NHS Hartlepool and Stocktonon-Tees. Commissioning Group Business Continuity Plan

Transcription

1 NHS Hartlepool and Stocktonon-Tees Clinical Commissioning Group Business Continuity Plan Ratified Status Issued Approved by Approved Governance and Risk Committee Consultation Governance and Risk Committee Implementation date 13/09/2016 Core Standard reference Equality Impact Assessment Distribution BS part 1, ISO 22301, NHSE Emergency Preparedness Framework 2013, NHSE Core Standards for Emergency Preparedness, Resilience and Response 2013, NHSE Command and Control Framework All members of staff Review September 2018 Author Andrew Carter, Corporate Governance and Risk Officer Version V2.0 Reference No Location S Drive and Hard Copy in IR room Version Control Version Date Amendment V1.0 12/03/2014 Approved V1.1 02/03/2015 Inclusion of section on and copy of CCG recovery plan V1.2 12/11/2015 Update of RTO resource information V2.0 13/09/2016 Revised BCP to ensure it meets current guidance Page 1

2 Contents Page 1 Introduction 3 2 Purpose and Scope 3 3 Categorisation and Prioritisation of Services 4 4 Operation of the Plan 6 5 Communications 11 6 Service Priorities 13 7 Criteria for Stand down/ de-escalation 14 8 Debrief 14 9 Training and Exercises 15 Appendix 1 Business Continuity Plan Business 16 interruption factors/hazard identification Appendix 2 Categorisation of activities and prioritised 22 activity response plan (PARP) Appendix 3 Action cards 23 Appendix 4 Incident assessment and situation report 29 Appendix 5 First meeting agenda 31 Appendix 6 Debrief template post-incident 33 Appendix 7 Business continuity communications 35 Page 2

3 1. Introduction 1.1 Business Continuity Background As Category 2 responders under the Civil Contingencies Act 2004, CCGs are required to have a Business Continuity Plan in place to manage the effects of any incident that might disrupt its normal business. This Business Continuity Plan (BCP) describes how NHS South Tees CCG will discharge its functions in the event of an incident that causes serious interruption of business operations. Business interruption is defined as an unwanted incident which threatens personnel, buildings, operational procedures, or the reputation of the organisation and which requires special measures to be taken to restore things back to normal. The BCP outlines the critical functions and services, and provides details of how it is intended that business continuity is maintained when faced with loss of premises, staff and other resources. 1.2 Commissioning Support Unit Business Continuity The CCG s Business Continuity Plan is also dependent upon the Commissioning Support Unit s (CSU) business continuity arrangements as a provider of a number of the CCG s services. The CSU has its own business continuity arrangements in place including a corporate Business Continuity Plan and Directorate-specific Plans outlining critical functions, services and recovery plans. The CCG s business continuity plan is aligned with the CSU s arrangements and has been developed in conjunction with the CSU s Governance team. 1.3 Links with Risk Management Business continuity is complementary to the risk management framework that sets out to understand the risks to operations or business, and the consequences of those risks. Reference should be made to the organisation s risk management strategy and risk register which relate to corporate and directorate risk assessments that may be considered in conjunction with this continuity planning process. 2 Purpose and scope 2.1 Purpose The purpose of this Plan is to ensure business continuity arrangements are in place which Page 3

4 identify and maintain critical activities during and after any interruption; restore them to full functionality; promote recovery as quickly as possible. To perform its duty on a day-to-day basis, the CCG depends upon a wide range of complex systems and resources, and seeks to maintain a good reputation. Inevitably, there is potential for significant interruption to normal business or damage to the organisation s reputation through loss of those systems and resources. The CCG s priorities when faced with a significant interruption (whether actual or impending) will always be to: 2.2 Scope Ensure the safety and welfare of its personnel and visitors; Endeavour to meet its obligations under legislative requirements; Secure replacement critical infrastructure and facilities; Protect its reputation; Minimise the exposure to its financial and reputational position; Facilitate a return to normal operations as soon as practicable. The Business Continuity Plan addresses the potential requirements of the CCG it is not intended to be a major incident plan. The CCG will continue to participate, as required, in major incident on-call rotas and exercises in line with the broader NHS strategic emergency planning function (emergency preparedness, resilience and response). The BCP conforms with BS 25999, legislative requirements within the Civil Contingencies Act (CCA) 2004 and NHSE guidance. 3 Categorisation and prioritisation of services 3.1 Categorisation To ensure the efficiency of the CCG s response to an incident, the CCG has defined the organisation s business services at all levels. In line with NHSE guidance, a priority scoring exercise has been undertaken, which determines the categorisation of activities depending on the maximum tolerable period of disruption to the service. These have been broken down into low, medium and high priority areas. Categorisation Definition HIGH Should be provided within the first 8 hours of an incident occurring. Page 4

