Emergency Preparedness, Resilience and Response Quarter 1&2 Report: April - September 2014

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1 Preparedness Resilience and Response Quarterly Report Q1&Q2 Preparedness, Resilience and Response Quarter 1&2 Report: il - September Introduction The NHS needs to be able to plan for, and respond to, a wide range of potential disruptions and emergencies that could impact health, patient care and/or the delivery of the Trust s critical and essential services. The programme of work associated with this planning is referred to in the health community as Preparedness, Resilience and Response (). This report is the Quarter 1&2 report to the Trust Board This update sets out to: inform the Board about the internal and external assurance processes in place to reassure the Board and our external auditors that the Trust processes are robust; and to provide an update to the Board on the Trust s Work Programme. 2. Trust Structure for The Trust s Interim Director of Operations is the Accountable Executive Officer (AEO) with strategic responsibility for across the Trust and for providing assurance to the Trust Board that the organisation meets its statutory and legal requirements. In the absence of a permanent appointment, this role is currently held by the Interim Director of Operations, Janet Phipps. In addition to the strategic oversight provided by the AEO the trust has identified Chris Snow as the Non-Executive Director to have within his portfolio. The Divisional General Manager for Services, Sharon Hinsley, has the operational lead responsibility for and is supported on a full time basis by an Preparedness Officer. Since the last quarterly update, the Preparedness Officer, Annette Crew, has retired and left the Trust. Following a successful round of external recruitment, this role has now been filled by Ben Collins, who joined the Trust on the 21 st July Each Head of Department (HOD) has responsibility for within their teams and services and are accountable to their line managers, Divisional General Managers and Executive Directors. 2.1 Preparedness, Resilience and Response Board The Board met once during the period on the 6 th May The key issues were: Remaining actions resulting from last year s submission were taken forward, including the development of a Communications and Media Strategy for Major Incidents; and Services Directorate Page 1 of 12

2 Preparedness Resilience and Response Quarterly Report Q1&Q2 Updates were received from the Local Health Resilience Partnership and Local Resilience Forum. The Board is next due to meet on the 15 th October Month Preparedness, Resilience & Response Work Programme September 2014 March 2016 Since starting in post, the Preparedness Officer has undertaken a full review of the Trust s emergency plans and procedures and used this to inform the development of an 18 month Work Programme (See Appendix 1) that will take the Trust up to il The new Work Programme includes: a full review of the Trust s emergency plans and procedures, to ensure all plans are up to date and in line with national guidance, regional and local plans, and the. work to ensure that relevant information to support a response to an incident (such as plans, policies, procedures and contact lists) can be readily accessed by those staff that require access; a full review of the equipment and facilities used to support the Trust s emergency plans and procedures. This includes the Trust s four identified Incident Coordination Centres as well as equipment to support a Chemical, Biological, Radiological, Nuclear or Explosive response; a full training needs analysis for all staff across the Trust and a programme of training to ensure staff have received the right level of training to correspond to their roles; a schedule of emergency exercises, to ensure the Trust s plans are robust and fit for purpose; active engagement with local Category 1 and Category 2 responders; and action to ensure that the Trust is able to provide full assurance against all 60 of the current. This Work Programme (attached) will be overseen by the Board and updates provided to the Trust Board as part of its existing quarterly reports. 4. Training 4.1 Tactical Leadership in a Crisis course All Executive Directors and out of hours on-call managers are required to complete the Strategic Leadership in a Crisis Course. In addition, the out of hours on-call managers, duty and Clinical Site Managers are required to complete the Tactical Leadership in a Crisis course. These courses are designed to equip staff with the skills to manage the Trust response to a significant or major incident. Services Directorate Page 2 of 12

3 Preparedness Resilience and Response Quarterly Report Q1&Q2 Tactical Leadership in Crisis training was held on Friday 4 July and attended by 8 senior on-call staff and Clinical Site Managers who may be required to fulfil the role of Incident Manager or another core role within the Incident Response Team. The Trust is holding a final Tactical Leadership in a Crisis training event on 11 th September and is due to be attended by a further 10 staff from the Trust. 5. Incidents 5.1 Quarter 1 Incidents There are no incidents to report from Quarter Quarter 2 Incidents At the time of writing, there were no incidents to report from Quarter planning 6.1 Maintenance projects From September 2014 through to March work is being undertaken to replace both passenger lifts at North Devon District Hospital. Work has been undertaken by the Capital Management Team, in liaison with the Preparedness Officer and other teams to ensure disruption from this work is kept to an absolute minimum. 6.2 Industrial Action Unite healthcare workers will be balloted between 26 August and 26 September on industrial action, in a dispute over pay. The union joins Unison, GMB and the Royal College of Nursing, who have all stated an intention to ballot around that time and carry out any industrial action during the autumn. To ensure disruption is kept to an absolute minimum, a planning meeting, led by the Workforce Team is being held at the beginning of October Severe weather forecasts and alerts The Preparedness Officer receives regular weather forecasts and severe weather alerts from the Met office. These are cascaded to Heads of Department and where there is risk of substantial impact and travel disruptions, to all staff. Where sufficient notice is given of severe weather, a pre-planning meeting is arranged with both the duty and on-call staff, as well as Clinical Site Managers to make sure contingency arrangements are in place and communication cascades reviewed. 7. Testing and Exercising There were no exercises scheduled for either Quarter 1 or 2. Services Directorate Page 3 of 12

