Powys Fra Faults

Knighton Hospital 17/06/2013
These are what I noted on my last vist
1. Overprovision of fire exit signage at base of stairs in clinic and opd building
2. FDW doors at base of stairs in clinic and OPD building
3. KNI 01 00 079 upgrade to FD30S staffroom at rear of kitchen
4. X corridor doors to be AFDKC not FDKS
5. COTTAGE VIEW KNI 010 00 024 FDW
6. Birthing Centre UTGA
7. Occy Therapy and Physio = No significant Findings
Brecon
This is whats currently on the system
GENERATOR/BOILER/SWITCHGEAR
Inappropriate heater location. MIU Store 156, confirm heater located behind storage is permanently disconnected. (Photo 176)
Unauthorised storage location. Boiler Room, remove storage and keep clear at all times.
Inadequate provision of Fire Action Notices. Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route to the
assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be displayed on all
staff notice boards. 1. Boiler Room. 2. High Voltage Room. 3. Compressor Room.
DENTAL DEPARTMENT
Inadequate provision of lighting to external exit External lighting should be provided sufficient to adequately illuminate any external exit route from the department.
route.
Uneven surface on external exit route. An even surface should be provided on external exit route from department.
None Firecode design standard used for The department was constructed as a protected route with self-closing fire doors to the rooms directly accessible off the corridor, it
refurbishment of unit. appears that an ‘Approved Document B’ approach was adopted as opposed to Firecode. Had Firecode been applied there would be
no necessity for the majority of these doors to be fire-rated or to have self-closing devices fitted. Due to the length of the corridor,
the alternative means of escape would be required under Approved Document B or Firecode, as the single direction means of
escape would otherwise exceed 18m. Having an escape route discharge via the end treatment room is not ideal, but in this instance
it is considered acceptable due to the use of the department (not an ‘in-patient’ facility) with the vast majority of patients treated
being considered as ‘independent’ as defined in Firecode. Furthermore an L1 standard of AFD has been provided. It is accepted that
there should be a ‘deregulation’ of the fire doors and the removal of the associated door-closers (consulting, examination, treatment
rooms and offices). This is subject to management procedures to ensure the alternative means of escape via the treatment room is
accessible at all times. Any fire hazard rooms would retain their fire resisting standard of FD30S and any cross-corridor doors should
also remain as installed.
CHILDRENS CENTRE & ANNEXE
Inadequate provision of automatic fire detection. Entrance lobby, provide smoke detectors to Tea Room and Store.
Inadequate provision of appropriate fire alarm Audio room 020, provide visual fire alarm device.
warning device.
Doors not to the required standard. The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards: : 1. Cross-corridor doors 023. 2. Cross-corridor doors 005. 3. Cleaner’s cupboard
008. 4. Stores 012, 013, 018, 019, 024. 5. Electrical Room (inside office 004).
Doors not to the required standard. The following doors should be upgraded to FD30 standard and upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards: : 1. Short dead end corridor, offices 001, 002, 004.
Tea point, multi plug adapters should not to be used to connect equipment to electrical supply.
The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed that the door(s) conform to all relevant parts of current standards: :
1. Store.
Remove photocopier to a side room.
Remove all storage from end of corridor and keep clear at all times
DIAGNOSTICS AND TREATMENT
Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all relevant
parts of current standards: : 1. Cross-corridor doors adjacent Beverage Room part door seals missing.
Doors not to the required standard. The following doors should be upgraded to FD60S standardand upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards: : 1. Cross-corridor doors leading to rear of Operating Theatres suite.
staff notice boards. In particular: 1. Adjacent main entrance door
OUTPATIENTS DEPARTMENT
Inadequate provision of fire door signage. Provide AUTOMATIC FIRE DOOR KEEP CLEAR signs on the following doors: 1. Department main entrance doors. 2. All cross-corridor
doors.
None Firecode design standard used for The corridor was constructed as a protected route with self-closing fire doors to the rooms directly accessible off the corridor, it
refurbishment of unit. appears that an ‘Approved Document B’ approach was adopted as opposed to Firecode. Had Firecode been applied there would be
no necessity for the majority of these doors to be fire-rated or to have self-closing devices fitted. Due to the length of the corridor,
the alternative means of escape would be required under Approved Document B or Firecode, as the single direction means of
escape would otherwise exceed 18m. Having an escape route discharge via the small waiting room is not ideal, but in this instance
it is considered acceptable due to the use of the department (not an ‘in-patient’ facility) with the vast majority of patients treated
being considered as ‘independent’ as defined in Firecode. Furthermore an L1 standard of AFD has been provided. It is accepted that
there should be a ‘deregulation’ of the fire doors and the removal of the associated door-closers (consulting, examination, treatment
rooms and offices). This is subject to management procedures to ensure the alternative means of escape via the waiting room is
accessible at all times. The storeroom door (hazard room) would retain its FD30s standard of door and the double leaf cross-corridor
doors should also remain as installed.
Y BANNAU WARD
parts of current standards: : 1. Main entrance doors from Reception have an excessive gap at meeting edge and should be
adjusted.
conform to all relevant parts of current standards: : 1. Cross-corridor adjacent Bathroom 106. 2. Double doors leading to Epynt
Ward.
Estates to confirm Estates to confirm
Oxygen cylinders located on ward. Use and storage of oxygen cylinders requires constant monitoring and numbers kept to a minimum.
Obstructed means of escape. Side final exit door is partially obstructed by bench outside of doors.
CRUG WARD
Inadequate provision of fire door signage Provide PUSH BAR TO OPEN signs on the following doors: 1. Final exit door at end of ward.
conform to all relevant parts of current standards: : 1. All bedroom doors. 2. All store rooms. 3. Any vents in fire resisting doors to
be to 30 minutes fire resisting standard.
parts of current standards: : 1. Entrance doors to Day Hospital Centre have an excessive gap at meeting edge and should be
adjusted. 2. Main ward entrance doors have an excessive gap at meeting edge and should be adjusted.
Inadequate provision of automatic fire detection. Day Hospital Centre, Treatment Room, provide automatic smoke detector.
ST DAVIDS RECEPTION
Oxygen cylinders are used on site The use and storage of oxygen cylinders should be monitored and the numbers kept to a minimum.
conform to all relevant parts of current standards: : 1. Staff Facilities. 2. Cleaners store inside Visitor’s toilets) also confirm vent is 30
minutes fire resisting standard. 3. Store adjacent entrance to Crug EMI Ward. 4. Electrical High Voltage room.
Doors require attention. The following doors require attentionand upon completion of works it should be confirmed that the door(s) conform to all relevant
parts of current standards: : 1. Reception, doors leading towards Crug EMI Ward have an excessive gap at meeting edge and
should be adjusted. Also part door seals are missing and are loose in rebate making door not effectively self-closing.
Breaches to compartmentation. Electrical High Voltage room, infill breaches to ceiling. (Photo 175)
FIRST FLOOR ADMIN
Inadequate provision of fire exit signage. Provide fire exit signage. 1. Over either side of cross-corridor door in main building.
Inadequate provision of door signs. Provide AUTOMATIC FIRE DOOR – KEEP CLEAR signs. 1. Both stair enclosures in main building. 2. Both side corridors in main
building.
Inappropriate use of office accommodation. It was noted that part of one corridor was being used to provide sleeping accommodation. The provision of fire safety in this area is
not to the standard required for sleeping accommodation and will require considerable upgrading to make it so. It is recommended
that no sleeping accommodation be provided I this area.
Unauthorised storage location. Corridor outside large Medical Records room, remove all combustible storage, including cabinets, and keep clear at all times.
MAIN ENTRANCE / XRAY/ CONFERENCE ROOM
Inadequate standard of fire resisting glazing. Windows adjacent to X-Ray/Kitchen to be 60 minutes fire resisting and fixed in the closed position.
Unable to confirm the standard of Confirmation is required that the fire containment of hazard rooms & compartment walls has been adequately constructed to ensure
compartmentation in ceiling voids. there are no openings where fire resisting barriers are required within the suspended ceiling voids
Compartmentation of stairs not to required Both stairs discharging into the main corridor should be enclosed in 60 minutes fire resisting construction. The first floor occupancy
standard. is a non-patient area and operates 9-5 it also has adequate external means of escape and a high standard of automatic fire
detection. This is considered as suitable compensation and therefore this requirement can be dispensed with.
Combustible storage at base of both sets of Remove all storage and keep areas clear at all times.
stairs.
parts of current standards: : 1. Cross-corridor doors adjacent Central Store141 have an excessive gap at meeting edge and should
be adjusted.
conform to all relevant parts of current standards: : 1. Central Store 141 including any glazing over door. 2. Store 175 in Conference
Room.
SPEECH AND LANGUAGE THERAPY
conform to all relevant parts of current standards: : 1. Physiotherapy, cross-corridor doors to ward, also confirm vent in wall is 30
minutes fire resisting standard. 2. Activity Day Room. 3. Wheelchair store 016. 4. Occ. Therapy store 407. 5. Store 403. 6. Computer
cables room, also confirm vent is 30 minutes fire resisting standard. 7. Entrance doors 001 to Physiotherapy. 8. Physiotherapy store
004. 9. Side doors from main corridor 008 and 010 to Physiotherapy. 10. Kitchen 027. 11. Day/Dining Room, also confirm vent in
wall is 30 minutes fire resisting standard.
parts of current standards: : 1. Wheelchair store 016 doors have an excessive gap at meeting edge and should be adjusted. 2. Occ.
Therapy store 407 doors have an excessive gap at meeting edge and should be adjusted.
OPERATING THEATRES
Inadequate external envelope protection. Although not in accordance with HTM 05-03 Part K, the unprotected glazed areas adjacent to Diagnostics and Treatment Unit have
been considered acceptable.
Unable to confirm compartmentation in ceiling Confirmation is required that the compartmentation above Theatres entrance doors is to 60 minutes fire resisting standard.
void.
staff notice boards. In particular: 1. Adjacent door to Endoscopy. 2. Disposal corridor.
parts of current standards: : 1. Doors leading to Conference Room have an excessive gap at meeting edge and should be adjusted.
2. Doors leading Diagnostics corridor have an excessive gap at meeting edge and should be adjusted.
conform to all relevant parts of current standards: : 1. Female Change, in and out doors. 2. Male Change, in and out doors. 3. Store
178. 4. General Store 188. 5. Cleaners Room 187. 6. Equipment Store 189. 7. Disposal Room on disposal corridor. 8. Scrub Up 181.
9. Anaesthetics 182. 10. Theatre Disposal.
EPYNT WARD
Unauthorised storage location. Roof space access room should not be used for storage and the area should be kept clear at all times.
parts of current standards: : 1. Cross-corridor doors adjacent double doors leading to Y-Bannau Ward are not effectively self-closing
due to poor fit in frame.
BIRTHING UNIT
parts of current standards: : 1. Store missing part door seals.
conform to all relevant parts of current standards: : 1. Store.
CATERING
Inadequate protection of compartmentation If doors are required to be kept open an acceptable form of hold open device, connected to the fire alarm, should be provided
due to wedged open fire doors to main hospital
corridor.
CARDIOLOGY
parts of current standards: : 1. Store 132, confirm vent in door is to 30 minutes fire resisting standard. 2. Cross-corridor doors
leading towards Diagnostics and Treatment Unit one leaf is not effectively self-closing due to defective floor hinge. 3. Former
Kitchen 131, confirm vent in door is to 30 minutes fire resisting standard.
conform to all relevant parts of current standards: : 1. Electrical cupboards adjacent Linen store 134. 2. Linen store 134, sliding
door. 3. Store 135.
staff notice boards. In particular: 1. Adjacent fire alarm call point in corridor leading towards Diagnostic and Treatment Unit.
ROOF SPACES
Lack of sub division of roof space compartments. Provide FD30 door/hatch across opening at end of each leg of roof space and upon completion of works it should be confirmed
that the door(s) conform to all relevant parts of current standards:
NEWTOWN HOSPITAL
ADMIN/CONTACT CENTRE/STORES/CONTINENCE SERVICE OFFICE
Doors not to the required standard.

