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General Policy
Estates, Facilities and Capital Services
Estates Compliance Manager
Estates Compliance Officer, Fire Safety Advisors
Director of Property & Asset Management
31 January 2015
25 September 2023
25 September 2025


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

New policies will be subject to a review date of no more than 1 year from the date of the first issue. Reviewed policies 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 the policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published.


1.1 This Policy is written to comply with the statutory requirements of all current Scottish Government Fire Safety Legislation and mandatory guidance issued through NHS Scotland, the current primary guidance being CEL 11 (2011) Fire Safety Policy for NHS Scotland, and associated Firecode documents, and to ensure NHS Fife has an effective management structure in place to deal with all fire safety matters in buildings which it owns, occupies or manages including community workplaces.

1.2 To satisfy the above requirements, NHS Fife will:

• Appoint a Nominated Officer (Fire) and Deputy Nominated Officer(s) (Fire).
• Appoint Specialist Fire Safety Advisors.
• Identify the responsibilities of management and individuals to achieve these aims.
• Ensure operational procedures are in place to ensure appropriate training is implemented, emergency evacuation strategies are developed & fire risk assessments are carried out and actions to mitigate identified risks are implemented.
• Report fires involving death or serious injury to the Health and Safety Executive under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.
• Immediately notify the Head of Asset management, Capital & Facilities, Scottish Government of all fires involving death, injury, or damage which results in significant disruption to patient services, as per Annexe B section 8 of CEL 11 (2011) Fire Safety Policy for NHS Scotland.
• Record fire safety performance outcomes such as alarm incidents, unwanted fire signals & fire incidents on the ‘Fire Manager’ module for NHS Scotland.
• Develop fire safety strategies taking account of the requirements of the Equality Act 2010.
• Ensure that Emergency Response Teams (ERTs) are established, and that sufficient staff are available at all times to provide assistance with evacuation in a fire emergency from premises owned, occupied or managed by NHS Fife.
• Monitor fire safety performance and compliance with this policy.


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.

NHS Fife has responsibility to ensure fire safety in buildings owned by third parties where a service has been procured by NHS Fife and in buildings which are jointly occupied by NHS Fife and other organisations.

NHS Fife will ensure that all newly commissioned Healthcare buildings for owner occupation, leased newly constructed buildings from another party or occupying buildings provided under a PPP/PFI contract comply with all statutes bearing upon the Fire Safety of newly constructed buildings.


Responsibility Flow Chart

Responsibilities for fire safety management in NHS Fife are outlined in the NHS Fife Fire Safety Procedure GP/F2-1 and are in compliance with the NHS Scotland Fire Safety Policy CEL 11 (2011). In addition to the posts outlined in the chart above the NHS Fife Fire Safety Procedure GP/F2-1 also describes the responsibilities of the following posts:

• Overall Executive Lead for Fire Safety (NHS Fife Director of Property & Asset Management)
• Fire Wardens and Emergency Response Teams
• Role of Switchboard Staff
• Other Stakeholders
• NHS Fife Employees
• Scottish Fire and Rescue Service


4.1 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. The components parts of the operational system are listed below and are fully described in the NHS Fife Fire Safety Procedure GP/F2-1:

• Reporting fires and unwanted fire signals (false alarms)
• Fire logbooks
• Fire Safety Risk Assessments, Audits, Monthly Checklists & Fire Drills
• Improvements in Fire Safety
• Fire Drawings
• Maintenance Policy
• Fire Safety Strategy/Emergency Plans
• Training
• Passive Fire Safety/Means of Escape
• Fire Detection and Alarm Systems, Smoke and Fire Dampers
• Emergency Escape Lighting
• Fire-Fighting Equipment
• Textiles and Furniture
• Electrical Equipment
• Commissioning new or existing healthcare premises for owner occupation, leasing buildings from another party or occupying buildings provided under a Public/Private Partnership or third party contract
• Use of the Fire module of the NHS Scotland Strategic Asset Management System
• Operational system in Premises Jointly Occupied by NHS Fife Staff and Third-Party Staff
• Operational system in Third Party Owned Premises Solely Occupied by NHS Fife Staff
• Fire Safety Oversight and Monitoring
• Standard Operational Procedures

4.2 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 NHS Fife Fire Safety Procedures (GP/F2-1) describe the operational practices and systems necessary to meet the requirements of this policy.

4.3 NHS Fife will work with other duty holders in buildings owned by a third party but jointly occupied by NHS Fife Employees.


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.


6.1 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 StaffLink).

CEL 11 (2011) Fire Safety Policy for NHSScotland is available at:
Equality Impact assessment
Appendix 1 - Specific Operational Procedures and Forms
Appendix 2 - SOP Fire Alarm Activations
Appendix 3 - Training
Appendix 4 - Wilful Fire Raising
Appendix 5 - Responsibility Flow Chart Attached


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 83 Part 2 - Fire Safety Training
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:

7.2 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 
Non-domestic fire safety - Fire and rescue - (

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 Equality Act 2010
The above are available online at