Personal Emergency Evacuation Plan FormName of Care CentreThis Personal Emergency Evacuation PlanwasPrepared ForName of Re...
Personal Emergency Evacuation Plan FormThis Personal Emergency Evacuation Plan (PEEP) has been prepared by PHOENIX SAFETYT...
Personal Emergency Evacuation Plan Form                                                     AssessorName of Assessor;NameA...
Personal Emergency Evacuation Plan FormIs the evacuation aid the in correct location? Yes/NoIf NO Enter DetailsIs the evac...
Personal Emergency Evacuation Plan FormIf NO Enter DetailsDoes the resident require the centre’s emergency procedures to b...
Personal Emergency Evacuation Plan FormHave refuge points been provided on or adjacent to each escape route?Yes/NoEnter De...
Personal Emergency Evacuation Plan FormHow long would you estimate that it would take to evacuate the resident (other than...
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Transcript of "Personal emergency evacuation plan v 2.5.docx.docx"

  1. 1. Personal Emergency Evacuation Plan FormName of Care CentreThis Personal Emergency Evacuation PlanwasPrepared ForName of ResidentThe content of this document is confidential © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 1 of 7
  2. 2. Personal Emergency Evacuation Plan FormThis Personal Emergency Evacuation Plan (PEEP) has been prepared by PHOENIX SAFETYTRAINING SERVICES; its purpose is to identify the individual needs of a resident with regard to theirsafe evacuation in an emergency. The PEEP should be completed ONLY by a COMPETENT PERSONas defined in the Safety Health and Welfare at Work Act 2005. The PEEP Form is not exhaustive andwhere additional requirements are identified they should be entered in “Section D under OtherInformation” showing any remedial actions deemed necessary. Each resident should have a PEEPprepared prior to their arrival or if already a resident within the Care Centre.The PEEPshould as far as practicable be specific to individual areas in the Care Centre. However if forexample, a number of activities are proposed to take place in adjacent areas from which escape will beaffected using the same emergency provisions then it may be possible to assess the provisions on onePEEP Form. Hearing impaired residents will normally be able to be assessed on one PEEP Form since theprovisions made for this class of resident are likely to be the same regardless of location.It is important to distinguish in the PEEP whether the area to be accessed will be used inside or outside ofnormal working hours. It is likely that certain areas of the Care Centre will be inaccessible outside ofnormal working hours e.g. to assure security. The PEEP needs to demonstrate that this has beenadequately considered.If the PEEP Assessment deems that a particular area does not meet the general access requirements forthe resident being assessed then alternative management arrangements will need to be identified. Oncethese arrangements have been identified then a new PEEP will need to be undertaken to ensure that thenew location(s) is/are adequate. Additionally, the Assessor should complete new PEEPand sent to thePerson in Charge of the Care Centre.The PEEP should be updated at least every 3 months or on finding of a risk assessment that’s show theprevious PEEP Form is out of date.One or more of the following sections should be completed by theAssessor;A – Mobility, B – Visual Impairment, C – Hearing Impairment, D – General.Phoenix Safety Training Services does NOT accept any responsibility for the misinterpretation orassessments carried out by any individual completing the PEEP.The content of the PEEP Form is subject to COPYRIGHT and cannot be transcribed. If you require anyadditional information on the interpretation or use of the PEEP Form please contact Phoenix SafetyTraining Services at info@phoenixsts.ie or on 043 3349611.For more information on evacuation aid visit; http://www.phoenixsts.ie/shop/healthcare.htmlFor more information on fire safety training in Nursing Home/Care Centres visit;http://www.phoenixsts.ie/nursing-home-safety/ © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 2 of 7
  3. 3. Personal Emergency Evacuation Plan Form AssessorName of Assessor;NameAssessor Position; Choose Position Other; If OtherDate of Assessment; Date Time of Assessment;Hour:MinsWhat times or daysare covered by this assessment?Assessment Time/Day Area of AssessmentFloor; Floor Room No.Room No.Area of Assessment;Area of Assessment Residents InformationAge;Age D.O.B; DateNature ofImpairment(s);Nature ofImpairment(s) Section A – MobilityIs the resident a wheelchair user? Yes/No Type;TypeSize;SizemmIf YES Enter DetailsDoes the resident use other types of mobility aids?Yes/No Type;Type of Mobility AidIf YES Enter DetailsCan the resident be transferred to an evacuation aid in an emergency with assistance? Yes/NoEnter DetailsType of evacuation aid in use (Safe working load in Kg); Evacuation AidIs the evacuation aid the correct type? Yes/NoIf NO Enter DetailsWhere applicable what evacuation aid is required; Evacuation Aid © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 3 of 7
