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







  1. The purpose of this procedure is to provide all staff engaged by NHS Fife with the operational procedures necessary to support NHS Fife Fire Safety Policy GP/F2, by


  • identifying the responsibilities of management and individuals
  • defining operational procedures to fulfil these responsibilities.
  1. NHS Fife will manage fire safety by implementing NHS Scotland Firecode, Building Standards Technical Handbooks, and relevant British/European Standards. Current Firecode documents are available online at:


  1. NHS Fife will ensure that an organisational structure is in place to manage fire safety precautions in NHS Fife premises and to make all managers, employees and volunteers aware of their responsibilities for fire safety in the workplace. The structure and responsibilities are set out in Section 3 below.
  2. NHS Fife will employ specialist Fire Advisors to assist and advise on all legislation relating to Fire Safety and to provide specialist technical support.


  1. 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 measures in their workplace, and to attend annual mandatory fire training.


  1. This Procedure is written to comply with the fire safety requirements of:
  • NHS Scotland Fire Safety Policy (CEL 11:2011)
  • NHS Scotland Firecode (current version)
  • The Fire (Scotland) Act 2005 Part 3 and Fire Safety (Scotland) Regulations 2006 (current fire safety legislation)
  • The Construction (Design and Management) Regulations 2015
  • The Building (Scotland) Act 2003 and Building (Scotland) Regulations 2004 (as amended), and Technical Handbooks
  • The Management of Health and Safety at Work Regulations 1999
  • The Civic Government (Scotland) Order 2000 (as amended)
  1. NHS Fife recognises the importance of liaising with the Scottish Fire and Rescue Service (SFRS) in respect of fire precautions and fire fighting in NHS Fife premises, and will co-operate fully in enforcement of fire safety legislation.

2.         LOCATION


  1. This Procedure is applicable to all existing NHS Fife owned premises, or premises leased by NHS Fife, where NHS Fife staff or volunteers are employed, without exception.


2.2       This Procedure also applies to projects designed to provide new healthcare premises, or major extensions or changes of use of existing healthcare premises, regardless of the ownership or leasing arrangements of the premises or associated estate.



  1. NHS Fife Fire Safety Management Responsibility
  1. All persons employed or engaged by NHS Fife have a shared responsibility for fire safety management, however the extent of this responsibility is related to their day-to-day management role. The diagram and text that follows identifies the management responsibility and the relevant management role.


3.1.2   Fire Safety Management Responsibilities:




3.1.3          Chief Executive and Directorate General Managers/Heads of Divisions or Services/Director of Estates, Facilities and Capital Services

  • The Chief Executive has overall responsibility for fire safety within all NHS Fife premises.
  • General Managers, and Heads of Divisions or Services, have responsibility within their remits.
  • It is the responsibility of the Chief Executive and the Director of Estates, Facilities and Capital Services to ensure agreed programmes of investment in fire safety measures are accounted for in the annual business plans.

3.1.4           Nominated Officer (Fire)

  • Co-ordinating overall effective fire safety arrangements for NHS Fife and functions including design of effective fire safety management arrangements
  • Application of NHS Scotland Firecode and fire safety legislation
  • Budgetary planning for a fire safety compliance programme for both passive and active measures in both existing and new buildings;
  • Ensuring annual audits of each building/department/ward are undertaken and reported, and fire safety risk assessments are reviewed periodically 
  • Co-ordinating development of fire safety policies and procedures for NHS Fife premises and liaise with Divisional Management
  • Liaising with the Fire Advisors on all aspects of fire safety
  • Having overall responsibility for monitoring attendance at statutory fire lectures and fire drills
  • Receiving reports of all fire incidents from the Fire Advisors and informing NHS Fife Strategic Management Team of their content.  Arranging for any necessary action in accordance with Firecode
  • Ensuring a report is presented annually to the Director of Estates, Facilities and Capital Services, detailing the current state of fire safety within NHS Fife
  • 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
  1. Deputy Nominated Officer (Fire)
  • Carrying out the Nominated Officer (Fire) function within a sphere of responsibility as designated by the Nominated Officer (Fire)
  • Deputising for the Nominated Officer (Fire) in his/her absence


