Emergency Preparedness, Resilience and Response (EPRR) Quarter 1 report, April June 2013

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1 Emergency Preparedness, Resilience and Response (EPRR) Quarter 1 report, April June Introduction The NHS needs to be able to plan for, and respond to, a wide range of business continuity incidents and emergencies that could impact on, patient and/or the delivery of Trust core services. These could be anything from extreme weather conditions, to an outbreak of an infectious disease, or a major transport accident. This programme of work is referred to in the community as Emergency Preparedness, Resilience and Response (EPRR). The letter from the NHS Commissioning Board - Transition of Emergency Preparedness, Resilience and Response (EPRR) dated 22nd March 2013 expects that Accountable Emergency Officers (AEO) should provide quarterly updates on EPRR to their Executive management teams and Boards. This report is the first quarterly EPRR report to the Trust Board following the Board Briefing on EPRR in April 2013 and it: details the new NHS Command and Control structure for EPRR; describes the Trust s EPRR structure and programme; introduces the NHS England EPRR Core Standards 2013; informs the Board about the internal and external assurance processes in place to reassure the Board and our external auditors that the Trust EPRR processes are robust; updates the Board on the development of the EPRR programme; 2. NHS Emergency Preparedness, Resilience and Response (EPRR) Structure From 1 April 2013, the accountability for EPRR was handed over from statutory authorities, e.g. PCTs / SHA clusters and the HPA to NHS England (NHSE), Public Health England (PHE) and to local and unitary authorities. During times of severe pressure and when responding to significant incidents and emergencies, there needs to be a structured approach to leadership, accountable decision making and communications. Times of severe pressure can include winter periods, a sustained increase in demand for services (surge) or an infectious disease outbreak. Significant incidents or emergencies are usually referred to as major incidents. Emergency Services Directorate Page 1 of 36

2 NHSE has set out the NHS structure for responding to local, regional and periods of pressure, significant incidents or emergencies. 2.1 Surge / Escalation Clinical Commissioning Groups will provide oversight and support for the management of surge across the local system on a 24/7 basis. Examples of surge / escalation events include significant bed pressures or A&E activity and significant ambulance delays. 2.2 Major Incidents If an incident requires a wider NHS or multi-agency response, the co-ordination and leadership will be provided by an NHSE Area Team director. If an incident affects two or more areas, this may be escalated to the NHSE regional office to take command of all NHS resources across the region to support the response. If an incident escalates to level the Commissioning Board office will take command of all NHS resources across England. 2.3 Local Health Resilience Partnerships A key feature of the new arrangements is the establishment of Local Health Resilience Partnerships (LHRPs). These provide strategic forums for co-ordinated planning for emergencies impacting on or continuity of patient services and effective engagement across local. They are largely co-terminus with Local Resilience Forum (LRF) boundaries. They will provide input to the LRFs. LHRPs are non-statutory and accountability for emergency preparedness and response will remain with individual. Members of the LHRP will be executive representatives who are able to authorise plans and commit resources on behalf of their.. Each LHRP will be co-chaired by a lead Director of Public Health (DPH) from one of the local authorities in the area and by a Director responsible for EPRR from the NHSE Local Area Team. The DPH Co-chair will have specific responsibility to provide local public expertise and co-ordinate local government public input. The NHS Co-chair will provide local leadership on EPRR matters to all of NHS-funded and maintain engagement with the Clinical Commissioning Groups to ensure EPRR is commissioned effectively, reflecting local risks. 2.4 Local Authorities and Public Health England The NHS EPRR structure is supported by the Directors of Public Health within Local Authorities who are responsible for the initial leadership of the response to public incidents and emergencies within their local authority area. The DPH maintains an oversight of population and ensure effective communication with local communities. In addition PHE delivers and manages the specialist protection Emergency Services Directorate Page 2 of 36

3 services and works together with the NHS at all levels and where appropriate to develop joint response plans. 2.5 NHS Funded Organisations The term NHS funded reflects the commissioning arrangements in which, in addition to traditional NHS commissioning and provider, non-nhs commissioners and from the independent or third sectors may be responsible for service provision to significant parts of the population. Therefore all NHS work undertaken by independent and third sector must be compliant with the requirements of the NHSE Core Standards for EPRR (2013). NHS Funded are required to: identify an Accountable Emergency Officer (AEO) to take executive responsibility and leadership at service level; fulfil relevant legal and contractual EPRR requirements, including the Civil Contingencies Act 2004 (CCA) and ensure a robust and sustainable 24/7 response to emergencies; provide the resilience to manage emergencies and incidents that affect only them, with escalation where necessary; collaborate with local multi-agency partners to facilitate inclusive planning and response; ensure preparedness to maintain critical services in periods of disruption; facilitate NHSE EPRR assurance, including business continuity. 3. Trust Structure for EPRR The Trust s Director of Operations Kate Lyons, has been designated as the Accountable Emergency Officer and has strategic responsibility for EPRR across the Trust and for providing assurance to the Trust Board that the organisation meets its statutory and legal requirements. There are a number of core functions the board level director is expected to deliver which have been set out as part of the NHS England Emergency Preparedness Framework (21 March 2013). These are: Ensuring that the organisation is compliant with the EPRR requirements as set out in the Civil Contingencies Act (2004), the NHS planning framework, and the NHS standard contract, as applicable; Ensuring that the organisation is properly prepared and resourced for dealing with a major incident or civil contingency event; Ensuring their organisation, and any they commission, have robust business continuity planning arrangements in place which reflect standards set out in the Framework for Health Services Resilience (PAS 2015) and ISO Emergency Services Directorate Page 3 of 36