5 MEDIUM LOW Between 8 hours and 5 days. All remaining activities 3.2 Interruption/hazard factors This is a list of the possible interruption factors that represents the potential impact for the organisation; Loss of life or inacceptable threat to human safety; Disruption of essential services; Loss of public/stakeholder confidence; Loss of vital records; Loss of expertise; Significant damage or total loss of infrastructure; Significant loss of revenue or public funds; Disproportionate recovery costs. Within the organisation the interruption factors may include; Access to or the ability to operate normal services from a site which can be either fully or partially interrupted due to an incident occurring e.g. fire, loss of utilities; IT systems are interrupted or the network fails, causing significant disruption to either a single or more department; Failure of service provision arising from a key 3 rd party supplier or provider organisation; Greatly reduced staffing levels e.g. severe weather conditions (appendix 1), flu pandemic; and Loss of telephone communications. 3.3 Prioritised activities Appendix 2 provides a summary of the organisation s processes together with key stakeholders and resources required to reinstate the function within a set period of time (the recovery time objective). A prioritised activity response plan (PARP) is also provided. Page 5

6 4.0 Operation of the Plan Identifying the person in charge and area of responsibility The Chief Finance Officer will normally take charge, however, if the Chief Finance Officer is unavailable then the most senior person on duty will take charge and assume the role of the BCP Lead. Plan activation The following activation sequence will normally be used event notification identification of the potential/actual event that will trigger the initial phase. Standby will be used as an early warning of a situation which might at some later stage escalate and thus require implementation of this Plan. This is particularly important if an interruption occurs towards the end of office hours and staff may need to be asked to stay at work until the situation becomes clear or to be prepared for the implementation of the BCP the following day. Implement is the immediate activation of this plan. Stand Down will be used to signify the phased withdrawal of the activation of the plan e.g. the standing down of the incident room. Event Notification Notification of a business interruption may originate from any source, during working hours or out of hours. An alert can be raised by any member of staff to their head of department. The notified person will inform the Chief Officer or deputy and the Chief Finance Officer (as assigned BCP Lead). The Chief Officer and BCP lead will consider the appropriate response as to whether the organisation needs to be on standby or if the Plan should be implemented immediately. Activation of the business continuity plan is likely to be needed when something has happened that impacts on critical business functions, for example: All, or a substantial part, of the CCG office building/services or utilities are unusable for a period of time; Less than one third of the CCG s staff are available for work; Page 6

7 Major incident in, or around, the geographic area (pandemic, flooding etc); Increased severity of a business interruption that previously did not require activation of the BCP; Significantly heightened public or media interest. If it becomes apparent on arrival at the CCG headquarters that it will not be possible to access the premises, the following assembly points should be used for staff to meet and discuss the way forward: - If Billingham Health Centre is inaccessible, staff to meet in Billingham Community Centre - If the CCG office is inaccessible, staff to meet in reception in Billingham Health Centre. Standby If the decision is made for the organisation to be on standby, then all staff should be informed of the situation and an agreed communication plan be implemented to ensure that staff/key contacts can be kept informed of developments. Implementing the plan In the event of activation of the Plan, the BCP lead will identify an incident room, form the Incident Response Team (IRT) and provide a general status report for the IRT to consider appropriate actions. ROLE OF BCP LEAD (OR SENIOR MANAGER IN CHARGE) Take charge of the situation and allocate key roles of: - Incident Room Co-ordinator - BCP support. Identify a room to use as the incident room. (The incident room would normally be the CCG offices, however, should access be restricted then reciprocal arrangements are in place for the use of South Tees CCG accommodation. These can be accessed through contact TASKS Start documenting information and actions. Ensure the health and safety of staff is prioritised. Establish what the nature of the incident is and assess the impact on CCG critical functions. The table starting on page 10 can be used as an action checklist for senior manager in charge. Page 7