The following doors should be upgraded to FD30S standard: First floor: 1. Office 013. 2. Door 012 at head of stair. 3. Office 003 4. Stair door to Admin. corridor. 5. Stationery Store 010.
Second floor: 6. Door 001 to storage area.
Inadequate access to means of escape.
Office 006, door to fire exit must be secured by a single simple action device capable of being opened from the inside without recourse to a key.
Inadequate access to means of escape.
Offices 006 and 013, access to fire escape stair is via windows that require a step up. This has been considered acceptable under present conditions.
Main stairway has different rise and go and tapered steps in the flight
It has been considered acceptable under present conditions
Inadequate provision of compartmentation.
Second floor, the access to both roof voids should be enclosed by FD30S hatches.
Unable to confirm standard of compartmentation.
The fire resistance of the existing ceiling between ground and first floors could not be determined. Considered acceptable as the ground floor has AFD to an L1 standard.
Inadequate provision of external envelope protection.
Windows adjoining external fire escape should be half-hour fire-resisting standard. This requirement will not be necessary when the protected route to stairs is provided.
Inadequate provision of fire exit signage.
Provide fire exit signs in following locations: 1. Office 013, provide fire exit sign over door.
Inadequate provision of automatic fire detection.
Second floor roof voids, provide smoke detector in each void.
STAFF CHANGING AREA
Staff Changing Area

Food servery area adjacent Kitchen door Refrigerator and cooking appliances in use in this area
Staff Changing Area
Doors not to the required standard.
The following doors should be upgraded to FD30S standard: 1. Male changing room 015.
Staff Changing Area
Door into rear lobby from female change Door not available for use and has created an inner-inner room situation. Door also secured by key
Door into rear lobby to be retained as available for use, otherwise there will be inner-inner rooms. This door to be secured without recourse to a key.
Staff Changing Area
Female change Additional fire exit signage required to indicate rear exit route
BIRTHING UNIT
1. The firefighting 1. The firefighting equipment should be tested by a competent person.

equipment in the main
lounge adjacent to the fire
exit door appears to be
overdue for testing.
Inadequate provision of Oxygen store Room 036, provide Oxygen warning notice on outside of door.
Oxygen warning notice.
Inadequate provision of Fire Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line
Action Notices. drawing indicating the route to the assembly point should be displayed adjacent to all break glass
alarm points. Similar notices and drawings should be displayed on all staff notice boards. In
particular: Both side final exits from main circulation area.
Doors not to the required The following doors should be upgraded to FD30S standard: 1. Side door from rear office to main
standard. entrance foyer.
1.Inadequate provision of 1. A compressed gas warning notice should be provided on the outside face of the doors to Rooms
compressed gas warning 036 and 038 containing Oxygen cylinders.
notice on doors 036 & 038
BOILER SWITCH MORTUARY AND STORES
Switch Room Used as storage Do not store in this area

area
Oxygen Store Complies with HTM Maintain compliance with HTM 02-01
02-01
Boiler House Fire extinguishers Provide Foam and CO2 extinguisher with wall brackets adjacent front entrance
not fixed in location
1 Boiler House rear exit No fire 2 Provide fire action notice adjacent fire alarm call point
action notice adjacent fire alarm
call point
OPD/XRAY/FORMER PHYSIOTHERAPY
Firefighting equipment not being Store/Server Room, CO2 extinguisher is overdue for annual test.
adequately maintained.
Inadequate compartmentation Store 132, enclose ventilation ducting in 30 minutes fire resisting materials where it passes
around ventilation ducting. through store.
Doors not to the required The following doors should be upgraded to FD30S standard: 1. Store 130. 2. Store 123. 3.
standard. Records office 115. 4. Store/Server Room 114. 5. Store 132. 6. X-Ray Film Store 133. 7.
Cross-corridor doors adjacent X-Ray Dept. 8. Link door from Waiting Area leading to
Therapies Unit. 9. Electrical Room in corridor leading to Bryn Heulog Ward. 10. Store 128 (in
former physiotherapy). 11. Store 130 (in former Physiotherapy). 12. Admin. Store 112. 13.
File Store in former Reception office.
Inadequate provision of 1. Store/Server Room, provide smoke detector. 2. Store 128 provide smoke detector (in
automatic fire detection. former physiotherapy).
FAN GORAU
1. Inadequate provision of automatic 1. Provide automatic smoke detector in Store 013. 2. Provide automatic smoke detector
fire detection in Store 013 containing in electric cupboard 030
the electric cupboard.
Doors require attention. The following doors require attention: 1. Doors to Lounge 014 adjust door seals to make
effectively self-closing.
Doors not to the required standard. The following doors should be upgraded to FD30S standard: 1. Store 013.
Occupational therapy
Inadequate provision of FIRE DOOR Store 050 No Fire Door Keep Locked Shut notice on door Provide Fire Door Keep Locked
KEEP SHUT notices Shut notice on door Quite Room 045, adjacent Occupational Therapy No Fire Door Keep
Shut notice on door Provide Fire Door Keep Shut notice on door Store 042, adjacent
Occupational Therapy No Fire Door Keep Locked Shut notice on door. No electrical
hazard warning notice on door Provide Fire Door Keep Locked Shut notice on door.
Provide electrical hazard warning notice on door Store 044, adjacent Occupational
Therapy No Fire Door Keep Locked Shut notice on door Provide Fire Door Keep Locked
Shut notice on door Store 041, adjacent Occupational Therapy No Fire Door Keep
Locked Shut notice on door Provide Fire Door Keep Locked Shut notice on door Store
043, adjacent Occupational Therapy No Fire Door Keep Locked Shut notice on door
Provide Fire Door Keep Locked Shut notice on door
Store 042, adjacent Occupational Provide 2kg CO2 extinguisher in corridor adjacent store
Therapy Electrical hazard inside store
1. Kitchen 048 Door not to required 1. Upgrade door to FD30S standard 2.Upgrade door to FD30S standard 3. Upgrade door
standard of fire resistance 2. Entrance to FD30S standard
door 047 Door not to required standard
of fire resistance 3. Store 044, adjacent
Occupational Therapy Door not to
required standard of fire resistance
Doors not to the required standard. The following doors should be upgraded to FD30S standard: 1. Kitchen 048. 2. Entrance
doors 047. 3. Store 044 (in corridor).
1.Store 044, adjacent Occupational 1. Replace heat detector with smoke detector
Therapy Incorrect automatic fire
detector in store
HAFAN HOSPICE
Inadequate provision of 1. Store 005, replace heat detector with smoke detector.
automatic fire detection.
Doors not to the required The following doors should be upgraded to FD30S standard: 1. Store 005. 2. Store rear of Main
standard. Lounge 009.
1. Inadequate standard of fire 1. Upgrade Store doors 005 & 009 to FD30S.
resistance of door to Stores 005
& 009.
Inadequate provision of fire exit Provide fire exit signs in following locations: 1. Consulting Room 003, over rear final exit door.
signage.
Inadequate provision of Fire Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line
Action Notices. drawing indicating the route to the assembly point should be displayed adjacent to all break
glass alarm points. Similar notices and drawings should be displayed on all staff notice boards.
In particular: 1. Consulting Room 003, adjacent rear final exit door.
CATERING DEPARTMENT
Inadequate provision of Fire Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single
Action Notices. line drawing indicating the route to the assembly point should be displayed adjacent to all
break glass alarm points. Similar notices and drawings should be displayed on all staff notice
boards. In particular: Door to main stair enclosure.
Doors require attention. The following doors require attention: 1. Door to main stair enclosure is missing all door
seals. Provide combination smoke/intumescent seals to give 60 minutes fire resistance.
1Kitchen Unconfirmed fire 1 Kitchen to be enclosed in 60 minutes fire resisting construction

resisting standard of enclosure
of Kitchen
1 Store 019 No automatic fire 1 Provide smoke detector this area 2 Provide smoke detector this area
detection coverage 2 Corridor
adjacent rear exit No automatic
fire detection coverage
MAIN STAIR ENCLOSURE
Fire Coordinators Box Keep access to Fire Coordinators Box clear at all times. (Photo 184)
obstructed.
BRYN HEULOG
Inadequate provision of Therapies Unit office, provide automatic smoke detector.

