WLFS38 - Fire Procedures for The Orchard

WLFS38 - Fire Procedures for The Orchard

WLFS38 - Fire Procedures for The Orchard

West London Mental Health NHS Trust _ _ Page 1 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.3018 WLFS38 Fire Procedures for The Orchard Version: 10 RED ALERT PROCEDURE Approved by: Security Steering Group Date approved: 18th April 2018 Title of Author: Senior Nurses, Ward managers, Fire Officer, Head of Administration & Patient Services Responsible ED: Director of High Secure & Forensic Services Responsible Senior Manager Dawn Harwood Governance Committee Security Steering Group Date of Procedure 30th March 2018 Date issued: 29th June 2018 Review date: April 2019 Target audience: All staff and service users based in The Orchard Disclosure Status B: Can be disclosed to patients and the public

West London Mental Health NHS Trust _ _ Page 2 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 Version Control Sheet Version Date Title of Author Status Comment 2 4.1.2012 Senior Nurse Manager Approved Review in 1 year 3 29.8.2013 Senior Nurse & Managers Approved Review in 1 year 4 21.2.2014 Clinical Services Manager & senior managers Approved Review in 1 year 5 31.03.2014 Clinical Services Manager & Senior Managers Approved Review in 1 year 6 7.05.2014 Clinical Services Manager & Senior Managers Approved Review in 1 year 7 09.04.2015 Senior Nurse & Ward Managers Approved Review in 1 year 8 1.4.2016 Senior Nurse & Ward Managers Approved at SSG on 15.6.2016 Review in 1 year 9 27.4.2017 Senior Nurse, Ward Managers & Fire Officer Approved Review in 1 year 10 30.3.2018 Senior Nurse, Ward Managers & Fire Officer Approved Review in 1 year

West London Mental Health NHS Trust _ _ Page 3 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 The Orchard Unit - Fire Procedures INDEX Item Page 1 Introduction 4 2 The Orchard Unit 4 3 Action On Discovering a Fire 7 4 Action on Hearing the Fire Alarm 7 Appendix 1 Duties of the Fire Marshall and Deputies 11 Appendix 2 Role of Reception 12 Appendix 3 Duties of Heads of Departments/ Managers 13 Appendix 4 General responsibilities – All staff 14 Appendix 5 Escape Routes explanations 16 Appendix 6 Flash Cards (Summary) 18 Appendix 7 Evacuation Procedure (First Knock) 35 Appendix 8 Evacuation Procedure (Double Knock) 36 Appendix 9 Fire Alarm Action Card for The Orchard Unit 37

West London Mental Health NHS Trust _ _ Page 4 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 1 INTRODUCTION A Fire can have catastrophic consequences causing death and injury, widespread damage to buildings and disruption of services. It is of vital importance that all possible measures are taken to prevent a fire. It is essential that if a fire does occur that it’s effect is minimised by early detection, effective containment, rapid and correct response by staff. To achieve this all staff, including agency/temporary, contractors and visitors must take ownership of this procedure to ensure a safe environment for all.

This Procedure has been prepared as a requirement of fire safety legislation and to meet the requirements of the Trust F1 Fire Safety Policy & Strategy Document. This procedure document is for use as a local reference document for West London Mental Health Trust staff working in the Orchard Unit.

This procedure is a supporting document to the main West London Mental Health Trust F1 FIRE SAFETY POLICY& STRATEGY DOCUMENT that should be read in conjunction with this document. The WLMHT Policy can be accessed through the Trust Exchange on all WLMHT networked computers. The roles and responsibilities of managers and staff have been set out below. This Procedure applies to all Trust employees, contractors and temporary workers who are engaged to work in the Orchard Unit. 2 THE ORCHARD UNIT The Orchard Unit is a stand-alone 2 storey building situated within the grounds of St Bernard’s Hospital, Ealing for the West London Mental Health NHS Trust.

The Orchard Unit is a medium secure 60 bed unit.

