WLFS38 - Fire Procedures for The Orchard

WLFS38 - Fire Procedures for The Orchard
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




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Fire Procedures – The Orchard. First issued January 2011           This is current version 10. 30.3.3018
Version Control Sheet



 Version         Date            Title of Author                Status                  Comment
 2           4.1.2012        Senior Nurse                 Approved                Review in 1 year
                             Manager
 3           29.8.2013       Senior Nurse &               Approved                Review in 1 year
                             Managers
 4           21.2.2014       Clinical Services            Approved                Review in 1 year
                             Manager & senior
                             managers
 5           31.03.2014 Clinical Services                 Approved                Review in 1 year
                        Manager & Senior
                        Managers
 6           7.05.2014       Clinical Services            Approved                Review in 1 year
                             Manager & Senior
                             Managers
 7           09.04.2015 Senior Nurse & Ward               Approved                Review in 1 year
                        Managers
 8           1.4.2016        Senior Nurse & Ward          Approved at SSG         Review in 1 year
                             Managers                     on 15.6.2016
 9           27.4.2017       Senior Nurse, Ward           Approved                Review in 1 year
                             Managers & Fire
                             Officer
 10          30.3.2018       Senior Nurse, Ward           Approved                Review in 1 year
                             Managers & Fire
                             Officer




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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




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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
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   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.
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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.

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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.

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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.
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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.



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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.




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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

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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

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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.




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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
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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.




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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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Pearl 2 - Ground floor

    1. From the safe suite corridor, pass through corridor onto (Pearl 1) , or
    2. From the main entrance, pass along the corridor and into the central atrium, or
    3. Through fire exit to the secure garden.


Pearl 1 – Ground floor

    1. From the safe suite corridor, pass through corridor onto Pearl 2 , or
    2. From the main entrance, pass along the corridor and into the central atrium, or
    3. Through fire exit to the secure garden.

Damson Ward – Ground floor

    1. From main entrance pass through central atrium and into Pearl 1 or
    2. From main entrance into central atrium then into Pearl 2, or
    3. From lounge area through fire exit into secure garden

Aurora Ward – first floor

    1. Into Garnet through connecting corridor, or
    2. Into the adjacent Parkland, or
    3. Into the Courtyard area for Aurora then into Garnet.

Melrose Ward – first floor

    1. Into Parkland through connecting corridor, or
    2. Into the adjacent Garnet Ward or
    3. Into the Courtyard and then into Parkland Ward.

Garnet Ward – first floor

    1. Into Aurora Ward through connecting corridor, or
    2 Into the adjacent Melrose Ward, or
    3. Into the Courtyard and then into Aurora Ward

Parkland Ward – first floor

    1. Into Melrose Ward through the connecting corridor, or
    2. Into the adjacent Aurora Ward, or
    3. Into the Courtyard and then into Melrose Ward

Entire building evacuation

The final assembly point for the Orchard Unit in situations where the entire building needs
to be evacuated is the Secure Garden (External). East and West staircases can be used to
evacuate from 1st floor to ground floor.

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The Orchard Unit Local Fire Procedure
        APPENDIX 6 – FLASH CARDS



                        Item                                                            Page

                1.      List of Fire Evacuation “Flash Cards”                   18

                2.      Flash card 1 - Central Atrium                           19

                3.      Flash Card 2 - Visit Suite                              20

                4.      Flash Card 3 - Administration Offices                   21

                5.      Flash Card 4 - Main Reception waiting Area             22

                6.      Flash Card 5 - Pearl 2                                  23

                7.      Flash Card 6 - Pearl 1                                  24

                8.      Flash Card 7 - Damson                                   25

                9.      Flash Card 8 - Aurora                                   26

                10.     Flash Card 9 - Garnet                                   27

                11.     Flash Card 10 - Parkland                                28

                12.     Flash Card 11 - Melrose                                 29

                13.     Flash Card 12 - The Entire Building                     30

                14.     Flash Card 13 - PEEP                                    31
                        (Personal Emergency Evacuation Plans)




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Flash Card 1


                          FIRE EVACUATION PLAN

                                 CENTRAL ATRIUM

       EVACUATION – The Central Atrium



       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the centre of the atrium (if
       safe to do so). The person in charge will liaise with the Unit Co-ordinator via
       the two-way radio to give information about the fire (if it is in the Atrium) or
       receive instructions regarding the evacuation.



       Once the decision to evacuate has been made, the person in charge will
       ensure

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS ARE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.


