Version: v1.2 Date: February Mark Riley - Emergency Planning Officer Kenny Laing - Deputy Director of Nursing

Transcription

1 Corporate Major Incident Policy and Plan Document Control Summary Status: Replacement. Replaces: Major Incident and Business Continuity Plan Version: v1.2 Date: February 2016 Author/Title: Owner/Title: Mark Riley - Emergency Planning Officer Kenny Laing - Deputy Director of Nursing Approved by: Trust Management Team Date: October 2015 Ratified: Trust Board Date: October 2015 Related Trust Strategy and/or Strategic Aims Implementation Date: Provide high quality. Recovery focused services and Deliver regulatory, financial, performance and quality standards. November 2015 Review Date: November 2018 Key Words: Associated Policy or Standard Operating Procedures business continuity; major incident; emergency planning Divisional, Directorate and Team business continuity plans Version Dates Amendments 1.0 October 2015 Final Draft 1.1 December 2015 NHS England EPRR Framework Update 2015 included. 1.2 February 2016 Access to Mellor House (Out of Hours) included.

2 Major Incident Plan

3 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: ST. GEORGE S HOSPITAL Chief Executive s office, Mellor House Reception, Mellor House Hospital Co-ordinator Hatherton Centre Reception THE REDWOODS CENTRE Crisis Resolution Office THE GEORGE BRYAN CENTRE Reception CASTLE LODGE (Part Building Only) Crisis Team & Criminal Justice Liaison only. 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) 3

4 Contents Part Section Topic Page One General Information 1 Policy Framework Aim Objectives Legal Framework Roles & Responsibilities Defining a Major Incident Emergency Lockdown of Trust Buildings Risk Profile Functional or Hazard Specific Plans 16 2 Internal Command and Control Arrangements Operational Level (Bronze Control) Tactical Level (Silver Control) Strategic Level (Gold Control) 17 3 Incident Response and Management Issues for 18 SSSFT 4 Relationship with Business Continuity Planning 19 Two Management, Control and Co-ordination 1 Major Incident Management Arrangements - 21 Internal 1.1 Gold Control Silver Control Bronze Control Other Directors and Managers NHS Liaison Officers 23 2 Incident Control Room 23 3 Multi-Agency Response 23 4 Initial Response and Staff Roles Switchboard Chief Executive/Executive Director On-Call 23 Three Activation, Alert and Standby 1 Alerting Phase 26 2 Standby 26 3 Declaration of a Major Incident 26 4 Activation 26 Four Resources and General 1 Staff Response 28 2 Identity Badges 28 3 Shift Systems 28 4 Health and Safety Risk Management 28 5 Staff Support 28 6 Loggist Database 28 7 Video and Teleconferencing Facilities Alert System 29 9 Protocols for Record Keeping Financial Records 30 4

5 Five 11 Data Sharing People who are Vulnerable in a Crisis Communications Information Media Management Access to Mellor House Out of Hours Translating and Interpreting Services Helpline Use of NHS Resources and Logistical Support Roles and Responsibilities of other Responder 34 Organisations 21 Equality & Diversity Statement Monitoring Compliance Cyber Security 34 Recovery and Stand-Down 1 Returning to Normality 37 2 Internal Recovery Arrangements Stand-down Procedures Debriefing 38 Appendices A Action Cards 39 B Emergency Planning Contact Details 52 C Distribution Internal & External 62 D Examples of major Incidents 64 E Emergency Planning Structures 65 F Incident Log Notification Sheet 70 G Glossary of Terms 71 H Data Sharing Guide 72 I Aide Memoire for On-Call Staff 73 5

6 Foreword by the Chief Executive 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 NHS England Management Arrangements for the NHS in the North 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 29 th October 2015 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 6

7 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 at Appendix A. This Plan and its associated action cards is held by Service Heads in on-call folders. Neil Carr 7

8 Plan Owner This plan is owned by: Trust Lead for Emergency Planning, Business Continuity and Resilience and Trust Accountable Emergency Officer (AEO) assisted by Trust Emergency Planning Officer (EPO) 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: kenny.laing@sssft.nhs.uk mark.riley@sssft.nhs.uk 8