The unit comprises the following services: Ground floor: Wards  Pearl 2 (flats) : 5 beds  Pearl 1 : 10 beds  Damson : 5 beds Other areas  Main reception area  Visitors area  Office accommodation  Estates department plant rooms

West London Mental Health NHS Trust _ _ Page 5 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018  Tribunal suite  Primary Healthcare  Central atrium incorporating shops, bank, library, gym, hairdressers, boutique, café, ADL kitchen and green room.  Patients central store  Therapy areas  Main kitchen First floor: Wards  10 bedded - Aurora  10 bedded - Melrose  10 bedded – Parkland  10 bedded – Garnet All wards have their own dedicated outdoor space in addition to the central communal secure garden.

Number of Staircases 4 staircases service the building. North (staircase 1), South (staircase 3), East (staircase 2) and West (staircase 4) points. 2 staircases have lobbies and are suitable for use as fire escape facilities South (3) leads to communal garden East (2) leads to communal garden Lifts There are 2 lifts which are located at the North (Lift 1) and South (Lift 2) ends of the building North comes down into a non-patient area and the South lift comes down outside Pearl 1’s main entry door. LIFTS ARE NOT TO BE USED DURING EVACUATION PROCEDURES. Overview of Fire Alarm System 1. The system is a ‘Double Knock’ system 2.

This incorporates a ‘Time Delay’ for investigation purposes between initial activation(first knock) and the full alarm (second knock), to avoid ‘False Alarm call outs’ 3. The system will automatically alert the Contact Centre who will immediately alert the Fire Service whenever a fire is confirmed.

4. Fire Alarm Call Points (that activate a Double Knock) in patient areas are key operated 5. All fire alarm panels are networked panels.

West London Mental Health NHS Trust _ _ Page 6 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 6. All detector heads are the same multi-sensor type, but can be set to either smoke or heat. 7. Smoke detectors are fitted within all areas of the building with heat detector being fitted to high risk areas such as kitchen, plant/boiler rooms etc. 8. A PEEPs (Personal Evacuation Emergency Plan) must be completed for any visitor who has mobility problems or other physical issues and may require assistance in the event of a fire alarm being activated.

The Reception service will ask visitors if they have any mobility / other issues which will require this form to be completed. 9. A PEEP must also be completed for any service user, member of staff or visitor who has mobility problems / other physical issues or may require assistance in the event of a fire alarm being activated.

10. A PEEP must be completed for every episode of seclusion. (See Flashcard 13) Location of Fire Alarm Call points There are fire alarm call points throughout the building most of which are key operated to avoid malicious activation. Break-glass call points have been installed on Pearl 2. All Orchard key sets have fire alarm keys attached. These must be attached to the person at all times. Activation of a call point will activate a full alert. Location of Fire Exits There are 11 fire exits which lead into outdoor spaces ONLY 8 lead into secure garden spaces.

( 2 lead directly outside the secure perimeter and 1 leads into an area with a non secure garden).

These will be highlighted to new staff members as part of the building induction. Location of fire alarm panels There is a main fire alarm panel in the reception area of the building. A fire alarm panel is located within each compartment and will indicate the room/ area of any fire alarm activation. Location of Fire Extinguishers Fire extinguishers are housed either in ‘Staff Access Only’ areas, such as riser duct cupboards and clinical rooms and can be accessed using the Orchard key set.

West London Mental Health NHS Trust _ _ Page 7 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 Only staff who have been suitably trained should attempt to extinguish a fire with an extinguisher. Unit Coordinators and Fire Marshall’s The Orchard building is supervised by a designated Unit coordinator every shift who is also trained as a Fire Marshall. It is the unit coordinators responsibility to manage the fire alarm system and any fire related incidents that may occur.

In the event of the reception area becoming inaccessible due to fire or smoke, the THW Unit Coordinator will be instructed by the Orchard Unit Coordinator to collect the Orchard perimeter keys from the THW reception and wait for the Fire Brigade at the entrance to The Orchard 3 ACTION ON DISCOVERING A FIRE 1) Raise the fire alarm immediately you discover or suspect a fire, by activating the nearest fire alarm call point.

This will put the system into full alert) The signal will automatically go through to the St Bernards Contact Centre.

