Firecode: what’s new, and what do I need to do?

Ensuring fire safety in all healthcare premises is of the utmost importance. The amount of medical equipment and gases, the size and complexity of the buildings, and the vulnerability of our patients, means that it is a complex task. Following the tragic fire at Grenfell Tower in London in 2017, the Government initiated the Independent review of building regulations and fire safety,1 chaired by Dame Judith Hackitt. This looked primarily at safety in high-rise residential buildings, but some of the recommendations are applicable to healthcare buildings too. Dame Hackitt’s recommendations have resulted in primary legislation in the Building Safety Act 2022 (the Act), and a large amount of secondary legislation, including the Higher-Risk Buildings (Descriptions and Supplementary Provisions) Regulations 2023.

NHS England — in its role of ‘leading the NHS to deliver high-quality services for all’, is responsible for producing technical guidance and setting standards. An extensive scoping exercise in 2022 identified three key areas in the HTM 05 series of Firecode,2 which have now being revised and issued, as follows:

HTM 05-03: Operational Provisions
Part A: Training.
HTM 05-03: Operational Provisions
Part B: Fire detection and fire alarm systems, including the reduction of false alarm and unwanted fire signals.
HTM 05-03: Operational Provisions
Part K: Guidance on fire risk assessments in complex healthcare premises.

This article is the first part of a series looking at different aspects of these three documents. It will discuss management and maintenance of fire alarm systems, as well as false alarms and unwanted fire signals, as outlined in HTM 05-03 Part B. These are just some of the subjects covered in this revised HTM, and the whole document should be thoroughly read, understood, and applied.

Management

The revised Firecode Parts A, B, and K have re-defined existing roles for Authorised Persons, namely: Authorised Person (AP) fire safety training, AP fire safety maintenance, and AP fire safety risk assessment.

These roles may be currently undertaken by the Fire Safety Advisor (AP Fire), especially in smaller organisations. However in larger organisations several persons may be required, each competent in one or more areas.

In addition to the Authorised Person (Fire) described in HTM 05-01, this document introduces the new role of Authorised Person (Fire Safety Maintenance). Where necessary, this function may be shared by more than one person. In addition to appointing a competent person, as required in the Regulatory Reform (Fire Safety) Order 2005 (FSO) Article 18(1), for large sites with extensive fire alarm systems consisting of multiple panels, an Authorised Person(s) (Fire Safety Maintenance) should be designated who has extensive knowledge of the system. This person should be directly employed by the healthcare organisation, and their roles will include:

Briefing and liaising with design teams/project stakeholders, and receiving and reviewing proposed design and handover documentation.
Reviewing and commenting on proposed design variations from
HTM 05-03 and BS 5839-1.
Reviewing and verifying that contractor accreditation and competence is valid and appropriate for specified works (for example, third-party certification to appropriate scope).
Being an attendee at the Fire Safety Committee meetings.
Ensuring compliance with HTM 05-03 Part B.
Liaising with the fire alarm company (Competent Person).
Ensuring that any changes to the premises or changes of use are in line with HTM guidance, and do not compromise the existing fire detection and alarm system.
Forming part of the fire response team, and attending any actuations of the fire alarm.
In conjunction with the Authorised Person (Fire), investigating any false alarms with a view to reporting their cause and reducing their incidence as far as reasonably practical.
Overseeing the fire alarm isolation permit system.
Checking and responding to faults regularly.
Ensuring that an appropriate permit to work system is maintained for contractors, including for hot works.
Ensuring that critical spares are available.
Ensuring that the correct level of testing is being successfully completed.
Ensuring that a suitable emergency plan is in place to cover the non-functioning of part of the fire alarm system.
Preparing an annual report to be available to the director with fire safety responsibility on the fire alarm system, to include required maintenance and the incidence of false alarms.
At least annually, ensuring that the items in BS 5839-1, Section 45.3(b), are checked.

Fire alarm maintenance

The fire alarm system in a large hospital is different to that in any other building, in that:

There may be hundreds of detection and alarm zones.
There may be thousands of automatic detectors.
There may be thousands of fire alarm call points.
The cause and effect may extend to thousands of items.
In patient treatment areas the alarm is designed to alert staff, not to wake or alarm patients.
In patient treatment areas there are usually several staff who are trained in the emergency plan — including what to do on discovering a fire, such as how to raise the alarm.

