Version 1.0 Joint Fire Risk Assessment For Landlord responsible areas. University hospital of North Durham Fire Risk Assessment
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Fire Risk Assessment
FIRE RISK ASSESSMENT
Responsible person (e.g. employer) or person having control of the premises
Organisation CDDFT Consort Engie
Appointed Person Director of Estates
Consort Hospital Manager
Engie Contracts Manager
Address of Premises University Hospital of North Durham North Road Durham
Postcode DH1 5TW
Signature
29 November 2016
This risk assessment should be reviewed annually as suggested in the review frequency table below or at such a time if there is reason to suspect that it is no longer valid or there has been a significant change in the matters to which it relates.
Premises Type Maximum review
Main hospital
Building Annually
Suspect it is no longer valid, significant changes to the
premises i.e. Post new works,
Review Information
Reviewed by
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SIGNIFICANT FINDINGS
The Premises
4
Approximate floor area: (m²) (To include all floors of responsibility)
51.500m²
Brief details of construction: (Date of construction, brick, timber, purpose built or converted)
Traditional brick & glazed construction with Flat roof.
Design Criteria: Approved Document B & HTM Firecode. Note: The building was designed and constructed using the above guides, for further information on the building design please refer to the fire strategy design documents, plans and consultation process that compliment this fire risk assessment.
Primary usage: A large acute hospital, Retail space
Secondary usage: Not Applicable
Areas included in the assessment: This Joint Risk Assessment only covers areas identified in Appendix A, Areas of responsibility, shown as Consort areas. These are areas which the trust staff also patients and visitors require access such as hospital streets, escape routes and above ceiling access areas. This risk assessment does not include the external Consort areas, such as the service yard fire track and car park areas. This document has been written by the trust fire safety advisor to ensure the fire safety of trust employees when using areas for which its staff needs access for safe access and egress and shows the risk of above ceiling spaces. This document does not remove the responsibility from the responsible person for the control of the area under the FSO as shown in appendix A.
OCCUPANCY PROFILE
Maximum number of persons evenings: Number: 1000
OCCUPANTS ESPECIALLY AT RISK FROM FIRE
Sleeping occupants (Details of numbers - public/staff)
591
Disabled occupants (Personal Emergency Evacuation Plans in use when necessary)
The Equality Act 2010 - In the case of disability, employers and service providers are under a duty to make reasonable adjustments to their workplaces to
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overcome barriers experienced by disabled people. Where necessary, measures will be put in place to ensure evacuation procedures include persons with disabilities.
Occupants in remote areas (Lone working/isolated areas)
None
Young person’s ( Person who has not attained the age of 18)
Patients and staff may be under 18
Others (Details of Elderly/Infirm/Mental Ability)
Elderly and infirm inpatients, High dependency patients.
IDENTIFIED FIRE HAZARDS
Sources of Ignition: Above ceilings – Fixed electrical inc light fittings ,ventilation servos Corridors –Fixed electrical inc light fittings, vending machines. Escape routes and lift lobbies- fixed electrical inc light fittings,lift motor rooms
Sources of Fuel: Above ceilings –fuel sterile Corridors - disposable products (textiles, furniture) left out for disposal, waste bins.
Sources of Oxygen: Medical Oxygen Cylinders and fixed pipe There are no oxygen cylinders in the areas of audit Medical gas pipes are situated in voids
The following fire hazards have been considered as part of the assessment within the premises:-
Ignition sources (i.e. naked flames, sparks, portable heaters, smoking materials),
Sources of fuel (i.e. large quantities of paper, combustible fabrics, plastics, paints, thinners, chemicals, flammable gases),
Work processes,
Structural features that promote the spread of fire (large single uncompartmented buildings, open staircases, openings in walls and floors, large voids above ceilings and below floors).
EVALUATE, REMOVE, REDUCE AND PROTECT FROM FIRE RISK
Evaluate the risk of a fire occurring: The site is a non-smoking site
Staff are diligent when patients and visitors are on
premises for identifying risk of arson
Premises are externally/internally covered by CCTV.
Site has security patrols
contractors working on site.
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Evaluate the risk to people from a fire starting on the premises:
Full L1 alarm system, detection covering Corridors,
Escape routes and above ceiling voids. Detection
would quickly raise the alarm for persons to make
an escape.
Remove and reduce the hazards that may cause a fire:
disposable products (textiles, furniture) left out for
disposal- Products are collected by passing
Portering staff
suppressing.
Areas fire sterile
All areas are fully compartmented to a minimum of
30minute, smoke standard
Site is designed for horizontal evacuation
The following persons have been considered as part of the assessment within the premises:-
Employees,
Employees, visitors, and other persons whose mobility, hearing or eyesight is impaired,
Other persons in the premises if the premises are multi-occupied,
Varied working practices (i.e. areas of your premises occupied when others are not),
Areas where employees/others are isolated,
Visitors,
Young persons,
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1. ELECTRICAL SOURCES OF IGNITION
Reasonable measures taken to prevent fires of electrical origin.
a. Fixed electrical installations periodically inspected and tested? (Every 5 years) Alternate process
used
b. Portable appliance testing carried out (where appropriate) on a risk assessed basis? Yes
c. Suitable policy in place regarding the use of personal electrical appliances? This should be subject to a Trust policy from the user organisation
Yes
d. Suitable limitation and management of trailing leads and adaptors? Yes
e. Charging and storage of batteries undertaken on site? Arjo equipment. Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
a. Fixed Electrical installation
c. Trailing leads & Adaptors
Tested within last 5 years. Assessments carried out on departmental risk assessments Evidence of testing routine, cable leads and plugs in good condition. Assessments carried out on departmental risk assessments Cables do not pose a trip hazard or run in such a way as to cause cable wear.
The 5 yearly testing of fixed electrical installations is not carried out. Engineers have replaced this schedule with an annual record of inspection as per B7671 p59 guidance note 3‘’the 5 yearly test may be replaced by continuous monitoring on all distribution panels’’ as well as this Engie also carry out earth loop impedance testing on all circuits within the buildings Work schedules held as evidence in Engie offices. Applicable to below ceiling areas within departments and wards PAT testing is carried out on the whole site annually by an external contractor. Engie will also carry out testing when requested by department. Applicable to below ceiling areas within departments and wards, there are no trailing leads and adaptors in the areas covered in this assessment.
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Deficiencies and Comments: No Deficiencies Comments Fixed wire Installation Testing note The legislation of specific relevance to electrical maintenance and Fixed Installation Testing is the Health & Safety at Work Act 1974, the Management of Health & Safety at Work Regulations 1999, the Electricity at Work Regulations 1989 and the Workplace (Health, Safety and Welfare) Regulations 1992. Maximum period between inspection & testing 5 years for Hospitals, Offices, Residential accommodation, Commercial premises Portable electrical appliance Testing note The Electricity at Work Regulations 1989 requires that any electrical equipment that has the potential to cause an injury is maintained in a safe condition. However, the Regulations do not specify what needs to be done, by whom or how frequently (i.e. they don't make inspection or testing of electrical appliances a legal requirement, nor do they make it a legal requirement to undertake this annually). Further guidance can be sought from the HSE website
2. SMOKING
Reasonable measures taken to prevent fires as a result of smoking. Yes
a. Smoking prohibited in the building? Yes
b. Smoking permitted in appropriate areas? N/A
c. Suitable arrangements for those who wish to smoke? N/A
d. This policy appeared to be observed at the time of the inspection? No
Identified Hazards Existing Control Measures Additional Control Measures Required
a. Patients smoking at main and A&E entrances
Non Smoking policy and signage Staff and Security to enforce the non-smoking policy
Deficiencies and Comments:
The Trust has a no-smoking on site policy. Signage throughout the hospital grounds show no
smoking on site
Smoking materials found outside of buildings, this has been highlighted and a tanoy system has
been introduced at the main entrance. It has also been highlighted to staff to enforce the no-
smoking on site policy.
3. ARSON/DELIBERATE IGNITION
Basic security against arson by outsiders or other persons appears reasonable. Yes
a. Is there close proximity to the premises available for ignition by outsiders? No
Identified Hazards Existing Control Measures Additional Control Measures Required
Bins in corridors for general waste
Bins are HTM compatible and self- extinguishing
No action
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To be managed Once identified the areas are cleared.
Deficiencies and Comments: Occasional storage issues around the hospital with beds and trolleys in corridors, some days the issue is more prevalent than others. Once identified areas are to be cleared.
4. PORTABLE HEATERS
The use of portable heaters avoided as far as practicable? Yes
a. Is the use of portable heaters avoided as far as practicable?Note: Portable gas cylinder heaters and paraffin heaters are NOT to be used in NHS premises
b. If portable heaters are used:
b. (i) Is the use of the more hazardous type (e.g. radiant bar fires or lpg appliances) avoided?
N/A
b (ii) Are suitable measure taken to minimise the hazard of ignition of combustible materials?