4 Ensuring the organisation has a robust surge capacity plan that provides an integrated organisational response and that it has been tested with other and parties in the local communities served; Ensuring that the organisation complies with any requirements of the NHS England, or agents thereof, in respect of the monitoring of compliance; Providing NHS England, or agents thereof, with such information as it may require for the purpose of discharging its functions; Ensuring that the organisation is appropriately represented at any governance meetings, sub groups or working groups of the Local Health Resilience Partnership (LHRP) or Local Resilience Forum (LRF). The Accountable Emergency Officer should be supported, where appropriate, by a Non- Executive Director (NED), or other appropriate board member to endorse assurance to the board that the organisation is meeting its obligations with respect to EPRR and relevant statutory obligations under the Civil Contingencies Act Currently, the NED support is provided by Chris Snow. The Divisional General Manager for Emergency Services Sharon Hinsley is the operational lead responsibility for EPRR and is supported by Annette Crew, The Emergency Planning Officer. They represent the Trust on the Devon Cornwall and Isles of Scilly Local Resilience Forum, the Local Health Resilience Group and other multiagency forums to support EPRR planning and response. Each Head of Department (HOD) has responsibility for EPRR within their teams and services and are accountable to their line managers, Divisional General Managers and Executive Directors. 3.1 Emergency Planning Group NDHT has an Emergency Planning Group (EPG) with representatives from across Trust core services and support teams. The EPG is scheduled to meet monthly and has the following main functions, to ensure: compliance with the requirements of the Civil Contingencies Act 2004, Care Quality Commission s Standards and the emergency planning indicators in the Operating Framework; engagement at a strategic, tactical and operational level with, regional and local and multi-agency resilience agendas and appropriate Trust input in multi-agency plans and polices; robust and tested Major Incident and supporting plans are developed and implemented; that a range of other emergency plans is in place to respond to specific emergency situations such as Pandemic Influenza, Chemical, Biological, Radiological and Nuclear Incidents etc.; there is a robust exercise and testing schedule and that designated group members take responsibility for arranging tests and exercises; Emergency Services Directorate Page 4 of 36

5 staff are trained to an appropriate level with respect to role and function in an emergency situation; a robust Business Continuity Strategy with underpinning arrangements is developed and implemented; robust Business Continuity Management plans are in place which would enable the continued delivery of core services even whilst responding to an emergency; involvement of all Divisions and Directorates in the emergency planning and resilience agenda and that updates, potential risks and new initiatives are shared with respective management teams; compliance with any standards and deadlines for EPRR as set out by NHSE; provision of reports to provide Board Assurance. The EPG has had difficulty with maintaining quoracy and commitment to its meeting schedule, leading to a delay in some EPRR action areas. The Director of Operations will review the terms of reference, membership and frequency of meetings and will set out a schedule to revitalise the group. 4. EPRR Resources Following the Board briefing in April 2013 and a presentation of the risks to the Executive Director s Group, it was agreed to fund a full time substantive Emergency Planning Officer to address the EPRR workload from June The Risk Manager has been seconded to the role in to the interim pending further recruitment process. 5. NHS England EPRR Core Standards 2013 In its EPPR framework guidance, NHS England has set out minimum standards which NHS and of NHS funded must meet, including service resilience. The standards provide a consistent framework for self-assessment, peer review and more formal control processes carried out by the NHSE and other regulatory. These control processes will require evidence that the standards are being met. These core standards can be summarised as follows: 5.1 General NHS and of NHS funded MUST: 5.2 EPRR nominate an Accountable Emergency Officer who will be responsible for EPRR; contribute to area planning for EPRR through Local Health Resilience Partnerships (LHRPs) and other relevant groups. Emergency Services Directorate Page 5 of 36

