SUBJECT: EPRR CORE STANDARDS SUBMISSION 2016/17

Transcription

1 Affiliated Teaching Hospital BOARD OF DIRECTORS: 28 TH OCTOBER, 2016 AGENDA ITEM: 9.6 SUBJECT: EPRR CORE STANDARDS SUBMISSION 2016/17 RESPONSIBLE DIRECTOR: AUTHOR: Rebecca Brown (Chief Operating Officer) Imran Devji, Deputy Chief Operating Officer PREVIOUSLY CONSIDERED BY: Emergency Preparedness, Resilience and Response Group. EXECUTIVE SUMMARY: Over the course of the last 12 months progress has been made in a number of areas as we strive to develop a robust and value adding resilience programme. This includes: Validation of the county and regional Mass Casualty Plans Adoption of the command and control protocol in response to the Junior Doctor s Industrial Action The validation of the Trust s Pandemic Preparedness and Response Plan Developing closer partnerships with the health economy and responding agencies Development and delivery of training programmes for Senior Managers on Call Whilst this represents a continued improvement on the previous 12 months, there is still significant work required. Achieving full compliance will require a continued focus on, and ownership of, the Resilience & Business Continuity Work Programme. Key areas for improvement are shown below: Develop the Trust s CBRN capability to ensure it is fully compliant with NHS England s Core Standards. Enhance Business Continuity arrangements in order that they are aligned to ISO Increase emphasis on incident training at tactical and strategic level. ACTION REQUIRED: RISK TO THE TRUST (include reference to BAF or Corporate Risk Register) WORKFORCE ISSUES: (including training and education implications) DIVERSITY & INCLUSION: FINANCIAL IMPLICATIONS: Specify No/Yes (Detailed within the report). COMMUNICATION/CONSULTATION ISSUES (including patient and public involvement) STRATEGIC OBJECTIVE: (specify trust strategic objectives To receive and note the report. Not applicable Requirement for A&E staff to be appropriately trained on decontamination equipment (CBRN). Requirement for Senior Managers on Call and Directors on call to undertake one day incident response training. Equality Impact is Neutral Not Applicable Not Applicable Standard Contract 2016/17 (SC30 Emergency Preparedness, Resilience and Response CQC DOMAINS Safe Effective Well Led Chairman: Graham Foster Chief Executive: David Sissling

2 Affiliated Teaching Hospital RESILIENCE AND BUSINESS CONTINUITY ANNUAL REPORT 2015/16 1. BACKGROUND 1.1 The Trust is required to self asses its own performance against the core standards set by NHS England. This report documents where the Trust is fully compliant with the requirements and also the areas that have need of improvement. Copies of the self-assessment and work plan for the forthcoming year have been attached as part of this report. 2. OVERVIEW 2.1 The Trust is required to comply with the Core Standards set by NHS England and the obligations for a Category 1 responder as defined by the Civil Contingencies Act, There are 12 core standards and the table below summarises the Trust s position in summary. Further details are attached in the reports. NHS Core Standards KGH FT Self-Assessment Ratings with definitions (out of 12 core areas) Green = Fully compliant with Core Standards Light Green = Substantially compliant in the majority of assessed area Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months. Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months. 6 core standards (50%) 3 core standards (25%) 3 core standards (25%) Nil 3. POLICY 3.1 Emanating from the self-assessment process is a work programme for the forthcoming year (2016/17). This document demonstrates how the Trust s Resilience and Business Continuity Manager will prioritise the workload and bring the Trust s capabilities up to the standards required by the NHS England Core Standards. 4. RISK 4.1 Risks identified within EPRR work are by their nature likely to be of high impact, with low likelihood. As a consequence, risks identified during the EPRR process are recorded at the local level (Department). Chairman: Graham Foster Chief Executive: David Sissling

3 5. DATA QUALITY Not Applicable. 6. FINANCIAL IMPLICATIONS 6.1 Not Applicable 7. ACTION REQUIRED BY THE BOARD 7.1 Receive and note the report. IMRAN DEVJI DEPUTY CHIEF OPERATING OFFICER Chairman: Graham Foster Chief Executive: David Sissling

