Review of the EPRR Assurance Statement / Action Plan. Alison Whitehead, Head of Resilience. Fiona Noden, Director of Performance and Operations

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1 Trust Board Part 1 Agenda Item 14. Date: Title of Report Purpose of the report and the key issues for consideration/decision Review of the EPRR Assurance Statement / Action Plan For the Board to review and note. Prepared by: Name & Title Alison Whitehead, Head of Resilience Presented by: Fiona Noden, Director of Performance and Operations Action Required (please X) Approve Adopt Receive for information Strategic/Corporate Objective(s) supported by this paper Is this on the Trust s risk register? No Yes If Yes, Score Which Standards apply to this report? CQC NHSLA BAF Objectives WWL Wheel Have all implications related to this report been considered? Finance Revenue & Capital National Policy/Legislation NHS Contract Human Resources Consultation/Communication Other: If action required please state: Yes/No/ Any Action Required Equality & Diversity Patient Eperience Governance & Risk Management Terms of Authorisation Human Rights Carbon Reduction Yes/ No/ Yes Any Action Required No Previous Meetings Please insert the date the paper was presented net to the relevant group ECC Audit Quality & Safety Finance & Investment Management Board IM&T Strategy HR NED Other Na Na Na Na Na Na Na Na

2 Emergency Preparedness, Resilience and Response (EPRR) Board Assurance Update In November, 2014, the Trust was required to submit to the CCG a statement of against the Emergency Preparedness, Resilience and Response Core Standards. The Trust declared substantial as follows: Compliance Level Full Substantial Partial Non-compliant Evaluation and Testing Conclusion The plans and work programme in place appropriately address thee entire core ss that the organisationn is epected to achieve. The plans and work programme e in place do not appropriate ely addresss one or more the core d themes, resulting in the organisation being eposed to unnecessary risk. The plans and work programme in place do not adequately address multiple core themes; resulting in the organisation nal eposure to a high level of risk. The plans and work programme in place do not appropriate ly address several core d themes leaving the organisation open to significant error in response and /or an unacceptably high level of risk. Where areas required further action, this is detailed in the following core s improvement plan and will be reviewed inn line with the Organisation s EPRR governance arrangements. The Trust Board is requested to acknowledge the on-going work towards achieving full which will be achieved withinn the net si months.

3 Core description After every significant incident a report should go to the Board or appropriate delegated governing group. Risk assessments are informed by, consulted with and shared by this organisation and relevant parties Have arrangements for: mass countermeasures, mass fatalities Access to 24 hour radiation protection supervisor in line with local arrangements A report needs to be drafted after every significant incident and be presented to REMC / Board Risk assessments need to be shared / consulted with relevant parties e.g. LA, CCG There are GM plans in place and these need referencing to ensure staff are aware of them Identify local arrangements and ensure that this information is available Information sharing protocols Identify protocol for sharing ensure appropriate with LRF communications with Consider social networking partners tools Process to be implemented whereby a report goes to REMC / Board and actions monitored at this body Risk assessmentss will be shared / consulted with relevant parties Update the intranet, training, etc. to these plans Identify local arrangements andd put this information in the Decon Room and in the CBRN Plan Identify local protocol for sharing information. Consider the use of social networking sites and formalise if appropriate December 2014 December 2014 December 2014 Current Status EPRR standing agenda item Via HERG and WRF Intranet and training updated Information available with the decon Trust uses social media to share information including with partner agencies included in Comms Strategy

4 Core description Arrangements for responding Identify eisting arrangements to an incident affecting two or and ensure that thesee are more LHRP / LRFs made available locally Arrangements for responding Identify eisting arrangements to an incident affecting two or and ensure that thesee are more regions made available locally Plans define links between NHS England, Dept of Health Identify eisting arrangements and PHE including how and ensure that thesee are information will be coand shared made available locally ordinated Demonstrate organisation More multi-agency eercises wide appropriate participation neededd to be able to increase in multi-agency eercises participation Identify eisting arrangements Identify eisting arrangements Identify eisting arrangements Ensure that all appropriate personnel are encouraged to attend multi- disciplinary eercises June Current Status Plans in place cross boundary / GM wide Not achieved Head of EPRR for GM and Lancs recently in post and will clarify arrangements Where appropriate, noted in Plans Relevant personal are encouraged to attend, however, there have been a limited number of eercise locally or regionally

5 37 Core description All incident managers (on- call managers and eecutives) maintain a continuous personal development portfolio demonstrating EPRR training and / or incident / eercise participation All incident managers to ensure they maintain a portfolioo relating to EPRR All incident managers to ensure they maintain a portfolio relating to EPRR including mandatory training, eercises, etc. Current Status From April, all SMOCs / EXOCs will be provided with evidence of training attended for portfolio HAZMAT / CBRN decontamination risk assessments are in place Decontamination capacity available 24 / 7 List of required competencies Impact assessment of CBRN decontamination on other key facilities Insufficient CBRN trained staff Create list of competencies Undertake impact assessment Undertake training with all relevant personal in A&E Not achieved Impact assessment to be conducted post Ebola as decon has moved Further training has been provided around CBRN and VHF PPE etc. Training ongoing

6 Core description Accurate inventory of Routine checks on There is a preventative programme of maintenance in place for Sufficient number of trained decontamination trainers Update inventory Once inventory updated, put a processs in place for regular checking Equipment is checked as required but this does not form a formal programme of work / funding Need more trainers Update inventory Once inventory updated, put a process in place for regular checking Create a programme of maintenance for decon Identify staff and ensure they receive the relevant training Current Status Not achieved Inventory to be taken now Isolation Room fully equipped for VHF Not achieved Inventory to be checked post 43 Not achieved Programme to be implemented post 43 Further training has been provided around CBRN and VHF PPE etc. Training ongoing

7 Core description Current Status HAZMAT / CBRN Equipment E1.3 Repair kit E1.4 Tethering E17 Poly boom E18 Min 20 disrobe packs E19 Min 20 re-robe packs E26 Tabbards for decon team Chemical Equipment E27 Assessment Kits (ChEAKs via PHE) Discussions with Estates If required r by F&R Service DH, PHE and NHS England in discussions about procurement Purchased Under discussion Purchased Purchased On order Awaiting direction from DH and PHE