HCA HEALTHCARE UK POLICY
CORPORATE FIRE POLICY

Document Number:
HCAUK.HS.EST.POL.1003.2.0
Publication Date: 10/03/2022
Review Date: 10/09/2024
Document Owner: Group Head of Health,
Safety and Business Continuity
Expiry Date: 10/03/2025
Replaces Document:
HCAUK.HS.EST.POL.1003.1.2
Approved by:
Vice President for Capital and Facilities
Target Audience: All staff Date approved: 10/03/2022
Document Summary:
To identify and manage the duties of HCA
staff in accordance with the Regulatory
Reform (Fire Safety) Order 2005
Key words: Fire, Safety, Risk Assessment, Evacuation
Key linked policies/ guidelines
Corporate Education, Training and
Development Policy
HCAUK.HR.LD.POL.1002.1.3
Version Tracking
Date Version Number Changes made to document
09/11/2017 1.0 Additional references to updated HTM documents
have been added, clarification has been introduced
in the text of the document that an internal review
of a fire risk assessment where there are no
material changes is valid for one year only in line
with the review form.
25/10/2019 1.1 Very minor amendments and update in accordance
with role titles/ responsibilities.
09/11/2021 1.2 Removal of Fire booklet as this is now covered in
induction. Updated roles and responsibilities.
10/03/2022 2.0 Full review, rewrite and update in line with the new
competent advice.

HCA HEALTHCARE UK POLICY
CORPORATE FIRE POLICY
If printed this policy document is uncontrolled. Please access the Policy Library for the most current version.
Page 1 of 47
Document Number:
HCAUK.HS.EST.POL.1003.2.0
Publication Date: 10/03/2022
Review Date: 10/09/2024
Document Owner: Group Head of Health,
Safety and Business Continuity
Expiry Date: 10/03/2025
Replaces Document:
HCAUK.HS.EST.POL.1003.1.2
Approved by:
Vice President for Capital and Facilities
Target Audience: All staff Date approved: 10/03/2022
Document Summary:
To identify and manage the duties of HCA
staff in accordance with the Regulatory
Reform (Fire Safety) Order 2005
Key words: Fire, Safety, Risk Assessment, Evacuation
Key linked policies/ guidelines
Corporate Education, Training and
Development Policy
HCAUK.HR.LD.POL.1002.1.3
Version Tracking
Date Version Number Changes made to document
09/11/2017 1.0 Additional references to updated HTM documents
have been added, clarification has been introduced
in the text of the document that an internal review
of a fire risk assessment where there are no
material changes is valid for one year only in line
with the review form.
25/10/2019 1.1 Very minor amendments and update in accordance
with role titles/ responsibilities.
09/11/2021 1.2 Removal of Fire booklet as this is now covered in
induction. Updated roles and responsibilities.
10/03/2022 2.0 Full review, rewrite and update in line with the new
competent advice.

1 INTRODUCTION
A fire in a healthcare environment would pose a major threat to the lives of everyone within
it, but particularly to its more vulnerable patients. Therefore, hospitals and other healthcare
premises, such as those within the HCA suite of buildings, require a fire safety policy based
initially upon the avoidance of fire. In the event of a fire situation there must be the means
for: rapid detection and alarm; compartmentation to prevent the spread of smoke and
flames; ensuring the safety of occupants; supporting evacuation procedures and a suitable
number of trained staff for removing patients to places of safety either via internal
progressive horizontal evacuation procedures or to a place of ultimate security and safety
away from the building.
This policy relies upon a high level of senior management commitment and professional
competence. The whole policy must be supported by a procedure for appraising and

reappraising fire precautions and for the regular undertaking of high quality staff training.
Fire safety in the HCA suite of buildings, including the main hospitals and other facilities
such as outpatient buildings and offices, is the concern of everyone. Every member of staff,
external consultant and contractor is responsible for knowing the fire hazards within their
working environment, practicing and promoting high standards of fire prevention and
understanding the correct course of action to take in the event of a fire breaking out.
The policy is supplemented by local fire procedures at each Hospital or facility which outline
the specific local arrangements for that building. Local policies will be based upon the
principals of this document but will contain more specific site information and details.
Requirements of Primary Legislation
a) Regulatory Reform (Fire Safety) Order 2005
The Regulatory Reform (Fire Safety) Order 2005 was introduced in October 2006 in England
and Wales and was intended to simplify the law and strengthen the well-understood
process of risk assessment.
Previously, under the Fire Precautions Act 1971 there had been a need for premises to have
a fire certificate, issued normally by the local fire and rescue service. The Fire Safety Order
places the duty for fire safety on the employer and a greater emphasis on fire risk
assessment.
Therefore, the organisation must ensure that fire risk assessments are undertaken and kept
up to date in order to ensure that all the fire precautions in the premises remains current
and adequate.
The responsibility for complying with the Regulatory Reform (Fire Safety) Order rests with
the “Responsible Person”. In a workplace, this is the employer and any other person who
may have control of any part of the premises, e.g., the occupier (tenant occupying a small
area of the property or the sole tenant) or owner. In all other premises, the person or
people in control of the premises will be responsible. If there is more than one Responsible
Person in any type of premises (e.g., a multi-occupied complex as in some of the buildings
where HCA lease one or more of the floors) all must take reasonable steps to co-operate
and co- ordinate with each other.
In the case of HCA there are often contractors based permanently on site. HCA is
responsible for ensuring that permanent contractors based on site (for example those
providing catering and housekeeping personnel) have undertaken their own fire risk
assessments. Effective cooperation and coordination with contractors must be maintained
and recorded.
In the case of HCA existing buildings, the Fire and Rescue Authority is responsible for the
enforcement of the Regulatory Reform (Fire Safety) Order. They have the power to inspect
any or all of HCA premises, at any reasonable time, in order to check that they are
complying with their duties under the Regulatory Reform (Fire Safety) Order. They will look
for evidence that HCA has carried out suitable and sufficient fire risk assessments and has
acted upon the significant findings contained within that assessment. These inspections are
in addition to the more routine site familiarisation visits, known as 72D visits. They are
undertaken by the Fire and Rescue Service in order to obtain site information regarding the
specific hazards and the provision of the facilities required by them in the event of a fire.
If the enforcing authority is not satisfied with the standards of fire safety within the building,
they may issue an enforcement notice that requires certain improvements to be made, or in
extreme cases, a prohibition notice that restricts the use of all or part of the premises until
the recommended improvements have been made.
Section 2 of this document outlines how HCA has identified those with specific
responsibilities.
b) Dangerous Substances and Explosive Atmosphere Regulations 2002
The Dangerous Substances and Explosive Atmospheres Regulations 2002 require employers
to control the risks to safety from fire and explosions.
This is effected through the undertaking, where required, of an assessment of the hazards
that may exist and the implementation and management of appropriate control measures.
The risks within HCA hospital premises are generally in relation to the storage and use of
compressed medical gases in cylinders or tanks and the measures described in the Electrical
and Gas Factors section of the Fire Risk Assessments undertaken by the Fire Protection
Association (FPA) is intended to address these risks in that a separated DSEAR assessment
for each premises are not required.