Previous versions of HTM 05-03 part B relied on the relevant parts of 
BS5839-1 with regard to fire alarm maintenance. As the BS5839-1 guidance provides general guidance on this, some of the recommendations were inappropriate and ineffective in a complex healthcare environment. For example, in a hospital with thousands of call points and hundreds of alarm zones, it would take many years to cover the whole hospital using the weekly fire alarm test recommended in BS 5839-1. The weekly test may thus serve very little useful purpose. Modern fire alarm systems incorporate a high degree of monitoring, with the individual components of the system monitored continuously so that either (a) faults are automatically identified, or (b), the system can be interrogated to identify components that are outside of normal parameters.

Extensive section on maintenance

The revised Part B now includes an extensive section on maintenance, which is specific to complex healthcare premises. The status of this document as issued by a government department is akin to one issued under Article 50 of the Fire Safety Order. In the hierarchy of documents, this thus takes precedence over a British Standard — in this case BS 5839-1.

HTM 05-01, in appendix E, details protocols which should be developed to underpin the fire safety policy. 
These should include a protocol of maintenance of fire safety facilities and equipment, including fire alarms. When 05-01 is reviewed this will go into more detail.

Is the weekly fire alarm test necessary?

Unless there are critical systems/areas which require such testing, or the maintenance strategy/protocol requires it, the weekly test, as described in BS 5839-1, may be ineffective in a hospital with several thousand call points and numerous alarm zones. A risk-assessed approach may reduce or eliminate the necessity for weekly testing. Local staff, such as fire wardens, porters, security staff, or estates personnel, are best placed to complete regular checks of aspects of the fire alarm systems, which may include the monthly testing by the user.

Where feasible, and in line with the healthcare organisation’s protocols, a visual check should be made of all fire alarm detectors, call points, and sounders, to ensure that:

They are unobstructed and that call points can be easily seen.
They are in apparently good condition and undamaged.
The detectors do not have any stacked storage within 500 mm of the device, and no storage close to the detector is within 300 mm of the ceiling.
Detectors are not covered, and that smoke is not prevented from entering the detector.

These checks can be incorporated into monthly checks completed by Fire Wardens. In areas where there are no Fire Wardens, it should be ensured that the checks are completed (for example, in areas such as common parts and plantrooms).

Inspection and servicing by competent person

In fire alarm systems which continuously monitor detectors and faults, or in 
which warnings are annunciated, the following clauses in BS 5839-1 may become unnecessary subject to the 
cause-and-effect testing described in paragraph 7.20:

Section 45.4 a) b) c) d) j) (this includes call points and most fire detectors).

In addition to the guidance in BS 5839-1, the following should be implemented:

The cause-and-effect schedule for the system should be available, and there should be confidence in the schedule. The schedule should have been fully tested and proven prior to project handover. Where the following is in place the cause-and-effect should be checked: ­where any significant changes have occurred in the past 12 months, and where there are ­fire door release mechanisms which only operate on activation of detectors on either side of the door (as opposed to those that operate on activation of any device in that zone).

A percentage of the cause-and-effect is to be tested annually. This should include detection devices and call points. Such a percentage is to be rotated, so that different areas are checked annually, or as determined by the risk-based programme, which may deem that more regular testing is required. The percentage to be checked should be agreed by the Fire Safety Committee with relevance to the specific site and system. Where the checks uncover significant discrepancies, the percentage to be checked should increase accordingly.

False alarms and unwanted fire
signals

A ‘false alarm’ (see Figure 1) is defined as ‘activation of the fire detection and alarm system from a cause other than fire’. Given the thousands of fire and smoke detectors and call points typically found in a complex healthcare facility, Firecode Part B recognises that the complete elimination of false alarms may not be possible. However, each healthcare organisation should continuously strive for their elimination through careful design, appropriate equipment selection, adequate reporting, recording, and then investigation and rectification, of the causes of false alarms. Every false alarm should be investigated by the Responsible Person, Authorised Person (Fire Safety Maintenance), or the Authorised Person (Fire), and efforts taken to identify the root cause. The investigation should include the involvement of all stakeholders, and the action to be taken to eliminate recurrence.