8 ROLE OF BCP LEAD (OR SENIOR MANAGER IN CHARGE) with Jacqui Keane, ST Governance Manager or Simon Gregory, STCCG CFO telephone ) TASKS Refer to, and issue, action cards (appendix 3) The incident response room should ideally include: access to a computer and network or wifi, including access to a dedicated account and backup account, access to an A3 colour printer/photocopier, sufficient telephone lines or availability of mobile phones, stationery pack, white boards and pens/flip charts and pens and hard copy directories and maps. Communicate Ensure that all staff are briefed about the incident and given clear instructions, including, if applicable whether they should relocate or go home and when they are expected to return. Establish contact with key partners as necessary, including CSU. Undertake incident assessments and situation reports and take/direct any immediate remedial actions (eg. making an area safe). Arrange and chair the first meeting of the incident response team. Lead the organisation through the period of interruption and recovery, ensuring there is effective communication throughout, including details of the recovery plan and estimated recovery time objectives. Take any further actions required to ensure functions can continue/resume in line with agreed priorities. Appendix 4 contains the proforma. Ensure incident is logged onto SIRMS. Appendix 5 gives an agenda for the meeting The prioritised action plan (PARP) should be used as a guide. (appendix 2) Action cards are also provided at appendix 3 Once the main priorities have been Page 8

9 ROLE OF BCP LEAD (OR SENIOR MANAGER IN CHARGE) Stand down the incident room and the team at the appropriate time. Prepare final report and debrief; highlighting lessons learned. Ensure that the BCP is updated to reflect any lessons learned. TASKS dealt with, it might be appropriate to scale down the Incident Response team. Appendix 6 Report into team meetings, Executive Group (if appropriate) and Governance & Risk Committee Key roles, tasks and responsibilities There are a number of tasks that will need to be co-ordinated by the BCP Lead and these are given below. ROLE OPTION 1 OPTION 2 Senior Manager in charge BCP Lead Most senior member of staff on duty Business Continuity Incident Room Co-ordinator Any member of the senior management team Governance Risk Manager and Business continuity support Corporate Office Administrator Administrator A list of tasks to be considered and delegated are given below - these may be fulfilled by either CCG or CSU staff. Tasks for allocation Communications Developing an information and media response plan. Preparing for, and advising senior management on, crisis communications messaging relating to disruptions to critical and vital services. Estates and Facilities Ensuring suitable Incident Room is available. Page 9

10 Tasks for allocation Overseeing and co-ordinating the assignment of alternative facilities where required. Liaising with governance team and finance lead regarding asset registers of equipment, insurance and reporting arrangements of damage assessment. Liaising with NHS Property Services where there is damage to infrastructure. Liaising with emergency agencies where appropriate. Ensuring the security of employees and buildings during the emergency response. Liaising with the senior governance officer (health and safety) to assess safety and fire risks where appropriate. Working with the finance manager to adhere to emergency expenditure and procurement procedures. Human Resources Having available an up-to-date contact list of current employees and agencies that can supply temporary staff so as to help support essential services during a HR shortage. Liaising with the senior governance officer (health and safety) to ensure there are no risks to the health and safety of staff. Liaising with Occupational Health to secure post-incident counselling where appropriate. Advise on anticipated personnel concerns eg payroll, child care, transportation. Liaising with operational areas and the senior governance officer (IG) in identifying, prioritising and protecting all vital records. Finance Ensuring that appropriate insurance details are available. Ensuring asset registers are available. Page 10

