SUMMARY REPORT 1.15.98 (11) TRUST BOARD 26 November 2015 Subject Prepared by Approved by Presented by Emergency Preparedness, Resilience and Response (EPRR) Provider Assurance Process 2015 Matthew Overton, Emergency Planning Lead Paul Bostock, Chief Operating Officer and the EPRR Committee, TMC Operational Performance, Governance Committee Paul Bostock, Chief Operating Officer Purpose This report highlights the position RCHT has assessed itself against following the Emergency Preparedness, Resilience and Response provider assurance process 2015. This follows a review process lead by Kernow CCG in conjunction with NHS England Area Team. Receive Approve x x Trust Objectives Quality Preferred Provider Partnership Workforce Sustainability Finance X X X X Executive Summary NHS Trusts are designated as Category 1 Responders under the Civil Contingencies Act (2004) and are required to undertake a self-assessment against the core standards as set out in the NHS England EPRR Core Standards Matrix. This report sets out the current RCHT compliance against the EPRR Core Standards, the required actions and delivery time frame to address shortfalls. The trust is required to declare this position statement via the Trust Accountable Emergency Officer (AEO) at the Devon, Cornwall and Isles of Scilly Local Health Resilience Partnership (LHRP) on the 9 th December 2015. Key Recommendations 1. For the Trust Board to approve for the AEO to make a return of partially compliant for RCHT at the LHRP on the 9 th December 2015. 2. For this action plan and associated EPRR work to become part of business as usual for monitoring and oversight by the Emergency Preparedness, Resilience and Response (EPRR) Committee. 3. To ensure there are adequate funds for the work to be carried out to ensure the Trust is fully compliant against the core standards going forward. Assurance Framework The report identifies key risks and mitigating action to ensure that the Trust is fully compliant with the NHS England EPRR Assurance Framework and fulfils the legal requirement contained within the Civil Contingencies Act and Health and Social Care Act.
Next Steps For the Emergency Planning Lead and Divisions to undertake any actions required in the timeframe identified to ensure the Trust is fully compliant against the Core Standards. Corporate Impact Assessment CQC Regulations Outcome 4: the care and welfare of people who use services, outcome 6: co-operating with other providers and outcome 16: assessing and monitoring the quality of service provision. Financial Implications Legal Implications Equality & Diversity Workforce and Staffing Performance Management Communication Civil Contingencies Act and Health and Social Care Act. Acronyms / Terms used in Report CQC - Care Quality Commission BIA Business Impact Analysis BCP s Business Continuity Plans CBRN Chemical Biological Radiological and Nuclear (terrorist related contamination) CRR - Corporate Risk Register EPRR Emergency, Preparedness, Resilience and Response HAZMAT Hazardous Material (accidental contamination) IOR Initial Operational Response LHRP Local Health Resilience Partnership LRF Local Resilience Forum SWASFT South Western Ambulance Service Foundation Trust Page 2 of 8
Emergency Preparedness, Resilience and Response (EPRR) Provider Assurance Process 2015 Report 1. Summary The NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) are the minimum standards which NHS organisations and providers of NHS funded care must meet. Royal Cornwall Hospitals Trust is required annually to assess its performance against the Assurance Framework and issue a position statement against the set criteria. 2. 2014 Assurance Process In 2014 the Royal Cornwall Hospitals Trust self-assessed as being partially compliant against the Assessment Framework. Of the 96 criteria: 64 were compliant (green), 32 were partially met (amber) and 0 were non-compliant (red). At the time of the 2015 Assurance Process, the following themed areas were still outstanding from the 2014 Assurance Process: The CBRN/HAZMAT Decontamination Plan is out of date, training has not been delivered to sufficient numbers or a specifically required group of people (receptionists). Minor equipment is still missing and hasn t been procured in the last 12 months and work required in the decontamination room has not been completed. There are insufficient risk assessments in place and no routine preventative maintenance is carried out on equipment. Not all on-call managers or directors have received relevant training and do not have CPD in place. The Pandemic Flu and Severe Weather Plans have not been updated or ratified. 3. 2015 Assurance Process The 2015 Assessment Framework has 94 outcomes that relate to acute hospital provider compliance. It is recommended that Royal Cornwall Hospitals Trust should self-assess as being partially compliant against the Framework. The breakdown of compliance/noncompliance is as follows: 67 compliant (green), 27 partially met (amber) and 0 non-compliant (red). Of the partially met criteria, 12 relate to CBRN/HAZMAT preparedness, 12 relate to plans that need to be updated or amended (only 1 plan is completely absent) and the remaining 3 relate to training. Page 3 of 8
4. Conclusions By 31 March 2016 the Trust aims to be fully compliant against the 2015 EPRR Assurance Process. The needs to temporarily take over responsibility for the CBRN/HAZMAT decontamination work stream to ensure immediate measures are completed on problematic areas to ensure compliance. This is to include financial responsibility for CBRN/HAZMAT costs. Similarly pandemic flu needs to come under the responsibility of EP for planning purposes only. 5. Recommendations The Trust notes the current position of organisational compliance with the Emergency Preparedness, Resilience and Response (EPRR) Provider Assurance Process 2015 and provides a position statement to the Local Health Resilience Partnership of partially compliant. The Trust Board supports the Emergency Planning Lead in implementing the actions outlined in Appendix 1 to ensure full compliance is met. Page 4 of 8
Appendix 1 - EPRR Assurance Framework Action Plan 2015 Action No: Core Standard Ref: Criteria Action Responsible Completion Date RCHT Compliance Status 1 5 Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions. 2 8 Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. 2nd chase up email has gone out to BCP authors directly asking them to review and return. 3 rd chase up email likely to be needed. As above. Decontamination Plan ratified at November EPRR Committee. For presenting at TMC Operational Performance on the 18 th Nov. with assistance from Paul Bostock, AEO BCP's and BIA's are reviewed annually. Plans contain reference to CRR risks. Poor compliance on 2015 BCP annual review process at present. Business Continuity Strategy and divisional plans in place but some overdue review. Decontamination Plan in place however needs updating. Was ratified at TMC Operational Performance in Oct 15. Oct-15 Severe Weather Plan for winter 2015/16 needs ratification. Plan ratified at EPRR Committee in November and for presentation at TMC (Operational Performance) on the 18th. Pandemic Flu Plan currently being reviewed.