4 Preparedness Resilience and Response Quarterly Report Q1&Q2 8. plans The Trust s plans are currently under review, as per the 18 Month Work Programme. 9. External multiagency meetings During Quarter 1 and 2, the Trust has been represented at the following meetings: The Local Health Resilience Partnership (quarterly meeting); The Local Resilience Forum Monthly On Thursday meetings; The Local Health Resilience Group (quarterly meeting). 10. Ebola Introduction Dr Sarah Pinto-Duschinsky, Director of NHS Operations & Delivery sent a letter to Trust Chief Executives & Accountable Officers to ensure that Trust Boards are given assurance around Ebola identification, Personal Protective Equipment and Fit Testing Programmes. The driver for this request surrounds the current Ebola outbreak in West Africa. Whilst the Ebola outbreak is ongoing, and is expected to last for several months, NHS England continues to assess the risk to the UK and the NHS as being very low. This is as a result of the UK and NHS having much better infrastructure to manage and respond to an outbreak of an infectious disease Trust Preparedness - Ebola The Trust has in place a robust communication system for ensuring information is cascaded appropriately within the Trust. The Trust does not have, nor is it expected to have, any specific plans for Ebola. However, the Trust does have a policy for Viral Haemorrhagic Fever (VHF), of which Ebola is categorised, and has been updated by the Infection Control Team, in light of updated NHS guidance published in August The Trust also has an Outbreak Policy and an Incident Response Plan. The Trust has in place Personal Protective Equipment to support staff in mitigating the risks associated with patients either suspected/confirmed of having Ebola or other infectious diseases and the Trust has an ongoing training programme in place to ensure adequate numbers of trained staff are in place. If required, the Trust is able to get clinical information from the local Infectious Disease Unit in Bristol, via the Consultant On-Call for Infectious Diseases Summary The Trust is confident that its level of preparedness is proportionate and appropriate, given the level of risk currently exhibited from VHF/Ebola. Services Directorate Page 4 of 12

5 Preparedness Resilience and Response Quarterly Report Q1&Q2 Whilst the ongoing work associated with this is driven by the Ebola outbreak, its benefits extend to the Trust s resilience for seasonal flu planning, infectious diseases, outbreak planning, pandemic flu planning, emergency planning and business continuity. Future updates regarding Ebola will be given on an adhoc basis, if and when the situation requires it. Further information, if required, can be obtained from either the Director of Operations, the Director of Nursing, the DGM Services, the Preparedness Officer. Services Directorate Page 5 of 12

6 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Appendix 1: Preparedness, Resilience, and Response () 18 Month Work Programme Leading Up To 1 st il 2016 Work Area Project Position Action Required Driver Contacts Done By Management (BCM) Policy The Trust has a policy and strategy in place to support business continuity (2012) Full review to be undertaken of the current policy by the Officer, to ensure in line with national guidance and ISO:22301 Risk 2327 Management (BCM) Plan The Trust does not have a business continuity plan, nor a plan to support fuel disruption Development of a Trust wide Plan Jul Risk 2327 Management (BCM) Impact Analysis The Trust has a service prioritisation (2011) list but is not reflective of the current organisation setup, nor is it aligned to ISO22301 Development of a Trust wide Impact Analysis (to replace the existing service prioritisation ) Nov Risk 2327 Management (BCM) Disruption Risk Assessment The Trust does not have a specific risk assessment to support business disruption risks Development of a specific Risk Assessment for Disruption Nov Risk 2327 Management (BCM) Testing The Trust has not tested its business continuity Development of a business continuity testing programme (following the development of the above work) 2016 Risk 2327 Management (BCM) Assurance: IG Toolkit Evidence needs to be submitted for the IG Toolkit submission on an annual basis. The Trust needs to have in place a BCM Policy and Plan in order to reach Level 2 (the requirement) OR an action plan to demonstrate the Trust is working towards achieving this. This work programme, along with the BCM Policy will be used as evidence to support the Trust s submission under business continuity IG Toolkit Peter Atkinson Jan Framework / Policy The Trust is required under the to have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response. NDHC does not have this in place. Officer to develop an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response and have this agreed and signed off by the Trust Board. Page 6

