Emergency Preparedness, Resilience and Response (EPRR) Core Standard Assessment and Assurance

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1 Agenda Item: 13 Date of Meeting: 3 January 2017 Author: Clinical Lead: CCG Director/Manager: Jeanette George, Chief Operating Officer Mary Backhouse, Chief Clinical Officer Jeanette George, Chief Operating Officer Emergency Preparedness, Resilience and Response (EPRR) Core Standard Assessment and Assurance Recommendations (Endorse, approve, receive, discuss) The Governing Body is asked to: Receive an update on the CCG s status against the EPRR core standards and approve the action plan Receive an update on the level of compliance against the EPRR Core Standards for Weston Area Health Trust and North Somerset Community Partnership. Background The NHS service-wide objective for emergency preparedness, resilience and response (EPRR) is: "To ensure that the NHS is capable of responding to significant incidents or emergencies of any scale in a way that delivers optimum care and assistance to the victims, that minimises the consequential disruption to healthcare services and that brings about a speedy return to normal levels of functioning; it will do this by enhancing its capability to work as part of a multi-agency response across organisational boundaries." EPRR is a process that relies on embedding an effective structure of governance, developing organisational capability and capacity, and ensuring that preparedness activities are integrated with partners through Local Health Resilience Partnership (LHRP) and Local Resilience Forums (LRF). NHSE is committed to operating an assurance process across the country on an annual basis. The NHS England Core Standards for emergency preparedness, resilience and response (EPRR) set out clearly the minimum EPRR standards which NHS organisations and providers of NHSfunded care must meet. The Core Standards are intended to also enable agencies across the country to share a common purpose and to co-ordinate EPRR activities in proportion to the organisation s size and scope; and provide a consistent cohesive framework for self-assessment, peer review and assurance processes. This year s EPRR assurance deep dive topic is Business/Service continuity with an emphasis on 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 including LRFs. Page 1 of 15 Version 1

2 The CCG and providers submitted their self-assessments to NHSE in September 2016 subsequent to this, meetings were held with NHSE to discuss the returns and approve the current position against the standards and corresponding action plans. Purpose The purpose of this the paper is to present the outcome of the 2016/17 EPRR assurance process for the CCG against the 2016/17 EPRR core standards. The paper also presents the corresponding 2016/17 work programme to assure the Governing Body of work to date and future plans to address areas not rated green, as well as the status and progress of provider organisations for which the organisation is responsible. Overview EPRR Assurance Process In July 2016 NHS England (NHSE) published an updated set of the EPRR core standards. Commissioning organisations (including NHSE) are asked to undertake a self-assessment against the relevant individual core standards and rate their compliance. These individual ratings then inform the overall rating of compliance and preparedness for the Avon and Somerset Local Health Resilience Partnership (LHRP) and the NHS overall. In order to achieve a greater level of national consistency the definitions of the overall organisational rating have tightened up. Organisations are expected to state an overall assurance rating as to whether they are fully, substantially, partially or non-compliant with the NHS EPRR Core Standards. The definitions of these ratings have been amended for the 2016/17 process and are detailed below: Page 2 of 15 Version 1

