Overview of NHS England Core Standards for Emergency Preparedness Response and Resilience (EPRR) 2014

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1 Item 8.2 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD TO BE HELD ON WEDNESDAY 26 NOVEMBER 2014 Overview of NHS England Core Standards for Emergency Preparedness Response and Resilience (EPRR) 2014 Strategic or Regulatory Requirement to which the paper reports NHS England' s Core Standards for Emergency Preparedness, Resilience and Response (EPRR) ACTION: The Trust Board is being asked: To note progress made in the last twelve months in meeting the NHS England Emergency Preparedness, Resilience and Response Core Standards and to note the work highlighted proposed to achieve compliance. To update the Board on the current position of the Trust in meeting NHS England' s Core Standards for Emergency Preparedness, Resilience and Response (EPRR) and in maintaining on-going compliance. Executive Summary All NHS Trusts must comply with the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) under the Health and Social Care Act The Core Standards provide a consistent and detailed suite of requirements and a platform for assurance. As part of the assurance process NHS Trusts are required to provide their NHS England Area Team with an annual update on their progress against the Standards. In submitting its initial return in October 2013, the Trust assessed itself as future compliant for a number of the standards. In line with this year's requirement, the 2014 self-assessment was endorsed and submitted to the NHS Area Team on 24th October 2014 by Sue Hartley, Executive Director of Nursing who acts as Accountable Emergency Officer (AEO) under the Health and Social Care Act A copy of the return is included at Appendix 2 for information. The 2014 return demonstrates relatively limited progress since last year, resulting in continued partial compliance against the Standards. This is in measure a consequence of the departure in July 2014 of the Trust's in-house Emergency Planning Officer. As a result of this, Executive Directors of Operations and Nursing agreed for the post to be transferred to the Governance department within the Risk and Safety team and identified scope for savings to be achieved in relation to rationalising common areas of work particularly with the Trust Security Management specialist. An external assessment of the Trusts emergency planning arrangements has been undertaken following the transfer of responsiblity and this has identified a number of areas which require improvement. A programme of work has been identified to be delivered by end December 2014 which will result in: I. A new core standard compliant Business Continuity Management (BCM) Policy II. A combined Major Incident and Business Continuity Plan and supporting materials which, in addition to achieving the necessary Core Standards compliance will better suit the structure and services delivered by the Trust III. Associated training and exercising programme IV. Establish sufficient infrastructure to be able to demonstrate a cost saving for future years 1 P age

2 This work is being supported by external expertise which has been procured to establish a sustainable framework for business continuity management. BOARD DIRECTOR SPONSOR: Sue Hartley, Executive Director of Nursing REPORT AUTHOR: Peter Hughes Associate Director of Governance APPENDIX: Appendix 1 Copy of Progress report submission Core Standards compliance. 2 P age

3 1. Background 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 as part of the Health and Social Care Act They are intended to provide a consistent framework for self-assessment, peer review and more formal control processes carried out by NHS England and regulatory organisations. To comply fully with the Core Standards, NHS organisations and providers of NHS funded care must demonstrate as a minimum that they: Have nominated a suitable Accountable Emergency Officer (AEO) who will be responsible for EPRR. Contribute to area planning for EPRR through Local Health Resilience Partnerships (LHRPs) and other relevant groups. Have suitable, up to date plans which set out in detail how they: o Plan for, respond to and recover from major incidents and emergencies as identified in local and community risk registers. o Maintain continuous service when faced with disruption from identified local risks. o Resume key services that have been disrupted by, for example, severe weather, IT failure, an infectious disease, a fuel shortage or industrial action. This planning should follow the principles of ISO and PAS Test these plans through: o A communications exercise every six months. o An Incident Control Room (ICR) exercise every six months. o A desktop exercise once a year. o A major live or simulated exercise every three years. Have suitably trained, competent staff and the right facilities available around the clock to effectively manage a major incident or emergency. Share their resources as required to respond to a major incident or emergency. As part of the assurance process NHS Trusts are required to provide to their NHS England Area Team with an annual update on their progress against the Standards. In October 2013 a detailed Red/Amber/Green-rated self-assessment against each of approximately 120 individual Standards and an associated action plan to address any shortfall in compliance was submitted to the NHS England Birmingham, Solihull and Black Country Area Team. In submitting its return at this time, the Trust assessed itself as future compliant (Amber) for a number of the standards. Following a mid-year review in May, for October 2014 EPRR Core Standards progress reporting took the form of a straightforward update against areas of non-compliance in the Trust's initial 2013 return, including where appropriate revised compliance ratings. In line with this year's requirement, this update was endorsed and submitted to the NHS Area Team on 24th October 2014 by Sue Hartley, who acts as its Accountable Emergency Officer (AEO) under the Health and Social Care Act A copy of the return is included at Enclosure 2 for information. 3. Key Issues The Self-Assessment and Action Plan submitted for the 2014 return has been drafted on the basis that arrangements are in hand to develop a new Major Incident & Business Continuity 3 P age