Where false alarms are persistent, 
they can cause disruption to services, erode staff morale, and cause patients distress. This can also lead to a loss in confidence in the fire alarm system, with the risk that people will not respond appropriately when a fire detection and alarm system raises an alert to a real incident.

The number of false alarms should be reported at least quarterly, and should be included in the healthcare organisation’s annual report, including trends over the past three years. The Authorising Engineer (Fire) should include this in their audit, and it should be included in the annual internal audit, as outlined in HTM 05-01.

Unwanted fire signals

The term, ‘An unwanted fire signal (UwFS)’, refers to the point at which a false alarm results in a request to the fire and rescue service to attend. UwFS are disruptive and costly to the fire and rescue service. They can divert essential fire and rescue service resources from real emergencies, putting life and property at risk. They cause unnecessary risk to fire crews and the public while responding to an UwFS. Hospitals are a major source of UwFS.

A ‘seek and search’ system may be introduced for specific buildings. However, generally, it is preferable to have the same system in place site-wide. ‘Seek and search’ in this context refers to a delayed call to the fire and rescue service. A robust protocol should be established and disseminated to all staff concerned, to ensure that the appropriate procedures are followed for each alarm signal generated.

These arrangements should be included in the fire risk assessment, fire safety policy, and emergency plan for the healthcare facility, and will be dependent on the healthcare facility, its occupancy, and use. In addition to using information from the facility’s users, modern technology provides a range of options for confirming the cause of an alarm. The best way to prevent false alarms from being transmitted as UwFS to the fire and rescue service is to stop them on site.

On activation of an alarm, the fire response team should be sent to investigate the incident without compromising their safety. Those staff sent to investigate should be appropriately trained, and have sufficient means of readily contacting the central point from which the incident is being controlled. On arrival at the area where the alarm activation occurred, attending staff should communicate the status of the incident immediately to the central control point. This allows the fire and rescue service to be summoned at the earliest opportunity, or the alarm to be cancelled, and a call to the fire and rescue service avoided as appropriate.

If there are no signs of fire apparent, but the fire alarm will not reset, and there is no obvious cause (such as a broken call point), the fire and rescue service should be called to assist in the investigation. There should be a suitable timing device used to assess the ‘seek and search’ time. This may form part of the fire alarm panel. The system should be fail-safe, and result in a general fire warning without intervention.

Suitable communication

There should be suitable communications between the fire investigation team and the switchboard or other person responsible for calling the fire and rescue service. Seek and search teams are responsible for identifying if there are any signs of a fire, not the fire itself. These include sounds, smells, and signs of smoke. They should always operate with a minimum of two people, and should never put themselves at risk. If the cause of the alarm is not identified within the pre-determined time, and the fire alarm reset, the fire and rescue service should be called.

Generally, the fire and rescue service would be summoned where an investigation by trained hospital staff has resulted in the discovery of a real-time fire incident requiring intervention from the service. However, the following situations should always result in the fire and rescue service being summoned:

A telephone call from a member of staff on the designated emergency number (even if the fire alarm is not actuating) indicating that there are signs of fire (sight, sound, smell).
More than one device (call point, fire detector, etc.) actuating on the fire alarm.
Actuation of the fire alarm in an area where there are very high dependency patients.

Conclusions

HTM 05-03 part B introduces an opportunity for those responsible for fire alarm systems in complex healthcare premises to develop their own protocols for the management of maintenance, false alarms, and unwanted fire signals. There is scope to develop systems which make best use of available resources and comply with legislative requirements.

Next article

The next article in this series will take a close look at HTM 05-03 Part A, which now solely covers fire safety training. In addition, NHS England will be hosting a webinar on the new 05 series HTMs, and is continuing to work on reviewing the HTM 05 series, the next of which will be HTM 05-01 on fire safety management.

References

1 Independent Review of Building Regulations and Fire Safety: final report. Ministry of Housing, Communities & Local Government, 17 May 2018. https://tinyurl.com/5n84cvym

2 HTM 05-03: Firecode — Fire Safety in the NHS — Operational Provisions. NHS England, 12 April 2024. https://tinyurl.com/bdezc5xm