2nd Edition September 2010

WORKING TOGETHER IN PARTNERSHIP

CONCORDAT BETWEEN

The Welsh Assembly Government’s Department for Health and Social Services

and

The Chief Fire Officers’ Association Wales

JULY 2007

2nd Edition September 2010

WORKING TOGETHER IN PARTNERSHIP FOREWORD

The excellent fire safety record achieved in the NHS in Wales bears witness to the importance that the Welsh Assembly Government and the Chief Fire Officers’ Association place on fire safety. Whether as patients, visitors or staff, we have all come to expect to be able to use healthcare facilities in complete safety, confident that measures have been put in place to minimise the risk of fire. We have also come to expect that, in the event of a fire, the design of healthcare premises and the operational policies and strategies underpinning the use of those premises, will provide maximum protection for their users. Key to the success of the fire safety record in the NHS has been the longstanding co-operation between the NHS and the Fire and Rescue Service in applying fire safety guidance and legislation. The difficulty in interpreting and applying this guidance and legislation to healthcare premises, widely acknowledged as some of the most complex building types to be found in Wales, should not be underestimated. Along with the complexity of the buildings, the constant advances in fire safety technology dictate the need for a professional approach to the implementation of fire safety measures and a better understanding between all parties involved in the delivery of fire safety. This Concordat between the Welsh Assembly Government and the Chief Fire Officers’ Association is a vital step along the path of partnership working. It provides a framework for establishing close and harmonious working relationships between the NHS and the Fire and Rescue Services in Wales, delivering improvements in fire safety measures and, ultimately, safeguarding the welfare of patients, visitors and staff using healthcare facilities.

Ann Lloyd Chief Executive, NHS Wales

Richard Smith Chief Fire Officers’ Association

2nd Edition September 2010

INFORMATION READER BOX CONTENTS INTRODUCTION 1 CONFIDENTIALITY 2

ROLES 2

CHIEF FIRE OFFICERS’ ASSOCIATION WALES THE WELSH ASSEMBLY GOVERNMENT’S DEPARTMENT FOR HEALTH AND SOCIAL SERVICES

PRINCIPAL AIMS 3 DISSEMINATION 5 APPENDIX A WHC(2006)74 Fire Safety Policy for the NHS Estate in Wales APPENDIX B NHS Contact Details

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CONCORDAT BETWEEN

The Welsh Assembly Government’s Department for Health and Social Services

and

the Chief Fire Officers’ Association Wales INTRODUCTION This concordat is an agreement between the Welsh Assembly Government’s Department for Health and Social Services and the Chief Fire Officers’ Association Wales. It is a voluntary arrangement that does not impose any legally enforceable obligations and is intended to be binding in honour only. The concordat provides a framework to ensure that the roles and responsibilities of the organisations are effectively translated into practical working arrangements. The aim is to promote the establishment of close and harmonious working relationships between the Chief Fire Officers’ Association Wales (CFOA Wales), the Fire and Rescue Authorities in Wales, the Welsh Assembly Government’s Department for Health and Social Services, Welsh Health Estates and the wider NHS in Wales. The parties to this concordat have agreed to work together in partnership to meet the shared objective of improving fire safety measures to safeguard the welfare of patients, visitors, staff and premises throughout the NHS property portfolio in Wales. (It should be noted that this concordat does not extend to privately operated GP surgeries treating NHS patients). To facilitate these arrangements the Welsh Assembly Government’s Department for Health and Social Services and CFOA Wales will oversee the implementation of the concordat through Welsh Health Estates and the Fire and Rescue Authorities in Wales. Further information on the Assembly’s Department for Health and Social Services, Welsh Health Estates, CFOA Wales and the Fire and Rescue Authorities in Wales can be found on their respective websites:

Welsh Assembly Government http://www.wales.gov.uk Welsh Health Estates http://www.wales.nhs.uk/whe Chief Fire Officers’ Association http://www.cfoa.org.uk North Wales Fire and Rescue Authority http://www.nwales-fireservice.org.uk Mid & West Wales Fire and Rescue Authority http://www.mawwfire.gov.uk South Wales Fire and Rescue Authority http://www.southwales-fire.gov.uk