7 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Work Area Project Position Action Required Driver Contacts Done By Incident Response Plan The Trust has an Incident Response Plan that was reviewed and updated in May Action Cards were not included in this update. Officer to review and update the latest version of the Incident Response Plan. This review will include: compatibility checks against other Trust plans compatibility checks against different parts of the Trust (Acute, Community, Out of Hours etc.) checks against latest to ensure full compliance is achieved revised format to aid usability/simplicity redevelopment of the Action Cards improved SITREPS and CRIP Forms revised information for accessing information during an incident (i.e. on-call resources / plans / contacts etc.) arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver command in managing these events arrangements to have access to 24-hour radiation protection supervisor available in line with local and national mutual aid arrangements Officer to review the distribution list for the Trust s Incident Response Plan and distribute accordingly ED Incident Response Plan The Trust currently has a separate Incident Response Plan for the Department in Draft The Department, with support from the Officer, to complete ED Incident Response Plan. This review will ensure the plan is consistent with NHS guidance and other existing Trust plans Department Incident Control Centre (ICC) The Trust has two Incident Control Rooms in place Officer to review the current Incident Control Rooms and ensure facilities are in line with Mass Casualty Plan There s an LRF-wide Mass Casualty Plan currently being developed and there is an expectation that the Trust will develop a local plan to complement these arrangements Officer to develop a revised Mass Casualty Plan, in line with and the new LRF Mass Casualty Plan The Trust has a plan for mass casualties, but this needs to be better formalised and included within the revised Incident Response Plan (V5) LRF Mass Casualty Plan Page 7

8 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Work Area Project Position Action Required Driver Contacts Done By CBRNe CBRNe Plan A CBRNE Plan was agreed in il 2013 and is due for review in November 2016 CBRNe CBRNe Equipment Heatwave To support the Trust s CBRNe Plan, the Trust has a range of CBRNe equipment, currently stored in the White Shed at NDDH The Trust has a Heatwave Plan (V2.2) that was agreed in June 2014 Officer to review and update the CBRNe Plan, following an external audit which is to be carried out by the Local Area Team (LAT) and Ambulance Service in October 2014 (as part of the NHS Submission). This review will include: ensuring outcomes and recommendations of the audit are implemented quickly checks against latest to ensure full compliance is achieved revised format to aid usability/simplicity compatibility checks against the Ambulance Service s plans for CBRN compatibility checks against the Fire Service s plans for CBRN a rostering process to ensure rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7 Officer to review the Trust s CBRNe Equipment following an external audit which is to be carried out by the Local Area Team (LAT) and Ambulance Service in October 2014 (as part of the NHS Submission). This review will include: ensuring outcomes and recommendations of the audit are implemented quickly checks against latest to ensure full compliance is achieved compatibility checks against the Ambulance Service s plans for CBRN compatibility checks against the Fire Service s plans for CBRN A full audit of the equipment in place A maintenance schedule for the CBRNe Equipment Ensuring the Trust has a suitable number of PRPS suits that are in date Checking the calibration of the RAM GENE monitors Obtaining FFP3 masks, specifically for HART personnel only Replacing existing Toxiboxes with Chemical Equipment Assessment Kits (ChEAKs) (via PHE) Officer to review lessons learned from Summer 2014 and review the existing plan, ready for Summer National Heatwave Plan Department Services Divisional Staff Department Services Divisional Staff Department Services Divisional Staff Page 8