11 Tasks for allocation Ensuring appropriate staff are authorised to make emergency expenditures when required. Liaising with the appointed estates and facilities manager to ensure that emergency expenditure and procurement procedures are adhered to. IT Liaising with the CSU to prioritise IT systems recovery in business critical areas where necessary. Liaising with operational areas and ensuring IT systems are recovered within time objectives or set up if staff have been relocated. Ensure IT policies have been adhered to when storing/backing up information. Liaising with the finance manager where assets require replacing due to loss/damage. Liaison with CSU re emergency procurement if required. Liaising with operational areas and the senior governance officer (IG) in identifying, prioritising and protecting all vital electronic information. Administration Co-ordinator Liaising with the BCP lead. Ensuring available resources in the incident room e.g. hard copies of plans, stationery, writing materials, flip chart, telephone, computer and printer access. Taking notes/logging action. Type final reports. 5.0 Communications Effective communications are crucial. It is essential to disseminate accurate and timely information to staff, partners, stakeholders and where necessary the public during the response to a business interruption. The Incident Room Co-ordinator Page 11

12 will liaise with the communications manager as needed to ensure effective, ongoing communications. This will be overseen by the senior manager in charge. A checklist is given as Appendix 7. The CCG s main stakeholders are given in the table below. All contact details for key CCG contacts are saved in the corporate calendar contact list which is accessible via Outlook or nhs.mail. Organisation GP Member Practices Commissioning Support Unit (North of England Commissioning Support Contact details Available in corporate calendar or potentially contact via LMC: Tel: Fax: jackie.jameson@nhs.net general switchboard Health, safety, fire and security lead Lee Crowe : NHS Property Services Security alarm provider Lift maintenance/supplier Cleaning contractors Counter Fraud Specialist Information governance lead Liane Cotterill HR lead Catherine Gilburt North Tees & Hartlepool NHS Foundation Trust South Tees Hospitals NHS Foundation Trust Tees, Esk & Wear Valley NHS Foundation Trust IT Helpdesk In and out of hours Via NHS Property Services Via NHS Property Services Via NHS Property Services (Ray Scanlan) or (Graham Thompson) North East Ambulance Service NHS Foundation Trust NHS England or NHS South Tees CCG NHS Darlington CCG NHS Durham Dales, Easington and Sedgefield CCG Page 12

13 Organisation Contact details Hartlepool Borough Council Stockton-on-Tees Borough Council Alternative meeting facilities Billingham Forum SRC Bede Sixth Form Centre Billingham Community Centre Service Priorities All functions of the organisation have been designated a level of priority. This assumes IT functionality is maintained in line with IT business continuity and disaster recovery plans and the business continuity plan in place for the CSU. PRIORITY AND DEFINITION High priority functions An essential function needing to be restored within 0-8 hours NHS Hartlepool and Stockton-on-Tees CCG activities Inability to access building, IT or telephone systems Patient care and safety e.g. continuing care, safeguarding, serious incidents Senior leadership function IT systems (CSU) Complaints handling and MP letters Medium priority functions An important function needing to be restored within 5 working days Communications and media relations, including patient and public involvement activities (could be time sensitive) Payroll function (time sensitive to payroll schedule) Freedom of information requests Financial systems (time sensitive) Page 13

14 PRIORITY AND DEFINITION NHS Hartlepool and Stockton-on-Tees CCG activities Contract management Commissioning cycle (time sensitive) All these functions are administered by the CSU on behalf of the CCG but require CCG input Low priority functions - A function which can be restored progressively after 5 working days. All other functions Managing corporate meetings (time sensitive) Corporate reporting, eg NHSE returns (time sensitive) 7.0 Criteria for stand down/de-escalation The BCP Lead will determine when the BCP will be stood down. Criteria for deescalation could include: Resolution of issues; 8.0 Debrief Reduction in internal resource requirements; Reduced severity of the incident; Reduced public or media interest. At the conclusion of the incident, the BCP Lead will hold a debrief session and prepare a report on the incident (Appendix 6), to include issues identified by the debriefing process. This should take place between 24 hours and fourteen days following the incident. The report will be considered at a meeting of the incident response team, staff team meetings (and Delivery Team if appropriate) and submitted to the Governance and Risk Committee together with any recommendations and action plan. Page 14