9 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 (CCU). The Roles and Responsibilities of Non Acute Trusts Core responsibilities for NHS organisations are described in the NHS Emergency Planning Guidance This Guidance replaces and supersedes the original NHS Emergency Planning Guidance : 3/dh_ pdf 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. 9

10 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. 10

11 PART ONE General Information 11

12 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. 1.2 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 international standard ISO and the Civil Contingencies Act 2004; 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. 1.3 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 organisation s are described in the NHS Emergency Planning Guidance 2011; 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. This plan takes account of the NHS England Emergency Preparedness Resilience and Response Framework Update 2015 in that SSSFT recognizes the need to be compliant with the requirements of the NHS England and the Clinical Commissioning Group Emergency Preparedness Resilience and Response (EPRR) Core Standards as part of the annual national assurance process. 1.4 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; 12

13 Provision of staff; Provision of facilities; Provision of capacity; Provision of equipment. 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 (Trust AEO) 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 curricula 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. Trust Security Management Specialist is responsible for: Producing Lockdown Risk Profiles for all in-patient areas of the Trust and to provide any specialist security related guidance and/or direction in relation to the implementation of this Policy or the Trust s response to a major incident. 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: 13

14 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 organisation s; 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 CCG s, NHS England 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; 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. 1.5 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 14

15 types of casualties as to require special arrangements to be implemented by hospitals, ambulance Trusts or primary care organisation s. 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 organisation s 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, regardless of their cause Pre-planned Major Events Major events that require planning, such as sports fixtures, mass gathering of people, demonstrations etc. The NHS England Emergency Preparedness Resilience and Response Framework Update 2015 defines three levels of incident escalation: 1. Business Continuity Incident 2. Critical Incident 3. Major Incident A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. Including and not limited to: Capacity Incidents Business Continuity Incident 15

16 1.6 Emergency Lockdown of Trust Buildings In line with its responsibility to ensure a safe and secure environment, NHS Protect has developed guidance to explain the planning and execution of a lockdown in NHS healthcare sites, which will usually be either primary or secondary care Trusts in England. Recognition is also given to the law of the land in respect of Civil Contingencies Act 2004, Public Health Act and articles 5 (Right of Liberty) and 12 (Right to Marry and family) of the Human Rights Act. The Trust will develop plans and procedures based on such guidance to achieve hospital lockdown: to prevent freedom of entry/exit and movement to a site or other specific Trust building or area, in response to an identified risk, threat or hazard that might impact upon the security of patients, staff and assets or indeed the capacity of a Trust facility to operate. Defining site/building lockdown The execution of Emergency Lockdown procedures are designed to be implemented as part of a major incident response or in such a high risk situation as highlighted within this Policy document. It should however be recognised that there will be occasion where an individual in-patient area may be required to restrict egress from the building as a result of a local risk being identified. Such guidance in these circumstances is contained within Trust Locked Door Procedures. For the purpose of this procedural guidance, a Lockdown is defined as follows: A Lockdown is the process of controlling the movement and access both entry and exit of people (staff, patients and visitors) around the Trust or other specific trust building/area in response to an identified risk, threat or hazard that might impact upon the health and safety/security of patients, staff and assets or, indeed, the capacity of that facility to continue to operate. A lockdown is achieved through a combination of physical security measures and the deployment of personnel. It is important to note that in locking down the Trust there are three key elements: preventing the entry, exit and movement of people the Trust or in a building or part of a building. In preventing the entry, exit or movement of people, or a mixture of the three, the overarching aim of implementing a lockdown is to either exclude or contain staff, patients and visitors. A lockdown is the process of preventing freedom of entry to, exit from or movement within the Trust. In this way, the Trust can either contain or exclude staff, patients or visitors. Supporting the overarching objective of excluding or containing staff, patients or visitors, a lockdown may be characterised as a partial (static or portable), progressive or full lockdown. A partial lockdown can be defined in a number of ways. In most instances, a partial lockdown is the locking down of a specific part of the Trust or a specific building or part of a building. A partial lockdown is also when entry restrictions are placed on a specific building to control the flow of people into it via identification checks for 16