2 SCOPE
Workplaces under the control of HCA or at which employees of HCA work.

3 FIRE POLICY STATEMENT
It is HCA policy that the risks of any fire starting within their premises shall be minimised so
far as is reasonably practicable.
HCA will meet its statutory duty under the Regulatory Reform (Fire Safety) Order 2005 and
accept its responsibility as an employer under the Department of Health Firecode and
related European Commission / European Union Directives (EC / EU), to provide a safe
working environment for all of its employees, patients, visitors and contractors with regard
to fire safety in the workplace.
Additionally, HCA will seek to promote fire safety awareness throughout both its healthcare
premises and other facilities through management initiatives, fire safety campaigns and
mandatory fire training.
It is also the policy that for all premises:
 suitable means of detecting and giving warning in case of fire are established and
maintained;
 adequate means of escape and arrangements supporting the means of escape are
maintained at all times;
 suitable means to fight fire are provided;
 adequate means to summon the emergency services are available;
 adequate and effective fire compartments and sub-compartments shall be
established and maintained at all facilities which, in the case of those facilities which
are intended to be used for inpatients or other patients who cannot be promptly
evacuated, are consistent with a progressive horizontal evacuation procedure;
 adequate information, instruction, training and supervision shall be provided as
appropriate to all staff, patients, visitors and contractors. Staff training shall include
the correct use of evacuation aids (chairs, ski sheets, ski pads etc.);
 plans are created and regularly tested for serious and imminent danger in so far as it
relates to the evacuation of premises and the continued safety of building occupants
following an evacuation;
 regular fire drills are undertaken as required, with full accurate records to be
maintained;
 in compliance with the Fire Safety Order, relevant guidance and related EC / EU
Directives, HCA will conduct its activities in such a way as to ensure that people who
may not be employees, but who may be affected by those activities, are not exposed
to risk to their health and safety in relation to fire, e.g. the general public,
contractors, employees of contractors, patients and temporary workers.
HCA is committed to provide effective resources to implement this policy.
All employees, consultants and contractors have a personal responsibility to safeguard
themselves and others. Their actions, either by instruction, example or behaviour; should
not put other people, plant or property in jeopardy. They must co-operate with the
employer in regard to the Fire Safety Policy.
4 ROLES AND RESPONSIBILITIES
HCA has also identified specific responsibilities to be discharged at various levels throughout
the organisation’s management structure as detailed below:
a) The President and Chief Executive Officer (CEO) –
The CEO is responsible for ensuring that current fire legislation is met and that, where
appropriate, Firecode guidance is implemented in all premises owned or occupied by HCA.
Chief Executives are required to have appropriate fire safety policies and programmes of
work in place, in order to improve and maintain fire precautions within the organisation’s
premises.
b) Facility Chief Executive Officer
At each hospital or facility, the relevant CEO has overall responsibility for fire safety within
the premises under his or her control. They will also be responsible for appointing the
hospital or facility fire officer, the fire team, fire controllers and fire marshals, and for the
availability of an up to date local fire policy and fire procedure which will be drawn to the
attention of all staff, consultants and relevant contractors.
c) Hospital or Facility Fire Safety Officer
The appointed Fire Safety Officer will act at all times as the fire safety champion within the
meaning set out for Fire Safety Manager within Department of Health, Firecode HTM 05-01
Managing Healthcare Fire Safety in buildings where this is applicable, and will be responsible
for ensuring the effectiveness of fire safety standards and policy for all HCA premises under
their control. They will also be responsible for the maintenance of fire precautions
throughout the premises under their control.
In particular their responsibilities include: arranging for a fire risk assessment to be
completed by a competent person and keeping this up to date; ensuring the maintenance of
the fire detection and alarm systems, emergency lighting and firefighting apparatus is
undertaken; arranging fire evacuation drills; ensuring that up to date fire policies, plans and
procedures are available; ensuring that fire action notices are correctly completed and
posted; maintaining directional fire signs; commenting on fire safety performance; carrying
out weekly fire alarm tests and (where appropriate) weekly sprinkler system tests and
ensuring that staff training is undertaken and regularly refreshed.
The Hospital or Facility Fire Safety officer is also responsible for maintaining and facilitating
the relationship with the local Fire brigade including arranging and facilitating familiarisation
visits with local watch commanders where required or requested and any inspections
requested by the Fire Safety Authority.
d) Vice President, Capital and Facilities
The Vice President, Capital and Facilities has been assigned responsibility in the Company
Health and Safety Policy statement for ensuring that there is a coordinated programme of
fire risk assessments undertaken by a suitably competent person, that standards of
maintenance and testing of fire safety related systems and equipment under the control of
Estates Managers are monitored, and that adequate account is taken of the need to
incorporate fire safety provisions into both new capital projects and refurbishment works.
e) Hospital Facilities and Estates Manager
The Hospital or Facilities Estates Manager is responsible for the establishment and
maintenance, within the facilities for which they have responsibility, of fire compartments
and sub-compartments including fire resisting door sets, fire walls and floors, service risers
fire dampers in air handling ducts, and other openings in fire walls and floors. They are also
responsible for controlling work by maintenance contractors working with sources of
ignition and or adversely impacting on the fire alarm system in accordance with the HCA
Permit to Work System.
f) Department Managers
All Departmental Managers have direct duties and responsibilities in respect of fire and fire
safety. They must:
 Ensure that a high standard of fire safety, including good housekeeping, is maintained
throughout their department, including the means of escape routes from it, at all times.
 Be directly responsible for ensuring that fire safety instructions are brought to the
attention of and observed by their own staff and relevant others such as consultants and
contractors, and to ensure that every member of their own staff participates in fire
precautions training. Ensure that effective training is undertaken for all staff without
exception as this is of vital importance. All staff must have basic fire instruction in fire
precautions at least once every twelve months and, if necessary, training appropriate to
their own particular category and specific need.
 Managers must ensure that all staff are aware of how to access a copy of the Corporate
Fire Safety Policy, (located with training material in the Learning & Development folder
on Grapevine).
 Ensuring that there are the correct number of fire marshals trained within the
department and that they appropriately allocated on to shifts.
g) Employees, visitors, consultants, temporary and bank staff
All individuals must co-operate with HCA to ensure the workplace is safe from fire and its
effects and must not do anything that will place themselves or other people at risk.
Everyone has a duty of care under the Regulatory Reform (Fire Safety) Order 2005 and the
Health and Safety at Work Act 1974 to take reasonable care for the safety of themselves or
others who may be affected by their acts and omissions at work and to cooperate with HCA
in achieving the objectives of this policy.
• It is the duty of every employee to report to management any instances where
proper procedures are not being fully implemented, e.g. fire doors wedged open;
escape routes blocked by furniture or accumulation of rubbish, hazardous
combustible or flammable materials adjacent to escape routes, faulty electrical
equipment and gas appliances etc.
• All new staff must receive instructions on fire precautions and procedures during
departmental orientation and as part of the corporate and facility induction
training. It is the duty of the Head of Department to ensure that new staff attend
the first fire lecture available.
• All staff are required to attend a corporate induction programme on joining the
business which includes an element of fire safety.
h) Learning Academy Manager
The Learning Academy Manager is responsible for ensuring that training is undertaken and
suitably recorded for:
 all staff in general fire safety awareness;
 fire marshals which will include practical hands-on training in the use of portable fire
extinguishers where appropriate; and
 fire controllers.
 They will ensure that training records are updated and available to Facility Fire Officers
on a regular basis.
HCA recognise that e-learning is not acceptable as the sole means of training staff. The
Learning Academy Manager will ensure that, in line with the requirements of HTM 05-03
Part A, e-learning can only be used to support training delivered by a competent fire safety
adviser.
It is HCA policy that in any circumstance (such as the unavailability of competent trainers)
staff should not receive refresher training via e-learning more than once in a two-year
period with the other years training taking the form of face-to-face learning.
i) Fire Controllers
Fire Controllers are responsible for managing a fire event including evacuation where
required. The role of the Fire Controller will relate to the risk profile of the building and be
set down in the facility or building SOP.
The Fire controller will be responsible for liaising with the Fire service and also for the
escalation in line with the Facility or building Business Continuity card.
In a shared premises where HCA is not the primary tenant the Fire Controller duties may be
carried out by the landlord or a third party. In this case the fire marshals will communicate
directly with the third party. This must be part of the local SOP.
j) Fire Marshalls
Fire Marshalls are members of staff who are assigned specific responsibilities in relation to
Fire Safety. The responsibilities of the Fire Marshall may vary from facility to facility
depending on the risk. The duties will generally include:
 Ensuring that fire routes remain clear of combustible materials and fire exits are not
blocked.
 Monitoring flammable and combustible materials within their department to ensure
that they are managed appropriately.
 Ensuring that Fire extinguishers are in date for servicing and haven’t been tampered
with.
 Being aware of and understanding their responsibilities under the local emergency
action card.
 Ensuring that fire doors within the area close correctly and report any faults to the
Estates department.
 Marshalling evacuation during fire alarms and ensuring all staff, patients, visitors
contractors leave as appropriate.
 Communicate with the Fire controller as appropriate.
 Any other local responsibilities as set down in the local Fire SOP.
k) Health, Safety and Risk Committee
The Health, Safety and Risk Committee will meet quarterly to monitor and review all fire
safety issues escalated through the facility Health and Safety Committee.
The Health & Safety and Risk Board is the sub-committee with responsibility for providing
the Quality and Safety Board with oversight of assuring that HCA Healthcare discharges its
health and safety, risk management, business continuity (including emergency planning,
resilience and response (EPRR)) responsibilities chaired by HCA’s UK’s Divisional Vice
President of Quality. This includes ensuring the continued safe and effective delivery and
management of healthcare across HCA with the object of promoting the well-being and
safety of the safety of its patients, employees, third parties and others who may be affected
by its activities.
The membership of the committee is made up of the following:
• Division Vice President of Quality (Chair)
• Group Head of Quality & Risk (Deputy Chair)
• Group Head of Health & Safety and Business Continuity
• Nursing/Clinical Services representation
• Head of Imaging Services (Radiation Protection)
• Quality Review Systems Manager
• Ethics and Compliance Officer (Speak up Guardian)
• Vice President of Capital and Estates
• Legal Services representation
• Head of HR Operations
• Head of Security
• Supply Chain Operations Officer
• Chief Information Officer/IT representation
• Governance Administrator (note taker)
Other Directors, managers and staff may be invited to attend, particularly when the Board is
considering areas that are within their responsibility.
j) Premises with more than one Employer
Where shared premises exist, such as, for example, where HCA lease certain floors within a
building, each employer is legally responsible for managing fire safety in their respective
area.
Formal arrangements must be made to co-operate and co-ordinate on fire safety matters.
This is effected by the sharing of information regarding potential risks, emergency
procedures, shared escape routes staff training etc. in order to ensure that fire safety
measures are not compromised.
Where shared common areas exist, such as escape routes, the person with ultimate control
of the building will have the responsibility for managing fire safety. This is commonly the
Managing Agents, Landlord or building owners. This does not remove the requirement for
individual risk assessments to be undertaken by each respective tenant.
k) Sanctions
Failure to comply with the information within this fire safety policy may be regarded as a
potential disciplinary offence.