3 The self-assessment is subject to a check and challenge process by NHSE EPRR leads. The Core Standards assurance ratings and rectification (action) plan for each organisation forms the basis of a submission to the LHRP. The LHRP undertakes a formal calibration process via a confirm and challenge meeting. Once this process has taken place organisations are expected to take a statement of compliance to their Governing Bodies or Boards as appropriate. North Somerset CCG also received Self Assessments from the following provider organisations: Weston Area Healthcare Trust (WAHT) North Somerset Community Partnership (NSCP) As the commissioner of these services the CCG is responsible for ensuring that action plans for addressing any areas of non-compliance are managed through our contract arrangements. The assurance review meetings for these providers are led by the NHSE EPRR lead in partnership with the CCG s Accountable Emergency Officer, the Chief Operating Officer. North Somerset CCG In agreement with NHSE, North Somerset CCG has taken a joint approach to the CCG assurance process as it was felt that this would more accurately reflected our collaborative ways of working in respect of the wider EPRR agenda. The CCG worked with Bristol CCG and South Gloucestershire CCG to bring together a single BNSSG CCG response to the EPRR Assurance process. This process has reflected the overall BNSSG wide arrangements that are already in place for mutual support and resilience across BNSSG, as well as local positions but has meant that work has only had to be done once across BNSSG with only one NHSE check and challenge meeting required. The review has shown an improved position on the 2015/16 position with all three CCGs now achieving a 92% compliance, with only 3 individual core standards remaining outstanding. NHSE have noted the level of improved compliance across BNSSG as follows: Bristol CCG moving from Partially Compliant to Substantially Compliant North Somerset CCG moving from Non-Compliant to Substantially Compliant South Gloucestershire CCG moving from Non-Compliant to Substantially Compliant Key outcomes from the assurance review Collectively the BNSSG CCGs are now fully compliant against: Section Core Standard Governance Standard 1-4 Duty to risk assess Standard 5 7 Duty to maintain plans Standard 8 (covering 9 individual plans of which 8 are fully compliant) through to Standard 14 Command and Control Standard Duty to communicate with the public Standard Information sharing Standard 24 Co-operation Standard 25, 30 and 33 Training and Exercising Standard 33, 34, 36 and 37 Remaining outstanding core standards Duty to Maintain Plans Pandemic Flu (Core Standard 8) Co-operation Mutual Aid Arrangements (Core Standard 27) Page 3 of 15 Version 1

4 Training and Exercising Ongoing Exercise Programme (Core Standard 35) Work programme priorities for 2016/17 During the review by NHSE, BNSSG CCG work priorities for 2016/17 were discussed and agreed as follows Pandemic Flu All three CCGs to incorporate Pandemic Flu into BC Plans Mutual Aid Review and strengthen CCG mutual aid agreement Training Programme CCG Training programme to be reviewed to ensure it is aligned and addresses training identified in the LHRP Training needs analysis The BNSSG CCG work priorities are highlighted in yellow in the work programme below. There are also annual activities that each CCG needs to assure NHSE that these have been undertaken to maintain compliance and these are also included in the work programme which is as follows: Core Standard Duty to Assess Risk 1 Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions Core Standard 5 2 There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners Core Standard 7 Duty to maintain plans emergency plans and business continuity plans 3 Corporate and service level Business Continuity (aligned to current nationally recognised BC standards) Core Standard 8 Undertake a full risk assessment as part of the review of the CCGs Business Continuity Plan in December 2016 and present as part of the annual report to Governing Body in January Share risk assessment of the CCGs business continuity plans with other CCGs, SCW CSU, provider organisations, North Somerset Council and NHSE and ask for comment on any gaps and the proposed mitigating actions December February Review and update the CCGs Business Continuity Plan ensuring this is also aligned to Bristol and South Gloucestershire plans wherever possible January - March Pandemic Flu Core Standard 8 Ensure Pandemic Flu plan is fully reflected in all CCGs Business Continuity plans and service level BIA s - January Page 4 of 15 Version 1

5 Core Standard 5 Fuel Disruption Core Standard 8 Ensure Fuel Disruption plan is fully reflected in the CCGs Business Continuity plans and service level BIA s - January Utilities, IT and Telecommunications Failure Core Standard 8 7 Arrangements include how to continue your organisation s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical Core Standard 11 8 Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content Core Standard 13 Duty to communicate with the public 9 Arrangements ensure the ability to communicate internally and externally during communication equipment failures Core Standard 23 Co-operation 10 Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained Core Standard 27 Training and Exercising 11 Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents Core Standard Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work Core Standard 35 Complete Mobilisation of new CSU services to ensure that IT services are fully compliant with BNSSG CCG requirements December 2016 Review and update the CCGs Business Continuity Plan January 2017 Share risk assessment of the CCGs business continuity plans with other CCGs, SCW CSU, provider organisations, North Somerset Council and NHSE and ask for comment on any gaps and the proposed mitigating actions January March Complete Mobilisation of new CSU services for BNSSG CCGs to ensure that IT services are fully compliant with CCG requirements December 2016 Review and update BNSSG CCG Mutual Aid agreement in the light of changing commissioning arrangements March 2017 BNSSG CCGs to review Training programmes to ensure this is aligned and addresses training identified in the LHRP Training needs analysis March 2017 BNSSG CCG EPRR leads to undertake an exercise needs analysis and develop and agree the exercising programme for 2017 January 2017 Page 5 of 15 Version 1