17 example. This is also known as 'controlled access' to a site or building. On these occasions, the partial lockdown can also be characterised as being static - i.e. the partial lockdown is sustained at a specific part of the Trust or building and it remains there. Any decision to implement a partial lockdown will usually be the initial response to an incident. A partial lockdown which may originally have been static in nature may evolve into a portable lockdown. A portable lockdown is when an on-going lockdown is moved from one location of the Trust to another. A progressive lockdown, which can also be called an incremental lockdown, can be a step-by-step lockdown of a building in response to an escalating scenario. A full lockdown is the process of preventing freedom of entry to and exit from either the entire Trust or from a specific building. Lockdown Risk Profiles In line with guidance issued through NHS Protect the Security Management Specialist will develop lockdown risk profiles (including site floor plans) for all inpatient areas of the Trust on the St. Georges Hospital and Redwoods Centre sites and all other satellite inpatient areas such as the George Bryan Centre. All completed risk profiles shall be held within the Major Incident response file and Site Co-ordinator/Duty Nurse Manager File and will form an integral part of any response the Trust and partner agencies implements as a result of a major incident occurring. Implementing Lockdown It will be the specific responsibility of the appropriate person within the Bronze, Silver or Gold Command arrangements in line with major incident response guidance, or the Site Co-ordinator/Duty Nurse Manager in circumstances outside of a major incident response, to make the formal decision to implement any lockdown procedure as previously highlighted. Testing Lockdown The implementation of Lockdown procedures will be tested on sample in-patient areas every 6 months under the direction of the Security Management Specialist and Duty Nurse Manager/Site Co-ordinator. Feedback from such sample testing will be fed back to the Major Incident & Business Continuity Group and The Safety Committee to ensure effective governance arrangements are maintained. 1.7 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 17

18 manage the operational responsibilities of SSSFT, and manage the delivery of mental health services during a major incident. 1.8 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. 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) & HAZMAT Plan Ebola 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. 18

19 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. 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 Liaise with CCG s and NHS England 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 organisation s. 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 organisation s. 19

20 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, CCG s and NHS England. 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 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, SSSFT 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 ISO 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 CCG. 20

21 Command and Control Arrangements in the event of a health economy wide incident are detailed at Appendix E. 21

22 PART TWO Management, Control and Co-ordination 22

23 1 Major Incident Management Arrangements - Internal Within the Trust, the Accountable Emergency Officer (AEO) is the lead 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. 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 2011; 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/organisation s 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 CCG S AND NHS England 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 NHS England Incident Control Team; Determine the need for SSSFT Liaison Officers to provide communication links between multi-agency coordinating 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. 23

24 Depending on the nature of the incident, the Major Incident Commander may wish to co-opt external organisation s 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 (WMAS); Public Health England (PHE) Health Protection Unit West Midlands; Staffordshire and Shropshire County Councils NHS England Area Team Control Room. 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 DoH Emergency Planning Guidance 2011; 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. 24

25 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 coordinating groups or control points and the Trust. The requirement for such support will normally be coordinated by NHS England. 2 Incident Control, Rooms (ICR) 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 or it is deemed more acceptable to hold the ICR elsewhere, there is an alternative designated ICR room, which is the Facilities and Estates Resource Room within the Wenlock building, Redwoods Hospital, Shrewsbury. Each of the ICR s contains sufficient equipment to facilitate an ICR. 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 (Gold On Call) and Second Level on-call (Silver) within the on-call pack. The Second Level on-call (Silver) 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, then the NHS England interoperability arrangements will be activated. 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 (Strategic) 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 CCGs other NHS agencies and other responding agencies. 25

26 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 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. 26

27 PART THREE Activation, including Alert and Standby 27

28 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 on call 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 coordinated 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. When declaring a major incident, the on-call CCG and NHS England Representative should 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 / organisation s. In the absence of the Chief Executive during the working day, the on-call Director of SSSFT will assume this role. 28

29 PART FOUR Resources and General 29

30 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. Access to Mellor House out of Hours Outside of normal office hours, Mellor House, Trust HQ, will be secured and alarmed; to gain access outside of these hours, it will be necessary to contact the Hospital Site Manager via the switchboard, who will arrange for the on-call Estates Engineer to attend and open up the building and deactivate the alarms. 3. 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. 4. 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. 5. 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 Coordinator. 6. Staff Support 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. 30

31 7. Loggist 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 Trust Company Secretary maintains a list of staff who are trained and prepared to act as Loggists in an incident. Minute takers will be appointed as required. 8. 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. 9. 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. 10. 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: 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); 31