       Depending on the location of the fire, the evacuation route will be
       1. Either Tribunal suite for fire on the west side of the Atrium or therapy
           Space for fire on the east side of the Atrium (music, pottery or group
           therapy 1).

       2.    Using the exit at the far end of the Atrium into the communal secure
             garden.




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Flash Card 2


                          FIRE EVACUATION PLAN

                                         VISIT SUITE

       EVACUATION – Visit Suite



       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       Staff must ensure that all visitors are accounted for before vacating the area.
       A record should be held within the reception area of the names and number
       of all visitors within the building


       Visitors should be evacuated to a separate assembly point to patients.



       Once the decision to evacuate has been made, the person in charge will
       ensure


       ALL DOORS ARE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.


       Depending on the location of the fire, the evacuation route will be to

       1) The Atrium if safe to do so




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Flash Card 3


                          FIRE EVACUATION PLAN

                        ADMINISTRATION OFFICES

       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the 2 way radio.

       .




       It is the responsibility of each member of staff to know the location of all fire
       exits from their work environment and make a decision as to where they will
       be safe in the event of a fire evacuation.




       ALL DOORS MUST BE CLOSED EN-ROUTE



       DO NOT USE THE LIFT DURING ALARM ACTIVATION.




       Evacuation from this area can be either the main entrance or alternative exit
       through staircase 2 (East Entrance)




West London Mental Health NHS Trust__________________________________________________Page 21 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 4


                          FIRE EVACUATION PLAN

      MAIN RECEPTION WAITING AREA & OFFICE
                    SPACES

       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the 2 way radio.

       .


       It is the responsibility of each member of staff to know the location of all fire
       exits from their work environment and make a decision as to where they will
       be safe in the event of a fire evacuation.




       ALL DOORS MUST BE CLOSED EN-ROUTE



       DO NOTUSE THE LIFT DURING ALARM ACTIVATION.




       Evacuation from this area can be either the main entrance or alternative exit
       through the Atrium.




West London Mental Health NHS Trust__________________________________________________Page 22 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 5


                            FIRE EVACUATION PLAN

                            PEARL 2 (FLATS) WARD

       EVACUATION – Pearl 2 Ward



       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Pearl 2) or receive
       instructions regarding the evacuation.



       Once the decision to evacuate has been made, the nurse in charge will take:

                       a)    The service users’ nominal role
                       b)    The staff duty rota
                       c)    The two-way radio
                       d)    Prescription chart
                       e)    The Leave folder / observation charts

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire the evacuation will be

       From the safe suite corridor, pass through corridor onto Pearl 1 Ward, or

        the main entrance, pass along the corridor and into the central Atrium and
       into Pearl 1 Ward, or

       Through the Fire Exit to secure garden.

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.
West London Mental Health NHS Trust__________________________________________________Page 23 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 6


                          FIRE EVACUATION PLAN

                                   (PEARL 1 WARD)

       EVACUATION – (Pearl 1 Ward)


       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users and staff will assemble in the open dining area (if safe to do
       so). The nurse in charge will liaise with the Unit Coordinator via the two-way
       radio to give information about the fire (if it is on Pearl 1) or receive
       instructions regarding the evacuation.

       Once the decision to evacuate has been made, the nurse in charge will take:

                       a) The service users’ nominal role
                       b) The staff duty rota
                       c) The two-way radio
                       d) Prescription chart
                       e) The Leave folder / observation charts

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire

       From the safe suite corridor, pass through corridor onto Pearl 2 Ward

       From the main entrance, pass along the corridor and into the central Atrium,
       and into Pearl 2 Ward, or

       Through Fire Exit to secure garden.

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.



West London Mental Health NHS Trust__________________________________________________Page 24 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 7


                          FIRE EVACUATION PLAN

                                    DAMSON WARD
       EVACUATION – Damson Ward


       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Damson) or receive
       instructions regarding the evacuation.

       Once the decision to evacuate has been made, the nurse in charge must
       gather or allocate responsibility to collect the following

                             a)   The service users’ nominal role
                             b)   The staff duty rota
                             c)   The two-way radio
                             d)   Prescription chart
                             e)   The Leave folder / observation charts

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOTUSE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire, the evacuation route will be

       Via the main entrance, pass through central Atrium, or

       From main entrance into central Atrium, or

       From lounge area through fire exit into secure garden.

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.

West London Mental Health NHS Trust__________________________________________________Page 25 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 8


                            FIRE EVACUATION PLAN

                                     AURORA Ward
       EVACUATION – Aurora Ward


       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Aurora) or receive
       instructions regarding the evacuation.



