BOARD OF DIRECTORS 31 August 2017

Transcription

1 BOARD OF DIRECTORS 31 August 2017 NURSING, QUALITY AND PATIENT EXPERIENCE NHS ENGLAND S EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE (EPRR) CORE STANDARDS ASSURANCE 2017/ Executive Summary This paper provides a summary of the outcome of the Trust s Emergency Preparedness Resilience and Response (EPRR) self-assessment submission to NHS England for 2017/18. It assures, as far as reasonably practicable, cohesive coordination in all aspects of emergency preparedness, resilience and response across all sites and services provided by the Trust, and outlines the next steps in the assurance process. 2.0 Introduction 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). 3.0 NHS England EPRR Core Standards 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. Page 1 of 11

2 4.0 NHS England EPRR Core Standards Self-Assessment The EPRR Core Standards assurance process is an annual survey which is submitted to NHS England on behalf of the Trust. The purpose of this process is to assess the preparedness of the NHS against common NHS EPRR Core Standards, commencing with a self-assessment. The Core Standards are as follows: Governance Duty to assess risk Duty to maintain plans emergency plans and business continuity plans Command and Control Duty to communicate with the public Information sharing mandatory requirements Co-operation Training and exercising GOVERNANCE DEEP DIVE Hazmat (hazardous material) CBRN (chemical, biological, radiological and nuclear) preparedness, decontamination equipment and training The evidence used by the Trust s Head of EPRR to complete the self-assessment is outlined in appendix 2. The Self-Assessment was subsequently tabled at the Trust Health, Safety, Security and Emergency Preparedness Committee for approval 5.0 Assurance Deep Dive Each year, NHS England uses the EPRR Core Standards assurance process to undertake a deep dive looking at a specific topic relating to emergency preparedness, resilience and response. There has been a significant amount of organisational change over recent years and there is a need to ensure that EPRR is secured appropriately across the Health community. Thus, this year s assurance deep dive was core EPRR organisational Governance and included assurance of areas such as internal organisational EPRR accountability, regular reports to public Board meetings, a realistic work program and a solid training and exercise programme. 6.0 Outcome of Self-Assessment The outcome of the Trust self-assessment showed full compliance with all NHS England EPRR Core Standards. A Statement of Compliance for signature by the Chief Executive and Accountable Emergency Officer is appended to the end of this report. Once signed, this will then be forwarded to NHS England North Midlands and Clinical Commissioners. 7. Process of Assurance Following submission of the self-assessment to NHS England together with the signed Statement of Compliance, NHS England will lead the process to seek assurance that the Trust is able to respond to emergencies and is resilient in relation to continuing to provide safe patient care. This will be in the form a Confirm and Page 2 of 11

3 Challenge meeting between the Trust, NHS England and the Nottingham and Nottinghamshire Clinical Commissioning Groups which will held in October. 8. NHS Strategic Assets In light of the current UK risks and threats, this year s assurance process includes an emphasis on NHS Strategic Assets. These are organisations that are considered to provide vital services. Rampton High Secure Hospital is considered to provide a vital service and, as a Strategic Asset, will be subject to a greater level of scrutiny. NHS England will lead the advanced assurance process with a site visit to Rampton Hospital in October. The visit will consist of representation from NHS England, NHS Improvement and the Lead Commissioner. The team will meet with Dr Julie Attfield, Trust Accountable Emergency Officer, Head of EPRR and key staff at Rampton hospital Conclusion The Board of Directors can be assured that, through the outcome of the selfassessment process the Trust is able to respond to the challenges of threats, hazards and major disruptive events and Civil Protection duties and is fully compliant with the NHS England Core Standards for EPRR 2017/ Recommendations The Board of Directors is asked to: Approve the signing of the formal Statement of Compliance with the NHS England Core Standards for EPRR 2017/18 by the Chief Executive and Accountable Emergency Officer (attached). Caroline Brookes Head of Emergency Preparedness, Resilience & Response August 2017 Page 3 of 11