  4. 4. Personal Emergency Evacuation Plan FormIs the evacuation aid the in correct location? Yes/NoIf NO Enter DetailsIs the evacuation aid in good order? Yes/NoIf NO Enter Details Section B – Visual ImpairmentHas the resident a visual impairment? Yes/NoIf YES Enter DetailsDoes the resident require the emergency escape procedure to be on tape/CD/MP3?Yes/No/NADoes the resident require the emergency escape procedures to be in Braille?Yes/No/NAIf YES Enter DetailsDoes the resident require the emergency escape procedures to be in large print? Yes/No/NAIf YES Enter DetailsCan the resident read the fire notes signs?Yes/NoEnter DetailsHave any hazardous projections or other structural components been identified on residents escaperoutes? Yes/NoIf YES Enter DetailsAre all escape routes clearly sign posted to meet residents requirements? Yes/NoIf NO Enter DetailsAre all escape corridors designed so as to prevent visual confusion in resident’s circumstances?Yes/NoIf NO Enter DetailsAre all escape staircases fitted with adequate colour contrasting nosing and a suitablehandrail?Yes/No/NAIf NO Enter Details Section C - Hearing ImpairmentHas the resident a hearing impairment? Yes/NoIf YES Enter DetailsCan the resident hear the fire alarm in normal circumstances? Yes/No © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 4 of 7
  5. 5. Personal Emergency Evacuation Plan FormIf NO Enter DetailsDoes the resident require the centre’s emergency procedures to be provided to them in an alternativeformat to the standard written instructions? Yes/NoEnter DetailsWhere applicable, is resident’s bedroom fitted with a (hard wired) flashing light, and (vibrating pillow)linked to the fire alarm? Yes/No/NAEnter DetailsWhere applicable, is the resident’s (shower/bathroom) fitted with a flashing beacon linked to the firealarm? Yes/No/NAEnter Details Section D – GeneralAt the intended time of use how many escape routes are available for use?Choose NumberAt the intended time of use, how many escape routes are available for residents living with a disabled?Choose NumberIf only one escape route is available how far, approximately (in meters) is the exit from the area/floorwhere the resident is to a place of temporary safety or safety? Metersm.How long approximately would it take to evacuate the resident from the area/floor, record the time inminutes for each available place of temporary safety or safety up to a maximum of three?Time 1 Minutes – Time 2 Minutes – Time 3 MinutesAre all escape routes free from any structural features that will present either a hazard or a barrier to theresident using any of the available routes? Yes/NoIf NO Enter DetailsDo any of the escape routes involve escape into an adjoining building or areas allowing for progressivehorizontal evacuation?Yes/NoEnter DetailsDoes the existing fire escape signage clearly lead you to a place of temporary safety or safety? Yes/NoEnter DetailsIs there furniture obstructing in room/area? Yes/NoIf YES Enter Details © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 5 of 7
  6. 6. Personal Emergency Evacuation Plan FormHave refuge points been provided on or adjacent to each escape route?Yes/NoEnter DetailsHas the evacuation plan been explained to the resident? Yes/NoEnter DetailsCan the resident raise the alarm if they discover a fire (operate the manual call point)? Yes/NoIf NO Enter DetailsIn an emergency can the resident contact staff in the area in which the resident is located? Yes/NoIf NO Enter DetailsDoes the resident required assistance to get out of their bedroom in an emergency? Yes/NoIf YES Enter DetailsCan the resident move quickly in the event of an emergency? Yes/NoIf NO Enter DetailsIs the resident on oxygen therapy? Yes/NoIf YES Enter DetailsHas staff practiced appropriate evacuation drill to meet the resident’s needs? Yes/NoIf NO Enter DetailsIs there an up-to-date record of staff receiving training in the use of evacuation aids? Yes/NoIf NO Enter DetailsDoes the resident’s bedroom and bedroom door have an appropriate level of fire resistance? Yes/NoIf NO Enter DetailsIs the resident’s bedroom door fitted with smoke seals and in good order?Yes/NoIf NO Enter DetailsHave all possibilities for relocating the activity or service provision on the ground floor (of this or anyother building) been exhausted?Yes/NoEnter DetailsAre you aware of any other measures that could be introduced in the Care Centre under assessment thatcould further aid the resident’s evacuation in case of an emergency? Yes/NoIf YES Enter DetailsNumber of staff required providing assistance to resident? Number of Staff © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 6 of 7
  7. 7. Personal Emergency Evacuation Plan FormHow long would you estimate that it would take to evacuate the resident (other than with the help of anyitems identified above), in the event of an emergency? Time MinutesOther Information;Other InformationAs the Assessor do you denote that the Care Centre is suitable for the resident? Yes/NoSigned (Assessor) _________________________________ © Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford. Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie V2.5 – Page 7 of 7

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