Major Incident Policy - Southern Health NHS … NCP 56 Major Incident Policy Version: 3 ... Head of...

1 SHFT Major Incident Policy Version 3 April 2016

SH NCP 56

Major Incident Policy

Version: 3

Summary:

This Major Incident policy provides the framework of Emergency Preparedness, Resilience and Response (EPRR) by which Southern Health NHS Foundation Trust (SHFT) will prepare for, respond to and recover from a major incident or emergency regardless of cause utilising the Trust Incident Response Plan (Major Incident Plan).

Keywords (minimum of 5): (To assist policy search engine)

Emergency/major incident preparedness, resilience, response, recovery arrangements.

Target Audience:

All employees of Southern Health NHS Foundation Trust. Non-Executive Directors, Volunteers, Governors and Contractors.

Date Issued: April 2016

Approved and Ratified by:

EPRR Working Group Date of meeting: 29 April 2016

Next Review Date: April 2019

Author:

Philip Rudin, Business Continuity & Emergency Preparedness Officer

Sponsor:

Fiona Richey, Head of Risk & Business Continuity


Version Control

Change Record

Date Author Version Page Reason for Change

14.06.13 T Pettis 1 Numerous Inclusion of information relating to the changes in the NHS

Removal of references to Strategic Health Authorities

Removal of references to Primary Care Trusts

Addition of references to NHS Commissioning Board

Addition of references to NHS England

Addition of cascade alerting arrangements as interim

To this document pending final agreement by NHS England

15.09.2014 T Pettis 2 Production of Incident Response Plan (IRP) to replace existing major Incident policy in line with NHS England EPRR Doctrine.

24.03.2016 P. Rudin 3 Numerous Reflect change of NHS Commissioning Board to NHS England. Changes in definitions and procedures to reflect latest version of NHS England Emergency Preparedness, Resilience and Response Framework published 10 November 2015

Reviewers/contributors

Name Position Version Reviewed & Date

T Pettis Business Continuity & Resilience Manager V1 date: 14.06.13

T Pettis Business Continuity & Resilience Manager V 1 12.06.2014

T Pettis Business Continuity & Resilience Manager & Emergency Preparedness, Resilience and Response Working group (EPRR WG) members

V2 15.09.2014

P. Rudin Business Continuity & Emergency Preparedness Officer, and Emergency Preparedness, Resilience and Response Working group (EPRR WG)

V3 April 2016


Contents

Page

1. Introduction

5

2. Scope

6

3. Definitions 3.1 Major incident or emergency 3.2 Types of incident 3.3 Incident Levels 3.4 Mass casualty incident 3.5 Mutual aid 3.6 Lockdown

6 6 6 7 7 7 8

4. Duties, responsibilities and roles 4.1 The legal context 4.2 Southern Health NHS Foundation Trust planning

responsibilities 4.3 Southern Health NHS Foundation Trust response

responsibilities 4.4 The Chief Executive 4.5 Designated Executive and Non-Executive Directors 4.6 Role of the Director, Divisional and Area Managers

on Call 4.7 Head of Risk and Business Continuity 4.8 Director of Workforce and Communications 4.9 Director of Finance 4.10 Head of Information, Communication and Technology 4.11 Associate Director of Communications and

Engagement 4.12 Divisional Directors, Area and Service Managers 4.13 All Southern Health NHS Foundation Trust

employees 4.14 Southern Health NHS Foundation Trust

responsibilities to its staff 4.15 Southern Health NHS Foundation Trust

responsibilities to vulnerable people 4.16 NHS England, EPRR responsibilities 4.17 NHS England, South EPRR responsibilities 4.18 NHS 111 Services EPRR responsibilities 4.19 Multi-agency responsibilities

8 8 9

9

10 10 11

12 12 13 13 13

14

14 15

15

15 16 16 16

5. Alerting 5.1 Request to a member of Southern Health NHS

Foundation Trust staff 5.2 Southern Health NHS Foundation Trust declaration

of a major incident 5.3 Alerting messages

20 21

21

21

6. Southern Health NHS Foundation Trust major incident response 6.1 On call arrangements 6.2 Role of the Director on Call, Divisional and Area

