Title of Report: Prepared By: Sponsor: Action Required: Statement of Assurance/Readiness Preparedness to Major Incidents Ben Cockerill, Emergency Planning Officer Kevin O Leary, Deputy Director of Operations 1. The Board is asked to receive this report and note its content. 2. The Board is asked to give its support to the plans for achieving continued compliance on those points raised as for immediate assurance in action plan attached. Purpose of Paper: Key Messages/Issues: Statement of Trust Assurance/Readiness in relation to Major Incident response Following the recent major incident in Paris, France there was a request from NHS England that Trusts provide assurance at their next public Board meeting regarding compliance with a number of the Emergency Preparedness Resilience and Response (EPRR) core standards relating to: On call cascade systems and loss of primary communications systems Arrangements for staff to access sites during periods of disruption to the transport infrastructure Plans to increase critical care capacity and capability (Acute Hospitals) Plans to gain specialist support for victims of blast and ballistic trauma (Acute Hospitals) Assurance can be given that the above elements of the EPRR are in place. This timely review indicates a number of actions where reinforcement will strengthen the Trust s ongoing compliance. An action plan has been created to support delivery. Links to Strategic Objectives: To deliver an exceptional patient experience first time, every time To provide excellent care, ensuring effective, person-centred clinical outcomes To be an employer for whom people choose to work To be an active partner, always ready to improve by working with others To be an efficient organisation providing excellent services PB53 26 January 2016 Page 1 of 2
Resource Implications, if any: Emergency Planning Officer to complete as appropriate Links to BAF: Business Continuity Has an Equality Impact Assessment been completed? NO Paper History: Requested national assurance check of compliance with EPRR Core Standards that were signed off by this Trust Board s Safety & Quality Committee in September 2015. Considered by Date Summary of Outcome PB53 26 January 2016 Page 2 of 2
Report to Public Trust Board 26 January 2016 Statement of Assurance / Readiness Preparedness to Major Incidents 1. Purpose of Report 1.1 To provide assurance to the Trust Board that the Trust is prepared for Major Incidents in line with the Emergency Preparedness Resilience and Response (EPRR) core standards. This is in response to a request from the National Director Commissioning Operations for NHS England that immediate assurance is given on specific areas of readiness as part of the annual statement and, at a public Trust Board meeting. 2. Background 2.1 In light of the tragic attacks in Paris on Friday 13 November 2015, Dame Barbara Hakin National Director: Commissioning Operations for NHS England wrote to Trusts requesting a statement of assurance / readiness to ensure preparedness in relation to specific parts of their Major Incident Plan. The letter is attached at Annex 1, the key areas of which are: I. On call cascade systems and loss of primary communications systems II. Arrangements for staff to access sites during periods of disruption to the transport infrastructure III. Plans to increase critical care capacity and capability (Acute Hospitals) IV. Plans to gain specialist support for victims of blast and ballistic trauma (Acute Hospitals) 2.2 It is important to be clear that the threat level remains unchanged since 29 August 2014. The threat assessment to the UK from international terrorism in the UK remains SEVERE. SEVERE means an attack is highly likely. The above request therefore relates to a confirmation of current processes being in place, rather than an escalation. 2.3 The Trust undertakes an assessment for the Emergency Preparedness Resilience and Response (EPRR) Core Standards Framework annually, which is in line with the requirements set out in Annex 1. This is approved on an annual basis at the September meeting of the Trust s Safety & Quality Committee prior to submission to NHS England via the Local Health Resilience Partnership (LHRP). Figure 1 illustrates The EPRR Core Standards governance process as it currently stands for the 2015 submission. The core standards are reviewed and republished every year, the formal letter informing the Trust of the update is sent in May annually by NHS England. Page 1 of 6
Figure 1: The EPRR Core Standards governance process 3. Key issues & Recommendations 3.1 As part of the annual assurance process for the EPRR Core Standards, the Trust reviews compliance against each standard and provides updates to NHS England; this goes through the annual governance process identified in Figure 1 and 2.3 above. 3.2 In terms of the more immediate assurance required as identified in Annex 1 and 2.1 above, the key issues for this Trust relate to the first two points, the second two relating to critical acute care settings: 3.2.1 You have reviewed and tested your cascade systems to ensure that they can activate support from all staff groups, including doctors in training posts, in a timely manner including in the event of a loss the primary communications system; i. The Trust cascade systems works through the on-call structure coordinated at St. Michael s 24 hour Switchboard. The on-call functionality to Operational Managers, Doctors, Estates Department, Information Page 2 of 6
