Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version

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1 Policy No: OP89 Version: 1.1 Name of Policy: Emergency Preparedness, Resilience and Response (EPRR) Policy Effective From: 15/11/2016 Date Ratified 12/08/2015 Ratified EPRR Committee Review Date 01/08/2017 Sponsor Deputy Chief Executive Expiry Date 11/08/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1

2 Version Control Version Release Ratified Author/Reviewer by/authorised by /11/2015 Andy Colwell EPRR Committee Peter Harding Deputy Chief Exec (AEO) Changes Date (Please identify page no.) 12/08/2015 New Policy /11/2016 Peter Weatherburn Peter Harding QEF Chief Exec 14/11/2016 P12 sec 8.1 added wording around training attendance list. Also appendix 1 attendance list added. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 2

3 Contents 1. Introduction Policy scope Aim of policy Information sharing Duties (roles and responsibilities) Definitions EPRR Committee Structures for EPRR Emergency Incident Plans Reviews and Approvals Exercising for Major Incidents The Learning Cycle Command and Control Risk Assessments Training Emergency Planning Staff Other Staff Diversity and Inclusion Monitoring compliance with the policy Consultation and review Implementation of policy (including raising awareness) References Associated documentation Appendix Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 3

4 Emergency Preparedness, Resilience and Response 1. Introduction The NHS needs to be able to plan for and respond to a wide range of incidents and emergencies that could affect health or patient care. These could be anything from severe winter weather to an infectious disease outbreak or a major transport accident. This work is referred to in the health service as Emergency Preparedness, Resilience and Response (EPRR). Planning for emergencies has developed significantly since the introduction of statutory duties under the Civil Contingencies Act Category One responders, must show that that they are working with other responders to assess risks, develop and maintain plans, share information and co-operate on civil contingency response. 2. Policy scope The scope of this policy covers all staff employed by the Trust either directly or indirectly and to any other person or organisation that uses Trust premises for any purpose. 3. Aim of policy Gateshead Health NHS Foundation Trust Emergency Preparedness, Resilience and Response Policy provides a framework within which the Trust can fulfil its duties as a Category 1 Responder under the Civil Contingencies Act The policy underpins the processes which the Trust employs in order to comply with principles as detailed in the NHS Emergency Preparedness Framework (2013), the NHS England Core Standards for EPRR and the EPRR requirements as required in the NHS Standard Contract 2015/16 (service condition 30) all of which the Trust must meet. There are various emergency plans which support these requirements and these are detailed within this policy. Policy outcomes will increase organisational resilience and outline the formal process for the effective management of our EPRR requirements including the need to provide assurance to Board, Commissioners and users of our services that resilience plans and business continuity management systems are up to date and relevant. 4. Information sharing Under the CCA 2004 responders have a duty to share information with partner organisations. This is seen as a crucial element of civil protection work, underpinning all forms of cooperation. Trust representatives will attend the Local Health Resilience platform (LHRP) and the Local Resilience Forum (LRF). These meetings are attended by representatives from other Category 1 responders as well as the support services (Cat 2 responders) e.g. police, local authority, fire service, utility providers, ambulance service, met office, CCGs etc. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 4

5 Relevant information must also be shared with partner organisations. Working collaboratively will improve organisational cohesion and ensure patients and the public are safeguarded during an incident. 5. Duties (roles and responsibilities) Board of Directors The Board of Directors is responsible for ensuring that there is a robust system of Corporate Governance within the organisation. This includes having a systematic process for the development, authorisation and management of policies. This policy has been ratified by the Board of Directors and therefore must be followed by all staff. With specific regard to this policy, the Board of Directors must be aware of the organisations legal duties to ensure preparedness to respond to a major incident or other significant incident in the health community. They must also be aware of any factors within organisations which will have a negative impact on public protection within their health community as a result of a significant incident or emergency. They will be responsible for the identification of board level director as Director of EPRR and Accountable Emergency Officer. Deputy Chief Executive/ Accountable Emergency Officer (AEO) The Deputy CEO is the Trusts Accountable Emergency Officer and is responsible for the following, To ensure that the organisation is compliant with the EPRR requirements as set out in Civil Contingencies Act (2004) the Health and Social Care Act (2012), the NHS EPRR and business continuity management frameworks, and the NHS standard contract; To ensure that the organisation is properly prepared and resourced to respond to a significant incident or emergency; To ensure that the organisation and any providers they commission have robust business continuity arrangements in place which are aligned to ISA and the Framework for health Services Resilience (PAS 2015); To ensure that the organisation has plans to deal with increases in activity; To ensure that the organisation cooperates with any NHS Commissioning Board or agents thereof, in respect of the monitoring of compliance and assurance; To ensure that the organisation is represent at and contributes to governance meetings, sub-groups and working groups of the LHRP and LRF. To provide annual assurance to the Board of Directors that the organisation has strategies, systems, training, policies and procedures in place to ensure an appropriate response from the Trust in the event of a major incident or civil contingency event. Executive Directors/ Associate Directors Directors and Associate Directors who are sponsor or lead on the development, implementation and review of Trust policies must ensure that they and the staff within their departments comply with this policy. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 5