15 9.0 Training and exercises Responsibility for overseeing the relevant training, testing and exercising of the plan lies with the Chief Finance Officer as BCP Lead. Reporting on this will form part of the annual review of the Plan. The Governance and Risk Manager will undertake on-line Business Continuity Plan training annually. Staff from the CCG will participate in any exercise designed to test and improve the CCG s preparedness. As part of this training and exercise process, the CCG will adopt a culture which encourages staff at all levels to participate in the identification of alternative methods of working should normality ever be disrupted and where appropriate, these suggestions will be incorporated into the Plan. The CCG will also continue to work with the Local Health Resilience Partnership to access relevant training and larger scale major incident exercises. Graeme Niven Chief Finance Officer/BCP Lead September 2016 Page 15

16 Hazard Fire Business Continuity Plan Business interruption factors/hazard identification How hazard impacts CCG Service delivery Loss of use of some or all premises Likelihood Impact Risk scor e Controls in place Appendix 1 Short term action Longer term action Action card Fire procedure Staff work at home or hot desk at other sites. Prioritise work of staff affected. Use of annual leave Website notice and comms plan Temporary alternative work base for key staff to enable point of contact and / internet access. Prioritise work of staff affected. 1 Flood Service delivery Loss of use of some or all premises Staff work at home or hot desk at other sites. Prioritise work of staff affected. Use of annual leave Website notice and comms plan Temporary alternative work base for key staff to enable point of contact and / internet access Prioritise work of staff affected. 1 Criminal attack (including theft or damage). Service delivery Information security Loss of use of some or all premises and/or equipment Security policies Alarm system. Staff work at home or hot desk at other sites. Prioritise work of staff affected. Use of annual leave Temporary equipment loan/supply - CSU Website notice and comms plan Temporary alternative work base for key staff to enable point of contact and / internet access Prioritise work of staff affected. Temporary equipment loan/ supply (CSU) 1 Major chemical contamin- Service delivery Loss of use of some or Patch-wide emergency response plan Staff work at home or hot desk at other sites Prioritise work of staff affected Staff work at home or hot desk at other sites Prioritise work of staff 1 Page 16

17 Hazard How hazard impacts CCG Likelihood Impact Risk scor e Controls in place ation all premises Use of annual leave Short term action Longer term action Action card Website/comms plan affected. IT failure/ loss of data Service delivery Information security IT back-up systems. Remote working through NHSnet. Website notice and comms plan As short term 3 No access to , electronic files, telephones Loss of power Service delivery No access to , electronic files, telephones Some mobile phones are 4G enabled and able to access nhs.net Staff work at home or hot desk at other sites Prioritise work of staff affected. Website notice and comms plan Staff work at home or hot desk at other sites Prioritise work of staff affected. 1 Loss of use of premises Loss of water Service delivery Staff wellbeing Staff work at home or hot desk at other sites Prioritise work of staff affected Temporary portable toilets. 1 Access to toilets and beverages. Cleaning functions. Use of annual leave Website notice and comms plan Bottled water. Loss of use of premises Loss of landline telephone Service delivery Reputation Extensive use of mobile phones. Use of mobile phones. Website notice and comms plan Temporary alternative work base/ work from home. 1, 4 Limited telephone Page 17

18 Hazard How hazard impacts CCG communication. Potential impact on / internet Likelihood Impact Risk scor e Controls in place Short term action Longer term action Action card Simultaneous resignation or unavailability of number of key staff Service delivery Inability to comply with Standing Orders/ Constitution (re. authorised signatories, AO statements etc) Notice period in contracts Scheme of Delegation) Temporary staff. Liaison with NHS England re alternatives for leadership and potential emergency changes to Constitution. Accelerate normal recruitment processes. Secondments to cover gap and provide continuity. Changes to Constitution 2 Reputation Staff wellbeing Loss of leadership or support function. Staff illness or epidemic Service delivery Staff wellbeing Loss of significant number of staff Some buddying and shadowing arrange-ments in place to help with continuity Prioritise work Cancel leave arrangement if appropriate Potential use of CSU staff (by negotiation) Prioritise work. Cancel leave arrangements if appropriate Appoint temporary staff where feasible, including secondment 1b CSU unable to deliver appropriate support. Service delivery Staff wellbeing Reputation SLA with CSU Use directly employed staff and/or agency staff to delivery critical functions. CSU to action CSU to remedy. If it cannot, seek alternative sources of support and compensation from CSU. 2 Loss of support staff or Page 18

