APPENDIX 1 to

The Norfolk & Norwich University Hospital NHS Trust

Fire Safety Policy

FIRE INSTRUCTION NOTICE

Raising the alarm
There are three means of raising the fire alarm:
1. Verbally: Shout FIRE! FIRE! FIRE!
2. Manually: By breaking the glass of the nearest call point
3. Automatically: By smoke and heat detection

If you Discover or Suspect a Fire:

1. Sound the alarm verbally as described above
2. Remove anyone in immediate danger and close the door
3. Break the glass of the nearest fire alarm call point
4. Dial 2222 and advise the switchboard of the location & nature of the fire
5. Fight the fire (if it is safe to do so) using available fire-fighting equipment
Action By Persons Hearing the Fire Alarm:
Intermittent alarm: (The fire is in an adjacent area)
Close all doors and windows
Non-essential Clinical Staff
Report, to the nearest fire alarm panel and wait there for instructions
All other staff
Remain where you are
Continuous alarm: (The fire is in this area)
Check your working area, if you discover a fire, deal with it as described above
If you do not discover a fire, report to head of department and assist

Head of Department/Senior Person:

If the cause is apparent – Evacuate beyond at least one set of fire doors
If the cause is not apparent – Prepare to evacuate
Hand over to the Fire Team on their arrival

IN THE EVENT OF A COMPLETE EVACUATION BEING

ORDERED BY THE FIRE TEAM OR FIRE SERVICE
YOUR ASSEMBLY POINT IS

THE ADJACENT CAR PARK

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 APPENDIX 2 to
The Norfolk & Norwich University Hospital NHS Trust
Fire Safety Policy

FIRE RESPONSE TEAMS

INITIAL RESPONSE TEAM:

Initial response to a fire alarm between 08.00 and 17.00 Monday to Friday will involve:

Those persons in the affected area and, as well as an automatic request for assistance from the
Fire Service, a small rapid response team formed by key personnel led by a manager from within
the affected wing of the hospital.

Initial response to a fire alarm between 17.00 and 08.00 Monday to Friday, Weekends and
Bank Holidays, will involve:

Those persons in the affected area and, as well as an automatic request for assistance from the
Fire Service, the same rapid response team formed by key personnel but led by a Site Practitioner.

WEST WING CENTRE EAST WING

Team SERCO Estates Team Pharmacy Team RADIOGRAPHY
leader Management leader Manager leader P.A.C.S Supervisor
or or or
Site Practitioner Site Practitioner Site Practitioner
Team Security Team Security Team Security
members members members
Maintenance Maintenance Maintenance
Technician Technician Technician

Responsibilities of the Initial Response Team:

In response to an alert via the pager system to an incident in an occupied area:

1. Confirm location on nearest fire alarm panel

2. Proceed with caution to location
3. Check with H.O.D. or Senior Person – situation so far:

Situation under control: Silence alarm

Situation needs further response: Dial 2222 and request:

Second call to fire service
Further assistance for Fire or Chemical spill

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Check that the affected area:

i) has been evacuated (and all occupants are in a safe area behind at least one set of fire
doors)

ii) has been cordoned off (position staff to ensure no-one can enter affected area)

Establish:

Control of entry to affected department (Use security staff)

Prepare:

For further evacuation (H.O.D responsibility)

In response to an alert via the pager system to an incident in an unoccupied area:

Meet security at the entrance to the area, allow the Fire Service entry and assist them as necessary

SPECIALIST RESPONSE TEAM:

In the event of the initial response team requesting further assistance, a specialist response team,
formed from key personnel with specific responsibility or specialist knowledge, will respond from
all parts of the building.

The team will consist of the following personnel or their deputies

Nominated Officer (fire)

Senior Nurse Manager
Senior Estates Officer
Clinical Manager Theatres
Risk Manager
Security Staff
Porters

The responsibility of the Specialist Response team is to manage the incident in association with
the Local Authority Emergency Services and to decide whether to initiate the MAJAX plan.

All response team members will be issued with designated proximity cards.

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 APPENDIX 3 to
The Norfolk & Norwich University Hospital NHS Trust
Fire Safety Policy

PROCEDURE FOR SWITCHBOARD STAFF IN RESPONSE TO A FIRE ALARM

In response to a fire alarm indication at the Norfolk and Norwich University Hospital
switchboard staff should:

(If the alert is received directly via 2222 request the caller to sound the fire alarm)

1. Dial 999 and inform Fire Service Control that:

“THE FIRE ALARM IS SOUNDING IN

(Give location as shown on panel)
THE NORFOLK & NORWICH UNIVERSITY HOSPITAL,
COLNEY LANE, NORWICH”

“RENDEZVOUS POINT” (as shown on panel)