N/A
c. Are fixed heating installations subject to regular maintenance? N/A
Considerations to minimise the hazard of ignition of combustible materials due to these heaters.
Always position heaters so the heater back is against a wall and the heating element is facing into the room.
Switch heaters off if you are not in the room. Unplug electric heaters at cease work
Always follow the manufacturers' operating and maintenance instructions
Ensure the electrical power lead does not create a trip hazard
Do not use flammable materials, aerosols or cleaning fluids near heaters.
Do not place heaters close to furniture, curtains or bedding. 1metre is all directions
Do not stand or sit too close to heaters, some clothes may ignite easily.
Do not place heaters on uneven surfaces or where they can be knocked over easily
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Actions required
Deficiencies and Comments: There are no portable heaters in the assessment area, which includes below ceilings in departments and ward were applicable. Hospital uses thermostatically controlled water radiators and chilled and heated water vent systems.
5. FIXED HEATING INSTALLATIONS
Are there fixed heating installations such as boilers are used within the premises?
Yes
a. Are fixed heating installations subject to regular maintenance? Yes
b. Are suitable measures taken to minimise the hazard of ignition of combustible materials due to these heaters?
Yes
There are no fixed boiler installations in the assessment area
No Actions required
Deficiencies and Comments: Boiler fuel supply – Main Gas. Main boiler system situated in the energy centre adjacent to Aykley heads entrance
6. COOKING
Reasonable measures taken to prevent fires as a result of cooking? Yes
a. Filters cleaned or changed and ductwork cleaned regularly? Yes
b. Suitable extinguishing appliances available? (e.g. Fire blanket, Wet Chemical etc.) Yes
c. Suitable Shut Down Procedures in place? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
Engie restaurant and kitchen Ward Zonal Kitchens below roof void Ward Beverage Bays
Engie Risk Assessment CDDFT Risk Assessments
No Action required No Action required
Deficiencies and Comments: Area controlled by Engie
7. LIGHTNING
Does the building have a lightning protection system? Yes
a. Is the lightning protection system subject to a suitable maintenance regime? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Actions required
Deficiencies and Comments: Lightning conduction Test carried out as part of an 11 month test regime.
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8. DANGEROUS SUBSTANCES
Dangerous substances are, or could be used or stored, within the premises? (a substance or preparation that because of its chemical and sometimes physical properties and the way it is present and/or used at work creates a fire or explosion risk to people)
Yes
Are the general fire precautions adequate to address the hazards associated with dangerous substances used or stored within the premises?
Yes
If dangerous substances are present, has a risk assessment has been carried out as required by the Dangerous Substances and Explosive Atmospheres Regulations 2002? Medical Treatment areas e.g. Operating Theatres & Treatment Rooms excluded from DSEAR.
N/A
No Hazards identified No Actions required
Deficiencies and Comments: There are no Dangerous substances held within the assessment area, other than below ceiling level which are covered by department and ward risk assessments
9. HOUSEKEEPING
Is the standard of housekeeping adequate? Yes
a. Combustible materials appear to be separated from ignition sources? Yes
b. Appropriate storage of hazardous materials? N/A
c. Avoidance of inappropriate storage of combustible materials? (Escape routes and final exits are kept clear of any combustibles including storage and furniture)?
Yes
d. Avoidance of unnecessary accumulation of combustible materials and/or waste? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
Delivery of goods to lower ground floor
Goods are moved to wards and departments as soon as practical on delivery CCTV monitoring of area
To be Managed as necessary
Deficiencies and Comments: The areas covered by the risk assessment are relatively fire sterile, any items which are left out are cleared as soon as possible, Items found to have little fire loading and are HTM compliant.
10. HAZARDS INTRODUCED BY CONTRACTORS AND BUILDING WORKS
Fire safety conditions have been imposed on both external contractors and in-house maintenance staff?
Yes
Is there satisfactory control over works, including use of hot work permits, where appropriate, carried out in the building by external contractors? .
Yes
Possible breaches of compartmentation due to works
Ensure that contractors reseal any breeches made and report any breeches found. The integrity of the fire compartmentation is to be examined periodically by Hospital Estates Estates alert Ref: DH/2014/003
To be managed as necessary
Deficiencies and Comments:
A full Above ceilings audit was carried out in the University hospital of North Durham by Engie.
Breeches identified have been actioned.
Oxyacetylene, is not allowed to be used on site without the fire managers express permission
and a risk assessment.
11. OTHER SIGNIFICANT FIRE HAZARDS THAT WARRANT CONSIDERATION
Are there any other fire hazards that warrant consideration within the premises? (This to include any fire hazards from any process; heat producing, spark or friction generating, chemical or other process which has the capacity to ignite, create excessive or rapid heat or generate oxidising or flammable gas that impact on the general fire precautions)
Identified Hazards Existing Control Measures Additional Control Measures Required
There are no significant hazards in the assessment area.
No Actions required
Deficiencies and Comments: There are no significant fire hazards in the assessment area
12. EVACUATION STRATEGY
The evacuation strategy for this premises is detailed below
PROGRESSIVE HORIZONTAL EVACUATION Relevant persons are dependent on staff to assist with their escape. Provisions have been made to move such persons from an area affected by fire, through a fire resisting barrier to an adjoining fire protected area on the same level, where they can wait in a place of safety whilst the fire is dealt with, or await further evacuation down a protected route to total safety.
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NOTE - Progressive Horizontal Evacuation is subject to the following Protected areas should be designed to provide: • Sufficient capacity to accommodate the number of occupants who will need to use them. For this purpose a protected area should be sufficient capacity to accommodate its normal occupants and the occupants of the largest adjoining protected area. • Progressive movement away from a fire via sequential adjoining protected areas. • Means for escape via stairway(s) should this become necessary. The number and size of the protected areas depends on a number of factors: • the time it will take to evacuate people from the area of a fire to an adjacent protected area; • the number of people to be evacuated; • the level of any mobility impairment; • the number of staff to assist in evacuation; • the fire protection arrangements; • layout of the premises; and • location and number of staircases; Primary Construction for this Building Applies to the main fabric of a building, walls, floors, roof & internal dividing walls Buildings are categorised into 3 classes Class A - complete non-combustible construction, i.e. elements of structure, floors, and walls, supporting structure of brick or concrete. Class B - traditional construction, i.e. non-combustible walls with combustible floors Class C - combustible construction, i.e. timber floors & walls. The evacuation times that are generally accepted as Class A - 3 minutes Class B – 2 ½ minutes Class C - 2 minutes These are not hard and fast times, and can be extended or reduced according to the particular circumstances of the case, but they do form a reasonable basis for most situations.
Written copies of Evacuation Procedures are located as follows: On the intranet
Fire procedure and fire action notices: next to call points throughout assessment areas.
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Action required
Deficiencies and Comments: Hospital designed for horizontal evacuation , with staged alarm system and compartmentation
No Vertical hospital evacuation aids required in an emergency, the lifts within the alarm zone will return
to ground level. Those lifts outside the alarm zone will still operate and therefore may be utilised.
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PROVISION OF ELEMENTS OF FIRE SAFETY AS SECONDARY CONTROL MEASURES
13. MEANS OF ESCAPE FROM FIRE
It is considered that the premises are provided with reasonable means of escape in case of fire.
Yes
b. Reasonable distances of travel when:
b. (i) Where there is escape in a single direction?
Yes
Yes
c. Suitable protection of escape routes? (Fire resisting construction) Yes
d. Adequate provision of exits? Yes
e. Exits easily and immediately open-able where necessary? Yes
f. Escape routes unobstructed? Yes
g. Fire exits open in the direction of escape where necessary? Yes
h. Avoidance of sliding or revolving doors as fire exits where necessary? Yes
i. Satisfactory means for securing exits? Yes
j. Suitable fire precautions for all inner rooms and dead ends? Yes
k. It is considered that the premises are provided with reasonable arrangements for means of escape for disabled people?
Yes
No Hazards identified No Action required
Deficiencies and Comments: Hospital designed to HTM standard with adequate means of escape and escape routes
14. MEASURES TO LIMIT FIRE SPREAD AND DEVELOPMENT
It is considered that there is:
a. Compartmentation of a reasonable standard. (Fire resistant to collapse, fire penetration and transfer of excessive heat
Yes
b. Reasonable limitation of linings that may promote fire spread. (Flame spread across surfaces including walls, ceilings and other internal structures)
Yes
c. As far as can be reasonable ascertained, fire dampers are provided in ducts or vents as necessary to protect critical means of escape against passage of fire, smoke and combustion products in the early stages of a fire?
Yes
No Hazards identified No Action required
Deficiencies and Comments: Note
A full Above ceilings audit was carried out in the University hospital of North Durham by Engie. Breeches identified have been actioned. To comply with Estates alert Ref: DH/2014/003 A ridged system of work instigated so that any breaches in above ceiling compartmentation can be identified and rectified promptly this was signed off as complete by estates.