19 Hazard How hazard impacts CCG business functions Likelihood Impact Risk scor e Controls in place Short term action Longer term action Action card Travel disruption preventing staff getting to base. Service delivery Staff wellbeing Loss of significant number of staff Location of CCG offices near varying road networks/railst ation. Staff work at home or other premises. Use of annual leave. Cancellation of annual leave if appropriate As short term. 1b Ability to access nhs.net Reciprocal arrange-ment with ST CCG Travel disruption preventing staff getting home. Staff wellbeing Disruption to work due to need to accommodate staff Location of CCG offices near road networks/ rail station. Ability to access nhs.net If possible, obtain food and blankets to enable staff to stay overnight. As short term. 1b, 4 Reciprocal arrange-ment with ST CCG Widespread industrial action. Staff wellbeing Service delivery Staff engagement and HR policies CSU staff may Prioritise work Potential use of CSU staff (subject to negotiation) Prioritise work. Appoint temporary staff where feasible. 2 Page 19

20 Hazard How hazard impacts CCG Reputation Loss of significant number of staff. Likelihood Impact Risk scor e Controls in place not be affected. Short term action Longer term action Action card Loss of use of lift facilities Staff wellbeing Service delivery Compliance with legal requirements re access for people with disabilities Service arrange-ments for use of lift Consider impact of staff and expected visitors and make alternative arrangements as appropriate (hot-desk, home working, meeting venues) Notice in lift lobby. Agree process for Reception staff to follow. Cancel or rearrange meeting venues as appropriate. As short term. 1 Significant fraud or other criminal act Service delivery. Reputation Restriction on business activities Potential financial impact & lack of immediate access to funds Staff wellbeing Anti-fraud Policy Financial author-isation limits Notification to Counter Fraud specialist. NHS England notification Seek assistance as required (re staffing, finance, health welfare) 2 Theft or damage of assets Loss of use of IT equipment, furniture etc Security policies Security system Staff work at home Use of old or borrowed equipment (CSU, other CCGs) Purchase, hire replacement equipment 1, 3, 4 Insurance Page 20

21 Risk Scoring No. Probability Impact 1 Rare Insignificant 2 Unlikely Minor 3 Possible Moderate 4 Likely Major 5 Almost certain Catastrophic Risk matrix Low : 1-6 Medium : 8-12 High : Page 21

22 Appendix 2 Categorisation of activities and prioritised activity response plan (PARP) See Excel spreadsheets Page 22

23 Appendix 3 Action Card 1 Action card 1 Temporary relocation/staff working at home In the event of loss of use of CCG offices Action to be taken by Chief Officer/Senior Manager in charge 1. Assess likely length of loss of use of offices (in conjunction with Health & Safety specialist, NHS Property Services, Insurance assessors as appropriate). 2. Ensure all staff are safe and premises are secured and that all personal identifiable information is secure. 3. Contact South Tees CCG where reciprocal arrangements are in place to establish availability of usable office accommodation. ( ) 4. Ensure communication plan is in place (staff, stakeholders, website, social media) 5. If necessary obtain IT support from CSU to assess capability to establish and internet links. 6. Prioritise critical functions as per appendix Obtain assessment of staff needs which staff can work at home (from personal and work perspective), which need to be in an office base with colleagues/access to shared drive facilities. 8. If necessary, obtain IT support to ensure all staff working at home have remote access to computer systems. Take into consideration all information governance requirements re. access/personal information etc. 9. Determine who will: work in alternative premises, work from home or take annual leave/flexible arrangements. 10. Review arrangements daily, ensuring safety of staff and suitability of temporary location. Page 23

