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Fire Safety Policy


St Mary’s University takes the safety and wellbeing of its employees, students and visitors very seriously. St Mary’s University (SMU) has ownership of over 30 buildings across the university estate; and the university regularly hosts functions and welcomes visitors.

SMU has 5,000 Students and 750 Staff members that either work, study or live within the campus. Of the 5,000 students 700 currently reside in student accommodation halls offered by the university.

SMU mitigates the risks presented with fire in a number of proactive ways; this fire safety policy will highlight what the university does to make sure everyone that attends the university can be welcomed into a safe and healthy environment. Additional measures put in place by the university include insurance and risk management provided by UMAL insurers specialising in cover for Universities and Higher and Further Education Colleges and Institutions.


The St Mary’s University Fire Safety Policy is designed to protect both life and physical assets where appropriate, and to safeguard all persons who may be affected by the outbreak of fire at any of the University’s premises. To reduce the occurrence of fires; To minimise the potential for fire to disrupt the work of the University; To minimise the incidence of unwanted fire alarm signals and malicious false alarms; To protect the environment.

Aim and Scope

This policy applies wherever SMU owes a duty of care to students, staff or other individuals. All SMU Students, staff and visitors will be subject to and adopt the University’s Fire Safety Policy and Procedures.
The effectiveness of this policy depends not only on physical precautions designed to prevent the occurrence and spread of fire, but also on the cooperation of every member of staff, student, visitor and contractor that attends SMU.

All members of the SMU community, their visitors and contractors, have a statutory responsibility in ensuring compliance with the law and complying with the fire safety provisions defined within this policy. The relevant Fire safety legislation for SMU property is as follows;

  • The Regulatory Reform (Fire Safety) Order 2005 (RRO)
  • Health and Safety at Work Act 1974
  • Approved Document B (fire safety) volume 1: dwellinghouses
  • Approved Document B (fire safety) volume 2: buildings other than dwellinghouses (2006 edition incorporating the 2010 and 2013 amendments)

Other relevant legislation and governmental guidance as and when they are published will be reviewed and incorporated into this policy.

At no point should any British Standard Regulations or Governmental Guidance be acted upon in conflict with the RRO if this is the case then the RRO takes precedence over all other legislation and guidance in relation to fire safety matters.

The principal objectives of the Fire Safety Policy are; to ensure that the University has clearly defined fire safety policies with supporting protocols and procedures thus ensuring compliance with the Fire Safety Order, and in particular, Articles 8-22 and any regulations made under Article 24. (Article 5(1)).

Roles and Responsibilities

The Board of Governors has overall accountability and responsibility for the activities of the organisation, which includes fire safety and has delegated its oversight of Health and safety to the Finance and Resources Committee (FRC).

The Board of Governors, via FRC, will:-

  • Discharge its responsibilities for fire safety through the Vice Chancellor.
  • Discharge its responsibilities as a provider of education to ensure that suitable and sufficient governance arrangements are in place to manage fire related matters.
  • Provide appropriate levels of investment in the Estate and staff resources to facilitate the implementation and maintenance of suitable Fire Safety precautions.

The Vice Chancellor will:-

  • On behalf of the Board of Governors, via FRC, be responsible for ensuring that current Fire Safety Legislation, British Standards and other accepted codes of practice are being conformed to as far as reasonably practical, within all premises owned, occupied or under control of SMU.

The Chief Operating Officer has been given delegated authority for fire safety matters and for ensuring the implementation of the University’s fire safety policy and will:-

  • Delegate operational responsibility for ensuring the effective management of Fire Safety within SMU.
  • Ensure, as chair of the Health and Safety Subcommittee (HSSC), which reports to FRC, that HSSC exercise appropriate governance of Fire safety.
  • Ensure that the oversight and operation of Health and Safety and Fire Safety are fully integrated and consistent.
  • Ensure SMU has a clearly defined Fire Safety Policy with supporting protocols and procedures.
  • Ensure that an annual audit of Fire Safety and Fire Safety management is undertaken and the outcomes communicated to the University operating board and FRC.
  • Ensure serious Fire Safety issues are reported promptly to the Vice Chancellor and FRC.
  • Be responsible for the proposal of programmes of works relating to Fire Safety as part of the business planning process.