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Yes Yes
No Hazards identified No Action required
Deficiencies and Comments: There Full coverage of emergency lighting within the assessment area of corridors, escape routes and lift lobby landings Note. The existing emergency escape lighting system within UHND will not conform in full to current recommendations (e.g. in respect of luminance levels).This might be perfectly acceptable, but it is appropriate for new systems, and new work associated with upgrading of existing systems to conform to the current recommendations. Attention is drawn to current recommendations in BS 5266-1 and to the requirements of BS 5266-7 and BS 5266-8.
16. FIRE SAFETY SIGNS AND NOTICES
Reasonable standard of fire safety signs and notices? This includes fire exit, fire escape signage, fire resisting door and hazard signage.
Yes
No Hazards identified No Action required
Deficiencies and Comments: All signage within the assessment areas correct Note. It is a requirement of the Health and Safety (Safety Signs and Signals) Regulations 1996 that these signs incorporate the appropriate pictogram. BS 5499-5:2002 Graphical symbols and signs. Safety signs, including fire safety signs. Signs with specific safety meanings Superseded by BS ISO 7010:2011 - Prescribes safety signs used for accident prevention, fire protection, health hazard information and emergency evacuation
17. MEANS OF GIVING WARNING IN CASE OF FIRE
Reasonable manually operated fire warning system provided? Based on visual inspection, but no audibility tests or verification of full compliance with relevant British Standard carried out. Compliance with this will be carried out by a competent person who will provide certification on compliance or recommend works to comply with the standard.
Yes
If yes give details: (e.g. Break glass call points, fire bell, air horn, klaxon etc.) Full category L1 alarm system fitted in the assessment area with both manual call points and automatic smoke detection in all areas of the hospital including ceiling voids.
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a. Automatic fire detection provided? If yes, to what Standard? (e.g. BS 5839 Part 1Grade L1/L2 etc.) L1 System. Approximate age of system 15 years
Throughout areas applicable to this FRA Yes
Part of Premises only N/A
b. Extent of automatic fire detection generally appropriate for the occupancy and fire risk?
Yes
c. Remote transmission of alarm signals to an Alarm Receiving Centre? (continuously manned premises, remote from those in which a fire alarm system is fitted, where the information concerning the state of the fire alarm system is displayed and/or recorded, so that the fire and rescue service can be summoned where necessary)
NO
No Hazards identified No Action required
Deficiencies and Comments: Hospital fitted with a Full category L1 alarm system with both manual call points and automatic smoke detection in all areas of the hospital including ceiling voids. Activation of the fire alarm is monitored by the hospitals telephone exchange who contact the fire brigade on an activation The main hospital fire alarm panel is situated in A&E on the ground floor,There are fire alarm indicator panels situated in the following locations:- Level –1 At rear entrance Level 0 Accident and Emergency entrance
- Street adjacent to staircase D - Street adjacent to staircase B - Main reception - Cardio Catheter Laboratory
Level 1 Street adjacent to staircase D - Street adjacent to staircase B - Outpatients Department reception - Hospital Switchboard
Level 2 Street adjacent to staircase D - Street adjacent to staircase B - Lift lobby adjacent to entrance to staff dining room
Level 3 Adjacent to staircase D - Adjacent to staircase A - Street adjacent to lift motor room number L4/5
The Fire alarm is tested weekly with a rolling annual programme of tests
18. MANUAL FIRE EXTINGUISHING APPLIANCES
a. Reasonable provision of portable fire extinguishers? Yes
b. Are all fire extinguishing appliances readily accessible and unobstructed? (i.e. mounted on walls or on appropriate bases)
Yes
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No Hazards identified No Action required
Deficiencies and Comments: Wall mounted 9ltr Water extinguishers provided in all corridors 9ltr water and 2kg CO2 extinguishers throughout assessment area Extinguisher positions shown on fire maps throughout area
19. RELEVANT AUTOMATIC FIRE EXTINGUISHING SYSTEMS
Type of fixed system and location: (Inert gas suppression systems, sprinklers/misting systems etc.)
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards identified No Action required
Deficiencies and Comments: No Fixed systems in assessment areas, Fixed systems are covered by local departmental and ward risk assessments e.g. inert gas drench lower ground floor IMT area.
20. OTHER RELEVANT FIXED SYSTEMS AND EQUIPMENT
Type of fixed system and location: All hospital streets are fitted with dry riser outlets which are fed from 5 inlets situated :- 1x main entrance 1xoutside A&E 3xfire track All outlets are colour coded with the colour on the inlet box window
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards identified No Action required
Deficiencies and Comments: Note Pressure test and Private fire hydrant tests carried out by Engie.
21.FIREFIGHTER SWITCH – HIGH VOLTAGE LUMINOUS TUBE SIGNS ETC
Suitable provision of fire fighters switche(s) for high voltage luminous tube signs, etc. (to include location)?
N/A
No Hazards identified No Action required
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MANAGEMENT OF FIRE SAFETY
22. PROCEDURES AND ARRANGEMENTS
Fire safety is managed by the Responsible Person for the Relevant Persons, which includes, employees, members of the public, visitors, contractors from other organisations and the self employed
CDDFT Board-Chief Executive Officer- Executive Director Fire- Fire Safety Manager: a nominated person with responsibility for carrying out day-to-day management of fire safety Duty Holders: nominated persons who are responsible for fire safety measures in the premises to ensure the safety of persons in case of fire. Note: Responsible Persons at the premises must cooperate and coordinate their fire safety measures and activities.
Fire Safety Managed in the risk assessed parts of the premises by
Consort, Engie and CDDFT
Are competent person(s) appointed to assist in undertaking the preventative and protective measures (i.e. relevant general fire precautions)? Person(s) appointed with fire safety roles include – Fire Warden(s). Fire Evacuation Marshall(s) (Taking into consideration the Fire Safety (Employees Capabilities) (England) Regulations 2010 (SI 2010/471)
Yes
Is there a suitable record of the fire safety arrangements? Yes
Appropriate fire procedures in place? Yes
Are procedures in the event of a fire appropriate and properly documented? Yes
Are there suitable arrangements for summoning the Fire and Rescue Service? Yes
Are there suitable arrangements to meet the F&RS on arrival and provide relevant information, including that relating to hazards to fire fighters?
Yes
Is there a plan of the building available indicating basic layout and any areas of significant risk?
Yes
Are there suitable arrangements for ensuring that the premises have been evacuated? Yes
Is there a suitable fire assembly point(s)? Yes
Are there adequate procedures for evacuation of any disabled people who are likely to be present?
Yes
Persons nominated and trained to assist with evacuation, Including evacuation of disabled people? A Disabled person(s) evacuation strategy must not rely on rescue of disabled people by the fire and rescue service. Assistance with their evacuation is provided by nominated persons within the premises
Yes
Appropriate liaison (if necessary) (e.g. F&RS crews visiting for familiarisation visits)? Yes
Routine in-house inspections of fire precautions (e.g. in the course of health and safety inspections)?
Yes
Deficiencies and Comments:
All fire procedures and policies are available on the intranet, all procedures are current and correct and identify what staff do in the event of an incident
Familiarisation visits are conducted by the fire safety advisor with the fire brigade on a regular basis
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23. TRAINING AND DRILLS Fire safety training is managed by:
A nominated Fire Safety Manager for each occupier/tenant organisation.
Are arrangements in place to ensure that all new staff and visitors (where necessary) provided with fire safety induction and local building familiarisation?
Yes
Is this induction training recorded? Yes
Are arrangements in place to that all staff undertake annual fire safety refresher training and familiarisation where necessary, and to ensure that it is recorded?
Yes
Are staff with special responsibilities (e.g. fire wardens and fire evacuation marshals) been appointed and provided with additional training?
Yes
Are fire drills carried out at appropriate intervals and a record of such drills recorded? Yes
When the employees of another employer work in the premises:
Is the employer given appropriate information (e.g. on fire risks and general fire precautions)?
Yes
Is it ensured that the employees are provided with adequate instructions and information?
Yes
Yes
Does all staff training provide information, instruction or training on the following:
Fire risk in the premises? Yes
The fire safety measures in the premises? Yes
Action in the event of fire? Yes
Action on hearing the fire alarm signal? Yes
Method of operation of manual call points? Yes
Location and use of fire extinguishers? Yes
Means for summoning the F&RS? Yes
persons to assist with evacuation? Yes
Other measures-including risk of arson and UWFS Yes
Deficiencies and Comments: 3
rd party persons receive fire training from the trust fire safety advisor
Note. Where two or more organizations share a premise, adequate fire safety for all occupants will only be achieved if the organizations co-operate with one another to co-ordinate their fire safety measures. For example, there needs to be co-ordination of fire procedures, fire drills and fire management strategy. It needs to be ensured that one occupier’s activities and practices do not create a risk to those in another occupier’s part of the premises.
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Adequate maintenance of premises? Yes
Weekly testing and periodic servicing of fire detection and alarm system to include ancillary equipment (e.g. door hold open devices, door locks etc.) Manual call point(s) tested weekly on a rotational basis?