automatic fire detection.
Doors require attention. The following doors require attention: Therapies Unit: 1. Assessment Kitchen 069 doors have an
excessive gap at meeting edge and should be adjusted. 2. Store 066 doors have an excessive gap at
meeting edge and should be adjusted. Bryn Heulog Ward: 3. Store 091 doors have an excessive gap at
meeting edge and should be adjusted. 4. Ward entrance 058 doors have an excessive gap at meeting
edge and should be adjusted.
Doors not to the required The following doors require attention: Therapies Unit: 1. Assessment Kitchen 069 doors have an
standard. excessive gap at meeting edge and should be adjusted. 2. Store 066 doors have an excessive gap at
meeting edge and should be adjusted. Bryn Heulog Ward: 3. Store 091 doors have an excessive gap at
meeting edge and should be adjusted. 4. Ward entrance 058 doors have an excessive gap at meeting
edge and should be adjusted.
Doors not to the required The following doors should be upgraded to FD30S standard: Therapies Unit: 1. Store 074. 2. Wax Store
standard. 075. 3. Store 078. 4. Store 080. 5. Store 066. 6. New Records Store adjacent new Reception, both doors.
7. Assessment Kitchen 069. 8. Store 064. Bryn Heulog Ward: 9. Medical Store 088.
Reduction in the level of Admin Office 082 (former part of Day Room) – The 30 minute fire resisting sub-compartment line
compatmentation in ceiling enclosing the former Day Room is breached by the location of the new door to Admin Office 082. This is
voids. deemed acceptable as the newly formed Admin Office 082 and the newly formed Group Room 079 are
not deemed to be fire hazard rooms.
Ceiling tiles missing. Bryn Heulog Ward: Store091, replace missing ceiling tiles. (Photo 185)
Inadequate provision of fire exit Provide fire exit signs in the following locations: 1. Cross-corridor doors 063, both sides.
signage.
Inadequate provision of Fire Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing
Action Notices. indicating the route to the assembly point should be displayed adjacent to all break glass alarm points.
Similar notices and drawings should be displayed on all staff notice boards. In particular: 1. Group
Therapy Room 079.
WELSHPOOL
HOSPITAL STORE/PLANT ROOMS
(7/11)Inadequate provision of fire door Exit doors facing Electrical Plant Room/Hospital Store require TURN TO OPEN sign over door
signage. release mechanism.
(7/11)Inadequate provision of Fire Action Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line
Notices details. drawing indicating the route to the assembly point should be displayed adjacent to all break glass
particular: 1. Main Electrical Plant Room.
(7/11)Storage under external stair. The storage under external stair is acceptable as the stair is no longer in use and access to the
head has been removed.
(7/11)Inappropriate storage in Electrical Remove all storage beyond the demarcation barrier and keep area clear at all times.
Plant Room/Hospital Store.
KITCHEN/STAFF DINING/STAFF CHANGING
(7/11)Unable to confirm PPM for ducting Confirm appropriate cleaning PPM is being undertaken for ducting in Kitchen.
in Kitchen.
(7/11)Doors require attention. The following doors require attention and upon completion of works it should be confirmed that
the door(s) conform to all relevant parts of current standards: : 1. Kitchen Store 018 not
effectively self-closing due to catching on lock mechanism. 2. Kitchen main entrance doors 016
have an excessive gap at meeting edge and should be adjusted. 3. Staff Dining Room Store 017
doors have an excessive gap at meeting edge and should be adjusted. 4. Staff Dining Room 019
doors have an excessive gap at meeting edge and should be adjusted.
(7/11)Inadequate provision of Fire Action Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line
Notices details. drawing indicating the route to the assembly point should be displayed adjacent to all break glass
particular: 1. Staff Dining Room
(7/11)Inadequate provision of fire door Provide FIRE DOOR KEEP SHUT signs on the following doors: 1. Staff Changing Rooms, Male and
signage. female. 2. Kitchen 016. 3. Kitchen disused doors.
(7/11)Inappropriate location of Kitchen, relocate CO2 extinguisher in