The Director of Estates and Campus Services will:-

  • Administer a budget which will include funds to provide for structural and other fire precautions such as precautions for new building work undertaken by the Senior Asset Manager; and any alterations to existing premises undertaken under the control of the Maintenance Manager. These precautions will include structural features aimed at ensuring adequate means of escape in the event of fire and also provision and maintenance of alarm systems, fire detection systems, emergency lighting systems and firefighting equipment.
  • Ensure, as far as reasonably practicable, all new building work and alterations to existing premises that are carried out under their control are carried out in accordance with the fire safety requirements of the Building Regulations 2000 (as amended) as well as Approved Document B: Fire Safety Volume 1 – Dwelling Houses 2006 and Volume 2 – Buildings other than Dwelling Houses (2006 edition incorporating the 2010 and 2013 amendments).
  • Ensure that all electrical equipment is inspected for safety by a competent person at regular intervals. Records of the inspections and any inspection reports provided by the competent person will be kept for at least five years.
  • Ensure that fire alarm systems, fire detection systems and emergency lighting systems are inspected and tested by a competent person at regular intervals and repaired as necessary. Intervals are not to exceed one year. Records of the inspection and test, and also of any repairs made, will be kept for at least five years.
  • Ensure that all work that has implications for fire precautions in new and existing buildings are carried out to a satisfactory standard which conform to all relevant statutory and mandatory fire safety requirements.
  • Ensure that all proposals for new buildings and alterations to existing buildings are referred to the Fire Safety Officer or Health and Safety Officer before Building Regulation approval is sought.
  • In line with delegated authority, devolve the day to day fire safety duties to the Fire Safety Officer and Health and Safety Officer.

The Health and Safety Officer will:-

  • Administer a budget to provide funds for the provision of Fire Safety training, information and also Fire Safety signs including fire action notices.
  • Ensure that identified fire risks are reported through the management committees as appropriate.

The Fire Safety Officer:-

  • Liaise with managers, staff, and others to ensure the effective implementation of this policy;
  • Undertake and review Fire Risk Assessments of all SMU premises on an annual basis;
  • Work with Faculty / Professional Service Managers, The Health and Safety Sub Committee and others to ensure suitable emergency plans are prepared for each location within the University estate;
  • Liaise with Faculty / Professional Service Managers regarding the organisation of effective fire drills at each location. The Fire Safety Officer will, attend such drills, observe, and if necessary recommend to the relevant managers measures to improve the effectiveness of such drills;
  • Advise the Maintenance Manager and others as appropriate on all aspects of Fire Safety and in particular adequate means of escape from the buildings, provision, suitability and maintenance of firefighting measures, fire alarms and fire detection equipment;
  • Will develop and present suitable staff induction training for Fire Safety which will include training on Fire Safety matters and in particular the measures to take on discovering a fire and on hearing the fire alarm;
  • Will work with and advise those responsible for student induction to ensure that student induction programmes include details of what to do on discovering a fire and on hearing the fire alarm.
  • Complete Personal Emergency Evacuation Plans in conjunction with Student Services and Faculty / Professional Service Managers.
  • Liaise with the Health & Safety Officer to ensure that firefighting equipment, fire action notices and fire safety signs are suitable and sufficient for the buildings comprising SMU.
  • When notified of a Fire, providing advice on formal responses to the Fire and Rescue Service during their enquiries.
  • Review of both Actual Fire events and unwanted fire alarm signal with recorded information on lessons learnt.

Faculty/ Professional Service Managers will:-

Anyone who is, or may exercise control of all or part of the premises, have responsibility for the fire safety management in those areas.

  • Ensure that local fire emergency action plans are developed and brought to the attention of all staff.
  • Liaise with the Fire Safety Officer to ensure that fire drills are held at every location within the University estate at least once per annum and that such fire drills are effective in evacuating persons from the buildings.
  • Ensure sufficient numbers of trained staff are available at all times to implement the local fire evacuation plan such as Fire Marshals.
  • Identify and rectify any deficiencies found within their area of responsibility in respect of general fire precautions on a daily basis.
  • Take responsibility to inform the Facilities Helpdesk of any observed building defects in respect of fire precautions within their area of responsibility.
  • Notify the Health and Safety Team of any proposals for ‘change of use’, including temporary and events, that may impact on the risk assessment or emergency action plan for that area.
  • Ensure that new staff and students to their areas are aware of local fire action and emergency evacuation procedures. These can be found in the Fire Log Book located in all areas with present Fire Marshals.

