CCG BOARD MEETING Emergency Preparedness, Resilience and Response

Transcription

1 CCG BOARD MEETING Emergency Preparedness, Resilience and Response 1. Executive Summary 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). The NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) are the minimum standards which NHS organisations and providers of NHS funded care must meet. The director level accountable emergency officer and/or governing body in each organisation is responsible for making sure these standards are met. These standards are reviewed and updated as lessons are identified from testing, national legislation and guidance changes and/ or as part of the rolling NHS England governance programme. 2. Introduction A paper was presented to the Board in January 2015 which set out the CCG s 2014 selfassessment against the EPRR core standards and the associated work plan arising from this self-assessment. This paper provides an update on this work plan as well as the timescales and expectations of the 2015 assurance process. The CCG s work plan will be revised subject to the outcome of this year s assurance process. 3. Background NHS England and Public Health England are Category 1 Responders under the Civil Contingencies Act 2004 (CCA). As such NHS England is the lead agency for the Page 1 of 28

2 management of the NHS response to Major Incidents, whilst Public Health England is the lead agency for incidents involving public health outbreaks. CCGs are Category 2 Responders under the Civil Contingencies Act 2004 and are required to co-operate with Category 1 Responders and other Category 2 Responders and share key EPRR information. The role of CCGs as Category 2 responders in summary is to: Ensure contracts with provider organisations, including providers of NHS funded care, contain relevant emergency preparedness, resilience (including business continuity) and response elements. This will include ensuring provider processes and plans are fit for purpose including escalation procedures when hospitals are under pressure. Support NHS England in discharging its EPRR functions and duties locally. This requires 24/7 on call arrangements to be in place locally to support any actions in response to major incident. Provide a route of escalation for the Local Health Resilience Partnership (LHRP) should a provider fail to maintain necessary EPRR capacity and capability. Fulfil the responsibilities as a Category 2 responder under the CCA including maintaining business continuity plans for their own organisation. Be represented on the LHRP (either on their own behalf or through representation by a lead CCG). Seek assurance that provider organisations are delivering their contractual obligation. BaNES CCG is a member of the Avon & Somerset LHRP, but also links with the LHRP covering Gloucestershire, Swindon and Wiltshire. The LHRP is a group which brings together a range of organisations to help enhance and coordinate a multi-agency response to an emergency or major incident. The LHRP is committed to assessing and assuring the ability of the local health community to respond effectively to EPRR requirements. Providers and CCGs are required to carry out a RAG rated self-assessment against the NHS England EPRR Core Standards as part of the assurance process and to provide an improvement plan, together with presenting a statement of compliance to the Board. The CCG s Accountable Emergency Officer is the Head of Commissioning Development. The CCGs Urgent Care Network Programme Lead is the Tactical lead for management of the CCGs EPRR and system management response. The CCG also has an Emergency Planning Officer (EPO) in place with specific emergency planning expertise and skills. 4. Work Programme Update Appendix 1 sets out the current work programme updated to reflect the progress that has been made since January The Board is asked to note the key improvement areas as follows: Duty to maintain plans the CCG s business continuity plan is currently being updated in light of scenario testing with staff in June. The CCG s major incident plan will also be Page 2 of 28