Yes
Monthly and annual testing routines for emergency escape lighting? Function test monthly with annual discharge. OR PPM in place
Yes
Yes
Six monthly inspection and annual testing of rising mains? Yes
Weekly and monthly testing, six monthly inspection and annual testing of fire-fighting lifts? N/A
Weekly testing and periodic inspection of sprinkler installations? N/A
Routine checks of final exit doors and/or security fastenings? Yes
Annual inspection and testing of lightning protection system? Yes
Are suitable systems in place for reporting and subsequent restoration of safety measures that have fallen below the required standard?
Yes
Other relevant inspections or tests: Give details:
Deficiencies and Comments: All maintenance carried out by Engie with records kept in the Engie main office block
25. RECORDING
Yes
Maintenance and testing of other fire precaution systems? Yes
Location of Records: (Available for inspection by Fire Authority if required) Fire training records held by learning and development All maintenance carried out by Engie with records kept in the Engie main office block
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Work Number SLA/Minor Works/New Works/Capit
al
Target Date Date Action Completed
1.Occasional storage issues around the hospital with beds and trolleys in corridors, some days the issue is more prevalent than others.
Once identified areas are to be cleared.
M Portering staff are to clear area when conducting walk around
N/A As Necessary On-going Existing standard
2.Delivery of goods to lower ground floor
Goods are moved to wards and departments as soon as practical on delivery CCTV monitoring of area
M Managers are to ensure Portering staff clear area
N/A As Necessary On-going Existing standard
3.Patients smoking at main and A&E entrances
Inform patients of Non Smoking policy.
M Staff and security to enforce the non-smoking policy
N/A As Necessary On-going Existing standard
4.Possible breaches of compartmentation due to works
Prevent breeches in compatmentation
H Estates are to brief contractors also ensure that contractors reseal any breeches made to the red book standard and report any breeches found. The integrity of the fire compartmentation is to be examined periodically by Hospital Estates Estates alert Ref: DH/2014/003
N/A As Necessary On-going Existing standard
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RISK ASSESSMENT METHODOLOGY
The following simple risk level estimator is based on a more general health and safety risk level estimator.
Taking into account the fire prevention measures observed at the time of this risk assessment, it is considered that the hazard from fire (likelihood) at these premises is: Likelihood:
Rare
Unlikely Possible x Likely Almost Certain
In this context, a definition of the above terms is as follows: Rare: May occur only in exceptional circumstances. Unlikely: Unusually low likelihood of fire as a result of negligible potential sources of ignition. Possible: Normal fire hazards (e.g. potential ignition sources) for this type of occupancy, with fire hazards generally subject to appropriate controls (other than minor shortcomings). Likely: Lack of adequate controls applied to one or more significant fire hazards, such as to result in significant increase in likelihood of fire. Almost Certain: Lack of adequate controls, taking into account the nature of the building and the occupants, as well as the fire protection and procedural arrangements observed at the time of this fire risk assessment, it is considered that the consequences for life safety in the event of fire would be: s No Severity:
Negligible x Minor Moderate Major Harm
Catastrophic
In this context, a definition of the above terms is as follows: Negligible: Outbreak of fire unlikely to result in injury.
Minor harm: Outbreak of fire unlikely to result in serious injury or death of any occupant (other than an occupant sleeping in a room in which a fire occurs).
Moderate harm: Outbreak of fire could foreseeably result in injury (including serious injury) of one or more occupants, but it is unlikely to involve multiple fatalities.
Major harm: Outbreak of fire could foreseeable result in; Significant potential for serious injury or death of one or more occupants.
Severity of Fire ↓
Likelihood of Fire →
Rare - 1 Unlikely - 2 Possible - 3 Likely - 4 Almost certain -
5
Minor - 2 2 4 6 8 10
Moderate - 3 3 6 9 12 15
Major - 4 4 8 12 16 20
Catastrophic - 5 5 10 15 20 25
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Catastrophic Outbreak of fire could foreseeable result in multiple fatalities. Accordingly, it is considered that the risk to life, consequence from fire at these premises is:
Low x
Medium High Extreme
Comments: A suitable risk-based control plan should involve effort and urgency that is proportional to risk. The following risk-based control plan is based on one advocated by BS 18004:2008 for general health and safety risks:
Definitions of Priorities
Risk Level Action and Timescale
Low - Priority 4 No action is required other than to maintain existing standards. To be monitored and looked at again at next review.
Medium - Priority 3 No major additional controls required. However, there might be a need for improvements that involve minor or limited cost. To be completed within 6 months of date of issue of report, or in period of time as specified by the assessor, if this is greater or less than 6 months, reasons for the extended or reduced time must be explained.
High - Priority 2 It is essential that efforts are made to reduce the risk. Risk reduction measures should be implemented within a defined time period. To be completed within 2 month of date of issue of report, or in period of time as specified by the assessor, if this is greater or less than 2months , reasons for the extended or reduced time must be explained.
Extreme - Priority 1 Considerable resources might have to be allocated to reduce the risk. If the building is occupied, urgent action should be taken to reduce the risk and consideration given to temporary suspension of services. If the building is unoccupied, it should not be occupied until the risk has been removed or reduced to a tolerable level. To be completed immediately or within 24 hours or in period of time as specified by the assessor, if this is greater than 24hrs reasons for the extended time must be explained.
(Note that, although the purpose of this section is to place the fire risk in context, the above approach to fire risk assessment is subjective and for guidance only. All hazards and deficiencies identified in this report should be addressed by implementing all recommendations contained in the following action plan. The fire risk assessment should be reviewed regularly.) Any item in the report may be given a higher priority than the score indicates; when this has been the case the reason for this must be indicated in the report The time scale in the report may be extended, past that which the priority rating recommends; when this has been the case the reason for this must be indicated in the report
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APPENDIX A : AREAS OF RESPONSIBILITY
Regulatory Reform (Fire Safety) Order areas of responsibility UHND Regulatory Reform (Fire Safety) Order 2005 section 3 Responsible person:- (a) in relation to a workplace, the employer, if the workplace is to any extent under his control; (b) in relation to any premises not falling within paragraph (a)— (i) the person who has control of the premises (as occupier or otherwise) in connection with the carrying on by him of a trade, business or other undertaking (for profit or not); or (ii) the owner, where the person in control of the premises does not have control in connection with the carrying on by that person of a trade, business or other undertaking.
Area Department Responsible
Mortuary Pharmacy Pathology Laboratories CSSD Medical Engineering IMT Stores Delivery Post room Linen Services RDU
Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie Engie
Hospital Building Ground Floor
A&E CCU Ward 1 Ward 2 Ward 3 Ward 4 Reception Department of rehabilitation Cardiology and respiratory investigations Endoscopy Chemotherapy UCC/Orthopaedic Outpatients X Ray Department Cardiac Day Unit WRVS Shop
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust
Hospital Building First Floor
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust
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Ward 8 Ward 9 Ward 10 Antenatal and Gynaecology OPD Special Care Baby Unit Family Services Telephone exchange Telephone Operators Office Security office
Trust Trust Trust Trust Trust Trust Trust Engie Engie
Hospital Building Second Floor
Main Operating Theatres ITU/HDU Ward 16 Ward 15 Dressing Clinic Ward 14 Ward 13/Surgical admissions Ward 12 Ward 11 Day Surgery Unit Dermatology outpatients Department Medical Photography Surgical Management Occupational Health Catering Services Restaurant
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie
Hospital Building Third Floor
Engie Engie Engie
Corridors Main Hospital Streets Staircases and escape route staircases Lift Lobby’s
Consort/Engie/Trust Consort/Engie/Trust Consort/Engie/Trust
Engie Trust
Trust Engie
Storage and Waste Storage areas Trust Pharmacy/Pathology Flammable liquids Building Service and Delivery yard Storage areas,Engie Main Hospital Waste Compound
Trust Trust Consort/Engie Engie Engie
Natural Gas Supply External Buildings Engie
Medical Gasses Manifold Rooms Engie
Medical Gas Cylinder Store External Building Engie
Bulk Oxygen Liquid Plant External Area Trust
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Hospital Plant Rooms Switchgear Rooms LV/HV rooms and external buildings Emergency generator plantroom Pool plantrooms Manifold rooms
Engie Engie Engie Engie Engie Engie
Trust Headquarters Trust Offices Car Parks Reception Consort offices Plantroom
Trust Engie Consort Engie
East Wing corridor Cardiac Rehabilitation Learning and development Outpatients C Specialist Nurses Pain Management Diabeties Dietetics and Stoma Care Hispeadia Offices Health Records Ambulance Drivers Complex Engie Offices East Wing Corridor Plant rooms, service ducts
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie
Engie Buildings Workshops Complex Office Complex Domestics Complex
Engie Engie Engie
Trust Engie
Trust Engie
Engie Engie
FIRE RISK ASSESSMENT
Responsible person (e.g. employer) or person having control of the premises
Organisation CDDFT Consort Engie
Appointed Person Director of Estates
Consort Hospital Manager
Engie Contracts Manager
Address of Premises University Hospital of North Durham North Road Durham
Postcode DH1 5TW
Signature
29 November 2016
This risk assessment should be reviewed annually as suggested in the review frequency table below or at such a time if there is reason to suspect that it is no longer valid or there has been a significant change in the matters to which it relates.