6 NHS and of NHS funded MUST: have suitable, up to date, plans which set out how they plan, for, respond to and recover from major incidents and emergencies as identified in, local and community risk registers; test these plans through: o a communications exercise every six months; o a desktop exercise once a year; o a major live or simulated exercise every three years. have suitably trained, competent staff and the right facilities available round the clock to effectively manage a major incident or emergency; share their resources, as required, to respond to a major incident or emergency. 5.3 Service resilience planning NHS and of NHS funded MUST have suitable, up to date, plans which set out how they will: maintain continuous service when faced with disruption from identified local risks; resume key services which have been disrupted by, for example, severe weather, IT failure, an infectious disease, a fuel shortage, or industrial action. This planning should follow the principles of ISO 22301, Business Continuity management systems - requirements and PAS 2015, Framework for Health Services resilience. The full EPRR Core Standards checklist provides the basis for the assurance process carried out routinely and jointly by the NHS England Local Area Team and the Clinical Commissioning Group. See Appendix 1 EPRR Core Standards checklist Internal and External Assurance Process 6.1 Internal Audit review In 2011/2012, Internal Audit completed a review which identified that there was a high risk to the Trust s corporate objectives and targets due to emergency planning and business continuity arrangements not being robust. A total of 25 recommendations for action were made, of which all but five were completed in year. The recommendations were managed and monitored via the Corporate Risk Register and Risk Management Committee. Emergency Services Directorate Page 6 of 36

7 During April June 2013, as part of the 2012/13 Annual Audit Plan, Internal Audit completed another planned review of emergency planning and business continuity arrangements within the Trust. The audit focused on the following areas: a review of the Emergency Preparedness, Pandemic Flu and Business Continuity Plans to confirm they meet the requirements of the Civil Contingencies Act 2004; the results of live, desk-top and communications testing of each plan; key staff responsibilities identified in each plan and key staff training has been received; and reporting to the Board to ensure the Board has approved each plan and is updated on results of testing exercises. The audit has identified significant progress in emergency planning and business continuity arrangements since last year and the risk reduced from high to medium. A total of 13 recommendations for action have been made, which include the five outstanding from last year. The actions are targeted at: completion and timely review of incident response plans; contingency planning for business continuity; training staff in their EPRR roles and responsibilities; testing and exercising plans; Identifying resources to manage the EPRR programme and workload. The recommendations will be managed and monitored via the Corporate Risk Register and Risk Management Committee. 6.2 External Assurance Programme The Trust EPRR arrangements will be audited quarterly by the NHSE LAT and New Devon CCG using the EPRR Core Standards checklist The first Trust assurance meeting for 2013/14 took place on Tuesday 30 April Prior to the meeting the Trust was required to complete a self-assessment using the above checklist. The results of the self-assessment mirrored the findings from the internal audit. Following the meeting an action plan was agreed with the NHSE LAT and CCG. This will form the basis of the Trust s EPRR work plan for 2013/14. It will be cross referenced to the Internal Audit actions and any additional recommendations will be managed and monitored via the Corporate Risk Register and the EPG. The next assurance meeting took place in July 2013 and there was a significant improvement in the compliance. At least annually, the Trust will be required to Emergency Services Directorate Page 7 of 36

8 provide evidence of compliance to support the self-assessment and external audit process. 7. Training 7.1 National Occupational Standards for Civil Contingencies NHS must have suitably trained competent staff to effectively manage incidents and disruptions to business continuity. The EPRR core standards state that key knowledge and skills must be based on the National Occupational Standards (NOS) for Civil Contingencies. The NOS describe the knowledge and skills competencies that staff need to perform their EPRR roles and responsibilities effectively. They allow a clear assessment of competence against ly agreed standards of performance, across a range of workplace circumstances, for specific roles. The Trust will identify individuals who have specific responsibilities when responding to an emergency and ensure that they are given adequate and appropriate training to enable them to discharge their roles. This will be done by reviewing the EPRR training matrix with the Learning and Development team and basing the content of the training on the NOS. 8. Incidents There have been no major or business continuity incidents in Quarter 1 that have necessitated an Incident Response Team to be convened. 9. Testing and Exercising 9.1 Communications exercises Twice a year, the Trust participates in a communications cascade exercise initiated by South Western Service NHS Foundation Trust (SWAST) Exercise Alarm Call. This tests the major incident cascade system. On receipt of the exercise call and message, NDDH Switchboard notifies the Duty Executive Director, Duty Manager and Clinical Site Manager and records their response times. These are then returned to SWAST, providing assurance that the call has been noted. NDHT successfully participated in Exercise Alarm Call on Wednesday 29 May In June 2013, SWAST changed to an automated system to deliver information to its partners for Major Incident and Standby notification and for testing and exercising cascades. The system requires the Duty or Clinical Site Manager to dial an automated message line to receive a full situation report and enter a PIN to register receipt of the message. The new system also provides regular updates throughout the course of the incident. The Trust participated in testing of the new system on 17 th June 2013 and has amended its process for receipt and management of Major Incident/Standby declaration from SWAST. The next test of the system is scheduled for October Emergency Services Directorate Page 8 of 36