Managers on call 6.3 Authority 6.4 Establishment of the Southern Health NHS

22

22 22

22 23


Foundation Trust Incident Coordination Centre 6.5 Associated Plans and Action Cards 6.6 Mass casualty response 6.7 Mutual aid

25 25 26

7. Stand down 7.1 Debrief

27 27

8. Recovery

27

9. Record keeping and preservation of documents 9.1 Record keeping and compilation of Logs 9.2 Preservation of documents

28 28 28

10. Training requirements

29

11. Exercising Programme

29

12. Monitoring compliance

30

13. Policy review

30

14. Associated documents

30

15. Supporting references

30

Appendix 1 Training Needs Analysis (TNA) UNDER REVIEW

32

Appendix 2 Equality Impact Assessment

33


Major Incident Policy 1 Introduction 1.1 The aim of this policy is to provide the strategic framework of Emergency

Preparedness, Resilience and Response (EPRR) whereby Southern Health NHS Foundation Trust (SHFT) will prepare for, respond to and recover from a major incident, or emergency, regardless of cause. The policy is divided into 2 parts:

Main body of the policy including emergency preparedness, alerting, response and recovery

Incident response Plan (not available for public disclosure to protect confidential information)

1.2 The objectives of this policy are:

To outline SHFT’s responsibilities for emergency preparedness, resilience, response and recovery, and those of specific divisions and staff members

To define what constitutes a major incident or emergency

To outline the structures, systems, processes and procedures that are in place to ensure that SHFT, in collaboration with partner agencies, is prepared for, can respond to and recover from major incidents and emergencies

To outline the roles and responsibilities of key partner organisations

To outline the national, regional and local NHS response, and how this dovetails with other multi-agency partners through multi-agency command and control

1.3 The Civil Contingencies Act 2004 (CCA 2004) and the NHS England’s Emergency

Preparedness, Resilience and Response (EPRR) Guidance documents set out the legal and statutory responsibilities that SHFT has a duty to meet. They are outlined in section 4.1.

1.4 SHFT has the following key roles in the event of a major incident or emergency:

Maintenance of critical services

Identification of vulnerable people in the community who may be affected by the major incident, and supporting delivery of care to them

Support to acute hospitals in the early discharge of patients into the community and to community hospitals and facilties

Use of its minor injury facilities to support the major incident response

Provision of nursing support to displaced people in conjunction with Local Authorities at Humanitarian Assistance Centres by advising people with regard to medical problems and linking with local GPs and pharmacies

Provision of vaccination or prophylaxis as required to mitigate the effects of a major incident

1.5 All SHFT staff may have a role in supporting the response to a major incident. It is

therefore important that clear plans are made available to ensure SHFT maximises the skill and commitment of all staff in circumstances that will test us all. It is therefore fundamental to the Trust’s ability to respond to a major incident that everybody is aware of this policy’s content and their own responsibilities.

1.6 This policy is available from the SHFT website and staff intranet.


2. Scope 2.1 This policy describes how Southern Health NHS Foundation Trust will meet its

responsibilities for major incident preparation, response and recovery and as such applies to all staff in all services in all Divisions.

3. Definitions 3.1 Major incident or emergency

The Civil Contingencies Act (CCA) 2004 defines an emergency as “an event or a situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK”. For the NHS England, a major incident is defined as “any occurrence that presents serious threat to the health of the community, disruption to the service, or causes, or is likely to cause, such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care.” A major incident can be sudden, known as a “Big Bang” incident. Examples of a “Big Bang” incident are a major transport accident, or a series of smaller incidents which, cumulatively, test the capacity of the NHS to respond. A major incident can also develop over a period of time, known as a “rising tide” incident. Examples of a “rising tide” incident are a developing infectious disease outbreak or progressively more serious flooding in an area. NHS organisations are accustomed to significant fluctuations in the daily demand for services. Whilst at times this may lead to facilities being fully stretched, such fluctuations are managed without activation of special measures by means of established management procedures and escalation policies. Major incident management in Southern Health NHS Foundation Trust (SHFT) is therefore concerned with exceptional events and exceptional increases in the demand for services.