4 Plan and associated Business Continuity Policy and supporting materials will be accepted and, as a consequence, proposals delivered by end December As a result associated Core Standards can legitimately be rated as Amber (Compliance scheduled but not yet achieved). In the context of the Core Standards, successful development and rollout of this work is key to delivering substantial compliance and to providing on-going assurance that the Trust, in line with current NHS best practice, has: a. Clearly identified those key services which, if interrupted for any reason, would have the greatest impact upon the community, the health economy and the organisation. b. Identified and reduced the risks and threats to the continuation of these key services. c. Developed plans which enable the organisation to maintain and/or recover core services in the shortest possible time. d. Clear command and control and reporting frameworks to support decision making during the management of incidents of varying source, scale and complexity e. The required infrastructure in place to support the management of major incidents. This includes access to Incident Control Rooms and Logists. f. Appropriately trained staff at all levels in their roles during the management of incidents g. Routinely tests its resilience in maintaining key patient care during the management of incidents. 4. Recommendation to the Board The Board is asked both to note progress made in the last twelve months in meeting the NHS England Emergency Preparedness, Resilience and Response Core Standards and to endorse the further work identified. 4 P age

5 PROGRESS AGAINST 2013 ACTION PLAN TO IMPROVE CORE STANDARDS COMPLIANCE Insert Organisation name Birmingham & Solihull Mental Health NHS Foundation Trust Insert Organisation type(s) Mental Health Insert name & title of completing officer TBC Insert name & title of authorising officer Sue Hartley Insert submission date 24/10/ Self Assessment 2014 Mid Year Update Oct 2014 Self Assessment Ref NHS Core Standards for Emergency Preparedness, Resilience & Response (EPRR) 2013 Self Assessment Red (arrangements not in place or scheduled for completion after Jan 2014) Amber (Draft/scheduled for completion Dec 2013) Actions Identified in 2013 to Improve Compliance Against Core Standards (including timescales) Progress to Date Self-Assessment - Current Position Green - now complete Amber - scheduled for completion by end June 2014 Red - No progress/scheduled for completion after end June 2014 Progress to Date Self-Assessment - Current Position Green - now complete Amber - scheduled for completion Red - No progress/scheduled for completion 4.1 System Assurance for Emergency Preparedness Organisations must have an annual work programme to reduce risks and learn the lessons identified relating to EPRR (including details of training and exercises). This work programme must link back to the National Risk Assessment (NRA) and Community Risk Register (CRR). Complition of sign off of EPRR report to designated committee Plan of work developed by EPRR Lead and EPRR Manager, Reports to be signed off within Trust Planning and Development Committee as required Plan of work developed by EPRR Lead and EPRR Manager in consultation with BounceBack Solutions. Reports signed off within Trust Planning and Development Committee as required 4.2 Organisations must maintain a risk register which links back to the National Risk Assessment (NRA) and Community Risk Register (CRR). BCM development process on going and reactionary to changes within Trust structure, service delivery configuration BCM development continues, initial focus on in-patient settings, then to be rolled out to Community teams, this is over and above the already in place 'Individual Team Local Action Plans (0-6hr +) New BCM Policy which is informed by ISO22301 and PAS2015 to include risk assessmsnt methodology which links back to the NRA and CRR to be developed and in place by end Dec Incident Response Plan - 'Preparedness' be based on risk-assessed worst-case scenarios; 5.3 make sure that the funding and resources are available to cover the EPRR arrangements; 5.7 Interoperability refer to all other associated plans identified by local, regional and national risk registers; Completion/ progress in relation to Business Continuity Impact Analysis process Consideration of development of specific stand alone budget for EPRR within BSMHFT Review of MI/BC plan to include / refernce Local, Regional and National risk registers / reference BSBC-AT IRP Business Continuity Impact Analysis across Trust continues in line with new service area configurations There is no direct funding (Specific budget) available to cover EPRR arrangements, funding would be via services, issue has been discussed within Trust MI/BC plan reviwed and ammendments made, subject to periodic review Workplan to work with all service area to complete business disruption risk assessments in line with proposed new BCM policy for completion by end Dec 2014 To be addressed through new ISO compliant BCM Policy including clear roles and responsibilities re. Funding. Refinement of Action Cards within Major Incident / BCM Plan to include setting up of cost/budget codes to record and monitor expenditure. To be developed and in place by end Dec Governance be approved by the relevant board; review of MI/BC plan to include reporting structure, currently this is within ToR 5.14 be signed off by the appropriate Senior review of MI/BC plan to include sign off Responsible Officer; process by Responsible Officer 5.20 include an audit trail to record changes and updates; Ammendment sheet has been developed but not approved at this time MI/BC plan reviewed and ammendments made, subject to periodic review Mi/BC plan is signed off by Responsible office following review Ammendment sheet developed following each/ any review of MI/BC plan - on going as MI/BC plan reviewed periodically 5.21 explain how predicted and unexpected spending will be covered and how a unique cost centre and budget code can be made available to track costs; and Development of a specific Finance Advisor Action Card Development of Finance action card ongoing Finance Adviser Action Card to be included as element of new Major Incident and Business Continuity Plan To be developed and in place by end Dec demonstrate a systematic risk assessment process in identifying risks relating to any part of the plan or the identified emergency. Development of a specific Finance Advisor Action Card Development of Finance action card ongoing Proposed Major Incident and Business Continuity Plan will refer explicitly in main content and in Action Cards to use of existing Policies and Strategies as appropriate. New Trust Business Continuity Policy will refer to use of risk registers. Risk Assessment methodology to be evidenced in new Plan. To be developed and in place by end Dec Staff Competence & Training There must be an annual work programme setting out training and exercises relating to EPRR and how lessons will be learnt Key knowledge and skills for staff must be based on the National Occupation Standards for Civil Contingencies. Directors on NHS on-call rotas must meet NHS published competencies. Develop/ review work programme Annual work plan developed, subject to review at EPRR group and EPRR manager supervision West Midlands EPO Network developing guidance on NOS and training requirements Progress has been made and work is anticipated to be completed by the West Midlands Health Emergency Planning Network by end November 2014