9 9.2 Exercises and tests Chivenor exercise On 26 June 2013, a live exercise was held at Chivenor Camp. A simulated terrorist explosion outside the gates of the camp saw a multi-agency exercise response from the military, fire and rescue services, SWAST, police, local authorities and NDHT. A multi-agency Silver control was set up at the new Silver control room at Bideford Fire Station. NDHT was represented at Silver by Sharon Hinsley, Divisional General Manager for Emergency Services. Participation in the exercise enabled NDHT and SWAST to assess the planning assumptions on capability and capacity of the Trust to accept casualties from the scene of the incident Emergo exercise This Exercise took place on 2 July The exercise was delivered by staff from Public Health England and the aim was to test the Major Incident plan in response to a major incident affecting the core services at NDDH. This exercise enabled the Trust to comply with the requirement to hold a live or simulated exercise every three years. Planning for the exercise was very complex as it involved simulation of the hospital and departmental activity, staffing and equipment resources on the day, to enable participants to make realistic judgments and decisions. The exercise involved the setting up of the Incident Control Team, led by an Executive Director and supported by teams from divisional management and clinical site, emergency department, theatres and ICU to respond to a large scale incident generating significant numbers of casualties. Although the main focus of the exercise was focused on NDDH, there where participants from across the Trust to exercise the whole Trust capability and capacity to discharge and transfer patients. External observers attended from NHSE National and Local Area Teams, New Devon Clinical Commissioning Group and other Acute Trust partners. Each team was observed, performance assessed and scored by a team facilitator against a number of key performance indicators. There is a pass/fail threshold of scoring followed by production of an exercise report for the Trust which is also made available to NHSE LAT and New Devon CCG. The Emergo results and report will be presented to the Board in October with the Q2 EPRR report. 10. EPRR plans Emergency Services Directorate Page 9 of 36

10 The flowchart at Appendix 2, illustrates the Major Incident and Business Continuity challenges that the Trust must plan for. During Q1, April June 2013, the following plans and policies are being reviewed and amended Business Continuity Policy The Trust Business Continuity (BC) policy was approved by the Board in May It sets out the policy and procedures to ensure: the identification of potential risks to service provision and ensure that plans are put in place to eliminate or, so far as is reasonably practicable, minimise the effects a risk may pose; the continued provision of core services to the people of Northern Devon and community services in Exeter, East and Mid Devon through effective business continuity arrangements. The initial action following approval of the policy will be to ensure that BC leads are identified for all core services across the Trust. Following this there will be a programme of training and support to the BC leads to identify BC risks and to develop/review their BC contingency plans to mitigate the risks Major Incident Plan The Major Incident plan is scheduled to be reviewed and amended. The aim of the review is to produce an Incident Response plan that is fit for purpose for the whole Trust and ensure that the Trust can respond appropriately to a wide range of incidents, emergencies or disruptive challenges that could impact on patient and the safety and welfare of patients, visitors and staff. The timescale is for the review to be completed by end of July 2013 and a draft sent out for consultation by the end of September Following final amendments, the Board will be requested to approve the plan in October/November Chemical, Biological, Radiological and Nuclear Response plan The Chemical, Biological, Radiological and Nuclear (CBRN) Response plan has been reviewed and amended and will be circulated for wider consultation following the meeting of the EPG in July The plan sets out in depth arrangements for the Emergency Department, Clinical Site Managers, Incident Control and Estates and Facilities teams to respond to and manage an incident involving the potentially contaminated casualties attending NDDH, Minor Injury Units (MIU s) or Walk In Centres (WIC s) Heatwave plans Emergency Services Directorate Page 10 of 36

11 The Trust s Heatwave plan was reviewed and updated in line with the new Heatwave Plan for England for The Heatwave Health Watch period is 1st June - 15 September. The UK plan now clarifies responsibilities and actions for, local authorities and professionals in the light of the changes made to and social. It now separates actions for commissioners,, as well as for professional staff and for the wider community. The plan continues to be under pinned by a system of heatwave alerts. The alert levels have changed to emphasise that long term planning for heatwaves should take place throughout the year. A level 0 alert has been added to reflect this change. The Trust s action cards have been revised and the Heatwave Alert automatic cascade system to HOD s has been implemented. 11. EPRR work programme The EPRR work programme is currently under development following the assurance process and internal audit findings. It will be presented to the Board with Q2 EPRR report in October Emergency Services Directorate Page 11 of 36