3.2 Types of incidents For the NHS, incidents are classed as either:

Business Continuity Incident

Critical Incident

Major Incident Each will impact upon service delivery within the NHS, may undermine public confidence and require contingency plans to be implemented. NHS organisations should be confident of the severity of any incident that may warrant a major incident declaration, particularly where this may be due to internal capacity pressures, if a critical incident has not been raised previously through the appropriate local escalation procedure. Business Continuity Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation’s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services


can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed) Critical Incident A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. Major Incident A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented. For the NHS this will include any event defined as an emergency as in section

3.3 Incident Levels The NHS England guidance identifies four levels of incident Level 1 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Level 2 An incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. Level 3 An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level Level 4 An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level.

3.4 Mass casualty incident

A mass casualty incident is defined by the NHS England as:

A disastrous single or simultaneous event(s) or other circumstances where the normal major incident response of several NHS organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response.

3.5 Mutual aid

Mutual Aid is defined by the Cabinet Office as:

An arrangement between Category One and Two responders and other organisations not covered by the Civil Contingency Act, within the same sector, or across sectors and across boundaries, to provide assistance with additional


resources during an emergency, which may overwhelm the resources of an individual organisation.

3.6 Lockdown

A lockdown is the process of preventing freedom of entry to, exit from, or movement within a site. In this way an organisation can either contain or exclude staff, patients or visitors. A lockdown may be characterised as a partial (static or portable), progressive or full lockdown.

4. Duties, Responsibilities and Roles 4.1 The Legal Context 4.1.1 Civil Contingencies Act 2004

The Civil Contingencies Act 2004 has categorised responding agencies into Category One and Category Two responders. Southern Health NHS Foundation Trust (SHFT) is classified a Category One responder. As a Category One responder SHFT is subject to a full set of legal duties outlined in the CCA 2004. These duties fall into six specific areas:

To assess the risk of emergencies occurring and use this assessment to inform contingency planning

To put in place emergency plans

To put in place Business Continuity Management arrangements

To put in place arrangements to make information available to the public about civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency

To share information with other local responders to enhance co-ordination

To co-operate with other local responders to enhance co-ordination and efficiency Within the geographical operational area of the Trust the following Category One responders include:

Acute Hospitals

Community and mental Health providers

Statutory Ambulance Services

Police Constabularies

Fire & Rescue Services

Local Authorities including District & Borough Councils and Unitary Authorities

Environment Agency

Public Health England

Maritime & Coastguard Agency – Her Majesty’s Coastguard

NHS England Under the CCA 2004, Category Two responders have a duty to cooperate and share information with Category One responders. Category Two responders include:

Clinical Commissioning Groups

Gas, water, telecommunications and electric companies

Highways Agency

Transport companies

Airport operators


Health and Safety Executive 4.1.2 NHS England EPRR Guidance

Key responsibilities outlined within the guidance documents are that:

The Chief Executive is responsible for ensuring that SHFT has an Incident Response plan and is able to respond to a major incident

The SHFT Board is regularly briefed with reports on SHFTs preparedness, additional risks, training and exercising

An Executive Director Lead is nominated

A communications exercise is carried out every 6 months

A tabletop exercise is carried out yearly

A live exercise is carried out every 3 years 4.2 Southern Health NHS Foundation Trust EPRR responsibilities

SHFT major incident planning responsibilities are to:

Provide assurance of a 24/7/365 response

Appoint/nominate a Lead Director as the Accountable Emergency Officer (AEO) for Emergency Planning, Resilience and Response (EPRR) who is responsible for SHFT emergency planning. This person should report to the board regularly on risks to delivering SHFT services

Maintain an emergency planning network, chaired by the Lead Director for EPRR which meets at least quarterly to agree resilience issues

Undertake assurance via a mapping exercise and where there are capacity gaps, take measures to ensure coverage

Maintain a sufficiently resourced and adequately qualified and competent Emergency Preparedness, Resilience and Response team, which can manage the day-to-day EPRR work, and support the Lead Director for EPRR and Board

Maintain a 24/7 on-call rota that includes response and incident support

Ensure sufficient testing and exercising of communication plans in accordance with the 2013 NHS England Guidance. This should include testing both in hours and out of hours

Contribute fully to any local multiagency training and exercising programme, especially, but not limited to, exercises that are of a statutory requirement for local high risk sites, i.e. Nuclear Power installations, chemical plants, sports grounds etc.