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CONFIDENTIALITY The Concordat relies on mutual respect for the confidentiality and sensitivity of information exchanged. Therefore neither party will disclose unpublished information to third parties without the authority of the administration which originally provided the information, subject to the requirements of the law and other obligations. ROLES Chief Fire Officers’ Association Wales CFOA Wales aims to assist and support the Fire and Rescue Services in Wales to improve the well being of local communities in all matters relating to Fire Services’ activities, including the development of fire prevention and protection partnership working to secure greater safety. Within Wales there are three Fire and Rescue Authorities that are the principal statutory enforcing authorities for the Regulatory Reform (Fire Safety) Order 2005. These are: North Wales Fire and Rescue Authority Mid and West Wales Fire and Rescue Authority South Wales Fire and Rescue Authority The Fire and Rescue Authorities only have jurisdiction within their defined geographical areas. Each Fire and Rescue Authority has delegated powers to Chief Fire Officers of the Fire and Rescue Services to appoint inspectors to enforce the provisions of this Order to premises for which it is the enforcing authority. Responsibility for complying with The Regulatory Reform (Fire Safety) Order 2005 rests with the ‘responsible person’ as defined by the Order. The Welsh Assembly Government’s Department for Health and Social Services Within Wales, healthcare is delivered through 7 Local Health Boards and Velindre NHS Trust. These NHS Organisations are complemented by Public Health Wales, who provide independent public health advice, and the Welsh Ambulance Services NHS Trust which is responsible for providing services on an all Wales basis. Chief Executives have the ultimate responsibility for management of fire safety within their NHS organisations. Within their structure, they should have a nominated Board Level Director with responsibility for fire safety matters and nominated Fire Safety Managers/deputies as required by Welsh Health Circular (2006)74 ‘Fire safety Policy for the NHS Estate in Wales’ (Appendix A). The Welsh Assembly Government’s Department for Health and Social Services has mandated the NHS in Wales to comply with its Fire Policy Statement as referenced in the

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above circular. Welsh Health Estates, on behalf of the Assembly, monitors fire safety of NHS Trusts through the online Fire Audit Information System. PRINCIPAL AIMS CFOA Wales and the Welsh Assembly Government’s Department for Health and Social Services have agreed to work together to meet five principal aims to improve the fire safety at NHS premises within Wales:

1. Promote compliance with all relevant fire safety legislation; 2. Agree and develop fire risk assessment protocols; 3. Identify key contacts for each NHS provider organisation; 4. Promote the reduction of unwanted fire signals; 5. Work towards a consistent approach on all fire safety issues.

To assist in meeting these aims, CFOA Wales will: a. Adopt a positive approach to help ‘Responsible Persons’ comply with the Fire Safety

Order in NHS premises in Wales. Where necessary, appropriate Notices will be issued to ensure compliance.

b. Appoint a representative of CFOA Wales as a single point of contact for Welsh

Health Estates to consult on fire safety policy matters. c. Assist Welsh Health Estates with the implementation of Firecode HTM05-03 Part H

‘Reducing false alarms in healthcare’ (formerly FPN 11), by attending stakeholder meetings as necessary.

d. Provide Welsh Health Estates with data relating to healthcare fire incidents and

unwanted fire calls in an agreed format and frequency. e. Provide Welsh Health Estates with fire safety enforcement details issued to

healthcare premises. f. Meet with Welsh Health Estates at least once a year to review this concordat and

progress towards achieving the aims. The Fire and Rescue Authorities in Wales will not: • Act as a fire safety consultant for NHS premises. • Carry out fire safety risk assessment for NHS premises. • Devote a disproportionate level of resources to meet the aims of this concordat.

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To assist in meeting these aims, the Welsh Assembly Government through Welsh Health Estates will: a. Ensure all NHS Chief Executives within Wales are made aware of the provisions of

this concordat. b. Adopt proactive measures to ensure that the aims of the concordat are progressed. c. Ensure that, for each NHS provider organisation in Wales, a competent person and a

person of appropriate authority are identified to the Fire and Rescue Authorities in Wales.

d. Provide the Fire and Rescue Authorities in Wales with data, in an agreed

format/frequency, relating to fire incidents and unwanted fire calls. e. Provide the Fire and Rescue Authorities in Wales with information on relevant

hazard notices and safety issues. f. Meet with the Fire and Rescue Authorities in Wales at least once a year to review

this concordat and progress towards achieving the aims. g. Offer general fire safety advice and guidance to the NHS in Wales. h. Appoint a representative as a single point of contact to consult on fire safety policy

matters.

The Welsh Assembly Government through Welsh Health Estates will not: • Devote a disproportionate level of resources to meet the aims of this concordat.

Foot note “Competent person” means a person with the appropriate skills, knowledge and experience of fire safety matters with regard to the size and complexity of the undertakings. “Person of appropriate authority” means a person with sufficient authority to authorise decisions and make commitments with regard to implementing fire safety measures.

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DISSEMINATION Both parties agree that any mutually derived advice and guidance, produced as a consequence of this concordat, can be shared with other appropriate parties. To assist dissemination of information the following interaction is agreed:

• Annual meetings attended by: A member of the Welsh Health Estates fire safety team Nominated representatives from the NHS in Wales Chairperson of the Association of Healthcare Fire Officers (NAHFO) (Welsh

Branch) A nominated representative from each Fire and Rescue Service

• Additional meetings may be held at a local level with stakeholders as required.

