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Service Agreement Information Kit for Funded Organisations

4.1 Fire risk management - DHHS only

Department of Health and Human Services

Who does this policy apply to?

This policy applies to all facilities in which the Department Health and Human Services owns, operates or funds which provide bed-based care, support or sleeping accommodation for clients under its care, but does not include typical domestic style dwelling and Low, medium and high rise multi-dwelling facilities used for public housing stock for individual rental agreements with tenants or Accommodation facilities used as boarding facilities, guest facilities, hostels or the like, rooming facilities as defined in the Residential Tenancies Act 1997 and crisis accommodation.

Policy purpose

  • The purpose of this policy is to set minimum standards for documenting and compliance reporting with the Statutory and Guideline requirements; it also ensures that the delivering of fire and emergency response procedures that should be in place.
  • To manage the risks to life due to fire in certain types of buildings which are owned, operated or funded by the department.

Legislation and /or regulation

Organisation requirements

Chief executives and general managers of services, agencies, networks and other facilities are responsible for ensuring the implementation of appropriate fire risk management measures required to satisfy statutory requirements and the appropriate Department of Health and Human Services guidelines.

Protecting clients

Protecting clients from fire risk is an important part of their care and of paramount importance to the department. The Service Agreement acknowledges that an organisation is responsible for complying with all laws, mandatory standards relating to fire protection, safety, health and general safety that apply to any premises from which the organisation owns or operates, irrespective of whether the relevant regulatory requirements place the obligation on the owner or occupier of those premises. The applicable guidelines for fire risk for department owned, operated or funded buildings/services are the Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window).

An organisation entering into a Service Agreement must have in place an appropriate system to protect people under its care. For this reason, the Department is keen to clarify its role and the role of the organisation in protecting the Department's clients from fire risk.

Fire Safety Audit

Every facilities must conduct regular fire safety audits in accordance with the requirements of the Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) at least once every five years or as required by the Fire Risk Management Review Panel to monitor ongoing compliance, and whenever a modification or addition is proposed to be made to the structure of the building. A fire safety audit can only be undertaken by a practitioner who is accredited to undertake fire safety audits. Accreditation may be limited to specific building or buildings and/or occupancy types.

Fire Safety Handbook

Every facility must have a fire safety handbook which is a unique document for each building or facility that defines the fire safety strategy for that building in terms of the required levels of compliance, performance, design parameters and maintenance requirements for each physical or human measure/factor. The required template for the Fire Safety Handbook is on the departments website ‘Fire Risk Management’.

The Occupational Health & Safety Act 2004 (opens in a new window, external link) as amended (OHSA) and case law provide that what is ‘reasonably practicable’ is that which is reasonably able to be done at the particular time and in a particular circumstance. This is to be determined by taking into consideration to all relevant matters including the following:

(a) likelihood of the hazard or risk eventuating

(b) degree of harm that would result if the  hazard or risk eventuated

(c) knowledge – including what a person ought to know – about the hazard or risk and any ways of eliminating or reducing the hazard or risk

(d) availability and suitability of ways to eliminate or reduce the hazard or risk

(e) cost of eliminating or reducing that hazard or risk.

The severest degree of harm that may result from a fire can be multiple fatalities. In light of this, considerable efforts should be made to eliminate or minimise the likelihood of a fire occurring (for example, through choice of building materials and regulation of activities within buildings) and to eliminate or minimise harm to the health and safety of people from the fire (for example, through fire suppression and timely evacuation).

Services provided in own home

For services provided to a client in their own primary residence (whether leased or owned by the client), the department expects that the client (and where appropriate, the owner of the premises) will have responsibility for their own fire safety and ensure that the premises meet all relevant building local laws and regulations or legislation, including retrospective obligations.

The department notes that the relevant authorities (for example, local councils and fire authorities, Metropolitan Fire and Emergency Services Board and Country Fire Authority) are responsible for enforcement of fire safety provisions.

Responsibility for a client's fire safety is not specifically part of the funded service but is implied through common law or other duty of care requirements.