3 tested and reviewed later in the year. The on-call pack has been updated with legislative guidance and fuel disruption plan. Command and Control a review of the staff identified as loggists has been completed with work progressing to recruit additional staff to support the incident control centre. A training plan has also been developed to raise staff awareness of EPRR roles and responsibilities. Additional on-call equipment in line with national guidance is being purchased. Training and exercising a programme of training activities and training materials has been developed and written by the EPO and is set out in appendix 3. Through the LHRP, the CCG will review the demand for externally delivered courses including Strategic Leadership and Tactical Leadership in a Crisis and Surviving Public Enquiries. 5. Core Standards Assurance Process for 2015/16 NHS England published guidance for the 2015/16 EPRR assurance process on 20 th May The format and process will be very similar to that run in 2014/15. NHS England EPRR teams and LHRPs have been asked to conduct the assurance process during quarter 2 and quarter 3 of 2015/16. During quarter 4, the central EPRR team will meet with regional teams to receive the results of the local assurance process conducted. Following this the NHS England Board will receive an EPRR report providing them with the required assurance on the NHS in England and NHS England. This will also inform the Department of Health about EPRR assurance. Organisations who receive NHS funding will carry out a self-assessment against the NHS England EPRR core standards including acute providers, ambulance service providers, community service providers (this includes NHS Trusts, Foundation Trusts and social enterprises), mental health service providers, clinical commissioning groups and NHS England regional and national teams. Primary care (including out-of-hours primary care) will not be included in the 2015/16 EPRR assurance process. However, in BaNES BDUC will be required to complete a selfassessment on the basis they manage the Urgent Care Centre at the RUH. All organisations participating in the 2015/16 assurance process will need to ensure that their Boards are sighted on the level of compliance achieved, the results of the selfassessment and the action/work plan for the forthcoming period. It is expected that the evidence provided to reviewing organisations will be a copy of the organisation s paper to the relevant Board or Governing Body detailing: A declaration of the level of compliance achieved The results of the organisation s self-assessment against the NHS England EPRR core standards A resulting action/work plan stemming from their self-assessment against the core standards The results of a deep dive into Pandemic Flu preparedness. Page 3 of 28

4 Organisations will be expected to state overall whether they believe they are fully, substantially, partially or non-compliant with the NHS England core standards. These are set out below: Compliance Level Full Substantial Partial Non-compliant Evaluation & Testing Conclusion The plans and work programme in place appropriately address all the core standards that the organisation is expected to achieve. The plans and work programme in place do not appropriately address one or more of the core standards that the organisation is expected to achieve. The plans and work programme in place do not adequately address multiple core standards that the organisation is expected to achieve. The plans and work programme in place do not appropriately address several of the core standards that the organisation is expected to achieve. Should an organisation, following completion of its self-assessment, consider itself noncompliant then the LHRP will seek further evidence from that organisation. The core standards are set out in appendix 2, but the changes made for 2015/16 are as follows: Inclusion of Pandemic Influenza questions to support the pandemic influenza deep dive for EPRR Assurance in 2015/16 Inclusion of the Hazardous Area Response Team (HART) service specification for ambulance service providers and the reference to this in the EPRR Core Standards Inclusion of the Marauding Terrorist Firearms Attack (MTFA) service specification for ambulance service providers and the reference to this in the EPRR Core Standards Updated the requirements for primary care to more accurately reflect where they sit in the health economy Updated the requirement for acute service providers to have Chemical Exposure Assessment Kits (ChEAKs) (via Public Health England) to reflect that not all acute service providers have been issued these by PHE and to clarify the expectations for acute service providers in relation to supporting PHE in the collection of samples for assisting in the public health risk assessment and response phase of an incident, should this be required. The Avon & Somerset LHRP have set out their timeframes for the assurance process. By the end of September all organisations, including the CCG, needs to have completed and submitted their self-assessments to the CCG. The CCG will be responsible for carrying out assurance review meetings with providers which should take place during the months of Page 4 of 28

5 October and November. The expectation is that the CCG s accountable emergency officer will present the detailed system findings to the LHRP s executive meeting in December. The CCG will be undertaking assurance of the RUH, Sirona and BDUC. Gloucestershire CCG will undertake Arriva s assurance process on behalf of the other CCGs who commission the non-emergency patient transport service. There will be several stages for assurance in relation to the South West Ambulance Service which will be led by NHS England. Avon & Wiltshire Mental Health Partnership Trust s assurance process will be taken forward by the lead CCG. The CCG s assurance meeting with NHS England is anticipated to be on the back of the September CCG assurance meeting with NHS England South Central. Further details about the format, timings and who should be involved are still to be agreed. The CCG is liaising with South Gloucestershire CCG about Sirona s assurance process on the basis that the CCG s Emergency Planning Officer (EPO) also acts as the EPO for Sirona as well as the fact that both CCGs commission services from the provider. 6. Financial Impact The costs associated with the CCGs response is included within the budgets previously approved by Board. There are no additional costs associated with the assurance process. 7. Risks and Mitigating Actions The Avon & Somerset LHRP maintains a risk register for the whole health community and this has been used to inform the CCGs assessment of risks locally. Key risks from the LHRP risk register which impact on the CCG currently mainly relate to the development of plans within the new NHS landscape to manage specific events such as flu pandemic, mass casualty or radiation leakage within the resources available. There is also a key risk in relation to the CCG s ability to sustain a response to protracted incidents. Locally, the CCG s EPO reviews the LHRP risk register on a monthly basis which in turn informs the CCG s overall partnership risk register. The EPO also participates in the Tactical Local Health Resilience Partnership meetings on a quarterly basis and is involved in discussions and planning exercises to help mitigate these risks. The CCG also participates in the Strategic LHRP meetings 8. Conclusion and Next Steps The CCG has made progress in implementing the core standards over the last six months, but further training is required to enhance the CCG s on-call team s understanding of what to do in the event of a major incident or business continuity incident. Page 5 of 28