firefighting equipment. plate wash area to adjacent main
entrance doors.
ENGINEERING STORES
(7/11)Inadequate provision of Fire Action Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single
Notices details. line drawing indicating the route to the assembly point should be displayed adjacent to all
break glass alarm points. Similar notices and drawings should be displayed on all staff
notice boards. In particular: 1. Generator Room.
MINOR INJURIES UNIT
(7/11)No ventilation in Oxygen store in Provide Oxygen store in corridor with appropriate ventilation.
corridor.
(7/11)Inadequate clear space maintained CSSD Store 044, keep area adjacent automatic smoke detector clear.
adjacent automatic fire detection.
(7/11)Doors require attention. The following doors require attention and upon completion of works it should be confirmed
that the door(s) conform to all relevant parts of current standards: : 1. Childrens Exam
Room 040, doors have an excessive gap at meeting edge and should be adjusted. 2.
Resuscitation Room 042, doors have an excessive gap at meeting edge and should be
adjusted. 3. Recovery 043, doors have an excessive gap at meeting edge and should be
adjusted. 4. CSSD Store 044, neoprene door seals damaged. 5. Main entrance doors 037,
have an excessive gap at meeting edge and should be adjusted.
(7/11)Inadequate provision of means of Signed fire exit door is fitted with digital lock. Internal corridor has signed fire exit route
escape. that is unavailable when unit is locked. Either remove fire exit sign from emergency light
unit over doors, as alternative exit is available either side. Else maintain exit route available
by provision of electric lock that will failsafe unlocked on operation of fire alarm or failure of
electrical supply. A green manual emergency break glass box should also be provided
adjacent the lock.
(7/11)Inadequate provision of fire exit door Resuscitation Room 042, provide fire exit sign over door.
signage.
TRAINING BUILDING
(7/11)Inadequate provision of fire door Provide FIRE DOOR KEEP SHUT signs on the following doors: 1. Rooms 006, 007, 008 and
signage. 013.
(7/11)Inadequate compartmentation. Store cupboard in main room infill breach to ceiling with fire resisting materials.
MAIN ENTRANCE
(7/11)Library Services locker unlocked. Keep Library Services locker locked shut when not in use.
that the door(s) conform to all relevant parts of current standards: : 1. Cross-corridor doors
004 adjacent Reception have an excessive gap at meeting edge and should be adjusted.
(7/11)Artificial foliage plant in circulation Confirm artificial foliage plants are suitably fire resisting else remove from any circulation
space. space.
(7/11)Photocopier in circulation space. Relocate photocopier out of any circulation space.
BIRTH UNIT
(7/11) Inadequate provision of Fire Action Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single
Notices. line drawing indicating the route to the assembly point should be displayed adjacent to all
notice boards. In particular: 1. Side fire exit door.
(7/11)Inadequate provision of Oxygen Provide Oxygen warning notice on Main entrance doors to unit.
warning notice.
(7/11)Inadequate provision of automatic fire Cleaner’s cupboard, replace heat detector with smoke detector.
detection.
(7/11)Inappropriate storage in service Service cupboard in dirty Utility Room 084, remove all storage and keep clear.
cupboard.
MALDWYN WARD
(7/11) Unsecured store rooms. The following stores should be kept locked shut when not in use: 1. Stores 039 A to
E. 2. Stores 064 A & B.
(7/11)Doors require attention. The following doors require attention: 1. Main entrance doors have an excessive gap
at meeting edge and should be adjusted. Neoprene seals damaged. (Photos 161,162,
166,167) 2. Cross-corridor doors o51 have an excessive gap at meeting edge and
should be adjusted. 3. Store 044 requires lock fitting to door and not effectively self-
closing due to weak closing device. . 4. Store 064C have an excessive gap at meeting
edge and should be adjusted. 5. Cross-corridor doors 064 have an excessive gap at
meeting edge and should be adjusted. 6. Ward Pantry 048 have an excessive gap at
meeting edge and should be adjusted. 7. Rear ward doors to Occ therapy corridor
have an excessive gap at meeting edge and should be adjusted.
(7/11)Inadequate warning of Oxygen. Store 044, provide with Oxygen warning notice on outside of door.
(7/11)Inadequate fire door signage. Store 044, provide FIRE DOOR KEEP LOCKED SHUT notice on door.
(7/11)Inadequate provision of Fire Action Notices Fire Action Notices (with all details clearly legible and indelibly marked) and a simple
details. single line drawing indicating the route to the assembly point should be displayed
adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards. In particular: 1. Conservatory.
OUTPATIENTS DEPARTMENT
(7/11)SHROPDOC office 003 (former overnight Door no longer required to be fire resisting standard, remove FIRE DOOR KEEP SHUT
room) door signage is now redundant. sign from door.
(7/11)Inadequate standard of fire resisting New glazed screen adjacent entrance to OPD should be upgraded to sixty minutes fire
glazing. resisting standard (integrity and insulation) and upon completion of works it should be
confirmed that this conform to all relevant parts of current standards
7/11)Doors require attention. The following doors require attention and upon completion of works it should be
confirmed that the door(s) conform to all relevant parts of current standards: : 1.
Entrance doors to OPD 006, have an excessive gap at meeting edge and should be
adjusted. 2. Store 019, neoprene door seals damaged. 3. Recovery Room 5, inner doors
to Lobby 015 have an excessive gap at meeting edge and should be adjusted.
(7/11)Inadequate provision of automatic fire Recovery Room 5, provide automatic smoke detection to this area.
detection.
X RAY DEPARTMENT
(7/11)Inadequate provision of fire alarm call Provide fire alarm call point adjacent C R room rear fire exit door.
point.
that the door(s) conform to all relevant parts of current standards: 1. Entrance doors from
MIU corridor have an excessive gap at meeting edge and should be adjusted. 2. Cross-
corridor doors 039 to rear corridor have an excessive gap at meeting edge and should be
adjusted.
(7/11)Inadequate provision of fire door Provide FIRE EXIT KEEP CLEAR notice on outside of rear final exit door adjacent Electrical
signage. Room.
(7/11)Inadequate provision of Fire Action Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single
Notices. line drawing indicating the route to the assembly point should be displayed adjacent to all
notice boards. In particular: 1. C R room rear fire exit door.
ROOFSPACE
(7/11)Inadequate fire stopping Infill breaches in the sub compartment fire quilting in the following areas: 1. Between Physio and staff
between sub compartments. Dining. (Photo 147) 2. Between Administration and Main entrance. (Photos 148 to 150) 3. Between Birth
Unit and Main Entrance. (Photo 151)
(7/11)Inadequate fire stopping Infill high level breaches in the compartmentation between Physio and Occ Therapy
between compartments.
(7/11)No automatic fire detection It not considered necessary to provide automatic fire detection to this area.
provided.
OCCUPATIONAL THERAPY
(7/11)Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the
door(s) conform to all relevant parts of current standards: : 1. Activity Room 033 neoprene smoke selals
damaged and deteriorating.
(7/11)Storage in corridor. Corridor outside Occ. Therapy, remove all storage and keep clear.
ADMINISTRATION
door(s) conform to all relevant parts of current standards: : 1. Inner office 006 not effectively self-closing
due to catching on lock mechanism.
PHYSIOTHERAPY
door(s) conform to all relevant parts of current standards: : 1. Cross-corridor doors 023 adjacent Physio
Reception, have an excessive gap at meeting edge and should be adjusted. 2. Cross-corridor doors 038
adjacent Occ. Therapy, neoprene seals on top edge are damaged. Also there is an excessive gap at
meeting edge and should be adjusted.
BRONLLYS HOSPITAL
PAIN MANAGEMENT CENTRE
2011 Inadequate protection of ignition hazard. 2011 Enclose electrical cupboard in front stair with 30 minute fire resisting construction including /FD30S door.
Insufficient numbers of Fire Safety Managers/Deputy Fire Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management
Safety Managers (DNOFS) Not all staff attend annual Fire should ensure all staff attend annual Fire Awareness Training .
Awareness Training
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. All doors to all rooms in residential area of
premises, except toilets and bathrooms. 2. Door to roofspace.
2011 Doors require attention. 2011 The following doors require attention: 1. Door at base of front stair in admin corridor has loose fire resisting
glazed panel.
2011 Inadequate provision of compartmentation. 2011 1. Repair major breach between clock tower area in roofspace and sleeping accommodation below with 30
minutes fire resisting materials. 2. Ground floor Stores 017 and 006, upgrade uninsulated fire resisting glazing to
insulated 30 minutes fire resisting standard. 3. The small area of uninsulated glazing on the stair is considered to be
acceptable.
CONCERT HALL (PAIN MANAGEMENT)
2011 Inadequate provision of door signage. 2011 Provide PUSH BAT TO OPEN sign over door opening mechanism on final exit door foot of stair to Projection
Booth.
2011 Inadequate provision of Fire Action Notices. 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating
the route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and
drawings should be displayed on all staff notice boards. In particular: 1. Projection Booth.
2011 Inadequate provision of fire exit signage. 2011 Provide fire exit signs in following locations: 1. Ground floor over door at foot of stair leading to Projection Booth.
2011 Inadequate protection of means of escape. 2011 Projection booth should not be used due to the lack of adequate means of escape from the upper floor.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Door to stair leading to Projection Booth.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30 standard: 3. Door to Kitchen.
Insufficient numbers of Fire Safety Managers/Deputy Fire Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management
Safety Managers (DNOFS) Not all staff attend annual Fire should ensure all staff attend annual Fire Awareness Training .
Awareness Training
HILFA WARD
In the Psychology corridor adjacent to room 03/01/008 there is Remove storage and keep the area clear at all times.
a build up of combustible storage.
Insufficient numbers of Fire Safety Managers/Deputy Fire Safety Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained.
Managers (DNOFS) Not all staff attend annual Fire Awareness Management should ensure all staff attend annual Fire Awareness Training .
Training
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Cross-corridor door 03/01/007. 2. Cross-corridor
door 03/01/013, including partition over to 30 minutes fire resisting standard. 3. Cross-corridor door 03/01/014. 4.
Cross-corridor door 03/01/033
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30 standard: 1. Occ Health - Records Store 03/01/023, including
glazing over to 30 minutes fire resisting standard. 2. Psychology – File Room 03/01/011.
2011 Doors require attention. 2011 The following doors require attention: 1. Occ Health – cross-corridor door adjacent Room 03/01/020, smoke
seals painted over. 2. Occ Health – cross-corridor door 03/01/043, door not effectively self-closing
DOORS NOT TO REQUIRED STANDARD 1.In all areas there is an inadequate standard of fire doors. 2.Cross-corridor door 03/01/007 is not to the required
standard 3.Cross-corridor door 03/01/013 is not to the required standard 4.Cross-corridor door 03/01/014 is not to
the required standard 5.Cross-corridor door 03/01/033 is not to the required standard. 6.In the Occupational Health
department the door to the records store 03/01/023 is not to the required standard 7.In the Psychology department
the door to the File room 03/01/011 is not to the required standard. 8. In the occupational healthj department the
cross corriidoor door adjacent to room 03/01/020 is not to the required standard. 9. In the occupational health
department the cross corridor door 03/01/043 is mot effectively self closing.
DOORS NOT TO REQUIRED STANDARD 1.All fire doors (except cross-corridor doors) should be upgraded to FD30 standard. This to include any glazing over
doors 2.Upgrade door to FD30S standard. 3. Upgrade door to FD30S standard. 4. Upgrade door to FD30S standard.
5. Upgrade door to FD30S standard. 6. Upgrade door to FD30S standard. 7. Upgrade door to FD30S standard. 8.
Clean paint from smoke seals or replace as appropriate 9. Make door more effectively self closing.
1.In all areas there is an Inadequate provision of fire door 1. All fire doors should be provided with the following notices as appropriate: FIRE DOOR – KEEP SHUT; FIRE DOOR
notices 2.In Psychology the fire exit to the stair adjacent to the – KEEP LOCKED SHUT AUTOMATIC FIRE COOR-KEEP CLEAR 2. Fire exit sign to be located over door not on it
Chiropody Store 03/01/035 the Fire exit sign is incorrectly
located.
2011 Inadequate provision of fire door notices. 2011 All fire doors should be provided with the following notices as appropriate: FIRE DOOR – KEEP SHUT FIRE
DOOR – KEEP LOCKED SHUT
2011 Fire exit sign incorrectly located Chiropody store 2011 Fire exit sign to be located over door not on it.
03/01/035.
1.In the Occupational Health department corridor adjacent to 1. Fire extinguishers to undergo annual test 2. Fire extinguishers to undergo annual test
room 03/01/023 the Fire extinguishers are overdue for annual
test. 2.In the Psychology department corridor adjacent to room
03/01/013 the Fire extinguishers areoverdue for annual test .
2011 Firefighting equipment not adequately maintained. 2011 All fire extinguishers were overdue for annual inspection
HAFREN WARD
In all areas some of the extinguishers had been However sufficient extinguishers are present for area?s current use.
removed.
In all areas the firefighting equipment was due annual Firefighting equipment to be made the subject of an annual test.
testing.
In all areas there is an inadequate provision of Fire . Fire action notices should be provided adjacent to each fire alarm call point.
Action Notices
1.In all areas there is an Inadequate provision of fire 1. All fire doors should be provided with the following notices as appropriate: FIRE DOOR – KEEP SHUT FIRE DOOR – KEEP
door notices 2. The final exit door from the ward area LOCKED SHUT AUTOMATIC FIRE COOR-KEEP CLEAR 2. The final exit door from the ward area at the rear of the former
at the rear of the former Audiology Dept has no Push Audiology Dept has no Push Bar to Open notice. Provide a Push Bar to Open notice over the door mechanism.
Bar to Open notice.
1.On the corridors there is an inadequate standard of 1. All cross-corridor doors should be upgraded to FD30S standard. This is to include any glazing over the doors. 2. . All fire
fire doors. 2.In all areas there is an inadequate doors (except cross-corridor doors) should be upgraded to FD30 standard. This to include any glazing over the doors. 3.
standard of fire doors 3.The door at the end of the Upgrade the door to FD30S standard.
ward to X-Ray and the lift corridor is to an inadequate
standard.
2011 Breaches to compartmentation. 2011 1. Infill minor breach in ceiling of electrical cupboard in Entrance Lobby.
2011 Combustible materials stored in means of 2011 Following areas should have combustible materials removed and kept clear at all times: 1. First floor – corridor. 2. First
escape. floor – head of stair. v
2011 Inadequate protection of means of escape. 2011 Following fire doors should not be wedged open. 1. First floor - Three doors to offices.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. First floor – door to stair 04/01/009. 2. Ground floor –
doors either side of base of stair. 3. Ground floor – door to main corridor. 4. Door to medical records 04/01/007
2011 The following doors should be upgraded to 2011 The following doors should be upgraded to FD30 standard: 1. First floor – doors to all rooms opening onto dead end
FD30S standard: 1. First floor – door to stair corridor. 2. Entrance lobby – electric cupboard.
04/01/009. 2. Ground floor – doors either side of base
of stair. 3. Ground floor – door to main corridor. 4.
Door to medical records 04/01/007
Unknown Estates to check Low risk rating added until Estates have checked
Insufficient numbers of Fire Safety Managers/Deputy Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management
Fire Safety Managers (DNOFS) Not all staff attend should ensure all staff attend annual Fire Awareness Training .
annual Fire Awareness Training
Unknown Estates to check Low risk rating given for Estates to check
GLASBURY
In the T V Lounge the patient?s own chairs are in use. Change to chairs complying with HTM 05-03 Part C: Textiles & furnishings.
The Day Room has no fire alarm call point adjacent to Provide fire alarm call point adjacent patio doors
the patio doors.
1.In all areas there is an iInadequate standard of fire 1.All fire doors (except cross-corridor doors) should be upgraded to FD30 standard. This to include any glazing over doors 2.
doors. 2.In the Smoking Room 13/00/009 there is an Upgrade door to FD30S standard 3. Upgrade door to FD30S standard 4. Upgrade door to FD30S standard. 5. Upgrade door
iInadequate standard of fire doors. 3.The Cross- to FD30S standard 6.Upgrade door to FD30S standard 7.Replace part seals door set
corridor door adjacent Room 13/00/011 is an
inadequate standard of fire door. 4.Staff Room door
13/00/013 is to an inadequate standard. 5.Patient?s
Room door 13/00/014 is to an inadequate standard.
6.Inadequate standard of cross corridor door adjacent
to room 13/00/014 7. office - 13/00/010 Part seals
missing from door set.
Inadequate proviosn of fire safety signage. 1.Door onto main corridor Fire exit sign incorrectly located Fire exit sign to be located over door not on it 2. All areas
Inadequate provision of fire door notices All fire doors should be provided with the following notices as appropriate: FIRE
DOOR – KEEP SHUT; FIRE DOOR – KEEP LOCKED SHUT
1.Kitchen Fire blanket overdue for annual inspection. 1. Fire blanket to undergo annual inspection 2. Fire extinguishers to undergo annual test
2.In the Psychology unit corridor adjacent to room
03/01/013 the Fire extinguishers areoverdue for
annual test.
MANSION HOUSE
2011 Redundant firefighting equipment 2011 Remove all hose reels and their water supply.
2011 Inadequate provision of fire door notices. 2011 All fire doors should be provided with the following notices as appropriate: FIRE DOOR – KEEP SHUT FIRE DOOR – KEEP
LOCKED SHUT
2011 Inadequate provision of Fire Action Notices. 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the
route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should
be displayed on all staff notice boards. In particular: 1. Second floor adjacent fire alarm call point at head of stair.
2011 Inadequate provision of door signage. 2011 1. First floor final exit door to external fire escape adjacent Room 013 provide PUSH BAR TO OPEN sign over door
opening mechanism.
2011 Inadequate provision of fire exit signage. 2011 Provide fire exit signage in the following locations: 1. Ground floor – door adjacent Kitchen 020 leading towards final exit
door
2011 Combustible storage in means of escape. 2011 Remove all combustible storage from following locations: 1. Second floor at head of stair outside Room 001. 2. First floor
outside Room 013. 3. First floor corridor, outside Room 018. 4. Mezzanine floor stair outside Rooms 001 and 002. 5. Ground
floor final exit door adjacent Kitchen 020. 6. Reduce content of noticeboards to a minimum.
2011 Inadequate protection of means of escape. 2011 1. Second floor should not be used due to the lack of adequate means of escape from the area. 2. Ground floor drinks
area at rear of Room 003 final exit door should not be secures by a key. 3. Ground floor disused Reception hatch should be
fixed shut and any gaps filled with 30 minutes fire resisting materials.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. All doors opening onto a stair enclosure (except doors to
toilets containing no fire risk). This to include any glazing over doors. 2. All cross-corridor doors. This to include any glazing
over doors. 3. Ground floor link corridor to Terrapin Building.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30 standard: 1. All doors opening onto a corridor (except doors to toilets
containing no fire risk). This to include any glazing over doors.
2011 Doors require attention. 2011 The following doors require attention: 1. First floor cross-corridor doors 012 not effectively self-closing due to poor fit,
also wedged open. 2. First floor cross-corridor doors 008 was wedged open. 3. First floor door onto side stair from ante space
to Rooms 006 and 009 not effectively self-closing due to catching on floor. 4. First floor cross-corridor door 012 not effectively
self-closing due to catching in open position. 5. Ground floor door from rear corridor to main stair, remove cabin hook and
keep closed, door also warped and should be replaced. 6. Ground floor Room 006 opening into main stair not effectively self-
closing due to poor fit. 7. Ground floor Room 003 used as store and containing photocopier, opening onto stair was wedged
open.
Insufficient numbers of Fire Safety Managers/Deputy Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management should
Fire Safety Managers (DNOFS) Not all staff attend ensure all staff attend annual Fire Awareness Training .
2011 Inadequate provision of automatic fire detection. 2011 Due to complexity of the building and some single staircase conditions it is recommended that a BS 5839 Part 1:
Category L2 system be provided.
FELINDRE WARD
2011 Damaged soft furnishings with filling exposed. 2011 Any damaged soft furnishings should be replaced. In particular: 1. Female Quite Room 048. 2. Room (10) 044.
upholstered seating.
2011 Inadequate provision of automatic fire detection. 2011 1. Store 010 provide automatic smoke detector. 2. Store 011 provide automatic smoke detector.
estates to confirm Estates to confirm
2011 Doors require attention. 2011 The following doors require attention: 1. Male corridor, Quiet area 002 missing part door seals. 2. Bedroom 009
damaged door seals. 3. Smoking Lounge 026 missing part door seals and loose glazing panel. 4. Cross-corridor doors 025
have an excessive gap at their meeting edge and require adjustment. 5. Cross-corridor doors 032 have an excessive gap at
their meeting edge and require adjustment. 6. Treatment Room 034 doors have an excessive gap at their meeting edge and
require adjustment. 7. Occ. Therapy cross-corridor doors 080 require missing glazing bead replacing. 8. Defynog Ward
kitchen missing part door seals. 9. Defynog Ward office has damaged door by hinges. 10. Cross-corridor door 045 not
