Emergency Preparedness, Resilience and Response (EPRR) Core Standards Submission 2016/17

Transcription

1 Preparedness, Resilience and Response Core Standards Submission 2016/17 4 October 2016 Preparedness, Resilience and Response (EPRR) Core Standards Submission 2016/17 1. Introduction 1.1. The NHS needs to be able to plan for and respond to a wide range of emergencies and business continuity incidents that could affect health or patient safety. These could be anything from severe weather to an infectious disease outbreak or a major transport accident Under the Civil Contingencies Act (2004), NHS organisations and providers of NHS funded care must show that they can effectively respond to emergencies and business continuity incidents while maintaining services to patients This work is referred to in the health service as emergency preparedness, resilience and response (EPRR). 2. NHS EPRR Core Standards 2.1. The NHS EPRR Core Standards set out the minimum standards expected of NHS organisations and providers of NHS funded care with respect to emergency preparedness, resilience and response The NHS EPRR Core Standards enable agencies across the country to share a common purpose and to coordinate EPRR activities in proportion to the organisation s size and scope. In addition, they provide a consistent cohesive framework for self-assessment, peer review and assurance processes The EPRR Core Standards are reviewed and updated as lessons are identified from testing, changes to national legislation or guidance changes and/or as part of the rolling NHS England governance programme The Trust was notified on the 13 th June 2016 of the expectations for the 2016/17 EPRR assurance process The letter, from Tim Young, Interim Director of NHS Operations and Delivery, included the latest version of the Core Standards (V4.0), which NDHT has now used to perform a self-assessment. Operations Page 1 of 8

2 Preparedness, Resilience and Response Core Standards Submission 2016/17 4 October Assurance Deep Dive 3.1. Each year, NHS England uses the core standards assurance process to undertake a deep-dive look at a specific topic relating to emergency preparedness, resilience and response This year s EPRR assurance deep dive topic is business continuity, with an emphasis on the National Plan for Fuel. The fuel emphasis this year is designed to support a national cross-government initiative which is occurring across a number of other local services and local resilience fora (LRFs) Following on from the /16 deep-dive into incidents involving chemical, biological, radiological and nuclear (CBRN) substances, the CBRN assessment remains incorporated into the NHS EPRR Core Standards process. To support this process, North Devon District Hospital will in 2016/17 be audited by South Western Ambulance Service who will look to assess and challenge our existing level of preparedness for CBRN incidents. 4. NHS EPRR Core Standards Self-Assessment 4.1. As part of NHS England s EPRR assurance process for 2016/17, Northern Devon Healthcare NHS Trust was required to self-assess against a total of 51 core standards The self-assessment was completed by the Trust s Preparedness Resilience and Response and was submitted to NHS England and the NEW Devon Clinical Commissioning Group on the 29 th July The outcome of the self-assessment has shown that of the 51 applicable standards, the Trust is: fully compliant with 49 of the standards (green); partially compliant with 2 of the standards (amber); non-compliant with 0 of the standards (red) The results of the 2016/17 self-assessment enable the Trust to provide substantial compliance to NHS England and the NEW Devon Clinical Commissioning Group with respect to its emergency preparedness, resilience and response The results of the 2016/17 self-assessment are an improvement on the previous submission made during /16 and this represents the continued work undertaken by the Trust to improve its emergency preparedness, resilience and response. Operations Page 2 of 8

3 Preparedness, Resilience and Response Core Standards Submission 2016/17 4 October EPRR Work Programme 5.1. To accompany the EPRR core standards self-assessment, the Trust was required to submit an action plan detailing how it plans to address the 2 standards for which full compliance has not yet been achieved To meet this requirement, the Trust has submitted its existing EPRR Work Programme (Enclosed) which has been amended to reflect the outcomes of the EPRR core standards self-assessment The EPRR Work Programme is overseen by the Trust s EPRR Board which is chaired by the Trust s Accountable and Director of Operations. 6. Next Steps 6.1. The next steps for the assurance process will be: The Trust will have its plan for chemical, biological, radiological, nuclear (CBRN) incidents audited by South Western Ambulance Service Foundation Trust (date to be confirmed); The Trust Board is required to submit a Statement of Compliance against the Trust s self-assessment (Appendix A); The Local Health Resilience Partnership (LHRP) will review and consider providers, CCGs and NHS England s self-assessments, Board paper (or equivalent) and action/work plans and may request evidence, as deemed necessary; The Trust should receive formal feedback on its response during Quarter Conclusion and recommendations 7.1. During the last 12 months, the Trust has continued to invest in developing and improving its emergency preparedness, resilience and response arrangements This investment has resulted in the Trust being able to provide substantial compliance to NHS England and the NEW Devon Clinical Commissioning Group with respect to its emergency preparedness, resilience and response for 2016/ The Trust s Board is asked to approve the attached Statement of Compliance (Appendix 1). Operations Page 3 of 8