Ensure compliance with the Civil Contingencies Act 2004

Ensure compliance with the NHS England EPRR Guidance 2013

Communicate the availability of the major incident plan, and undertake regular review and testing of the plan

Maintain strong links with NHS England Area Teams in emergency planning leadership role and other health organisations within the Local Resilience Foras

To have in place an EPRR forum from which EPRR business is managed across the Trust.

4.3 Southern Health NHS Foundation Trust emergency response responsibilities

SHFT major incident response responsibilities are to:

Ensure an appropriate 24/7/365 response to a local incident

Support the local system wide response, including cross boundary mutual aid for emergency response


Continue to maintain provision and provide local system management for routine capacity issues, diversion and winter pressures

Ensure the Director on Call has clearly delegated authority to mobilise and direct SHFT resources across the SHFT area during an incident. This executive authority is able to be used when necessary without reference back to others and is critical if the Director on Call is required to attend the multi-agency Strategic or Tactical Coordinating Group

Maintain a capacity to provide 24/7/365 coordination to an incident via a suitably equipped Incident Coordination Centre for period of up to two weeks duration

4.4 The Chief Executive

The Chief Executive is responsible for ensuring SHFT:

Is able to comply with its duties as a Category One Responder under the CCA 2004 as detailed in section 4.1

Has a Major Incident Plan that meets the criteria set out in the NHS EPRR Guidance documents 2013 and has appropriate major incident command, control and coordination arrangements in place

Has an Executive Director of the Board designated to take lead responsibility for emergency preparedness, resilience and response

Has a Non-Executive Director nominated to support the designated Lead Executive Director for emergency preparedness, resilience and response

Has an adequately resourced Emergency Preparedness, Resilience and Response Team to support the Lead Executive and Non-Executive Directors in the discharge of their emergency preparedness duties

That the Board receives regular reports, at least annually, regarding emergency preparedness to include reports on exercises, training and testing, and assurance that adequate resources are available for the discharge of emergency preparedness responsibilities

Has overall accountability for the SHFT response to a major incident 4.5 Designated Executive and Non-Executive Directors

The Designated Executive and Non-Executive Directors of the Board have delegated responsibility from the Chief Executive for ensuring SHFT meets its emergency preparedness responsibilities. Specifically, the Designated Executive as the Accountable Emergency Officer (AEO) will be responsible for:

Ensuring that SHFT is compliant with the EPRR requirements as set out in the CCA 2004 the NHS England Core Standards for EPRR and the NHS standard contract as applicable

Ensuring that SHFT is properly prepared and resourced for dealing with a major incident or civil contingency event;

Ensuring that SHFT and any providers they commission, have robust business continuity planning arrangements in place which reflect standards set out in the Framework for Health Services Resilience (PAS 2015) and ISO 22301

Ensuring SHFT has a robust surge capacity plan that provides an integrated organisational response and that it has been tested with other providers and parties in the local community(ies) served

Ensuring that SHFT complies with any requirements of the NHS England, or agents thereof, in respect of the monitoring of compliance

Providing the NHS England, or agents thereof, with such information as it may require for the purpose of discharging its functions


Ensuring that SHFT is appropriately represented at any governance meetings, sub-groups or working groups of the Local Health Resilience Partnership (LHRP) or local resilience forum (LRF).

4.6 Director on Call, Divisional and Area Managers on Call

4.6.1 All on Call Managers will:

Be available and contactable 24 hours, 7 days a week during their period on call

Have access to their On Call Information Pack and Trust ID card at all times

Have key contact numbers programmed in their mobile phone i.e. all SHFT Flextel On Call numbers, the contact numbers of other members of their On Call rota (both in and out of hours), and the contact numbers for their teams (both in and out of hours)

Ensure they can travel within 2 hours to the SHFT Incident Coordination Centre (ICC). If circumstances prevent travel to the ICC within 2 hours, make arrangements with a colleague to fulfil this function

Undertake emergency planning training at least annually and participate in an exercise at least every two years

Abstain from drinking alcohol during their period on call as it may be necessary to undertake a key role in the management of a major incident or emergency, and drive to the SHFT ICC or other site.

