South Staffordshire and Shropshire Healthcare NHS Foundation Trust

Transcription

1 South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: Major Incident and Business Continuity Plan GREEN - Corporate New or Replacing: Replacing R/GRE/14v1.0 (2005) Document Reference: R/GRE/co/03 Version No. v2.0 Implementation Date: July 2011 Author: Approving body: Jacqueline Boam Quality, Effectiveness and Risk Committee Approval Date: 14th July 2011 Ratifying body: Trust Board Ratified Date: 25th August 2011 Committee, Group or Individual Monitoring the Document: Review Date: Major Incident Planning Group and the Staffordshire Civil Contingencies Unit August 2014 rolled forward to March 2015 pending completion of review

2 THIS PLAN SHOULD BE READ IN CONJUNCTION WITH THE TRUST S PANDEMIC FLU PLAN AND BUSINESS CONTINUITY PLANS. IF THIS IS A MAJOR INCIDENT, AND YOU ARE NOT FAMILIAR WITH THIS PLAN, DO NOT READ IT NOW GO STRAIGHT TO THE ACTION CARDS IN APPENDIX A All personnel must be familiar with the details of this plan before a Major Incident occurs. All key staff (Executive Directors, Managers, on call Managers and Service Heads) must be aware of its content and associated documentation, e.g. policies, procedures and attending appropriate training sessions. It is imperative that all such staff know and understand the specific role they play in the overall plan and the roles identified in the individual action cards contained in section 6. This Plan and its associated action cards will be held by Service Heads in on call folders. In addition Policy and Procedure documents will be held in the following locations: Directorate of Quality and Professional Practice George Bryan Centre front reception office Ward areas Margaret Stanhope Unit Director of Facilities & Estates office Hospital Co-ordinators office, St George s Hospital Hospital Co-ordinators office, Shelton Hospital Main Trust switchboard A copy of the basic plan minus Action Cards and Contact Numbers is to be included in the Policies and Procedures manuals held throughout (South Staffordshire & Shropshire Health Care NHS Trust) Page 2 of 56

3 Foreword by the Chief Executive Major Incident and Business Continuity Plan/R/GRE/co/03/v2.0 A major incident may occur at any time of day or night. It is vital that we are prepared with the ability to facilitate a co-ordinated range of emergency responses at short notice, providing mid to long-term services to those involved. Those involved will include victims, relatives, friends, and our own staff. As such, civil contingency and resilience issues are considered a priority within South Staffordshire & Shropshire Healthcare NHS Foundation Trust (SSSFT) to aid with the delivery to the populace of Staffordshire and Shropshire along with fellow Staffordshire Resilience Forum (SRF) members. This Major Incident Plan is a generic plan, which sets out operational and managerial arrangements to be undertaken by South Staffordshire and Shropshire Healthcare NHS Trust in the event of a major incident or emergency. It details procedures for activation, and for the alerting and mobilisation of staff. It sets out clear command and control mechanisms and links to regional command and control structures through the Emergency Resilience Management Arrangements for the NHS in the West Midlands. It describes the methods for communicating with the public, local community and partners at the time of a major incident. It also provides for the training of key staff, and the testing and exercising of the plan and supporting procedures in accordance with national guidance. It determines the links with the SSSFT s business continuity planning arrangements and the procedure for maintenance and revision of the major incident plan. The arrangements described in the plan are supported by role specific action cards for key staff. Whilst it is acknowledged that the SSSFT is not a designated responder under the definitions of the Civil Contingences Act 2004, it takes these responsibilities on board as it accepts that it has a role to play during a major incident; it also has obligations to its service users and families to continue to deliver an appropriate and acceptable level of care. The plan is provided in five sections to ease use in response situations. It is made available to all staff via the Trust s Intranet. Unrestricted sections of the plan are available to the public via the Trust s web-site. This plan is for use with effect from 1 May 2011 to ensure continued capability of responding in an emergency or major incident and to fulfill statutory responsibilities. The Civil Contingencies Act 2004 States: A Minister of the Crown in their role as monitoring and overseeing the new civil protection regime may ask any Category 1 or 2 responder to provide information about the action taken under the Act. The Minister may require Category 1 or 2 responders to explain why it has not taken action under the Act. If the Minister considers that a Category 1 or 2 responder has failed to comply with its obligations under the Act, he/she may take proceedings against that responder in High Court. This Major Incident & Business Continuity Plan is built on the principal duties of the Civil Contingencies Act 2004 (CCA) and its accompanying guidance. To this end all personnel must be familiar with the details of this plan before a Major Incident occurs. All key staff (Executive Directors, Managers, on call Managers and Service Heads) must be aware of its content and associated documentation, e.g. policies, procedures and attending appropriate training sessions. It is imperative that all such staff know and Page 3 of 56

4 understand the specific role they play in the overall plan and the roles identified in the individual action cards contained at Appendix A. This Plan and its associated action cards is held by Service Heads in on-call folders. Neil Carr Chief Executive, South Staffordshire & Shropshire Healthcare NHS Foundation Trust Signed: Dated: Page 4 of 56