Premises Type Maximum review
Main hospital
Building Annually
Suspect it is no longer valid, significant changes to the
premises i.e. Post new works,
Review Information
Reviewed by
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SIGNIFICANT FINDINGS
The Premises
4
Approximate floor area: (m²) (To include all floors of responsibility)
51.500m²
Brief details of construction: (Date of construction, brick, timber, purpose built or converted)
Traditional brick & glazed construction with Flat roof.
Design Criteria: Approved Document B & HTM Firecode. Note: The building was designed and constructed using the above guides, for further information on the building design please refer to the fire strategy design documents, plans and consultation process that compliment this fire risk assessment.
Primary usage: A large acute hospital, Retail space
Secondary usage: Not Applicable
Areas included in the assessment: This Joint Risk Assessment only covers areas identified in Appendix A, Areas of responsibility, shown as Consort areas. These are areas which the trust staff also patients and visitors require access such as hospital streets, escape routes and above ceiling access areas. This risk assessment does not include the external Consort areas, such as the service yard fire track and car park areas. This document has been written by the trust fire safety advisor to ensure the fire safety of trust employees when using areas for which its staff needs access for safe access and egress and shows the risk of above ceiling spaces. This document does not remove the responsibility from the responsible person for the control of the area under the FSO as shown in appendix A.
OCCUPANCY PROFILE
Maximum number of persons evenings: Number: 1000
OCCUPANTS ESPECIALLY AT RISK FROM FIRE
Sleeping occupants (Details of numbers - public/staff)
591
Disabled occupants (Personal Emergency Evacuation Plans in use when necessary)
The Equality Act 2010 - In the case of disability, employers and service providers are under a duty to make reasonable adjustments to their workplaces to
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overcome barriers experienced by disabled people. Where necessary, measures will be put in place to ensure evacuation procedures include persons with disabilities.
Occupants in remote areas (Lone working/isolated areas)
None
Young person’s ( Person who has not attained the age of 18)
Patients and staff may be under 18
Others (Details of Elderly/Infirm/Mental Ability)
Elderly and infirm inpatients, High dependency patients.
IDENTIFIED FIRE HAZARDS
Sources of Ignition: Above ceilings – Fixed electrical inc light fittings ,ventilation servos Corridors –Fixed electrical inc light fittings, vending machines. Escape routes and lift lobbies- fixed electrical inc light fittings,lift motor rooms
Sources of Fuel: Above ceilings –fuel sterile Corridors - disposable products (textiles, furniture) left out for disposal, waste bins.
Sources of Oxygen: Medical Oxygen Cylinders and fixed pipe There are no oxygen cylinders in the areas of audit Medical gas pipes are situated in voids
The following fire hazards have been considered as part of the assessment within the premises:-
Ignition sources (i.e. naked flames, sparks, portable heaters, smoking materials),
Sources of fuel (i.e. large quantities of paper, combustible fabrics, plastics, paints, thinners, chemicals, flammable gases),
Work processes,
Structural features that promote the spread of fire (large single uncompartmented buildings, open staircases, openings in walls and floors, large voids above ceilings and below floors).
EVALUATE, REMOVE, REDUCE AND PROTECT FROM FIRE RISK
Evaluate the risk of a fire occurring: The site is a non-smoking site
Staff are diligent when patients and visitors are on
premises for identifying risk of arson
Premises are externally/internally covered by CCTV.
Site has security patrols
contractors working on site.
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Evaluate the risk to people from a fire starting on the premises:
Full L1 alarm system, detection covering Corridors,
Escape routes and above ceiling voids. Detection
would quickly raise the alarm for persons to make
an escape.
Remove and reduce the hazards that may cause a fire:
disposable products (textiles, furniture) left out for
disposal- Products are collected by passing
Portering staff
suppressing.
Areas fire sterile
All areas are fully compartmented to a minimum of
30minute, smoke standard
Site is designed for horizontal evacuation
The following persons have been considered as part of the assessment within the premises:-
Employees,
Employees, visitors, and other persons whose mobility, hearing or eyesight is impaired,
Other persons in the premises if the premises are multi-occupied,
Varied working practices (i.e. areas of your premises occupied when others are not),
Areas where employees/others are isolated,
Visitors,
Young persons,
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1. ELECTRICAL SOURCES OF IGNITION
Reasonable measures taken to prevent fires of electrical origin.
a. Fixed electrical installations periodically inspected and tested? (Every 5 years) Alternate process
used
b. Portable appliance testing carried out (where appropriate) on a risk assessed basis? Yes
c. Suitable policy in place regarding the use of personal electrical appliances? This should be subject to a Trust policy from the user organisation
Yes
d. Suitable limitation and management of trailing leads and adaptors? Yes
e. Charging and storage of batteries undertaken on site? Arjo equipment. Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
a. Fixed Electrical installation
c. Trailing leads & Adaptors
Tested within last 5 years. Assessments carried out on departmental risk assessments Evidence of testing routine, cable leads and plugs in good condition. Assessments carried out on departmental risk assessments Cables do not pose a trip hazard or run in such a way as to cause cable wear.
The 5 yearly testing of fixed electrical installations is not carried out. Engineers have replaced this schedule with an annual record of inspection as per B7671 p59 guidance note 3‘’the 5 yearly test may be replaced by continuous monitoring on all distribution panels’’ as well as this Engie also carry out earth loop impedance testing on all circuits within the buildings Work schedules held as evidence in Engie offices. Applicable to below ceiling areas within departments and wards PAT testing is carried out on the whole site annually by an external contractor. Engie will also carry out testing when requested by department. Applicable to below ceiling areas within departments and wards, there are no trailing leads and adaptors in the areas covered in this assessment.
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Deficiencies and Comments: No Deficiencies Comments Fixed wire Installation Testing note The legislation of specific relevance to electrical maintenance and Fixed Installation Testing is the Health & Safety at Work Act 1974, the Management of Health & Safety at Work Regulations 1999, the Electricity at Work Regulations 1989 and the Workplace (Health, Safety and Welfare) Regulations 1992. Maximum period between inspection & testing 5 years for Hospitals, Offices, Residential accommodation, Commercial premises Portable electrical appliance Testing note The Electricity at Work Regulations 1989 requires that any electrical equipment that has the potential to cause an injury is maintained in a safe condition. However, the Regulations do not specify what needs to be done, by whom or how frequently (i.e. they don't make inspection or testing of electrical appliances a legal requirement, nor do they make it a legal requirement to undertake this annually). Further guidance can be sought from the HSE website
2. SMOKING
Reasonable measures taken to prevent fires as a result of smoking. Yes
a. Smoking prohibited in the building? Yes
b. Smoking permitted in appropriate areas? N/A
c. Suitable arrangements for those who wish to smoke? N/A
d. This policy appeared to be observed at the time of the inspection? No
Identified Hazards Existing Control Measures Additional Control Measures Required
a. Patients smoking at main and A&E entrances
Non Smoking policy and signage Staff and Security to enforce the non-smoking policy
Deficiencies and Comments:
The Trust has a no-smoking on site policy. Signage throughout the hospital grounds show no
smoking on site
Smoking materials found outside of buildings, this has been highlighted and a tanoy system has
been introduced at the main entrance. It has also been highlighted to staff to enforce the no-
smoking on site policy.
3. ARSON/DELIBERATE IGNITION
Basic security against arson by outsiders or other persons appears reasonable. Yes
a. Is there close proximity to the premises available for ignition by outsiders? No
Identified Hazards Existing Control Measures Additional Control Measures Required
Bins in corridors for general waste
Bins are HTM compatible and self- extinguishing
No action
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To be managed Once identified the areas are cleared.
Deficiencies and Comments: Occasional storage issues around the hospital with beds and trolleys in corridors, some days the issue is more prevalent than others. Once identified areas are to be cleared.
4. PORTABLE HEATERS
The use of portable heaters avoided as far as practicable? Yes
a. Is the use of portable heaters avoided as far as practicable?Note: Portable gas cylinder heaters and paraffin heaters are NOT to be used in NHS premises
b. If portable heaters are used:
b. (i) Is the use of the more hazardous type (e.g. radiant bar fires or lpg appliances) avoided?
N/A
b (ii) Are suitable measure taken to minimise the hazard of ignition of combustible materials?
N/A
c. Are fixed heating installations subject to regular maintenance? N/A
Considerations to minimise the hazard of ignition of combustible materials due to these heaters.
Always position heaters so the heater back is against a wall and the heating element is facing into the room.