Security Officers will:-

  • React accordingly to fire alarm signals provided by the alarm systems across the University buildings. Attend the area of activation and begin to search area / zone for signs of smoke or fire; evacuate all personnel who have not already left the building.
  • Be aware Staff / Students that have completed a Personal Emergency Evacuation Plan and attend to those that require assistance.
  • Be vigilant that escape routes in SMU buildings are kept clear, that fire doors are kept closed and that fire exit doors are kept unlocked while the building is occupied.
  • Be vigilant of the firefighting equipment provided in SMU buildings and ensure that any defective equipment is reported to the Fire Safety Officer.

Housekeeping Staff will:-

  • Ensure that flammable waste materials are not permitted to accumulate within the workplace, that waste paper bins are emptied at regular intervals, and located so that they do not cause obstructions to escape routes.
  • Not use Firefighting equipment to wedge Fire doors open.
  • Carry out regular inspections of the firefighting equipment provided in their buildings and ensure that any defective equipment is reported to the Health and safety team.
  • Be vigilant in the reporting of fire hazards to the Health and Safety team especially in student accommodation areas.

Fire Marshals will:-

The provision of Fire Marshals is a mandatory requirement to comply with current fire legislation. Local managers shall appoint Fire Marshals for their areas, which should be sufficient in numbers to cover all leave, sickness or shift patterns.

  • Fire marshals act as a focal point on fire safety issues and act as the “eyes and ears‟ within their local area, in close liaison with Health and Safety group leads.
  • Raise issues regarding local fire safety with line managers or Fire Safety officer.
  • Carry out monthly Fire Marshal checks.
  • Assist with the coordination of the response to an incident within the immediate vicinity.
  • Be trained to tackle fire with first aid fire- fighting equipment where appropriate.
  • Be able to support Faculty / Professional Service Managers on fire safety issues.

Staff, Contract Staff and Volunteers will:-

  • Comply with St Mary’s University Fire Safety Protocols and other related procedures.
  • Participate in Fire Safety Training and Evacuation Exercises where applicable.
  • Report deficiencies in Fire Precautions to any St Mary’s University Faculty / Professional Service manager within their area of work where the defect has been found or the Facilities helpline on Ext. 4036.
  • Promote Fire Safety at all times to help reduce the occurrence of Fire and unwanted Fire Alarm Activations.
  • Inform their Line Manager of any situation that may be considered a shortcoming in the University’s ability to provide protection arrangements for Fire Safety.
  • Not use objects to wedge Fire doors open.
  • Refrain from bringing privately owned portable electric heaters or similar electrical equipment into the University.

Students will:-

  • Comply with St Mary’s University Fire Safety Protocols and other related procedures.
  • Not use objects to wedge Fire doors open.
  • Refrain from bringing privately owned portable electric heaters or similar electrical equipment into the University.
  • Refrain from smoking in any St Mary’s University building.

In the event or situation where staff and/or students find that their fire safety roles and responsibilities arch over; it will be firstly expected that they act upon the responsibilities for the most senior fire safety role that they undertake within the university. Using the above list as a guide.

Fire Safety Provisions and Arrangements

Fire Risk Assessments

Fire Risk Assessments will be undertaken by The University’s Fire Safety Officer and will focus primarily on the condition and adequacy of the fire safety provisions within the assessment area. The assessment will look at general fire precautions, risk reduction, emergency plans and training requirements. Risks will be scored using the 5 x 5 risk grading (consequences x likelihood) matrix system.

Significant findings will be communicated to the Faculty / Professional Service Managers and Health and Safety Officer. All Fire risk assessments will include an action plan drawn up as necessary. Ownership of the risk will be dependent on the severity / nature and risk grading of the findings. Specific action plans will be drawn up to include the name of the nominated person with realistic completion dates for the actions to be completed.

Any High risks will be acted upon with immediate effect, and escalated to the Health and Safety Sub Committee. A regular report will be made to the HSSC on the progress in resolving all actions arising from such assessments.

Fire Drills

Annual Fire Drills will be scheduled in all buildings under control of St Marys University, with the exception of Accommodation buildings that will be scheduled to take place at the beginning of each semester.

Significant findings will be recorded by the Fire Safety Officer and communicated to the Faculty / Professional Service Managers and Health and Safety Officer.