Appendix B provides contact details for the Welsh NHS Organisations. Contact details for the Fire and Rescue Services are contained on their respective websites. It is for these individuals (or nominated members of their staff) to agree local arrangements for working towards meeting the aspirations of this agreement. The Fire and Rescue Authorities in Wales and Welsh Health Estates will take appropriate steps to facilitate a two-way flow of information.

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Appendix A

WHC(2006)74 Fire Safety Policy for the NHS Estate in Wales

WHC (2006) 74

WELSH HEALTH CIRCULAR

Parc Cathays Caerdydd CF10 3NQ

Cathays Park

Cardiff CF10 3NQ

Issue Date: 01 November 2006

Status: ACTION

Title: FIRE SAFETY POLICY FOR THE NHS ESTATE IN WALES

For Action by: NHS Trusts and Local Health Boards

Action required See paragraph(s) : 6

For Information to: See attached list

Sender: Andrew Walker, Head of Capital, Estates & Facilities, Resources Directorate, Department for Health and Social Services, Welsh Assembly Government

National Assembly contact(s) : Helen Field – DHSS – Telephone – 029 2080 1056

Enclosure(s): HTM05-01 Managing Healthcare Fire Safety (Welsh Edition) can be downloaded from the Information and Publications section of the WHE intranet site from 1st November 2006.

Tel: 029 20825111 GTN: 1208 Llinell union/Direct line: 029 2080 1056

Ffacs/Fax: 029 2082 5146 Minicom: 029 20823280

http://howis.wales.nhs.uk/whcirculars.cfm

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FIRE SAFETY POLICY FOR THE NHS ESTATE IN WALES

Dear colleague, Summary 1. The purpose of this circular is to advise NHS bodies of the Welsh Assembly Governments’

revised Fire Safety Policy for the NHS in Wales and to launch the Welsh Edition of Firecode HTM05-01 Managing Healthcare Fire Safety.

Background 2. The Regulatory Reform (Fire Safety Order) came into force on 1st October 2006. This

legislation consolidates and reforms over a hundred pieces of fire related legislation, including the Fire Precautions Act 1971 and the Fire Precautions (Workplace) Regulations 1997 (as amended).

3. As a result of this reform the Healthcare Firecode suite of documents is being revised.

HTM05-01 ‘Managing Healthcare Fire Safety’ (Welsh Edition) is the first document in the series to be published and replaces Firecode Policy and Principles 1994.

4. HTM05-01 contains the Welsh Assembly Government’s fire safety policy statement,

addresses the mandatory requirements of the Assembly and provides guidance on the effective fire safety management of healthcare premises.

5. This Fire Safety Policy supersedes the previous policy statement issued under cover of

WHC(2003)101 and continues to underpin the Assembly’s commitment to fire safety in the NHS, and strengthen the processes and procedures already in place.

Action 6. The implementation of this Fire Safety Policy will require actions by all NHS bodies as

detailed under Mandatory Requirements in section four of the attached policy at Annex A. 7. HTM05-01 Managing Healthcare Fire Safety (Welsh Edition) can be downloaded from

the Information and Publications section of the WHE intranet site. 8. Any queries concerning this circular should be directed to:

Andrew Walker, Head of Capital, Estates & Facilities Resources Directorate Department for Health and Social Services Welsh Assembly Government Cathays Park Cardiff. CF10 3NQ

Yours Sincerely Andrew Walker Head of Capital, Estates & Facilities Resources Directorate Department of Health and Social Care

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Distribution List

Chief Executives NHS Trusts Chief Executives Local Health Boards HR Directors Business Services Centres Director Welsh NHS Confederation Chief Officer Board of Community Health Councils in Wales Director Welsh Local Government Association Dean University of Wales, Bangor Chief Executive Commission for Racial Equality Chief Executive NLIAH Director British Dental Association (Wales) Dean Cardiff University Dental School Postgraduate Dean Cardiff University Dental School Postgraduate Dean Cardiff University Medical School Director information services Cardiff University Medical School Secretary British Medical Association (Wales) Regional Head of Health UNISON Director Royal College of Nursing (Wales) Welsh Council Representative British Dietetic Association Wales Secretary British Orthoptic Society Wales Secretary AMICUS MSF Regional Secretary The GMB Regional Secretary Transport & General Workers Union Chair Community Pharmacy Wales Chair Royal College of General Practitioners General Secretary Wales TUC Assistant Director Chartered Society of Physiotherapists Officer for Wales Society of Radiographers IR Officer Society of Chiropodists and Podiatrists Regional Secretary Union of Construction Allied Trades and Technicians Board Secretary for Wales Royal College of Midwives Officer for Wales AMICUS Electrical & Engineering Staff Association Regional Secretary AMICUS Amalgamated Electrical and Engineering Union Welsh Executive Royal Pharmaceutical Society of Great Britain Health & Social Care Policy Officer