24 Appendix 3 Action card 1b Action card 1b Loss of staff as a result of adverse weather/ fuel shortages/transport difficulties 1. The need to balance business continuity and staff availability during periods of adverse weather or fuel shortage is the responsibility of the whole staff team, led by the Chief Officer and senior management team. The safety of patients and staff is paramount. 2. It is the duty of each employee to make their own arrangements to get to work at the normal time. However, it is recognised that employees may experience severe difficulties in getting to and from work. 3. Individual members of staff should make contact with their line manager (or Chief Officer or member of the senior management team in the absence of their line manager) to discuss their options and plans. This should be at the earliest opportunity, even the evening before when adverse weather starts or is forecast. 3.1 The first option to consider is that the member of staff attends their usual place of work (the CCG office), taking into account any particular travel arrangements (e.g. allowing extra time, using public transport) 3.2 If the employee and manager agree that it is not practical for the employee to get to the office, then the second option is to consider going to the nearest CCG or CSU office where the employee can access the necessary IT systems, i.e. If this is agreed, the employee should speak to the senior manager in charge at that office immediately on arrival, as well as notifying their own line manager. 3.3 If the employee and manager agree that neither of these options are practical, then the line manager may consider that the employee can work from home. The work to be done and how contact will be maintained whilst the employee is working at home should be clearly agreed. 3.4 If the employee and manager agree that none of these options are practical, then the employee will have the option of: - flexible working (manager may agree revised working hours to enable the employee to fulfil their contracted hours); - annual leave Page 24

25 - unpaid leave. 4. It is essential that communication is maintained between the employee and manager, to keep the situation under review, maintain the safety of the employee and ensure adequate oversight of the work. As a minimum the manager should speak to the employee at the start of each working day, at least once during the day and at the end of each working day. 5. During prolonged periods of adverse weather the Chief Officer and senior management team will keep the matter of workload and office cover under daily review. Page 25

26 Action card 2 loss of staff In the event of staff illness, terrorist or criminal attack, simultaneous resignation of key staff Appendix 3 Action card 2 Action to be taken by Chief Officer/Senior Manager in charge 1. Assess likely possibility of losing more staff. Liaise with HR and health & safety departments. 2. Ensure all remaining staff are safe and well. Provide details of occupational health, counselling facilities etc are available. 3. Ensure communication plan is in place (staff, stakeholders, website, social media) 4. Obtain assessment of business and staff needs which staff can work at home (from personal and work perspective. 5. Prioritise critical functions as per appendix 2 6. Remaining staff and line managers to prioritise workload to assess which roles need replacing most urgently. 7. Assess whether additional support can be provided by CSU or via secondments from other organisations, temporary staff appointments. 8. If necessary, obtain IT support to ensure all staff working at home or offsite have remote access as required and that new staff have rapid access to relevant files all subject to relevant information governance requirements. 9. Review arrangements daily, ensuring safety of staff and suitability of plans in place. Page 26

27 Appendix 3 Action card 3 Action card 3 loss of IT systems Action to be taken by Chief Officer/Senior Manager in charge 1. Assess likely time period that IT systems will be unavailable. 2. Identify continued methods of working use of nhs.net from alternative premises; paper records; alternative work not requiring IT systems; availability of information from other stakeholders. 3. Obtain IT support from CSU to be able to use back-up systems if available. 4. Prioritise critical functions as per appendix Ensure communication plan is in place (staff, stakeholders, website, social media) 6. Obtain assessment of staff needs which staff can work at home, which need to be in an office base with (or without) colleagues. 7. If necessary, obtain IT support to ensure all staff working from home can have remote access to computer systems if possible, taking account of information governance requirements. 8. Review arrangements daily, ensuring safety of staff and suitability of temporary locations. Page 27

28 Appendix 3 Action card 4 Action card 4 loss of access or use of premises In the event of loss of access resulting from fire, flood, loss of water Action to be taken by Chief Officer/Senior Manager in charge 1. Liaise with NHS Property Services and Health & Safety Manager (CSU). 2. Assess the likely time period that the building will be out of operation. 3. Assess whether part of premises can be used, or whether arrangements can be made to facilitate use (eg. portable toilets, bottled water in the event of loss of water). 4. Prioritise critical functions as per categorisation of activities. 5. Ensure communication plan is in place (staff, stakeholders, website, social media) 6. Review arrangements daily ensuring safety of staff and suitability of locations. 7. Obtain assessment of business and staff needs re alternative working bases. Page 28

