Incident Management Plan

Incident Management Plan

Document Control Version 2 Name of Document NHS Guildford and Waverley CCG Incident Management Plan Version Date 1st October 2016 Owner Director of Governance and Compliance [Accountable Emergency Officer} Author Deputy Director of Governance and Compliance [Emergency Planning Officer] Next Review September 2017 by document Author GPMS [Business in Confidence] Document Location X:\Emergency Planning\Emergency planning\incident Management Plan\GWCCG IMP v2 Sept 2016.docx Purpose To explain how NHS Guildford and Waverley Clinical Commissioning Group will respond to a business continuity incident. NHS EPRR Core Standards require each NHS Funded Organisation to have and maintain an Incident Management Plan Significant change summary since last version Second edition 5.3 - Incident Definitions 7.7.2 Updated Incident Alert levels as defined by revised NHS England EPRR guidance 7.7.3 Involvement of CCG at Tactical Co-ordinating Groups Distribution and Accessibility This document will be made available to all staff via the Intranet The document and any revisions will additionally be e-mailed to all on-call staff. Executive Directors should ensure that relevant staff are aware of the plan and the procedures. Author Contact Details Mark Twomey Deputy Director of Governance & Compliance 01483 405 424 m.twomey@nhs.net INVOCATION OF THIS PLAN The On-Call Manager is responsible for the invocation of this plan. Page 2

Table of Contents Document Control... 2 1. Aim, purpose and background... 4 2. Objectives... 4 3. Scope... 4 4. Planning Assumptions... 5 5. Definitions... 6 6. Invocation and alert levels... 7 7. Decision making... 7 7.1 Joint Decision Making Model... 7 8. Incident Response Group... 11 8.1 Group Composition... 11 8.2 Recording and actions... 11 8.3 Meeting Location... 11 9. Communications... 11 10. Information Governance... 12 11. Specific risks, linking documents for mitigation and response... 13 12. Logging, Reporting, VIPs and documentation... 14 13. Stand-down, Recovery and de-brief... 14 14. Plan Review and Publication... 15 15. Training... 15 16. Acknowledgements... 15 Appendix... 15 Appendix A - Glossary... 16 Appendix B - Incident Response Group Meeting Template... 17 Appendix C Incident Report Form... 18 Appendix D Invocation Flowchart... 20 Page 3

1. Aim, purpose and background 1.1 To explain how NHS Guildford and Waverley Clinical Commissioning Group will respond to a business continuity incident or other incident affecting the operation of the business. 1.2 The plan will align to the expectations as laid out in the NHS England Emergency Preparedness Framework 2015 and the NHS England EPRR Core Standards 2015/16. 1.3 NHS Guildford and Waverley CCG is a category two responder under the Civil Contingencies Act 2004. Under this legislation the CCG has a duty to co-operate and information share with other responders including NHS England, Public Health England, Acute Trusts and Foundation Trusts, which are category one responders. 1.4 This plan is complementary and should be read in conjunction with the CCG Emergency Planning, Resilience and Response (EPRR) Policy, the GWCCG Emergency Response Directory and the Surrey Local Resilience Forum Major Incident Protocol (SMIP). 2. Objectives 2.1 To explain the context of the plan. 2.2 To detail the incident alert levels and how the CCG plans to react and respond at the relevant alert levels. 2.3 To set out how the CCG will plan for, respond to and recover from an emergency, significant incidents or major incident. 2.4 How this plan links to local, regional and national risk registers and maintains continuity of key services when faced with disruption from either an identified local risk or via an internal incident and resume services which have been disrupted. 2.5 Align arrangements where appropriate to the ISO 22301 standard, as required by the EPRR Core Standards and to incorporate where practicable the principles of the Joint Emergency Services Interoperability Principles (JESIP). 3. Scope 3.1 This plan will explain the processes to be used requiring a response to an incident. It is expected that minor disruption will be managed within directorates and business as usual processes. 3.2 This plan covers the areas and activities covered by the organisational business continuity policy. 3.3 This plan and the associated processes may be used to address other situations as necessary so that the CCG can discharge it s duties as required. Page 4