5 Contents Part Section Topic Page One General Information 1 Policy Framework 8 2 Internal Command and Control Arrangements Operational Level (Bronze Control) Tactical Level (Silver Control) Strategic Level (Gold Control) 12 3 Incident Response and Management Issues for 13 SSSFT 4 Relationship with Business Continuity Planning 14 Two Management, Control and Co-ordination 1 Major Incident Management Arrangements - Internal Gold Control Silver Control Bronze Control Other Directors and Managers NHS Liaison Officers 17 2 Incident Control Room 18 3 Multi-Agency Response 18 Three Activation, Alert and Standby 1 Alerting Phase 20 2 Standby 20 3 Declaration of a Major Incident 20 4 Activation 20 Four Resources and General 1 Staff Response 22 2 Identity Badges 22 3 Shift Systems 22 4 Health and Safety Risk Management 22 5 Staff Support 22 6 Volunteers Database 22 7 Video and Teleconferencing Facilities Alert System 23 9 Protocols for Record Keeping Financial Records Data Sharing People who are Vulnerable in a Crisis Communications Information Media Management Translating and Interpreting Services Helpline Use of NHS Direct Resources and Logistical Support Roles and Responsibilities of other Responder 25 Organisations 21 Equality & Diversity Statement Monitoring Compliance 26 Page 5 of 56

6 Five Recovery and Stand-Down 1 Returning to Normality 29 2 Internal Recovery Arrangements 29 Appendices A Action Cards 30 B Emergency Planning Contact Details 40 C Distribution Internal & External 50 D Examples of major Incidents 53 E Emergency Planning Structures 54 F Incident Log Notification Sheet 58 G Glossary of Terms 59 H Data Sharing Guide 60 I Aide Memoire for OnCall Staff 61 Plan Owner This plan is owned by: Trust Lead for Emergency Planning, Business Continuity and Resilience This Person is responsible for ensuring that this Plan remains up to date. The Plan owner is also responsible for ensuring that the Plan and the resources required are made available for testing and exercising. This Plan is a live document and will be regularly updated. All errors and/or changes should be made known to the Plan owner. The Plan owner is then to ensure that amendments are forwarded to all holders of this document once changes have come into effect. It is the responsibility of individual holders of the Plan to amend their copies of this Plan and record all changes on the amendment control sheet. It is the responsibility of the Plan owner to amend the Major Incident Control Room copy of the Plan. To report errors and/or changes or amendments to this document, contact the above named individual by the following means: Telephone: jackie.boam@sssft.nhs.uk Page 6 of 56

7 Acknowledgements South Staffordshire and Shropshire Healthcare NHS Foundation Trust wishes to thank members of the Staffordshire Resilience Forum, the Shropshire Resilience Forum and the Staffordshire Civil Contingencies Unit. The Roles and Responsibilities of Non Acute Trusts Core responsibilities for NHS organisations are described in the NHS Emergency Planning Guidance The roles and responsibilities described in this section are specific to non Acute Trusts. It is acknowledged that non Acute Trusts are not formally designated responders within the definitions of the Civil Contingencies Act However, it is considered good practice for non Acute Trusts to comply with the requirements of the Act. The responsibility of this Trust is to plan for its response to a major incident with major consequences for health or health services in partnership with other parts of the NHS, the emergency services and local authorities. We will participate in appropriate planning groups and forums will take into account our responsibilities for vulnerable groups of people including children. The potential contribution of South Staffordshire and Shropshire Healthcare NHS Foundation Trust may include: Support to victims of an incident including NHS Staff Provision of staff Provision of facilities Provision of capacity Provision of equipment South Staffordshire and Shropshire has also made the appropriate arrangements to ensure each essential clinical and non clinical area has their own business continuity plans which include recovery and restoration. Mental Health Trusts and other providers of mental health services potentially have specific responsibilities in the event of a major incident including: Linking with Primary Care Organisations locally and other NHS services in coordinating services Co-ordinate and directly provide the psychological and mental health support to staff, patients and relatives in conjunction with Social Services Advise on the long term effects of trauma on the casualties associated with the incident and recommend the appropriate level of psychological intervention required Ensure that mental health patients caught up in the incident are discharged home with appropriate support in the community from Community Mental Health Teams and Crisis Teams or their equivalent. As an NHS organisation with responsibility for provision of services to Prison Health Care Services we will consider and plan for the potential impact of a major incident on the population in prison and the ability of that organisation to provide those services. Page 7 of 56