3 9 Ensure that plans are prepared in line with current guidance and good practice. 4 11 Arrangements include how to continue your organisation s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical. 5 12 Arrangements explain how VIP and/or high profile patients will be managed. 6 16 Those on-call must meet identified competencies and key knowledge and skills for staff. 7 34 Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents. 8 37 Preparedness ensures all incident commanders (on-call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation. Revised mass casualties section of Major Incident Plan to be tested at Exercise Puffin Devil in November. Signed off at EPRR Committee in Nov. Draft Evacuation Plan about to be circulated for consultation. Revised Business Continuity Strategic Plan signed-off at EPRR Committee in Nov. As above Ratified at TMC Operational Performance. 1 st date scheduled for 27 th November. Mop-up session likely to be required. Training dates to be scheduled. Training and Exercising Passport not ratified at TMC Operational Performance. ESR to be utilised instead. Feb-16 Oct-15 Mar-16 Oct-15 Mass Casualties covered in Major Incident Plan and Escalation Plan but not in sufficient detail. Fire evacuation strategy in place but further evacuation plan does not exist. BCP's don't follow national accepted format and will need amendment. BIA and BCP's need to clearer identify critical activities. VIP policy needs sign-off. Not all staff trained. TNA exists but decontamination training and Silver/Gold training needs further scheduling. Training and Exercising Passport awaits ratification. Page 6 of 8
PANDEMIC FLU DEEP DIVE 9 DD1 Organisation have updated their pandemic influenza arrangements to reflect changes to the NHS and partner organisations, as well as lessons identified from the 2009/10 pandemic including through local debriefing. 10 DD2 Organisations have developed and reviewed their plans with LHRP and LRF partners. 11 DD4 Organisations have taken their plans to Boards / Governing bodies for sign off. HAZMAT/CBRN 12 38 There is an organisation specific HAZMAT/ CBRN plan. Plan ratified at November EPRR Committee and then presented at TMC Operational Performance. Tested at Exercise Mallard and has undergone external consultation. Plan ratified at November EPRR Committee and then presented at TMC Operational Performance. Plan signed-off at EPRR Committee in November and to be presented at TMC Operational Performance. Matt Overton, Sep-15 Plan has been drafted and currently being consulted on with interested parties within RCHT. Will be tested at Exercise Mallard. Final draft will be consulted on with appropriate partner agencies. Plan will be signedoff by EPRR Committee. Current plan needs updating. 13 40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation. 14 41 Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7. 15 42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7. 16 46 There is a preventative programme of maintenance (PPM) in place for the maintenance, repair, calibration and replacement Included in updated plan. All ED staff will be trained on a rolling basis. Other staff groups identified for training. Included in updated plan. Plan is to expand EPRR budget to transfer these costs from ED. Barbara Monk, Deputy COO and Matt Mar-16 Mar-16 Risk assessment will be incorporated into revised plan. It would be ideal to train all ED nursing staff so that rota issues will not be required. Currently contained in Major Incident Plan but will be transferred to revised and updated CBRN plan. Business case will be put forward for tent PPM contract with manufacturer. Page 7 of 8
of out of date decontamination equipment. Overton, EP Lead Business case will be put forward for cost of suit renewal. 17 49 Internal training is based upon current good practice and uses material that has been supplied as appropriate. Training package to be updated, further training dates to by scheduled by ED. and Simon Doble, ED CBRN Lead for training package revision, Mar-16 for majority of ED staff to be trained Current training package will incorporate Initial Operational Response - IOR principles. 20 staff have had initial training but only 7 staff have had refresher training in 2015. 18 51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant. IOR awareness training has been delivered to ED/UCC front of house staff. IOR has been incorporated into ED wet decon training. HAZMAT/CBRN EQUIPMENT 19 E3 Decontamination unit or room 7k funding available, awaiting estates to action minor work required to ensure this room is fully fit for purpose. Work to start in December 2015. 20 E15 Entry control board (including clock) Ordered and in place. Mar-16 IOR will be incorporated into 'wet decon' CBRN nurse training. IOR awareness training to be delivered to receptionists. Decontamination room available to handle a few casualties, some improvement needed. Not available at present. 21 E25 Signage Awaiting delivery. 22 E26 Tabbards identifying members of Ordered and in place. the decontamination team Not available at present. Not available at present. Page 8 of 8