       Once the decision to evacuate has been made, the nurse in charge must
       gather or allocate responsibility to collect the following

                       a)   The service users’ nominal role
                       b)   The staff duty rota
                       c)   The two-way radio
                       d)   Prescription chart
                       e)   The Leave folder / observation charts

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.
       Depending on the location of the fire, the evacuation route will be

       Into Garnet Ward through connecting corridor, or

       Into the adjacent Parkland Ward , or

       Into the courtyard area for Aurora Ward then into Garnet Ward

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.



West London Mental Health NHS Trust__________________________________________________Page 26 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 9


                          FIRE EVACUATION PLAN

                                      GARNET Ward
       EVACUATION – Garnet Ward



       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Garnet) or receive
       instructions regarding the evacuation.

       Once the decision to evacuate has been made, the nurse in charge must
       gather or allocate responsibility to collect the following:

                       a)   The service users’ nominal role
                       b)   The staff duty rota
                       c)   The two-way radio
                       d)    Prescription chart
                       e)   The Leave folder / observation charts

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOTUSE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire, the evacuation route will be

       In to Aurora Ward through connecting corridor, or

       Into the adjacent Melrose Ward, or

       Into the courtyard area for Garnet Ward then into Aurora Ward.

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.


West London Mental Health NHS Trust__________________________________________________Page 27 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 10
                            FIRE EVACUATION PLAN

                                   MELROSE WARD

       EVACUATION – Melrose Ward



       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Melrose) or receive
       instructions regarding the evacuation.



       Once the decision to evacuate has been made, the nurse in charge must
       gather or allocate responsibility to collect the following

                       a)    The service users’ nominal role
                       b)    The staff duty rota
                       c)    The two-way radio
                       d)    Prescription chart
                       e)    The Leave folder / observation charts

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOT USE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire, the evacuation route will be

       Into Parkland Ward through connecting corridor, or

       Into the adjacent Garnet Ward, or

       Into the courtyard area for Melrose Ward then into Parkland Ward.

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.

West London Mental Health NHS Trust__________________________________________________Page 28 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 11


                            FIRE EVACUATION PLAN

                                 PARKLAND WARD
       EVACUATION – Parkland Ward


       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.

       All service users, staff and visitors will assemble in the open dining area (if
       safe to do so). The nurse in charge will liaise with the Unit Coordinator via the
       two-way radio to give information about the fire (if it is on Parkland) or receive
       instructions regarding the evacuation.



       Once the decision to evacuate has been made, the nurse in charge must
       gather or allocate responsibility to collect the following

                       a)   The service users’ nominal role
                       b)   The staff duty rota
                       c)   The two-way radio
                       d)   Prescription chart
                       e)   The Leave folder / observation charts

       DO NOT WAIT TO COLLECT YOUR BELONGINGS

       ALL DOORS MUST BE CLOSED EN-ROUTE

       DO NOTUSE THE LIFT DURING ALARM ACTIVATION.

       Depending on the location of the fire, the evacuation route will be

       Into Melrose Ward through connecting corridor, or

       Into the adjacent Aurora Ward, or

       Into the courtyard area for Parkland Ward then into Melrose Ward

       Once evacuated a head count of staff and patients will be carried out. This
       will be communicated to the Unit Coordinator.


West London Mental Health NHS Trust__________________________________________________Page 29 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 12


                          FIRE EVACUATION PLAN

                             THE ENTIRE BUILDING

       EVACUATION – THE Orchard Building




       Reception staff will identify the location of the fire (from the Fire Panel located
       in Reception) and will inform the building via the two way radio.




       The final assembly point for The Orchard Unit in situations where the entire
       building needs to be evacuated is in the secure garden (external).



       East and west staircases can be used to evacuate from the 1st floor to the
       ground floor.




       ALL DOORS MUST BE CLOSED EN-ROUTE



       DO NOT ATTEMPT TO USE THE LIFT DURING ALARM ACTIVATION.