effectively self-closing due to catching on door seals. It was noted that the general condition of bedroom doors was poor due
to damage by residents
2011 Minor breaches to ceiling. 2011 1. Store 028 infill breach to ceiling with 30 minutes fire resisting materials. 2. Store 060 infill breach to ceiling with 30
minutes fire resisting materials.
2011 Inadequate provision of Fire Action Notices 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the
details. route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should
be displayed on all staff notice boards.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Extra Care Unit Room 018, confirm door is to FD30S
standard. 2. Treatment Room 034. 3. Defynog Ward store 063.
2011 Inadequate provision of emergency lighting. 2011 1. Assisted Bathroom 019 provide emergency light unit. 2. Any emergency light unit showing faults should be inspected
by a suitably qualified person. 3. It should be confirmed that the escape lighting provided is in accordance with BS5266 Part
1, supplemented by HTM 06-01 were appropriate.
COURTYARD
2011 Inappropriate location of firefighting equipment. 2011 Engineering Workshop relocate Water and Carbon Dioxide extinguishers in inner room to adjacent entrance door.
2011 Inadequate provision of firefighting equipment. 2011 Flammable Liquid Store provide Dry Powder extinguisher in weatherproof container outside store.
3,10,97,22,100,26
be displayed on all staff notice boards. In particular: 1. Stair outside Estates office.
2011 Inadequate provision of gas warning signage. 2011 Engineering Workshop provide gas warning signs on entrance door of inner room.
be displayed on all staff notice boards. In particular: 1. Independent Complaints Office. 2. Engineering Workshop. 3. Works
Managers office.
2011 Combustible materials on means of escape. 2011 1. Rear fire exit external stair remove all storage from under stair and keep clear at all times. 2. Engineering Store
remove all redundant combustible storage.
2011 Doors require attention. 2011 The following doors require attention: 1. Ground floor Estates door 004 missing door seals. 2. First floor Powys Public
Health office 010 missing door seals. 3. First floor Powys Public Health office photocopier room 009 confirm vent is 30 minutes
fire rated. 4. First floor Powys Public Health fax and filing room 006 not effectively self-closing due to catching on door latch.
2011 Inadequate provision of automatic fire detection. 2011 Engineering stores extend automatic fire detection to cover both end sections.
Insufficient numbers of Fire Safety Managers/Deputy Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management should
Fire Safety Managers (DNOFS) Not all staff attend ensure all staff attend annual Fire Awareness Training .
LLEWELWYN WARD
(09/08/2010) Oxygen cylinders stored in the link Oxygen cylinders should be relocated off evacuation routes.
corridor to the day hospital.
2011 Inadequate provision of manual fire alarm call 2011 Provide manual fire alarm call point adjacent French windows.
point.
(09/08/2010) Doors not to the required standard The following doors should be upgraded to FD30S standard: 1. Store room doors including any side wards used for storage).
2. Cross-corridor doors to ward adjacent Doctors Office 00/039 3. Doors to Link to Day Hospital
(09/08/2010) Doors require attention The following doors require attention: Cross-corridor doors adjacent Room 00/016 has defective hold open device.
2011 Doors require attention. 2011 The following doors require attention: 1. Cross-corridor doors 030 no door selector device. 2. Cross-corridor doors
adjacent Room 014 defective door selector device. 3. Cross-corridor doors 004 no door selector device.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Doors onto main corridor. 2. Doors to Link corridor to
Day Hospital. 3. Store 045, including glazing over to 30 minutes fire resisting. Confirm air transfer grille to 30 minutes fire
resisting standard. 4. Linen store 043. 5. Cross-corridor doors adjacent Equipment store 038. 6. Equipment store 038. 7.
Pantry 019, also confirm air transfer grille to 30 minutes fire resisting standard. 8. Ward kitchen. 9. Store 006. 10. Cross-
corridor doors adjacent Room 014, confirm air transfer grille to 30 minutes fire resisting standard.
(09/08/2010) The door to the kitchen is wedged in the The wedging open of doors contravenes fire safety requirements and places at risk the lives of occupants. in particular the
open position door to the kitchen must not be wedged open.
2011 Incorrect use of Link corridor to Day Hospital. 2011 Link corridor to Day Hospital. Should not be used to store wheelchairs or oxygen cylinders.
(09/08/2010) Inadequate provision of fire exit signage Provide fire exit sign over doors on long corridor side of cross-corridor doors 00/030
2011 Inadequate provision of Fire exit signage. 2011 Provide fire exit signs: 1. Cross-corridor doors 030, over side of doors adjacent Room 031.
(09/08/2010) Inadequate proviosn of method of Day room – Provide right directional SLIDE TO OPEN sign on patio door
operation signage.
(09/08/2010) Inadequate proviosn of AUTOMATIC All doors with hold open devices require AUTOMATIC FIRE DOOR KEEP CLEAR notices.
FIRE DOOR KEEP CLEAR SIGNAGE
2011 Inadequate provision of door signage. 2011 1. Cross-corridor doors adjacent Room 014 has AUTOMATIC FIRE DOOR KEEP CLEAR signs on wrong sides of doors. 2.
Cross-corridor doors adjacent Equipment store 038. require AUTOMATIC FIRE DOOR KEEP CLEAR signs on doors. 3. Cross-
corridor doors 030 require AUTOMATIC FIRE DOOR KEEP CLEAR signs on doors. 4. Cross-corridor doors 004 require
AUTOMATIC FIRE DOOR KEEP CLEAR signs on doors. 5. Final exit door adjacent Room 001 requires PUSH BAR TO OPEN
sign over door opening mechanism. 6. Final exit door adjacent Room 025 requires PUSH BAR TO OPEN sign over door
opening mechanism.
X RAY DEPARTMENT
1.All areas have an inadequate provision of fire door 1.All fire doors should be provided with the following notices as appropriate: FIRE DOOR – KEEP SHUT; FIRE DOOR – KEEP
notices. LOCKED SHUT; AUTOMATIC FIRE DOOR – KEEP CLEAR
In the corridor the CO2 extinguisher is not fixed in CO2 extinguisher to be fixed in situ in the corridor.
situ.
1.In the main area there is a cent in fire door. 2. In 1. Confirm vent in fire door is to 30 minutes fire rated. 2. Confirm vent in fire door is to 30 minutes fire rated. 3. Upgrade
the Dark room there is a Vent in the fire door. 3.Door door to FD30S standard.
to corridor leading to the Admin Dept is to an
inadequate standard.
1.The Lighting unit over the rear door in the main area 1.Repair the lighting unit over the main door.
is damaged.
CATERING BLOCK
2011 Inadequate provision of manual fire 2011 Kitchen, veg prep area provide fire alarm call point adjacent final exit door.
alarm call point.
2011 Inadequate protection of means of 2011 Kitchen loading bay outside rear corridor, provide pedestrian barrier across loading bay when not in use.
escape.
2011 Inadequate provision of Fire Action 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route to the
Notices details. assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be displayed on all
staff notice boards. In particular: 1. Kitchen adjacent rear corridor final exit door. 2. Support Services HQ.
BUNGALOWS
2011 Inadequate provision of Fire Action Notices 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the
details. route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards. In particular: 1. Magpie & Windermere units.
Insufficient numbers of Fire Safety Additional Fire Safety Managers/Deputy Fire Safety Managers (DNOFS) should be nominated and trained. Management should
Managers/Deputy Fire Safety Managers (DNOFS) ensure all staff attend annual Fire Awareness Training .
Not all staff attend annual Fire Awareness Training
2011 Inadequate provision of automatic fire 2011 Orchards 1-4 and The Lodge. Recommended that a BS 5839 Part 6 system be installed and linked to the site alarm
detection. monitoring system to replace battery operated fire alarms.
TERRAPIN
NO SIGNIFICANT FINDINGS
DAY HOSPITAL
2011 Inadequate provision of door signage. 2011 Cross-corridor doors adjacent Physio 027 require AUTOMATIC FIRE DOOR KEEP CLEAR signs on doors. Also requires
PRESS TO OEN sign on doors for when alarm operates.
route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings
should be displayed on all staff notice boards. In particular: 1. Adjacent fire alarm call point by Link corridor to Llewellyn
Ward.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Door to main corridor. 2. Store 010. 3. Cross-corridor
door adjacent Physio 027. 4. Link corridor to Llewellyn Ward. 5. Cleaner’s store 003.
TRAINING DEPARTMENT
2011 Inadequate provision of automatic fire 2011 IT area of Library provide automatic smoke detector.
detection.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Door onto main corridor 2. Cross-corridor door 017. 3. Cross-
corridor door 005A.
2011 Inadequate means of escape. 2011 1. Middle final exit door opens over a step.
2011 Inadequate provision of fire exit signage. 2011 Provide fire exit sign over inside of door from IT area of Library.
2011 Inadequate provision of Fire Action Notices. 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route to
the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be displayed on
all staff notice boards. In particular: 1. Adjacent door to main corridor. 2. Adjacent signed firer exit from Library.
2011 Inadequate provision of door signage. 2011 Remove FIRE DOOR KEEP SHUT signs from tea room/kitchen 022.
OUTBUILDINGS
2011 Inadequate provision of Fire Action Notices 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route to
details. the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be displayed on
all staff notice boards. In particular: 1. Oxygen store. 2. Old Boiler House Store. 3. Old Boiler House Store. 4. Coal Store. 5.
Carpenters shed.
2011 Inadequate provision of gas warning 2011 Oxygen store provide gas warning signs.
signage.
Not all staff attend annual Fire Awareness
Training
NURSERY
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30 standard: 1. Electrical cupboard. Door onto main corridor
2011 Inadequate provision of Fire Action Notices 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route
details. to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards. In particular: 1. Top room.
MONNOW WARD
2011 Fuel stored in corridors. 2011 Do not store adjacent Solar Power unit.
2011 Inadequate provision of fire separation. 2011 Solar Power unit, enclose with 30 minutes fire resisting materials including FD30 standard door.
2011 Inadequate provision of manual fire alarm 2011 Provide manual fire alarm call point adjacent Kitchen side final exit door.
call point.
2011 Inadequate provision of Fire Exit signage. 2011 Provide fire exit sign over both sides of cross-corridor doors 024 and 027.
2011 Inadequate provision of Fire Action Notices. 2011 Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route
to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards. In particular: 1. Main training area both side exits. 2. Final exit door adjacent Room 36.
2011 Doors require attention. 2011 The following doors require attention: 1. Cross-corridor doors 014 no door selector device. 2. Cross-corridor doors 018 no
door selector device. 3. Cross-corridor doors 027 defective door selector device.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30S standard: 1. Door to main corridor.
BASIL WEBB
Training
2011 Lack of fire door. 2011 Tea Area it is considered acceptable that these doors be removed due to the presence of automatic fire detection and the
provision of alternative means of escape from all areas.
2011 Doors not to the required standard. 2011 The following doors should be upgraded to FD30 standard: 1. All existing fire doors.
2011 Inadequate means of escape. 2011 Payroll rear final exit door opens over a step.
MULTISENSORY
Training
LLANDRINDOD WELLS
(7/11) Llangwyn - None essential services still active. Llangwyn - Turn off all none essential services and monitor condition of unit on a regular basis.
(7/11)Maintenance of wall coverings. All wall coverings in stairs and circulation spaces should be maintained as having Class O Surface Spread of Flame rating.
(7/11) Inadequate provision of automatic fire detection. Due to the arrangements of compartmentation it is necessary to treat all three units as being part of a multi occupied
premises. It is recommended therefore that the existing automatic fire detection system be upgraded to an L3X standard in
accordance with BS5839 & HTM 05-03. As a result of the Hazels being extended into Llangwyn on different floor levels and
the compartmentation being compromised, it is recommended that the alarm should be activated simultaneously
throughout the three units. Langwyn – Type of detectors will be dependent on future use of unit.
(7/11) Hazels - Doors not to the required standard due to The following doors should be upgraded to FD30 standard and upon completion of works it should be confirmed that the
dead end conditions. door(s) conform to all relevant parts of current standards:: 1. Office doors 005 and 021.
(7/11)Hazels/Merlin - Inadequate protection of stair A complete protected route incorporating FD30S standard doors should be formed from the second floor to a final exit.
enclosures with some doors not to the required standard. Although this partially exists some doors will require upgrading and any reception hatch to be 30 minutes fire resisting
standard.
(7/11) Provision of external fire escape stair. Access to the rear external fire escape is via a large step (400mm). The rise/going of such steps should be in accordance
with statutory legislation i.e. Building Regulations. The requirement for the external escape can be dispensed with subject
to the provision of the protected route.
(7/11) Unable to confirm standard of compartmentation. The existing construction is unlikely to attain 60 minutes fire resistance, however it has been deemed acceptable in this
particular instance due to low occupancy numbers and the proposed upgrading of the automatic fire detection system.
(7/11) Inadequate provision of fire exit signage. All fire exits must be conspicuously marked with fire exit notices complete with the running person pictogram and an arrow
if appropriate. Signs that comply with BS 5499 ‘Fire safety signs, notices and graphic symbols’ include such graphic
symbols. Fire exit signs should be displayed above not on the face of doors. Directional signs must be included along the
evacuation route to the fire exit(s) and be visible in all directions. In particular: 1. Hazels - Provide fire exit signs over, not
on, doors to rear final exit route.
OCCUPATIONAL THERAPY AND PHYSIO
Inadequate testing of manual firefighting equipment. Physio. Wax/Splint room 141, fire blanket is overdue for inspection.
Inadequate provision of fire exit door signage. Physio. rear final exit door, provide PUSH BAR TO OPEN sign over door opening mechanism.
(07/11)Inadequate compartmentation in roof space. Compartment wall between MIU corridor and Occ Therapy and Physiotherapy to be taken up to underside of roof.
Inadequate testing of manual firefighting equipment. Physio. Wax/Splint room 141, fire blanket is overdue for inspection.
THEATRE
(07/11) Unable to confirm the standard of Confirmation required that the floor area to staff change and dirty corridor over casualty department achieves 60 minutes
compartmentation to corridor floor. fire resistance.
(07/11) Compartmentation not to required standard. 1. Compartmentation between Maternity department and operating Theatre should be extended into the roof space and
fire stopped. (Photo ???) 2. Technically the 60 minute compartment wall and door, in 1. above, is correctly located,
however as a high fire risk area (i.e. kitchen) is located beneath, additional FD60S self-closing fire doors are
recommended to be provided at the end of the corridor facing the Theatre entrance doors
(07/11) Unable to confirm standard of envelope protection. It is recommended where the flat roofs above the kitchen and OPD abuts the external elevation, confirmation required
that these areas achieve 60 minutes fire resistance for a distance of 3m or provide AFD to an L1 standard to these areas.
(see Kitchen area assessment reference automatic fire detection)
(07/11) Unable to confirm that air transfer grille is to Confirmations should be sought that the air transfer grille in Male changing room door is to required 30 minutes fire
required standard. resisting standard.
(07/11) Sub compartmentation is generally recommended Because it is a single theatre operating department, this requirement has been dispensed with.
to ensure that no more than 50% of operating theatres
would be compromised at any one time in the event of a
fire.
(07/11) Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all
relevant parts of current standards: 1. Theatre entrance doors have an excessive gap at meeting edge and should be
adjusted. (Photo 134) 2. Anaesthetic room 052 doors have an excessive gap at meeting edge and should be adjusted.
(Photo 135) 3. Endoscopy Suite main doors have an excessive gap at meeting edge and should be adjusted. (Photo 136)
(07/11) Doors not to the required standard. The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed that the
door(s) conform to all relevant parts of current standards:: 1. Male changing room. 2. Equipment store 061. 3. Sterile
store 050. 4. Scrub Up 051. 5. Theatre entrance doors. 6. Anaesthetic room 052. 7. Endoscopy Suite main doors. 8. Used
Scopes 060 (formerly sister’s office).
CLEWEDOG WARD
(/07/11) Doors not to the required standard for patient The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed that the
bedrooms. . door(s) conform to all relevant parts of current standards:: Patient bedrooms provided specifically for: a. the elderly; b.
those suffering from mental illness; c. people with learning disabilities.
door(s) conform to all relevant parts of current standards:: 1. Store 125 (former bathroom0. 2. Store/Sluice 121. 3.
Kitchen 119. 4. Sitting/Dining Room 118. 5. Double store in Sitting/Dining Room.
Inappropriate storage in roof space. Remove all storage from roof space and keep clear at all times. (Photo 110)
Inadequate provision of automatic fire detection. 1. Store 125 (former bathroom), provide automatic smoke detection to this area. 2. Double store in Sitting/Dining Room,
provide automatic smoke detection to this area.
(07/11) Unable to confirm means of escape from garden Confirmation required that digital lock on external gate is linked to operation of fire alarm.
area.
PORTACABINS ADJ REAR OF THEATRES
Inadequate provision of firefighting equipment. Portacabin 1 (Claerwen Ward), provide one 9 litre water extinguisher adjacent entrance door. firefighting equipment.
Firefighting equipment not being maintained. Portacabin 2 (Porters), 9 litre water extinguisher requires annual testing.
Inadequate provision of automatic fire detection. Provide automatic smoke detection to both Portacabins.
EDW MATERNITY WARD
Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all
relevant parts of current standards:: 1. Main entrance doors from stair enclosure unable to close fully. 2. Cross-corridor
doors adjacent Midwife office 063 requires selector device. 3. Cross-corridor doors 021 have an excessive gap at meeting
edge and should be adjusted
(07/11) Inappropriate electrical fittings. 1. Store 026 remove electrical junction box from door frame. 2. Store 026 exposed electrical wiring on ceiling. (Photo 133)
(07/11) Inappropriate storage in roof space. The use of the roof space for storage should be discontinued on grounds of fire safety and health & safety. (Photo 95)
Staffing levels It is the responsibility of management to ensure that adequate numbers of staff will always be available and to devise
suitable arrangements to provide for the safe evacuation of patients in accordance with the emergency evacuation plan.
When the department is in use, there should be a minimum of two staff present at all times. These staff should have
received training in the methods of patient evacuation appropriate to the dependency of the patients and be familiar with
the evacuation procedures required. Staffing at night is from the adjoining ward. This has been considered acceptable
subject to the following conditions;- • the patient to staff ratio does not exceed 30 : 2, and • the alarm system is
programmed to operate continuously in both zones for the night-time period. Any staffing arrangements should also be
identified in the Trusts’ fire safety policy.
door(s) conform to all relevant parts of current standards:: 1. Linen store adjacent entrance to Theatre corridor 046. 2. Store
026. 3. Visitors Kitchen/Sitting room, both doors including glazing over doors.
(07/11) Stairway B not suitable for patient evacuation. This stairway is not suitable for mattress evacuation, and should be designated as an accommodation stairway only.
(07/11) Stairway not to required standard for mattress Stairway should be designated as an accommodation stairway only.
evacuation.
Single direction means of escape Deemed acceptable via Operating Theatre’s exit corridor
(07/11) Inadequate compartmentation of floor. Upgrade existing timber floor to achieve 60 minutes fire resistance.
(07/11) Breaches in ceiling. Store 026 infill breaches in ceiling with 30 minutes fire resisting materials.
(07/11) Unable to confirm fire resistance of partition Visitors Kitchen/Sitting room, confirm partition wall between side ward is to 30 minutes fire resisting standard.
wall.
(07/11) Unable to confirm that fire resistance of external Where the flat roofs above kitchen and OPD abut the external elevation, confirmation required that these areas achieve 60
elevation is to required standard minutes fire resistance for a distance of 3m, or provide an L1 standard of AFD to these areas. (see Kitchen area assessment)
(07/11) Inadequate compartmentation in roof space. 1. The rear of the storage cupboards space should be separated from roof space by fir resisting construction. (Photos 96,
97) 2. Compartmentation to be taken up to underside of roof and fire stopped between Maternity and Theatre corridor.
MAIN BOILER/GENERATOR
(7/11) Inadequate provision of Fire Action Notices Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route
details. to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards.
(7/11) Confirmation of compartmentation required. Boiler House - Confirm underground service duct is fire stopped to 60 minutes fire resistance where it leaves the building
towards Claerwen Ward. (Photo 131)
(7/11) Final exit doors open over step. 1. Boiler House – Rear exit, provide threshold step on outside of door. 2. Boiler House – Front exit, provide warning notice
on inside of door that door opens over step. Due to access requirements a threshold step is not recommended.
Estates to confirm. estates to confirm.
Combustible storage in Boiler House. Remove all combustible storage.