Switch heaters off if you are not in the room. Unplug electric heaters at cease work
Always follow the manufacturers' operating and maintenance instructions
Ensure the electrical power lead does not create a trip hazard
Do not use flammable materials, aerosols or cleaning fluids near heaters.
Do not place heaters close to furniture, curtains or bedding. 1metre is all directions
Do not stand or sit too close to heaters, some clothes may ignite easily.
Do not place heaters on uneven surfaces or where they can be knocked over easily
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Actions required
Deficiencies and Comments: There are no portable heaters in the assessment area, which includes below ceilings in departments and ward were applicable. Hospital uses thermostatically controlled water radiators and chilled and heated water vent systems.
5. FIXED HEATING INSTALLATIONS
Are there fixed heating installations such as boilers are used within the premises?
Yes
a. Are fixed heating installations subject to regular maintenance? Yes
b. Are suitable measures taken to minimise the hazard of ignition of combustible materials due to these heaters?
Yes
There are no fixed boiler installations in the assessment area
No Actions required
Deficiencies and Comments: Boiler fuel supply – Main Gas. Main boiler system situated in the energy centre adjacent to Aykley heads entrance
6. COOKING
Reasonable measures taken to prevent fires as a result of cooking? Yes
a. Filters cleaned or changed and ductwork cleaned regularly? Yes
b. Suitable extinguishing appliances available? (e.g. Fire blanket, Wet Chemical etc.) Yes
c. Suitable Shut Down Procedures in place? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
Engie restaurant and kitchen Ward Zonal Kitchens below roof void Ward Beverage Bays
Engie Risk Assessment CDDFT Risk Assessments
No Action required No Action required
Deficiencies and Comments: Area controlled by Engie
7. LIGHTNING
Does the building have a lightning protection system? Yes
a. Is the lightning protection system subject to a suitable maintenance regime? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Actions required
Deficiencies and Comments: Lightning conduction Test carried out as part of an 11 month test regime.
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8. DANGEROUS SUBSTANCES
Dangerous substances are, or could be used or stored, within the premises? (a substance or preparation that because of its chemical and sometimes physical properties and the way it is present and/or used at work creates a fire or explosion risk to people)
Yes
Are the general fire precautions adequate to address the hazards associated with dangerous substances used or stored within the premises?
Yes
If dangerous substances are present, has a risk assessment has been carried out as required by the Dangerous Substances and Explosive Atmospheres Regulations 2002? Medical Treatment areas e.g. Operating Theatres & Treatment Rooms excluded from DSEAR.
N/A
No Hazards identified No Actions required
Deficiencies and Comments: There are no Dangerous substances held within the assessment area, other than below ceiling level which are covered by department and ward risk assessments
9. HOUSEKEEPING
Is the standard of housekeeping adequate? Yes
a. Combustible materials appear to be separated from ignition sources? Yes
b. Appropriate storage of hazardous materials? N/A
c. Avoidance of inappropriate storage of combustible materials? (Escape routes and final exits are kept clear of any combustibles including storage and furniture)?
Yes
d. Avoidance of unnecessary accumulation of combustible materials and/or waste? Yes
Identified Hazards Existing Control Measures Additional Control Measures Required
Delivery of goods to lower ground floor
Goods are moved to wards and departments as soon as practical on delivery CCTV monitoring of area
To be Managed as necessary
Deficiencies and Comments: The areas covered by the risk assessment are relatively fire sterile, any items which are left out are cleared as soon as possible, Items found to have little fire loading and are HTM compliant.
10. HAZARDS INTRODUCED BY CONTRACTORS AND BUILDING WORKS
Fire safety conditions have been imposed on both external contractors and in-house maintenance staff?
Yes
Is there satisfactory control over works, including use of hot work permits, where appropriate, carried out in the building by external contractors? .
Yes
Possible breaches of compartmentation due to works
Ensure that contractors reseal any breeches made and report any breeches found. The integrity of the fire compartmentation is to be examined periodically by Hospital Estates Estates alert Ref: DH/2014/003
To be managed as necessary
Deficiencies and Comments:
A full Above ceilings audit was carried out in the University hospital of North Durham by Engie.
Breeches identified have been actioned.
Oxyacetylene, is not allowed to be used on site without the fire managers express permission
and a risk assessment.
11. OTHER SIGNIFICANT FIRE HAZARDS THAT WARRANT CONSIDERATION
Are there any other fire hazards that warrant consideration within the premises? (This to include any fire hazards from any process; heat producing, spark or friction generating, chemical or other process which has the capacity to ignite, create excessive or rapid heat or generate oxidising or flammable gas that impact on the general fire precautions)
Identified Hazards Existing Control Measures Additional Control Measures Required
There are no significant hazards in the assessment area.
No Actions required
Deficiencies and Comments: There are no significant fire hazards in the assessment area
12. EVACUATION STRATEGY
The evacuation strategy for this premises is detailed below
PROGRESSIVE HORIZONTAL EVACUATION Relevant persons are dependent on staff to assist with their escape. Provisions have been made to move such persons from an area affected by fire, through a fire resisting barrier to an adjoining fire protected area on the same level, where they can wait in a place of safety whilst the fire is dealt with, or await further evacuation down a protected route to total safety.
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NOTE - Progressive Horizontal Evacuation is subject to the following Protected areas should be designed to provide: • Sufficient capacity to accommodate the number of occupants who will need to use them. For this purpose a protected area should be sufficient capacity to accommodate its normal occupants and the occupants of the largest adjoining protected area. • Progressive movement away from a fire via sequential adjoining protected areas. • Means for escape via stairway(s) should this become necessary. The number and size of the protected areas depends on a number of factors: • the time it will take to evacuate people from the area of a fire to an adjacent protected area; • the number of people to be evacuated; • the level of any mobility impairment; • the number of staff to assist in evacuation; • the fire protection arrangements; • layout of the premises; and • location and number of staircases; Primary Construction for this Building Applies to the main fabric of a building, walls, floors, roof & internal dividing walls Buildings are categorised into 3 classes Class A - complete non-combustible construction, i.e. elements of structure, floors, and walls, supporting structure of brick or concrete. Class B - traditional construction, i.e. non-combustible walls with combustible floors Class C - combustible construction, i.e. timber floors & walls. The evacuation times that are generally accepted as Class A - 3 minutes Class B – 2 ½ minutes Class C - 2 minutes These are not hard and fast times, and can be extended or reduced according to the particular circumstances of the case, but they do form a reasonable basis for most situations.
Written copies of Evacuation Procedures are located as follows: On the intranet
Fire procedure and fire action notices: next to call points throughout assessment areas.
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards Identified No Action required
Deficiencies and Comments: Hospital designed for horizontal evacuation , with staged alarm system and compartmentation
No Vertical hospital evacuation aids required in an emergency, the lifts within the alarm zone will return
to ground level. Those lifts outside the alarm zone will still operate and therefore may be utilised.
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PROVISION OF ELEMENTS OF FIRE SAFETY AS SECONDARY CONTROL MEASURES
13. MEANS OF ESCAPE FROM FIRE
It is considered that the premises are provided with reasonable means of escape in case of fire.
Yes
b. Reasonable distances of travel when:
b. (i) Where there is escape in a single direction?
Yes
Yes
c. Suitable protection of escape routes? (Fire resisting construction) Yes
d. Adequate provision of exits? Yes
e. Exits easily and immediately open-able where necessary? Yes
f. Escape routes unobstructed? Yes
g. Fire exits open in the direction of escape where necessary? Yes
h. Avoidance of sliding or revolving doors as fire exits where necessary? Yes
i. Satisfactory means for securing exits? Yes
j. Suitable fire precautions for all inner rooms and dead ends? Yes
k. It is considered that the premises are provided with reasonable arrangements for means of escape for disabled people?
Yes
No Hazards identified No Action required
Deficiencies and Comments: Hospital designed to HTM standard with adequate means of escape and escape routes
14. MEASURES TO LIMIT FIRE SPREAD AND DEVELOPMENT
It is considered that there is:
a. Compartmentation of a reasonable standard. (Fire resistant to collapse, fire penetration and transfer of excessive heat
Yes
b. Reasonable limitation of linings that may promote fire spread. (Flame spread across surfaces including walls, ceilings and other internal structures)
Yes
c. As far as can be reasonable ascertained, fire dampers are provided in ducts or vents as necessary to protect critical means of escape against passage of fire, smoke and combustion products in the early stages of a fire?
Yes
No Hazards identified No Action required
Deficiencies and Comments: Note
A full Above ceilings audit was carried out in the University hospital of North Durham by Engie. Breeches identified have been actioned. To comply with Estates alert Ref: DH/2014/003 A ridged system of work instigated so that any breaches in above ceiling compartmentation can be identified and rectified promptly this was signed off as complete by estates.