29 Appendix 4 Incident Assessment and Situation Report Report details Date Name of person completing form Names of people contributing Time Summary of the current situation What are the facts about the incident? Use the aide memoir below as a guide C Number of casualties, if they require any primary care treatment H Hazards i.e. chemical, gas A Access (road closures etc) L Location (address of incident, type of building, where appropriate) E Emergency services (who should be contacted for more information) T Type (i.e. chemical/road traffic accident/outbreak/closure of building Other facts What are the assumptions about the incident? What additional information is required? Page 29

30 Alerting and informing What agencies are involved in the incident? Who has been informed (when and by whom, if known?) Do we need to inform or request actions of other individuals/services/partner organisations? Risks What are the main risks and consequences of the incident? What are the knock-on effects to other services and/or partner organisations? Media Will the incident attract media interest? What is the current situation with the media? Are actions required? Page 30

31 FIRST MEETING AGENDA - MEETING OF INCIDENT RESPONSE TEAM DATE, TIME AND PLACE: ATTENDEES: CHAIRED BY: Appendix 5 No Item Action Action owner 1 Analysis of impact Review Service Impact Analysis Sheets Brief team on nature, severity and impact of disruption. Identify information gaps Agree immediate action necessary Adjourn to take immediate action as needed Agree time to reconvene 2 Confirm roles Agree roles and responsibilities of staff during the disruption. If required revise roles and determine if additional staff/deputies are required. Identify additional team members that may be required Stand down members not required 3 Confirm key contacts at scene of disruption Main points of contact for ongoing information updates 4 Logs Ensure personal logs in place. (Written record of significant events and all communications) 5 Recovery management Review recovery priorities Determination of support requirements. 6 Welfare issues Have members of staff, visitors or third parties been affected? What is their location? What immediate support and assistance is required? What ongoing support and assistance might be required? 7 Communications Who should we inform? Are communications managers required? Professional public relations/media advisors required? Determine which, if any, external regulatory bodies should be notified. Determine any internal communications that need to take place (other sites, affected services etc. 8 Media strategy Action by when Page 31

32 No Item Action Action owner Determine the media strategy to be implemented. What is the story? What is the deadline? 9 Legal perspective Determine what legal action or advice is required. 10 Insurance position Determine whether insurance cover is available and if so, how best to use the support it may provide. 11 Next meeting Date, time, place and attendees of next meeting Action by when Page 32

33 Appendix 6 Debrief template post-incident Incident date: Outline of incident: This debrief template provides the framework for undertaking a structured debrief and will assist in the development of the post incident report which will cover What was supposed to happen? What actually happened? Why were there differences? What lessons were identified? Issue How prepared were we? Response What went well? What did not go well? What can we do better in the future? Is there a need to modify the plan/training? Other issues Communications Equipment Human resources 33

34 Planning and briefing Other issues Completed by.. Role.. 34

35 Appendix 7 Business Continuity Communications During the response to a business interruption it is important that staff are kept fully informed of progress. Staff directly affected by a business interruption will obviously be very concerned about the impact upon them personally. Staff not directly affected by a business interruption also need to be kept informed of progress as there may be an impact upon them (eg. additional work, impact on their deadlines etc). A clear, concise and accurate flow of information is essential. The severity of the business interruption will influence the level of detail and amount of information which needs to be issued to staff. The business continuity co-ordinator will liaise with the communications manager as needed to ensure effective, on-going communications. This will be overseen by the senior manager in charge and will cover, as a minimum: a. Are the normal day-to-day communication links with staff still in place? If yes, these should be used to issue information to staff. b. If normal day-to-day communication links are no longer in place, use any agreed fall-back procedure for issuing information to staff (eg. use of mobile phones, home phone numbers, CCG website). c. In the case of a business interruption, the BCP Lead will continually monitor staff instructions and ensure that all staff are aware of the current situation and plans. d. If information needs to be relayed to the public then this should be arranged with the CSU communications manager. 35