Featured in Health Estates Journal, September 2010
Peter Barker, Senior Consultant at Chiltern International Fire Ltd, discusses the importance of training and competence with a focus on estates departments within the healthcare sector.
When the Regulatory Reform (Fire Safety) Order 2005 (RRFSO) and Integrated Risk Management Plans (IRMP) for fire authorities were introduced, they represented a major shift in approach to fire safety in England and Wales, with a change in emphasis from intervention after the event to prevention.
Fire authorities are now tasked with managing potential risks and resources within their authority area using the IRMP process while, under the RRFSO, all premises must have a suitable and sufficient risk fire risk assessment. Healthcare premises are certainly no exception.
The effect of the new fire safety regime has been twofold:
- Those responsible for fire safety in healthcare premises have had to re-address their fire risk assessments and strategies to ensure compliance with the new legislation.
- It has been reported by healthcare fire officers that the emphasis the fire and rescue authorities now put on healthcare premises has greatly increased in terms of the number of inspections and the level of detail given to each inspection.
The outcome of this is that whilst the profile of fire safety within the healthcare sector has certainly been raised, shortcomings have been identified, not as commonly with the fire risk assessments and strategies for the hospital, but primarily with the equipment put in place to protect in case of fire.
It is important to look at what issues have been raised by the RRFSO in terms of training and competence of personnel, supported by an understanding of how to react to the findings of the fire risk assessment, and the role of PPM (Planned Preventative Maintenance). With a focus on passive fire protection, consideration will be given to why it is important in a health care environment and how best it can be maintained in times of budget restraints.
There has been a mixed reception to the RRFSO and despite being four years into the new regime, there remains a significant level of disparity among fire and rescue authorities in terms of enforcing the order. Some healthcare premises are being hit with enforcement notices, whereas in other areas the fire and rescue authorities are seemingly still adopting a lighter touch approach. Whatever the scenario for the service area that a particular healthcare premises is operating in, it is important to receive pragmatic advice for maintaining the fire safety provisions within a hospital, which should be considered best practice regardless of the fire safety law being dictated at the time.
Passive Fire Protection and Phased Horizontal Evacuation
Health sector buildings have particular fire safety challenges, predominately in safeguarding patients with a wide range of dependencies in the event of fire. In addition, the size and complexity of a modern day hospital or care centre will often mean that complete evacuation of the building is neither practical nor appropriate.
It is for this reason that the most common approach adopted in health care buildings is progressive horizontal evacuation, moving occupants from the fire-
affected area, through a fire resisting barrier to an adjoining area, which is designed to protect the occupants from the immediate danger of fire and smoke. The occupants then remain in the fire safe area (refuge) until the fire is extinguished or, if necessary, further evacuation is required to another refuge or down the nearest stairway.
Obviously key to this strategy, in conjunction with other fire safety measures, is the use of fire resistance compartment lines to form the barrier between the fire and the refuge points, and fire doors to allow the passage of persons and objects through them. If the fire resistant compartment lines cannot be relied on, the evacuation strategy for the hospital will be severely compromised and the lives of patients, staff and visitors will be placed in jeopardy.
Whilst there are an increasing number of new build and existing hospitals fitting sprinklers, and modern health care facilities built to a fire engineered design, currently the largest percentage of hospitals in the UK still adopt the above strategy and therefore rely heavily on adequate passive fire protection.
It is also worth remembering that healthcare premises cannot rely on external rescue by the attending fire and rescue authority, or manipulative types of escape appliance such as chutes or portable ladders. In an emergency, the patients and visitors should be able to move or be moved to a place of safety with the assistance of hospital staff only.
Responding to the Fire Risk Assessment
The majority of hospitals in the UK have evolved over many years and as a result the doorsets within each part of the hospital vary in condition and age. For the layperson this can make it very difficult to ascertain the current fire resistance performance of the doors, yet this is the question often raised by the fire risk assessor or inspecting fire officer.
Generally, all doors would have been originally installed as fire resisting doorsets, compliant with the relevant standards and codes in force at the time. However, over time, any supporting documentation may be lost and/or the door may be changed from its original specification. Changes to a fire resisting doorset are often made for non-fire related reasons, such as the addition of crash plates and edge guards for doors in heavy traffic areas and glazed apertures being cut to comply with a change in regulations such as the DDA (Disability Discrimination Act). All of these changes could have a negative impact on the door’s fire resistance if they are not compatible with the original supporting evidence or carried out correctly.
