NLG(14)266. DATE 24 June Trust Board of Directors Public REPORT FOR. Wendy Booth, Director of Clinical and Quality Assurance & Trust Secretary

Transcription

1 NLG(14)266 DATE 24 June 2014 REPORT FOR REPORT FROM CONTACT OFFICER SUBJECT Trust Board of Directors Public Wendy Booth, Director of Clinical and Quality Assurance & Trust Secretary Resilience Manager, Trustwide and Operations Centre Manager, SGH Emergency Preparedness, Resilience and Response BACKGROUND DOCUMENT (IF ANY) Civil Contingencies Act 2004 NHS Operating Framework Monitor Compliance Framework NHS England Core Standards for Emergency Preparedness, Resilience and Response NLG(13)185: Emergency Preparedness, Resilience & Response Annual Report for 2013/14 REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Trust Governance & Assurance Committee on 10 June 2014 EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) The report provides assurance on the Trust s Emergency Preparedness & Response arrangements including the work programme for 2014/15 HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? N/A N/A NO N/A ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? NO YES WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? YES THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED ACTION REQUIRED BY THE BOARD Ensures compliance with statutory requirements The Board is asked to note the report and consider the need for any additional actions at this stage

2 1.0 Background and Introduction The Northern Lincolnshire and Goole NHS Foundation Trust (NLAG), in common with other NHS organisations, has a duty to protect and promote the health of the community, including at times of emergency. As a Category 1 responder under the Civil Contingencies Act 2004, the Trust has a legal obligation to plan for and respond to any incident with major consequences for health or health services, in partnership with other parts of the NHS, the emergency services and local authorities. 2.0 NHS Emergency Preparedness, Resilience and Response (EPRR) Assurance Since April 2013, major changes to the health system, announced in the Health and Social Care Act 2012, became fully operational. These changes impacted significantly on current health system arrangements for EPRR. The expectations of NHS England are that acute Trusts: Fulfil relevant legal and contractual EPRR requirements 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 Identify an Accountable Emergency Officer (AEO) to take executive responsibility and leadership at service level Collaborate with local multi-agency partners to facilitate inclusive planning and response Ensure preparedness to maintain critical services in periods of disruption and facilitate NHS EPRR assurance, including business continuity NLAG is designated as a Category 1 Responder under the Civil Contingencies Act (2004) and was required to undertake a self-assessment against the NHS England Core Standards for EPRR during November 2013 culminating in a statement of compliance and an action plan for identified gaps being taken to the Trust Board in December The selfassessment submitted to NHS England via the Trust Board, demonstrated compliance in 96 of the 115 relevant core standards, with the remaining 19 creating the action plan to assure NLAG s state of compliance. Significant progress has been made since the submission against the core standards that were not fully compliant, with nine actions remaining (attached at Appendix A). NLAG s submission was subsequently commended by the Director of Operations and Delivery, North Yorkshire and Humber NHS England Area Team, in a letter dated 18 th March 2014 (Appendix B), stating they were assured in relation to the content of the submission. 3.0 Testing, Training and Working Together with Local Partner Agencies With the introduction of the new Emergency Preparedness, Resilience and Response structure nationally, and the changes to the wider NHS structure (NHS England, Public Health England, and Clinical Commissioning Groups) and the move of provision of local public health from primary care to a Local Authority responsibility, there has been significant changes to the established relationships and responsibilities both locally and nationally. To improve collaborative working and to assure a coordinated response in the event of an incident, NLAG has organised and also participated in several multi-agency exercises throughout the past 12 months. NLAG s commitment to EPRR exercising, training, and the on-going work programme and developments has been recognised by the Director of Operations and Delivery, North Yorkshire and Humber NHS England Area Team, in a letter to the Chief Executive dated 11 th July 2013 (Appendix C). Page 2 of 18