8 Part ONE General Information 1. Policy Framework 1.1 Aim The aim of this plan is the set out how South Staffordshire and Shropshire Healthcare NHS Trust (SSSFT) will manage its response to a major incident. 1.1 Objectives The objectives of this plan are to: Set out SSSFT s roles and responsibilities in the event of a major incident and establish a framework within which these can be fulfilled; Define what a major incident is and outline the types of emergency that the SSSFT might be expected to respond to; Identify the potential hazards that SSSFT faces locally; Outline the command, control and co-ordination arrangements both internally, in the NHS and in the multi-agency context by identifying other key stakeholders and operational plans, including the decision making process; Provide assurance that the SSSFT has robust business continuity plans in place, written in accordance with the current national standard BS25999 and the Civil Contingencies Act; Identify the arrangements for communicating information to staff, patients and stakeholders both prior to, during and after a major incident; Set out the process for recovery from a major incident. 1.2 Legal Framework The Civil Contingencies Act 2004 establishes a statutory framework of roles and responsibilities for local responders. The CCA 2004 is supported by Regulations (The CCA 2004 (Contingency Planning) Regulations) and statutory guidance (Emergency Preparedness). Core responsibilities for NHS organisations are described in the NHS Emergency Planning Guidance 2005; for the SSSFT, the underpinning Guidance for Non Acute Trusts and Foundation Trusts including specialist Trusts applies. Whilst it is acknowledged that the SSSFT is not formally designated as a responder within the definitions of the Civil Contingences Act 2004, it is considered good practice for non Acute and Specialist Trusts to comply with the requirements of the Act. 1.3 Roles & Responsibilities SSSFT is responsible for planning a response to a major incident with major consequences for health or health services, in partnership with other parts of the NHS, the emergency services and local authorities. The potential contribution may include: Support to victims of an incidents including NHS staff; Page 8 of 56

9 Provision of staff; Provision of facilities; Provision of capacity; Provision of equipment. Major Incident and Business Continuity Plan/R/GRE/co/03/v2.0 SSSFT is also responsible for ensuring that it has business continuity plans in place to ensure that core mental health services are provided and maintained at safe levels. The Chief Executive is responsible for assuring this policy is implemented within the Trust. The Director of Business and Development is responsible for: The development, monitoring and review of this plan and practice standards The provision of appropriate training to support the implementation of the plan. The Trust Lead for Emergency Planning is responsible for: Ensuring the general awareness of the Plan and associated actions throughout the organisation and that a system of testing is in place and applied. Developing the training curriculae and co-ordinating the delivery of the training programmes in Clinical Major Incident Planning The Emergency Planning/Business Continuity Group that monitors the implementation of this policy and reports to the Quality Effectiveness and Risk Committee. Service Directors, Clinical Directors and Service Managers are responsible for: Implementation and monitoring of this plan in their areas of responsibility Ensuring that systems and processes are in place and monitored to meet the requirements outlined in this plan The undertaking of appropriate training and education to support the plan implementation should it be enacted. Team leaders, departmental heads, ward and unit managers are responsible for: Ensuring that all appropriate employees in staff are aware of the Major Incident Plan and it s physical location within their area of work. Trust employees are responsible for: Ensuring awareness of the content of this policy SSSFT has further specific responsibilities in the event of a major incident, including: Linking with NHS Staffordshire, Shropshire and Telford & Wrekin locally and other NHS services in coordinating services; Leading and providing advice on the provision of psychological and mental health support to staff, patients and relatives in conjunction with Staffordshire and Shropshire County s Council social services departments, primary care providers and third sector organisations; Page 9 of 56

10 Advising on the long term effects of trauma on the casualties associated with the incident and recommending the appropriate level of psychological intervention required; Ensuring that mental health service users caught up in the incident are discharged home with appropriate support in the community from Community Mental Health Teams or their equivalent; Working with the PCT and Staffordshire & Shropshire County Councils to assess the effects of the incident on vulnerable care groups, such as those with mental health needs and learning disabilities; Proactively communicating information to all staff and ensure relevant guidance and advice is available; Continuing to provide core mental health services at safe levels; Maintaining liaison with the Strategic Health Authority through the West Midlands Emergency Resilience Management Arrangements (ERMA); Working with local authorities, other NHS Trusts and the community to support the recovery phase; Preserving all plans and documentation used or produced during the course of the response; Preparing a post-incident report Defining a Major Incident The CCA 2004 defines an emergency as: An event or a situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. The definition is concerned with consequences rather than the cause or source. For the purposes of this definition, an event or situation threatens damage to human welfare only if it involves causes or may cause: Loss of life; Human illness or injury; Homelessness; Damage to property; Disruption of a supply of money, food, water, energy or fuel; Disruption of a system of communication; Disruption of facilities for transport; or Disruption of services relating to health. For the NHS, major incident is the term in general use. However, the term emergency may be used instead of incident. For the NHS, a major incident is defined by the Department of Health as: Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance Trusts or primary care organisations. Page 10 of 56