CLAERWAEN WARD
(07/11) Inadequate provision of automatic fire Provide Store 101 (former bathroom) with automatic smoke detection.
detection.
(16/09/2008) Doors require attetion. The following doors require attention. 1.The door to the staff room has a defective electromagnetic hold open device. 2. The
cross corridor door 01/01/104 is not effectively selc closing due to catching on the lock.
(22/07/2010) Doors require attention. The following doors require attention: 1. The cross corridor doors adjacent to room 130 has a defective selector device. 2
The cross corridor doors adjacent to room 104 are not effectively self closing due to jamming.
door(s) conform to all relevant parts of current standards:: 1. Linen store opposite side ward 135. 2. Staff room 130A. 3.
Switchgear room 131. 4. Day room 087. 5. Cleaners store 089. 6. Electric cupboard adjacent toilet 090. Unable to gain
access, confirm door is to FD30S standard. 7. Laundry room 095. 8. Medical store 096. 9. Linen store adjacent Room 100.
10. Store 101 (former bathroom). 11. Kitchen 106.
(07/11) Ceiling hatch requires attention. The ceiling hatch in Linen store opposite side ward 135 does not fit correctly in frame.
(22/07/2010) Fire doors wedged in the open position. The wedging open of fire doors contravenes fire safety requirements and places at risk the lives of occupants. In particular
the folloiwng doors should not be wedged open. 1. Door 01/01/003 to the print room.
(22/07/2010) Fire doors wedged in the open position. The wedging open of fire doors contravenes fire safety requirements and places at risk the lives of occupants. In particular
the folloiwng doors should not be wedged open. 1. Door 01/01/003 to the print room.
(16/09/2008) Combustible storage adjacent to the Remove all storage from adjacent to the entrace to Clywedog ward and maintain this area clear of storage at all times.
entrance to Clywedog Ward.
(07/11)Storage in circulation space. Area adjacent entrance to Clwedog not to be used for storage.
(07/11) Inadequate compartmentation in roof space. 1. Breach to fire curtain between staff room and main ward. (Photo 1108) 2. Wall over Day room. (Photo 1106,1107)
(16/09/2008) Oxygen cylinders stored in corridor Remove the oxygen cylinders from the corridor.
adjacent to the entrance to Clywedog ward.
LIFT MOTOR ROOM

