"The main thing about the new Order," observes Peter Aldridge, fire safety manager at Leeds Teaching Hospitals NHS Trust, "is that the fire service does now have quite extensive powers of enforcement, working off the same model as the HSE inspectors, so the fire service really does have teeth now. And as healthcare has been identified as the highest-risk premise, there is an expectancy that fire officers are going to be very particular."

Aldridge understands better than most how the new regulations work. He was awarded the Chubb-sponsored Fire Safety Manager of the Year prize at the annual Fire Industry Awards last June, in recognition of his work at Leeds Teaching Hospitals since joining as fire safety manager in 2005.

His time in the past two years has been more than taken up with making sure the country's largest health trust was able to satisfy those fire officers that the trust meets the requirements of the Regulatory Reform (Fire Safety) Order 2005 (known variously as the RRO or FSO), which finally came into force in October 2006, replacing a broad set of fire-safety-related legislation with one single regulation.

Who's responsible?

The most significant change that came with the FSO was that it swept away the regime that involved a fire authority inspecting a building and issuing a Fire Certificate, and replaced it with one where an employer or "responsible person" in charge of the premises is required to assess fire risk and take steps to reduce or remove it.

This shift of emphasis means that an organisation must assign a responsible person as the principal duty holder under the FSO but, as Aldridge explains, that isn't quite where the buck stops.

"We have over 14,000 employees and at the top of the shop we have a chief executive. While an enforcement notice would be served against the chief executive officer, you've got to ask 'although a CEO has the ultimate responsibility, have they the sole responsibility in an organisation where they employ people looking at the very specific issues pertaining to risk on their behalf?'

"Wouldn't you then, under the CEO's remit, nominate people that you see within the organisation as having particular responsibility for fire safety? ... If something had gone wrong and the fire services were looking at enforcement, there could be a chain of people below the chief executive, who may have to account for their acts or omissions."

This chain is made up of the "competent" people that the FSO says the responsible person can appoint (either in-house or on a consultancy footing) to ensure their fire precautions are sound.

As the largest NHS Trust, Leeds Teaching Hospitals - with 14,902 staff and 3200 in-patients at any one time - decided such a major change in fire safety legislation required the creation of a dedicated fire safety manager post and in 2005 Aldridge took on the role (having served as a watch commander in the Royal Air Force Fire Service) with the remit of making the changes necessary to comply with the FSO.

How long is a piece of string?

Though he says in most areas he finds the fire services helpful and supportive, Peter Aldridge echoes the frustration of many managers tasked with ensuring compliance with the Fire Safety Order (FSO or RRO) about the difficulty in getting the authorities to define what some of its general requirements mean for day-to-day procedures.

"When you ask how often you should be doing this, that or the other, they say, 'It's up to you to do a risk assessment on that.' Then you'll find they come in and challenge your risk assessment. And you say, 'Well you told us to do a risk assessment, but you are not happy with the outcome of it. What would you recommend we do?' And they say, 'Well that's up to you, that's the whole spirit of the RRO.' But at other times they go the other way and come straight in and say, 'You have to do this, this and this' and be very prescriptive. It's difficult to come to common ground with them sometimes."

Widespread competence

Aside from Aldridge and the fire safety officer and fire engineer, the list of competent persons at the trust is now a long one. It takes in the director for estates and facilities, the maintenance managers for each building, external suppliers servicing the firefighting equipment, plus numerous ward matrons.

"To try and satisfy the requirements of an audit, we named those in our organisation who we believe have a specific responsibility for fire," explains Aldridge.

"This will include obvious people like the fire safety manager, but we also included matrons, because a matron has day-to-day management responsibility for patients, and part of that is patient care, which includes the safety of the patients in the wards and departments.

"We would also include people like our maintenance managers because they have the responsibility for ensuring that servicing is carried out on equipment in accordance with British Standards, and so on."

The trust stock comprises five acute hospital sites spread across the city centre and the outskirts of Leeds, plus seven premises that support their operation, including laboratory buildings, a pharmaceutical store, print unit and offices.

Fire prevention and management needs vary enormously across the different sites, from the laboratory or workshop areas working with flammable liquids and gases, to the hospital wards where the hazards are fewer but all the emphasis is on provisions for safe evacuation of patients who may have limited mobility.

Apart from the creation of a new fire safety hierarchy, the biggest change necessitated by the FSO was to the risk assessment process, says Aldridge.

"Although it had been a requirement under the Fire Precautions (Workplace) Regs to have risk assessments in place, those assessments could only be viewed as a very good baseline to start to look at compliance with the RRO."

He says the old regulations focused on working areas, but didn't take into account patient care. Special NHS guidance on risk assessment in such areas - the Health Technical Memoranda - gave more guidance on risk evaluation in wards and clinical areas, but it wasn't completely compatible with the FSO.

It required assessments based on average conditions, for example, while the new Order specified assessments that covered worst-case situations.

"The RRO also talks about risk assessments looking at all relevant persons on your premises: people coming in, people passing your front door. It called for a greater depth of risk assessment," he notes.