6 The timescales and next steps associated with the 2015/16 core standards assurance process are stated in section 5 above. 9. Recommendations The Board is asked to note the updated work programme and the Core Standards Assurance Process for 2015/16. The Board is recommended to receive by February 2016 the following: A declaration of the level of compliance achieved The results of the organisation s self-assessment against the NHS England EPRR core standards A resulting action/work plan stemming from their self-assessment against the core standards The results of a deep dive into Pandemic Flu preparedness. 10. Appendices Appendix 1 EPRR Work Plan Appendix /16 Core Standards Appendix 3 Training Schedule Page 6 of 28

7 Appendix 1: EPRR Work Programme Strategic Lead Tactical Lead Operational Lead Corinne Edwards, Head of Commissioning Development Dominic Morgan, Urgent Care Network Programme Lead Felicity Hudd, Emergency Planning Officer CCG Work Programme Work Area Activity Owner Priority Progress Start Date End Date Status Deadline if applicable Duty to maintain plans Organisations have an annual work programme to mitigate risks and incorporate lessons identified relating to EPRR and improve response. Annual work plan. Annual plan to be presented to board. All key staff to be made aware of the work plan. FH Complete but will be an open document to add new risks/ projects but will maintain open to add new risks/ projects too. Green FH Complete Green N/A FH Med Complete but will be an open document but will maintain ongoing updates. Green N/A N/A Effective arrangements are Relevant plans are fit for FH BC plan in review. Amber N/A Page 7 of 28

8 in place to respond to the risks in the CCG, appropriate to the role, size and scope and there is a process to ensure the likely extent to which types of emergencies will place demands on your resources and capacity. Command and Control Arrangements include a procedure for determining whether an emergency of business purpose. On Call staff trained to understand local plans. Adopt LHRP plans Pandemic Influenza. Adopt LHRP plans Fuel Disruption Decision Making Process to be identified. Inventory of resources to be developed. MI plan scheduled to be reviewed. FH On Call Pack developed and 1 to 1 mtgs held with key staff. FH Added legislation to On Call Pack for reference. New plan not been issued at present and indicated on LHRP risk register. FH Added legislation and plan to On Call Pack for reference. FH Process added to the On Call Pack and Inventory displayed within the Appendices of Green N/A Awaiting data from NHS England and A&S LHRP. Amber N/A Green N/A Green N/A Page 8 of 28

9 continuity incident has occurred. Identify resources we have and develop a wish list. Documents identify where and how an incident will be managed from i.e. An ICC and how to operate. Identify and develop plan for required resources to enhance EPRR service delivery. Training Pack to be developed and exercise to be delivered using the ICC. Review the staff list for Loggists/ ICC/ IRM s. Review resources and identify additional needs/ purpose for further equipment/ assets. the On Call pack for reference. FH Training pack developed, training programme dates set. Exercise to be delivered. FH Advertise EPRR support staff for ICC s and developed training plan to raise staff awareness on roles and responsibilities required. FH Med Training wish list reviewed using Nat Guidance and meeting with other CCG s additional On Call equipment Amber N/A Green Although advert recently posted for CCG to become more flexible in manpower. Working in liaison with Office Manager to identify key staff from admin team Green N/A Page 9 of 28