2) Evacuate the department / area immediately, escorting patients, staff and visitors to a safe area, using the most appropriate route as detailed in APPENDIX 5/6 3) The Fire Marshall may attempt to extinguish the fire if it is considered safe to do so, and they have received adequate training on the use of fire extinguishing equipment. 4) Any persons who have impaired hearing or vision or who are not in possession of an Orchard key set will have an allocated staff member to look after them in the event of a fire or any other emergency.

5) Do not put yourself at any unnecessary risk.

6) Where there is any doubt or uncertainty about whether a fire is real (e.g. because room access is restricted) staff are to assume that the fire is real and proceed accordingly. 4 ACTION ON HEARING THE FIRE ALARM A) Action at ‘First Knock’ on a patient area – (Low level alert sound in area of activation – pre alert ‘buzz’ at all other panels) 1) On activation of a fire alarm the Orchard building reception staff will announce area of activation on the on site two way radio system.

West London Mental Health NHS Trust _ _ Page 8 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 2) Check the department fire alarm panel for location of activation 3) A person designated by the nurse in charge/ should investigate the relevant room/area 4) If it is confirmed there is no fire, the alarm can be silenced and reset to avoid a call being made to the Fire Brigade. The unit coordinator must then attend the immediately and reset the alarm using the reset key held on the unit coordinators key set..

5) Resetting the alarm (If No Fire) can only be carried out by the Unit Coordinator 6) If it is confirmed that there is a fire, activate any call point which will send the system into full alert and request the attendance of the Fire Brigade via the Contact Centre (ext 3333) (OPERATION OF ANY TWO DEVICES WILL ESCALATE THE ACTIVATION INTO DOUBLE KNOCK) B) Action at ‘First knock’ on a non Patient area.

1) On the activation of a fire alarm on a non-patient area the Orchard building reception staff will announce area of activation on the on site two way radio system. 2) All unit response nurses and the designated Unit Coordinator/Fire Marshall will immediately attend the area of activation and investigate the relevant area. During working hours of the Atrium the staff supporting vocational or therapeutic sessions will investigate the fire as they will potentially be first on the scene and they will confirm whether there is a fire or not.

3) If it is confirmed there is no fire, the alarm can be silenced and reset to avoid a call being made to the Fire Brigade. 4) Resetting the alarm (If No Fire) can only be carried out by the Unit Coordinator. 5) If it is confirmed that there is a fire, activate any call point which will send the system into full alert and request the attendance of the Fire Brigade via the Contact Centre (ext 3333) (OPERATION OF ANY TWO DEVICES WILL ESCALATE THE ACTIVATION INTO DOUBLE KNOCK) C Action at ‘Double Knock’ – Full Alert. 1) On the activation of a fire alarm the Orchard building reception staff will announce area of activation on the on site two way radio system.

West London Mental Health NHS Trust _ _ Page 9 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 2) Confirm the room/area of activation by checking the Fire Alarm panel. 3) The person in charge must inform the Manager/nurse in charge, weekdays 9-5, and the Unit Coordinator, by means of the two way radio of the following: THE INTENSITY OF THE FIRE ANY INJURIES OF ANY KIND ARE ALL PERSONS ACCOUNTED FOR OR NOT ANY PEOPLE WHO HAVE SPECIAL NEEDS (PEEP’s) ANY OTHER RELEVANT INFORMATION NB – All non-essential radio traffic must be kept to a minimum during the sounding of the fire alarms and/or discovery of a fire.

4) Upon activation of the fire alarm or discovery of a fire, the nurse in charge of the immediate area and/or security nurse will take possession of:  The patient nominal role  The staff duty rota  Two way radio  Patient leave book  Personal Emergency evacuation Plans (PEEPS)  Prescription Charts 5) All response nurses/ will be dispatched to the location of the fire alarm to assist with removal of patients from the area. 6) Attempt to remove any patients who may be in the affected room/area if safe to do so 7) Evacuate all patients to the designated location – referred to in individual Flash Cards.

8) If the whole building has to be evacuated, all patients will be moved to the Main Assembly point; MAIN ASSEMBLY POINT: Communal Garden (External) 9) The designated Fire Marshall/Unit coordinator will take a roll call of all staff patients and visitors on the area affected by the fire, who will inform the Fire Brigade on their arrival.

West London Mental Health NHS Trust _ _ Page 10 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 10) Members of staff should make it known immediately, if any person is missing to a Fire Marshall.

