General Policy
Estates, Facilities and Capital Services
Senior Fire Advisor
Estates Compliance Manager, Fire Safety Advisor
Director of Estates, Facilities & Capital Services
31 January 2015
01 May 2018
01 May 2021

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy/procedure statements and aims to review policies within the timescales set out.

New policies/procedures will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies/procedures will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy/procedure is past its review date then the content will remain extant until such time as the policy/procedure review is complete and the new version published, or there are national policy or legislative changes.


The purpose of this policy is to provide all staff engaged by NHS Fife with an unambiguous statement of the Fire Safety Policy of NHS Fife, by

  • stating the aims of the Fire Safety Policy
  • identifying the responsibilities of management and individuals to achieve these aims
  • directing staff to the operational procedures necessary to fulfil these responsibilities.

This Policy is written to comply with the statutory requirements of all current Scottish Government Fire Safety Legislation and mandatory guidance issued through NHSScotland, the current primary guidance being CEL 11 (2011) Fire Safety Policy for NHSScotland, and associated Firecode documents.


2.1 This Policy is applicable to all existing NHS Fife premises, including leased and PFI/PPP premises, where NHS staff are employed or NHS patients receive any treatment or care.


1 Chief Executive

As Duty Holder under Part 3 of the Fire (Scotland) Act 2005 as amended, the Chief Executive will have overall responsibility for fire safety within all NHS Fife premises and is responsible for the mandatory requirements of CEL 11 (2011) Fire Safety Policy for NHSScotland.

2 Director of Estates, Facilitiesand Capital Services

It will be the responsibility of the Director of Estates, Facilities and Capital Services to ensure that agreed programmes of investment in fire safety measures are accounted for in the annual business plans and that the requirements of CEL 11 (2011) Fire Safety Policy for NHSScotland are met through the NHS Fife fire safety management structure.

3 Nominated Officer (Fire)

The Nominated Officer (Fire) is responsible for the implementation, monitoring and maintenance of effective fire safety arrangements for NHS Fife in accordance withNHS Scotland Firecode and CEL 11 (2011) Fire Safety Policy for NHSScotland. The Nominated Officer (Fire) will have one or more appointed Deputies to ensure a responsible person is alwaysavailable to assume the specified range of duties in his/her absence.

3.4 Deputy Nominated Officer (Fire)

The Deputy Nominated Officer (Fire) is responsible for carrying out the Nominated Officer (Fire) function within a sphere of responsibility as designated by the Nominated Officer (Fire), and will deputise for the Nominated Officer (Fire) in his/her absence.

3.5 Fire Advisors

The Fire Advisors are responsible for advising and liaising with the Nominated Officer (Fire) and Deputy Nominated Officers (Fire) to maintain co-ordinated and effective fire safety arrangements for NHS Fife, including the development of strategies and procedures to ensure compliance with NHSScotland, Firecode and CEL 11 (2011) Fire Safety Policy for NHSScotland. Primarily, the Fire Advisors will conduct Statutory Fire Risk Assessments across the NHS Fife Estate and will liaise with the Scottish Fire and Rescue Service with regards to annual Fire Safety Audits. The Fire Advisors will also provide training and advice as required to maintain statutory compliance.

7 Ward/Department/Location Managers

Managers will liaise with the Nominated Officer (Fire) and Fire Advisors with regards to fire safety in the premises/areas they are responsible for and for implementing fire safety procedures as required. They will also ensure that all staff participate in fire safety training at least annually, and also fire drills when required.

8 Fire Wardens

Fire Wardens will be responsible for organising and assisting in the fire safety regime for their workplaces and other relevant areas. Fire Wardens will also heave responsibility for assisting with emergency evacuation from their workplace area.

9 Duties of Employees

All staff members have duties and responsibilities in respect of fire safety. Fire safety legislation sets out a general duty on employees not to cause harm from fire to themselves or others by any act or omission. There are additional statutory duties on employees to co-operate with their employer’s fire safety precautions and to report any defects in fire safety. This includes participating in fire awareness training and fire drills.


1 The aims of this policy are to minimise the risk of harm from fire to all persons who use NHS Fife premises, and to promote and actively pursue a high standard of fire safety and protection within all premises owned, occupied or managed by NHS Fife.

2 NHS Fife draws the attention of all employees to their statutory obligations to act in accordance with NHS Fife Policies and Procedures relating to Fire Safety Precautions including the requirement for routine fire precautions, and to attend annual mandatory fire training.


The key risks involved in implementation of this policy are:-

5.1 Lack of staff awareness of this policy, resulting in non-compliance

5.2 Lack of robust organisational arrangements around policy implementation

5.3 Failure to implement and maintain the required procedures associated with the policy.


This section details the documentation relating to this Fire Safety Policy.

Details of the operational practices and systems necessary to meet the requirements of this Policy are contained within the NHS Fife Fire Safety Procedures document reference GP/F2-1 (available via Intranet).

CEL 11 (2011) Fire Safety Policy for NHSScotland is available at:

Equality Impact assessment


7.1 NHS Scotland Firecode

The NHS Scotland Firecode suite of documents contains policy and procedural guidance, Scottish Health Technical Memoranda (SHTM) and Scottish Fire Practice Notes (SFPN)

  • SHTM 81 Fire Precautions in New Hospitals
  • SHTM 82 Alarm and Detection Systems
  • SHTM 82 Supplement A: Automatic Fire Control Systems and Voice Alarm Systems
  • SHTM 83 Fire Safety in Healthcare Premises – General Fire Precautions
  • SHTM 84 Fire Risk Assessment in Residential Care Premises
  • SHTM 85 Fire Precautions in Existing Healthcare Premises
  • SHTM 86 Fire Risk Assessment
  • SHTM 87 Textiles and Furniture
  • SFPN 3 Escape Bed Lifts.
  • SFPN 4 Hospital Main Kitchens
  • SFPN 6 Arson Prevention and Control in NHS Healthcare Premises
  • SFPN 10 Laboratories on Hospital Premises
  • SFPN 11 Reducing unwanted fire signals in healthcare premises.

NHS Scotland Firecode is available online at

2 Statute Legislation and Guidance

  • The Fire (Scotland) Act 2005 Part 3 – Fire Safety
  • The Fire Safety (Scotland) Regulations 2006
  • Practical Fire Safety Guides (Suite of general and sector-specific guides)

The above are available online at

  • The Building (Scotland) Act 2003
  • The Building (Scotland) Regulations 2004
  • Technical Handbooks (Domestic and Non-Domestic)

The above are available online at

  • The Construction (Design and Management) Regulations 2015
  • The Dangerous Substances and Explosive Atmospheres Regulations 2002
  • The Management of Health and Safety at Work Regulations 1999
  • The Civic Government (Scotland) Order 2000 (as amended)
  • The Furniture and Furnishings (Fire Safety) Regulations 1988
  • The Health and Safety at Work Act 1974
  • The NHS and Community Care Act 1990
  • The Petroleum Consolidation Act 1928
  • The Highly Flammable Liquids Regulations 1972

The above are available online at

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