Other services

For services other than in the client's home, the organisation is required to ensure that the people in its care are appropriately protected from fire risk. This includes premises, operational readiness and client placement.

Premises

The department expects that the premises meet the relevant building local laws, regulations or legislation in force at the time of construction, including provisions that apply retrospectively (for example, requirement for smoke alarms). Any subsequent building works shall meet the relevant building approval provisions at the corresponding time.

Where this is not the case, or where the organisation determines that the premises do not provide an appropriate level of fire safety, the organisation is expected to ensure that the premises are brought up to minimum regulatory standard and in compliance with the Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window).

Operational readiness

The organisation must ensure that appropriate operational readiness measures are developed, implemented and reviewed. This includes (but is not limited to) fire emergency management and evacuation procedures, training of staff to implement the procedures developed, and maintenance of fire safety systems.

Management Tasks

The organisation must ensure that appropriate fire safety readiness measures are developed, implemented and reviewed. This includes:

(a) holding a current fire risk audit that is less than 5 years old,

(b) fire emergency management and evacuation procedures,

(c) training of staff to implement the procedures developed,

(d) maintenance of all the fire safety systems and any deviations through an alternative solution,

(e) holding or having access to a current Fire Safety Handbook as defined in the current Capital Development Guidelines Series 7, Fire Risk Management, August 2013 (external link, opens in a new window).

It is expected that an organisation prepares for, responds to, and recovers from, emergencies in accordance with the 'all hazards' approach. This includes, but is not limited to, fire, bushfire, flood, relocation, evacuation and prolonged service interruption.

Additionally, the organisation must ensure essential services are maintained.

Client placement

Where the organisation selects the clients for bed based services, the organisation must determine whether the premises are suitable for the client to be evacuated safely, taking into account the fire systems installed and the capacity of the client to evacuate. Where changes occur that may affect the client's ongoing ability to evacuate safely, the suitability of the placement must be reassessed immediately and appropriate action taken as soon as possible.

Where the organisation does not select the clients, the organisation is still required to monitor any relevant changes that may affect the client's ongoing ability to evacuate safely, assess the suitability of the placement, and take appropriate action as soon as possible.

Table 1 Fire safety - additional requirements

Standard No. Name of Standard Application (summarised - see Figure 1) Departmental Guideline accompanying the standard Fire Safety Certificate No.
1 Lead Tenant/Home Based Care Services Fire Safety Standard
  1. Lead tenant services - otherwise Standard No.5 applies.
  2. Bed based service provided in carer's private home and only to clients that are related - otherwise Standard No.5 applies.
Not applicable Not required
2 Support Service Only Fire Safety Standard Service provided to a person in their private home (owned or leased) and excludes shared accommodation by unrelated clients – otherwise Standard No.5 applies. Not applicable Not required
3 Relevant Authorities Fire Safety Standard

Bed based service intended for non-statutory clients in either government or non-government owned premise, either with or without 24 hour rostered/live in staff support or supervision.

Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 Fire Safety Compliance - Certificate No. 3 (opens in a new window - Word 76.0 KB)
4 Department's Fire Risk Management Standard Premises owned or leased by the State Government provided with bed based services receiving rostered/live-in staff support or supervision and intended to house statutory clients. Capital Development Guidelines, Series 7, Fire Risk Management Fire Safety Compliance - Certificate No. 4 (opens in a new window - word 76.0 KB)
5 Non-Government Organisation Premises Fire Safety Standard Premises (not a private home) owned or leased by organisations with bed based service receiving rostered/live-in staff support or supervision intended to house statutory clients. Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 Fire Safety Compliance - Certificate No. 5 (opens in a new window - Word 80.0 KB)
6 Hospitals Public or Private hospitals Capital Development Guidelines, Series 7, Fire Risk Management Fire Safety Compliance - Certificate No. 6(opens in a new window - PDF)

To check which standard applies, refer to Figure 1.