4. Planning Assumptions 4.1 This plan makes the following assumptions: 4.1.1 That the On-call manager will take the leadership in the initial stages of a response. Details and expectation of this role are set out in the organisational on-call protocol. 4.1.2 Other staff may be called upon to support the response should the extent, scale, nature or duration of a given situation be above and beyond the capability of the oncall manager to manage the situation. 4.1.3 If the incident duration passes 72 hours that business as usual resources will take over the running and management of an incident and be directed by the Executive Management Team (EMT) or a suitably appointed lead. EMT, or a nominated Executive Director, will assess the situation at this point and allocate resources going forward to manage the incident if not resolved within 72hrs. 4.1.4 That reasonable assumptions of community risk in the decision making are based on the Surrey Community Risk Register. In 2015/16 the very high risks identified for Surrey included major fluvial flooding, localised flooding of rivers and streams, a pandemic of infectious disease and an epidemic of infectious disease. 4.1.5 CCG staff, including those on-call, will be notified by the Accountable Emergency Officer, or Emergency Planning Officer, of any change in the UK Threat level for which support between local resilience partners maybe required on a dynamic basis either in preparedness or response. The current threat and actions are available on the Security Service website. Page 5

5. Definitions 5.1 The NHS England Emergency Preparedness Framework 20135 defines three types of incident: Business Continuity Incident; Critical Incident and Major Incident. 5.2 Each will impact upon service delivery within the NHS, may undermine public confidence and require contingency plans to be implemented. NHS organisations should be confident of the severity of any incident that may warrant a major incident declaration, particularly where this may be due to internal capacity pressures, if a critical incident has not been raised previously through the appropriate local escalation procedure Business Continuity Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed) Critical 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. Major Incident A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented. For the NHS this will include any event defined as an emergency. 5.3 NHS Guildford and Waverley CCG is a category two responder with the Surrey Local Resilience Forum (SLRF). The SLRF Major Incident Protocol explains how category one and two responders across the forum will respond and recover from incidents at a local level and how these arrangements link into the National Concept of Operations including the relationship, should it be activated, with the Cabinet Office Briefing Room (COBR). Page 6

6. Invocation and alert levels 6.1 Upon realising the extent of a given situation, the on-call director should assess whether the incident reaches the threshold to be declared a significant or major incident. 7. Decision making 7.1 Joint Decision Making Model 7.1.1 The Joint Emergency Services Interoperability Principles (JESIP) doctrine promote the use of the Joint decision making model, depicted below. This model is also supported through the NHS England Emergency Preparedness Framework 2015 and by the College of Policing Multi-Agency Gold Incident Commander s (MAGIC) course which is delivered locally for Surrey s Local Resilience Forum. Page 7

7.2 Actions, Information, Involvement and Mutual Aid Requests 7.2.1 Upon being informed of an incident, the on-call manager should take details of the informant, the time and date of receiving the information, the details of the incident at that point and the expectations of the CCG. The on-call manager should check back with the informant any details to ensure the details and expectations of the CCG have been recorded accurately. 7.2.2 The on-call manager should then, based on the information received, assign an alert level (as per the NHS 2015 EPRR Framework). Incident level Level 1 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Level 2 An incident that requires the response of a number of health providers within a defined health economy and will require NHS co-ordination by the local commissioner(s) in liaison with the NHS England local office. Level 3 An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to co-ordinate the NHS response in collaboration with local commissioners at the tactical level. Level 4 An incident that requires NHS England National Command and Control to support the NHS response. NHS England to co-ordinate the NHS Response in collaboration with local commissioners at the tactical level. 7.2.3 Based on the information received and the alert level designated, the on-call manager will notify the appropriate persons, providers and other stakeholders, including those listed below. 7.2.4 The on-call manager will maintain a log of those notified, the time, date and any delay or messages needing to be left. 7.2.5 The on-call manager may also be required to setup an Incident Control Centre (ICC) at the CCG HQ (Dominion House). The Break-out room of the 3 rd Floor will be used for this purpose as it has a computer, screen, phone line and whiteboards as well as space for additional support. Page 8