6 5.26 It must be clear how awareness of the plan will be maintained amongst all staff (for example, through ongoing education and information programmes or e-learning). Consideration and Development of a staff training plan to suppliment current awareness training / loggist training and exercise programme - consider development of e-learning Plans being developed to have all senior staff with specific roles trained via HEPT / PJ. E-learning package for more general awareness 5.27 It must be clear how key staff can achieve and maintain suitable knowledge and skills Incident 'Response' Include 24-hour arrangements for alerting managers and other key staff, and explain how contact lists will be kept up to date Explain how extended working hours will apply and how they can be sustained. Explain how handovers are completed. To be considered as part of ALL staff with specific role - as layed out/ identified in Action Cards - section Appendix D of MI/BC plan Add Incident management cascade / escalation diagram to MI/BC plan Action Cards reviewed and awareness sessions offered to staff with specific roles Incident management cascade diagram added to MI/BC plan Trust is currently reviewing its On-Call arrangements, consideration of emergency planning has been part of this process, New On-Call due to come into place Action Cards to be included in new Major Incident and Business Continuity Plan to be 5.55 Threat Specific pandemic flu; Completion of review process in preparation for potential incident/ outbreak 6.2 Incident Co-ordination Centre - 'Response' There must be detailed operating procedures to help manage the ICC (for example, contact lists and reporting templates). 7.1 Service 'Resilience' make sure that there are suitable financial resources for their BCMS and that those delivering the BCMS understand and are competent in their roles; Consideration of need for specific operating procedures for Gold EOC Further develoment required as per required evidence Review process on going, via EPRR Group and Infection Prevention Team Issue has been discussed within Trust, As per 5.3, Review process on going, still awaiting national flu pandemic guidance Comprehensive suite of ICC operating procedures, contact details and forms developed and in place Roles and responsibilities to be included in new Business Continuity Policy. Training plan included as Annex to new Major Incident and Business Continuity Plan to be developed and in place end Dec set out how finances and unexpected spending will be covered, and how unique cost centres and budget codes can be made available to track costs; To discuss with Finance Dept with plan to implement dependant on outcome Discussions on-going Finance Adviser Action Card in proposed new Major Incident and Business Continuity Plan to include a role empowered to address unexpected spending including the creation of unique cost centres and budget codes by end Dec develop business continuity strategies for continuing and recovering critical activities within agreed timescales, including the resources required such as people, premises, ICT, information, utilities, equipment, suppliers and stakeholders; and 7.4 develop, use and maintain business continuity plans to manage disruptions and significant incidents based on recovery time objectives and timescales identified in the business impact analysis 7.5 Governance Each organisation s BCMS must be based on its legal responsibilities, internal and external issues that could affect service delivery and the needs and expectations of interested parties. 7.6 Organisations must establish a business continuity policy which is agreed by top management, built into business processes and shared with internal and external interested parties. Review of existing and further development where required On going revew process - post any incident/ service change On going review process, plans are based on Organisations legal repsonsibilities and are reviewed post any incident, activation of plan and in relation to Organisational / service change. Compliention / progess in relation to comprehensive set of Business Contiuity plans across Trust at approriate levels Existing BCM's reviewed - requirement to be specifically included in new Plans and BCM policy to be developed and in place by end Dec 2014 To be explicitly addressed as part of new ISO and PAS 2015 compliant BCM Policy to be developed and in place by end Dec The BCMS policy and business continuity plan must be approved by the relevant board and signed off by the appropriate Senior Responsible Officer. 7.9 There must be an audit trail to record changes and updates such as changes to policy and staffing Organisational Knowledge Plans must be maintained based on risk-assessed worst-case scenarios. review of MI/BC plan to include sign off process by Responsible Officer and approval by relavant boards Ammendment sheet has been developed but not approved at this time Review and robusting of Sec 6 of MI/BC plan Now in place Now in place completed