If you have any questions about the application of fire safety standards in the premises from which services are delivered to clients, contact your assigned Local Engagement Officer (LEO) in the Agency Connections Team of the Division or other contacts as allocated by the department.

Compliance certification process

The CEO (or equivalent) of an organisation that provides bed based services (under standards 3, 4, 5 and 6 see table 1) is required to complete and provide the department with the relevant fire safety certificates as part of the service agreement process. Even though the service agreement is for a three year period, the certificates must be completed annually. This ensures that the organisation provides certification to the department that they have checked all relevant services and that they meet, and will continue to meet, the department's fire safety requirements. The CEO must have appropriate procedures in place to ensure ongoing maintenance and reporting.

The annual certificates to be used are included on the forms and certificates page of this site.

Certificates covering each financial year (1 July to 30 June) must be received by 1 September in the following financial year or at a date agreed in writing with the department.

Fire damage to asset report

Organisations are required to provide Fire damage to asset reports to the Department of Health and Human Services' Fire Risk Management Unit. Fire damage to asset reports will be accessible from the Funded Agency Channel website and are to be lodged as soon as possible after the incident.

Fire incident and false alarm reports - incident reports

Organisations are required to provide fire incident and false alarm reports to the department following the department's incident reporting instruction and reporting process. Refer to Section 4.3 Incident reporting of this kit for further information. Fire incident and false alarm reports should be lodged using the Incident Report form as soon as possible after the incident.

Definitions

Bed based service
A service contracted to provide overnight accommodation for clients.

Client
Has the same meaning as that defined in the Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) or as amended.

Lead tenant
A service which provides semi-independent accommodation in a household for people who are in transition to independent living using a live-in volunteer to facilitate a supportive environment.

Private home or residence
A home owned by the occupant(s), or a home formally or informally leased by the occupant(s).

Statutory client
Clients for whom the department has custody or guardianship. Clients may receive services pursuant to the Disability Act 2006 (opens in a new window, Word 1.18 MB) or the Children, Youth & Families Act 2005 (opens in a new window, external link).

24 hour support or supervision
Staff support or supervision is provided whenever clients are in residence and includes active night rosters, sleepover rosters and the 24 hour worker model.

Figure 1 Determining appropriate fire safety standards

Flowchart for determining appropriate fire safety standards

Refer to Figure 1 Determining appropriate fire safety standards (Word 134 KB) for an accessible version of the above diagram.

 

Fire safety standards

Lead tenant / Home based care services fire safety standard (Standard No. 1)

Application

Type of service:

Services provided from carer's private home (whether owned or leased by the carer) or Lead tenant.

A situation involving two or more unrelated statutory clients or clients (funding provided by the department) who are provided services by the carer in the carer owned or leased premises, is considered as a Non-Government Organisation Premises Fire Safety Standard (Standard No.5).

Specifications

The organisation is required to make certain that persons under its care are appropriately protected from the risk of fire. This protection includes:

(a) obtaining an assurance from the building owner that smoke alarms have been installed in accordance with the requirements of the Building Regulations

(b) implementing strategies in response to clients with known or suspected fire lighting tendencies. This includes:

i. seeking assessment for the person, to determine the severity of the behaviour and the likely risks

ii. identifying strategies for managing and modifying the behaviour and addressing related causal issues, as part of the Case Plan and Individual Plan

iii. actively implementing these strategies

iv. referral to appropriate services to modify fire lighting behaviour to a safe level, and

v. ensuring an adequate level of fire safety management in the household.

Client placement

Where the organisation selects the clients, the organisation must determine whether the premises are suitable for the client to be evacuated safely, taking into account any fire safety systems installed, and the evacuation capacities of the client. Where changes may affect the client's ongoing ability to evacuate safely, the suitability of the placement must be reassessed and appropriate action taken.

Where the organisation does not select the clients, the organisation must still monitor any relevant changes that may affect the client's ongoing ability to evacuate safely, assess the suitability of the placement, and take appropriate action.

Support Service only Fire Safety Standard (Standard No. 2)

Application

Type of service:
Services provided to clients in their private home (whether leased or owned by the client).