4 APPENDIX 1 STATEMENT OF COMPLIANCE Nottinghamshire Healthcare NHS Foundation Trust has undertaken a self-assessment against the NHS England Core Standards for EPRR These are the minimum standards which NHS organisations and providers of NHS-funded care must meet. Following self-assessment, and in line with the definitions of compliance stated below, the organisation declares itself as demonstrating Full compliance against the EPRR Core Standards. Compliance Level Full Evaluation and Testing Conclusion Arrangements are in place the organisation is fully compliant with all core standards that the organisation is expected to achieve. The Board has agreed with this position statement. Substantial Arrangements are in place however the organisation is not fully compliant with one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Partial Arrangements are in place however the organisation is not fully compliant with six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Non-compliant Arrangements in place do not fully address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance. I confirm that the above level of compliance with the EPRR Core Standards 2017/18 has been confirmed to the Nottinghamshire Healthcare NHS Foundation Trust s Board of Directors. Ruth Hawkins Chief Executive Dr Julie Attfield Executive Director of Nursing/Accountable Emergency Officer Date of Board of Directors Meeting: 31 August 2017 Date Signed: 31 August 2017 Page 4 of 11

5 APPENDIX 2 EVIDENCE USED TO ENSURE COMPLIANCE WITH THE EPRR CORE STANDARDS 2017/18 The evidence used to assure that arrangements are in place making the Trust fully compliant with all EPRR Core Standards that it is expected to achieve is detailed below. Some evidence is duplicated across two or more Core Standards. 1. EPRR Core Standard: Governance Dr Julie Hall is the Trust Accountable Emergency Officer and has Executive responsibility for EPRR and Business Continuity Management. The Trust Head of EPRR is responsible developing the EPRR and Business Continuity Management Annual Work Plan based on the Civil Contingencies Act 2004, National and Local Risk Registers, NHS Standard Contract, EPRR Core Standards and local knowledge of risks. Assurance of implementation is received through quarterly Divisional Reports tabled at the Trust Health, Safety, Security and Emergency Preparedness Committee. The Divisions each have Risk Registers and Risk Monitoring groups. The Trust has a suit of EPRR policies, procedures and plans (including the Major Incident Response Plan) which are version controlled, reviewed and updated on a regular basis and can be found on the Trust intranet, Connect. The Trust Emergency Preparedness & Resilience Policy 2.06 identifies Trust process for ensuring that plans and policies are developed and maintained to ensure both resilience and compliance with statutory and non-statutory duties under the Civil Contingencies Act 2014 and the NHS England Emergency Preparedness Resilience and Response Framework Learning from Serious Untoward Incidents and major incidents both (internal and external) is reflected in amendments to EPRR policies, procedures and plans where appropriate, following cold debriefs and circulation of post incident reports. The Board of Directors receives bi-annual update reports on EPRR and additional EPRR reports by exception. 2. EPRR Core Standard: Duty to assess risk There is a Trust-wide Risk Management Strategy The EPRR risks, both internal and external, are based on National Assessments, the LRF Risk Register and Community Risk Register. Additional risks are identified through the LRF Resilience Working Group and LRF meetings as wells as Local Health Resilience Partnership meetings as well following the occurrence of major incidents and events. Business Continuity Plans are developed to mitigate risks identified and placed on shared drives in Divisions for access by staff. The highest risks are reviewed regularly by Divisional Risk Monitoring Groups which meeting quarterly. There are Trust-wide plans for a major incident response, fuel shortages, winter resilience and pandemic influenza with local plans for pandemic influenza including staff absence, access to working environments, IT and communications failures, utilities failures, surge and escalation. These are version controlled and reviewed regularly. Page 5 of 11