12 Appendix 1 NHS Core standards for EPRR NHS COMMISSIONING BOARD CORE STANDARDS FOR EPRR 1 All NHS and of NHS funded must nominate an accountable emergency officer who will be responsible for EPRR and business continuity management 2 All NHS and of NHS funded must share their resources as necessary when they are required to respond to a significant incident or emergency 3 All NHS and of NHS funded must have plans setting out how they contribute to co-ordinated planning for emergency preparedness and resilience (for example surge, winter and service continuity) across the area through LHRPs and relevant sub-groups. These plans must include details of: X X X - X X X X X 3.1 director-level representation at the LHRP X X X - X - X X X 3.2 representation at the LRF - X X Emergency Services Directorate Page 12 of 36

13 4 All NHS and of NHS funded must contribute to an annual report on the sector s EPRR capability and capacity in responding to, regional and LRF incidents. Reports must include control and assurance processes, information sharing, training and exercise programmes and capabilities surveys. They must be made through the formal reporting structures 4.1 Organisations must have an annual work programme to reduce risks and learn the lessons identified relating to EPRR (including details of training and exercises). This work programme should link back to the National Risk Assessment (NRA) and Risk Register (CRR) 4.2 Organisations must maintain a risk register which links back to the National Risk Assessment (NRA) and Risk Register (CRR) 5 All NHS and of NHS funded must have plans which set out how they plan for, respond to and recover from disruptions, significant incidents and emergencies. Incident response plans must: X X X X Note¹ Note¹ Note¹ Note¹ Note¹ 5.1 be based on risk assessed worst case scenarios 5.2 make sure that all arrangements are trialled and validated through testing or exercises 5.3 make sure that the funding and resources are available to cover the EPRR arrangements 5.4 plan for the potential effects of a significant incident or emergency or for providing services to prisons, the military and iconic sites X X - X X X Emergency Services Directorate Page 13 of 36

14 5.5 include plans to maintain the resilience of the organisation as a whole so that the Estates Department and Facilities Department are not planning in isolation Incident response plans must be in line with published guidance, threat-specific plans and the plans of other responding partners. They must: X X - X X X 5.6 refer to all relevant guidance, other supporting and threat-specific plans (for example, pandemic flu, CBRN, mass casualties, burns, fuel shortages, industrial action, evacuation, lockdown, severe weather etc) and policies, and all other supporting documents that enhance the incident response plans 5.7 refer to all other associated plans identified by local, regional and risk registers 5.8 have been written in collaboration with all relevant partner 5.9 refer to incident response plans used by partners, including LRF plans X X X X X - X have been written in collaboration with Public Health England (PHE) X X X X X X - - X 5.11 have been written in collaboration with all burns, trauma and critical networks X X X X X - X X define how the organisation will meet the Prevent strategy s objectives for (1. Prevent people from being drawn into terrorism and ensure that they are given appropriate advice and support 2. Work with sectors and institutions where there are risks of radicalisation which we need to address, and the wider CONTEST strategy) X X X - X - - X X Incident response plans must follow NHS governance arrangements. They must: Emergency Services Directorate Page 14 of 36

15 5.13 be approved by the relevant board X X X X X - X X X 5.14 be signed off by the Chief Executive 5.15 set out how legal advice can be obtained in relation to the CCA X X X X X - X - X 5.16 identify who is responsible for making sure the plan is updated, distributed and regularly tested 5.17 explain how internal and external consultation will be carried out to validate the plan X X X X X - X X X 5.18 include version controls to be sure the user has the latest version 5.19 set out how the plan will be published (for example, on a website) 5.20 include an audit trail to record changes and updates 5.21 explain how predicted and unexpected spending will be covered and how a unique cost centre and budget code can be made available to track costs 5.22 demonstrate a systematic risk assessment process in identifying risks relating to any part of the plan or the identified emergency Staff must be aware of the Incident Response Plan, competent in their roles and suitably trained 5.23 Key staff must know where to find the plan on the intranet or shared drive 5.24 There must be an annual work programme setting out training and exercises relating to X X X X X - X X X Emergency Services Directorate Page 15 of 36

16 EPRR and how lessons will be learnt 5.25 Key knowledge and skills for staff must be based on the National Occupation Standards for Civil Contingencies. Directors of on-call rotas must meet published competencies 5.26 It must be clear how awareness of the plan will be maintained amongst all staff (for example, through ongoing education and information programmes or e-learning ) 5.27 It must be clear how key staff can achieve and maintain suitable knowledge and skills X X X X X - X X X X X X X X - X X X X X X X X - X X X Set out responsibilities for carrying out the plan and how the plan works, including command and control arrangements and stand-down protocols 5.28 Describe the alerting arrangements for external and self-declared incidents (including trigger points, decision trees and escalation/de-escalation procedures) 5.29 Set out the procedures for escalating emergencies to, regions, office and Department of Health 5.30 Explain how the emergency on-call rota will be set up and managed over the short and longer term 5.31 Include 24-hour arrangements for alerting managers and other key staff, and explain how contact lists will be kept up to date - - X X X - X X X X - - X X - Emergency Services Directorate Page 16 of 36