3 In respect of partnership working with Local Partner Agencies, NLAG is represented at the Local Resilience Forum, the Local Resilience Forum s Health Sub-Group, the Yorkshire and Humber Major Incident Practitioners Group, and the Local Health Resilience Partnership. Multi-agency table top exercises have taken place with health and social care partner organisations in both North and North East Lincolnshire to test multi-agency support and mutual aid with a particular focus on winter preparedness and shelter requirements. In December 2013, a multi-agency major incident was declared for the Humber Region due to the tidal surge flooding on the East Coast and associated river systems. NLAG was involved in the multi-agency review of the response in the Humber Region. As per last year s Board Report, there remains an interest from the Trust s Emergency Department staff in improving their knowledge of local industrial risks (Control of Major Accident Hazards (COMAH) sites) with attendance at off-site COMAH exercises continuing. There has been attendance from NLAG at a variety of exercises and training covering a broad range of EPRR relevant topics including developments in NLAG s evolving approach to managing major incidents. An extract from the Training Programme is included at Appendix D. 4.0 Emergency Preparedness, Resilience and Response - Work Programme Significant progress has been made against the original gap analysis (Trust EPRR Board Report 2012/13). Last year saw the introduction of the Emergency Preparedness Steering Group and the Business Continuity Steering Group to ensure a specific focus on the creation of a Business Continuity Management System of which a dedicated intranet-based system has been implemented, consisting of 150 business continuity plans covering over 400 named functions. These plans are supported by Directorate Overview Plans of Critical Functions to aid decision making during service disruptions. As a result of the progress made with business continuity over the last 12 months, this year the Steering Groups have been merged. It is recognised that any service disruption (e.g. major incident) requires both an initial incident management and a recovery response phase. The merged Steering Group will ensure that equal focus is maintained in these two key areas. This year will see a training programme developed that will ensure staff with key roles during a major incident response are confident and competent to carry out their actions, ranging from operational frontline staff (e.g. Switchboard and Emergency Department staff) to the Incident Coordination Centre Team (e.g. Directors, Senior On-Call Managers). The training will comprise of variety of sessions including discussion workshops, table top exercises and live exercises. The EPRR Work Programme (Appendix E) will continue to develop in line with the ever changing guidance and legislation to ensure the Trust maintains its compliance and readiness to respond to an incident. 5.0 Summary and Next Steps In summary, there continues to be a considerable amount of work in developing the Trust s EPRR arrangements. The Trust s EPRR arrangements were scrutinised by East Coast Audit Consortium in their Internal Audit Report, completed during March 2014, demonstrating that the Trust has significant assurance. There maintains a high level of focus and priority nationally and with the developing national guidance due to the expanding range of threats and events which the Trust must be prepared for, it is essential that there is a continued focus on the Trust s emergency preparedness and business continuity arrangements which should be seen as an on-going corporate priority. It is important that the Trust maintains and Page 3 of 18

4 continues to advance the reputation in the EPRR arena that has been developed over the last two years. 6.0 Trust Board Action Required The Board is asked to: note progress during 2013/14, noting the recognition the Trust has received from NHS England (Appendix B and C) note the assurance of progress against the NHS England Core Standards for EPRR Action Plan (Appendix A) note the Training Programme (Appendix D) and the Work Programme (Appendix E) for the coming year 2014/15 Page 4 of 18

5 Appendix A Action Plan for Compliance with NHS England Core Standards for EPRR Action Plan Last Updated: 07/05/2014 Action No EPRR Core Standard Action to be Taken Lead Organisations must maintain a risk - Create a Trust EPRR Risk Register register which links back to the National (as part of the Trust s wider Risk Risk Assessment (NRA) and Community Register) for recording risk Risk Register (CRR) assessments against local and national threats and hazards / Bill Parkinson, Health & Safety Manager [IRP must] have been written in collaboration with all burns, trauma and critical care networks [IRP must] set out how legal advice can be obtained in relation to the CCA [IRP must] demonstrate a systematic risk assessment process in identifying risks relating to any part of the plan or the identified emergency 5 Staff must be aware of the Incident Response Plan, competent in their roles and suitably trained Key knowledge and skills for staff must be based on the National Occupational Standards for Civil Contingencies. Directors on NHS on-call rotas must meet NHS published - National guidance has been published on surge and escalation for specialist networks To be included in Major Incident Plan - Include section on how Trust Solicitors can be contacted for legal advice in relation to the CCA in MIP - Create a procedure for the completion of an EPRR Risk Assessment and maintenance of the EPRR Risk Register - Create and deliver EP training sessions (capturing the MIP) available to all staff - Create and deliver a MIP Table Top exercise for key roles identified within the MIP Action Cards - Develop Training Needs Analysis for key roles within the MIP Resilience Manager Timescale for Completion March 2014 March 2014 March 2014 March 2014 June 2014 June 2014 Update / Date Action Completed Completed Trust EPRR Risk Register created on SHE System Completed Section on specialist networks included in Major Incident Plan v1.1 Completed Included in Major Incident Plan v1.1 On-going Procedure completed and awaiting approval at next EPRR Steering Group Completed 10 key role TNA created and approved at EPRR Steering Group Page 5 of 18