9 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Work Area Project Position Action Required Driver Contacts Done By Cold Weather Plan / Winter The Trust has a Cold Weather Plan, in accordance with national guidance for 2013 Officer to review and update the Trust s Cold Weather Plan following the release of the National Cold Weather Plan 2014 National Cold Weather Plan Department Nov Services Divisional Staff Pandemic Flu Plan The Trust s Pandemic Flu Plan was last updated in 2009, since which both national guidance and regional plans have changed. Work plan needs to be developed to oversee an thorough update to the Trust s Pandemic Flu Plan, in line with revised guidance Risk 1872 Infection Control Sept Needs to be reviewed and amended to reflect the DH Operational guidance on the implementation of the UK Influenza Pandemic Preparedness. Director of Ops Reps from Ops Divisions Estates Health & Safety Sodexo Local Area Team LRF Resilience Direct (RD) The Trust needs to have access to the RD website to obtain access to RD and include details of how the Trust will utilise the tool within the new Framework/Policy Local Resilience Forum Multi-Agency MTPAS The Trust has registered MTPAS users, all of which are based at NDDH and the Communications Department to review the current members of the Trust who are registered under MTPAS National Guidance for MTPAS LRF Comms Intranet Site There is an Page on BOB. Some of this information is out of date Full review and update of the information available on BOB to Trust Staff N/A On-call Policy The Trust has a series of on-call arrangements that would be utilised and relied upon during an incident The Trust needs to develop a standard policy for staff on call to ensure standardisation and common understanding of staff responsibilities N/A Nov Resources The Trust does not have a consistent means for allowing staff (on site or virtually) of accessing the latest plans, contact details, plans to develop a central portal from which staff can access resources as necessary Page 9

10 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Work Area Project Position Action Required Driver Contacts Done By Training The Trust has a draft training schedule to support to develop a comprehensive training programme to follow the redevelopment of the Trust s emergency plans. Training programmes to include: Exercising The Trust is required to undertake one tabletop exercise and two communication exercises before il Awareness Incident Response Plan Mass Casualty Plan CBRNe Plan / Equipment Loggist On-Call Incident Control Rooms Comms and Media Induction Tactical Leadership in a Crisis Strategic Leadership in a Crisis to implement a comprehensive testing programme to both inform and validate the redevelopment of the Trust s emergency and plans Workforce & Development Local Area Team Ongoing Governance & Assurance Multi-Agency Board The Trust is currently engaging with several forums, as required by national guidance. These include: Local Resilience Forum Local Health Resilience Partnership Local Health Resilience Group (LHRG) North Devon Resilience Group CRBN Forum The Trust has an identified Board Group that meets to lead on the programme and is supported by several sub-groups to ensure appropriate attendance by the Trust as required. Feedback to be taken to Trust monthly Group to update current Terms of Reference to develop a revised standard meeting agenda for the Board group to follow Local Area Team LRF Services Division Ongoing Ongoing Governance & Assurance Work Programme The Trust does not have a current work programme to direct individual project work for to develop an Work Programme to ensure the Trust is suitably resilient and to provide adequate assurance against the Services Division Oct 2014 Governance & Assurance Core Standard The Trust has been able to provide a good level of assurance against NHS Core Standards for (quarterly) Trust needs to make submission against Core Standards by 29 th August Trust needs to get a Statement of Compliance from the Board before 22 nd October Services Division Services Division Oct 2014 Oct 2014 Board Updates The Trust Board should be provided with regular updates and assurance regarding the Trust s resilience (at least annually) Officer to develop annual report for il Services Division 2014 Page 10

11 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Work Area Project Position Action Required Driver Contacts Done By Risk Assessment The Trust is required under the Civil Contingencies Act 2004 to assess the risk of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions The Trust Board meetings to lead on assessing risk of emergencies and ensuring these are reported appropriately Disruption risks to be assessed by individual departments and detailed in the revised Policy. Services Division Page 11

12 Preparedness Resilience and Response Quarterly Report Q1&Q2 (Appendix 1) Preparedness, Resilience, and Response () 18 Month Work Programme Leading Up To 1 st il 2016 Timetable & Updates Sept 2014 Oct Nov 2014 Dec 2014 Jan Feb Mar May Jun Jul Aug Sept Oct Nov Dec Jan 2016 Feb 2016 Mar 2016 UPDATE Framework / Policy Incident Response Plan (V5.0) Mass Casualty Plan Incident Control Room(s) Setup CBRNe Plan CBRNe Equipment Heatwave Winter Resource Resilience Direct Review Intranet Pages On-Call Policy Pandemic Flu BCM Policy BCM Plan (Trust wide) Impact Analysis Disruption Risk Assessment BCM Testing IG Toolkit Submission Training: Awareness Training: Incident Response Plan Training: ED Incident Response Plan Training: Mass Casualty Plan Training: CBRNe Plan & Equipment Training: Loggist Training: On-Call Training: Incident Control Rooms Training: Comms and Media Training: Induction Update Training: Tactical Leadership in a Crisis Training: Strategic Leadership in a Crisis Exercise: Communications Exercise: Tabletop Exercise: Live (Full Plan Activation) Core Standards Board Meetings Multi-Agency Page 12