The result was a complete overhaul of the risk assessments for each area, still ongoing, preceded by a full audit of the trust's fire safety procedures and a review of all the fire equipment.

"One of the big differences between a hospital and, say, a factory or an office block is that we have to carry out an individual risk assessment for each area or ward or department area," he says. "So you are looking at hundreds and possibly thousands of assessments. It isn't going to be something you can do overnight."

As Aldridge and his team complete the new risk assessments for each department or building, the documents are collected in a local register. The register includes the date when the risk assessment was carried out and when it is due for review. The goal is to review each assessment within 12 months, or earlier if any local change might alter the risk level.

"If there was any change of use of the ward or department area, for instance, we'd go back to it," he explains, "or if there's any structural work or refurbishment. Or we might review the assessment as the result of a false alarm."

It's important, he believes, to view the risk assessment as "very much a working document that's on the go all the time. It's not something you do and park it on the shelf. We're constantly revisiting it."

First response

As a result of Aldridge's review, each of the hospital sites now has a dedicated fire response team. A typical day team will include hospital security staff, an engineer and the estates manager. On the night team, the estates manager would normally be replaced by the site matron or senior nurse who will carry a fire bleep. The team will respond to the fire call, deal with the fire brigade and give them access to restricted areas.

Training has played a very important part in developing the fire safety programme. There are 20 different modules of training depending on where the individual works and their level of responsibility.

"Every single member of staff receives a minimum 45 minutes of fire training a year," says Aldridge. "Normally it's an hour ... Each member of staff is almost trained to the level of a fire marshal, so on a day-to-day basis if they see a problem they'll report it. And if a fire alarm goes off, everyone takes responsibility to ensure rooms are checked.

"We don't have just one specific person who does it because it becomes almost unmanageable in a hospital, because we have a very transient population, so the chances of one fire warden being in the department when a fire alarm goes off is unlikely.

"If everybody understands that if a fire alarm goes off we've got to check patients' toilets etc, and look after relatives and visitors, we'll have covered all bases."

They rotate the annual fire training update for nursing staff to cover topics such as fire extinguisher use or service continuity and care of especially vulnerable patients (such as those with dementia) during a fire evacuation.
Training for the matrons and managers nominated as "competent" for the purposes of the FSO is updated at six-monthly management workshops.

"We'll concentrate on a specific issue each time," he explains, "so the one at the back end of last year focused on arson, and how they, as managers, can control some of the issues that lead to arson in hospitals: making sure their areas are kept clear and waste procedures are followed."

Apart from its value in an emergency, Aldridge says the training is an important element of the trust's proof to fire safety inspectors that they are adhering to the FSO.

"It's no good saying we do train staff," he says. "They want to see the evidence, so they need to see lists of attendance, what that fire training session included and was it appropriate to what that member of staff is expected to do in event of a fire. And it's also important to prove that your evacuation procedures work and if they work at 2 o'clock in the afternoon they will also work at 2 o'clock in the morning."

Fire and evacuation drills are no easy thing in a hospital, because moving patients is unlikely to speed their recovery. Aldridge has found his own ways of enacting fire scenarios in wards.

So when determining the dynamics of evacuating a bed through a fire door, for instance, he says you don't necessarily need a patient on it to check the safest way. Where bodies are essential, he organises role-play sessions where staff double up in the roles of patients and visitors.

Aside from people and procedures, Aldridge and his team also became "more robust in the way our equipment was serviced." They brought a new supplier in to take care of fire safety maintenance, which included the provision of more than 4000 new fire extinguishers across the site.

In the spotlight

Leeds Teaching Hospitals Trust is aiming to have the risk assessments for every single building in a form that fully complies with the RRO by this July. At the moment, there are still three different forms of risk assessment on file in different areas involved.

"It's not something they could get into place overnight, so we've started to look at all the risk assessments with the aim to get them into one format by July 2008," says Aldridge. "It's no quick job to get to a line of compliance.

Fire and rescue authorities, he reports, "have been very helpful on timelines because they appreciate you can't get these things done overnight, and provided you've a baseline and they can see that you're moving these issues forward then they're fine with it."

One of the aims of the new regime introduced by the Order was that, in lifting the responsibility for certificating all premises from the fire services' shoulders, it would free them up for more important work, including a tighter focus on those with the highest risk.

This includes healthcare facilities. "Hospitals have been identified as the highest-risk premises in any area by a government computer programme that scores buildings on a points system," he explains. "It takes into account all sorts of issues including the impact on the community if you lost the building through fire.

"I disagree with that ranking because they are focusing just on the outcome of a fire, which can be catastrophic. But what they are not taking into account is the likelihood of a fire. If you look at the NHS in general, there are very few fires that spread beyond the item of origin, let alone the room of origin. If you look at the statistics for injuries and fatalities from fire in the NHS, we come out as the second safest building in any community."

Nevertheless, the way the points system works at present means that the Leeds Teaching Hospitals Trust is likely to receive frequent audits from the local fire authority. Aldridge's efforts over the past year and-a-half should make it well able to bear the scrutiny.