6 competencies [IRP must] explain how extended working hours will apply and how they can be sustained. Explain how handovers are completed [IRP must] 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 [IRP must] have agreements in place with local 111 providers so they know how they can help with an incident [IRP must] consider using helplines in an emergency. Set up procedures in advance which explain the arrangement. Make sure foreign language lines are part of these arrangements [IRP must] explain how VIPs will be managed, whether they are casualties or visiting others who are casualties [Link the IRP to threat-specific incidents] pandemic flu - Include section in MIP on how extended working hours will apply and be sustained - Approve a Communications Strategy which includes the strategy in preparation for, during, and after an emergency - Agree arrangements with 111 provider at regional meeting - Investigate options for using foreign language lines through the Hospital Helpline - Include a section on VIP casualties and visitors in the MIP - Include section within Communications Strategy - Review the requirement for an illness specific plan (Pandemic Flu Plan) Sarah Mainprize, Head of Communications and Marketing Yorkshire Ambulance Service Cath Butterill, IT Services March 2014 Completed Included in Major Incident Plan v1.1 March 2014 On-going Communications Strategy has been approved and issued. SM creating a supporting EPRR Comms protocol March 2014 March 2014 March 2014 August 2014 Completed Escalated at LHRP as current NHS 111 escalation procedures only cover NHS 111 s service provisions and doesn t support other organisations responses. Also escalated at NHS North Lincs 111 Governance Group Completed Helplines available to be issued during a major incident response Completed Included in Major Incident Plan v1.1 On-going National Flu guidance referenced in Major Incident Plan v1.1. Page 6 of 18

7 All NHS organisations and providers of NHS funded care 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 [Business continuity plans must set out] how mutual aid arrangements will be called into use and maintained [Business continuity plans must set out] the insurance arrangement that are in place and how they may apply [Business continuity plans must have] recovery and restoration processes and how they will be set up following an incident [Business continuity plans must set out] how the organisation will respond to the media following a significant incident, in line with the formal communications strategy - Reference the Pandemic Flu Plan in the MIP - Purchase a copy of ISO Bring the BC Policy and BC Plans into line with ISO Discuss at LHRP local arrangements for mutual aid - Create a Significant Incident Plan (SIP) - Include section on insurance arrangements in the SIP - Include section on the recovery stage in the SIP - Approve a Communications Strategy which includes the strategy in preparation for, during, and after an internal Significant Incident - Include section on communications in the SIP Resilience Manager Sarah Mainprize, Head of Communications and Marketing August 2014 March 2014 June 2014 June 2014 New national flu guidance being developed for release late 2014 On-going ISO22301 standards purchased. BC Policy and Plans to be reviewed Completed Mutual aid arrangements discussed at LHRP and confirmed via NHS England Area Team On-going Significant Incident Plan draft created On-going Significant Incident Plan draft created March 2014 On-going Communications Strategy has been approved and issued. SM creating a supporting EPRR Comms protocol Page 7 of 18

8 [Business continuity plans must have] reference to the National Occupational Standards for Civil Contingencies and NHS England competencies when identifying key knowledge and skills for staff [NHS Acute Trusts must also include] detailed evacuation procedures [NHS Acute Trusts must also include] 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 - Develop Training Needs Analysis for key roles within the SIP - Agree evacuation techniques and routes at all Trust premises - Liaise with Humberside F&RS to agree evacuation locations - Create a Hospital Full and Partial Site Evacuation Plan - Include section on patient tracking and process for reuniting with relatives in the Evacuation Plan Bill Parkinson, Health and Safety Manager / Ahmed Hussain, Health and Fire Safety Advisor June 2014 June 2014 June 2014 Completed 10 key role TNA created and approved at EPRRSG (SIP utilises same command structure and action cards as the MIP) On-going Multi-agency meetings taken place with F&RS, Ambulance and Police to discuss evacuation response. Evacuation Plan in development On-going Evacuation Plan in development Page 8 of 18