6 Core Standard 13 Preparedness ensures all incident commanders (on call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation Core Standard 37 Develop, agree and implement a preparedness passport for all oncall directors and managers March 2017 Updates will be sought by NHSE at quarterly meetings with CCG leads from the BNSSG area. North Somerset CCG will report internally on assurance through the Quality and Assurance Group on a six-monthly basis. EPRR Assurance - Provider Organisations Weston Area Health Trust (WAHT) There has been a change in approach regarding the compliance ratings for acute providers. The 2015/16 process only took account of compliance against the generic core standards, but this year it has been extended to also include the HAZMAT/CBRN specific core standards, meaning the Trust is now being assessed against a total of 60 individual core standards and not just the original 46. Having assessed the findings from the review meeting the trust is currently achieving 75% compliance against the core standards with 15 individual core standards remain outstanding. The 15 outstanding standards relate to areas of work that potentially carrying significant risk to the Trust and have been outstanding for some time with limited progress in 2015/16. However, the CCG and NHSE have both been reassured by the recent engagement of an interim Emergency Planning Manager for the next 10 months to lead on improving the Trusts position against what is a very challenging EPRR programme of work and hope that this engagement signifies the Trusts commitment to addressing the shortfalls in its current level of compliance. The 2016 review of assurance has shown that the Trust remains non-compliant. Progress against the Trusts work programme will be closely monitored during quarterly EPRR review meetings with the CCG and NHSE as well as via standard contract meetings. Outstanding core standards Duty to Maintain Plans o Corporate and Service Level Business Continuity (Core Standard 8) o Pandemic Flu (Core Standard 8) o Mass Casualty (Core Standard 8) o Fuel Disruption (Core Standard 8) o Surge and Escalation o Evacuation (Core Standard 8) o Lockdown (Core Standard 8) o Excess Deaths / Mass Fatalities (Core Standard 8) o Plans prepared in line with current guidance and good practice (Core Standard 9) o Arrangements on how to continue your organisations prioritised activity (Core Page 6 of 15 Version 1

7 Standard 11) o Arrangements to explain how VIP / High Profile patients are managed (Core Standard 12) Command and Control o On call staff competencies based on National Occupational Standards (Core Standard 16) Training and Exercising o Training plan, with training needs analysis and ongoing training of staff (Core Standard 34) o Ongoing exercise programme (Core Standard 35) o On call directors / managers maintain a continuous personal portfolio demonstrating training and / or incidents / exercise participation (Core Standard 37). Deep Dive The deep dive for 2016/17 has focused on Business Continuity, including fuel and it was evident from the plans produced by the Trust for the review that further work is needed to ensure plans meet current national guidance and are aligned to ISO Key outcomes from the assurance review The assurance review demonstrated continued compliance in a number of areas listed below and improvement in the area of HAZMAT and CBRN which is in recognition of the plan being finalised and exercised during a CBRN event in partnership with Avon Fire and Rescue Services last year. Generic Core Standards Governance Duty to risk assess Duty to communicate with the public Information sharing Co-operation Incidents affecting more than one LHRP Training and Exercising HAZMAT/CBRN Core Standards Preparedness Decontamination Equipment HAZMAT /CBRN Training Agreed work programme priorities for 2016/17 The Trust has been asked to take a risk based approach in developing their work programme, with individual leads identified and clear realistic timescales set. The priorities identified are as follows: Page 7 of 15 Version 1