11 The NHS is accustomed to normal fluctuations in daily demand for services. Whilst at times this may lead to facilities being fully stretched, such fluctuations are managed without activation of special measures by means of established management procedures and escalation policies. It therefore follows that a major incident is any event whose impact cannot be handled within routine service arrangements. What is a major incident to the NHS may not be a major incident for other responding agencies. SSSFT can therefore declare a major incident when its own facilities and/or resources or those of partner organisations are overwhelmed. A major incident may arise in a variety of ways and the SSSFT response will be sufficiently flexible to assess and respond appropriately to any of these situations. Examples Big Bang A serious transport accident, explosion, incident at a SSSFT site or series of smaller incidents Rising Tide A developing infectious disease epidemic, or capacity/staffing crisis Cloud on the Horizon A serious threat such as a major chemical or nuclear release developing elsewhere and needed preparatory actions Headline News Public or media alarm about a personal threat Internal Incidents Anything that affects the TRUST s ability to deliver services such as fire, breakdown of utilities, major equipment failure, hospital acquired infections, violent crime Deliberate Release Chemical, biological or nuclear materials Mass Casualties Casualty numbers that are beyond the capacity created by the local implementation of major incident plans or other major disruptive challenges to the delivery of health care, regardlessof their cause Pre-planned Major Events Major events that require planning, such as sports fixtures, mass gathering of people, demonstrations etc. 1.5 Risk Profile The potential hazards that may affect the communities of South Staffordshire, Shropshire and Telford & Wrekin have been identified, assessed and the ranked according to severity of potential impact and the likelihood of occurrence, and can be found on the LRF s Risk Register. The Risk Register takes into account national and regional hazard assessments mirroring the National Capabilities programme. SSSFT is represented on the Staffordshire Local Resilience Forum and the West Mercia Local Resilience Forum.. This plan is designed as an all risks generic plan to manage the operational responsibilities of SSSFT, and manage the delivery of mental health services during a major incident. 1.6 Functional or Hazard Specific Plans In addition to this Plan, SSSFT has a number of other functional emergency plans. These plans cover a range of activities, which may be needed to support the overall response structure. These are all contained in the Incident Control Room, Trust HQ. These plans include: SSSFT corporate Business Continuity Plan and associated service area business continuity plans 9 from October 2011); Page 11 of 56

12 SSSFT Pandemic Influenza Contingency Plan; SSSFT Communication Policy Other Supporting Health Plans include: Winter/ Capacity Plan Drinking Water Contamination Serious crime in hospital Systematic Laboratory error Communicable Disease outbreaks Smallpox Outbreak Plan Heatwave Plan Radiation Plan Shropshire and health economy pandemic influenza plan Pandemic flu communication and engagement plan for Telford & Wrekin & Shropshire West Midlands local resilience forum plan Meir Tunnel Major Incident Plan Foot and Mouth Disease Response Plan Major Accident Hazard Pipelines Emergency Plan Railway Incidents Plan Major Incident Handbook Temporary Mortuary Plan Chemical, Biological, Radiological & Nuclear Incident (CBRN) Plan 2. Internal Command and Control Arrangements In South Staffordshire and Shropshire NHS Foundation Trust we have three internal levels of Incident Control. 2.1 Operational Level (Bronze Control) The Operational Level of control is represented by those individuals who operate on the ground. This level can be; wards, clinics and other departments. The Operational Level will consider the extent of the problem(s) and concentrate upon specific tasks within their areas of responsibility. The Bronze Commander will usually be the senior member of staff at the scene but usually he/she will be subject to police or fire service primacy as the incident dictates. 2.2 Tactical Level (Silver Control) The Silver Tactical Level of command and control (Silver Control) will be responsible for enacting the strategy/policy agreed by the Gold Control. Membership of Silver Control will consist of senior managers from within the Trust, for instance, Directorate/Divisional Managers, Directorate Accountant, Head of Communications, Corporate Heads of Service. Silver Control may be location specific for instance the establishment of a Shropshire Silver Control. The Silver Commander will be the Chief Operating Officer (in office hours) or the Hospital Coordinator (outside office hours). Silver Control will be usually co- located near to Gold Control and will act as the main conduit for information transfer between Bronze and Gold Controls. Page 12 of 56

13 The purpose of the Tactical Level of management (Silver Control) is to: 2.3 Strategic Level (Gold Control) The Gold Control will consist of the Major Incident Gold Commander, usually the Chief Executive and other Executive Directors, Heads of Service, Senior Managers as necessary and/or appropriate. The purpose of the Strategic Level of management (Gold) is to: Establish a framework of policy within which Silver/Bronze Incident Control Teams will operate Set media strategy Give support to the Silver/Bronze Incident Control Teams by providing resources. Give consideration to the prioritisation of demands Liaising with other Trusts/organisations for mutual aid Determine plans for the return to a state of normality following the stabilisation of the incident 3. Incident Response and Management Issues for SSSFT Directors and Senior Managers will be expected to support the Gold and Silver Commanders during the response to a major incident, and endeavour to ensure the delivery of critical services. This support is expected whether the incident affects the Trust alone or involves a number of other health economy organisations. During the early stages of an incident, Directors and Managers (Gold and Silver Control) must be aware of staffing levels and seek information regarding the length of time the incident may be expected to last. This may be difficult to assess and the worst case scenario should be planned for. When a Major Incident is declared by SSSFT, the Gold Control Team will convene in the Chief Executive s office and set the strategic objectives for the Trust, develop the Media Strategy and carry out the longer term identification of support and resources necessary as well as liaison with other organisations. The Silver Control Team will consist of senior managers who will deal tactically with any incident and will be based within the Incident Control Room, Mellor House, and Stafford. All normal management arrangements are over-ruled for the duration of the incident. To create capacity to deal with the incident the Silver and/or Gold Control Team may: Draw resources (e.g. staff) from any area of the SSSFT s business; Scale down any SSSFT service, or Suspend any area of SSSFT business. Given the roles and responsibilities of the SSSFT during a major incident there is likely to be an on-going commitment to the provision of psychological and mental health services which will extend beyond the initial response into the medium to long term. The Chief Executive will review decisions about resources in consultation with SSSFT s Senior Management Team, Trust Board and the PCT. SSSFT has a duty both to respond to a major incident and also to maintain its normal business activities during the major incident as far as is reasonably practicable. This may involve difficult decisions which seek to balance differing priorities. The ICT will be Page 13 of 56