3.1.6    Fire Advisors

  • Advising and liaising with the Nominated Officer(Fire) and Deputy Nominated Officers (Fire) to maintain co-ordinated overall effective fire safety arrangements for NHS Fife, including development of strategies and policies to ensure compliance with legislation and NHS Scotland Firecode
  • Providing specialist technical advice to managers, Fire Wardens and all staff to support effective fire safety arrangements for NHS Fife, including development of local strategies and procedures to ensure workplace compliance management fire safety measures
  • Preparing and delivering staff fire training in accordance with the planned programme and any identified training needs
  • Carrying out fire risk assessments and acting on outcomes of assessments, in liaison with general and local management, the Fire and Rescue Service (FRS) and other enforcing authorities
  • Liaising with, and assisting, the FRS in periodic enforcement audits of NHS Fife premises, and advising general and local management on the outcomes of audits 
  • Monitoring and investigating fire-related incidents, training returns, audit outcomes and other indicators to identify failures in compliance and recommend remedial actions
  • Advising and assisting NHS Fife senior management, Partnership management and project managers in the interpretation and application of provisions of legislation, Firecode in Scotland and other official guidance in respect of fire safety in NHS Fife premises
  • Producing periodic authoritative reports to senior management about the state of fire safety measures in NHS Fife premises, directly and via Health and Safety Committees
  • Liaising with Service Heads, Senior Managers and others in the identification and assessment of fire risks in NHS Fife premises, including identifying and recommending priorities in respect of fire safety improvements
  • Liaising with Service Heads and Project Managers, Local Building Control and Fire Authorities in the specification of fire safety measures in new premises and alterations to existing premises
  • Identifying training needs and developing programmes for all NHS Fife staff.  Liaising with the Nominated Officer (Fire) in managing the organisation of regular fire drills and staff training.  Analysing the effectiveness of fire drills and recommending remedial action when necessary.  Arranging for accurate records of staff training and fire drills to be kept.
  • Advising on the provision and location of all first aid fire-fighting equipment, fire safety signs, notices, etc.
  • Investigating fires in suspicious circumstances in conjunction with fire and police authorities
  • Ensuring that fires and unwanted fire signals are reported internally using the designated form, and following up reports as required
  • Ensuring that following major incidents, fire reports, in the designated format, are forwarded to the Scottish Government Health Directorates, and that a detailed fire report is forwarded as soon as reasonably practicable, supported by further investigation reports if necessary.



  1. General Managers, Ward/Department Managers
  • Liaising with the Nominated Officer (Fire) and Fire Advisors with regards to fire safety in premises where they are responsible
  • Making arrangements to carry out an annual audit of fire safety within their area of responsibility, liaising with the Nominated Officer (Fire) and the Fire Advisors, ensuring relevant checks have been completed, i.e. monthly fire safety checks, and records kept and available for inspection.
  • Supervising the day-to-day management of the established Fire Safety Policy and Procedures
  • Ensuring availability of one or more appointed deputies to ensure that a responsible person is always available to assume the specified range of duties when the principal officer is absent
  • Directorate General Managers will be responsible to the Chief Executive in respect of Fire Safety within their sphere of responsibilities
  1. Senior NHS Person in Charge (Health Centre, Clinic etc)
  • Liaising with the Nominated Officer (Fire) and Fire Advisors with regards to fire safety in premises where they are responsible
  • Making arrangements to carry out an annual audit of fire safety within their area of responsibility, liaising with the Nominated Officer (Fire) and the Fire Advisors
  • Completing monthly Fire Safety Checklist and retaining records for inspection within ward/area/dept. (may be delegated to the Fire Warden)
    • Supervising the day-to-day management of the Fire Safety Policy, Fire Strategy and Procedures
    • Assisting, if required, with fire drills and staff training
    • Co-ordinating and directing staff, patients and visitors during a fire or fire alert during working hours, in accordance with local/site fire procedures
    • In the event of a fire alert during working hours, the senior person in charge will take control until the Fire and Rescue Service arrives, and act as a focus point for liaison purposes thereafter