4.6.2 The Director on Call will:

Provide advice and support to Divisional Managers on Call for operational issues out of hours

Be the main point of contact for Serious Incident Requiring Investigation (SIRI) out of normal working hours

Be the main point of contact for media related concerns out of hours ensuring close liaison with the SHFT Communications on Call for media related support

Strategically manage SHFT services during periods of demand fluctuations

Lead on out of hours systems resilience teleconferences for SHFT

Lead on SHFT Business Continuity incidents to Red Essential Services and Amber Services which could be scaled down if necessary

In the event of a major incident or emergency undertake the role of Incident Director making an initial assessment of the level of response and resources required, implementing the Major Incident Policy and Action Cards, and strategically managing SHFT services

Activate the SHFT Incident Team and open the SHFT ICC, calling in support staff as appropriate

Contact and/or liaise with NHS England Director on Call/Clinical Commissioning Group(s) on call in the event of a major incident and as appropriate

Notify and brief other Executive team members as required

Provide SHFT situation reports to NHS England Area Team and/or CCG ICC(s).

As requested, attend the Strategic Co-ordinating Group or Tactical Co-ordinating Group or NHS England, Area Team ICC locations.

Proactively communicate with SHFT staff regarding the major incident or emergency and ensure relevant guidance and advice is available

Ensure SHFT staff are not exposed to unnecessary health and safety or other risks, and that adequate shift and rota breaks are built into prolonged incident management arrangements

Ensure support to any activated local authority Rest Centre(s) if required


4.6.3 The Divisional and Area Managers on Call will:

Provide advice and support to operational issues out of hours

Inform the appropriate Manager at the start of the next working day of any incident out of hours

Liaise with the Director On Call as appropriate

Lead on SHFT Business Continuity incidents to Green Services which could be discontinued if necessary

As appropriate, attend the Tactical Co-ordinating Group, SHFT Incident Coordination Centre, or SHFT Incident Team in the event of a major incident or emergency

Provide Divisional/Area situation reports to the Director on Call

4.7 Head of Risk and Business Continuity

The Head of Risk and Business Continuity supported by the Business Continuity and Emergency Preparedness Officer is responsible for coordinating SHFT’s major incident emergency preparedness by:

Leading the development, coordination and performance monitoring of SHFT’s major incident planning, business continuity planning and response arrangements

Representing SHFT across Local Resilience Forums, major incident planning networks

Identifying national, regional and local emergency planning policy changes and developments that impact on SHFT and translating these into operational practice

Providing assurance to the SHFT Board and senior managers on the resilience of SHFTs major incident planning and response arrangements

Identifying major incident planning training needs, ensuring appropriate training is delivered so that SHFT staff understand their role and responsibilities in a major incident response and are competent to perform them

Ensuring the mobile phone numbers of key Executive and senior managers are registered with the Mobile Telecoms Privileged Access Scheme

During a major incident supporting the Incident Commander as appropriate

During a major incident ensuring the preservation and protection of all documents relating to the major incident, collating and archiving as appropriate

Ensuring a debrief takes place immediately following a major incident, and a thorough debrief shortly after the major incident

Compiling a report of the SHFT major incident response with recommendations for change and ensuring the Major Incident Policy, associated Plans and Action Cards, Business Continuity Management Policy and Business Continuity Plans, and Risk Management Policy are updated as necessary

4.8 Director of Workforce and Communications

The Director of Workforce and Communications is responsible for ensuring that:

Human Resource policies ensure all staff are aware of their responsibility to support SHFT in responding effectively to incidents, major incidents and emergencies

Staff records include information on staff dependencies and skills to allow for redeployment

Ensuring senior HR staff are aware of their responsibilities in the event of an incident, major incident or similar emergency

During a major incident or emergency, HR services are prioritised to enable the SHFT workforce to meet the needs of the situation i.e. timely recruitment of staff, retired staff, and volunteers


Robust sickness reporting information is available as demanded by the incident

Workforce issues as a result of a request for mutual aid from another organisation resulting in the temporary transfer of staff between organisations are managed. This may include in consultation with the Incident Commander invoking the SHFT policy An Emergency Event: Guidelines on Managing the Workforce Issues