14 assisted in these decisions by emergency plans developed to deal with specific types of incident and by SSSFT s corporate Business Continuity Plan and associated service area recovery plans. N.B. Police primacy In the United Kingdom the principle of police primacy means that the police will be the organisation in ultimate charge of the incident, over the other organisations that may attend. Limited exceptions to this occurs if the incident involves a fire or other dangerous hazard, in which case the fire service will have overall charge of the area inside the inner cordon where fire fighting or rescue is taking place and railway accidents, where primacy (if there is no apparent evidence of serious criminality) will lie with the Rail Accident Investigation Branch. 4. Relationship with Business Continuity Planning Whilst this plan deals with the organisation of the necessary response to (normally) rapid on-set emergencies or disasters, SSSFTT s corporate Business Continuity Plan and associated service area recovery plans deal with the continuity of services during times of crisis, be it a crisis created by an emergency, such as failure of power or water supply, or service disruption such as loss of a supplier. SSSFT s corporate Business Continuity Plan, prepared in accordance with the BS standard, details the services that SSSFT considers to be critical. Although SSSFT s service area recovery plans aim to minimise disruption to these services as far as possible, it is possible that some routine or non-urgent services will need to be delayed, suspended or delivered by alternative means. It is also possible that critical services may face disruption and resources will have to be re-prioritised in order to deliver them. Decisions about service provision will not be made unilaterally as decisions in one area will have knock-on effects on other services and sectors. Service Managers will be responsible for activating their service area recovery plans in a timely manner. The ICT will oversee the provision of critical services and take decisions on the reduction or suspension of non-critical services if necessary after consulting the PCT and/or SHA. Command and Control Arrangements in the event of a health economy wide incident are detailed at Appendix E. Part TWO Management, Control and Co-ordination 1 Major Incident Management Arrangements - Internal Within the Trust, the Director of Business Development is the Lead Director responsible for emergency planning. However, final responsibility for emergency planning rests with the Chief Executive, in line with the NHS Emergency Planning Guidance The Director of Business Development is supported by the Trust Lead for Emergency Planning, Business Continuity and Resilience. Routine on-call management arrangements are detailed at Appendix E. Page 14 of 56

15 1.1 Gold Control The Trust s response to a major incident will be managed by its Gold Control Team, convened by the Major Incident Gold Commander from available Directors, Associate Directors, Senior Managers plus other staff of SSSFT. This may mirror the Executive Management Team. The Major Incident Gold Commander will normally be the Chief Executive but in his absence the role will be assumed by the Executive Director On-Call. Gold control will: Ensure that SSSFT meets its responsibilities under the DH Emergency Planning Guidance 2005; Determine SSSFT s strategic aim and objectives, and review them regularly; Decide if the Incident Control Room is required; Make an initial assessment of the situation and determine the key staff/organisations with which to establish communications; Assess the potential impact of the incident on mental health services; Establish a framework for the overall management of the incident, considering response in the short, medium and long term and the recovery phase; Formulate and implement an integrated media policy; Identify vulnerable communities in conjunction with the PCT and Staffordshire and Shropshire s respective County Council s and develop plans to support their needs, activating functional plans where appropriate; Ensure access to any necessary expert advice; Co-ordinate staff welfare, and ensure that there is long-term resourcing and expertise for management resilience. Where requested to do so, deploy a Liaison Officer to represent SSSFT on the PCT s Incident Control Team; Determine the need for SSSFT Liaison Officers to provide communication links between multi-agency co-ordinating groups or control points; Maintain a log of on-going events and decisions made for briefing, debrief and public inquiry; Decide when the incident is over and stand down SSSFT s response; Ensure that any lessons learned are incorporated into future incident response arrangements and an incident report (where appropriate) is written. The Gold Control Team will be chaired by the Major Incident Gold Commander and is likely to include Directors, Business Unit Leads and other senior managers. Action Cards, which detail the roles of key Gold Control members and other staff with a specific role to play, are included at APPENDIX A. Depending on the nature of the incident, the Major Incident Commander may wish to co-opt external organisations onto the ICT; these might include: South Staffordshire, Shropshire and Telford & Wrekin Acute Hospitals Trusts; South Staffordshire, Shropshire and Telford &Wrekin NHS Provider Services; West Midlands Ambulance Service; Health Protection Agency, Health Protection Unit West Midlands; Staffordshire and Shropshire County Councils Strategic Health Authority through the ERMA Level 2 Commander. Page 15 of 56