7.2.6 For a level 1 incident, the CCG will be expected to lead the incident if required to do so including, if appropriate, the setting up and chairing of a system call. The Emergency Response Directory should be used to activate the required agencies. Agencies, regardless of time of day, should always be activated through their official on-call point of contact. 7.3 Royal Surrey County Hospital 7.3.1 The Royal Surrey County Hospital should be officially notified through their on-call manager via their paging system. The manager on-call should confirm receipt of the notification and call the CCG to discuss next steps. 7.4 Community and Mental Health Providers 7.4.1 NHS Guildford and Waverley CCG has one main community provider Virgin Care Limited. Virgin Care will be notified through their on-call manager. 7.4.2 NHS Guildford and Waverley CCG has one mental health provider Surrey and Borders Partnership NHS Foundation Trust (SABP). SABP will be notified through their on-call manager. 7.4.3 Unless directed to do otherwise, for level 1 incidents, the providers should keep the CCG updated on key significant events or updates. Where the Area Team has become involved, updates maybe directed to NHS England for the purposes of ensuring information is passed to those in command and control of an incident in a timely and effective way. 7.5 Primary Care 7.5.1 NHS England is the commissioner of primary care. The lead responsibility rests with NHS England to contact primary care organisations however the CCG as a Category Two responder may be required to co-operate with NHS England as a Category One responder in discharging necessary actions and messages. Where an incident occurs during working hours, this could be discharged by business as usual lines as this is most likely to achieve a more effective outcome. 7.6 Out of Hours Primary Care 7.6.1 The out of hours primary care service for the CCG area is provided by Care UK. For any incident occurring out of hours, Care UK should be notified through their on-call manager. 7.7 NHS England South (South East) Area Team 7.7.1 NHS England Area Team is the first escalation point for emergencies and incidents. The Area Team provide the leadership in an incident for the NHS and will normally attend any Strategic Co-ordinating Group (SCG) (Gold) meeting if called. 7.7.2 During an incident it is important to keep the Area Team updated on anything of significance as the conduit to other parts of the command structure that may emerge and/or contract in accordance with the needs of an incident. Page 9

7.7.3 Where the incident is of a nature that demands greater levels of co-ordination, the Area Team may set up an Incident Control Centre (ICC), at the Horley HQ. CCG presence may be required, either here or at a partnership tactical co-ordination group, and the on-call manager should consider who best to send if required. Consideration should be given to the duration of the expected presence and consider a rota from the outset. 7.7.4 The Area Team may require support at SCG meetings if required, particularly for longer running incidents. 7.8 Surrey County Council 7.8.1 Surrey County Council operate a Duty Officer, Duty Manager and Duty Director system for emergencies and incidents. All requests for information and services out of hours will be directed through the County Emergency Management Duty Officer. 7.9 Public Health England Kent, Surrey and Sussex Centre 7.9.1 The Public Health England Centre has an on-call system which can be accessed through their on-call manager and the CCG should activate this in conjunction with NHS England as required. 7.10 Surrey Strategic Co-ordinating Group (SCG) 7.10.1 The Surrey SCG when convened will normally be at the Surrey Police Headquarters at Mount Browne, Sandy Lane, Guildford GU3 1HG 7.10.2 If the CCG manager on-call is asked to attend, consideration should be given to taking a loggist or other manager in support. 7.11 Mutual Aid Requests 7.11.1 Mutual Aid requests during times of response will be decided at Executive level. Page 10

8. Incident Response Group 8.1 Group Composition 8.1.1 The Incident Response Group (IRG), will principally be activated for CCG business continuity incidents however this function can be activated for incidents that would benefit from wider co-ordination in support of the on-call manager. The group will normally comprise of a core membership but with additional members as required: One Member of the Executive Management Team (unless already the designated on-call manager) On-Call Manager Deputy Director of Governance & Compliance (unless already the designated on-call manager) or the CCG EPRR Officer Estates and Facilities Manager Head of Information and Performance or deputy, representing the Finance Directorate CCG Communications Manager Deputy Director of Clinical Commissioning or designated deputy Head of Medicines Management A member of the Administration Team (to act as note taker) 8.1.2 The Chair of the Group will normally be the Executive Director unless decided otherwise, with the Deputy Director of Governance and Compliance in attendance or the Emergency Planning Resilience and Response Officer. 8.2 Recording and actions 8.2.1 All meetings and actions of the Incident Response Group will be recorded by a trained loggist. 8.2.2 A generic template agenda should be used which can be found at Appendix B. 8.3 Meeting Location 8.3.1 The designated meeting location will be in the CCG Boardroom unless designated otherwise if Dominion House is available. 8.3.2 In the event that Dominion House is not available, an arrangement is in place for NHS Guildford and Waverley CCG to use the offices of NHS East Surrey CCG. This location can be activated through the NHS East Surrey CCG On-call. 9. Communications 9.1 Incidents may attract media interest and/or other stakeholders. Most communications will be handled by the CCG on-call director to stakeholders. Where media enquiries are involved, the CCG Communications Manager should be advised and will facilitate/ co-ordinate liaison with the media and other stakeholders. Page 11