3.1.9    Line Managers and Supervisors

  • Ensuring that ALL staff participate in fire safety training at least annually, and fire drills when required
  • Ensuring that during health and safety walkabouts they monitor the type, location and effective maintenance of all first aid fire-fighting equipment and other fire safety measures
  • Completing monthly Fire Safety Checklist and retaining records for inspection within ward/area/dept.
  • Supervising the day-to-day management of the Fire Safety Policy, Fire Strategy and Procedures
  1. Fire Wardens


  • Carrying out a daily walkthrough of the area they are responsible for to check fire safety precautions are in place and in operable condition
  • Ensuring that escape routes are always unobstructed and available for use
  • Ensuring that fire hazards are identified and remedial action initiated as appropriate
  • Assisting department/ward/health centre management with monthly Fire Safety Awareness checklist
  • Keeping and submitting written reports of any observations to the Fire Advisors for action
  • Taking appropriate action if fire occurs, in accordance with local/site/ward fire procedures
  • Ensuring their part of the premises are evacuated in the event of emergency
  • Checking that the emergency plan is being carried out
  • Where the immediate area has been evacuated, carrying out a rapid search to ensure no one remains (keeping personal safety uppermost)
  • If the extent of the fire is known ensuring this information is passed to the relevant person (NHS Fife or Fire and Rescue Service (FRS))
  • Ensuring that no person re-enters the building until it is safe to do so; the senior FRS Officer will give this permission


3.1.10  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.

Line managers are responsible for ensuring that fire safety policies and instructions are brought to the attention of their staff, and that staff are aware of the specific fire safety measures or evacuation systems in their specific workplace. Line Managers will also ensure that every member of staff participates in fire safety training and drills.  All staff will have both basic instructions in fire safety and, where appropriate, training relative to their place of work including:

  • Understanding the character and hazards of fire, smoke and toxic fumes
  • Knowing the Hazards involved in their working environment
  • Practice and promotion of fire safety and its relation to other policies e.g. Smoking Policy
  • Following the procedures in which they were trained in the event of a fire alert
    • Following the procedures for reporting all fire incidents to their Line Manager

3.2     Fire Safety Oversight and Monitoring

The requirement for monitoring and oversight of fire safety within NHS Fife is within the remit of the Estates and Facilities Risk & Fire Monthly Meetings. Committee meetings will be attended by the Nominated Officer (Fire) and a Fire Advisor, who will advise and assist the Committee to: 

  • implement, monitor compliance with, and review Fire Safety Policy
  • review Fire Risk Assessments
  • share information relevant to Fire Safety performance
  • review all reports from the Fire Advisors

The status of the Committee is long-term, and meetings are held monthly, chaired by the Estates Compliance Manager.


4.1       The aim of this procedure is 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, including community workplace activities.

4(a).   General Operational Procedures

4(a).1   Reporting fires and unwanted fire signals (false alarms)

It is the responsibility of Security Officers (in acute hospitals) and Facilities/Estates/Health Centre management staff (other premises) to report all occurrences of fire alarm activation using the appropriate Incident Report Form (see Section 6). This must be forwarded to the Fire Advisors  who will carry out any necessary investigation and report the outcome of the investigation to the Nominated Officer (Fire).

The forms should be completed for all incidents, using the guidance and/or codes provided and completing text sections as accurately as possible. Where possible, for a false alarm, the cause of the unwanted fire signal should be determined and recorded on the report form, as this will allow the Fire Advisors to identify trends and possible faults. All fires must be reported using the Fire Incident report form, including as much detail as possible, as this is the initial report in a fire investigation. 

4(a).2  Fire logbooks

Each site owned or operated by NHS Fife must have a Fire Logbook or equivalent containing the following:


a.         Current Fire Risk assessments

b.         Fire Drawings

c.         Maintenance records covering

  • Fire alarm systems
  • Fire fighting equipment
  • Emergency lighting installations
  • Other relevant issues e.g. emergency shut-off equipment

d.         Training records

e.         Emergency plans

f.          Fire and False Alarm Report Forms


The logbook will be held at each site and be available to Fife Fire and Rescue Service enforcing officers, Fire Advisors and NHS staff during inspections and audits.