4 Preparedness, Resilience and Response Core Standards Submission 2016/17 4 October Appendix A: Statement of Compliance Vikki Pothecary Coordinator Northern Eastern Western Clinical Commissioning Group Newcourt House Old Rydon Lane Exeter EX2 7JU 01 November 2016 Chairman s Office Suite 8, Munro House North Devon District Hospital Raleigh Park Barnstaple EX31 4JB Tel: rogerfrench1@nhs.net Dear Vikki RE: Preparedness, Resilience and Response provider assurance process This letter is to provide you with the Trust statement of compliance with NHS England s Core Standards for Preparedness, Resilience and Response 2016/17, as requested in the Assurance Process letter sent out from Tim Young, Interim Director of NHS Operations and Delivery on 13 June On Tuesday 4 th October, the Trust Board received a briefing on the assurance process, the evidence that was available to support the self-assessment and the current compliance position for the Trust from Robert Sainsbury, Director of Operations and the Trust s Accountable. The outcome of the Trust s self-assessment shows that against the 51 applicable core standards, Northern Devon Healthcare NHS Trust is: fully compliant with 49 of the standards (green) partially compliant with 2 of the standards (amber); non-compliant with 0 of the standards (red). At the Trust Board meeting on 4 th October 2016, the self-assessment, statement of compliance and Preparedness, Resilience and Response Work Programme were all formally approved and noted in the minutes of the meeting. I attach a copy of the Trust s Preparedness, Resilience and Response Work Programme which will be monitored by the Trust s Preparedness, Resilience and Response Board and exception reported to the Trust s Board, when required, but no less frequently than annually. Please do not hesitate to contact me if I can be of any further assistance. Yours Sincerely DR. ALISON DIAMOND Chief Executive Operations Page 4 of 8

5 Preparedness, Resilience & Response Annual Report Trust Board 2 nd August Appendix A: EPRR Work Programme for 2016/17 APPENDIX B: Preparedness, Resilience, and Response (EPRR) Work Programme for 2016/17 Work Area Project Position Action Required Driver Contacts Done By Incident Response Plan Incident Response Plan Incident Response Plan The Trust s incident definitions are not aligned with the most up to date EPRR Framework from NHS England () There is a risk that the Trust s existing mechanism for notifying staff of an incident (critical/major/business continuity) is not robust The Trust tests the equipment in its Incident Coordination Centres on an annual basis The Trust needs to align its incident definitions with those described in the NHS England EPRR Framework The Trust needs to review and change its mechanism for notifying staff of an incident critical/major/business continuity) The Trust needs to test the equipment in its Incident Coordination Centres on a quarterly basis June 2016 June 2016 There are inconsistencies in the way which services and departments document their business continuity arrangements The Trust has not reviewed or audited the business continuity plans belonging to individual services and departments The Trust s Disaster Recovery Plans are not determined by the priorities set out in the Trust s new Business Impact Analysis Awareness of business continuity is limited to service and departmental managers All services and departments should document their business continuity plans in their new business continuity toolkits The Trust should audit all service s and department s business continuity plans and where they are not suitably robust ensure that arrangements are put in place to address these The outcomes of the Trust s business impact analysis should be shared with IM&T to determine disaster recovery plans and priorities The Trust should hold a Week to: Encourage staff to familiarise themselves with their local service/department s business continuity plans Raise awareness of business continuity risks Encourage services and departments to complete their business continuity resilience work plans Share good practice between services, departments, divisions and directorate Test and exercise the Trust s new business continuity arrangements October 2017 October 2016 November 2016 Services and departments have not had the opportunity to test their new business continuity plans Develop a Exercise Simulation Pack for implementation by service/departmental business continuity leads during the Week The Trust has not tested its new business continuity plan Hold a tabletop exercise for divisional/directorate business continuity leads to: o o o Test command and control arrangements during a disruptive incident involving more than one division/directorate Enable divisional/directorate leads to understand the challenges and priorities for each of the other divisions/directorates Identify any gaps in the Trust s business continuity plans The Trust has not tested its new business continuity plan The Trust s E-Learning package does not accurately reflect the arrangements set out in the new business continuity plan The Trust should rehearse a full scale activation of its business continuity plan, requiring all services to submit their business continuity incident sitrep The Trust s EPRR E-Learning package should be updated to reflect the Trust s new business continuity arrangements August 2016 Operations Page 5 of 8