Inadequate provision of Fire Action Notices details. Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the route
to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings should be
displayed on all staff notice boards.
Inadequate provision of escape lighting via roof space Additional escape lights required in roof space exit route.
exit route.
Confirmation of compartmentation required. Confirmation required that Lift motor room hatch is 30 minutes fire resisting standard. (Photo 91)
ELAN WARD
(22/07/2010) Automatic fire detection is not to the required Upgrade the automatic fire detection to L1 standard
standard.
(22/07/2010) A break glass fire alarm call points is required Provide a break glass fire alarm call point adjacent to LWM 01 01 004
adjacent to LWM 01 01 004
(07/11)Doors not to the required standard The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed
that the door(s) conform to all relevant parts of current standards:: 1. Ward kitchen 017.
(07/11)Doors require attention The following doors require attention and upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards:: 1. Main entrance doors unable to close fully.
(22/07/2010) Inadequate proviosn of FIRE DOOR-KEEP "FIRE DOOR-KEEP LOCKED SHUT" signage is required on all store and service cupboard doors
LOCKED SHUT signage
(22/07/2010) Inadequate provision of FIRE DOOR KEEP "FIRE DOOR-KEEP SHUT" required on LWM 01 01 007
SHUT signage.
(07/11)Inadequate provision of fire door signage. Provide FIRE DOOR KEEP LOCKED SHUT sign on Linen store doors.
(22/07/2010) Directional exit signage required above, All fire exits must be conspicuously marked with fire exit notices complete with the running person pictogram and an arrow if
not on doors appropriate. Signs that comply with BS 5499 ‘Fire safety signs, notices and graphic symbols’ include such graphic symbols.
Fire exit signs should be displayed above not on the face of doors. Directional signs must be included along the evacuation
route to the fire exit(s) and be visible in all directions.
(22/07/2010) A fire exit sign with a straight on/straight All fire exits must be conspicuously marked with fire exit notices complete with the running person pictogram and an arrow if
up directional exit sign is required above door 016 appropriate. Signs that comply with BS 5499 ‘Fire safety signs, notices and graphic symbols’ include such graphic symbols.
Fire exit signs should be displayed above not on the face of doors. Directional signs must be included along In particluar,
above the door 01/01/016.
(07/11)Stairway D from rear of ward not suitable for all patient Use by Independent Patients: The dimensions are not as per the requirements (see Site Wide
access categories likely to use stair. Recommendations), but are minor infringements and this stairway is considered acceptable for means of escape
by this category of patient. Use by Dependent Patients: The stairway is not considered suitable for means of
escape for Dependent Patients. It is recommended that this issue be addressed when considering the design of
the proposed Renal Unit in this area.
MIU
(07/11)Confirmation of compartmentation required. 1. Confirmation required that the new lift doors maintain 60 minutes fire resistance. 2. The Georgian wired glass in
the sub-compartment wall adjoining maternity has been considered acceptable. 3. Confirmation required that
underground service duct from Boiler House is fire stopped to 60 minutes fire resistance where it enters the
building inside Service Riser, adjacent Room 070
(07/11)External envelope protection. Where the flat roof above OPD abuts the external elevation, confirmation is required that these areas achieve 60
minutes fire resistance for a distance of 3m.
(07/11)Inadequate compartmentation in roof space. Fire stopping required to sub-compartmentation within roof space.
KITCHENS
(16/09/2008) Doors require attention. The following doors require attention: 1. The cross corridsor doors are not effectively self closing due to catching in
the closed position.
7/11) Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards:: 1. Main entrance doors 056 are not effectively self-closing due
to catching on floor. Also missing part door seals. Also doors have an excessive gap at meeting edge and should be
adjusted.
(7/11) Inadequate provision of automatic fire detection. Provide additional automatic detection to provide coverage to all areas of the Kitchen (see Operating Theatre area
assessment reference envelope protection)
OUTPATIENTS AND X RAY
(7/11) Inadequate provision of automatic fire detection. Proposed IT server room (former x-ray film store), provide automatic smoke detection.
(07/11) Doors not to the required standard in X-Ray. The following doors should be upgraded to FD30S standard in X-Ray and upon completion of works it should be confirmed
that the door(s) conform to all relevant parts of current standards:: 1. Door to proposed IT server room (former x-ray film
store).
The corridor doors from the OPD are wedged in the open The wedging open of fire doors contravenes fire safety requirements and places at risk the lives of occupants.In particular
position. the cross corridor doors from the OPD onto the main corridor.
(7/11) Inadequate compartmentation of ducts. Sub-basement below proposed IT server room (former x-ray film store), separate both duct runs where they enter the
sub-basement area with 60 minute fire resisting materials.
BOILEROOM UNDERNEATH PHYSIO
Inadequate provision of Fire Action Notices . Fire Action Notices (with all details clearly legible and indelibly marked) and a simple single line drawing indicating the
route to the assembly point should be displayed adjacent to all break glass alarm points. Similar notices and drawings
should be displayed on all staff notice boards.
Inadequate compartmentation. Undercroft may remain undivided subject to provision of automatic fire detection to all areas. (Photo 111)
Inadequate protection of compartmentation. Provide intumescent collar to soil pipe in Undercroft where it passes through the floor above.
Inadequate provision of automatic fire detection. Provide automatic smoke detection in undercroft.
OCCY THERAPY AND PHYSIO
(07/11) Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all relevant
parts of current standards:: 1. Physio. main entrance doors 138 are missing smoke seals. 2. Kitchen 149 doors have an excessive gap
at meeting edge and should be adjusted. 3. Therapy Area 150 doors have an excessive gap at meeting edge and should be adjusted.
4. Entrance to Occ. Health one leaf not effectively self-closing due to catching on floor. 5. Cross-corridor doors, adjacent Treatment
room 142, have an excessive gap at meeting edge and should be adjusted. 6. Cross-corridor doors, adjacent room 144, have an
excessive gap at meeting edge and should be adjusted.
(07/11) Doors not to the required standard. The following doors should be upgraded to FD30S standard and upon completion of works it should be confirmed that the door(s)
conform to all relevant parts of current standards:: 1. Physio. store 147.
(07/11)Inadequate compartmentation in roof Compartment wall between MIU corridor and Occ Therapy and Physiotherapy to be taken up to underside of roof.
space.
Inadequate provision of fire exit door signage. Physio. rear final exit door, provide PUSH BAR TO OPEN sign over door opening mechanism.
THEATRE
(07/11) Inadequate provision of PUSH BAR TO Provide PUSH BAR TO OPEN signage in the following locations: 1. On the exit door from adjacent Equipment store 061.
OPEN signage.
(07/11) Standard of refuge provided not to Operating Theatres normally require a high standard of refuge. In this instance because of the ground floor location, this
required standard. requirement has been dispensed with.
RECEPTION AND MEDICAL RECORDS
(7/11) Inadequate compartmentation. The hatch to Reception/Medical records should be provided with a 60 minute fire resisting shutter linked to operation of fire alarm.
(7/11) Inadequate compartmentation. Provide 60 minutes fire resisting enclosure to duct inside of store off Room 030. (Photo 121)
(7/11) Confirmation of compartmentation Confirmation required that underground service from Boiler House is fire stopped to 60 minutes fire resistance where it enters the
required. building inside service Riser 025.
(7/11) Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all relevant
parts of current standards:: 1. Male staff change room 023. 2. Female staff change room 028. 3. Reception/ Medical Records
MEDICAL GAS STORE
A1. Is smoking permitted or are smoking Medical Gas Evidence of smoking The Trust no smoking policy should be 2
7 materials present? Store adjacent Medical Gas Stores enforced fully and the situation monitored. 0
A5. Does the assessment area have a history of Medical Gas Estates to confirm Estates to confirm 1
3 generating Unwanted Fire Signals? Store
FIRST FLOOR OFFICES
(07/11) Combustible storage in circulation routes. Remove cardboard boxes from on top of filing cabinets.
(07/11) Inadequate provision of fire exit signage All fire exits must be conspicuously marked with fire exit notices complete with the running person pictogram and an arrow if
appropriate. Signs that comply with BS 5499 ‘Fire safety signs, notices and graphic symbols’ include such graphic symbols. Fire
exit signs should be displayed above not on the face of doors. Directional signs must be included along the evacuation route to
the fire exit(s) and be visible in all directions. In particular: 1. Provide a fire exit sign over cross-corridor door leading to
Maternity.
estates to confirm estates to confirm
(07/11) Doors not to the required standard due to The following doors should be upgraded to FD30 standard and upon completion of works it should be confirmed that the
dead end conditions. door(s) conform to all relevant parts of current standards:: 1. All office doors opening onto corridor.
ADMIN AND PATIENT SERVICES
Inadequate provision of fire alarm visual warning Provide fire alarm visual warning device in Audiology room.
device.
Doors require attention. The following doors require attention and upon completion of works it should be confirmed that the door(s) conform to all
relevant parts of current standards:: 1. Store 001, defective hold open device with exposed electrical wiring
(16/09/2008) Main office, rear exit door obstructed. Remove all obstructions to the rear exit door and maintain this door clear and readily available at all times.
MAIN ENTRANCE
(7/11) Surface finish standard of fire resistance requires Confirmation required that the timber panelling has been treated to achieve Class ‘O’ surface spread of flame rating.
confirmation.

