Chief Executive Officers Annual Fire Statement (See Appendix 1) for Assurance

• Chief Executive Officers Annual Fire Statement (see Appendix 1) – for assurance
• Fire Health and Safety Compliance Summary (see Appendix 2) – for assurance
• Equality and Diversity (see Appendix 3) – for assurance and approval

• Chief Executive Officers Annual Fire Statement (see Appendix 1)
• Fire Health and Safety Compliance Summary (see Appendix 2)
• Equality and Diversity (see Appendix 3)

Impact

Directorate involvement and sign off prior to submission to committee / board. Please state role titles or state n/a if appropriate

Annual Compliance Update

1. Background / History

The CCG maintains a compliance infrastructure to ensure that key statutory obligations and compliance best practice activities are implemented ongoing. Included in this report are the following:

• Chief Executive Officers Annual Fire Statement (see Appendix 1) – for assurance
• Fire, Health and Safety Compliance Summary (see Appendix 2) – for assurance
• Equality and Diversity (see Appendix 3) – for assurance and approval

Other areas of corporate compliance including Information Governance, Freedom of Information and Subject Access Requests are monitored by the Audit Committee and Information Governance Executive Assurance Group.

1. Proposal

The compliance assurance reports are set out to provide the context and a position statement for the year in respect of Fire, Health and Safety and Equality and Diversity.

1. Progress / Barriers to Progress / Key Risks

Implementation of the Fire Policy is monitored by the Audit Committee. The HealthEast Executive Team monitor the following:

-Health and Safety Action Plan

-Progress against the desktop assessment grid

-Fire and Health and Safety Assessment action plans to progress the implementation of recommendations generated from the formal assessments carried out by the landlord to safeguard tenant risks in respect of Fire and Health and Safety.

1. Options for consideration

The Equality Delivery Scheme includes the national Equality and Delivery Scheme 2 objectives which the CCG has agreed to adopt in full. The Governing Body are recommended to continue to adopt the objectives that make up this significant document seen as best practice for NHS organisations in delivering its Equality and Diversity duties.

1. Conclusion

The documents included in the appendices following are intended to provide assurance and by reporting them together as part of an Annual Compliance update it is envisaged the strategic assurance and any subsequent feedback will be consistent across compliance agendas.

1. Recommendation

The Governing Body area asked to review the report appendices as follows:

1. Review the accompanying appendices that form the annual compliance update for Governing Body assurance in respect of the following regulated aspects governing corporate compliance:

• Chief Executive Officers Annual Fire Statement (see Appendix 1)
• Fire, Health and Safety Compliance Summary (see Appendix 2)
• Equality and Diversity (see Appendix 3)

2. Approve the objectives set out in the Equality and Diversity Objectives and Outcomes Grid in section 3.2 to Appendix 3.

1. Appendices

Appendix 1 Chief Executive Officers Annual Fire Statement

Appendix 2 Fire, Health and Safety Compliance Summary

Appendix 3 Equality and Diversity

Appendix 1Chief Executive Officer’s Annual Statement of Fire Safety

1. Assurance Required

This assurance report is presented by the Chief Executive Officer as the role with overall responsibility for Fire Safety for the CCG, as required by the NHSGYW CCG Fire Policy (section 7.) The section notes:

The Chief Executive is required to provide evidence annually of compliance with the Regulatory Reform (Fire Safety) Order 2005 this will be done via an Annual Statement of Fire Safety prepared by the Nominated Director for reporting to the Governing Body on behalf of the Chief Executive. This will be reported on to the area responsible for Estates Monitoring via NHS Property Services.

1. Fire Risk

There remains an ongoing fire risk at Beccles House. The risk is assessed as low in relation to the activities on site being office and administration in nature. Whilst the risk is low, the CCG considers the requirements to mitigate this risk as high priority to secure the Health and Safety of staff and site resources of the CCG and NHS Property Services. To that end the CCG ensures the following activities are maintained to mitigate the risk:

• Liaison with landlord in respect of the mix of responsibilities between tenant, joint occupying entities and landlord via contribution to Beccles House User Group and Annual Fire Risk Assessment;
• Work with ECCH Health and Safety Officer to ensure full list of Fire Marshals and procedure and Fire Emergency Plan are maintained and equipment for example high visibility jackets and fire equipment is maintained and tested (including regular fire alarm testing);

• Annual compliance in respect of annual fire drill, fire marshal training, mandatory employee fire training and annual compliance update to the Chief Executive for the purposes of this Fire Safety Statement. Implementation of relevant actions to meet the recommendations following the Fire Risk Assessment

1. Annual Fire Risk Assessment and Audit Committee Review

A noted above a key part the CCG assurance process in respect of Fire Safety is the review of compliance with the Fire Officer recommendations made following theirdetailed Annual Fire Risk Assessment in 2015. This assessment includes building Fire Safety, operational practice in respect of staff and resources, drills, incidents and false alarm management and the policy and procedure infrastructure in place at the CCG. As part of the ongoing work programme the detailed requirements of these recommendations are considered and any required actions implemented as part of the Beccles House Joint User Group and liaison with landlord and facilities coordinator, NHS Property Services to ensure the building remains compliant. The 2015 assessmentrecommendations were added to the action plan reference in Appendix 2.

The following were reviewed as part of the annual Audit Committee Review into Fire Safety in January 2015:

• The detailed controls and position in respect of the full scope of fire safety work
• Implementation of the policy

The Audit Committee are to receive an update of the progress in implementing the recommendations following the 2015 assessment in March 16.

This Audit Committee review forms part of its role in providing assurance that the CCG controls and practices in this respect are compliant and follow best practice.

1. CCG Fire Policy and Procedure and Beccles House Emergency Fire Plan

This is the second and ongoing annual reporting commitmentrequired as part of the assurance processes underpinning the implementation of the Fire Policy and Procedures for the CCG. The CCG along with other occupying entities of Beccles House, contributed to the setting of the Fire Emergency Plan, led by the ECCH Health and Safety Officer. TheFire Policy and Procedure was approved by the Audit Committee at itsJanuary 2014 meeting and the revised document sent out to all staff. It is next due for review January 2017 subject to any change in legal requirements that would necessitate an earlier review of the policy.

1. Health and Safety Action Planning and Third Party Assurance

The CCGprocures consultancy advice from a Health and Safety specialist advisor who provides an update on Health and Safety compliance at the year end. The CCG has in place a general Health and Safety Policy and Health and Safety WorkAction Plan. In addition a staff presentation on the Risk Assessment process was carried out in year. These assurance mechanisms are referenced in Appendix 1 to this compliance report.

1. Current Resourcing and Training

The Director of Partnership and Delivery monitors Fire Safety on behalf of the Chief Executive Officer and the Nominated Officer and provides steer for the Governance Manager in the operational delivery of Fire Safety requirements. Various staff contribute to the Beccles House User Group Meetings and work with the lead fire marshal and the ECCH Health and Safety Manager in respect of compliance requirements highlighted above. Several fire marshals are in place and these roles receive specific fire marshal training with the wider staff group receiving mandatory training in respect of Fire Safety.

Signed:

Chief Executive Officer NHSGYW CCG

Date:

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Appendix 2 Fire, Health and Safety Compliance Summary

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