8 Core Standard 1 Corporate and Service Level Business Continuity (Core Standard 8) Existing plans to be fully reviewed to ensure they meet national guidance and are aligned to ISO Pandemic Flu (Core Standard 8) To be updated and reviewed to ensure it meets national guidance 3 Mass Casualty (Core Standard 8) Internal Standing Operating Procedures to be developed detailing trust response to a mass casualty incident and the management of P1, P2 or P3 patients that may arrive at site. 4 Fuel Disruption (Core Standard 8) Fuel element currently embedded in Trust BC Plan, but fails to detail trust response to a fuel shortage. Appears to be copy and paste of guidance information from the National Plan. Needs full review. 5 Surge and Escalation BNSSG operation surge arrangements in place, but currently no procedures for how trust might link into Burns, Trauma and Critical Care Networks during major / mass casualty incidents. 6 Evacuation (Core Standard 8) Trust to review plan against national guidance and template plan produce by the Avon and Somerset LHRP Acute Trust Sub Group. 7 Lockdown (Core Standard 8) Plan needs to be aligned to national guidance and cover both partial and full site lockdown 8 Excess Deaths / Mass Fatalities (Core Standard 8) 9 Plans prepared in line with current guidance and good practice (Core Standard 9) 10 Arrangements on how to continue your organisations prioritised activity (Core Standard 11) 11 Arrangements explain how VIP / High Profile patients are managed (Core Standard 12) 12 On call staff competencies based on National Occupational Standards (NOS) (Core Standard 16) 13 Training plan, with training needs analysis and ongoing training of staff (Core Standard 34) 14 Ongoing exercise programme (Core As per 13 above Trust has capability to increase capacity which is currently only supported by verbal agreement with partners. Written agreements need to be formalised and signed off. Links to items 1 to 8 above Links to item 1 above. Further work required to embed departmental / service plans into overarching corporate plan to ensure strategic oversight and support strategic decision making Unclear if trust has existing Operation Consort Plan in place. If not needs to be developed and staff briefed No evidence presented during review that this standard is being met. AEO / EP Lead to establish if training records exist showing on call staff are being trained to NOS Trust to develop internal training plan that is aligned to LHRP training needs analysis (TNA) Page 8 of 15 Version 1

9 Core Standard Standard 35) 15 On call directors / managers maintain a continuous personal portfolio demonstrating training and / or incidents / exercise participation (Core Standard 37. Trust to put in place process to maintain robust training plans that demonstrate continuous personal training / incident / exercise portfolio North Somerset Community Partnership (NSCP) The 2015/16 EPRR review process only took account of compliance against the generic core standards for community providers but for 2016/17 this has been extended to also include the HAZMAT/CBRN specific core standards, meaning that Community providers are now being assessed against a total of 50 individual core standards and not just the original 43. The 2016 review of assurance has shown an improved position on last year for NSCP, with them now achieving 90% compliance and only 5 individual core standards not being fully met. This means that NSCP continues to be assessed as substantially compliant. Outstanding core standards Duty to Maintain Plans o Mass Casualty (Core Standard 8) o Evacuation (Core Standard 8) o Lock Down (Core Standard 8) Command and Control o On call staff competencies based on National Occupational Standards (Core Standard 16) HAZMAT Training o Internal Training (Core Standard 49) The review demonstrated that full compliance is being maintained by NSCP in the following areas: Generic Core Standards Governance Duty to risk assess Duty to communicate with the public Information sharing Co-operation Incidents affecting more than one LHRP Training and Exercising HAZMAT/CBRN Core Standards Preparedness Decontamination Equipment Deep Dive Page 9 of 15 Version 1