10 Duty to Communicate with the Public Arrangements Warning and demonstrate Informing plans in warning and place to ensure informing comms are processes for resilient in house. incidents. Identify key risks which may affect resilience with communications and connectivity accessing data. Identify local risks in relation to communications and review back up arrangements. being purchased. TM Med Comms have been added to the On Call pack for staff to notify in the event of an incident. TM Med Comms are developing a guide to how to talk to the media in the event of an incident, looking at key FH/ TM/ J messages. FH reviewing BC plan and identifying risks with key partners and looking at back-up solutions Green N/A Amber N/A Amber N/A Have arrangements in Warning and Informing plans in TM/ FH Med Exercise Bugle embedded into Green N/A Page 10 of 28

11 place for resilient comms as practicable, based on risk. Training and Exercising On Call staff are able to demonstrate their awareness of plans and their on call responsibilities. On Call staff participate in NHS England Bugle Exercises monthly. On Call staff participate in Exercise Teleconferences monthly. place to ensure comms are resilient. On Call Pack developed, 1 to 1 meetings held with team, updates provided on a monthly basis or where required to keep staff informed. Cascade exercises set by NHS England. New addition to training calendar for LHRP. On Call Pack and Comms made aware of process. FH On Call Pack developed, periodic updates circulated to inform staff on any changes. FH/ On Call Team FH/ On Call Team Developed simple On Call instructions of what to do in receipt of telephone call. Developed guidance and prepared On Call staff with briefing on notification of upcoming exercise Green N/A Green Added PHE into the cascade on their request Monthly Exercises Green N/A On Call staff in house training: Develop EPRR workbook on FH/ CCG Developed EPRR Partial complete. N/A Page 11 of 28

12 Basic awareness of EPRR legislation and responsibilities. staff Workbook to gain full CCG understanding of roles and responsibilities. On Call staff in house training: Set up the ICC On Call staff in house training: Working with your loggist On Call staff in house training: Working with your ICC staff On Call staff in house training: Shared peer to ICC training planned for admin, content written; undertake a walk-through of capabilities to freshen staff s awareness. Content written. Plan to deliver with admin team. Content written. Plan to deliver with admin team. Plan sessions for peer to peer training across On FH/ On Call team FH/ On Call team FH/ On Call team FH/ CE/ TC/ On Call Circulated to admin CCG staff in first instance. ICC resources identified need to walk through and refresh staff ICC capabilities. Scheduled with admin team training. Scheduled with admin team training. Liaise with Corinne and Tracey to Work content complete but will stay Amber until scheduled training date, once delivered, item turns green. N/A As above N/A As above N/A On-going periodically N/A Page 12 of 28

13 peer learning Call team. team organise. On Call staff in house training: Role Play exercise FH/ On Call team N/A Introduction to EPRR and my role within the CCG for Admin Team. Review the EPRR opportunities available. EPRR workbook discussion and Q&A. ICC volunteer and review the setup. Incident Response Room Manager Develop training session. Develop training session. Develop training session. Develop training session. Develop training session. FH/ Admin Team FH/ Admin Team FH/ Admin Team FH/ Admin Team FH/ Admin Team Developed training content. Content to be delivered on date shown. Developed training content. Content to be delivered on date shown. Developed training content. Content to be delivered on date shown. Developed training content. Content to be delivered on date shown. Developed training content N/A N/A Will turn green once training has been undertaken. N/A As above N/A As above N/A Page 13 of 28

14 responsibilities. ICC familiarisation site visits to NHS England. Exercise admin components role play. Review of External Standard Training across CCG staff. Liaise and book visits through NHS England. Develop training exercise using training session content. Training records captured for On Call staff and maintained in staff portfolios. FH/ Admin Team FH/ Admin Team FH/ CCG Content to be delivered on date shown. Awaiting confirmation through NHS England. Developed mini role play scenario to test ICC and Loggist capability. Recognise which staff have undertaken external training and which require courses. August 2015 August 2015 As above N/A As above. N/A On-going when new staff join CCG. Green N/A Page 14 of 28