16 1.2 Silver Control Team The Silver Control Team is made up of seniors managers who deal tactically with any incident, The Team may request the attendance of specialists from within the organisation, such as HR, Finance, and Estates & Facilities to provide advice on specific aspects. Silver Control will be lead by the Chief Operating Officer and their remit is to: Ensure that SSSFT meets its responsibilities under the DH Emergency Planning Guidance 2005; Make an initial assessment of the situation and determine the key actions which need to be taken Assess the potential impact of the incident on mental health services; Establish a framework for the overall management of the incident, considering response in the short, medium and long term and the recovery phase; Ensure access to any necessary expert advice; Ensure the delivery of SSSFT s critical services to agreed levels; Maintain a log of on-going events and decisions made for briefing, debrief and public inquiry; Ensure that all staff who have been involved in the response to the incident are debriefed. 1.3 Bronze Control Team The Bronze Control Team will consist of those Managers closest to the incident and will usually be those staff heading up the service and/or department involved. These personnel will primarily be involved with managing the incident at close quarters, evacuating patients and so forth. 1.4 Other Directors and Managers All senior managers should as far as possible seek to: Release staff from their normal duties or call in staff to resource the response to the incident as directed by Silver Control; Consider future input should the incident last beyond a few hours (e.g. rest periods and rotation of staff); Deliver SSSFTs critical services in accordance with the corporate Business Continuity Plan and service area recovery plans; Consider vulnerable communities that are directly or may be affected by the incident. 1.5 NHS Liaison Officers As well as supporting the response within the local NHS economy, SSSFT may be expected to contribute to the multi-agency response. The Gold Control Team will determine the need for SSSFT Liaison Officers to provide communication links between multiagency co-ordinating groups or control points and the Trust. The requirement for such support will normally be coordinated by ERMA. 2 Incident Control, Room (ICR) Page 16 of 56

17 SSSFT has a designated incident control room (ICR) at its HQ at Mellor House, Corporation Street, Stafford. The room is a functioning Board Room on the first floor within the Executive Suite. If, for whatever reason, this room is unavailable there are a further two designated ICR room. he designated area within Shelton Hospital, serves as a locality based ICR. The room is located within the Darwin Suite and is a functioning administrative resource room. A further room has been designated within the Learning Centre & Network, Corporation Street, Stafford. Each of the ICR s contains a Major Incident Resources cupboard. Further details are included within Appendix A. Each of the ICR areas has a number of adjoining spaces available for use as break-out rooms. 24/7 access procedures and the set up arrangements for the rooms are detailed in APPENDIX A and are held by Executive and Second Level on-call within the on-call pack. The Second Level on-call will be responsible for setting up the ICR. 3 Multi-Agency Response SSSFT may also be expected to contribute to the multi-agency response. Where the response to a major incident extends beyond the health economy within South Staffordshire, Shropshire and Telford & Wrekin, the Emergency Resilience and Management Arrangements for the NHS in the West Midlands (ERMA) will be activated. More details about ERMA can be found at Appendix E. 4 Initial Response and Staff Roles 4.1 Switchboard Switchboard will Take the initial call Take as much detail about the incident as possible Immediately contact the Chief Executive and/or the Executive on call Relay the information received about the incident The Switchboard ACTION CARD is at APPENDIX A 4.2 Chief Executive/Executive Director On-Call Whatever the cause or nature of a major Incident, the Chief Executive or, out of hours, the Executive Director on-call assumes the responsibility of the Gold Control Commander. He/she has the responsibility for ensuring that the Trust is able to respond appropriately. The Chief Executive/Executive Director on-call is responsible for strategic control of the overall response and for consulting and cooperating with the Strategic Health Authority, other NHS agencies and other responding agencies. Initial actions to be taken are: Conduct an internal risk assessment Call out the Gold Control Major Incident Response Team. Convene a meeting of the Gold Control Response Team Page 17 of 56

18 Assume strategic control of the overall response Chair meetings of the Gold Control Incident Response Team Agree on the location(s) for dealing with the incident (Shropshire and/or Stafford) Open the dedicated Major Incident Room or establish an alternative Response Centre Agree on roles, initial tasks and distribute appropriate Action Cards. The Gold Control Commander ACTION CARD is at APPENDIX A. Part THREE Activation, including Alert and Standby 1. Alerting Phase Any staff member may be alerted by either external or internal sources to the possibility of a NHS major incident. For external sources the routes of notification are normally through the Ambulance Service or local authority emergency planning officers. All staff should notify their respective Directorate/Divisional Director or if out of hours the Senior Manager on call if they believe there is the possibility of a major incident, who after an initial assessment should notify the Chief Executive, or the Executive on-call out of hours. The major incident alert report (APPENDIX F refers) should be used to keep a record of all telephone contacts, their names, contact numbers and the time of call and substance of message. Upon being notified of a potential major incident the Chief Executive or Executive oncall should assume the role of Major Incident Gold Commander and either place SSSFT on STAND-BY or decide on the ACTIVATION of this plan. 2. Stand-By This alerts the organisation that a major incident may need to be declared. Major incident standby is likely to involve making preparatory arrangements appropriate to the incident, and the Major Incident Gold Commander should consider calling together the key staff to make an assessment of the current situation, and consider any immediate actions that are needed. Placing individuals and key staff on Standby provides time for them to come to a state of readiness in preparation for a co-ordinated response. It is far better to be ready to respond to an incident than initiate procedures after a major incident has been declared. 3. Declaration of a Major Incident If the incident is considered to be of sufficient size or complexity, the Major Incident Gold Commander should declare a major incident, convene the Gold Control Team (calling in other Directors and Senior Managers to populate the team) and maintain effective liaison with partner agencies. Page 18 of 56