West London Mental Health NHS Trust__________________________________________________Page 30 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
Flash Card 13



                                       GUIDANCE NOTES
                       TO COMPLETE A
PERSONAL EMERGENCY EVACUATION PLAN (PEEP) FOR A SERVICE USER IN
                         SECLUSION
             SERVICE USER IN SECLUSION
        PERSONAL EMERGENCY EVACUATION PLAN
                       (PEEP)
CSU                                    West London Forensic Service

Ward
Patient Name

NATURE OF SPECIAL REQUIREMENT                          (PLEASE tick all fields that are relevant to the service
user)

   MOBILITY                  SIGHT               HEARING            LANGUAGE            COMPREHENSION

Wheel Chair            Partial                Impaired

Walking Aid            Blind                  Deaf

Assistance
Risk of
Violence

INDIVIDUALS            SPECIAL         NEEDS        OR     REQUIREMENTS               IDENTIFIED             FOR
EVACUATION
In the event of Fire alarm activation the nurse in charge must carry out the necessary assessments to
determine whether there is a need to prepare for evacuation as per local fire procedure. It is the nurse in
charge of the ward who is ultimately responsible for the safety of everyone on that ward; this includes service
users, staff and visitors.

If there is evidence of a fire / smoke within the ward environment, the nurse in charge must consider whether
the affected area can be isolated by closing the fire doors to contain the risk and spread of the fire/smoke so as
to allow time to seek further resources and advice from the designated fire marshal for that ward/area. (The
nurse in charge must work in close collaboration with the unit coordinator to identify safe
containment zones within the ward that is in line with their local fire procedures.

If there is an immediate need to implement strategies to evacuate all staff and patients to a place of safety, the
nurse in charge must deploy staff to immediately escort those who are risk manageable to the nominated
place of safety. This must be demonstrated through necessary, proportionate and justifiable responses.
Once this has been achieved and the appropriate resources are available, the nurse in charge or
appropriate fire marshal will make the necessary risk assessments to plan and execute the
evacuation procedure for the service user in seclusion.

This assessment must consider:

 West London Mental Health NHS Trust__________________________________________________Page 31 of 31
 Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
   To consider the immediate risks to others (smoke / fire and risk of violence that may impede
       / prolong staff’s evacuation)
      Current presentation
      Advance Directives (agreed collaborative strategies)
      Planning of resources to affect a safe evacuation of the secluded service user ie. How many
       staff are required to safely evacuate the service user and to identify clear individual roles and
       responsibilities.
      To determine the necessary PMVA techniques, ie precautionary holds, wrist locks
       as informed by the risk assessment.
      Assess compliance to staff requests (is there any expected resistance?). Non-compliance will
       inform how many staff are required and what PMVA techniques are used to safely evacuate
       the service user.
      Nurse in charge/Unit Coordinator to arrange an appropriate place of safety (ideally to
       another seclusion room on the same floor) to ensure the appropriate level of observation is
       maintained.
OTHER RELEVANT INFORMATION (ie any other special requirements)
ADAPTATIONS / CHANGES TO THE ENVIRONMENT OR WORKING PRACTICE
THAT ARE REQUIRED / HAVE BEEN IMPLEMENTED TO ACCOMMODATE THE
INDIVIDUAL

   1. Staff working within this ward must receive the necessary PMVA training to safely facilitate
      expected evacuation.
   2. Developed PEEP must be included as part of the staff handover communication processes to
      inform others of the intended approaches in advance, to avoid any uncertainty or confusion
      during a live evacuation.
   3. The PEEP plans must be a live document that reflects current needs.
   4. The PEEP plan should be tested regularly (scenario based) by the MDT to determine its
      effectiveness.

Statement Prepared by –


Signature

Designation
Statement agreed by- Service
Director
Signature


Statement agreed by –
Patient

Signature
Date


Date For Review


 This record must be held within the relevant department documentation and departmental risk
 assessment.


 West London Mental Health NHS Trust__________________________________________________Page 32 of 31
 Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
IN CONFIDENCE

             SERVICE USER IN SECLUSION
        PERSONAL EMERGENCY EVACUATION PLAN
                       (PEEP)
CSU                                   West London Forensic Service

Ward
Patient Name

NATURE OF SPECIAL REQUIREMENT                          (PLEASE tick all fields that are relevant to the service
user)

   MOBILITY                 SIGHT               HEARING             LANGUAGE            COMPREHENSION

Wheel Chair           Partial                Impaired

Walking Aid           Blind                  Deaf

Assistance
Risk of
Violence

INDIVIDUALS            SPECIAL        NEEDS        OR      REQUIREMENTS               IDENTIFIED             FOR
EVACUATION




 West London Mental Health NHS Trust__________________________________________________Page 33 of 31
 Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
ADAPTATIONS / CHANGES TO THE ENVIRONMENT OR WORKING PRACTICE
THAT ARE REQUIRED / HAVE BEEN IMPLEMENTED TO ACCOMMODATE THE
INDIVIDUAL




Statement Prepared by –


Signature

Designation
Statement agreed by- Service
Director
Signature


Statement agreed by –
Patient

Signature

Date

Date For Review

 NB This record must be held within the relevant department documentation and
 departmental risk assessment.