A list of staff involved in the major incident is maintained and that those staff have access to appropriate support services such as occupational health and counselling, and that any necessary changes to the Services Level Agreements are negotiated

4.9 Director of Finance

The Director of Finance is responsible for:

Ensuring that adequate resources are made available for the discharge of SHFTs emergency planning responsibilities

Recognising the need for a contingency budget

Ensuring that emergency cost codes are available

Leading the recovery following a major incident, both financial and general

That Service Level Agreements are in place with suppliers who have sound emergency planning and business continuity arrangements

The Director of Finance is also the SHFT Designated Security Management Executive Director and responsible for the overall management of SHFTs security, and for ensuring this policy and associated plans and action cards comply with national best practice and are relevant to SHFT, its services and premises.

4.10 Head of Information, Communication and Technology

During a major incident the SHFT Incident Team, and other key staff, will require robust access to the Information Communication and Technological (ICT) systems. The Head of ICT is responsible for:

Developing plans to ensure the SHFT Incident Team, and other key staff, have access to ICT support during a major incident both inside and outside of office hours

Ensuring there are Emergency Planning and Generic email accounts available to the Incident Team to use within the Incident Coordination Centre

Ensuring there are Business Continuity Plans for ICT services

Ensuring these plans are well communicated to the Senior and Area Managers on Call, clinical and ICT staff

Developing mutually beneficial relationships with partner organisations to allow for mutual aid

4.11 Associate Director of Communications and Engagement

The Associate Director of Communications and Engagement is responsible for:

Maintaining the On Call communications rota

Developing and maintaining the SHFT major incident communications plan

Providing a representative at the NHS England communications group

Maintaining links with NHS England communications team and with other local NHS Trust communications leads and as required during an incident

Ensuring that the SHFT communication staff have had the appropriate training

Taking part in exercises as required

Having appropriate mechanisms in place to establish telephone lines for the public


Developing beneficial relations with the media 4.12 Divisional Directors, Area and Service Managers

Divisional Directors, Area and Service managers are responsible for ensuring:

Sufficient resources are allocated to deliver the requirements of this policy and assurance arrangements are in place to monitor compliance

All staff are familiar with this Major Incident Policy, its associated Plans and Action Cards, and their services Business Continuity Plans

That their Division, Area, and Service can contribute to the SHFT response to major incidents, emergencies or any situation that may challenge the delivery of services

That every Division, Area and Service has a nominated lead for emergency planning and business continuity which is clearly defined and resourced

That the Divisional nominated lead for emergency planning and business continuity is an active member of the Trust’s Business Continuity and Resilience Group

That robust local Business Continuity Plans are in place for all services, sites and functions within their Division, Area or Service

Ensuring Business Continuity Plans are tested and exercised at least annually, and records maintained of these tests and exercises

Ensuring staff are released to attend major incident training

Identifying any unmet training needs at supervision and appraisal

Maintaining an up to date list of the names and contact details (in and out of hours) of the staff within their teams

4.13 All Southern Health NHS Foundation Trust employees

All SHFT employees are responsible for:

On appointment and periodically thereafter familiarising themselves with the SHFT Major Incident Policy, associated plans and action cards, and their service’s Business Continuity Plan

Familiarising themselves with how they should report for duty should a major incident occur, and their roles and responsibilities within a major incident

Attending major incident training, and for identifying any unmet training needs at supervision and appraisal

Taking part in major incident exercises as required

Being vigilant to the security of premises and staff

Ensuring that any change in their home address or contact details is reported to their line manager to enable up to date out of hours contact lists to be maintained

Cooperating with SHFT during a major incident, undertaking duties within their scope of practice as and where requested, cooperating with redeployment into different roles at different sites, working flexibly to meet the needs of their service, and for fulfilling their contractual duties wherever possible

Having up to date formal identification cards on their persons at all times while on duty

During a major incident SHFT employees are expected to make every effort to attend work. If this is not possible e.g. for safety reasons employees must report this each day. If it is possible for employees to work at home they can do so as long as this is with the agreement of their line manager and they can arrange cover. If employees are unable to attend work and cannot work at home, they can, with agreement from their line manager, make up the hours subsequently, take annual leave or take unpaid leave.