9.2 Where an incident takes place out of hours, and the Communications Manager is not available, the Deputy Director of Governance and Compliance should be contacted in the first instance, followed by the Director of Governance and Compliance. 9.3 It is likely that incidents that involve media will be classed as level 2 incidents, where the Area Team Communications lead will take the primary ownership of the incident. 10. Information Governance 10.1 At all times, all incidents and emergencies should adhere to CCG procedures around information governance. This includes ensuring use of secure (nhs.net) e-mail accounts, both from and to, and complying with rules around patient identifiable data. Page 12

11. Specific risks, linking documents for mitigation and response All Local Resilience plans are accessible through Resilience Direct. Specific Risk Arrangements in place Action to consider Severe Weather SLRF Severe Weather Plan Actions to be agreed with NHS England Pandemic Influenza GWCCG Pandemic Influenza Plan SLRF Pandemic Influenza Plan Activate GWCCG Pandemic Flu Plan Refer to SLRF Plan Refer to NHS England for dynamic advice at time of incident Fuel Disruption Surge and Escalation Management GWCCG Incident Management Plan SLRF Fuel Plan Activate GWCCG Incident Management Plan Incident Response Group GWCCG Surge Plan Activate GWCCG Incident Management Plan Incident Response Group Infectious Disease Outbreak Evacuation Lockdown Utilities, IT and Telecommunications Failure Surrey LHRP Outbreak Plan SLRF Mass Evacuation CCG has a security Policy and lockdown covered within this plan GWCCG Incident Management Plan Emergency Response Directory SLRF Telecommunications Plan Liaise with NHS England around specific actions Liaise with NHS England around specific actions Liaise with NHS England around specific actions Liaise with NHS England around specific actions Excess Deaths/ Mass Fatalities SLRF Excess Deaths Plan SLRF Mass Fatalities Plan SCC Temporary Mortuary Plan RSCH Business Continuity Plan GWCCG Incident Management Plan Liaise with NHS England around specific actions Page 13

12. Logging, Reporting, VIPs and documentation 12.1 Incidents of all natures will need to be logged by all roles involved. Where appropriate, the on-call director should consider the use of a loggist to ensure all information is captured and decisions can be made in order to ensure the effective and timely response to an incident. 12.2 The Incident report form found at appendix C should be used to note the incident and establish the type and extent. Noting the relevant information the form asks for will help inform the response, information required for decision making and be the basis for the convening of the incident response group in the case of a business continuity incident or a system call for other types of incident. 12.3 Once completed, all incident documentation should be returned to the Estates and Facilities Manager. 12.4 For level 2-4 incidents or other types of incidents for which the Local Resilience Forum is co-ordinating, there may be further reporting required, sometimes daily or even more frequently. Some incidents, where the Cabinet Office Briefing Room (COBR) is in operation will require the completion of a Common Recognised Information Picture (CRIP). The CRIP reports often require information at short notice and may require data and information from providers that the CCG will need to collate. 12.5 During an incident it is possible that VIPs may visit aspects of the response, potentially including the scene of an incident or the co-ordination centre. On notification of any visits, the Chair and Chief Executive should be made aware and NHS England should be advised if not already aware. 13. Stand-down, Recovery and de-brief 13.1 Stand-down for incidents only involving the CCG will be determined by the on-call Director. Incidents where the NHS England Area Team are involved will have a stand-down determined by the Area Team in consultation with other partners. 13.2 From the onset of an incident, consideration should also be given to the recovery phase of an incident and the earliest notification to other partners that may be required so that arrangements can be prepared. Consideration should be considered as an input to Strategic and Tactical Co-ordinating Groups. 13.3 A De-brief following significant incidents should be held as soon after an incident as is reasonably practicable. This will be led by the on-call director but maybe facilitated by other staff not associated with the incident in order to objectively identify best practice and learning outcomes. Page 14

14. Plan Review and Publication 14.1 This plan will be reviewed by the Author and Owner annually or at a point of significant change. 14.2 The plan will be published on the CCG Intranet and Website. 15. Training 15.1 This Incident Management Plan will be used in all exercises to ensure validity and to inform updates and reviews. 15.2 All on-call directors will be trained on the plan as part of their induction and the plan will be made available to all staff via the intranet and advertised accordingly and with any subsequent updates. 16. Acknowledgements 16.1 NHS Guildford and Waverley CCG would like to acknowledge the support of the Surrey County Council Emergency Management Team in helping provide materials in the interests of sharing best practice. Appendix A Glossary B Incident Response Group Template agenda and considerations C Incident Report Form D Invocation Flowchart Page 15