 West London Mental Health NHS Trust__________________________________________________Page 34 of 31
 Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
EVACUATION PROCEDURE
                                            ‘FIRST KNOCK’
        Low level alert sound in area of activation – pre alert ‘buzz’ other area panels


               RECEPTION STAFF ANNOUNCE ACTIVATION OVER THE RADIOS



   WARD AREA                   NON WARD AREA                                    NON WARD AREA -
                                  9-5PM                                            5pm – 9am
   NURSE IN CHARGE DELEGATES ATRIUM STAFF, UNIT                                UNIT COORDINATOR &
   A STAFF MEMBER TO CHECK    COORDINATOR &                                    RESPONSE NURSES
   THE LOCATION            RESPONSE NURSES                                          CHECK THE
                                CHECK THE                                           LOCATION
                                 LOCATION



                                           CONFIRMED NO FIRE



                           NURSE IN CHARGE PRESS SILENCE BUTTON
                               FIRE BRIGAGE NOT CONTACTED



                                       UNIT COORDINATOR
                                   RESET THE PANEL WITH THEIR KEY
                                          NEAREST PANEL




West London Mental Health NHS Trust__________________________________________________Page 35 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
EVACUATION PROCEDURE
                                      ‘DOUBLE KNOCK’
                                             FULL ALERT
            RECEPTION STAFF ANNOUNCE ACTIVATION OVER THE RADIOS



NON WARD AREA 9-5PM                                                    NON WARD AREA 5PM-9AM
UNIT COORDINATOR,                                                          UNIT COORDINATOR &
ATRIUM STAFF &                                                             RESPONSE NURSES
RESPONSE NURSES
                                              CHECK THE
                                               LOCATION




                                       FIRE LOCATED


NURSE IN CHARGE                               UNIT COORDINATOR&
COLLECTS :                                    RESPONSE NURSES & FIRE MARSHALL
1. THE PATIENT NOMINAL ROLE                   EVACUATE THE PATIENTS
2. STAFF DUTY ROTA                            HORIZONTAL MOVEMENT
3. TWO WAY RADIO                              IF SAFE TO DO SO
4. PATIENTS LEAVE BOOK
5. PEEPS
6. PRESCRIPTION CHARTS


                                 EVACUATE TO RELEVANT AREA




                             COMMUNAL GARDEN
             UNIT COORDINATOR IS THE MAIN LINK TO THE FIRE BRIGADE




             REST SYSTEM ONLY ON APPROVAL FROM FIRE BRIGADE AND
                            INFORM CALL CENTRE


West London Mental Health NHS Trust__________________________________________________Page 36 of 31
Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018
FIRE ALARM ACTION CARD
                              for THE ORCHARD UNIT



                     ALARM ACTIVATED IN (First Knock)
                       Low level ‘Continuous’ Sound


           CHECK PANEL (Press Accept/View Points for Room/Location of Incident)




                 STAFF TO CHECK ROOM/AREA AS INDICATED ON PANEL.




                                                                                     NO
            YES                     IS IT A FIRE?


 IMMEDIATELY ACTIVATE NEAREST                                                      PRESS
   KEY OPERATED CALL POINT                                                 Accept - Silence (once)
(Contact Centre are Automatically Called)                                        (Countdown Stops)
                                                                            RESET:-
                                                                            UNIT CO-ORDINATOR
                                                                                   ONLY
   Follow Fire Procedures for                                               (Access key required)
          Evacuation                                                      DO NOT RESET IF THE
                                                                          ALARM HAS GONE INTO
                                                                          DOUBLE KNOCK - EVEN IF
                                                                          IT IS A FALSE ALARM
DO NOT RESET              Prepare to give full
ALARMS UNTIL                 details of the
FIRE BRIGADE              incident to the Unit
ATTEND                      Co-ordinator –
– They Will               especially missing
Advise When                   persons etc
You Can Do So.
     West London Mental Health NHS Trust__________________________________________________Page 37 of 31
     Fire Procedures – The Orchard. First issued January 2011            This is current version 10. 30.3.2018

   Fully comply with the Fire                                       Complete and
    Brigade – have keys etc
 immediately available for their                                      submit an
             use.                                                  Incident Report
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