17 5.32 Set out the responsibilities of key staff and departments 5.33 Set out the responsibilities of the Chief Executive or nominated Executive Director 5.34 Explain how mutual aid arrangements will be activated and maintained X X X X X - X X X 5.35 Identify where the incident or emergency will be managed from (the Incident Control Centre) X X X X X - X X X 5.36 Define the role of the loggist to record decisions made and meetings held during and after the incident, and how an incident report will be produced X X X X - - X X X 5.37 Best Practice: use an electronic data logging system to record the decisions made X X Best Practice: use the National Resilience Extranet (NRE) X X X X X Refer to specific action cards relating to using the incident response plan 5.40 Explain the process for completing, authorising and submitting standard threatspecific situation reports and how other relevant information will be shared with other 5.41 Explain how extended working hours will apply and how they can be sustained. Explain how handovers are completed 5.42 Explain how to communicate with partners, the public and internal staff based on a formal communications strategy. This must take into account the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 duty to communicate with the public. Social networking tools may be of use here X X X - X - X X X Emergency Services Directorate Page 17 of 36

18 5.43 Have agreements in place with local 111 so they know how they can help with an incident 5.44 Consider using helplines in an emergency. Set up procedures in advance which explain the arrangements. Make sure foreign language lines are part of these agreements X X X X X X - X Describe how stores and supplies will be maintained X X - - X X X X X 5.46 Explain how specific casualties will be managed (for example, burns, paediatrics and those from certain faiths) 5.47 Explain how VIPs will be managed, whether they are casualties or visiting others who are casualties X X X X X X - X X 5.48 Explain the process of recovery and returning to normal processes 5.49 Explain the debriefing process (hot, local and multi-agency) at the end of an incident X X X X X - X X X 5.50 Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental services) X X X X X - X X X Set out how surges in demand will be managed 5.51 Explain who will be responsible for managing escalation and surges 5.52 Describe local escalation arrangements and trigger points in line with regional escalation plans and working alongside acute, ambulance and community Emergency Services Directorate Page 18 of 36

19 Link the Incident Response Plan to threat-specific incidents: X X X - - X X X X 5.53 CBRN incidents X X X X X X mass casualty incidents X X X X X X pandemic flu X - X - - X X X X patients with burns requiring critical X X X X X severe weather - X X - - X X X X 6 All NHS must provide a suitable environment for managing a significant incident or emergency (an ICC). This should include a suitable space for making decisions and collecting and sharing information quickly and efficiently X X X X Note² Note² Note² Note² Note² 6.1 There should be a plan setting out how the ICC will operate 6.2 There must be detailed operating procedures to help manage the ICC (for example, contact lists and reporting templates) 6.3 There must be a plan setting out how the Incident Co-ordination Team will be called in and managed over any length of time 6.4 Facilities and equipment must meet the requirements of the Corporate Incident Response Plan Emergency Services Directorate Page 19 of 36

20 7 All NHS and of NHS funded must develop, maintain and continually improve their business continuity management systems. This means having suitable plans which set out how each organisation will maintain continuity in its services during a disruption from identified local risks and how they will recover delivery of key services in line with ISO Organisations must: 7.1 make sure that there are suitable financial resources for their BCMS and that those delivering the BCMS understand and are competent in their roles 7.2 set out how finances and unexpected spending will be covered, and how unique cost centres and budget codes can be made available to track costs 7.3 develop business continuity strategies for continuing and recovering critical activities within agreed timescales, including the resources required such as people, premises, ICT, information, utilities, equipment, suppliers and stakeholders 7.4 develop, use and maintain business continuity plans to manage disruptions and significant incidents based on recovery time objectives and timescales identified in the business impact analysis Business continuity plans must include governance and management arrangements linked to relevant risks and in line with inter standards 7.5 Each organisation s BCMs should be based on its legal responsibilities, internal and external issues that could affect service delivery and the needs and expectations of interested parties 7.6 Organisations should establish a business continuity policy which is agreed by top management, built into business processes and shared with internal and external interested parties Emergency Services Directorate Page 20 of 36

21 7.7 Organisations must make clear how their plan will be published (for example, on a website) 7.8 The BCMS policy and business continuity plan must be approved by the relevant board and signed off by the Chief Executive 7.9 There must be an audit trail to record changes and updates such as changes to policy and staffing 7.10 The planning process must take into account ly available toolkits that are seen as good practice Business continuity plans must take into account the organisation s critical activities, the analysis of the effects of disruption and the actual risks of disruption 7.11 Organisations must identify and manage internal and external risks and opportunities relating to the continuity of their operations 7.12 Plans must be maintained based on risk assessed worst case scenarios 7.13 Risk assessments should take into account community risk registers and at the very least include worst case scenarios for: severe weather (including snow, heatwave, prolonged periods of cold weather and flooding) staff absence (including industrial action) the working environment, buildings and equipment fuel shortages surges in activity IT and communications Emergency Services Directorate Page 21 of 36