Fire Safety Training

All new employees must to be informed of the fire safety provisions that are relevant to the workplace. Their line manager is responsible for ensuring that arrangements are made to ensure new employees are advised of the following;

Fire action arrangements, including the Fire Safety Policy, Means of escape within the premise, Location of fire exits, Location and types of firefighting equipment, Details in relation to relevant findings of the fire risk assessments and dangerous substances. This information is available to all staff in the Fire log books provided and fire marshals should be required to assist with providing this information. In addition staff will complete other types of training such as the E-Learning module annually, and fire marshal training completed by nominated staff members every three years.

Fire Log Book

The Fire Log Book has been developed to inform staff and managers of responsibilities imposed on SMU and provided fire safety guidance and other safety information. The information held should be kept up to date by the local Fire Marshals in those areas and be easily accessible to all staff especially new starters.

Reporting of Fire and False Alarms

The collection of data for fire incidents and the requirement for investigation of incidents, in educational premises is important. Fire alarm signals will be initially investigated by Security services both in and out of hours and a subsequent report then written and shared with the relevant persons. Lessons can be learned from these routine reports. Where a small fire has occurred and was subsequently extinguished without activating the fire alarm system, Security services must still be immediately informed and an incident report completed and forwarded.

Prevention of Arson

Arson is a major concern in any premises, in particular where public access is available. Risk from arson by visitors, staff, contractors and unauthorised persons are a real threat, in particular if sources of fuel are readily available. Accumulation of waste in and around buildings is to be managed by those persons and departments responsible for waste removal. Rubbish should not be allowed to build up and action should be taken by staff to raise their concerns when this happens.

Waste skips should be covered when possible and are not to be placed directly under building areas or near emergency exits.

Fire System Testing

The following fire related systems will undergo regular testing conducted by a competent person;

  • Fire alarm test – Weekly Thursday (Regal House – Friday)
  • Fire alarm system service – 6 monthly
  • Monthly Emergency light test – all luminaires and signs shall be checked to ensure that they are present, clean and functioning correctly.
  • Annual Emergency light test – A full rated duration test of 3hrs must be carried out. The emergency lights must still be working at the end of this test.
  • Annual Fire Protection System Service – Service of suppression system fire

All tests will be certificated, recorded and reported to the Maintenance Manager, Fire Safety Officer and/or relevant service areas. Any recorded failures will then be rectified by the either the in-house maintenance team or referred to relevant contractors.

Fire Doors

Fire doors make up a key part of the fire compartmentation in a building and must be adequately installed and maintained. An asset list should be created and the condition of door sets periodically inspected both by the Fire Safety Officer during Fire risk assessments and in-house maintenance team for general repairs.

Fire Safety Signage

SMU follows the British format for fire safety signs throughout campus and university buildings this standardisation of signage reduces confusion and is fully compliant to (BS EN ISO 7010) signs. The Fire Safety Officer will routinely inspect the placement and condition of fire safety signs throughout SMU; in addition Fire Marshals are asked to be aware of the signs that are on display in their areas and report any defects that they may find.

Fire Safety Equipment and Media

Fire safety equipment and media at SMU will consist mainly of Water, Foam, Co2 extinguishers and Fire Blankets with the acceptation of some specialised work areas.

The Fire Safety Officer will work closely with the extinguisher service contractors and report any issues that arise. An asset list should be created and extinguishers serviced and replaced within the required life span.

Provisions and Arrangements for Disabled People

PEEP – Personal Emergency Evacuation Plan, the Fire Safety Officer will complete PEEP’s in conjunction with Student Services and Faculty / Professional Service Managers for students, staff and any visitors on request. This will enable a plan to be tailored to individual needs and for those who require assistance in understanding the actions to take in an evacuation, the layout of the building and what provisions are in place.

Refuge points are designed as a place of safety for wheelchair users or those that may not be able to fully evacuate a building during a fire alarm activation. They must include clear signage, be easily accessible and have communication links.


Compliance with this policy will be audited internally via The Estates and Campus Services Director, H&S Manager and Fire Safety Officer. Findings from audits and any trends, themes and learning identified will be reported to the Health and Safety Sub Committee.


This Policy will be formally reviewed by the author annually, whereby the policy will be processed through the appropriate approval routes, namely HSSC, University Operating board and Finance and Resources committee.

  • Document Title: Fire Safety Policy
  • Version: 1
  • Last Updated: June 2021
  • Review Date: June 2023