A situation of shared accommodation (two or more) by unrelated statutory clients or client’s (funding provided by the department) in owned or leased premises is considered as a Non-Government Organisation Premises Fire safety Standard (Standard No.5).

Specifications

The department expects that the client (and where appropriate the owner of the premises) is responsible for their own fire safety and ensuring that the premises meet all relevant building local laws, regulations or legislation, including those that apply retrospectively.

The department notes that the relevant statutory authorities (for example, local councils) are charged with enforcing fire safety provisions.

The responsibility for a client's fire safety is not specifically part of the service purchased from the organisation, but is implied through common law (or other duty of care) requirements.

Client placement

The relevant organisation must determine whether the lead tenant premises are suitable for young people to be evacuated safely and must take into account the individual capacity of each young person to evacuate. Young people with any history of fire-lighting behaviours must be assessed to determine the currency of the behaviour and the level of risk. Where it is determined that a young person is at risk of lighting fires, they are not suitable to be placed in lead tenant accommodation.

Where a young person or lead tenant has a condition (temporary or ongoing) that would impede their capacity to evacuate safely, the placement must be reassessed immediately and appropriate action taken as soon as possible by the organisation.

Relevant Authorities Fire Safety Standard (Standard No. 3)

Application

Type of service:

Bed based with 24 hours rostered/live-in staff support/supervision.

State government owned or Non-government owned premises (but not a private home) where the department's Fire Risk Management Standard has not been specified or the service is not intended specifically to house statutory clients or clients provided with 24 hour care funding.

May include some disability, placement and support and bed-based overnight respite residential services.

Specifications

The organisation is required to make certain that the persons in its care are appropriately protected from risk from fire. This protection includes:

  • Premises - the department expects that the premises meet all relevant building local laws, regulations or legislation, including provisions that apply retrospectively (for example, requirement for smoke alarms). It is expected that the premises were constructed to meet the requirements of relevant building by-Laws, regulations or legislation in force at the time of construction and that building works have been undertaken in accordance with relevant building approval provisions since that time.

Where this is not the case, or where the organisation otherwise determines that the premises do not meet a standard which provides an appropriate level of fire safety, the organisation is expected to ensure that the premises are brought up to provide an appropriate level of fire safety protection.

The department notes that the relevant statutory authorities (for example, local councils and fire authorities Melbourne Fire Brigade and Country Fire Authority) are responsible for the enforcement of fire safety provisions.

*In each case a reference to premises refers to those premises from which the service (which is subject to this Service Agreement) is provided.

  • Operational readiness - the organisation must ensure that appropriate operational readiness measures are developed, implemented and reviewed. This includes (but is not limited to) development of fire emergency management and evacuation procedures, training of staff to implement the procedures developed, and maintenance of fire safety systems.
  • Maintenance of essential safety measures - the organisation shall ensure that all Essential Safety Measures (including all fire safety equipment/systems) are being adequately maintained, in accordance with the Building Regulations.

Completion of the Weekly checklist (opens in a new window, Word 194 KB) will assist in providing documentation to support completion of the annual Essential Safety Measures Report.

  • Client placement - Where the organisation selects the clients, the organisation must determine whether the premises are suitable for the client to be evacuated safely, taking into account any fire safety systems installed and the evacuation capacities of the client. Where any relevant change may affect the client's ongoing ability to evacuate safely, the suitability of the placement must be immediately reassessed and appropriate action taken as soon as possible.

Where the organisation does not select the clients, the organisation must still monitor any relevant changes that may affect the client's ongoing ability to evacuate safely, assess the suitability of the placement, and take appropriate action as soon as possible.

  • Fire Safety Certification - Fire Safety - Certificate No. 3 (opens in a new window - Word 76.0 KB) must be returned by 1 September in the following financial year or by a date to be agreed between the organisation and the department's assigned Local Engagement Officer (LEO) in the Agency Connections Team of the Division. This date will take into account any relevant upgrade works that are scheduled.