4 RESILIENCE & BUSINESS CONTINUITY ANNUAL REPORT 2016/17 Shaun Thompstone - Head of Clinical Operations Mark Engledow Resilience & Business Continuity Manager July 2016 Agenda item 9.6 Appendix 1

5 Contents Executive Summary Introduction Regulatory framework Resilience & Business Continuity structure Disruptive events in 2014/ Key achievements in 2014/ Compliance v statutory regulations /16 work programme Work, Exercise & Training Programme Risks Monitoring progress Conclusion...7 Appendix 1 NHS England EPRR Core Standards...8 Appendix 2 Trust Resilience & Business Continuity Work Programme (as at July 2016)...9 Agenda item 9.6 Appendix 2

6 Executive Summary 2015/16 has seen progress in a number of important areas relating to the Trust s resilience. Over the course of the last 12 months progress has been made in a number of areas as we strive to develop a robust and value adding resilience programme. Highlights include: Validation of the county and regional Mass Casualty plans. Adoption of the command and control protocol in planning and management of the Junior Doctor s Industrial Action. Trust Pandemic Preparedness and Response Plan exercised, updated. Closer working relations with health economy and responding agencies through Northamptonshire Resilience Forum, the Local Health Resilience Partnership. Development of training programmes for Senior Managers on Call, which has been aligned to the National Occupational Standards Whilst this represents a continued improvement on the position reported 12 months ago there is still significant work required to enable the Trust to declare full compliance with NHS England s Emergency Preparedness, Resilience and Response (EPRR) core standards. Achieving this important goal will require a continued strong focus on, and ownership of, the Resilience & Business Continuity Work Programme at strategic, tactical and operational level along with a closer alignment of resilience with the operational agenda. Key areas for improvement over the forthcoming months include: ensuring that the Trust is capable of meeting the CBRN requirements outlined in the EPRR Core Standards, closer alignment of Business Continuity arrangements with ISO2301, development of a full site evacuation plan, continued provision of emergency/business continuity response training for key roles. Agenda item 9.6 Appendix 3

7 1. Introduction This report outlines the Trust s progress in relation to Resilience & Business Continuity for the period September 2014 to the end of August 2016 and sets out the priorities for the next 12 months. 2. Regulatory framework As an Acute NHS trust, KGH has legal obligations relating to Resilience and Business Continuity. Along with CQC Registration and Monitor s Compliance Framework this has formed the backbone of the regulatory framework to which KGH has had to comply in recent years. This framework includes the Civil Contingencies Act (2004), the Health and Social Care Act (2012), the NHS Standard Contracts and NHS England s Emergency Preparedness Resilience and Response (EPRR) Core Standards (2013), NHS England Command and Control (2013) and NHS England Business Continuity Management Framework (2013). 3. Resilience & Business Continuity structure Following a re-organisation, the Capacity & Resilience Team has been re-established within the organisation, bringing Resilience & Business Continuity closer to the day to day operation. This has helped towards the continued integration of resilience into the operational mind-set of the organisation. The role of the Resilience & Business Continuity Manager, which has responsibility for the day to day development, coordination and management of the Resilience & Business Continuity work programme, is now firmly established within the organisation. The Trust continues to see an improvement in the engagement of executives and senior management via the Emergency Preparedness Resilience and Response (EPRR) Group. As a result the ownership of the Resilience & Business Continuity Work Programme and its delivery is now more widely seen as being a Trust-wide issue than had previously been perceived. The EPRR Group continue to challenge non-delivery or late completion of actions. Recent work includes: working in partnership with other healthcare providers, Nene CCG and NHS England to develop a three year LHRP Work Programme, which encompasses risk management, capabilities mapping, integrated planning, training and exercising, publication of the revised Business Continuity Plan, planning for and support during the Junior Doctor s Industrial Action, completion of the Initial Operational Response decontamination training for A&E staff and additional training for strategic and tactical level incident management which will be provided in July and September, Externally the Trust continues to be represented at the Northamptonshire Resilience Forum, the Local Health Resilience Partnership and the associated Health Resilience Working Group. Through membership of these groups the Trust demonstrates its commitment to interoperable working in regard to the risks and threats that may impact upon Northamptonshire. Additionally, links developed through working in these groups will enable, not only a more cohesive response within the health economy, but also across the county. 4. Disruptive events in 2015/16 The Resilience & Business Continuity programme exists to ensure the Trust can respond to any reasonably foreseeable disruptive event (a list of these can be found on the Northamptonshire Community Risk Register). During the last year, the Trust has faced two noticeable challenges, the first of these being localised flooding in Rockingham wing, which was effectively and efficiently dealt with using well-rehearsed local business continuity arrangements. Additionally the Trust planned for and managed a series of disruptions as a consequence of the Junior Doctor s Industrial Action. These incidents involved significant planning and effectively utilised the Trust s Command and Control Structure. The industrial action not only enabled the Trust to test the effectiveness of its internal business continuity arrangements, but also provided the opportunity to test external links with other Northamptonshire healthcare providers and Nene/Corby CCG, via the Health Economy Tactical Co- Agenda item 9.6 Appendix 4