5 POLICY REQUIRMENTS
a) Fire Statutory Standards Surveys – Fire Risk Assessments
The Vice President, Capital and Facilities has been assigned responsibility in the Company
Health and Safety Policy statement for ensuring that there is a coordinated programme of
fire risk assessments, that are undertaken by a suitably competent person.
They will ensure that there is a current Fire Risk Assessment in every building or facility
which takes account of all the specific hazards and risks relating to the premises and the
operational issues of the building.
Currently HCA fire risk assessments are undertaken by a specialist external company, The
Fire Protection Association (FPA).
The Hospital and Facilities Estate Managers are responsible for ensuring that the Fire Risk
Assessment and all its records are readily available at all times, both for recording and
inspection purposes.
It is recommended that further reviews and re-assessments take place at periodic intervals
commensurate with Company Policy as described below, the prevailing risk on site and in
line with the guidance within the Regulatory Reform (Fire Safety) Order and HTM 05-02.
Where no material alterations to the buildings occur, there are no changes to the number of
or types of building users, and no changes to the processes or activities undertaken within
the buildings then a formal internal review of the fire risk assessment should take place
within 12 months and the assessment revisited by a competent external assessor within 24
months. Such reviews / reassessments should be recorded.
See Annex B for the annual internal fire risk assessment review form.
b) Fire Procedures, Procedures for Serious and Imminent Danger
HCA recognises its duty to provide appropriate procedures to be followed in the event of
serious and imminent danger from fire to relevant persons including staff, consultants,
patients, visitors, contractors and others that may be impacted by a fire. A sufficient number
of competent persons will be provided to implement these procedures.
The procedures will be supported by appropriate training and instruction including safety
drills as per articles 16 and 18–21 of the Regulatory Reform (Fire Safety) Order 2005.
The Order defines a place of safety as – “in relation to premises, means a safe area beyond
the premises.” However, it is recognised that where further movement is possible from an
area which offers temporary protection from the fire to a place where relevant persons will
no longer be affected by the fire at all, that area may be regarded as a place of reasonable
safety (the area away from the premises where relevant persons are no longer at risk being
regarded as places of total safety). This is effected through a progressive horizontal
evacuation strategy where possible within the healthcare premises.
HCA will establish adequate site specific emergency plans which will ensure that provisions
for the welfare of patients, staff and potentially visitors following an evacuation are
established and documented for each HCA building in line with the requirements of the
guidance NHS England EPRR – Planning for the shelter and evacuation of people in
healthcare settings. Such a plan (which may include diagrams or drawings) may also include
requirements to inform persons of the nature of the hazards and of the steps to be taken to
protect them, to stop work immediately and proceed to a place of safety in certain areas,
and to prevent the resumption of work where serious danger still exists.
Often, due to the nature and location of the premises, this will involve relocation to a
nearby HCA property, however it may include some reliance on the National Health Service
for additional support.
In healthcare buildings a two stage automatic fire detection and alarm system is in
operation and will support the progressive horizontal evacuation strategy for the building. In
smaller facilities such as outpatients and office use buildings a single stage full simultaneous
evacuation policy is usually in place.
See annex C for Evacuation Procedures documents
c) Operational Fire Risk Assessment
Each department manager will, in conjunction with the Hospital or Facility Fire Safety
Officer, ensure that there is a current Fire Risk Assessment which takes account of all the
risks relating to the premises and the operational issues within their department.
They will ensure that The Operational Plan / Fire Risk Assessment and all its records will be
readily available at all times, both for recording and inspection purposes.
A regular review will be carried out to ensure that all fire precautions are maintained
effectively within each department.
d) Fire Equipment Maintenance
The Hospital and Facilities Estates Manager is responsible for ensuring that all fire
equipment maintenance is undertaken in accordance with relevant British Standards and
manufacturers’ guidelines.
They are responsible for ensuring that HCA pre-approved competent contractors are used
for inspection, servicing and equipment maintenance with trained in-house staff as
appropriate for more routine inspections.
See Annex D for a breakdown of the relevant fire equipment maintenance
recommendations in line with various British Standards and Codes of Practice’s.
e) Fire / Unwanted Fire Signals and Other Reporting
The Hospital and Facilities Estates Managers are responsible for ensuring that all fire related
incidents and near-misses are accurately recorded in the company electronic incident
reporting system.
Relevant actions must be taken in order to minimise any false alarms or unwanted fire
signals in line with the recommendations contained within both BS 5839 Part 1 and HTM 05-
03 Part B.
Each employee, worker, healthcare consultant and contractor has a responsibility to report
any relevant information that could assist in improving the standards of fire safety within
HCA buildings, including for example:
• defects in fire safety equipment such as damaged fire doors or missing fire
extinguishers
• electrical faults or overloading of electrical sockets
• evidence of bad practice such as poor housekeeping
• obstructed means of escape routes
• any dangerous working practices
f) Purchase of furniture, furnishings and textiles
HCA policy is that all items of furniture and other textiles used throughout all premises are
only to be purchased in accordance with the guidance set out in both BS 7176 and HTM 05-
03 Operational Provisions Part C Textiles and Furnishings.
Any damaged or non-compliant items will be removed from site and replaced as
appropriate.
Certain spaces may contain items of furniture brought onto the premises by members of
staff or consultants (such as armchairs and sofas). It will be ensured that in all such
circumstances the safety of the item is confirmed, where appropriate removed from the
premises.
All personal items of furniture brought onto a premises will be checked for compliance with
relevant standards and provisions.
g) Means of Escape
Means of escape in HCA buildings must remain clear and unobstructed at all times. They
must not be used for short, medium or long term storage.
Regular inspections will be undertaken with records maintained describing any remedial
actions taken for issues found including the retraining of staff or contractors as appropriate.
Lifts must not be used when a fire alarm is activated or in the event of a fire situation unless
they are designated firefighting lifts or protected for use for evacuation purposes.
Personal Emergency Evacuation Plans (PEEPs) should be completed for staff and visitors
who require assistance during an evacuation; these plans should be completed at the
earliest opportunity in consultation with the Hospital or Facility Fire Safety Officer and / or
company Health and Safety Advisor.
For general evacuation needs, such as those undergoing theatre operations and those
within wards who require assistance as a result of procedures, a Generic Emergency
Evacuation Plan (GEEP) should be in place and will likely form part of the building
progressive horizontal evacuation plans.
See Annex E for a Personal Emergency Evacuation Plan template.