The department's fire risk management standard (Standard No. 4)

Application

Type of service:

Bed based with rostered/live-in staff support/supervision. May include disability (including respite), placement and support, secure welfare, juvenile justice, secure facilities and residential services.

Premises

Owned or leased by the State Government (the Crown, the Secretary of the department or the Director of Housing), but not rental general stock (RGS).

Accompanying document

Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) (the relevant guidelines applicable for specific occupancy types for which the organisation has responsibility). The guidelines can be accessed on the Fire Risk Management policy, procedures and guidelines.

Specifications

The organisation is required to make certain that persons in its care are appropriately protected from risk from fire. This protection includes:

The organisation must ensure that any non-compliance with these guidelines that it becomes aware of is reported to the building owner (the appropriate representative of the Crown, the Secretary or the Director of Housing, as relevant) so that remedial action may be taken.

*In each case a reference to premises refers to those premises from which the service (which is subject to this service agreement) is provided.

  • Operational readiness - the organisation must ensure that appropriate operational readiness measures are developed, implemented and reviewed as a minimum in accordance with Australian Standards: AS 4083-2010, Planning for emergencies - Health care facilities as appropriate. This includes (but is not limited to) development of fire emergency management and evacuation procedures, training of staff to implement the procedures developed, and conducting regular evacuation drills.

For organisations providing disability and/or placement and support residential services, operational readiness measures shall be in accordance with the department's Fire and Emergency Response Procedures and Training Framework (as amended from time to time). The framework can be accessed on the department's website (Publications section under the heading of Fire Risk Management, 'Fire and Emergency Response Procedures and Training Framework').

  • Maintenance of Essential Safety Measures - the department will fulfill its responsibilities as owner of the premises by maintaining fire safety systems. The organisation must ensure that any factor that may affect the performance or operation of fire safety equipment, fire safety fittings, fire safety measures, exits and essential services that it becomes aware of is reported to the building owner.

Completing the Weekly checklist (Word 194 KB, opens in a new window, ) will assist in providing documentation to substantiate adequate maintenance of essential safety measures.

  • Client placement - Where the organisation selects the clients, the organisation must determine whether the premises are suitable for the client to be evacuated safely, taking into account any fire safety systems installed and the evacuation capacities of the client. Where any relevant change may affect the client's ongoing ability to evacuate safely, the suitability of the placement must be reassessed immediately and appropriate action taken as soon as possible.

Where the organisation does not select the clients, the organisation must still monitor any relevant changes that may affect the client's ongoing ability to evacuate safely, assess the suitability of the placement, and take appropriate action as soon as possible.

  • Fire Safety Certification - Fire Safety Certificate No. 4 ( Word 76.0 KB, opens in a new window) must be returned by 1 September in the following financial year, or by a date to be agreed between the organisation and the department's assigned Local Engagement Officer in the Agency Connections Team of the Division. This date will take into account any relevant upgrading works that are scheduled.

Funded organisation (owned / leased) premises fire safety standard (Standard No. 5)

Application

Type of service:

Bed based with rostered/live-in staff support/supervision for statutory clients. May include disability (including respite), placement and support, mental health, drug and alcohol and residential services.

Premises*:

Owned, operated or leased by the organisation, but not a private home (subject to conditions refer Standard 1 and 2 above).

Accompanying document

Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) (the relevant guidelines applicable for specific occupancy types for which the organisation has responsibility). The guidelines can be accessed on the Fire Risk Management procedures and guidelines web page (external link, opens in a new window).

Specifications

The organisation is required to make certain that the persons in its care are appropriately protected from risk from fire. This protection includes:

  • Premises - The premises must meet the requirements of the relevant Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) as amended from time to time) applicable to those premises*. The department will discuss the process of fire safety assessment and upgrade works and availability of funds (where this has not already been done) to meet these requirements.

    * in each case a reference to premises refers to those premises from which the service (which is subject to this service agreement) is provided.