10 The deep dive for 2016/17 has focused on Business Continuity, including fuel. It is evident from the plans produced for the review that NSCP has very robust business continuity arrangements in place and that they are fully compliant with standards for these areas. Agreed work programme priorities for 2016/17 Work programme priorities for NSCP were agreed at their review meeting led jointly by NHSE and the CCG. These priorities were as follows: 1. Mass Casualties Develop internal Standard Operating Procedure (SOP) for mobilisation of Medical Treatment teams and identify volunteers to be trained as medical team members. 2. Evacuation Plan Plan for Clevedon Community Hospital Plan is complete but requires testing once hospital reopens 3. Lockdown Plan Lockdown procedures for key sites have been finalised, but action cards and staff training needs to be implemented 4. On call staff competencies on call training to be rolled out to new executive members of staff to close down gab created by recent turnover of senior staff 5. HAZMAT / CBRN Training MIU staff training to be incorporated in the annual training programme NSCP is developing a clear work plan to deliver these priorities and this will be monitored through their contract meetings. Best Practise As part of the NHSP EPRR assurance review the following best practice was identified. These areas will be considered for inclusion in the final LHRP report and shared with LHRP partners NSCP has highlighted their internal induction training and the organisations use of Huddle, a cloud based service. They ask all new starters to complete a best endeavours form during their induction training that captures their wider skill base, not just the skills specific to their role and also seeks their interest in using these skills to supporting the organisation during incidents. Huddle is used by NSCP to store all their on call information and response plans and because it is a cloud base system it means that the most up to date documents are always available 24/7 to on-call staff from anywhere that they may have access to the internet, which has provided a greater level of resilience to the organisations response. Financial Impact and Risks There will be some financial impact to meet training requirements and in the event of any incident (Major incident or Business Continuity incident). The CCG is required as part of the assurance to have an identified budget line identified to support this work and support mutual aid arrangements in the event of a major incident Legal Impact There are no legal implications anticipated in relation to this report. Page 10 of 15 Version 1

11 LIKELIHOOD IMPACT 3 4 Governing Body Risk Implications, Assessment & Mitigation CCGs must meet statutory guidance under the Civil Contingencies Act (2004) and the requirements set out in the NHSE Framework and Guidance documents for EPRR that are for both planning and response. This includes ensuring that key provider organisations are able to meet their requirements under this Act. This report shows the current position and actions in place to meet the requirements. The CCGs EPRR responsibilities are risk assessed and key risks and mitigations are on the CCGs risk register which is continually reviewed. Risk Mitigations RISK RATING (Impact x Likelihood) As a result of a lack of an overarching business continuity policy and plan there is a risk that WAHT will be unable to respond robustly an emergency. Which may result in a loss of patient services. Currently in place: 1 Outline Business Continuity plan and Policy in place 2. Updates on progress through IQPQM Contract meetings 3. Chemical, biological, radiological and nuclear (CBRN) Plan tested by WAHT with Avon Fire & Rescue Service in April WAHT have tested the set-up of their Incident Control Centre and were generally assured. 12 Outstanding: 1. Gaps remain on business continuity on a number of emergency plans and not up to required standard. 2. Resilience of responses being discussed with neighbouring Trusts. 3. General concerns around training and exercising 4. Unable to demonstrate they have validated plans in place for: Hospital Evacuation Hospital Lockdown Pandemic Flu Mass Casualties Fuel Disruption Excess Deaths / Mass Fatalities Page 11 of 15 Version 1

12 LIKELIHOOD IMPACT Governing Body Risk Mitigations RISK RATING (Impact x Likelihood) Assurance is lacking that provider organisations can continue to maintain a service during fuel disruption. National contingency reserves currently would not be made available and is need for local arrangements. Other Local plans for Pandemic Flu arrangemnets and Mass Casulty plan still to be finalised 15 Currently in place: 1. The plan is now signed off 2. Some pilot work ongoing in Somerset to see how health and the LA can work together, also try to engage with other LAs. Outstanding: 1. national agreement on how fuel will be distributed to providers in the event of major fuel disruption Lack of coordinated response and special measures in the event of a mass casualty incident due to lack of operational plans and training. This increases the likelihood of substandard care and impacts on the health system. LHRP Mass Casualty Plans including Emergency Treatment Centre (ETC) Standard Operating Procedure for P3 management and how to manage P1s and P2s Plans to be tested in regional mass casualty exercise July Medical Treatment Team SOP signed off by LHRP. Community Health Partners progressing with operational plans and identifying volunteers to become members of the Medical Treatment Team. NHS / SWAST Joint Training package to be developed. LHRP Mass Casualty Response Concept of Operation to be reviewed upon release of NHS England South Mass Casualty Framework. Page 12 of 15 Version 1

