Classification: Official
Publication reference: PR2122

With NHS trusts implementing plans to support additional levels of patient care during the busy winter period, this document provides an important reminder of the legal duties around fire safety along with some basic checks that should be made in order to mitigate any potential risks.

NHS trust chief executives, chief operating officers and directors of estates and facilities should be aware of the document when making changes to the NHS estate to increase capacity and patient throughput.

Overview

As we continue to find extra capacity in the estate by newly using (or re-using) parts of hospitals for patient treatment or care, or increasing the capacity of existing areas, we would like to remind you of how any change of use of areas may affect fire safety requirements.

Under no circumstances must fire compliance be compromised on sites which have been changed. We write to remind organisations of their legal duties and to make recommendations for basic checks to be in place to mitigate this risk.

Each organisation has a legal duty to ensure that:

1. The premises are safe (from fire).
2. The fire safety risk assessment is reviewed.
3. Fire safety arrangements are appropriate, including planning, organisation, control, monitoring and review – these must be recorded.
4. The risk from presence of dangerous substances (such as medical gases including cylinders) is reduced so far as is reasonably practicable.
5. There are appropriate fire detection systems and fire extinguishers.
6. Escape routes are suitable to enable evacuation as quickly as possible and such routes are kept clear.
7. Emergency plans are updated and tested by an evacuation drill (the nature of such a drill is to be determined given the circumstances).
8. Fire safety equipment and devices must be maintained in an efficient state, efficient working order and good repair.

To achieve this, it is recommended that the following is implemented:

Prior to any part of the hospital being brought into use for patient treatment or care
or increasing the capacity of existing areas

1. The advice of a competent fire safety advisor (with extensive site knowledge) regarding the use of such areas is obtained.
2. A new fire safety risk assessment is completed. If changes are minor, eg one or two additional beds, then the existing fire risk assessment should be reviewed. All fire risk assessments should be written in line with fire safety guidance as set out in health technical memoranda (HTM) 05-03 – Part K and completed by a competent person with extensive site knowledge.
3. The area should be compliant with design guidance in HTM 05-02 (Fire).
   Note: where there are minor variations from the HTM guidance – and the fire safety advisor considers that the areas remain suitable – such variations (along with any compensatory measures) are to be recorded in the fire risk assessment including the name of the advisor.
4. Management should be compliant with the requirements set out in guidance HTM 05-01.
5. Records for items 1-4 should be kept for auditing purposes.
6. You advise the local fire and rescue service (FRS) of the additional areas being used including (a) location, (b) additional numbers of persons, and (c) FRS access and facilities.
   Where this is an ongoing process, it would be sufficient to advise them of the concept and procedures being followed.

On commencing use of the area

1. The fire risk assessment is reviewed by a competent person.
2. Management is compliant with guidance in HTM 05-01.
3. The FRS is advised that the area is now in use or that the concept has commenced.

If further support is needed, please contact england.estatesandfacilities@nhs.net, marked for the attention of Mazin Daoud.