4(a).3  Fire Safety Risk Assessments and Audits


Fire safety risk assessments are carried out for all premises where NHS Fife has employees. Fire safety risk assessments are carried out jointly between a Fire Advisor and the manager of the department/ward/health centre being assessed. Assessments will be based on either SHTM 86 (for healthcare premises) or the appropriate Practical Guide to Fire Safety (for offices, workshops and other support functions). Fire safety risk assessments are reviewed periodically, dependant on life risk present, and the date of the next review added to the assessment.


If a fire safety risk assessment is no longer valid for any reason, the assessment will be reviewed by a Fire Advisor and the relevant manager, and reported to the Head of the department or service concerned. Persons managing any upgrading work or changes to clinical service, must inform the Fire Advisors as the risk assessment may require review.


Where short-term maintenance or improvement works, or changes of service provision, are likely to affect the fire safety measures, the person managing the works or service must inform the Fire Advisors prior to commencing. For emergency works when it is not possible to contact a Fire Advisor in advance, notification should be made as soon as possible. The Fire Advisors will advise on any temporary amendment of the fire risk assessment or alteration of the fire safety measures.


Annual audits of fire safety measures will be carried out in all premises with NHS Fife employees or patients, by the persons identified in section 3 above liaison with the Fire Advisor and Nominated Officer (Fire). Fire safety awareness is monitored within premises where NHS Fife staff are employed, by completion of a monthly checklist.


4(a).4  Improvements in Fire Safety

Fire Advisors will identify issues of fire safety compliance and prepare Action Plans to initiate remedial action. Identified issues will be added to compliance registers, to identify how the remedial action is to be funded.


Annually, the Nominated Officer (Fire) will identify capital projects for fire safety improvements, to be considered along with other statutory compliance projects as part of the NHS Fife Estates Statutory Capital Plan. The improvement programme will be prioritised by risk rating, and will be drawn from the Fire Compliance Capital Register Enforcement and other Notices from the Fire and Rescue service, Backlog Maintenance reports and Datix records. 





4(a).5  Fire Drawings

            Detailed site plans and drawings showing the fire precautions arrangements of the site buildings indicating escape routes, compartmentation and other fire resisting construction and all active fire safety measures shall be prepared and maintained by the relevant Estates department.


4(a).6  Maintenance Policy

Maintenance of all fire detection and alarm systems and other related fire/life safety systems, including automatic fire dampers, fire doors, fire fighting equipment and emergency lighting, will be carried out to relevant regulation and standards in force at the present time. Records of all maintenance carried out on fire safety systems will be kept in the site fire logbook or central maintenance records (major hospitals only).

4(a).7  Fire Safety Strategy/Emergency Plans

A Fire Safety Strategy containing Emergency Plans will be developed for each area of all NHS Fife premises.  They will follow the guidance documents listed in Section 6 below.  The Fire Safety Strategy and Emergency Plan must be developed in conjunction with Site/Department/Ward staff. Fire Advisors will give advice on the content of the plans.


Employees who may have need for additional assistance to escape from fire, due to disability or a medical condition, will be offered a Personal Emergency Evacuation Plan (PEEP). The employee’s line manager is responsible for preparing the PEEP, in consultation with the employee and assisted by the Fire Advisors if required. Guidance on producing a PEEP is available at Appendix A, Special Operational Procedures.


A Fire Training programme (including content and organisation of sessions) will be prepared on an annual basis.  This will be based upon training needs analysis and any advice received by the Fire Advisors and will take account of the previous year’s activities, and any needs identified by other Directorates or Services.


Records of staff attending will be kept by the Fire Advisors, and also in the ward/department/clinic training records or fire logbook, and will include:

  • location of training venue
  • names of course attendees
  • date, subjects and type of training given

The Nominated Officer (Fire) will oversee training programmes to ensure statutory training needs are met, including part-time, agency and night duty staff.