8 ordination Group. The resilience and flexibility of staff within the Trust were key to the successful way in which these incidents were dealt with. 5. Key achievements in 2015/16 Amongst the key achievements in the last 12 months are: A revised Corporate Business Continuity Plan Management of the Junior Doctor s Industrial Action. Closer working with other healthcare providers in Northamptonshire through the Health Economy Tactical Working Group. Trust Pandemic Preparedness and Response Plan reviewed, exercised and updated. Provision of training aligned to the National Occupational Standards for Directors on Call, Senior Managers on Call and loggists. Maintenance of dedicated Resilience and Business Continuity Pages on KNet Business continuity planning and management as a consequence of the disruption caused by building works above the main theatre block and its impact on Pharmacy and Pathology. 6. Compliance & statutory regulations The standards by which we are evaluated have changed little in the last year, although this year s assurance process incorporates deep dives into business continuity and Chemical, Biological, Radiological and Nuclear (CBRN) decontamination. Of the 57 core standards for 2016/17, 37 address generic emergency preparedness/response and business continuity issues, 6 are specific to the business continuity issues and the remaining 14 are specific to the Trusts hazardous materials response capabilities. Within the generic domain of emergency preparedness and business continuity the Trust is able to assess itself as being fully compliant against 32 core standards with the Trust being non-compliant against 5 core standards. The attached action plan describes how these areas will be improved. The main issues being the need to develop closer alignment to business continuity standard ISO 22301, develop a full site evacuation plan and ensure full compliance on CBRN issues. Within the business continuity deep dive, there are six core standards. Here the Trust is fully compliant on four standards, but is required to develop a more accurate Strategic Impact Assessment that incorporates Maximum Tolerable Periods of Disruption (MTPD) for each critical function. Addressing the Trust s ability against specific CBRN core standards has proved challenging in the last year. In January the area set aside for deployment of the decontamination tent was lost as a consequence of the expansion of A&E. The Resilience and Business Continuity Manager has sought the assistance of Estates, EMAS and Northamptonshire Fire and Rescue in order to identify a suitable alternative site. However, such a location has been difficult to identify. Staff training and maintenance of PPE continues to be conducted as far as possible, but in order for this matter to be addressed a decision is required as to whether to invest in a facility built into the structure of the Trust, or use a demountable structure. The full self-assessment against Core Standards, can be found at appendix 1 with a summary of compliance against the major elements shown below: NHS Core Standards KGH FT Self-Assessment Ratings with definitions (out of 12 core areas) Green = Fully compliant with Core Standards 6 core standards (50%) Light Green = Substantially compliant in the 3 core standards (25%) majority of assessed area Amber = Not compliant but evidence of progress 3 core standards (25%) and in the EPRR work plan for the next 12 months. Red = Not compliant with core standard and not in Nil the EPRR work plan within the next 12 months. Agenda item 9.6 Appendix 5