6 Head of Facilities (HoF) The HoF has delegated responsibility from the AEO for the strategic delivery of EPRR ensuring that an effective, robust EPRR system is in place including reviewing national / local guidance, assessing EPRR risks and developing appropriate responses though corporate plans. The HoF will represent the Trust/ AEO at groups of the LHRP, LRF and other partner organisations. Business Continuity, Health and Safety Manager The Business Continuity, Health and Safety Manager will support the Head of Facilities in delivery of the EPRR work plan including Business Continuity. Non-Executive Director for EPRR A non-executive director or other appropriate board member will be appointed by the board to endorse assurance to the board that the organisation is meeting its obligations with respect to EPRR and the Civil Contingencies Act. This supporting role will also seek assurance that the organisation has allocated appropriate resources to meet these requirements, including the support of properly trained and competent emergency planning officers and business continuity managers as appropriate. 6. Definitions Emergency and Emergency Preparedness An Emergency is defined by the Civil Contingencies Act as an event or situation which threatens serious damage to human welfare or the environment, or war or terrorism which threatens the security of the United Kingdom Damage to human welfare is further defined as follows; Loss of human 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 Emergency preparedness Means having plans in place to help mitigate the disruption caused by an emergency. Major Incidents A Major Incident is any event whose impact cannot be handled within routine service arrangements. It requires the implementation of special procedures by one or more of the emergency services, the NHS, or a Local Authority to respond to it. In addition, each individual NHS organisation has a legal obligation to plan for responding to incidents in which its own facilities or neighbouring ones may be overwhelmed. Planning successfully for these wider disruptive challenges requires more than simply Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 6

7 7. EPRR scaling up the current plans; it requires the creation of Emergency Incident Plans to deal with Major Incidents. Major Incident Casualty Plan The Trusts Major Incident Casualty Plan deals with many casualties from an incident scene and is not to be considered or implemented in response to localised increased activity across the Trust, for example winter pressures. The appropriate escalation plans are to be used for this type of scenario. Business Continuity Business continuity is a holistic management process that identifies potential threats to an organisation and the impacts to business operations those threats, if realised, might cause, and which provides a framework for building organisational resilience with the capability of an effective response that safeguards the interests of its key stakeholders, reputation, brand and value-creating activities. (ISO2230l;3.4) Examples of such threats may include the pressure placed on services brought on during an outbreak of infectious disease, or the recovery period after Major Incident. Business Continuity Plans Business Continuity plans contain the actions necessary to mitigate the effects of surge and pressure on systems and services such that declaration of a pressure related Major Incident may be avoided and services can be maintained at defined `normal levels Committee Structures for EPRR EPRR Committee This committee has representatives from across the Trust and has a responsibility to oversee and consult on all resilience and business continuity planning activity within the Trust to ensure that robust arrangements are in place which comply with laws, guidelines and Trust policies. Business Continuity Sub- Group This sub group of the EPRR committee has special responsibility for overseeing all aspects of Business Continuity for the Trust. More details and the terms of reference for this group are provided within the BCP Policy (RM 66) 7.2. Emergency Incident Plans Suitable, proportionate and up to date emergency incident plans will be developed in response to specific scenarios relating to outcomes from EPRR risks assessments which may adversely affect the overall operations of the Trust. In addition, Emergency Incident Plans will also be developed to comply with EPRR core standard requirements e.g. HAZMAT. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 7