Appendix A - Glossary CCG COBR CRIP EMT EPRR GWCCG ICC IMP JESIP LHRP MAGIC NHS England RSCH SCC SCG SLRF SMIP SCG Clinical Commissioning Group Cabinet Office Briefing Room Common Recognised Information Picture Executive Management Team Emergency Planning, Resilience and Response NHS Guildford and Waverley Clinical Commissioning Group Incident Control Centre Incident Management Plan Joint Emergency Services Interoperability Programme Local Health Resilience Partnership Multi Agency Gold Incident Command The Commissioning Board of the NHS for England Royal Surrey County Hospital Surrey County Council Strategic Co-ordinating Group Surrey Local Resilience Forum Surrey Major Incident Protocol Strategic Co-ordinating Group Page 16

Appendix B - Incident Response Group Meeting Template Agenda / Actions To be chaired by the Executive Director / Director on-call Assign Note taker 1. Introduction of attendees, roles and responsibilities 2. Confirm the nature and extent of an incident 3. Allocate an incident alert level and review as appropriate at subsequent meetings 4. Urgent actions and decisions required 5. Confirm actions agreed 6. Ensure welfare of all staff at all times 7. Confirm resources required to facilitate an effective response 8. Communication with all those involved in the incident and relevant stakeholders are informed and involved 9. Confirm time and date of next meeting 10. Confirm and communicate a stand-down where appropriate 11. Commission a de-brief where appropriate. If holding meeting by teleconference, consider: Participants calling in within a 5 minute window before meeting starts to avoid disruption All participants should engage their mute button when not talking to avoid background noise Follow ABC Be Accurate, Brief and Concise Reminder this is not a normal conference call and the call should last 15-20 mins at the latest. Key Questions: Have staff been affected in any way? (Consideration to the health and safety of staff, contractors and members of the public and patients) Have there been any loss of facilities? (Resources, access to buildings etc) What is the impact if any resources have been affected? Are any other services impacted? Do any other plans need to be activated Who else should be informed and involved? Page 17

Appendix C Incident Report Form INCIDENT REPORT FORM Event / Incident Date Time Person Reporting Contact Number EVENT / INCIDENT INFORMATION Description of Event Including time(s) and location, postcode etc. Person Recording Exec Director notified? Chair notified? Impact What is the effect of the incident on people, premises and provision of service? Are any critical activities affected? ACTION Actions already taken By whom and to what affect Actions needed Include priorities Page 18

COMMUNICATION Who has been notified and when Name and time of those informed Patients and Public NHS ENGLAND ACUTE COMMUNITY OOH PRIMARY CARE MENTAL HEALTH RADIO PRACTICES TWITTER FACEBOOK WEBSITE Other Stakeholders UPDATE Time and date of next update expected CRIP Required? (Date and time) NOTES / COMMENTS Page 19

Appendix D Invocation Flowchart INCIDENT / EVENT / SITUATION On-call Director informed START LOG Other CCG Contact informed Assessment of incident to be made and if necessary escalated to below. **Use Joint Decision Model Process** Confirm date and Time of Incident Take name and contact details of caller Confirm who else has been informed. Is NHS England On-call aware if so, who Confirm expectations of caller What level is the incident? Level 1 Level 2-4 Consider whether the incident can be managed within CCG resources. If so call Incident Response Group Meeting if appropriate and activate Business Continuity Plan If affecting the CCG economy, consider calling teleconference/ meeting with relevant stakeholders Ensure NHS England is aware of incident NHS England Oncall to lead response CCG as Category two Responder to co-operate and support response When Incident is over CONFIRM and COMMUNICATE STAND-DOWN LOGS To be retained for safe and secure keeping by Estates and Facilities Manager Page 20

NHS Guildford and Waverley Clinical Commissioning Group 3 rd Floor Dominion House Woodbridge Road Guildford Surrey GU1 4PU Telephone: 01483 405 450 E-mail: gwccg.info@nhs.net Twitter: @NHSGWCCG Website www.guildfordandwaverleyccg.nhs.uk Page 21