19 When declaring a major incident, the ERMA Level 2 Commander must be informed refer to APPENDIX B for contact numbers. 4. Activation Any staff member can request activation of this plan. The Major Incident Gold Commander should establish the nature of the incident, the potential roles of the SSSFT and the contact details of key colleagues / organisations. In the absence of the Chief Executive during the working day, the oncall Director of SSSFT will assume this role. Part FOUR Resources and General 1. Staff Response When staff become aware that a major incident may be declared, they should check the Trust s intranet pages for the latest information. Staff at home should not attempt to contact the Trust either in person or by telephone. Staff not involved in the incident should assume normal duties unless instructed otherwise by the Trust. Senior Management who become aware of a possible major incident should place themselves on stand by and await further contact from the Gold or Silver Control Team. 2. Identity Badges All staff will be expected to wear their SSSFT identification badges for access to buildings and through police cordons, and to provide assurance to the public. 3. Shift Systems The principals of SSSFT s Guide to the Working Time Regulations apply. In an emergency situation, it will be important to ensure that staff continue to receive appropriate rest breaks. Until confirmed as not required, the Incident Control Room Manager/Business Continuity Lead will identify and manage staffing levels for Incident Control Room administrative support and organise a rota or shift system for loggists/minute takers. During a prolonged incident, issues such as catering, rest periods, duty and travelling time should be monitored. Certain situations may be very demanding and stress levels will also need to be considered. 4. Health and Safety and Risk Management SSSFT s Health and Safety Policy, and associated policies and procedures apply. This includes the need to conduct formal written and/or dynamic visual risk assessments. All staff must take reasonable care of their own health and safety and that of others, and report any concerns to their own manager, or the Major Incident Co-ordinator. 5. Staff Support Page 19 of 56

20 SSSFT s Sickness Policy and Guidelines applies. Staff can access support through the Occupational Health Service, who will refer to appropriate medical support or counselling as appropriate. 6. Volunteers Database In the main, SSSFT relies on staff volunteering to assist in a major incident situation for the important roles of Loggist and Minute Takers. The Emergency Planning Lead maintains a volunteers database of staff (plus any relevant skills) from the Trust that would be prepared to be called in during an emergency. This information is held by the Emergency Planning Lead. 7. Video and Teleconference Facilities In order to facilitate the business of SSSFT during a major incident, video and telephone conferencing facilities are available to be used, in addition to face-to-face meetings. 8. alert system SSSFT has a generic Alert process which is used to cascade public health links and alerts. This system will be utilised to communicate and cascade information to staff during a major incident. 9. Protocols for Record Keeping Record keeping assists decision makers in reaching a reasoned, lawful and justifiable decision at the time of a major incident. Written records may be required as evidence and/or as the basis in litigation (which includes coroner s inquests and public inquiries). Good record-keeping serves a further purpose, whether or not there is a formal inquiry. It allows lessons to be identified and made more widely available for the benefit of those who might be involved in future incidents. SSSFT must therefore preserve all plans and documentation used or produced during the course of the emergency response (for a minimum of seven years). Records include very rough contemporaneous written notes, a computer generated log, hand written log, video footage, photographs or any other item that acts as a diary of events e.g. cassette tape from a hand held tape recorder. It is the responsibility of Loggists and Minute Takers to ensure a robust record of events is taken and specific training has been provided to volunteers on the data base. During an incident, the following actions must be taken: Suspend any procedures for destroying both archived files and current documents. Only lift the suspension when procedures are in place to ensure incident records are not accidentally destroyed. Keep an accurate log of information received, decisions made (with the justification for those decisions) and actions taken. Ensure that records are maintained of media management issues. After an Incident the following actions must be taken: Page 20 of 56