8 Scenarios will be ascertained from local and national guidance, local Community Risk Registers and the National Risk Register. 1 The term Emergency Incident plans will also apply to Business Continuity Plans which are considered separately under the BCP Policy (see BCP Policy RM 66). Where necessary plans will be shared with partner organisations/other responders. 7.3 Reviews and Approvals Emergency Incident Plans will be reviewed at least annually or in response to exercises outcomes or a heightened risk being identified. In addition plans may need to be reviewed if the estate changes involving locations of buildings or departments which Emergency Incident Plans refer to, for example. The Trusts EPRR committee will review and approve changes to Emergency Incident Plans. 7.4 Exercising for Major Incidents The Trusts response to Major Incidents will be exercised according to the requirements of current government legislation and government approved guidance. In addition, the EPRR work plan will include the planned exercise programme for the coming year. Items for inclusion on the exercise plan will include the following; Communication exercises, every 6 months (minimum) Table top exercises, every 12 months (minimum) A `Live exercise every 3 years (minimum) Command post exercise every 3 years (minimum) The Trust will share information on lessons identified and learnt from training, exercising, emergencies or significant incidents with the wider NHS through the LRHP strategic groups. Plans will be prepared in liaison with key partners both inside and out with the Trust in accordance with the requirements of the NHS Commissioning Board standards; 7.5 The Learning Cycle The national business continuity guidance offers a useful model for a learning cycle that can be adopted for EPRR purposes. 1 WA_Final.pdf Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 8

9 7.6. Command and Control The Trusts single point of contact for receiving notification of an emergency or business continuity incident is designated as the Hospital Switchboard. Escalation of a notification will be to an executive level e.g. Director on Call (24/7) Where an incident requires a defined management response the Trust will implement its Incident Command Centre (ICC). The ICC will operate for as long as required to deal with the incident including recovery. There are specific plans and action cards for key roles located within the ICC which detail how to manage an incident. The ICC will be responsible for coordinating all responses from the Trust in relation to situational reports (SITREPS) as well as approving decisions relating to reducing elective capacity. A dedicated telephone line and account will be activated for exclusive use by the ICC Risk Assessments EPRR risks assessments of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions will be undertaken annually and a summary presented to the EPRR committee. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 9

10 8. Training Risk assessments will take account of community risk registers and include reasonable worst case scenarios for, Severe weather Staff absence including industrial action The working environment, buildings and equipment (including denial of access) Fuel shortages Surges and escalation of activity IT and communications Utilities failure Response to a major incident. Mass casualty event Supply chain failure and Associated risks in the surrounding area (COMAH sites), Internal risks (flooding etc.) 8.1 Emergency Planning Staff The Trust will ensure that staff are competent to undertake Emergency Planning and as a minimum are able to understand the following principles. Integrated Emergency management (IEM) Risk Assessment Command, Control and Coordination Roles and Responsibilities of Partner Organisations involved in Response and Recovery Major Incident Management and Support in the hospital An attendance list (appendix 1) must be filled in with the details of those partaking in all training this must then be passed on to the OD&T department for central records by the training facilitator. 8.2 Other Staff Staff with particular roles will receive appropriate training at operational, tactical or strategic level. Staff who have a specific role to play if an incident is declared are responsible for ensuring that they maintain any practical and professional skills which are required in order to fulfil the requirements of their action card in the incident plan. Departmental Managers should provide on the job training and resilience awareness as part of their induction training. Staff with specific command and control roles must undertake training appropriate to their level of responsibility and in accordance with current guidance and legislation. Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 10

11 9 Diversity and Inclusion The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat staff reflects their individual needs and does not unlawfully discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy aims to uphold the right of all staff to be treated fairly and consistently and adopts a human rights approach. This policy has been appropriately assessed. 10. Monitoring compliance with the policy Monitoring compliance with the policy will be undertaken by the EPRR committee who will review the EPRR work plan. In addition compliance measures may be undertaken in the format of action plans which will be monitored by the EPRR committee. When developed, actions plans will be included within the EPRR work plan. 11. Consultation and review This policy has been undertaken in consultation with the trusts ICC strategic command leads as well as EPRR leads from NHS England and local trusts. 12. Implementation of policy (including raising awareness) This policy will be available on the Trust Intranet. All staff will be alerted to it by . This policy will be implemented on approval by the EPRR committee. 13. References BCP Policy RM Associated documentation Trusts Business Continuity Policy RM National Risk Register for Civil Emergencies Civil Contingencies Act NHS EPRR standards for Providers Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 11

12 Appendix 1 Attendance List Exercise/Training: Date: Name Dept./area/ward Signature Emergency Preparedness, Resilience and Response (EPRR) Policy v1.1 12