9 Core Standard for EPRR To meet with the core standard you need to ensure the below have procedures or are in place Fully compliant Substantially compliant Not compliant (included in work plan) Not in place Key Gaps 1 Governance 2 Duty to assess risk 3 4 Duty to maintain plans emergency plans and business continuity plans Command and Control arrangements The Trust is required to enhance its CBRN capability. Requirement to complete full site evacuation plans. Business continuity arrangements need to be closer aligned to ISO Duty to communicate with the public 6 Information Sharing mandatory requirements 7 Co-operation 8 9 Training and Exercising Business Continuity (Deep Dive) Maintain a personal development log of all on call Directors and Senior Managers in order that the Trust can demonstrate training compliance at the tactical and strategic level. The trust is not fully compliant against two core standards. In order to rectify this situation there is a need to review the current strategic Business Impact Assessment and closer align the Trust to ISO Hazardous Materials - CBRN There is a need to identify a suitable approach to decontamination. 10 Hazardous Materials - Decontamination equipment Identification and procurement of outstanding resources 11 Hazardous Material - Training CBRN training leads in A&E have been trained. Awaits identification of suitable site and resources. Agenda item 9.6 Appendix 6

10 /17 Work Pogramme The detailed and prioritised work programme setting out the actions required across the Trust in the next year can be found at appendix 2. This addresses the gaps identified against the EPRR Core Standards document in appendix 1. Key areas for improvement in 2016/17 are: development of the Trust s CBRN capabilities, closer alignment of business continuity arrangements with ISO22301 and development of a full site evacuation plan. All three areas are currently being addressed by the Resilience and Business Continuity Manager and work will be progressed over the forthcoming year to the timescale indicated in the Work Programme. The Emergency Planning Resilience and Response Group reviewed and approved the work programme and its initial priorities. Areas considered to be fully compliant have been incorporated into the work programme as there is a need to ensure that reviews and updates are conducted as required. Filters have been applied to the document in order to assist identifying areas that are not fully compliant and where significant work is taking place. 8. Work, Exercise & Training Programme Risks As in previous years, the timescales set out in the work programme may be subject to change in the event of emerging situations. Delivery of the programme is largely dependent on appropriate CBU and / or Directorate resources being made available where and when required. The experiences of previous years indicate that this is the single biggest contributor to delays in delivery. The lack of the Trust being able to provide decontamination to presenters has been identified as a risk for the Trust and will be presented to the Risk Management and Steering Group in July. Changing external priorities from commissioners, NHS England or other regulatory bodies, along with the need to respond to disruptive challenges may result in further changes to the work programme. 9. Monitoring progress Progress against the Resilience & Business Continuity Work Programme will be monitored on a monthly basis by the EPRR Group and reported through to the Trust Management Committee. 10. Conclusion The work conducted during 2015/16 has taken the Trust forward in a number of areas, but a great deal of important work remains. It is essential that work continues with the same, or greater momentum achieved over the last year and that resilience remains high on the Trust agenda. Providing progress continues and appropriate resources are allocated, the Trust will move to a position whereby it can be confident it can declare itself fully compliance with regulatory requirements. Agenda item 9.6 Appendix 7

11 Appendix 1 NHS England EPRR Core Standards The EPRR Core Standards spreadsheet has 5 tabs: Introduction - this tab,. outlining the content of the other 4 tabs and version control history EPRR Core Standards tab - with core standards nos 1-37 (green tab) Business Continuity tab:- with deep dive questions to support the review of business continutiy planning for EPRR Assurance (blue tab) with a focus on organisational fuel use and supply. HAZMAT/ CBRN core standards tab: with core standards nos Please note this is designed as a stand alone tab (purple tab) HAZMAT/ CBRN equipment checklist: designed to support acute and NHS ambulance service providers in core standard 43 (lilac tab) KGH core-standards-eprr 20 Agenda item 9.6 Appendix 8

12 Appendix 2 Trust Resilience & Business Continuity Work Programme KGH Work Programme Core-Stan Agenda item 9.6 Appendix 9