22 supply chain failure associated risks in the surrounding area (for example, COMAH and iconic sites) 7.14 Organisations must develop, use and maintain a formal and documented process for business impact analysis and risk assessment 7.15 They must identify all critical activities using a business impact analysis. This should set out the effect business disruption may have on the organisation and how this will be overcome, including the maximum period of tolerable disruption 7.16 Organisations must highlight which of their critical activities have been put on the corporate risk register and how these risks are being addressed Business continuity plans should set out how the plans will be called into use, escalated and operated 7.17 Organisations must develop, use, maintain and test procedures for receiving and cascading warnings and other communications before, during and after a disruption or significant incident. If appropriate, business continuity plans should be published on external websites and through other information-sharing media. Plans should set out: 7.18 the alerting arrangements for external and self-declared incidents, including trigger points and escalation procedures 7.19 the procedures for escalating emergencies to and the area, regional and teams hour arrangements for alerting managers and other key staff, including how up-to-date contact lists will be maintained Emergency Services Directorate Page 22 of 36

23 7.21 the responsibilities of key staff and departments 7.22 the responsibilities of the Chief Executive or Executive Director 7.23 how mutual aid arrangements will be called into use and maintained X X X X X - X X X 7.24 where the incident or emergency will be managed from the ICC X X X X X - X X X 7.25 how the independent sector may help if required 7.26 the insurance arrangements that are in place and how they may apply Business continuity plans should describe the effects of any disruption and how they can be managed. Plans should include: 7.27 contact details for all stakeholders 7.28 alternative locations for the business 7.29 a scalable plan setting out how incidents will be managed and by whom 7.30 recovery and restoration processes and how they will be set up following an incident 7.31 how decisions and meetings will be recorded during and after an incident, and how the incident report will be compiled 7.32 how the organisation will respond to the media following a significant incident, in line with the formal communications strategy 7.33 how staff will be accommodated overnight if necessary Emergency Services Directorate Page 23 of 36

24 7.34 how stores and supplies will be managed and maintained X X - - X X X X X 7.35 details of a surge plan to maintain critical services Business continuity plans should specify how they will be communicated to and accessed by staff. Plans should include: 7.36 Organisations must use, exercise and test their plans to show that they meet the needs of the organisation and of other interested parties. If possible, these exercises and tests should involve relevant interested parties. Lessons learnt must be acted on as part of continuous improvement 7.37 Plans should identify who is responsible for making sure the plan is updated, distributed and regularly tested 7.38 Organisations must monitor, measure, analyse and assess the effectiveness of their BCMs against their own requirements, those of relevant interested parties and any legal responsibilities 7.39 Organisations must identify and take action to correct any irregularities identified through the BCMS and must take steps to prevent them from happening again. They must continually improve the suitability and effectiveness of their BCMs Business continuity plans should specify how they will be communicated to and accessed by staff. Plans should include: 7.40 details of the training provided to staff and how the training record is maintained Emergency Services Directorate Page 24 of 36

25 7.41 reference to the National Occupation standards for Civil Contingencies and competencies when identifying key knowledge and skills for staff (directors of oncall X X X X X - X X X rotas to meet published competencies) 7.42 details of the tools that will be used to make sure staff remain aware through ongoing education and information programmes (for example, e-learning and induction training) X X X X X - X X X 7.43 details of how suitable knowledge and skills will be achieved and maintained X X X X X - X X X 8 NHS Acute Trusts must also include: detailed lockdown procedures X detailed evacuation procedures X details of how they will manage relatives for any length of time, how patients and relatives will be reunited and how patients will be transported home if necessary X details of how they will manage fatalities and the relatives of fatalities X Best Practice: reference to the Clinical Guidelines for Major Incidents X X NHS Trusts must also: - X refer to the National Service Command and Control Guidance 2012 and any other relevant ambulance specific guidance relating to major incidents - X Emergency Services Directorate Page 25 of 36