6 IMPLEMENTATION PROCESS
The policy is approved by the Corporate Health and Safety Committee and will be
implemented through the facility Health and Safety Committees

7 MONITORING ARRANGEMENTS
It is HCA policy that this fire policy be reviewed by the internal Group Head of Health,
Safety and Business Continuity and the Health Safety and Risk Committee on an annual
basis to ensure the contents are current and relevant to the organisation. The policy will
have a full formal review every 3 years.
The review date shall be recorded and any relevant amendments or changes tracked on
the document.
8 TRAINING
a) Training requirements associated with this Policy
HCA recognise their responsibilities with regards to staff fire safety training as detailed
within the Regulatory Reform (Fire Safety) Order, HTM 05-01 and HTM 05-03.
All training records are maintained on an online portal ‘Learning Academy’ which provides
monthly reports to Department Heads and provides prompts when refresher training is
required.
Mandatory Training
• All staff are required to attend a corporate induction programme on joining the
business which includes an element of fire safety training. On joining the individual facilities,
a further face to face local induction will be delivered by the Learning Academy Manager
which covers in more detail the local fire safety arrangements relevant to the building they
will be working in.
• Once placed in a Department additional location specific fire safety information will
be provided by the Head of Department.
• Regular contractors and healthcare consultants are required to undertake site
specific training relevant to their roles and the local fire evacuation policy.
• All staff are required to complete annual refresher ‘Fire awareness’ training which is
conducted via a rotating process of online and face-to-face delivery.
• There are fire wardens appointed for each facility with training being provided. This
is refreshed annually and includes e-learning regarding the use of portable fire
extinguishers.
• Training in the use of any evacuation aids within the facilities is provided by internal
staff who have completed appropriate ‘train the trainers’ courses.
Specific Training not covered by Mandatory Training
• Competent persons, quality controllers and Designated Medical Officers (DNO) are
appointed in relation to the use of medical gases (the DNO is not named but will be the Duty
Manager). All nominated persons will receive suitable instruction and training. The
Authorised Persons for the systems are the Estates Managers and Chief Engineers.
• Ad-hoc and refresher training sessions based on an individual’s training needs as
defined within their annual appraisal or job description, for example porters and
pharmacists etc.
• Some sites have cryogenic tank facilities for the provision of oxygen. It should be
noted that these are provided by external organisations who undertake the maintenance,
servicing and refilling of these tanks which fall outside of the control of HCA.
Fire Drills
• The local fire safety policy indicates that fire drills should be undertaken at least
annually with post exercise records being retained in the fire log book.
• Given the nature of the premises, it must be ensured that drills are scheduled with
sufficient frequency and timing so that all staff, including those on site overnight, get an
opportunity to practice the evacuation routines.

9 REFERENCES
HCA UK H&S Policies
• Corporate Education, Training and Development Policy HCAUK.HR.LD.POL.1002
• Corporate Safety Signs and Signals Policy HCAUK.HS.HS.POL.1010
• Corporate Control of Contractors + Permit to Work Policy HCAUK.HS.HS.POL.1006
• Corporate Risk Recording and Assessment Policy HCAUK.GOV.RM.POL.1015
• Corporate Health, Safety and Wellbeing Policy HCAUK.HS.HS.POL.1023
• Corporate Incident and Serious Incident (SI) Management Policy
In addition to the corporate policies listed above, Empires and individual facilities also have
dedicated and bespoke policies relating to their premises and activities as required.
British Standards
BS 5266:
• Part 1:
• Part 8: Emergency lighting
Code of practice for the emergency lighting of premises Emergency escape lighting systems
BS 5306:
• Part 3:
• Part 8: Fire extinguishing installations and equipment on premises Commissioning
and maintenance of portable fire extinguishers. Selection and positioning of portable fire
extinguishers.
BS 5839:
• Part 1: Fire detection and alarm systems for buildings
Code of practice for system design, installation, commissioning and maintenance
BS 7671: Requirements for electrical installations. IET Wiring Regulations
BS 8214: Timber-based fire door assemblies – Code of Practice
BS 9999: Code of practice for fire safety in the design, management and use of
buildings
BS EN 1125: Building hardware. Panic exit devices operated by a horizontal bar, for us on
escape routes. Requirements and test methods.
BS EN 12845: Fixed firefighting systems. Automatic sprinkler systems. Design, installation
and maintenance
BS ISO 3864:
• Part 1:
• Part 3: Graphical symbols. Safety colours and safety signs Design principles for safety
signs and safety markings
Design principles for graphical symbols for use in safety signs
BSEN ISO 7010: Graphical symbols. Safety colours and safety signs. Registered safety
signs
BS EN 15004:
Part 1: Fixed firefighting systems. Gas extinguishing systems Design, installation and
maintenance
BS 7273
Part 4: Code of practice for the operation of fire protection measures.
Actuation of release mechanisms for doors
BS7176 Specification for resistance to ignition of upholstered furniture for nondomestic seating by testing composites
Other References
• Regulatory Reform (Fire Safety) Order 2005
• Equality Act 2010
• Disability Discrimination Act (2005)
• Health and Safety at Work Act .1974
• Fire Safety Approved Document B – Volume 2
• Management of Health and Safety at Work Regulations 1999
• HM Government Fire Safety Risk Assessment Guide for Healthcare Premises
• HM Government Fire Safety Risk Assessment Guide for Offices and Shops
• HTM 05-01 Managing Healthcare Fire Safety
• HTM 05-02 Guidance to support functional provisions for health premises
• HTM 05-03 Operational provisions
 Part A – General Fire Safety
 Part B – Fire detection and alarm systems
 Part C – Textiles and furnishings
 Part D – Commercial enterprises on healthcare premises
 Part E – Escape Lifts in healthcare buildings
 Part F – Arson prevention in the NHS
 Part G – Laboratories
 Part H – Reducing false alarms in healthcare premises
 Part J – Guidance on fire engineering of healthcare premises
 Part K – Guidance on fire risk assessment in complex healthcare premises
 Part L – NHS Fire statistics
 Part M – Guidance on fire safety of atria in healthcare building