2. Initiate a FIRE GROUP pager message stating:

‘FIRE ALARM AT
(Give location shown on panel)
FIRST RESPONSE’

3. Once further information is received via 2222 make a further 999 call and inform Fire Service
Control that:

“THE INCIDENT REPORTED EARLIER AT

(as shown on panel)
IS CONFIRMED AS A FALSE ALARM”
or
“IS CONFIRMED AS A”
(Give as much information as possible about the incident)

4. If a request for assistance is received via 2222 from the first response team:

Initiate a FIRE GROUP pager message stating:

‘FIRE ALARM AT
(Give location shown on panel)
CONFIRMED FIRE/CHEMICAL SPILL ETC.
SECOND RESPONSE’

5. When information is received from the response team leader that the incident is terminated:
Initiate a FIRE GROUP pager message stating:
FIRE ALARM AT
(Give location shown on panel)
‘TERMINATED
TEAM LEADER TO SWITCHBOARD TO COMPLETE REPORT’
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 SWITCHBOARD RESPONSE TO A FIRE ALERT
AT THE
NORFOLK AND NORWICH UNIVERSITY HOSPITAL
COLNEY LANE, NORWICH

2222 CALL RECEIVED

TELL CALLER TO SOUND FIRE

FIRE ALARM SOUNDED

DIAL 999 INFORM FIRE SERVICE CONTROL:

“FIRE ALARM SOUNDING IN ∗ (Give location, Hospital address and rendezvous point)”

INITIATE FIRE GROUP PAGER STATING:

‘FIRE ALARM AT ∗ (give location)
FIRST RESPONSE’

2222 CALL RECEIVED

CONFIRMED AS CONFIRMED AS
FIRE/CHEMICAL SPILL ETC. FALSE ALARM

DIAL 999 INFORM FIRE CONTROL:
“INCIDENT REPORTED EARLIER AT ∗
IS CONFIRMED AS A FIRE/CHEMICAL
SPILL ETC.”
Give all information available.
DIAL 999 INFORM FIRE CONTROL:
“INCIDENT REPORTED EARLIER AT ∗
IS CONFIRMED AS A FALSE ALARM”
Give all information available.

REQUEST FOR ASSISTANCE FROM FIRST

RESPONSE TEAM

INITIATE FIRE GROUP PAGER

STATING:
‘FIRE ALARM AT ∗
CONFIRMED AS FIRE/CHEM SPILL ETC.
SECOND RESPONSE’

When response team leader confirms via 2222 that the incident is terminated

INITIATE FIRE GROUP PAGER STATING:

‘FIRE INCIDENT TERMINATED
TEAM LEADER TO SWITCHBOARD TO COMPLETE REPORT’
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 APPENDIX 4 to
The Norfolk & Norwich University Hospital NHS Trust
Fire Safety Policy
FIRE EVACUATION PLANS

The need for evacuation of large numbers of beds or of large areas of the hospital is minimised by
the incorporation of passive and active fire safety measures into the design and construction of the
building.

Using the building in accordance with design principles and following the requirements of this
policy will ensure that the possibility of large scale evacuation is minimised.

Aims:

The primary aims of evacuation are:

a) to remove all occupants, within the affected area, from immediate danger;

b) to keep the distance of any movement as short as possible;

c) to avoid routes which may need to be used by the emergency services;

d) to remove patients to a safe area remote from the fire and suitable for their comfort and
continued treatment, possibly for a prolonged period.

e) to remove visitors to a safe area, from which they can proceed to the fire assembly points
in the ground floor atria and adjacent car parks.

Method:

The evacuation method employed in the hospital is that of ‘Progressive Horizontal Evacuation’,
the principle of which is to move the patients from an area affected by fire, through a fire-resisting
barrier to an adjoining area (refuge) on the same level. The refuge is designed to protect the
occupants from the immediate dangers of fire and smoke while the fire is dealt with or decisions
are made with regard to further evacuation if necessary.

In the first instance patients should be moved from the room affected by fire in the most expedient
way possible. This may involve moving the beds, transferring patients to wheelchairs or simply
encouraging and assisting ambulant patients to leave. Once the initial evacuation has taken place
the need for further movement can be assessed.

In most instances there will be no need to progress the evacuation further, however, if the need
arises the following points should be considered:

(1) Does the refuge have the necessary facilities for a prolonged situation
(2) Do you have to pass an area of higher risk on route
(3) Does the refuge offer the opportunity for further evacuation if necessary

The following pages detail the direction of evacuation for all departments. More details are
available in department policies or on the Trust Intranet.

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 APPENDIX 5 to
The Norfolk & Norwich University Hospital NHS Trust
Fire Safety Policy

CHEMICAL SPILL PLAN

To Be Issued