6 The plans and policies have been shared with partner organisations when requested. The Procurement Department holds responsibility for ensuring that external suppliers are able to maintain their contracts and seek assurances as appropriate. 3. EPRR Core Standard: Duty to maintain plans emergency plans and business continuity plans The Trust has a comprehensive suite of EPRR incident response policies, procedures and plans which sit alongside the Trust Major Incident Response Plan. These include: Heatwave Policy 2.01 Severe Weather Policy 2.02 Dealing with Multiple Enquires (Help Line) Policy 2.03 Preventing Radicalisation or Terrorism (Prevent) 2.04 Evacuation and Shelter Policy 2.05 Emergency Preparedness & Resilience Policy 2.06 Bomb Threat (Incendiary or Explosive Device) Policy 2.07 Emergency Communications Policy 2.08 Hostage Policy 2.11 Lockdown Policy 2.12 Management of Self Presenting Patients HAZMAT/CBRN 2.13 Reporting of Accidents, Incidents and Neat Miss Situations Managing External Inspections, Visits, Accreditations, Reports and Feedback Fire Safety Policy Business Continuity Plan Fuel Resilience Plan Pandemic Influenza Plan Winter Resilience Plan Mass Casualty Plan Evacuation plans exist for key sites including off site evacuation and shelter plans for Rampton High Secure Hospital, Wathwood Medium Secure Hospital, Arnold Lodge Medium Secure Hospital and Wells Road Centre Low Secure Unit. The latter two plans are awaiting approval. Work on these plans has been supported by Commissioners who have engaged the Trust with independent providers. Ministry of Justice approval will be gained for an evacuation of the Forensic Units and contact details are listed in the plans. Off-site plans have also being developed for Highbury Hospital, Millbrook Unit and the Trust services in Bassetlaw Hospital which are being tested later in the year as table top exercises with live exercises with partner agencies early in The Trust Major Incident Response Plan takes into account how vulnerable adults and children will be managed to avoid admissions, and the provision of nursing staff to support healthcare delivery displaced populations in rest centres and survivor reception centre. Arrangements are in place to co-ordinate and provide mental health support to patients and relatives, in collaboration with Social Care if necessary, during and after an incident as required. The mental health needs of and support for patients involved in a significant incident or emergency following discharge are also detailed. The needs of self-presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are detailed in the Trust Management of Self Presenting Page 6 of 11

7 Patients HAZMAT/CBRN Procedure Trust-wide plans are in place for Fuel Shortages, Mass Casualties, Pandemic Influenza. The Trust also has a suite of Infection Control policies. All Directorates have business continuity plans having undertaken risk assessments aligned with best practice guidelines. All Trust EPRR policies, procedures and plans are version controlled with review dates identified. However, if there is learning from internal or external incidents, these will be reviewed and amended as necessary. Activation of such policies, procedures and plans is clearly detailed. A suite of Action Cards have been developed for GOLD SILVER and BRONZE Command. Details of Incident Control Centres are included in the Trust Major Incident Response Plan, as well as a recovery template. EPRR policies, procedures and plans are ratified by the Trust Executive Leadership Team or the Trust Quality Committee with details of ratification shown on the front of each document. Locally developed procedures and plans are approved by the appropriate Divisional Leadership Team. All Trust EPRR policies, procedures and plans, which are flexible and allow for the unexpected so they can be scaled up or down, are circulated to Trust Leadership Council members as part of the consultation process for review and comment and the Trust Health Safety Security & Emergency Preparedness Committee. Whilst EPRR policies, procedures and plans are based on the Cabinet Office Emergency Planning Annexes 5B and 5C as well as the NHS EPRR Framework, they contain references and list of sources. The Trust has 24/7 On Call management rotas both at Executive level and within Directorates; contact details held by 24/7 Switchboard and on mobile phones. The decision to move into Command and Control mode is based on whether or not the event is manageable within normal processes. The decision to escalate an internal incident is usually made by the 1st On Call Manager. In the event of escalation, the 2nd On Call Manager is contacted. They in turn make the decision to contact the Executive Director on Call. Appropriate plans will then be activated. The Executive Director on Call will make the decision if an external incident requires a Command mode response. Directorate Business Continuity Plans identify critical services that must be maintained following the completion of Business Impact Assessments for each key risk identified. Rampton Hospital High Secure Hospital has a suite of plans specific to High Secure Hospital Directions that are issued by the Ministry of Justice. This includes the management of high profile patients. The management of VIPs in included in the Trust Major Incident Response Plan but detailed arrangements are included in the Trust Policy for Managing External Inspections, Visits, Accreditations, Reports and Feedback The Trust Emergency Communications Policy 2.08 and Trust Dealing with the Media Policy 2.10 detail communications and media management arrangements. Page 7 of 11