11) The Unit Coordinator is to make them self easily identifiable by wearing the ‘Hi Vis’ vest and MUST meet the Fire Brigade on their arrival and inform them of the current situation and of any person(s) not accounted for or any areas of concern. 12) It is forbidden to re-enter the building until it is declared safe to do so by the Fire Brigade.

West London Mental Health NHS Trust _ _ Page 11 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 Orchard Unit Local Fire Procedure APPENDIX 1 – DUTIES OF THE FIRE MARSHALLS The Unit Coordinator Rota should ensure that a Fire Marshall is always available to assume the duties specified below during any fire alarm activations In the event of an emergency the designated fire marshall/unit coordinator should be able to take command until the Fire Brigade arrives and to act as a focus for liaison purposes thereafter.

The fire marshals should remain on the clinical area to prepare for evacuation and would only leave their area if instructed to do so by the Unit Coordinator.

In a Fire Alarm activation, their duties are: 1) To respond to the fire alarm activation within the 3 minutes. 2) To respond to a ‘First Knock’ alarm. 3) To effect an immediate evacuation of patients and Staff, via the most appropriate route, upon hearing a ‘Second Knock’ alarm. 4) To be responsible for the co-ordination and direction of staff actions at a fire evacuation, in accordance with the relevant Local Fire Safety Procedure. General Fire Safety Management Duties 1) To supervise the effective day-to-day upkeep of the relevant Fire Action Plan and Local Fire Safety Procedure established for the premises.

2) To participate in the implementation of Fire Drills in their nominated area. 3) To support the Service Manager/Head of Department in the management of fire safety matters. 4) To liaise with the Trust Fire Safety Advisors, in relation to all fire matters and ensure such matters are acted upon as appropriate. 5) To assist the Fire Safety Advisors in fire safety inspections and risk assessments in the area for which they are responsible. 6) To ensure all fire safety equipment is inspected and tested on a regular basis, that local records are kept and to report any defects to the Estates Department.

7) Any other associated duties as detailed in the Trust F1 Fire Safety Policy & Strategy Document 8) To make sure all staff are kept up to date with training on both Trust and local fire policies/procedures

West London Mental Health NHS Trust _ _ Page 12 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 Orchard Unit Local Fire Procedure APPENDIX 2 – RECEPTIONIST DUTIES One of the main responsibilities of the receptionist on duty is to ensure that all visitors and staff inside the building can be accounted for at all times. This involves ensuring that all visitors have signed in and out and key audits are up to date. Additionally any visitors with physical healthcare support requirements need a Personal Emergency Evacuation Plan (PEEP) 1) The receptionist will remain at post (if safe to do so) until he/she receives instructions from the Unit Coordinator or a member of the fire brigade to evacuate the building.

2) On hearing the fire alarm, the receptionist will announce the location of fire activation over the 2 way radio and take account of all personnel and clients within the building 3) All other personnel working within the reception area will evacuate the building on the sounding of the alarm. 4) No attempts should be made to re-enter the building for whatever reason until you are advised by the Unit coordinator or an officer of the fire brigade. 5) The front of the building remains the main designated fire assembly point for staff and visitors.

6) During alarm activation all visitors, delivery drivers and staff must be advised not to enter the building, other than personnel who will be dealing with the fire.

e.g., Fire Officer Hospital Security Fire Brigade Estates Officer Senior Nurse/Senior Nurse on Call Response nurses from other parts of the West London Forensic Service. NOTE: - Do not use the lifts during a fire or fire alarm situation

West London Mental Health NHS Trust _ _ Page 13 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 The Orchard Unit Local Fire Procedure APPENDIX 3 – DUTIES OF HEADS OF DEPARTMENT/ MANAGERS Heads of Departments have the following responsibilities in addition to those described within the Trust F1 Fire Safety Policy & Strategy Document  Co-ordination and recording of staff fire training appropriate to their duties  Ensure that fire safety incidents are reported by the designated persons as per the incident reporting procedure  Ensure fire drills are undertaken as required  Consult with staff and appointed safety representatives on fire safety matters  Ensure that local fire safety instructions and action plans are in place and the contents brought to the attention of staff, and are observed by staff  Attend Fire Drills  Monitor fire safety precautions within the workplace and initiate actions to correct any shortfalls  Notify the Estates Department of any proposed change of use of the areas within their control.

