FIRE SAFETY


Dust build-up in a ventilation duct. Ducts not accessible for thorough cleaning should always be categorised ‘high risk’.


NHS Confederation survey2 in June 2022


– and this will come as no surprise to HEJ readers – sounded the alarm over the ability to meet the Government’s ‘ambitious targets’ to reduce the elective care backlog being ‘hampered by the £9.2 bn maintenance bill that has built up over the past decade’.


Defining the problem The root cause of so many fire dampers dropping out of the regular inspection and testing regime is that ventilation systems throughout much of the NHS estate lack the access hatches needed to facilitate mandatory inspection, cleaning, and regular fire damper testing. Estates teams may have lost track of the infrastructure in older buildings over the years, as changes are made incrementally, or they may fall foul of fundamentally bad design and installation in newer establishments. Often there are no accurate asset registers – Estates teams may not know where their dampers are, let alone their condition or model numbers for spares. In theory, new buildings and


refurbishments should not have these issues, as lack of access should largely have been designed out by the guidance in the 2021 revision to HTM-03 Part A: The concept, design, specification, installation and acceptance testing of healthcare ventilation systems, which was a major rewrite of its 2007 predecessor. Right up front in its introduction, it now emphasises the fundamental importance of designing with future maintenance, cleaning, and testing, in mind. (More specific guidance on damper design and installation is given in HTM 05-02: Fire safety in the design of healthcare premises).


Estates & Facilities Alert warning Of course, all that is cold comfort if your design preceded the guidance. So, let’s look at what that Department of Health Estates and Alert said in more detail: ‘There have been recent reports in the national media regarding the lack of


64 Health Estate Journal November 2022


Easily accessible ducting post-clean.


suitable access to fire and smoke dampers, and their actuating mechanisms, to enable inspection, maintenance, and testing, to be completed in a safe and competent manner.


‘It has been highlighted that in certain


circumstances, due to incorrect design and installation, maintenance personnel cannot gain safe access to facilitate the necessary statutory inspection of the fire and smoke dampers and their actuating mechanisms. In addition, there has been a failure to record the full details of where fire- stopping has been installed, hence causing difficulties in ensuring its integrity is maintained. This results in the organisation responsible for the building potentially being in contravention of Article 17 of the Regulatory Reform (Fire Safety) Order 2005, thereby putting patients, visitors, and staff at risk in the event of a fire.’


The Action Plan The 2014 Estates Facilities Alert goes on to outline an Action Plan to maintain essential fire-stopping, as follows:


Fire and smoke dampers ‘All healthcare organisations should review their existing risk assessments and inspection/maintenance regimes relating to the inspection, maintenance, and testing of fire and smoke dampers, and their associated actuating mechanisms and control systems. They should ensure that they have a full inventory of all installed fire and smoke dampers within their premises. All installed fire and smoke dampers, and their associated actuating mechanisms and control systems, should be included in a formal maintenance programme to ensure that they are inspected and tested in order to confirm that they: meet regulatory guidance and are fit for the purpose they are intended for, and are in good working order, and have not been damaged, disconnected, or wedged open. ‘Where a lack of safe access to a fire or smoke damper, and its associated actuating mechanism, is identified, this


should be brought to the immediate attention of the Director of Estates & Facilities and the Trust Fire Safety Manager / Fire Advisor. Where problems are identified, a programme to repair or replace damaged fire and smoke dampers, and associated actuator mechanisms, should be put in place. Once any repair or replacement programme has been completed, the fire risk assessment for the premises should be updated, and key findings brought to the attention of all staff that might be affected.


Fire-stopping ‘All healthcare organisations should review their existing risk assessments and inspection regimes relating to the inspection of fire-stopping. They should ensure that they have a full inventory of fire stopping within their premises (see HTM 05-01 Appendix E – Developing fire safety protocols for advice on the information that should be collated). ‘If not already in place, systems should be implemented to ensure the integrity of fire-stopping can be confirmed within the organisation’s premises. This should incorporate permit-to-work systems that ensure fire-stopping is reinstated during, and following, works (e.g. construction, installation or maintenance) that may impinge on the integrity of the installed fire-stopping.


Is there an alternative approach? The answer to this question is – in a nutshell – no. Inspection and testing are essential, and need to be scheduled. If fire dampers cannot be accessed, new hatches need to be fitted. Unfortunately, sometimes it is not just a case of fitting access hatches, since some dampers are not safely accessible without the installation of safe stairways, walkways, and adequate lighting.


Plenty of guidance – including from IHEEM There is much guidance on the topic of


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