– End Document –

There are no significant material changes to the following:
 Use of the premises, or extensions or conversions or organisational changes;
 The nature of the clinical services, facilities, number of patients, substances and
equipment provided;
 Measures in relation to the means of fighting fires;
 Measures in relation to the means of escape and;
 Measures supporting the means of escape.
APPENDIX(S)
10 APPENDIX 1 – ANNUAL REVIEW OF THE EXISTING FIRE RISK ASSESSMENT (VALID FOR ONE YEAR
ONLY)
Note – The HCA Fire Policy is that fire risk assessment reviews should take place within 12months of the
original assessment. The assessment can be reviewed once internally with the assessment revisited by a
competent external assessor within 24 months or if there areany material changes to the building, the
types of building users or the activities undertakenwithin it.
1. Name and address of Hospital and /or Facility to which the existing Fire Risk
Assessment applies:
2. Date of existing Fire Risk Assessment:
3. Date of this review:
4. Declaration of reviewer (not valid unless signed)a)
The likelihood of fire starting is unchanged and;
 The premises, and facilities, equipment and devices provided for the purposes of
fire safety are maintained in an efficient state, in working order and in good repair;
 The fire alarm servicing is carried out at least six monthly and all weekly tests are
carried out;
 The action table from the existing Fire Risk Assessment has been updated or a
plan developed for compliance.
c) I declare that the above is an accurate statement and that the Fire Risk Assessment
remains valid for one further year only from its original issue
Name (In Capitals):
Job Title:
Professional Qualifications:
Signed:
Date:
11 APPENDIX 2 – EVACUATION PROCEDURES PART 1 – HOSPITAL FACILITIES
On discovering a fire
 You should alert people in the immediate vicinity and raise the building alarm by
operating the nearest manual call point which are sited on every story exit, final
exitand within 45 metres of any point in the building.
 You should close the door in order to contain the fire to the room of origin.
 Ensure that the local procedures for alerting the fire and rescue service are
beingfollowed.
HCA Hospitals are fitted with two stage alarm systems
 The first stage (intermittent alarm) indicates that an alarm has been activated in
another part of the Hospital but not in the area where you can hear the
intermittentalarm.
 The second stage (continuous alarm) indicates that there is a fire in the area
wherethe alarm is sounding or that the whole hospital is required to evacuate
either to outside or to a separate compartment depending on the area you are in.
On Hearing an intermittent alarm
 Account for your patients and ensure that all visitors are made aware of the situation.
 Fire marshals will assist in directing all visitors, staff that are not needed to assist
withpatient evacuation and ambulant outpatients, to leave via the nearest available
exit and proceed to the fire assembly point.
 If patients are not in immediate danger, they should await instructions from the
firecontroller.
 All nursing staff will report to their nursing stations, if safe to do so, to prepare for
theevacuation of patients as required.
 Reception staff will contact the fire and rescue service via the 999 system in
additionto the actions of the Alarm Receiving Centre (ARC).
 The Senior Nurse on each floor will collect the patient and nurse duty list for a roll
callto be implemented at the assembly point.
 If you are not in your department when the intermittent alarm sounds, report to
thefire marshal of the department and if you are not needed to assist in patient
evacuation or you are not in a patient department leave and proceed to the fire
assembly point.
On Hearing a Continuous Fire Alarm
 Without putting themselves at risk, fire marshals and other trained staff will assist
in ensuring that anyone in immediate danger from the fire is evacuated to the
nearestsafe area.
 Patients who can be safely moved without putting them at risk should be relocated
to the next fire compartment and preferably beyond two sets of fire doors away
from thefire.
 Any ambulant patients should be evacuated first – take them to the nearest fire
exit.Do not stop to collect personal belongings or luggage.
 If possible, and you can do so without risk, move any portable gas cylinders to the
next compartment as soon as the patients have been evacuated.
 For patients who would be put at risk by being moved and for all patients in
Operating Theatres and ITU, which are not in immediate danger from fire,
awaitinstructions from the Fire Controller.
 In the operating theatres and recovery, the anaesthetist will, if the patients are
required to be evacuated, make a decision to switch from hospital gas to cylinder
gassupply.
 Do not use lifts unless you have received specific instructions to do so.
 Where safe to do so ensure that all windows and doors are closed.
 Do not take personal risks.
 The fire marshal in each department will assume responsibility.
 All staff must be familiar with:
a. The location of the nearest fire exit routes and final exits.
b. The location of the fire assembly point(s).
c. The location of portable fire extinguishers (you should only use fire
extinguishers if you have been trained to do so and you know which type
of extinguisher to use on which type of fire).
d. The location of all manual call points and how to operate them.
e. How to use any specialist evacuation equipment if relevant to your job role.
 When the fire alarm sounds, the duty telephonist will call the fire brigade.
State address of hospital and ask for confirmation.
 Relevant staff should switch off all gas appliances via the emergency shut off
switches in the areas they work in.
 When all patients have been evacuated, the senior person must isolate all
medical gases on the floor.
 Staff who are not needed for a patient evacuation must leave and proceed to the
fire assembly point.
 Without putting themselves at any risk, other staff should standby and
await instructions from the fire marshal or fire controller.
 The reception staff must take the following action:
 Prevent all people from entering the building (i.e. patients and relatives).
 Where relevant ensure that lifts are secure at ground level unless
otherwiseinstructed by the fire controller or where there is a special local
procedure.
Progressive Horizontal Evacuation
The procedure for patient evacuation from departments containing high or very high
dependency patients should be that where evacuation is necessary it will initially be
undertaken as progressive horizontal evacuation whereby non ambulant patients are movedto
separate fire compartments with at least one hour’s fire separation from the area of the fire.
If necessary, further horizontal evacuation will subsequently be made to the next fire
Compartment on the same floor level until such point that the only option is to continue the
evacuation vertically.
Non ambulant and unconscious patients should be moved in accordance with local procedures
using wheelchairs or beds for horizontal evacuation, or fire evacuation chairs, ski pads or ski
sheets, for vertical evacuation. Beds should only be used for horizontal evacuation where it is
possible to do so without preventing the evacuation of all patients.
Vertical evacuation, using the provided evacuation aids will be undertaken where it is necessary
to safeguard patients on a particular floor or where a total evacuation of the Hospital is ordered
by the Fire Brigade or the Fire Controller. It is Hospital Policy that ski sheets are fitted to all
Hospital beds.
Instructions to Fire Controller and Fire Team
During normal working hours the Fire Controller will be a trained member of staff usually a
nominated Head of Department or Senior Manager.
At night/weekends, the use of on-duty staff is required to assist in emergency situations.
Fire Team: Out of Hours:
1. Engineering Personnel 1. Duty Administrative Person/Deputy
2. Portering Personnel 2. Portering Personnel
3. Resident Medical
Officer On hearing the fire alarm, the following procedures should be
followed:
1. The Fire Controller and Fire Team will then don the fire jacket/arm bands.
Note location (zone) of fire on the fire panel.
2. A note should be made of the time of alarm, location of the device activated
and any other relevant information.
3. The Fire Controller will collect the two-way radios from reception, check
its operation and allocate one to the Fire Team Leader.
4. The fire plans should be collected from reception.
5. At least two members of the fire team should, without putting themselves at
any risk, attend the area in which the alarm has been raised in order to confirm
the cause of the alarm activation. They should communicate the information
via thetwo-way radio system to the Fire Team Leader.
6. All visitors and staff should be prevented from entering the building whilst
thealarm is sounding. At the same time the fire team should ensure that all
accesses are clear for the arrival of the Fire and Rescue Service.
7. Keep those in charge of the Operating Theatres, Intensive Care Unit, and any
other high dependency units informed of the situation and any spread of
smokeor fire.
8. The Fire and Rescue Service should be met on arrival at the Hospital and
briefed on the situation.
9. Only when informed by the Fire Team Leader of all clear, may the Fire Controller
authorise the alarm to be silenced.
10. Only on the directions of the Fire Controller or Fire or Rescue Service may the
stand down order be given.
11. The Fire Panel can only be reset by a trained member of the Fire Team on the
direction of the Fire and Rescue Service.
Once the situation has been resolved it must be ensured that the correct fire incident report
form is completed and signed by the Fire Controller. The report should be forwarded to
theChief Engineer/Health and Safety Officer.
Any interaction with the media must be undertaken by the Chief Executive Officer or their
representative. No other employees should communicate with the media regarding the
situation.