15 Appendix 2: Core Standards for Assurance 2015/16 (Core Standards for CCG identified below) NHS England Core Standards for Emergency preparedness, resilience and response v3.0 The attached EPRR Core Standards spread sheet has 6 tabs: EPRR Core Standards tab - with core standards no s 1-37 (green tab) Pandemic Influenza :- with deep dive questions to support the pandemic influenza 'deep dive' for EPRR Assurance (blue) tab) HAZMAT/ CBRN core standards tab: with core standards no s Please note this is designed as a stand-alone tab (purple tab) HAZMAT/ CBRN equipment checklist: designed to support acute and ambulance service providers in core standard 43 (lilac tab) MTFA Core Standard: designed to gain assurance against the MTFA service specification for ambulance service providers only (orange tab) HART Core Standards: designed to gain assurance against the HART service specification for ambulance service providers only (yellow tab). This document is V3.0. The following changes have been made: Inclusion of Pandemic Influenza questions to support the pandemic influenza deep dive for EPRR Assurance Inclusion of the HART service specification for ambulance service providers and the reference to this in the EPRR Core Standards Inclusion of the MTFA service specification for ambulance service providers and the reference to this in the EPRR Core Standards Updated the requirements for primary care to more accurately reflect where they sit in the health economy update the requirement for acute service providers to have Chemical Exposure Assessment Kits (ChEAKs) (via PHE) to reflect that not all acute service providers have been issued these by PHE and to clarify the expectations for acute service providers in relation to supporting PHE in the collection of samples for assisting in the public health risk assessment and response phase of an incident, should this be required. Page 15 of 28

16 CCGs Governance Core standard Clarifying information Evidence of assurance Organisations have a director level accountable emergency officer who is responsible for EPRR (including business continuity management) Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response. Lessons identified from your organisation and other partner organisations. NHS organisations and providers of NHS funded care treat EPRR (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s) - lessons identified from exercises, emergencies and business continuity incidents - restructuring and changes in the organisations - changes in key personnel - changes in guidance and policy Ensuring accountable emergency officer's commitment to the plans and giving a member of the executive management board and/or governing body overall responsibility for the Emergency Preparedness Resilience and Response, and Business Continuity Management agendas Having a documented process for capturing and taking forward the lessons identified from exercises and emergencies, including who is responsible. Appointing an emergency preparedness, resilience and response (EPRR) professional(s) who can demonstrate an understanding of EPRR principles. Appointing a business continuity management (BCM) professional(s) who can demonstrate an understanding of BCM principles. Being able to provide evidence of a documented and agreed corporate policy or framework for building resilience across the organisation so that EPRR and Page 16 of 28

17 4 Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response. Arrangements are put in place for emergency preparedness, resilience and response which: Have a change control process and version control Take account of changing business objectives and processes Take account of any changes in the organisations functions and/ or organisational and structural and staff changes Take account of change in key suppliers and contractual arrangements Take account of any updates to risk assessment(s) Have a review schedule Use consistent unambiguous terminology, Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested; Key staff must know where to find policies and plans on the intranet or shared drive. Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. Include references to other sources of information and supporting documentation Business continuity issues are mainstreamed in processes, strategies and action plans across the organisation. That there is an appropriate budget and staff resources in place to enable the organisation to meet the requirements of these core standards. This budget and resource should be proportionate to the size and scope of the organisation. Page 17 of 28

18 Duty to assess risk The accountable emergency officer will ensure that the Board and/or Governing Body will receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and those adequate resources are made available to enable the organisation to meet the requirements of these core standards. 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. There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers. After every significant incident a report should go to the Board/ Governing Body (or appropriate delegated governing group) Must include information about the organisation's position in relation to the NHS England EPRR core standards self-assessment. Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for: severe weather (including snow, heat wave, prolonged periods of cold weather and flooding); staff absence (including industrial action); the working environment, buildings and equipment (including denial of access); fuel shortages; surges and escalation of activity; IT and communications; utilities failure; response a major incident / mass casualty event supply chain failure; and associated risks in the surrounding area (e.g. COMAH and iconic sites) There is a process to consider if there are any internal risks that could threaten the performance of the organisation s functions in an emergency as well as external risks e.g. Flooding, COMAH sites etc. Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving risk assessments Version control Consulting widely with relevant internal and external stakeholders during risk evaluation and analysis stages Assurances from suppliers which could include, statements of commitment to BC, accreditation, business continuity plans. Sharing appropriately once risk assessment(s) completed Page 18 of 28