 Ensure that fire risk assessments are undertaken for all areas of their responsibility. The outcomes of the risk assessments will be communicated to all staff and safety representatives.

West London Mental Health NHS Trust _ _ Page 14 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 Orchard Unit Local Fire Procedure APPENDIX 4 – GENERAL RESPONSIBILITIES – ALL STAFF  All staff have a duty to be familiar with the requirements for fire prevention, fire precautions, fire fighting and evacuation procedures as detailed in the Local Fire Policies and Fire Safety Plans.

 They are required to attend a fire lecture at least once a year and participate in fire drills that are held locally.

 Ward staff are required to attend bariatric chair and mat training at least once a year.  Every member of staff has a duty to report to their Manager or the Workplace Fire Marshal or Deputies any instances where proper procedures are not being implemented.  All members of staff are responsible to ensure that fire escape routes, fire exits and fire fighting equipment are maintained free from obstruction and that clear access and egress is maintained at all times.  All fire alarm activations points in areas accessed by patients are key operated. It is therefore essential that all staff carry fire alarm activation keys at all times.

 All staff should familiarize themselves with the location of all fire alarm points and fire fighting equipment in their areas of responsibility, and their place of work. They must also know where the tabards are kept.

All fire fighting equipment in patient access areas is housed within secure boxes and all staff must carry keys to these boxes at all times.  All defects are to be reported to the manager immediately  All non- ward based staff must inform the reception if they are working out of hours.  All staff are to be made aware of the following points FIRE CHECKS / EQUIPMENT  All Unit staff must familiarize themselves with the location of all fire alarm points, fire fighting equipment and methods of opening all electronic fire exits. Keys to be carried at all times.  All fire alarms are tested on a regular basis.

 Check that all Unit personnel have access to all fire fighting equipment at all times.

 All electronically operated fire exits must be tested routinely.  Smoking in prohibited areas must be actively discouraged especially in

West London Mental Health NHS Trust _ _ Page 15 of 31 Fire Procedures – The Orchard. First issued January 2011 This is current version 10. 30.3.2018 bedrooms.  Fire exits must be kept clear at all times.  Fire doors to be kept closed at all times.  Two-way radios must be checked on a shift by shift basis for function. Tabards must be kept in an accessible place.

West London Mental Health NHS Trust _ _ Page 16 of 31 Fire Procedures – The Orchard.

First issued January 2011 This is current version 10. 30.3.2018 The Orchard Unit Local Fire Procedure APPENDIX 5 – ESCAPE ROUTES N.B. THE CHOICE OF EVACUATION ROUTE MUST BE BASED ON THE LOCATION OF THE FIRE AND THE SAFETY OF ALL RELEVENT PERSONS Evacuation Routes from central atrium 1) East side fire: tribunal suite 2) West side fire: therapy spaces (music, pottery or group therapy) 3) Exit at the far end of the atrium into the communal secure garden 4) Visitors should be escorted out of the building through the main entrance or via corridor past Damson through to non secure garden Evacuation Routes from Primary Healthcare Evacuate through Primary Healthcare corridor into central Atrium.

Evacuation Routes from visit suite or Tribunal suite Staff must ensure that all visitors are accounted for before vacating the area. A record should be held within the visit area by staff of names and numbers of all visitors.

VISITORS should be evacuated to a separate assembly point to patients ideally through the main reception to outside of the secure perimeter. Only if it is not safe to leave via the main reception fire exit should visitors be escorted to the nearest safe area. PATIENTS within the visits area should be evacuated to the atrium if it is safe to do so Evacuation Routes from administration offices Evacuate through either the main entrance or the alternative exit through staircase 2(East staircase entrance) Evacuation Routes from main reception waiting area and office spaces Evacuate through the main entrance or the alternative exit through the atrium.

Evacuation routes for ward areas Each ward has a minimum of 3 evacuation routes. The primary route is always the preferred option. (Other routes can be used where it is impractical to relocate to the primary location)

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