12 APPENDIX 3 – EVACUATION PROCEDURES PART 2 – OTHER FACILITIES
For the majority of other HCA facilities such as outpatient and staff only office buildings, the fire
detection and alarm system is configured to facilitate a single stage evacuation strategy.The
alarm will sound at the same time in all areas of the building and everybody should
immediately evacuate upon hearing the fire alarm.
On discovering a fire
 You should alert people in the immediate vicinity and raise the building alarm by
operating the nearest manual call point which are sited on every story exit, final
exitand within 45 metres of any point in the building.
 You should close the door in order to contain the fire to the room of origin.
 Ensure that the local procedures for alerting the fire and rescue service are
beingfollowed.
On Hearing a Continuous Fire Alarm
 Without putting themselves at risk, fire marshals and other trained staff will assist
inensuring that building occupants are evacuated to the nearest safe area.
 Any ambulant patients should be evacuated first – take them to the nearest fire
exit.Do not stop to collect personal belongings or luggage.
 If possible, and you can do so without risk, move any portable gas cylinders to the
next compartment.
 Do not use lifts unless you have received specific instructions to do so.
 Where safe to do so ensure that all windows and doors are closed.
 Do not take personal risks.
 The fire marshal in each department will assume responsibility.
 All staff must be familiar with:
a. The location of the nearest fire exit routes and final exits.
b. The location of the fire assembly point(s).
c. The location of portable fire extinguishers (you should only use fire
extinguishers if you have been trained to do so and you know which type of
extinguisher to use on which type of fire).
d. The location of all manual call points and how to operate them.
e. How to use any specialist evacuation equipment if relevant to your job role.
 When the fire alarm sounds, the duty telephonist will call the fire brigade.
State address of hospital and ask for confirmation.
 Relevant staff should switch off all gas appliances via the emergency shut off
switches in the areas they work in.
 The reception staff must take the following action:
 Prevent all people from entering the building (i.e. patients and relatives).
 Where relevant ensure that lifts are secure at ground level unless
otherwise instructed by the fire controller or where there is a special local
procedure.
Instructions to Fire Controller and Fire Team
The Fire Controller will be a trained member of staff usually a nominated Head of
Department or Senior Manager.
On hearing the fire alarm, the following procedures should be followed:
1. The Fire Controller and Fire Marshals will then don the fire jacket/arm bands.
2. A note should be made of the time of alarm, location of the device activated
and any other relevant information. The fire plans should be collected from
reception.
3. All visitors and staff should be prevented from entering the building whilst
the alarm is sounding. At the same time the fire team should ensure that all
accesses are clear for the arrival of the Fire and Rescue Service.
4. The Fire and Rescue Service should be met on arrival at the facility and briefed
on the situation.
5. Only when informed by the Fire Team Leader of all clear, may the Fire Controller
authorise the alarm to be silenced.
6. Only on the directions of the Fire Controller or Fire or Rescue Service may the
stand down order be given.
7. The Fire Panel can only be reset by a trained member of the Fire Team on the
direction of the Fire and Rescue Service.
Once the situation has been resolved it must be ensured that the correct fire incident report
form is completed and signed by the Fire Controller. The report completed on datix.
Any interaction with the media must be undertaken by the Chief Executive Officer or their
representative. No other employees should communicate with the media regarding the
situation.

13 APPENDIX 4 – FIRE EQUIPMENT MAINTENANCE
The following table indicates the minimum standards for testing and maintenance of fire
safety related equipment throughout HCA properties.
The Hospital and Facilities Estates Manager are responsible for ensure that all fire equipment
maintenance is undertaken in accordance with relevant British Standards and manufacturers’
guidelines.
Equipment In house inspections External maintenance regimes
External metal
staircases
Weekly visual inspections 5 yearly inspection by a structural
engineer in accordance with BS 9999.

Kitchen
suppression
systems
N/A. Annual maintenance by a competent
third party certified contractor.
Local suppression
systems such as those
within server rooms
N/A Annual maintenance by a competent
third party certified contractor.
Emergency lighting Monthly
“flick”
tests to
confirm
operation.
Annual full duration drain down by a
competent third-party certified
contractor in accordance with BS 5266.
Kitchen Extraction
Deep Cleaning
N/A Defined by the size and usage of the
range. At least annually and to be
undertaken by a contractor registered to
the LPS 2084/BESCA VHE scheme.
Fixed Electrical Testing N/A At least 5 yearly but could be less
depending on the age and condition of
the system by a competent electrician
in accordance with BS 7671.
Note – for larger buildings it is not
uncommon for an annual inspection to
complete 20% of the system at a time to
ensure 100% over the five years period.
Portable Appliance Testing N/A Company policy is dependent on the risk
associated with the equipment requiring
testing.
Gas Safe Testing N/A At least annually by a competent
engineer in accordance with the Gas
Safety (Installation and Use)
(Amendment) Regulations 1996.
Lightning Protection System N/A At least once every eleven months by a
competent contractor in accordance
with BSEN 62305.
Medical Gas system N/A Quarterly inspection by a competent
third party certified contractor.