26 9.2 manage up to four incidents at a time in urban areas and two in rural areas - X have flexible IT and staff arrangements so that they can operate more than one control - X centre and manage any events required 9.4 have formal arrangements for recalling staff to duty if necessary - X be able to provide a forward control team if necessary - X have an on-call and an on-duty loggist drawn from a wide pool of staff - X have arrangements to communicate with and control resources from other ambulance - X have a 24-hour specialist adviser for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support gold and silver command in managing these events - X have 24-hour radiation protection supervisor arrangements in line with local and mutual aid arrangements - X make sure all commanders maintain a continuous personal development portfolio - X have a Hazardous Area Response Team (HART) in line with the current service specification, including a vehicles and equipment replacement programme - X be able to respond to firearms incidents in line with National Joint Operating Procedures - X have a Mobile Emergency Response Incidence Team (MERIT) to cover the area in line with Department of Health guidance 9.14 be able to manage a casualty clearing station with large numbers of patients for a long period of time in line with Department of Health guidance - X X Emergency Services Directorate Page 26 of 36

27 9.15 be able to identify the location and availability of assets across the organisation and the - X country 9.16 be able to respond with assets across the organisation and the country and provide situation reports to the National Co-ordination Centre - X be able to dispatch and receive assets following an agreed trigger mechanism, supported - X by a robust audit process 9.18 have a trigger mechanism for requesting mutual aid and a nominated person to agree to these requests, supported by a clear profile of what is required, what can be provided and - X how the response will be managed in the field 9.19 have systems to manage the media at Emergency Operational Centres, fall-back locations and across the organisation - X have arrangements in place for routine public events, for example, demonstrations and - X public gatherings 9.21 attend safety advisory groups to reduce organisational risk during planning and at the - X actual event 9.22 have arrangements in place to deal with public disorder incidents - X have arrangements in place to provide radiation protection supervisors - X have arrangements in place to train voluntary and community first responders - X have arrangements in place to provide training support to NHS partners in the use of personal protective equipment for chemical, biological, radiological, nuclear, hazardous - X material and casualty clearing 9.26 have processes and an audit trail which allow all staff to train with partner agencies - X Emergency Services Directorate Page 27 of 36

28 9.27 have arrangements in place to train with the voluntary sector - X have arrangements in place to train with acute - X have arrangements in place to share the outcome of training and exercises with other - X ambulance and government stakeholders across the country 9.30 have strong processes for profiling staff and managing facilities to accommodate EPRR - X and store assets in line with CCA requirements 9.31 have arrangements in place for counselling and supporting staff, and advising on longterm - X clinical following a traumatic or high-profile incident 9.32 have suitable IT arrangements in place to support a significant incident or any event that - X requires specialised IT 9.33 explain the systems for alerting, mobilising and co-ordinating all primary NHS resources necessary to deal with an incident on the scene (in co-ordination with area team - X gold command) 9.34 list their key strategic, tactical and operational responsibilities as set out in the NHS - X Emergency Planning Guidance 2005 (or subsequent relevant guidance) 9.35 explain how and when MERIT, HART and MIA (Medical Incident Adviser) will be used - X identify how voluntary aid societies will be used - X explain working arrangements with all emergency services - X explain the arrangements for managing triage, treatment and transport for casualties - X state who will represent the service at LHRP, LRF and similar groups - X explain the roles of the Hospital Liaison Officer (HALO) and Hospital Liaison Control Officer (HALCO) in acute - X Emergency Services Directorate Page 28 of 36

29 9.41 refer to other relevant plans such as REAP - X explain how the Mobile Privileged Access Scheme (MTPAS) and Fixed Telecommunications Privileged Access Scheme (FTPAS) will be provided across the organisation 9.43 describe how Airwave systems will be managed within the organisation and how talk groups will be used to communicate with the emergency services - X X must also: - - X make sure that the incident response plans for all in an LRF are co-ordinated and compatible - - X define when the NHS will take the leading role in a significant incident or emergency - - X mobilise primary and secondary resources to support acute and non-acute - - X - X describe the arrangements for setting up a Science and Technical Advice Cell (STAC) in - - X X consultation with local Public Health England centres 10.5 identify who will attend the Strategic Co-ordination Group (SCG) - - X X provide a co-chair and secretariat for LHRPs - - X define the roles and responsibilities of LHRP - - X develop plans which demonstrate the command and control of resources from all NHS and of NHS funded within an LRF area to respond to a significant incident or emergency - - X Emergency Services Directorate Page 29 of 36

30 11 corporate and regional offices must also: X assign an area team to each LHRP or LRF X define how strategic EPRR advice and support will be given to these teams X make sure that area team incident response plans in a region are co-ordinated and X compatible 11.4 outline the procedure for responding to incidents which affect two or more LHRPs or LRFs X outline the procedure for responding to incidents which affect two or more regions X define how links will be made between the, the Department of Health and PHE - - X X define how the NHS s ability to respond to emergencies will be measured and controlled X outline how the Department of Health will be supported in its emergency response role X outline how information relating to emergencies will be co-ordinated and shared - - X X establish a link between the Regional Prevent Co-ordinator in the local area and those involved in Protect X will in addition: X Emergency Services Directorate Page 30 of 36