9 Appendix B NHS England Letter NLAG s EPRR Assurance Page 9 of 18

10 Appendix C NHS England Letter NLAG s Exercising Page 10 of 18

11 Appendix D Date Emergency Preparedness, Resilience and Response Training Programme 2013/15 Training Training Type Provided By NLAG Attendance Multi-Agency 21/04/2013 Op Spring - SGH Live Decontamination Exercise 3 Live NLAG A&E, EP, Ops NLAG, HF&RS, HP, NHS NY&H 11/06/2013 Advanced Casualty Clearing Station (ACCS) Exercise Live YAS EP, A&E YAS, NLAG, NHS Eng, HF&RS 19/06/2013 Heatwave Plan Exercise Table Top NLAG Ops, Comms, Matrons, Pharmacists, EP NLAG 04/09/2013 Partial Site Evacuation Live Northallerton EP NLAG as Observers only Hospital 12/09/2013 Chemical Fatality Multi-agency Training Live Humberside Police EP, A&E NLAG as Observers only 24/10/2013 Astral Climb - Military Nuclear Transport Exercise Live HM Armed Forces EP NLAG as Observers only 25/10/2013 YAS Safety Advisory Seminar Training YAS EP YAS, NLAG, LA, Police 14/11/2013 North Lincolnshire Winter / Surge Exercise Table Top NLAG EP, Ops, Community NLAG, NLC & Therapy 17/12/2013 North East Lincolnshire Winter / Surge Exercise Discussion NEL CCG EP, Ops NEL Health Partners 25/11/2014 Hospital Major Incident Medical Management and Support (HMIMMS) Course ALSG EP Yorkshire & Humber Region Health 06/01/2014 Major Incident Switchboard Cascade Test 1 - Practical NLAG EP, Switchboard NLAG only Office Hours - DPOWH 15/01/2014 Major Incident Switchboard Cascade Test 1 - Practical NLAG EP, Switchboard NLAG only Office Hours - SGH 24/03/2014 EPS Branch Study Day Training EPS EP EPS Branch 28/03/2014 Strategic Leadership in a Crisis Course External Trainer EP, COO Regional Health Partners 25/04/2014 Phillips66 Humber Refinery COMAH Exercise Table Top Phillips66 & LA EP, A&E LRF Mulit-agency 14/05/2014 Loggist Training Session - SGH Training NLAG Loggists NLAG only May-14 Major Incident Switchboard Cascade Test 1 - Out Practical NLAG EP, Switchboard NLAG only of hours - DPOWH May-14 Major Incident Switchboard Cascade Test 1 - Out Practical NLAG EP, Switchboard NLAG only of hours - SGH 02/06/2014 Loggist Training Session - DPOWH Training NLAG TBC NLAG only Page 11 of 18

12 23/06/2014 Loggist Training Session - SGH Training NLAG TBC NLAG only 07/07/2014 Loggist Training Session - DPOWH Training NLAG TBC NLAG only Before Mar- 14 Before Jun- 14 Before Oct- 15 Before Apr- 16 ICC Test 1 - DPOWH Practical NLAG TBC NLAG only ICC Test 1 - SGH Practical NLAG TBC NLAG only Major Incident Training Session Training NLAG TBC NLAG only Major Incident Plan 2 - Table Top Table Top NLAG TBC NLAG only Major Incidnet Plan 3 - Live Live NLAG TBC LRF Mulit-agency Site Evacuation 2 - Table Top - DPOWH Table Top NLAG TBC NLAG only Site Evacuation 2 - Table Top - SGH Table Top NLAG TBC NLAG only Site Evacuation 2 - Table Top - GDH Table Top NLAG TBC NLAG only Site Evacuation 3 - Live Live NLAG TBC LRF Mulit-agency Emergency Blood Stock Shortage 2 Table Top NLAG TBC NLAG only Adverse Weather Exercise 2 Table Top NLAG TBC NLAG only Mass Vaccination / Treatment Plan 2 Table Top NLAG TBC NLAG only Heatwave Plan 2 Table Top NLAG TBC NLAG only CBRN Plan 3 - Live - DPOWH Live NLAG TBC LRF Mulit-agency CBRN Plan 3 - Live - SGH Live NLAG TBC LRF Mulit-agency Page 12 of 18