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Yes Yes
No Hazards identified No Action required
Deficiencies and Comments: There Full coverage of emergency lighting within the assessment area of corridors, escape routes and lift lobby landings Note. The existing emergency escape lighting system within UHND will not conform in full to current recommendations (e.g. in respect of luminance levels).This might be perfectly acceptable, but it is appropriate for new systems, and new work associated with upgrading of existing systems to conform to the current recommendations. Attention is drawn to current recommendations in BS 5266-1 and to the requirements of BS 5266-7 and BS 5266-8.
16. FIRE SAFETY SIGNS AND NOTICES
Reasonable standard of fire safety signs and notices? This includes fire exit, fire escape signage, fire resisting door and hazard signage.
Yes
No Hazards identified No Action required
Deficiencies and Comments: All signage within the assessment areas correct Note. It is a requirement of the Health and Safety (Safety Signs and Signals) Regulations 1996 that these signs incorporate the appropriate pictogram. BS 5499-5:2002 Graphical symbols and signs. Safety signs, including fire safety signs. Signs with specific safety meanings Superseded by BS ISO 7010:2011 - Prescribes safety signs used for accident prevention, fire protection, health hazard information and emergency evacuation
17. MEANS OF GIVING WARNING IN CASE OF FIRE
Reasonable manually operated fire warning system provided? Based on visual inspection, but no audibility tests or verification of full compliance with relevant British Standard carried out. Compliance with this will be carried out by a competent person who will provide certification on compliance or recommend works to comply with the standard.
Yes
If yes give details: (e.g. Break glass call points, fire bell, air horn, klaxon etc.) Full category L1 alarm system fitted in the assessment area with both manual call points and automatic smoke detection in all areas of the hospital including ceiling voids.
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a. Automatic fire detection provided? If yes, to what Standard? (e.g. BS 5839 Part 1Grade L1/L2 etc.) L1 System. Approximate age of system 15 years
Throughout areas applicable to this FRA Yes
Part of Premises only N/A
b. Extent of automatic fire detection generally appropriate for the occupancy and fire risk?
Yes
c. Remote transmission of alarm signals to an Alarm Receiving Centre? (continuously manned premises, remote from those in which a fire alarm system is fitted, where the information concerning the state of the fire alarm system is displayed and/or recorded, so that the fire and rescue service can be summoned where necessary)
NO
No Hazards identified No Action required
Deficiencies and Comments: Hospital fitted with a Full category L1 alarm system with both manual call points and automatic smoke detection in all areas of the hospital including ceiling voids. Activation of the fire alarm is monitored by the hospitals telephone exchange who contact the fire brigade on an activation The main hospital fire alarm panel is situated in A&E on the ground floor,There are fire alarm indicator panels situated in the following locations:- Level –1 At rear entrance Level 0 Accident and Emergency entrance
- Street adjacent to staircase D - Street adjacent to staircase B - Main reception - Cardio Catheter Laboratory
Level 1 Street adjacent to staircase D - Street adjacent to staircase B - Outpatients Department reception - Hospital Switchboard
Level 2 Street adjacent to staircase D - Street adjacent to staircase B - Lift lobby adjacent to entrance to staff dining room
Level 3 Adjacent to staircase D - Adjacent to staircase A - Street adjacent to lift motor room number L4/5
The Fire alarm is tested weekly with a rolling annual programme of tests
18. MANUAL FIRE EXTINGUISHING APPLIANCES
a. Reasonable provision of portable fire extinguishers? Yes
b. Are all fire extinguishing appliances readily accessible and unobstructed? (i.e. mounted on walls or on appropriate bases)
Yes
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No Hazards identified No Action required
Deficiencies and Comments: Wall mounted 9ltr Water extinguishers provided in all corridors 9ltr water and 2kg CO2 extinguishers throughout assessment area Extinguisher positions shown on fire maps throughout area
19. RELEVANT AUTOMATIC FIRE EXTINGUISHING SYSTEMS
Type of fixed system and location: (Inert gas suppression systems, sprinklers/misting systems etc.)
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards identified No Action required
Deficiencies and Comments: No Fixed systems in assessment areas, Fixed systems are covered by local departmental and ward risk assessments e.g. inert gas drench lower ground floor IMT area.
20. OTHER RELEVANT FIXED SYSTEMS AND EQUIPMENT
Type of fixed system and location: All hospital streets are fitted with dry riser outlets which are fed from 5 inlets situated :- 1x main entrance 1xoutside A&E 3xfire track All outlets are colour coded with the colour on the inlet box window
Identified Hazards Existing Control Measures Additional Control Measures Required
No Hazards identified No Action required
Deficiencies and Comments: Note Pressure test and Private fire hydrant tests carried out by Engie.
21.FIREFIGHTER SWITCH – HIGH VOLTAGE LUMINOUS TUBE SIGNS ETC
Suitable provision of fire fighters switche(s) for high voltage luminous tube signs, etc. (to include location)?
N/A
No Hazards identified No Action required
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MANAGEMENT OF FIRE SAFETY
22. PROCEDURES AND ARRANGEMENTS
Fire safety is managed by the Responsible Person for the Relevant Persons, which includes, employees, members of the public, visitors, contractors from other organisations and the self employed
CDDFT Board-Chief Executive Officer- Executive Director Fire- Fire Safety Manager: a nominated person with responsibility for carrying out day-to-day management of fire safety Duty Holders: nominated persons who are responsible for fire safety measures in the premises to ensure the safety of persons in case of fire. Note: Responsible Persons at the premises must cooperate and coordinate their fire safety measures and activities.
Fire Safety Managed in the risk assessed parts of the premises by
Consort, Engie and CDDFT
Are competent person(s) appointed to assist in undertaking the preventative and protective measures (i.e. relevant general fire precautions)? Person(s) appointed with fire safety roles include – Fire Warden(s). Fire Evacuation Marshall(s) (Taking into consideration the Fire Safety (Employees Capabilities) (England) Regulations 2010 (SI 2010/471)
Yes
Is there a suitable record of the fire safety arrangements? Yes
Appropriate fire procedures in place? Yes
Are procedures in the event of a fire appropriate and properly documented? Yes
Are there suitable arrangements for summoning the Fire and Rescue Service? Yes
Are there suitable arrangements to meet the F&RS on arrival and provide relevant information, including that relating to hazards to fire fighters?
Yes
Is there a plan of the building available indicating basic layout and any areas of significant risk?
Yes
Are there suitable arrangements for ensuring that the premises have been evacuated? Yes
Is there a suitable fire assembly point(s)? Yes
Are there adequate procedures for evacuation of any disabled people who are likely to be present?
Yes
Persons nominated and trained to assist with evacuation, Including evacuation of disabled people? A Disabled person(s) evacuation strategy must not rely on rescue of disabled people by the fire and rescue service. Assistance with their evacuation is provided by nominated persons within the premises
Yes
Appropriate liaison (if necessary) (e.g. F&RS crews visiting for familiarisation visits)? Yes
Routine in-house inspections of fire precautions (e.g. in the course of health and safety inspections)?
Yes
Deficiencies and Comments:
All fire procedures and policies are available on the intranet, all procedures are current and correct and identify what staff do in the event of an incident
Familiarisation visits are conducted by the fire safety advisor with the fire brigade on a regular basis
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23. TRAINING AND DRILLS Fire safety training is managed by:
A nominated Fire Safety Manager for each occupier/tenant organisation.
Are arrangements in place to ensure that all new staff and visitors (where necessary) provided with fire safety induction and local building familiarisation?
Yes
Is this induction training recorded? Yes
Are arrangements in place to that all staff undertake annual fire safety refresher training and familiarisation where necessary, and to ensure that it is recorded?
Yes
Are staff with special responsibilities (e.g. fire wardens and fire evacuation marshals) been appointed and provided with additional training?
Yes
Are fire drills carried out at appropriate intervals and a record of such drills recorded? Yes
When the employees of another employer work in the premises:
Is the employer given appropriate information (e.g. on fire risks and general fire precautions)?
Yes
Is it ensured that the employees are provided with adequate instructions and information?
Yes
Yes
Does all staff training provide information, instruction or training on the following:
Fire risk in the premises? Yes
The fire safety measures in the premises? Yes
Action in the event of fire? Yes
Action on hearing the fire alarm signal? Yes
Method of operation of manual call points? Yes
Location and use of fire extinguishers? Yes
Means for summoning the F&RS? Yes
persons to assist with evacuation? Yes
Other measures-including risk of arson and UWFS Yes
Deficiencies and Comments: 3
rd party persons receive fire training from the trust fire safety advisor
Note. Where two or more organizations share a premise, adequate fire safety for all occupants will only be achieved if the organizations co-operate with one another to co-ordinate their fire safety measures. For example, there needs to be co-ordination of fire procedures, fire drills and fire management strategy. It needs to be ensured that one occupier’s activities and practices do not create a risk to those in another occupier’s part of the premises.
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Adequate maintenance of premises? Yes
Weekly testing and periodic servicing of fire detection and alarm system to include ancillary equipment (e.g. door hold open devices, door locks etc.) Manual call point(s) tested weekly on a rotational basis?