4.14 Southern Health NHS Foundation Trust responsibilities to its staff

A major incident will impact on the availability of SHFT staff to undertake their normal duties. Similarly SHFT staff may be required to work longer hours than normal, and may be adversely affected by the incident either personally or professionally. SHFT has a responsibility to ensure that staff welfare is considered and promoted. The SHFT policy An Emergency Event: Guidelines on Managing the Workforce Issues provides the framework whereby SHFT ensures it is able to continue its functions while meeting its responsibilities to its staff. The policy An Emergency Event: Guidelines on Managing the Workforce Issues will take precedence over all existing HR policies in the event of a major incident. The decision to implement the policy will be taken by the Incident Commander/Director on Call in liaison with the Director of Workforce and Communications, Chief Executive, or appropriate deputy. SHFT will ensure that:

Staff welfare is considered and promoted during and following a major incident

Occupational Health are informed of any staff involved in a major incident so that any necessary follow up support can be given

Staff have access to an Employee Assistance Programme (which gives independent advice, information and provides a counseling service)

4.15 Southern Health NHS Foundation Trusts Responsibilities to vulnerable people

The CCA 2005 places a duty on Category 1 Responders (i.e. SHFT) to have regard for the needs of vulnerable people in a major incident. It is difficult to define in advance who would be vulnerable in any particular major incident or emergency. However there are three categories of vulnerable people that should always be considered:

Those who have mobility difficulties i.e. with a physical or mental disability, a medical condition, pregnant women

Those with mental health problems

Others who are dependent, such as children, people with learning disabilities, the frail elderly, those dependant on drugs dressings, or medical equipment,

People with sensory difficulties e.g. blindness, deafness, or who are unable to understand instructions e.g. non-English speakers

4.16 NHS England EPRR responsibilities

The NHS England, Area Team is the Health EPRR lead and as such has specific planning and response responsibilities which include:

Maintaining a health emergency planning network, co-chaired by its Lead Director for EPRR, and the Director for Public Health via the Local Resilience Health Partnership ensuring all NHS organisations in the area meet at least quarterly to agree health resilience issues.

Representing the local health economy at LRF Strategic level.

The NHS England Area Team Lead Director for EPRR is responsible for ensuring the local NHS contributes fully to any local multiagency training and exercising programme, especially, but not limited to, exercises that are of a statutory requirement for local high risk sites etc

Ensuring NHS Trusts within the area comply with NHS England, Core Standards for EPRR 2013 and their duties under the CCA 2004

Maintaining strong links with NHS England, South in its leadership role


In a large scale incident coordinating and strategically managing the NHS response across the geographical area of operation.

Ensuring a mechanism for local organisations (particularly Local Authority, Police and Ambulance Trusts) to access through a single point of contact, NHS Primary Care and Community Services

Ensuring the Director on Call has clearly delegated authority to mobilise and direct the resources of any NHS organisations across the area during an incident. This authority can be used when necessary without reference back to others. This senior level delegated responsibility is critical if the Director on-call is required to attend the multi-agency Strategic Coordinating Group, or Gold Command

To liaise with Public Health England to establish and support a Scientific and Technical Advice Cell (STAC) to provide science and technical advice to the Strategic Coordinating Group and Police Incident Commander

Jointly access the public health impact of a major incident, with Public Health England and Local Authority, Director of Public Health.

Provide a strategic view on long term threats

4.17 NHS England, South EPRR responsibilities In the event of a major incident that crosses LRF borders, or is of such size that the NHS within a large operational area would be overwhelmed, NHS England, South is responsible for coordinating necessary contingency arrangements across the wider area, which could include the use of other area or national assets.

4.18 NHS 111 Service EPRR responsibilities In the event of a major incident, 111 services can be used to support the response by answering public questions about the health effects of incidents and to give advice to the public either by agreed statements or via predetermined algorithms to provide a single point of access for all non-emergency NHS services.

4.19 Multi-agency Responsibilities 4.19.1 General

The emergency services normally provide most of the initial response, supported by the local authorities, utility companies (gas, water, telecommunications and electricity) and voluntary (third sector) organisations. The emergency services main role will most frequently be to save life. The Fire and Rescue Service is responsible for rescuing survivors. The Ambulance Service is responsible for triaging casualties, treating casualties and transferring casualties to hospital. The Police are responsible for taking the lead in co-ordinating the multi-agency response, as well as investigating crime scenes and identifying responsibility for cause (if criminal activity suspected).