14 APPENDIX 5 – PERSONAL EMERGENCY EVACUATION PLAN (PEEP) TEMPLATE
PERSONAL EMERGENCY EVACUATION PLAN (PEEP)
Questionnaire is to be completed if a person is identified as not being able to evacuate the
building without assistance in an emergency. This questionnaire is to be completed by the
Line Manager (or appointed competent person) in consultation with the individual. If
evacuation assistance is required, a PEEP will be developed to specify what type of
assistance is needed and how it will be provided.
Individual’s name
Department (if employee)
Type of person (staff, contractor, visitor, patient)
Person visiting (if not employee)
Company name (if not HCA)
Hospital/Facility name and address
HCA HEALTHCARE UK POLICY
CORPORATE FIRE POLICY
If printed this policy document is uncontrolled. Please access the Policy Library for the most current version.
Page 31 of 47
1. Where are you normally located? (include the floor of the building and room number)
2.Are you regularly located in other areas of this building or other buildings? (if yes give
details)
3. How are you provided with information on the evacuation procedure? (e.g. written
information, signage, training, demonstration, verbal)
4. Do you need any further assistance? (e.g. sign language, Braille, large print, language
interpretation, verbal instruction, further training, physical demonstration)
5. Could you be alone or isolated while in the building?
6. Can you clearly see the signs which mark emergency routes and exits?
7. Can you clearly hear the fire alarm?
8. Could you raise the alarm if you discovered a fire?
9. Could you move quickly and unaided in the event of an emergency? please describe any
limitations.
10.Are you regularly located in other areas of this building or other buildings? (if yes
give details)
11. How are you provided with information on the evacuation procedure? (e.g.
written information, signage, training, demonstration, verbal)
12. Do you need any further assistance? (e.g. sign language, Braille, large print,
language interpretation, verbal instruction, further training, physical demonstration)
13. Could you be alone or isolated while in the building?
14. Can you clearly see the signs which mark emergency routes and exits?
15. Can you clearly hear the fire alarm?
HCA HEALTHCARE UK POLICY
CORPORATE FIRE POLICY
If printed this policy document is uncontrolled. Please access the Policy Library for the most current version.
Page 33 of 47
16. Could you raise the alarm if you discovered a fire?
17. Could you move quickly and unaided in the event of an emergency? please describe
any mtaotns.
18.Would you have difficulty walking to the assembly area or safe zone, or using stairs?
please describe limitations.
19.Do you use a wheelchair or walking aid? please give details
20.In an emergency, could you contact the person(s) in charge of evacuating the building(s)
and tell them where you were located?
21.What assistance needs to be provided in order for you to be able to evacuate?
Please detail below the plan for how this individual will be evacuated in an emergency
situation.
Include details on:
 the type of evacuation (progressive horizontal for example),
 list the location of any required evacuation aids and identify staff who are trained to
use them,
 give the names and details of any buddies who may be required,
 detail any equipment other than evacuation aids that may be required, for example
vibrating pillows or pagers,
 explain how the person will be alerted to the fire alarm
Name of person completing this form
Signature
Date
Name of individual requiring this PEEP
Signature
Date
Name of person authorising this PEEP
(Senior Manager or HR)
Signature
Date
15 APPENDIX 6 – FIRE DRILL RECORD
Hospital:
Department:
Floor:
Date: Time:
Observer:
Signature:
Job Title:
Checklist
Fire Alarm:
(please tick as appropriate)
Did the Alarm Sound: Intermittent Continuous Not Active
Or did the Beacon: Activate Not Activate
Yes No N/A Comments (where appropriate)
Fire Doors:
(please tick as appropriate)
Were any doors on automatic hold-open devices?
If yes, did they close when the alarm activated?
Were fire doors closed other than those held openby
automatic devices?
Organisation and Communication:
Did a senior member of the management team
take charge as the area controller?
Was contact established with the Incident
Controller?
If it was, how was it established?
(e.g. phone call to reception/ staff member went to
reception/ fire team member arrived/ phone call
made from reception)
Fire team members arrived once phone call from
Switchboard was received
Were patients given suitable reassurance?
Fire Team:
Did the team assemble in a timely manner at thefire
panel?
Was the Incident Controller identified with a
fluorescent jacket?
Was the source of the alarm identified correctly?
Was the stand down instruction given?
Did FOH staff direct people away from the
building?
Yes No N/A Comments (where appropriate)
Evacuation:
Did non clinical staff leave the building in a timely
manner on the sounding of the alarm?
Were more than one fire exit used without
problem?
Did fire marshals tour all their areas?
Did fire marshals report to the Incident Controller?
Was there enough staff available to move non
ambulant patients to a safe area on the same
floor?
Was there enough staff to move non ambulant
patients up or down the stairs?
Time Exercise Commenced:
Time Evacuation Complete:
Time of Stand Down:
Areas Identified for Improvement Action Status
1.
2.
3.
4.
5.

16 APPENDIX 7 – GENERAL FIRE PRECAUTIONS
All Heads of Department and Fire Marshals have a responsibility for monitoring the generalfire
precautions within their areas of the building. This includes the following:
 Ensuring that the use of highly flammable materials or liquids is avoided whenever
practicable. Any essential products must be suitably stored in flame resisting cabinets
which should be maintained locked.
 Every effort should be made to ensure that no personal rechargeable electronic
equipment is used unless it displays the CE mark of conformity and is in good condition
with no evidence of damage. This includes those brought into the building by patients
as well as staff, consultants and contractors.
 The charging of any electrical equipment must take place in a safe controlled
environment and consideration should be given to provision of dedicated charging
locations. No charging should be undertaken within protected internal escape
routessuch as corridors or staircases.
 Heads of department should ensure that all staff are aware of the importance
ofremaining vigilant to evidence of poor electrical safety practices, such as:
 Electrical charger/battery/device over heating
 Damage to any electrical leads
 Damage to any plugs
 Signs of overheating to plugs, cables or chargers
 Overloading of electrical extensions
 Daisy chaining of electrical extensions
 The use of uncoiled extension reels
 The use of inappropriate cube adapters
 Chargers should be unplugged whenever batteries have been fully charged
 Portable electrical devices must not be used in oxygen rich environments
 Non-essential electrical appliances should be switched off with their
plugsremoved, wherever possible, when not in use
 Ensure good standards of housekeeping are observed at all times, particularly
withregards to the following:
 Ensure equipment, deliveries and packages are stored in designated areas only
and not in escape corridors, staircases, plant rooms, voids, risers etc.
 Ensure that regular inspections are undertaken in order to ensure that
corridorsand escape routes are clear of storage and obstructions and that final
exits areclear and accessible
 Other general fire precautions
 Ensure that the smoking policy is strictly adhered to at all times and that
anyexternal smoking areas are regularly inspected and are suitable for use
 Monitor security provision and external housekeeping practices to minimise
therisk of arson to as low as reasonably practicable
 Ensure cleaning regimes are followed, especially in areas such as kitchens and
internal laundry rooms containing tumble dryers
 Ensure that no plug in air fresheners are used within the buildings
 Ensure that no items of fire safety equipment are obstructed
 Ensure that no fire doors are unsuitably wedged open

17 APPENDIX 8 – ARRANGEMENTS FOR THE STORAGE AND USE OF MEDICAL OXYGEN
CYLINDERS
Medical gas cylinders are used on a daily basis in HCA hospitals and some other facilitiessuch
as outpatient’s buildings, the most common of which is oxygen.
Oxygen behaves differently to air, compressed air, nitrogen and other inert gases. At high
pressure, such as from a cylinder, pure oxygen can react violently with some common
materials, particularly oils and greases. Other materials may catch fire spontaneously.
Nearly all materials, including textiles, rubber and even metals can burn vigorously in an
oxygen enriched environment.
A leak from an oxygen cylinder, for example from the valve or a damaged hose can quickly
increase the oxygen concentration, particularly if inside a poorly ventilated room, or
confinedspace.
Even a relatively minor increase in the oxygen level in the atmosphere can be hazardous. The
chances of a fire starting are increased and the intensity in which it will then burn can be
greater. Fires in oxygen enriched atmospheres are also very difficult to extinguish.
An oxygen enriched situation is one where the oxygen level is greater than in air. As oxygenis
colourless, odourless and tasteless the presence of an oxygen enriched atmosphere cannot
be easily detected without specialist equipment.
The main causes of oxygen enriched atmospheres are: –
 Leaks as a result of damaged or faulty hoses, pipes and valves
 Leaks from poor connections
 Valves being left open either deliberately or accidentally
 Inadequate ventilation where oxygen is being used
It should be ensured that safety control measures are followed at all times to minimise the
risk posed by the use of medical oxygen cylinders.
 Oxygen cylinders should be regularly inspected for damage or potential leaks,
particularattention should be paid to the hoses and valves.
 Only materials compatible with the use of oxygen should be used in the
immediate vicinity of the cylinders
 The use of oxygen in areas that are not suitably ventilated should be avoided. Cylinders
should not be used in confined spaces.
 Staff should be routinely monitored and observed to ensure that any incorrect or
careless operation of oxygen equipment is identified and rectified by updated training
orwhere necessary by following HCA disciplinary processes
 Cylinders should always be stored and transported in the upright position and
sitedaway from any sources of heat and flammable materials
 When not in use the cylinders should be stored in a secure, well ventilated area
andseparated from cylinders of flammable gas
 Suitable warning signage should be in place on the outer faces of all doors containing
oxygen cylinders or other medical gases
 If a cylinder should leak, it must be taken outside immediately and the Estates
Department informed. If this type of incident occurs on a hospital site, Porters will
assist
 Ensure new members of staff are aware of the location of oxygen cylinders and
thesafety procedures to follow
 All users of oxygen should receive training in the use of oxygen equipment.
When using oxygen cylinders, the following precautions should be observed:
 Where possible a purpose built trolley should be used to move cylinders
 Cylinders should be chained or clamped where possible in order to prevent them
fromfalling over
 All oxygen equipment should be maintained clean in order to prevent
potential contamination by particulate matter such as dust or general
atmospheric debris
 All personnel should use clean hands or ideally gloves when assembling oxygen
equipment e.g. attaching the pressure regulator or making connections
 Suitable clean clothing should be worn which are free from oil and easily
combustiblecontaminants