19 Duty to maintain plans emergency plans and business continuity plans 8/ 9 There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners. Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive): Other relevant parties could include COMAH site partners, PHE etc. Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan)) corporate and service level Business Continuity (aligned to current nationally recognised BC standards) Severe Weather (heat wave, flooding, snow and cold weather) Pandemic Influenza (see pandemic influenza tab for deep dive questions) Fuel Disruption Surge and Escalation Management (Inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care) Infectious Disease Outbreak Evacuation Utilities, IT and Telecommunications Failure Aim of the plan, including links with plans of other responders Info about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions Trigger for activation of the plan, alert/ standby procedures Activation procedures Identification, roles and actions Identification, roles and actions including communications Relevant plans: demonstrate appropriate and sufficient equipment (Inc. vehicles if relevant) to deliver the required responses identify locations which patients can be transferred to if there is an incident that requires an evacuation; outline how, when required (for mental health services), Ministry of Justice approval will be gained for an evacuation; take into account how vulnerable adults and children can be managed to avoid admissions, and include appropriate focus on providing healthcare to displaced populations in rest centres; include arrangements 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; make sure the mental health needs of patients involved in a significant incident or emergency are met and that they are discharged home with suitable support ensure that the needs of self-presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are met. for each of the types of emergency listed evidence can be either within existing response plans or as stand-alone arrangements, as appropriate. Page 19 of 28

20 Location of incident co-ordination centre (ICC) Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents Complementary generic arrangements of other responders (including acknowledgement of multiagency working) Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes Contact details of key personnel and relevant partner agencies Plan maintenance procedures (Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006)) Enable an identified person to determine whether an emergency has occurred - Specify the procedure that person should adopt in making the decision - Specify who should be consulted before making the decision - Specify who should be informed once the decision has been made (including clinical staff) Decide: - Which activities and functions are critical - What is an acceptable level of service in the event of different types of emergency for all your services - Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation s functions, espec critical activities Explain the de-briefing process (hot, local and multi-agency, cold) at the end of an incident. Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnel Page 20 of 28

21 NHS England published competencies are based upon National Occupation Standards. 10 Ensure that plans are prepared in line with current guidance and good practice which includes: This should be proportionate to the size and scope of the organisation. Being able to provide documentary evidence that plans are regularly monitored, reviewed and systematically updated, based on sound assumptions: Being able to provide evidence of an approval process for EPRR plans and documents Asking peers to review and comment on your plans via consultation Using identified good practice examples to develop emergency plans Adopting plans which are flexible, allowing for the unexpected and can be scaled up or down Version control and change process controls List of contributors References and list of sources Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental health services). 11 Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources. On call Standards and expectations are set out Include 24-hour arrangements for alerting managers and other key staff. Page 21 of 28

22 13 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. 14 Command and Control (C2) 15. 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 Arrangements include a debrief process so as to identify learning and inform future arrangements Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event and about: - Any immediate actions to be taken by responders - Actions the public can take - How further information can be obtained - The end of an emergency and the return to normal arrangements Communications arrangements/ protocols: - have regard to managing the media (including both on and off site implications) - include the process of communication with internal staff - consider what should be published on intranet/internet sites - have regard for the warning and informing arrangements of other Category 1 and 2 responders and other organisations. Specify who has been consulted on the relevant documents/ plans etc. Page 22 of 28

23 Duty to communicate with the public Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary. Those on-call must meet identified competencies and key knowledge and skills for staff. Documents identify where and how the emergency or business continuity incident will be managed from, i.e. the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist. Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident. Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised These must take into account and include DH (2007) Data Protection and Sharing Guidance for Emergency Planners and Responders or any guidance which supersedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 duty to communicate with the public, or subsequent / additional legislation and/or guidance. NB: mutual aid agreements are wider than staff and should include equipment, services and supplies. Explain how the emergency on-call rota will be set up and managed over the short and longer term. Training is delivered at the level for which the individual is expected to operate (i.e. operational/ bronze, tactical/ silver and strategic/gold). For example strategic/gold level leadership is delivered via the 'Strategic Leadership in a Crisis' course and other similar courses. Arrangements detail operating procedures to help manage the ICC (for example, set-up, contact lists etc.), contact details for all key stakeholders and flexible IT and staff arrangements so that they can operate more than one control/co0ordination centre and manage any events required. Page 23 of 28