Product certification is explained in greater detail in the last section of this article, but it is worth mentioning here because it is possible that some of the doors within a hospital were installed before the existence of such schemes. A product certification scheme certifies compliance with the requirements of a recognised document and provides confidence that the product will perform as expected, as well providing an audit trail back to the manufacturer, and the supporting test evidence. Although product certification is not currently mandated in the UK, NHS bodies are encouraged to utilise such schemes, through the advice given in HTM 05-02: Guidance in support of functional provisions for healthcare premises. HTM 05-02 also highlights the importance of schemes for the accreditation and certification of installers and maintenance firms as they will offer confidence in the standard of workmanship provided.
If the condition of the doors in terms of the overall fire strategy of the hospital is uncertain, or if their location within the hospital is particularly high risk in terms of escape in the event of fire, such as an intensive care unit, the risk assessor or the inspecting fire officer might ask for supporting evidence of the doors’ fire resistance from an independent expert body.
If the inspecting officer considers the fire doors are particularly deficient, the request for proof of performance or suitable upgrading may also be coupled with an enforcement notice.
In the absence of a ‘paper trail’ or certification plug or label clearly linking the door to the original manufacturer and the relevant supporting test data, proving the fire resistance performance of the door is very difficult and leads to the question of whether the doors should be replaced or upgraded.
Financially it simply is not possible to replace all of the doorsets within a hospital with new fire doors that carry the appropriate supporting documentation and/or certification and this isn’t actually necessary in the majority of cases. It is, however, possible for a suitably qualified independent body to survey the doors to establish their expected existing fire resistance and specify the necessary remedial works to reinstate it to what it should be. Survey work can be planned to coincide with a programme of upgrading of fire safety provisions to suit the hospital.
The survey process will identify those doorsets that cannot be upgraded to meet the required level of fire resistance. It will also identify the doors that can be retained and the report will sit as the supporting documentation for the performance of the doors providing the required remedial works are carried out in full. Overall it should save the hospital a significant amount of money by avoiding unnecessary replacement or inappropriate upgrading. The survey process can also be linked to the hospital’s PPM programme in order to maintain a log for each door on site to identify its current status (replaced, upgraded or retained).
Fire Doors – Damage Prevention and Maintenance
Fire risk is something that has always been taken seriously within hospitals, as has the installation of equipment to help mitigate the effect of fire and to aid the process of evacuation. Virtually all healthcare premises, therefore, have good strategies in place for fire risk management.
Understandably one of the biggest problems in a hospital is the maintenance of fire safety equipment, especially those assets that are prone to a high level of abuse and wear and tear, for example fire doors.
There are other areas of passive fire protection that become degraded over time within the built environment, eg the fire stopping of services and penetrations through compartment lines. It is beyond the scope of this article to cover all aspects of passive fire protection in detail. However, much of what is covered with respect to fire doors can be applied to all elements of fire safety (competency, training, certification of products and personnel).
Preventing Damage
There are a number of reasons why the condition of a fire door becomes degraded over time:
- Location of the door in a heavy traffic area
- Incorrect specification of a doorset (not suited to environmental conditions)
- Deliberate vandalism
- Ignorance and misuse
Deliberate vandalism cannot always be avoided and any door located in a heavy traffic area will degrade over time, but it is possible to correctly specify a door for an end use with knowledge of the options available. The key reasons why fire doors break down is misuse as a result of a lack of knowledge in the role of a fire door, in terms of its performance in fire, and how its performance becomes seriously degraded by damage.
The ideal situation is to prevent damage in the first place. Damage is predominately caused by staff within the building, transporting patients and goods, and an important contribution to the condition of the door can be made if the staff are encouraged to use the installation in a caring manner. This is especially important for personnel who use equipment and machinery that have a high risk of damaging the door, such as manually operated lifting devices,, food/goods trolleys, beds etc.
The main points to stress are:
- The cost of repairing, maintaining and installing fire resisting doorsets. By looking after the fire doors, a significant contribution is made in maintaining the value of the estate and it allows money to be spent elsewhere within the hospital.
- Repairing and replacing fire doors disrupts business continuity and negatively impacts on the patients’ environment.
- Ultimately a fire door that has been seriously damaged will not perform its required function to resist the passage of fire and smoke. Fire doors are integral to the fire safety and escape strategy for most hospitals. By damaging fire doors, staff could be potentially affecting the patients’ and visitors’ safety as well as their own.
- Defective passive fire protection could allow a fire to destroy a greater part of the building. This will increase disruption to the hospital and have a negative impact on the community in terms of available healthcare provisions until the wing/hospital is rebuilt.
Staff training should include why fire doors are relevant in the overall fire strategy of the hospital and how the performance can be degraded by misuse. This is best visually displayed by showing what fire conditions a fire door has to cope with and examples where fire doors and items of passive fire protection have not only aided escape, but also helped with property protection and business continuity.