Wales Council for Voluntary Action

National Member for Wales AMICUS - Guild of Health Care Pharmacists Business manager Institute of Health Care Management Welsh Division Deputy Chief Executive Association of Optometrists Librarian British College of Optometrists Director General Audit Commission (Wales) Director Business Service Centres Patch Managers Business Service Centres across Wales (6 copies each) Secretariat Statutory Health Advisory Committees

Academy of Royal Colleges Wales Regional Directors NHS Wales Regional Offices Chief Executive Health Commission Wales (Specialist Services) Librarian National Public Health Service Chief Executive Welsh Language Board / Bwrdd yr Iaith Gymraeg Librarian Health Promotion Library Chief Executive Healthcare Inspectorate Wales Chief Fire Officer North Wales Fire and Rescue Service Chief Fire Officer Mid and West Wales Fire and Rescue Service Chief Fire Officer South Wales Fire and Rescue Service

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Annex A WELSH ASSEMBLY GOVERNMENT

NHS WALES FIRE SAFETY POLICY

1. Purposes and Context 1.1 The Welsh Assembly Government recognises the good fire safety record of the NHS in

Wales, achieved through the implementation of fire safety guidance issued to the NHS over many years. This Fire Safety Policy is intended to provide an unambiguous statement applicable to the NHS in Wales and premises where NHS patients receive treatment or care.

1.2 This policy supersedes all previous fire policy statements issued by the Welsh Assembly

Government. 2. Policy Aims

This fire safety policy has the following aims: • to minimise the incidence of fire throughout the NHS estate in Wales; • to minimise the impact from fire on life, safety, delivery of service, the environment

and property. 3. Statements of Policy

1 All NHS organisations in Wales fall within the scope of this policy. 2 All NHS organisations in Wales must comply with legislation relating to fire safety. 3 All NHS organisations in Wales commissioning new buildings, leasing new

buildings, or occupying buildings under a PPP/PFI contract must be satisfied that such buildings comply with legislation relating to fire safety.

4 The Assembly’s Department for Health and Social Services will ensure that

appropriate advice and guidance on all matters related to fire safety will be available to NHS organisations in Wales through the Firecode suite of guidance.

5 The Assembly expects that all contracts for health services placed by

commissioners will contain clauses to ensure that premises comply with, and will continue to comply with, all statutory fire safety provisions and, where appropriate, Firecode.

4. Mandatory Requirements for the NHS in Wales All NHS organisations must: • have a clearly defined fire safety policy covering all buildings they occupy; • nominate a board level director accountable to the Chief Executive for fire safety; • nominate a Fire Safety Manager to take the lead on all fire safety activities; • have an effective fire safety management strategy which enables:

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o the preparation and upkeep of the organisation’s fire safety policy; o adequate means for quickly detecting and raising the alarm in case of fire; o means for ensuring emergency evacuation procedures for all areas, at all

times the premises are occupied, without reliance on external services; o all staff to receive fire safety training appropriate to the level of risk and

duties they may be required to perform; o reporting of all fire and unwanted fire signal incidents via the “Fire & UwFS

incident reporting system” database (http://nww.firesystems.wales.nhs.uk/fire/login.cfm);

o the development of partnership initiatives with other bodies and agencies involved in provision of fire safety.

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Appendix B

NHS Contact Details

NHS Organisation Corporate Office/Headquarters Abertawe Bro Morgannwg University Health Board

One Talbot Gateway Baglan Energy Park Baglan Port Talbot SA12 7BR

Aneurin Bevan Health Board

Mamhilad House Block A Mamhilad Park Estate Pontypool Torfaen NP4 0YP

Betsi Cadwaladr University Health Board

Ysbyty Gwynedd Penrhosgarnedd Bangor LL57 2PW

Cardiff & Vale Health Board

Whitchurch Hospital Park Road Whitchurch Cardiff CF14 7XB

Cwm Taf Health Board

Chief Executive's Offices Ynysmeurig House Navigation Park Abercynon CF45 4SN

Hywel Dda Health Board

Merlin's Court Winch Lane Haverfordwest Pembrokeshire SA61 1SB

Powys Local Health Board

Mansion House Bronllys Hospital Bronllys Powys LD3 0LS

Velindre NHS Trust

2 Charnwood Court Heol Billingsley Parc Nantgarw Cardiff CF15 7QZ

Public Health Wales

1 Charnwood Court Heol Billingsley Parc Nantgarw Cardiff CF15 7QZ

Welsh Ambulance Services NHS Trust

Trust Headquarters HM Stanley Hospital St Asaph Denbighshire LL17 0R

For the purpose of updating, these contact details will be an agenda item at the annual meetings and any revisions will be disseminated electronically via the dedicated NHS Fire Services website.