  • Operational readiness - The organisation must ensure that appropriate operational readiness measures are developed, implemented and reviewed as a minimum in accordance with Australian Standards: AS 4083-2010, Planning for emergencies-Health care facilities as appropriate. This includes (but is not limited to) development of fire emergency management and evacuation procedures, training of staff to implement the procedures developed, and conducting regular drills.

    For organisations providing disability and/or placement and support residential services, operational readiness measures shall be in accordance with the department's fire and emergency response procedures and training framework (as amended from time to time). The framework can be accessed on the department's website (Publications section under the heading of Fire Risk Management, 'Fire and Emergency Response Procedures and Training Framework').

  • Maintenance of essential services - The organisation shall ensure that all Essential Safety Measures (including all fire safety equipment/systems) are adequately maintained in accordance with the Building Regulations.

    Completion of the Weekly checklist (Word 194 KB, opens in a new window) will assist in providing documentation to support completion of the annual Essential Safety Measures Report.

  • Client placement - The organisation must determine whether the premises are suitable for the clients to be evacuated safely, taking into account any fire safety systems installed, and the evacuation capacities of the client. Where any relevant change may affect a client's ongoing ability to evacuate safely, the suitability of the placement must be reassessed immediately and appropriate action taken as soon as possible.

Where the organisation does not select the clients, the organisation must still monitor any relevant changes that may affect the client's ongoing ability to evacuate safely, assess the suitability of the placement, and take appropriate action as soon as possible.

  • Fire Safety Certification - Fire Safety Certificate No. 5 (Word 80 KB, opens in a new window) must be returned by 1 September in the following financial year or by a date to be agreed between the agency and the department's assigned Local Engagement Officer (LEO) in the Agency Connections Team of the Division. This date will take into account any relevant upgrading works that are scheduled.

Hospital premises fire safety standard (Standard No. 6)

Application

Type of service:

A building, or part thereof, used on a 24-hour basis for medical, obstetrical or surgical care of four or more inpatients, including acute hospitals. May include disability (including respite), placement and support, mental health, drug and alcohol and residential services within a hospital.

Premises*:

Owned operated or funded by the department or an agency subject to a Service Agreement with the department.

Accompanying document

Capital Development Guidelines Series 7, Fire Risk Management, August 2013 (external link, opens in a new window) the relevant guidelines applicable for specific occupancy types for which the organisation has responsibility. The guidelines can be accessed on the Fire Risk Management procedures and guidelines web page (external link, opens in a new window).

Specifications

The organisation is required to make certain that the persons in its care are appropriately protected from risk from fire. This protection includes:

  • Premises - The premises must meet the requirements of the relevant Capital Development Guidelines, Series 7, Fire Risk Management, August 2013 (external link, opens in a new window)(as amended from time to time) applicable to those premises*. The department will discuss the process of fire safety assessment and upgrade works and availability of funds (where this has not already been done) to meet these requirements.

* In each case a reference to premises refers to those premises from which the service (which is subject to this service agreement) is provided.

  • Operational readiness – The organisation must ensure that appropriate operational readiness measures are developed, implemented and reviewed as a minimum in accordance with Australian Standards: AS 4083-2010, Planning for emergencies - Health care facilities and AS 3745-2010, Emergency Control Organisation and Procedures for Buildings as appropriate. This includes (but is not limited to) development of fire emergency management and evacuation procedures, training of staff to implement the procedures developed, and conducting regular drills.
  • Maintenance of Essential Safety Measures - The organisation shall ensure that all Essential Safety Measures (including all fire safety equipment/systems) are adequately maintained in accordance with the Building Act, Building Regulations.
  • Fire Safety Certification - Fire Safety Certificate No. 6 (Word 80 KB, opens in a new window) must be returned by 1 September in the following financial year or by a date to be agreed between the agency and the department. This date will take into account any relevant upgrading works that are scheduled.

For further information

Hank Van Ravenstein, Principal Manager, Fire Risk Management Unit
Telephone: (03) 9096 5381
Email: fireriskmanagementunit@dhhs.vic.gov.au