6 Preparedness, Resilience & Response Annual Report Trust Board 2 nd August 2016 Work Area Project Position Action Required Driver Contacts Done By Mass Prophylaxis The Trust doesn t not currently review the business continuity arrangements of its providers or subcontractors The Trust has no plan in place for mass countermeasures or prophylaxis The Trust needs to ensure that any provider it commissions and any sub-contractors have robust business continuity planning arrangements in place aligned to ISO:22301 The Trust should develop a Mass Treatment and Prophylaxis Plan EPRR Core Standards August 2016 Heatwave The Trust is required to plan for extreme temperatures associated with the summer months The Trust should ensure it meets the requirements of the National Heatwave Plan for England Heatwave Plan for England June 2016 Cold Weather Plan / Winter The Trust is required to plan for extreme temperatures associated with the summer months The Trust should ensure it meets the requirements of the Cold Weather Plan for England Cold Weather Plan for England November 2016 Business Continuity Management Fuel Disruption Plan Risk Management The Trust has no local arrangements in place to support a disruption to fuel supplies The Trust should develop a Trust-specific fuel disruption plan The EPRR Board should complete an assessment of the risks identified in the Incident Response Plan to ensure that mitigating controls and actions have been identified and add them to the Trust s Risk Register EPRR Core Standards Assurance Action Estates & Facilities EPRR Board Accountable June 2016 September 2016 Senior Governance Manager (Risks & Incidents) Fire, Security & Lockdown Risk Management Fire, Security & Lockdown Training Training The EPRR Work Programme should provide the detail of where the risk assessments will be shared (e.g. ambulance trust, clinical commissioning groups, etc.) The Fire, Evacuation, and Lockdown Plans should be added to the NDHT On-Call Secure Webspace (OCSWeb) to ensure that all plans are available in the same location The EPRR Training Register should be updated to identify dates of training for all members of staff who have completed EPRR training and attended exercises Estates & Facilities Operations Page 6 of 8

7 Preparedness, Resilience & Response Annual Report Trust Board 2 nd August 2016 Work Area Project Position Action Required Driver Contacts Done By Training Training The EPRR Training Register should have the details of the Executive On-Call Team dates of training for gold, silver and bronze levels of command training Training Training The Trust should ensure that a suitable method of recording EPRR training is established to meet the requirements of the EPRR Core Standards Training Manager Plans The Trust should identify access to a 24-hour specialist advisor for incidents involving firearms and include this information in the CBRNE Plan Communications Media Strategy Equipment & Resources Training CBRN Training The Trust must provide annual training to its staff who may be involved in a response to a CBRN incident Training Loggist Training The Trust should provide refresher training to its trained loggists on an annual basis The EPRR Core Standards require that a Media Strategy is in place, however it would be sufficient for the Marketing and Public Relations Strategy to be reviewed and updated to ensure it meets the needs of the Core Standards The emergency preparedness equipment inventory should provide the details of a named role to carry out the equipment inspection to ensure it always remains in date and tested. This will confirm where the responsibility is for the task and any actions required to be taken The Trust should provide training sessions for staff who may be involved in a response to a CBRN incident and which have not already undertaken training The Trust should provide refresher training to staff who have been trained on responding to a CBRN incident The Trust should provide trained loggists with the opportunity to practice their skills OR provide refresher training to keep their skills current NHS Guidance EPRR Core Standards NHS Guidance EPRR Core Standards Head of Communications ED EPRR Lead ED EPRR Lead August 2016 Training E-Learning Training The Trust must provide basic training to all its staff on an annual basis The Trust should develop a shorter e-learning module (E-MOT) for EPRR based on the existing fulllength EPRR E-Learning package currently available to staff Workforce Development August 2016 Head of Workforce Development Operations Page 7 of 8

8 Preparedness, Resilience & Response Annual Report Trust Board 2 nd August 2016 Work Area Project Position Action Required Driver Contacts Done By Testing & Exercising Communications Test (1) The Trust is required to hold two tests of its communication arrangements each year The Trust should test the communication arrangements set out in its EPRR arrangements NHS Guidance October 2016 Testing & Exercising Communications Test (2) The Trust is required to hold two tests of its communication arrangements each year The Trust should test the communication arrangements set out in its EPRR arrangements NHS Guidance Testing & Exercising Tabletop Exercise The Trust is required to hold an annual tabletop exercise The Trust should hold a tabletop exercise to test its EPRR arrangements NHS Guidance January 2017 Testing & Exercising Live Exercise The Trust is required to hold a live exercise every three years The Trust should hold a live exercise of its EPRR arrangements NHS Guidance Multi-Agency Working Meeting Groups The Trust is currently engaging with several forums, as required by national guidance. These include: Local Resilience Forum (LRF) Local Health Resilience Partnership (LHRP) Local Health Resilience Group (LHRG) North Devon Resilience Group Acute s Trust Meeting Group CRBN Forum The Trust should ensure each meeting group/forum is appropriately represented by the Trust and feedback provided to the EPRR Board NHS Guidance Civil Contingencies Act 2004 DGM, Services & Medicine Accountable Ongoing EPRR Governance & Assurance EPRR Board The Trust has an identified EPRR Board Group that meets to lead on a specific programme of work for EPRR The Trust should ensure its EPRR Board continues to meet on a quarterly basis and to ensure its EPRR Work Programme is completed in full for 2016/17 EPRR Core Standards Assurance Action Accountable Governance & Assurance EPRR Core Standard The Trust has been able to provide a good level of assurance against NHS Core Standards for EPRR (quarterly) The Trust should aim to provide full compliance against NHS England s EPRR Core Standards EPRR Core Standards Accountable December 2016 EmergencPlanng Governance & Assurance Board Updates The Trust Board should be provided with regular updates and assurance regarding the Trust s resilience (at least annually) The Trust should provide an annual report to the Trust Board NHS Guidance EPRR Core Standards Accountable September 2016 Operations Page 8 of 8