13 Appendix E Emergency Preparedness, Resilience and Response Work Programme 2014/15 Key: Green - Completed Amber - Within Month of Deadline Red - Overdue Deadline Light Blue - Not Near Deadline Subject Task Deadline Status Notes Chemical, Biological, Radiological and Nuclear (CBRN) CBRN Plan DPOWH Exercise SGH Exercise DPOWH Post- Exercise Report SGH Post- Exercise Report Actions from DPOWH Postexercise Report Actions from SGH Postexercise Report COMAH Data Sheets Carbon Monoxide Exposure Management ICE (Individual Chemical Exposure) Create plan and get approved Live Decontamination exercise at DPOWH Live Decontamination exercise at SGH Create and submit postexercise report Create and submit postexercise report Ensure actions listed in Post-exercise report are completed Ensure actions listed in Post-exercise report are completed Create unrestricted COMAH Data Sheets for EP Website Ensure a consistent multiagency response Multi-agency chemical fatalities and off-gassing patients protocols 31/05/2013 Completed Plan tested during DPOW and SGH exercise. Final version approved at EPSG 04/07/ /10/2012 Completed Exercise successfully met all its objectives and highlighted any gaps in the plan / process 21/04/2013 Completed Exercise successfully met all its objectives and highlighted any gaps in the plan / process 16/11/2012 Completed Report completed. WB presented to Trust Board 31/05/2013 Completed Report completed 31/12/2012 Completed All actions completed 31/07/2013 On-going Actions 7-13 have been completed. Actions 1-6 outstanding for A&E Manager 31/12/2012 Completed All 27 local COMAH site Data Sheets have been created and uploaded onto the EP Website (03/01/13) 01/12/2013 Completed Met with LA / F&R / Police / HPA. ed AE / ECC / MIU regarding training with CCDC at Public Health England. Multi-agency CO2 Exposure Management Protocol created and disseminated throughout the region 01/11/2013 Completed Humberside Police leading working group to test capability to manage chemical fatalities. NLAG attended a live exercise in Rotherham as observers and have participated in the working group Page 13 of 18

14 Incorporate new JESIP guidance into CBRN Plan Ensure appropriate decontamination management inline with developing guidance Awaiting guidance Future Development Major Incident Plan Major Incident Plan Update Major Incident Plan Major Incident Plan Training Session Major Incident Plan Table Top Exercise Review, update and get approved Make minor amendments to plan as detailed in EPRR Action Plan Create an MIP / EP training session and organise dates for through the year Create an MIP table top exercise and organise a dates for delivery at both DPOWH and SGH 31/08/2013 Completed Major Incident Plan approved at 14/11/2013 Emergency Preparedness Steering Group 31/03/2014 Completed Version 1.1 issued 31/06/2014 Future Development 31/06/2014 Future Development Incident Coordination Centre (ICC) DPOWH Major Incident Cupboard SGH Major Incident Cupboard Incident Coordination Centre Manual ICC On-Call Manager Training Loggist Book ICC Documentation Review and ensure sufficiently stocked Review and ensure sufficiently stocked Create manual to aid setup and running of ICC Incorporate ICC brief into On-Call Manager training Create loggist book that can be printed in-house Review and update ICC documentation 31/10/2013 Completed ICC major incident cupboard stocked and checked 31/10/2013 Completed ICC major incident cupboard stocked and checked 31/10/2013 Completed ICC Manual Approved at 14/11/2013 Emergency Preparedness Steering Group 31/03/2014 Completed Major Incident Plan and ICC presentation created for delivery in 2014 On-Call Manager Training 30/04/2013 Completed Agreed at EPSG. Log books in ICC major incident cupboards 31/10/2013 Completed Document templates incorporated into the ICC Manual Page 14 of 18

15 Loggist Training Sessions Train a pool of Loggists On-going Completed Training sessions at DPOWH and SGH booked and volunteers registered for Loggist training EPRR Steering Group Terms of Reference BC Distribution List EP Distribution List Business Continuity Plans Business Continuity Policy Business Continuity Management System Business Continuity Plans Promote Business Continuity in Trust Directorate Critical Services Overview Plans Trustwide Specific Risk BC Action Cards Purchase copy of ISO22301 Review BC Policy and BC Plans Create and get approved 31/01/2013 Completed EPSG and BCSG approved at TGAC. Terms of Reference updated in April 2014 for newly merged EPRR SG Create a distribution list 31/01/2013 Completed from the TOR Create a distribution list 31/01/2013 Completed from the TOR Create and get approved 30/04/2013 Completed Approved at BCSG Agree approach and method for Trust's BCM Create template for BC Plans through Sharepoint Promote Business Continuity in Trust Create Directorate Critical Services Overview Plans Identify what specific risk BC Action Cards are required and create Purchase copy of ISO22301 Check compliance of BC Policy and BC Plans against ISO /04/2013 Completed System created and agreed at BCSG 12/09/2013 Completed BC Plan templates on Sharepoint. Individual Directorate Reps populating plans and now responsible for reviews BC plans now in place covering over 400 named functions 30/11/2013 Completed Trust Inductions, BCSG 31/12/2013 Completed Overview Plan for each Directorate uploaded onto EP webpage 31/08/2014 Completed Electricity Failure BC Action Card approved 31/08/2014 Completed Purchased 31/08/2014 Future Development Page 15 of 18