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Knighton Hospital 17/06/2013

These are what I noted on my last vist

CHILDRENS CENTRE & ANNEXE

Remove photocopier to a side room.

DIAGNOSTICS AND TREATMENT

Estates to confirm Estates to confirm

FIRST FLOOR ADMIN

MAIN ENTRANCE / XRAY/ CONFERENCE ROOM

SPEECH AND LANGUAGE THERAPY

Estates to confirm Estates to confirm

ADMIN/CONTACT CENTRE/STORES/CONTINENCE SERVICE OFFICE

Doors not to the required standard.

Staff Changing Area

1. The firefighting 1. The firefighting equipment should be tested by a competent person.

Switch Room Used as storage Do not store in this area

1Kitchen Unconfirmed fire 1 Kitchen to be enclosed in 60 minutes fire resisting construction

MAIN STAIR ENCLOSURE

Inadequate provision of Therapies Unit office, provide automatic smoke detector.

HOSPITAL STORE/PLANT ROOMS

KITCHEN/STAFF DINING/STAFF CHANGING

(7/11)Inappropriate location of Kitchen, relocate CO2 extinguisher in

MINOR INJURIES UNIT

(7/11)Photocopier in circulation space. Relocate photocopier out of any circulation space.

PAIN MANAGEMENT CENTRE

CONCERT HALL (PAIN MANAGEMENT)

estates to confirm Estates to confirm

Estates to confirm Estates to confirm

OCCUPATIONAL THERAPY AND PHYSIO

PORTACABINS ADJ REAR OF THEATRES

Estates to confirm Estates to confirm

EDW MATERNITY WARD

Estates to confirm. estates to confirm.

Combustible storage in Boiler House. Remove all combustible storage.

LIFT MOTOR ROOM

Estates to confirm Estates to confirm

Estates to confirm Estates to confirm

Estates to confirm Estates to confirm

Estates to confirm Estates to confirm

OUTPATIENTS AND X RAY

BOILEROOM UNDERNEATH PHYSIO

Estates to confirm Estates to confirm

MEDICAL GAS STORE

FIRST FLOOR OFFICES

estates to confirm estates to confirm

Estates to confirm Estates to confirm

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