21 The Gold Major Incident Commander will collect and collate all documents relating to the incident and identify a person to ensure records are secured and access restricted (this would usually be the Information Governance Manager or equivalent); As required, staff will receive professional advice regarding making written statements; Consider the need for witness training for relevant staff; Consider the need for legal representation. 10. Financial Records Each directorate is required to keep an accurate record of expenditure incurred as a result of the emergency. Expenditure should be allocated to the following specific cost code to ensure accountability can be shown. Cost Centre, TBA All receipts and time sheets should be held in accordance with the Protocols for Record Keeping at section 9 above. 11. Data Sharing Although the Data Protection Act 1998 is the key law governing data protection, secondary legislation in the form of the Civil Contingencies Act 2004 gives clear legal power to share information. The correct management of information is vital in an emergency. Data Protection and Sharing provides concise guidance on data protection and sharing in emergency situations. APPENDIX H provides a guide to enable SSSFT to make an informed decision on whether to share data when there is insufficient time to seek professional advice. 12. People who are vulnerable in a crisis Vulnerable groups is used as a collective term for a wide range of individuals who face particular disadvantage in accessing mainstream public services, including the NHS and social care. Vulnerable individuals known to health and social services (e.g.an older person with mobility problems) will continue to rely on these services during a major incident situation and it may be difficult to sustain their normal levels of care. However, while all people caught up in an emergency could be (and in some circumstances will be) defined as vulnerable due to their proximity to the event, planning and response arrangements should focus on those who are assessed as not being self-reliant and may require external assistance to become safe. 13. Communications Communications during the incident should be clear, concise and constructive. SSSFT will make the most of available technology to deliver communications. SSSFT s Communications Policy applies. The Head of Communications has overall responsibility for notifying appropriate parties (staff, service users, carers, media and members of the Page 21 of 56

22 public) that an incident has occurred and for keeping those parties updated on the status of the incident, and any implications that this might have on the provision of services. 14. Information The Information Team, working with the Chief Operating Officer and Directorate Leads is responsible for collating information about the status of services in order that the ICT is able to make appropriate and timely decisions. They should also act as a focal point for incoming information and ensure it is complete, accurate and current. 15. Media Management During normal working hours, all media enquiries will initially be directed to the Chief Executive s office where the Chief Executive will decide on who is to respond and the nature of that response. It will not necessarily be the Chief Executive who will personally prepare such a response, but rather the Executive Director who is best placed to act on behalf of the Trust e.g. the Medical Director. Occasionally, other senior colleagues with particular or specialist knowledge may be asked by the Chief Executive to respond on behalf of the Trust. Outside normal working hours, the Executive on-call should be contacted and, depending upon the circumstances, will either respond at the time on behalf of the Trust, or report the matter to the Chief Executive the following day. Where a press release is prepared, it will be the responsibility of the Chief Executive, or other senior colleague acting on his behalf, to agree the wording of any such release, as and when appropriate, with other NHS and external organisations (e.g. the PCT or the County Council) who may be implicated. In some circumstances, it will be important for the Chief Executive to agree the wording of any press release, prior to its publication, with the Chairman. In all circumstances, copies of all formal press releases should routinely be made available to all Board members. 16. Translation and Interpreting Service The Trust s Translation Policy applies. 17. Helpline For some major incidents, SSSFT may decide to provide psychological or mental health support through a helpline facility. This may be for members of the public involved in an incident, or for NHS staff or staff from other organisations involved in the response to an incident. This is likely to be a 2 tiered approach. The first tier will receive all initial calls and will be operated by people with a basic knowledge of the incident and with the skills necessary to deal with concerned members of the public. First tier operators should have the option of referring a caller to the second tier, where more detailed information and in depth discussion can take place. The second line operators must have some detailed knowledge of the specific problem. SSSFT will identify a helpline coordinator to establish the helpline and ensure that all telephone operators have the necessary information. Helpline operators will be kept upto-date with information and events by the helpline coordinator. Page 22 of 56

23 18. Use of NHS Direct On many occasions it may be more appropriate to establish a helpline through the services of NHS Direct. The appropriateness of this should be decided by the ICT. The helpline coordinator should establish contact with NHS Direct and familiarize themselves with their potential use in incidents. 19. Resources and Logistical Support Any equipment required to maintain the function of the Incident Control Room or at locations where SSSFT has deployed staff is to be requested via the Control Room Manager, who will endeavour to obtain the item(s) as expediently as possible. 20. Roles and Responsibilities of Other Responding Organisations Further details on the roles and responsibilities of multi-agency Category 1 and 2 responders are contained at Appendix E. 21. Equality & Diversity Statement South Staffordshire and Shropshire Healthcare NHS Foundation Trust firmly believes that equality of opportunity and of diversity is vital to its success and an essential prerequisite to achievement of its goals in delivering the best possible care that is accessible, appropriate and responsive to meeting the diverse needs of individuals. In working towards the achievement of our goals it is ever more important that staff (potential and existing), users of our service are treated equitably, with dignity and respect, involved and considered in every aspect of changes affecting their employment or health care within the Trust Monitoring Compliance This policy will be reviewed bi annually or earlier in light of new national guidance or other significant change in circumstances. Compliance with this policy will be monitored through the mechanisms detailed in the table below. Where compliance is deemed to be insufficient and the assurance provided is limited then remedial actions will be drawn together through an action plan. This progress against the action plan will be monitored at the specified committee/group. The results of the audits will be escalated to the appropriate committee/group where appropriate. In addition to the below, reviews of lessons learned from incident and investigation reviews are carried out on an ad-hoc basis by the Risk Management Department. This information will be used to provide sight into compliance with this policy and used to highlight any areas of non-compliance. Where the policy has not been followed and implemented appropriately actions are to be taken. 1 Equality and Diversity Policy d6d945eb56db/h-blu-dr-03.aspx Page 23 of 56