13 LIKELIHOOD IMPACT LIKELIHOOD IMPACT Governing Body Risk Mitigations RISK RATING (Impact x Likelihood) National outbreak of Influenza Pandemic leading to up to 50% of population affected across the country making it a national catastrophic incident Robust Influenza Pandemic Plans/ Business Continuity Plans in place across the health system. Part of annual training and exercising calendars for LRF and all NHS organisations 12 LHRP strategic framework in place and exercised through LHRP table top exercise on 5th November 2015Organisational pandemic flu response plans to be in place December NHS England South West to lead of development of operational response plans for Antiviral Collection Points. An ineffectual radiation monitoring unit causing loss of public confidence and ineffective monitoring. Would also cause further strain on NHS resources already stretched by the response A draft national template plan is under consultation however resourcing implications on the local NHS where significant 15 Draft LRF Framework has been produced, but waiting publication of national guidance before final version can be complete. A Business Continuity desk top exercise was undertaken by the CCG in line with our exercise plan in December 2016 and this highlighted the following key risk: Risk Mitigations RISK RATING (Impact x Likelihood) Page 13 of 15 Version 1

14 LIKELIHOOD IMPACT 3 3 Governing Body Risk Mitigations RISK RATING (Impact x Likelihood) Once the CCG migrates to NHS Mail2 its main portal that the CCG s resilience is reduced in the event of a failure of the NHS Mail system thus compromising the CCG s business continuity plans. To be advised. Currently being considered by SCW CSU IM&T. 9 To be advised. Currently being considered by SCW CSU IM&T. Consultation, Involvement and Engagement The CCG is a member of the LHRP and TPG (Tactical planning group). The CCG is required to have a Director/Officer level Accountable Emergency Officer (this is the Chief Operating Officer) who continues to work closely with the NHSE Head of Emergency Preparedness, Resilience and Response to assess and monitor provider organisations compliance and to ensure progress is made within reasonable timeframes. Meeting Date Outcome (Discussed, Agreed, Approved, Rejected) Comments BNSSG CCG Assurance Meeting Oct-16 CCG Self-assessment updated Key priorities agreed WAHT Assurance Meeting Oct-16 WAHT Self-assessment updated Key priorities agreed NSCP Assurance Meeting Oct-16 NSCP Self-assessment updated Key priorities agreed QAG Nov-16 Approved plan agreed Equality Impact Not applicable for this particular update. Equality Impact Assessments are completed for individual plans where applicable. Evidence and Research Not applicable Appendices None Glossary EPRR EPRR stands for Emergency Preparedness Resilience and Page 14 of 15 Version 1

15 Business Continuity Management LRF LHRP ICC Glossary Response. EPRR is defined by a series of statutory responsibilities under the Civil Contingencies Act (2004). This requires NHS-funded organisations to maintain a robust capability to plan for, and respond to, incidents or emergencies that could impact on health or services to patients. Business Continuity Management is generically defined as 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. A Local Resilience Forum is the body that oversees emergency planning and civil contingencies and is coterminous with police boundaries. It comprises senior officials representing all Category 1 Responders, as defined under the Civil Contingences Act 2004, together with key partners. Whilst it is not a statutory body it is seen as the principal mechanism for facilitating multi-agency co-operation across the responding bodies to a major incident. An LHRP is a Local Health Resilience Partnership. LHRPs provide strategic forums for joint planning for emergencies for the new health system and support the health sector s contribution to multi-agency planning through Local Resilience Fora (LRFs). They are not statutory organisations and accountability for emergency preparedness and response remains with individual organisations. Incident Co-ordination Centre - each NHS organisation has the responsibility to provide a suitable environment for managing a significant incident or emergency. This is known as an Incident Coordination Centre as described in the NHS CB Command and Control Framework (2013). It provides a functional space for making decisions and collecting and sharing information quickly and efficiently. Page 15 of 15 Version 1