Yes
Monthly and annual testing routines for emergency escape lighting? Function test monthly with annual discharge. OR PPM in place
Yes
Yes
Six monthly inspection and annual testing of rising mains? Yes
Weekly and monthly testing, six monthly inspection and annual testing of fire-fighting lifts? N/A
Weekly testing and periodic inspection of sprinkler installations? N/A
Routine checks of final exit doors and/or security fastenings? Yes
Annual inspection and testing of lightning protection system? Yes
Are suitable systems in place for reporting and subsequent restoration of safety measures that have fallen below the required standard?
Yes
Other relevant inspections or tests: Give details:
Deficiencies and Comments: All maintenance carried out by Engie with records kept in the Engie main office block
25. RECORDING
Yes
Maintenance and testing of other fire precaution systems? Yes
Location of Records: (Available for inspection by Fire Authority if required) Fire training records held by learning and development All maintenance carried out by Engie with records kept in the Engie main office block
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Work Number SLA/Minor Works/New Works/Capit
al
Target Date Date Action Completed
1.Occasional storage issues around the hospital with beds and trolleys in corridors, some days the issue is more prevalent than others.
Once identified areas are to be cleared.
M Portering staff are to clear area when conducting walk around
N/A As Necessary On-going Existing standard
2.Delivery of goods to lower ground floor
Goods are moved to wards and departments as soon as practical on delivery CCTV monitoring of area
M Managers are to ensure Portering staff clear area
N/A As Necessary On-going Existing standard
3.Patients smoking at main and A&E entrances
Inform patients of Non Smoking policy.
M Staff and security to enforce the non-smoking policy
N/A As Necessary On-going Existing standard
4.Possible breaches of compartmentation due to works
Prevent breeches in compatmentation
H Estates are to brief contractors also ensure that contractors reseal any breeches made to the red book standard and report any breeches found. The integrity of the fire compartmentation is to be examined periodically by Hospital Estates Estates alert Ref: DH/2014/003
N/A As Necessary On-going Existing standard
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RISK ASSESSMENT METHODOLOGY
The following simple risk level estimator is based on a more general health and safety risk level estimator.
Taking into account the fire prevention measures observed at the time of this risk assessment, it is considered that the hazard from fire (likelihood) at these premises is: Likelihood:
Rare
Unlikely Possible x Likely Almost Certain
In this context, a definition of the above terms is as follows: Rare: May occur only in exceptional circumstances. Unlikely: Unusually low likelihood of fire as a result of negligible potential sources of ignition. Possible: Normal fire hazards (e.g. potential ignition sources) for this type of occupancy, with fire hazards generally subject to appropriate controls (other than minor shortcomings). Likely: Lack of adequate controls applied to one or more significant fire hazards, such as to result in significant increase in likelihood of fire. Almost Certain: Lack of adequate controls, taking into account the nature of the building and the occupants, as well as the fire protection and procedural arrangements observed at the time of this fire risk assessment, it is considered that the consequences for life safety in the event of fire would be: s No Severity:
Negligible x Minor Moderate Major Harm
Catastrophic
In this context, a definition of the above terms is as follows: Negligible: Outbreak of fire unlikely to result in injury.
Minor harm: Outbreak of fire unlikely to result in serious injury or death of any occupant (other than an occupant sleeping in a room in which a fire occurs).
Moderate harm: Outbreak of fire could foreseeably result in injury (including serious injury) of one or more occupants, but it is unlikely to involve multiple fatalities.
Major harm: Outbreak of fire could foreseeable result in; Significant potential for serious injury or death of one or more occupants.
Severity of Fire ↓
Likelihood of Fire →
Rare - 1 Unlikely - 2 Possible - 3 Likely - 4 Almost certain -
5
Minor - 2 2 4 6 8 10
Moderate - 3 3 6 9 12 15
Major - 4 4 8 12 16 20
Catastrophic - 5 5 10 15 20 25
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Catastrophic Outbreak of fire could foreseeable result in multiple fatalities. Accordingly, it is considered that the risk to life, consequence from fire at these premises is:
Low x
Medium High Extreme
Comments: A suitable risk-based control plan should involve effort and urgency that is proportional to risk. The following risk-based control plan is based on one advocated by BS 18004:2008 for general health and safety risks:
Definitions of Priorities
Risk Level Action and Timescale
Low - Priority 4 No action is required other than to maintain existing standards. To be monitored and looked at again at next review.
Medium - Priority 3 No major additional controls required. However, there might be a need for improvements that involve minor or limited cost. To be completed within 6 months of date of issue of report, or in period of time as specified by the assessor, if this is greater or less than 6 months, reasons for the extended or reduced time must be explained.
High - Priority 2 It is essential that efforts are made to reduce the risk. Risk reduction measures should be implemented within a defined time period. To be completed within 2 month of date of issue of report, or in period of time as specified by the assessor, if this is greater or less than 2months , reasons for the extended or reduced time must be explained.
Extreme - Priority 1 Considerable resources might have to be allocated to reduce the risk. If the building is occupied, urgent action should be taken to reduce the risk and consideration given to temporary suspension of services. If the building is unoccupied, it should not be occupied until the risk has been removed or reduced to a tolerable level. To be completed immediately or within 24 hours or in period of time as specified by the assessor, if this is greater than 24hrs reasons for the extended time must be explained.
(Note that, although the purpose of this section is to place the fire risk in context, the above approach to fire risk assessment is subjective and for guidance only. All hazards and deficiencies identified in this report should be addressed by implementing all recommendations contained in the following action plan. The fire risk assessment should be reviewed regularly.) Any item in the report may be given a higher priority than the score indicates; when this has been the case the reason for this must be indicated in the report The time scale in the report may be extended, past that which the priority rating recommends; when this has been the case the reason for this must be indicated in the report
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APPENDIX A : AREAS OF RESPONSIBILITY
Regulatory Reform (Fire Safety) Order areas of responsibility UHND Regulatory Reform (Fire Safety) Order 2005 section 3 Responsible person:- (a) in relation to a workplace, the employer, if the workplace is to any extent under his control; (b) in relation to any premises not falling within paragraph (a)— (i) the person who has control of the premises (as occupier or otherwise) in connection with the carrying on by him of a trade, business or other undertaking (for profit or not); or (ii) the owner, where the person in control of the premises does not have control in connection with the carrying on by that person of a trade, business or other undertaking.
Area Department Responsible
Mortuary Pharmacy Pathology Laboratories CSSD Medical Engineering IMT Stores Delivery Post room Linen Services RDU
Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie Engie
Hospital Building Ground Floor
A&E CCU Ward 1 Ward 2 Ward 3 Ward 4 Reception Department of rehabilitation Cardiology and respiratory investigations Endoscopy Chemotherapy UCC/Orthopaedic Outpatients X Ray Department Cardiac Day Unit WRVS Shop
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust
Hospital Building First Floor
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust
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Ward 8 Ward 9 Ward 10 Antenatal and Gynaecology OPD Special Care Baby Unit Family Services Telephone exchange Telephone Operators Office Security office
Trust Trust Trust Trust Trust Trust Trust Engie Engie
Hospital Building Second Floor
Main Operating Theatres ITU/HDU Ward 16 Ward 15 Dressing Clinic Ward 14 Ward 13/Surgical admissions Ward 12 Ward 11 Day Surgery Unit Dermatology outpatients Department Medical Photography Surgical Management Occupational Health Catering Services Restaurant
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie
Hospital Building Third Floor
Engie Engie Engie
Corridors Main Hospital Streets Staircases and escape route staircases Lift Lobby’s
Consort/Engie/Trust Consort/Engie/Trust Consort/Engie/Trust
Engie Trust
Trust Engie
Storage and Waste Storage areas Trust Pharmacy/Pathology Flammable liquids Building Service and Delivery yard Storage areas,Engie Main Hospital Waste Compound
Trust Trust Consort/Engie Engie Engie
Natural Gas Supply External Buildings Engie
Medical Gasses Manifold Rooms Engie
Medical Gas Cylinder Store External Building Engie
Bulk Oxygen Liquid Plant External Area Trust
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Hospital Plant Rooms Switchgear Rooms LV/HV rooms and external buildings Emergency generator plantroom Pool plantrooms Manifold rooms
Engie Engie Engie Engie Engie Engie
Trust Headquarters Trust Offices Car Parks Reception Consort offices Plantroom
Trust Engie Consort Engie
East Wing corridor Cardiac Rehabilitation Learning and development Outpatients C Specialist Nurses Pain Management Diabeties Dietetics and Stoma Care Hispeadia Offices Health Records Ambulance Drivers Complex Engie Offices East Wing Corridor Plant rooms, service ducts
Trust Trust Trust Trust Trust Trust Trust Trust Trust Trust Engie Engie
Engie Buildings Workshops Complex Office Complex Domestics Complex
Engie Engie Engie
Trust Engie
Trust Engie
Engie Engie
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