18 APPENDIX 9 – KITCHEN GAS SUPPLIES
In addition to the provision of electrical supplies, some HCA properties use natural gas for central
heating systems and within their catering kitchens. If these systems are not regularlyserviced and
correctly maintained the risk of a fire due to electrical faults or the ignition of natural gas if
increased to an unacceptable level.
Annex D gives some information as to the frequency of routine inspections and maintenanceof
these systems, and Annex H covers some of the day-to-day safety precautions to follow.
This Annex is intended to cover the routines for ensuring catering gas risks are minimised toas low
as reasonably practicable.
Manually ignited gas-fire catering equipment
HCA should ensure that all relevant staff and contractors are given suitable and sufficient levels of
training and instruction on the safe systems of work with regards to catering equipment. This
training should be provided immediately upon induction and be refreshed atregular intervals.
Flame failure devices should be fitted, where reasonably practicable, to older pieces ofequipment
that do not have such components installed to them.
All catering appliances should be regularly serviced and maintained in accordance with the
manufacturer’s instructions.
Ventilation and extraction
In addition to the large quantities of heat, catering and cooking activities can also lead to the
production of significant quantities of fumes and vapours. Inadequate ventilation or flueing
arrangements can also result in the accumulation of combustion products, such as carbon
monoxide.
The term ‘make-up’ air, relates to the provision of an adequate supply of air via a ventilation
system, or by using a flueing system.
Kitchen ventilation is a requirement in order to assist in creating a safe working environment.It will
assist in the removal of heat, fumes and vapours from the immediate area and in discharging them
to a safe external location.
The cleaning of the extraction system is a key requirement to ensure the systems can operate
safely. This should be undertaken on a risk assessed schedule depending on theuse of the cooking
range. Any contractors used for cleaning should be accredited to LPS 2084/BESCA VHE scheme and
must provide a full report showing a schematic of the ventilation system and before and after
cleaning photographs.
Safety during emptying and cleaning of fryers
Whenever staff or contractors are undertaking the emptying and cleaning of fryers they areat risk
of burns from hot oil, contact with hot surfaces and inhaling the fumes from cleaningchemicals.
Any manual emptying and/or filtering of fryers should only be undertaken after the oil has been
allowed to cool to a temperature below 40 degrees Celsius.
The following safety precautions must be adhered to:
 All staff and contractors should be suitably trained in the safe procedures
foremptying and cleaning fryers.
 Suitable personal protective equipment (PPE), where required by the risk
assessment, should be provided. This could include eye protection and heatresistant gloves and aprons.
 The fryer and cooking range must be serviced and maintained in line with
industrybest practice and the recommendations of the manufacturer.
 Provision must be made to ensure that any oil spillages can be safely and effectively
cleaned immediately.
 Fat fryers must not be left unattended when in use. They should be switched
offwhen unattended.
 It is recommended that manual oil filtering and cleaning is undertaken at the start
ofeach day rather than as part of the closing-down procedure.
Procedure in the event of a fire or fire alarm activation
 It should be ensured that all gas supplies are shut off. If the shut off is not interfaced
with the fire detection and alarm system, then the emergency shut off buttons
should be used or the mains valves should be switched off.
 All cooking appliances should be turned off and any hot pans removed to a safe
location if safe to do so.
 Staff should follow the site specific fire evacuation policy. If the kitchen is joined to
the restaurant, then staff should direct users of the restaurant area to the nearest
exit whilst not putting themselves at any increased risk.

19 APPENDIX 10– FIRE DETECTION REQUIREMENTS
HTM 05-03 Part B: Fire detection and alarm systems gives guidance on the fire detection and alarm systems in
Healthcare Premises. Although written for the National Health Service(NHS) it is relevant to the HCA Hospital
buildings.
For another facilities guidance on the fire detection and alarm system is contained in BS5839 Part 1.
 Addressable fire alarm systems are preferred to conventional systems as they allow
the device that has activated to be identified. This is vital to a progressive horizontal
evacuation strategy.
 Analogue detectors should be used to assist in minimising unwanted fire signals
(false alarm activations).
 A category L1 system should be provided throughout all parts of hospital premises.
Detectors are not normally required (subject to fire risk assessment) in the
following:
 Voids and roof spaces which contain only MICC or wiring clipped to a metal
tray or within metal conduit or trunking, non-combustible pipework and
ductsor metal or plastic pipes used for water supply or drainage
 Bath or shower rooms
 Toilets in staff areas
 Small cupboards less than 1 square metre
 Operating theatres
 For healthcare premises other than hospitals such as outpatient’s buildings a
category L2 or L3 could be acceptable dependant on the findings of the fire risk
assessment.
 Where possible each sub-compartment in buildings where progressive
horizontal evacuation is utilised should be a separate zone on the fire detection
and alarm system.
 A two-stage alarm is recommended where there are patient areas in hospitals.
 Ancillary services interfaced with the fire detection and alarm system should
operate as designed to. These include:
 Automatic door releases
 Access control systems
 Ventilation and damper control systems
 Fuel supplies
 Lifts
 Fixed extinguishing systems
 Smoke control systems
 Stairway pressurisation systems
 Site signalling system
 Shutters

20 APPENDIX 11 – PLAN DRAWING RECOMMENDATIONS
An as built drawing of each building should be provided in
accordance with HTM 05-02Appendix G. It should show the
location of:
 Escape routes
 Lines of compartmentation and sub-compartmentation
 Fire resisting doorsets, self-closing doors and doors equipped
with relevant hardware(e.g. panic locks)
 Location of fire alarm devices such as smoke detector
heads, manual call points,sounders etc.
 Fire safety signage
 Emergency lighting
 Portable fire extinguishers
 Dry or wet risers
 Sprinkler system components such as isolating valves etc.
 Smoke control and ventilation systems including the
modes of operation, inlet air routes etc.
 High risk areas, such as plant etc.
 Specifications of any fire safety equipment provided
 Assumptions in the design of the fire safety
arrangements regarding the management of the
building
Fire drawings, using symbols based on BS 1635 should also be provided and should
show:
 A location plan
 A site plan
 A floor plan of each storey, prepared at a scale of not less than 1:200
 A floor plan of each department, prepared at a scale of
not less than 1:100 and preferably at scale of 1:50
 A set of elevations