8 The Trust Leadership Council is consulted on all EPRR policies, procedures and plans when in draft or following review. The members of the Council forward these to Directorate Teams as appropriate for additional comment. The Trust Health Safety Security and Emergency Preparedness Committee is also consulted, as is the Trust Equality and Diversity Sub Committee. Hot and Cold debriefs are detailed in the Trust Major Incident Response Plan. These will be held for Trust staff involved in the incident as well as with partner agencies who may have responded to the incident. The Trust is represented at multi agency debriefs as appropriate. 4. EPRR Core Standard: Command and Control The Trust has 24/7 on call arrangements for 1st On Call Managers and 2nd On Call Managers. In addition, there is 24/7 rota for Executive Directors who provide strategic advice and support. The Exec Director on Call is the single point of contact for the notification by external agencies of a major incident. Training is delivered by accredited trainers at the level at which each individual on call is expected to operate. This includes BRONZE, SILVER, GOLD, Loggist, Intensive Loggist and Business Continuity management training. All courses are based upon the National Occupational Standards. All new Trust Executive Directors attend the Emergency Planning College 'Strategic Emergency and Crisis Management' course. On Call Managers have access to Divisional On Call manuals appropriate to the level of command function they will fulfil. Instructions for establishing a Command and Control Room in the 24/7 accessible buildings identified for an Incident Control Centre (ICC) in the north or south of the county are included. All Trust trained Loggists are provided with a copy of the Trust Loggist Handbook which details setting up the ICC rooms. Hard copies of Action Cards are retained in the ICC Rooms. On Call Managers are invited to attend an Intensive Loggist course to ensure they understand the importance of recording information during a major incident or business disruption. The 2017 e-learning package for Working with A Loggist has been recommended to all on-call managers. Where practical trained Loggists are used to record the decisions and timescales. A list of trained Loggists is available. Minute of meetings are taken by a member of Admin. Situation Reports (SitRep) and Common Recognised Information Picture (CRIP) templates are included in the MIRP for completion by the BRONZE, SILVER and GOLD Commanders as appropriate. These are used to inform management teams as necessary and external agencies as requested. 5. EPRR Core Standard: Duty to communicate with the public The Trust Emergency Communications Policy 2.08 describes the emergency communications response arrangements that are in place. The policy details target audiences including staff, service users, volunteers, the public and other agencies in order to provide information that both encourages and empowers individuals to help themselves during a major incident. It also allows for appropriate information to be circulated ensuring individuals are kept up to date on how an internal situation is being managed and when things are likely to return to normal. It details how the media will be used to support the delivery of such advice and information. The policy Page 8 of 11

9 is updated regularly to reflect lessons learned and reflect useful information or processes previous information campaigns to inform the development of future campaigns. The Trust Dealing with the Media Policy 2.10 also identifies working with the media for warning and informing. All Executive Directors and the Head of EPRR have received media training. Trust staff are advised that they are not expected to speak to the media directly in these policies as well as the Trust Major Incident Response Plan as this will be the role of an Executive Director or the Chief Executive. The Trust Communications Team has systematic processes for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes. The Trust also has a Dealing Multiple Enquiries (Helpline) Policy 2.03 in the event of an incident that is likely to result in many calls to the Trust for information. Trust EPRR policies, procedures and plans are published on the Trust public facing website. The Trust uses Social Media such as Twitter and Facebook In the event of communications failures, key sites have radios to ensure communication is maintained. Mobile phones will also be used as well as Runners will be used to share information and provide updates in the event of a total communications failure as necessary. During the recent Cyber Attack the Trust used Runners to communicate internally as well as setting up WhatsApp Groups and Microsoft Teams App on mobile phones. The use of communication Apps is being given further consideration. The Trust has a Twitter Account and Facebook page managed by the Comms Team for sharing information with the public as part of social networking. 6. EPRR Core Standard: Information sharing mandatory requirements The Trust has Information Sharing Agreements with Health and Social Care partners and police forces as appropriate. The Data Protection Act 1998 and FOI Act 2000 are followed in relation to the sharing information with partners to ensure only appropriate and proportionate information is shared if required. 7. EPRR Core Standard: Co-operation The Trust is represented at Local Resilience Fora (LRF) and LRF Resilience Working Groups by the Heads of EPRR in NHSE North Midlands and Midlands and East (Central Midlands). Minutes, Reports, Plans and Exercise reports are shared from these meetings to ensure sharing of relevant information and lessons learned and good practice. The Trust is represented by the Head of EPRR on several LRF Sub Groups including Humanitarian Assistance and Crisis Support, Exotic Animal Disease, Flu, Fuel and Critical Infrastructure. Mutual aid agreements are reflected in LRF multi agency response plans. Page 9 of 11