In fact it is also worth remembering that it is a legal responsibility of staff under article 23 of the RRFSO not to interfere with or misuse anything (building elements) provided by an employer in the interests of fire safety.
The Role of the Estates Department
Generally speaking, the maintenance of the building systems and infrastructure provided for fire safety is the responsibility of the director of estates or other senior manager responsible for the relevant maintenance budget.
A large number of estates departments within health care organisations use Planned Preventative Maintenance (PPM) as the best approach for providing an efficient maintenance service by regular inspections of the equipment dictated by relevant risk assessment, professional judgment and local circumstances. Fire doors therefore feature heavily in the PPM process.
In a demanding environment such as a hospital it is inevitable that there will be damage to fire doorsets over time and the PPM process will pick up the doorsets in the problem areas.
The maintenance team can then look at suitable repair works, upgrading measures such as edge protectors, replacement of glazing, crash plates. Other items of careful planning should always be considered, for example:
- Providing recessed pockets in busy corridors within which the fire door is on a hold-open device wired to the detection system. This prevents the doors from becoming damaged by impact from trolleys etc but still allows the doors to swing shut on activation of the alarm. If it is not possible to provide recesses for the doors, hold open devices can still be used in conjunction with buffer posts protecting the leading edges of the door.
- Fitting wheeled equipment with soft buffers to limit impact damage
- Delayed action self-closing devices to allow the passage of goods and persons with reduced mobility.
Regardless of whether external contractors initially installed the fire doors, it is invariably the estates team in a hospital that will be carrying out the repairs.
Estates departments may have the skills for carrying out the required maintenance of fire resisting doorsets, but only with the correct training. A suitably trained engineer will not only know what to look for in terms of critical damage to a fire doorset, but also how to repair the door to reinstate its integrity.
A comprehensive training programme, carried out by an independent expert, should demonstrate the relevance of maintaining and correctly specifying fire resisting doorsets and also highlight the importance of considering doorsets as a complete installed assembly. The training should ideally be tailored to suit the needs of the estates department.
Without suitable training the inherent risk is that critical problems with the doors are missed during the PPM process or a lot of money is spent on upgrading the door and little is achieved in improving or reinstating the doorsets’ fire resistance. In more than one instance, we have spoken to a building manager who has spent a considerable amount of money upgrading doors, only to discover they are unlikely to perform for more than 10 minutes in a fire because of an oversight in a fundamental component such as glazing. The main danger is the subsequent reliance on systems that will not perform as expected.
Certification of Products and Personnel
Certification of products and personnel is ideally suited to the health care environment. It is possible for members of an estate department to become certified installers of fire doors should it be desirable to bring the skills in house, instead of using external contractors.
Fire resistance is proven through destructive fire testing and by assessment. Third-party certification, such as the BM TRADA Q-Mark, goes beyond testing, in that it demonstrates consistency of manufacture which, in combination with test evidence, provides the confidence that every product will perform as expected. A rigorous certification scheme usually insists on audit tests on the product and verification of factory production control procedures. This type of scheme will ensure that:
- The quality of the product, when sold to an end-user, is of a similar quality to that tested, and
- The product should be expected to achieve the minimum stated fire resistance period that has been tested and claimed.
The complete manufacturing process must be quality controlled to the relevant Internationally recognised quality management standard (such as an ISO 9000 series or similar system), with the process audited annually to ensure that areas such as calibration of equipment, handling of materials, stock control manufacturing processes and documentation are all controlled and meet prescribed standards. Further audit fire testing of the product is also required, usually every three years.
Fire door installation is an equally specialised area and there are increasing calls for installers, too, to be certified under a similar third-party scheme. Training will usually form part of the scheme, along with on site audits to ensure consistency. Estates managers can therefore be assured that if certified products are installed by registered installers they will perform as expected should a fire occur.
Summary
Competency of individuals is critical for any industry involved with life safety, and fire protection is no exception. As defined by the RRFSO and HTM 05-02, this means someone who has sufficient training, experience or knowledge and other qualities to properly assist in undertaking the preventative and protective measures.
The estates department have a key role in maintaining protective measures within the hospital and it should be ensured that they have the necessary knowledge to accompany this by appropriate training and/or certification of individuals within the team.
It is also clear that explaining to all members of staff that by using fire doors in a caring manner they can play a significant part in reducing damage to the hospitals fire safety provisions, which benefits all users of the hospital or healthcare facility.
PDF: Passive Fire Protection: Planning, Preventing and Maintaining
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