respect of wall-mounted notice boards.

The following guidance should be followed with regard to the fixing of notice boards.

6.7.2 - Enclosed Notice Boards.

Glass fronted notice-boards, and other types of fire resisting enclosure can be used in
all areas as they will not contribute to fire spread.
They do however need to be lockable to ensure that the enclosures remain closed.

6.7.3 - Unenclosed Notice Boards.

Due to their potential to contribute to fire spread, the provision and use of unenclosed
Notice boards are subject to the following restrictions:
• Unenclosed notice boards are not permitted within dead-end corridors or protected
staircase enclosures or any area of high Fire Risk
• Automatic fire detection is required in any corridor or circulation area where
unenclosed notice-boards are provided.
• The materials from which the notice-board is made must be inherently fire retardant.
• The maximum size of any single display area shall be no larger than three metres wide
by one metre high (or equivalent).
• If the required area of display space exceeds the above limit, it will need to be
subdivided into separate blocks such that there is a minimum gap of one metre
between each display area.
• The total length of unenclosed notice-boards on any particular wall shall be no more
than 25% of the length of the wall on which it is situated.

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 • Any materials to be displayed on the notice-boards must be fixed at all four corners and
be no more than a single sheet in thickness.
For further information pertaining to Notice Boards please contact the NHSL Fire Safety
Department.

6.8 - Batteries (Fire Risk).

6.8.1 - Storing New and Waste Batteries

There are no specific Health and Safety requirements for storing batteries, but normal
health and safety rules apply. This includes that the responsible person should assess
health and safety risks.
NHSL Fire Safety considers the risk of storing small quantities of portable batteries to be
very low if sensible common sense precautions are taken. But these should be taken
into account in the health and safety risk assessment.

Recommendations –

• Batteries should be stored and disposed of in accordance with the manufacturer’s

instructions
• Batteries should be separated from other materials and stored in a non-combustible,
well ventilated structure with sufficient clearance between walls and battery stacks. If
possible lithium batteries should be stored outside the premises.
• Do not place batteries near heating equipment, nor expose to direct sunlight for long
periods.
• Do not place batteries in drawers where they are likely to come into contact with Coins,
paper clips or other metal objects.
• Tape terminals or provide plastic covers for lithium batteries to prevent short circuiting
• Ensure waste batteries are regularly removed from premises to avoid significant
accumulations.
• Protect batteries against being damaged, crushed or punctured
• Do not store batteries within fire escape routes.

6.8.2 - Battery Recycle Bins / Disposal.

Battery Recycling reduces the need to mine new materials, cutting CO2 emissions and
saving resources.

Batteries Must not be disposed of in ordinary waste disposal/recycle bins, they must only
be disposed of in properly indentified battery recycle disposal bins

Battery Recycle bins must only be used in suitably Risk Assessed Areas, Recycle bins
should be constructed from Paper, plastic or other non-metallic material.
Bins should not be stored within Escape Corridors or any means of escape, and should
not be stored beside Fire Exits internally or externally.
Always tape terminals or provide plastic covers for lithium batteries to prevent short
circuiting
Ensure waste batteries are regularly removed from premises to avoid significant
accumulations.
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 6.9 – Fire Procedures.

In all NHS Lothian premises there will be an established procedure to be followed by all staff
in the event of fire and fire alarms.

Fire procedures will be particular to the nature and requirements of the individual sites and
where necessary, areas within those sites.

The principal objective of the procedure will be to achieve a rapid and effective response to
all fire emergencies consistent with the safeguarding of all life and property and minimum
disruption to the health care environment.

Fire Procedures will include plans for:-

• Raising the alarm in the event of fire

• Calling the Fire and Rescue Service
• Notifying essential personnel
• Staff action on hearing the fire alarm
• The co-ordination of emergency action
• First aid fire fighting
• The control of fire and smoke
• The isolation/disconnection of services as necessary
• The evacuation of personnel as necessary
• Assessment and reporting of the event

7 Summary

NHS Lothian recognises its responsibility for ensuring the observance of:-

ALL STATUTORY REQUIREMENTS relating to fire safety and fire precautions in all properties
owned by NHS Lothian or other properties occupied by the NHS Lothian.

The basic aim of this procedure is to secure the maximum degree of fire safety in premises for
which NHS Lothian is responsible, consistent with operational efficiency, reasonable cost and
the maintenance of the health care environment.

The main Acts and Regulations bearing on fire safety in NHS Health Care premises are: -

• The Fire (Scotland) Act 2005

• The Health and Safety at Work Act 1974
• The Building (Scotland) Act 1959
• The Nursing Home Regulations (Scotland) Act 1938
• The Housing (Scotland) Act 1987
• The NHS and Community Care Act 1990

This procedure will be reviewed and updated at regular intervals to take account of changes in
the structures of buildings, their functions and contents, and any other matters which may
have a bearing on FIRE SAFETY.
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NHS in Scotland Firecode (SHTM Revised December 99)

• A Model Management Structure for Fire Safety

• Scottish Office Department of Health, Fire Safety Policy.
• SHTM 81 Fire Precautions in New Hospitals.
• SHTM 82 Alarm and Detection Systems.
• SHTM 83 Fire Safety in Healthcare Premises, General Fire Precautions
• SHTM 84 Fire Safety in NHS Residential Care Premises.
• SHTM 85 Fire Precautions in Existing Hospitals. viii)
• SHTM 86 Fire Risk Assessments in Hospitals.
• ix) SHTM 87 Textiles and Furniture.

NHS in Scotland Firecode (SFPN’s Revised December 99)

• SFPN 3 Escape Bed Lifts.

• SFPN 4 Hospital Main Kitchens.
• SFPN 5 Commercial Enterprises on Hospital Premises.
• SFPN 6 Arson Prevention Control in NHS Premises.
• SFPN 7 Fire Precautions in Patient Hostels.
• SFPN 10 Laboratories on Hospital Premises

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