24 information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response. 22 Examples include completing of SITREPs, cascading of information, supporting mutual aid discussions, prioritising activities and/or services etc. 23 Information Sharing Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents. Arrangements ensure the ability to communicate Have emergency communications response arrangements in place Be able to demonstrate that you have considered which target audience you are aiming at or addressing in publishing materials (including staff, public and other agencies) Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders Using lessons identified from previous information campaigns to inform the development of future campaigns Setting up protocols with the media for warning and informing Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads'. Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes. Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work. Have arrangements in place for resilient communications, as far as reasonably practicable, Page 24 of 28

25 mandatory requirements internally and externally during communication equipment failures. based on risk. 24 Staff are clear about their roles in a plan Training is linked to the National Occupational Standards and is relevant and proportionate to the organisation type. Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the purpose of ensuring that the plan(s) is effective Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective Co-operation Arrangements contain information sharing protocols to ensure appropriate communication with partners. Exercises consider the need to validate plans and capabilities Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested parties. Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live exercise at least once every three years. Where possible channelling formal information requests through as small as possible a number of known routes. Sharing information via the Local Resilience Forum(s) / Borough Resilience Forum(s) and other groups. Collectively developing an information sharing protocol with the Local Resilience Forum(s) / Borough Resilience Forum(s). Page 25 of 28

26 26 27 Training And Exercising Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate) Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained. If possible, these exercises should involve relevant interested parties. Lessons identified must be acted on as part of continuous improvement. Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective Social networking tools may be of use here. Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and membership is quorate. Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups Taking lessons learned from all resilience activities Using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to consider policy initiatives Establish mutual aid agreements Identifying useful lessons from your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and membership is quorate. Page 26 of 28

27 Arrangements include a training plan with a training needs analysis and on-going training of staff required to deliver the response to emergencies and business continuity incidents Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work. Demonstrate organisation wide (including on call personnel) appropriate participation in multi-agency exercises Preparedness ensures all incident commanders (on call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation. Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups Taking lessons learned from all resilience activities Using the Local Health Resilience Partnership to consider policy initiatives Establish mutual aid agreements Identifying useful lessons from your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Health Resilience Partnership to share them with colleagues Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area Taking lessons from all resilience activities and using the Local Health Resilience Partnership and network meetings to share good practice Being able to demonstrate that people responsible for carrying out function in the plan are aware of their roles Through direct and bilateral collaboration, requesting that other Cat 1. And Cat 2 responders take part in your exercises Refer to the NHS England guidance and National Occupational Standards For Civil Contingencies when identifying training needs. Being able to demonstrate lessons identified in exercises and emergencies and business continuity incidents have been taken forward Programme and schedule for future updates of training and exercising (with links to multi-agency exercising where appropriate) Comms exercise every 6 months, table top exercise annual/ live exercise at least every three years Page 27 of 28

28 Appendix 3: Training Schedule EPRR Training Programme for CCG Staff No: Training/ Type: Date/ Time: Room/ Venue: 1 Introduction to EPRR and my EPO role within the CCG Fri 26 th June John Plas 2, Bath Discussion based 1pm to 3pm 2 Review the EPRR opportunities available Fri 26 th June John Plas 2, Bath Discussion based 1pm to 3pm 3 EPRR work book/ review together Fri 3 rd July John Plas 2, Bath Review work book/ Q&A session 1pm to 3pm 4 ICC volunteer and look at the setup Fri 10 th July John Plas 2, Bath Review action cards and physically set up equipment Incident Response Room Manager and responsibilities 2pm to 3:30pm 5 Loggist Training Fri 17 th July John Plas 2, Bath PowerPoint/ Discussion based, with group tasks 1:30pm to 5pm 6 ICC Familiarisation Site Visit to NHS England Bewley House and Sanger House Fridays in August Hayley Bray to confirm 2 sessions Bewley House NHS England Sanger House NHS England 7 Exercise the components of recent EPRR learning s -Admin team Fri 28 th August John Plas 2, Bath & Admin Team office Role Play exercise 1pm to 4:30pm 8 On Call Team working with your loggist and understanding their Sept dates to be agreed with To be set role On Call Team 9 On Call Team working with your ICC volunteer and Sept dates to be agreed with To be set understanding their role On Call Team 10 Exercise full team in role play October Date TBC To be set to include full CCG Page 28 of 28