Specialised training for Fire Marshals/Wardens and selected other staff will be determined by the Fire Advisors, based on skills required to implement the fire evacuation plan for the premises.  Some staff will be trained in routine fire safety measures and in some cases first aid fire-fighting. 


The Fire Advisors will define the standards of performance to be achieved by staff in meeting the requirements of the fire safety policy, whilst retaining compatibility with day-to-day operational functions.


All NHS Fife employees and volunteers must attend fire safety training on commencement and annually thereafter. Line managers and/or e-KSF reviewers must include fire safety training in individual Personal Development Plans and monitor attendance. More specialised training, as outlined above, is additional to the individual’s annual training and must be recorded separately.


Attendance at Corporate (or other) Induction is not within the control of the Fire Advisors, however as this includes a fire awareness input, this will be recorded as the individual’s commencement fire training if not previously carried out. In-house Core Training contains a fire lecture which is the equivalent of attending annual fire training in that year, and should be recorded as such.


Fire safety training will be tested by practical fire drills to be conducted at least once a year during day or evening. Fire drills will be programmed on a sample basis at intervals throughout the year, to ensure that a sufficient number of wards and departments are tested to allow an accurate identification of staff effectiveness. Fire Drill planning is the responsibility of the Fire Advisors in liaison with Directorate management. The effectiveness of staff performance will be monitored and a report prepared by the Fire Advisors.


Joint exercises will be carried out as required in partnership with the Scottish Fire and Rescue Service (SFRS) taking account of the following:


  1. Directorate managers to be notified at least two weeks in advance of any such exercise.  The exercise must be assessed in terms of operational disruption, by Directorate Managers, Fire Advisors and the SFRS, and a joint risk assessment agreed.
  2. Warning notices should be placed at all main doors informing members of the public that an exercise is taking place and what is expected of them.  The risk assessment must identify where notices are to be erected and specify the alternative egress available during the exercise.  These notices will be positioned in a manner which will inform people NOT directly involved, to ensure that those targeted in the exercise are presented with a situation as realistic as would be expected in a genuine emergency.
  3. Staff providing outer/inner cordons must be fully briefed on their roles during an incident and be conversant with a floor plan marking out the exercise area and, where necessary, clearly indicating alternative safe routes.  Sufficient staff conversant with the exercise should be available at all times in key areas to ensure that the operational effectiveness of the service is not compromised.
  4. Staff manning any cordon must be vigilant in the need to recognise emergency requirements and be supplied with mobile communication, e.g. DECT phones/radios, for contact with the incident control officer.
  5. A de-brief must take place as soon as possible after an exercise with previously identified stakeholders and all those who took part, to ensure all staff have a forum to make comment.
  6. The Fire Advisor must ensure that the SFRS makes allowances for dealing with medical emergencies.



4(a).9   Passive Fire Safety/Means of Escape

NHS Fife will ensure that all passive fire safety requirements are implemented throughout the NHS Fife. The basic concepts governing means of escape from premises are:


  • The occupants, including patients assisted as appropriate, should be able to turn their backs on a fire, wherever it occurs, and travel away from it directly through circulation spaces and stairways to a place of safety, first within the premises and then, if necessary, to oneoutside the building. Evacuation strategies and training for staff will be based on this principle of Progressive Horizontal Evacuation.
  • Access and egress will at all times be unimpeded by obstructions and instructions in respect of fire doors etc. must be strictly enforced.  Building or engineering work in progress will not be allowed to compromise these arrangements and where necessary, temporary fire compartmentation must be established for the duration of the work.
  • NHS Fife will comply with The Building Standards Technical Handbook Section 2 Fire, including maintaining vehicle access for the FRS.  All staff will ensure that road access is kept clear at all times.


4(a).10Fire Detection and Alarm Systems, Smoke and Fire Dampers

Fire detection and alarm systems will conform to BS 5839: Part 1 (Design), BS 5839: Part 8 (Voice Alarms) and NHS Scotland Firecode (current versions). Where automatic fire detection is fitted to protect a patient treatment area, this must provide coverage to BS 5839 Category L1 i.e. detection in all areas/spaces. Any variation from this benchmark must be agreed in advance with the Nominated Officer (Fire) and the Fire Advisors. 