7 7.13 Risk assessments must take into account community risk registers and at very least include worst-case scenarios for: severe weather (including snow, heatwave, prolonged periods of cold weather and flooding); staff absence (including industrial action); the working environment, buildings and equipment; fuel shortages; surges in activity; IT and communications; supply chain failure; and associated risks in the surrounding area (e.g. COMAH and iconic sites). Plans subject to periodic review or following activation / lessons learned, new guidance from LRF/ Area Team To be addressed expliciitly via new Business Continuity Policy and Major Incident and Business Continuity Plan which will includetrust-wide BDRAs. To be 7.14 Organisations must develop, use and maintain a formal and documented process for business impact analysis and risk assessment They must identify all critical activities using a business impact analysis. This must set out the effect business disruption may have on the organisation and how this will be overcome, including the maximum period of tolerable disruption Organisations must highlight which of their critical activities have been put on the corporate risk register and how these risks are being addressed. Business Continuity development on going across trust Review previous data Data reviewed Consider development of EPRR specific Risk Register Discussion on-going To be explicitly addressed as part of new ISO and PAS 2015 compliant BCM Policy to be developed and in place by end Dec 2014 which includes BIA and BDRA toolkits To be explicitly addressed via procedures outlined in proposed new compliant BCM Policy to be developed and in place by end Dec 2014 including BDRA methodolgy and risk escalation pprocess 7.18 Strategy Plans must set out: the alerting arrangements for external and self-declared incidents, including trigger points and escalation procedures; Add Incident management cascade / escalation diagram to MI/BC plan In place 7.40 Embedded in the Organisation details of the training provided to staff and how the training record is maintained; 7.41 reference to the National Occupation standards for Civil Contingencies and NHS England competencies when identifying key knowledge and skills for staff; (directors of NHS England on-call rotas to meet NHS England published competencies); 7.42 details of the tools that will be used to make sure staff remain aware through ongoing education and information programmes (for example, e-learning and induction training); and 7.43 details of how suitable knowledge and skills will be achieved and maintained. Development of training plan for roles with specific roles, consideration of e- learning package Consider for future usage and to inform Specific Training needs of role specific staff Consideration of development of training plan for role specific staff, consideration of development/use of e- Learning EPRR package Consideration of development of training plan for role specific staff, consideration of development/use of e- Learning EPRR package e-learning package under development Work on-going with West Mids EPO network colleagues to develop NOS specific work/action cards to influence training requirements e-learning package under development e-learning package under development Progress has been made and work is anticipated to be completed by the West Midlands Health Emergency Planning Network by end November 2014