10 The Trust is represented at Local Health Resilience Partnership (LHRP) meetings by the Trust Accountable Emergency Officer or deputy, the Head of EPRR. Information provide by NHS is circulated across the Trust as appropriate. NHS England have developed mutual aid agreements and memorandum of understanding of which the Trust is a signatory 8. EPRR Core Standard: Training and exercising The annual EPRR Training Needs and Awareness Plan is based on reviewing need for new staff to undertake training in key Command roles and those requiring refresher training All Trust staff who undertake on call roles have received appropriate training in Command and Control. This is a rolling programme delivered by accredited trainers and reflects National Occupational Standards for Civil Contingencies and NHS England guidance. Staff skills are then tested in live and table-top exercises held across the Trust. Emergency Services colleagues are invited to take part in table-top and live exercises in order to test elements of their organisational plans and to see how they fit in with Trust plans. Lessons learned from exercises are captured in post exercise reports which are then shared at the Trust Health Safety Security and Emergency Preparedness Committee and used to amend plans, policies and procedures as necessary which are then reissued. Lesson shared at the LHRP are also reflected in plans and training scenarios where appropriate. All Trust staff receive information describing major incident arrangements and their roles on joining the Trust. The Trust It also holds table top exercises annually and live exercises at least every three years as a minimum. It also engages in multi-agency exercise where appropriate and facilitates the training of staff from partner agencies that are likely to respond to Trust incidents to ensure they are familiar with sites such as the secure premises. Trust staff also share in training delivered by partner agencies such as the Police (eg shield training, fire response). The Trust takes part in an external Communications exercise run every 6 months by NHS England. 9. EPRR Core Standard: GOVERNANCE DEEP DIVE The Accountable Emergency Officer took the result of the 2016/17 EPRR Core Standards assurance process and annual work plan to the Board of Directors meeting for sign off on 29 September 2016 as part of the EPRR Bi Annual Report. Minutes of Board of Directors meetings are available on the Trust public facing website. The Trust's Annual Report is a tightly governed document driven by the NHS Improvement NHS Foundation Trust Annual Reporting Manual and does not, therefore, include results of the 2016/17 NHS EPRR assurance process. This results are included in the Minutes of the Board of Directors meeting are placed on the public facing Trust website. Page 10 of 11

11 A Non-Executive Director, Stephen Jackson, an active member of the Board of Directors, holds the EPRR portfolio. The Trust Health, Safety, Security and Emergency Preparedness Committee which meets at least quarterly and is Chaired by the Trust Accountable Emergency Officer (AEO), agrees the EPRR work priorities and oversees the delivery of the EPRR function. All meetings are minuted. The Trust Accountable Emergency Officer has attended the Local Health Resilience Partnership on and and Minutes available. When unavailable to attend responsibility is delegated to the Head of EPRR who is also a member of the LHRP. 10. EPRR Core Standard: Hazmat (hazardous material) CBRN (chemical, biological, radiological and nuclear) preparedness, decontamination equipment and training The Trust Managing Self Presenters - HAZMAT/CBRN Procedure 2.13 complies with the NHS London Primary Care HAZMAT/CBRN Guidance. This procedure is version controlled and is reviewed regularly and updated as appropriate. The Trust also has a Bomb Threat (Incendiary or Explosive Device) Policy 2.07 that is version controlled and reviewed regularly. Emergency Response boxes are located at Reception desks and Admin staff are tested on their familiarity with the contents and use thereof during annual walk through Lockdown exercises. All Policies procedures and plans are available on Trust Intranet and in hard copy where appropriate. Decontamination processes are detailed in the Managing Self Presenters - HAZMAT/CBRN Procedure 2.13 and includes check lists and action cards to follow. The Trust will follow the Waste Management Policy where necessary. Staff are made aware of all new policies, plans and procedures which includes who to contact externally to manage/support the incident. In this instance the first point of contacted with be the ambulance services for advice and support. Completed inventory lists are available in the Emergency Response Boxes of items for use if a contaminated individual presents at a Health Centre or other key Trust site. The contents follow best practice guidance in Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities' (NHS London, 2011). Further CBRN/HAZMAT decontamination training recorded in ESR and including bomb threat training and response is arranged for December Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant through Lockdown exercises and training. Reception staff at Health Centres and key Trust sites are identified as key staff in the Trust Management of Self Presenters Procedure Page 11 of 11