16 Adverse Weather Adverse Weather Plan (Community Services) Review Community Service impact and incorporate guidance 30/09/2014 Future Development Rest Centres Ensure Appropriate Health Response Planned Create a Rest Centre Plan to ensure appropriate Health reponse to supporting Rest Centres with Ref to LA Plans 30/04/2013 On-going Copy of NL Council's Rest Centre Plan obtained. NLAG plan to be created for support to Rest Centres Heatwave Plan Heatwave Plan Review plan to reduce content and understand Nursing impact 31/05/2013 Completed Heatwave Plan created. Sent out for comments to EPSG. Approved at EPSG 04/07/2013 Heatwave Plan Exercise Table Top Exercise to test the draft Heatwave Plan 20/06/2013 Completed Table top exercise took place on 19/06/2013 at Dining Room, DEC, SGH & Business Continuity Website Create Webpage Upload Documents Work with IT to create webpage and organise libraries Upload all relevant documents at launch of webpage 31/10/2012 Completed EP webpage created on SharePoint, with design focused on quick and easy access for staff 31/12/2012 Completed Induction Training Induction Training Create an EP Induction presentation 31/01/2013 Completed Induction presentation completed and in use Training Program Training Program Create and maintain a structured training program 31/01/2013 Completed Training spreadsheet created within Work Programme Page 16 of 18

17 Mass Vaccination / Treatment Mass Vacination / Treatment Plan Mass Vaccination / Treatment Exercise Update Mass Vaccination Plan Mass Vaccination Exercise 25/03/2013 Completed Approved at EPSG 25/03/2013 Completed NHS England / Public Health / N.Lincs Community Services exercise to test Mass Vaccination Plan conducted on 25/03/2013 Mass Casualties Mass Casualties Plan Create a Mass Casualties Plan for NLAG that is consistent with the Humber Plan Partial or Total Site Evacuation Site Evacuation Plan Site Evacuation Exercise Create a Site Evacuation Plan for partial and total site evacuation Organise and conduct a Site Evacuation Table top Exercise 30/10/2014 Future Development 31/06/2014 On-going Draft in development. Multi-agency meetings to agree multi-agency response have taken place 31/06/2014 Future Development HPA Exercise Template reviewed and will be able to be used after being modified to meet specific requirements for NLAG Trust EPRR Risk Register EPRR Risk Register Procedure for EPRR Risk Assessments EPRR Risk Assessments Create register on SHE 31/03/2014 Completed Trust EPRR Risk Register created on SHE System Create a procedure for the completion of EPRR Risk Assessments Complete risk assessments on SHE Training Needs Analysis (TNA) Training Needs Analysis 31/03/2014 On-going Draft completed. Awaiting approval at EPRR SG on 22/05/ /03/2014 On-going List of risks compiled. Risk assessments to be completed on SHE Create a TNA Template 31/06/2014 Completed TNA's approved at EPRRSG on 27/03/2014 Page 17 of 18

18 Template Complete TNA for Major Incident Plan Complete TNA for Significant Incident Plan Complete TNA for CBRN Plan Complete TNA for Evacuation Plan Complete TNAs 31/06/2014 Completed TNA's approved at EPRRSG on 27/03/2014 Complete TNAs 31/06/2014 Completed TNA's approved at EPRRSG on 27/03/2014 Complete TNAs 31/06/2014 Completed TNA's approved at EPRRSG on 27/03/2014 Complete TNAs 31/06/2014 Future Development Pandemic Flu Plan Pandemic Flu Plan Review the requirement for an illness specific plan 31/08/2014 Future Development Nationally the Flu pandemic response is being reviewed and national exercises to take place in Oct New Flu planning guidance to be agreed and disseminated after this date Significant Incident Plan Significant Incident Plan Create a Significant Incident Plan 31/06/2014 On-going Draft in development Escalation and Surge Management Escalation and Surge Policy Escalation and Surge Management Create Policy 31/12/2013 Completed Policy agreed at Executive Team Create and implement action cards 31/12/2013 Completed Action Cards ed to relevant Managers and incorporated into escalation s Page 18 of 18