Technology (IT) & Executive Directors is used and tested on a daily basis. Any issues which arise are highlighted immediately to the Emergency Planning Officer and subsequently addressed with relevant members of staff; these are reviewed to ensure lessons are learnt. ii. From February 2016 there is a fixed timetable to complete 6 monthly mandatory communication tests within the Trust. This is designed to test on-call systems in a variety of different incident scenarios. iii. The Trust has a high level of resilience in relation to the loss of primary communication systems. This includes two data centres designed to back each other up; they are located in two different geographic areas to minimise chance of disruption to both. iv. The Trust has Voice Over Internet Phones (VOIP) telephones which acts as an extra layer of resilience should there be a disruption to analogue phone lines, with analogue also acting as a back-up should the VOIP service be disrupted / fail. v. In the event of a loss of primary communication systems the Trust is currently exploring the option to join the Mobile Telecommunication Privileged Access Scheme (MTPAS) through our IT and Telephony departments and Coventry, Solihull & Warwickshire (CSW) Resilience Team as the Local Resilience Forum (LRF) Coordinators. Should this option be approved and used the Trust will prioritise who would internally be involved in the MTPAS scheme. 3.2.2 You have arrangements in place to ensure that staff can still gain access to sites in circumstances where there may be disruption to the transport infrastructure, including public transport where appropriate, in an emergency: i. The Trust has an online Car Sharing Policy available on the Trust intranet, called Faxi. There are car sharing groups set up on the Faxi website for the following destinations: ii. Wayside House, Brooklands, City of Coventry Health Centre, Swanswell Point, Paybody Unit, The Railings, Manor site, St. Michael's Hospital and the Caludon Centre. Page 3 of 6
iii. This allows Trust members of staff to share car journeys, this could be further utilised in a disruption to transport service across the region. iv. The Trust has a cold weather plan which identifies internal arrangements for extreme cold weather conditions, which works in conjunction with Trust Major Incident and Business Continuity Plans. v. The Trust has an adverse weather and disruption to transport policy, which identifies and acknowledges that staff may experience difficulty in travelling to and from work in severe weather or disruption to transport services. It outlines the process for staff members who encounter issues during severe weather, including the roles / responsibilities of all involved. vi. The Trust has access to a 4x4 vehicle (Mitsubishi L200) within the Estates and Facilities Department. vii. There is support offered from CSW Resilience with regard to assisting critical work within the Trust requiring access to sites in severe cold winter weather conditions. This option has been used in previous severe weather/ disruption to transport and a 24 hour emergency line to CSW is available within Trust emergency plans. viii. The Trust has contracts with gritting companies which are prioritised for buildings used 24/7 within the Trust; they are automatically triggered when certain temperature thresholds are reached. ix. There is a Trust fuel plan which prioritises the provision of fuel to staff fuel in scenarios where there is a fuel shortage these plans are currently being reviewed regionally at the LHRP for accuracy. 4. Implications 4.1 Although assurance can be given that the above elements of the EPRR are in place, this timely review indicates a number of actions where reinforcement will strengthen the Trust s ongoing compliance: Page 4 of 6
Table 1: Actions to address activity required to ensure continued compliance to EPRR Core Standards Action Lead Timescale Revisit staff awareness of formal reporting system for failures in cascade system Emergency Planning Officer On call system being reviewed due to Directorate / Service changes and will form part of review in Q1 2016/17. More immediate comms during Q4 2015/16 to highlight reporting system Cascade system communications tested on a 6 monthly basis as part of the EPRR Core Standards requirements Trust sign up to MTPAS for resilience against primary loss of communications Heightening awareness of staff across Trust of: Faxi Trust Care Sharing Scheme, The Trust Cold Weather Plan Trust Adverse Weather and Disruption to Transport Policy Confirm staff prioritisation in a fuel crisis through the Trust Fuel Plan Emergency Planning Officer Emergency Planning Officer Communications & Marketing Emergency Planning officer to align with below testing. As of February 2016, 6 monthly communications tests commence. Currently under review The awareness of the Faxi scheme is being raised with staff during January / February 2016 and supports the review of staff car parking. Awareness of cold weather procedures are raised with staff through all user communications at the beginning of the cold weather period and as required following bad weather alerts. These are being reviewed at LHRP sub group EPAG in February 2016 which will report to LHRP for agreement on further action. Page 5 of 6
5. Recommendations 5.1 The Board is asked to receive this report and note its content. 5.2 The Board is asked to give its support to the action plan for achieving continued full compliance in relation to points 1 and 2 as identified. Ben Cockerill Emergency Planning Officer January 2016 Annex 1 Dame Barbara Hakin 9 December 2015 Letter to NHS Trust s NHS Preparedness for a Major Incident - Page 6 of 6