Automatic smoke and fire dampers will conform to SHTM 81, SHTM 03-01 and BS 9999 (or BS 5588: Part 9 dependant on age of system) and will close automatically on operation of the alarm and detection system either side of the compartment wall. Automatic smoke and fire dampers must be able to be reset remotely e.g. from a control panel. Air transfer grilles in compartment walls or fire doors must comply with the same conditions as automatic smoke and fire dampers.


4(a).11Emergency Escape Lighting

Escape lighting is provided to illuminate escape routes and circulation spaces in the event of a fire and/or failure of the regular lighting electrical supply. Escape lighting will be either artificial lighting supplied from a protected circuit or emergency lighting as appropriate. Emergency lighting will conform to BS 5266 and Firecode.


4(a).12Fire-Fighting Equipment

NHS FIFE will provide the appropriate first aid fire-fighting equipment including portable hand operated extinguishers, fire blankets and fixed fire-fighting equipment in accordance with BS EN 3, where appropriate.


4(a).13 Textiles and Furniture

NHS Fife will ensure that all furniture and equipment purchased for use within its premises complies with NHS Scotland Firecode. This is controlled and monitored through the Supplies Department responsible for ordering equipment used within NHS Fife. Patients are not permitted to use their own bed coverings such as duvets as they may not meet the standard of fire retardance required by Firecode.


4(a).14Electrical Equipment

Line Managers have a responsibility to ensure all electrical equipment has been tested by the Estates Department prior to being put into operation.  All electrical equipment and its wiring must be used safely and in a manner for the purpose intended.


Electrical equipment will be checked by the Estates Department periodically, but it is the responsibility of all staff to ensure equipment is safe to use before it is put into operation i.e. by a visual check and confirming a current test label is applied.


Electrical extension leads must be suitably protected by fuses. Block-type socket adaptors must not be used. Extension leads should not be used unless agreed in advance with the Estates Department. If used, extension leads must not be joined together. Advice on fusing and overload prevention is available from Estates department or the Fire Advisors.


Refer to NHS Fife Electrical Safety Policy GP/E3

4(b) Specific Operational Procedures

4(b).1   In addition to the above general procedures, it is necessary to issue Specific Operational Procedures to provide sufficient information and guidance on specific processes or equipment. Specific Operational Procedures are contained in Appendix A of this Procedure.


5.         Risk Management


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

  • Lack of staff awareness of this policy, resulting in non-compliance
  • Lack of robust organisational arrangements around policy implementation
  • Failure to implement and maintain the required procedures associated with the policy.






6.         Related Documents

6.1       This section details the necessary documentation to implement this Fire Safety Policy.  The following documents are included;


a)         Fire Safety Audit Checklist – Annual

b)         Fire Safety Awareness Monthly Checklist

c)         Fire Emergency Plans – Ward Evacuation Check Sheets

d)         Fire Emergency Plans – Template

e)         Personal Emergency Evacuation Plan Questionnaire and Recording Form

f)          Fire Drill - Recording Form

g)         Fire Equipment and Maintenance Checklists:

  • Maintenance Test Records – Fire Detection and Alarm Systems/Fire Dampers
  • Maintenance Test Records – Portable and Hand Fire Extinguishing Equipment
  • Maintenance Test Records – Emergency Lighting Installation

h)         Unwanted Fire Signal and Fire Incident Report Forms

I)          NHS Fife Electrical Safety Policy GP/E3

j)          PFI Annual Fire Report

6.2       Risks associated with fire will be managed by a process of risk assessment and review, staff training and by a programme of works to continually improve fire safety in NHS Fife premises. The documents listed above form an integral part of this process.


  1. Samples of the above forms are contained in Appendix B of this Procedure.

7.         References


7.1       NHS Scotland Firecode

NHS Scotland Firecode brings together in one comprehensive suite of documents, fire safety benchmarks and standards for the layout, design, construction and fire safety management of hospitals and other NHS premises. The 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






  1.                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 (as amended)

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