4.19.2 Hampshire and the Isle of Wight and Thames Valley Local Resilience Forum(s) Emergency Preparedness Responsibilities Under the CCA 2004, multi-agency emergency preparedness is undertaken in areas known as Local Resilience Forums (LRFs) based on Police service boundaries. The Hampshire and the Isle of Wight (HIOW) LRF is based on the Hampshire Constabulary boundary. Thames valley LRF (TVLRF) is based on Thames valley Police operational boundary. A summary of the top risks on both LRF Community Risk Register include:

Large toxic chemical release


Localised industrial accident involving large toxic release

Low temperatures and heavy snow

Flooding: Major coastal and tidal flooding affecting more than two UK regions

Flooding: Severe inland flooding affecting more than two UK regions

Local coastal / tidal flooding affecting more than one Region

Local coastal / tidal flooding in one Region

Influenza-type disease - pandemic

Telecommunications infrastructure – human error The UK's threat level is set by the UK Security Service (MI5) and the Joint Terrorism Analysis Centre (JTAC) working together. The five threat levels are:

Critical - an attack is expected imminently

Severe - an attack is highly likely

Substantial - an attack is a strong possibility

Moderate - an attack is possible but not likely

Low - an attack is unlikely 4.19.3 Local Resilience Forum Emergency Response Responsibilities

In the event of a major incident or emergency, the range of response activities and support will be complex. Coordination between different organisations is necessary to provide a timely, targeted and effective response. The multi-agency response to an incident in HIOW is coordinated in accordance with the LRF Strategic Response Framework for Emergencies. Three management tiers can be put in place to manage the incident; Operational, Tactical and Strategic. The multi-agency co-ordinating groups at these levels are the Tactical Coordinating Group (TCG) and the Strategic Coordinating Group (SCG). In addition to these levels of management a Scientific and Technical Advice Cell (STAC) may be established to provide specialist advice to the SCG. The operational level is the management of immediate "hands-on" work undertaken at the site(s) of the incident. Operational Commanders concentrate their efforts and resources on specific tasks within their area of responsibility. If the management of an incident becomes complex it may be necessary to establish a number of functional and location Operational Commanders. The tactical level deals with the overall management, tasking and resourcing of the frontline response in accordance with the strategy set by the strategic level. The TCG will:

Determine priorities for allocating resources

Plan and co-ordinate how and when tasks will be undertaken

Obtain additional resources if required

Assess significant risks and use this to inform tasking of operational commanders

Ensure the health and safety of the public and responders The tactical level will usually comprise the most senior officers of each agency committed within the area of operations, who will assume tactical command of the situation. Certain types of incident may require more than one tactical location or a specific tactical group dealing with a particular function, such as mass evacuation. In most instances the police will co-ordinate the multi-agency tactical level. In the initial stages of a major incident the tactical level will assume the strategic function. The TCG will meet at the Incident Control Point at a suitable place near to the scene.


The group may move to premises that are better equipped, but further from the scene, as operations progress. The Tactical Co-ordinating Group will normally include the following.

Police: Police Incident Officer (Silver Police), Senior Investigating Officer, if this applies, Minute taker

Fire: Incident Commander Scientific advisor if applicable

Ambulance: Ambulance Incident Officer

Local authorities: A senior representative

NHS: A Senior Manager from NHS England or designated officer from an NHS organisation to represent NHS services

Others: Depending on the type of incident

The strategic level will be required in those cases where it becomes clear that resources, expertise or co-ordination are required beyond the capacity of the tactical level to take overall command and set the strategic direction. A Strategic Co-ordinating Group (SCG) will form, bringing together commanders from relevant organisations. The purpose of the strategic level is to establish the policy and strategic framework for the response and recovery. The SCG will:

Determine a clear strategic aim and objectives, disseminate them and review them regularly

Establish a policy framework for the overall management of the event or situation

Prioritise the requirements of the tactical tier and allocate personnel and resources accordingly

Formulate and implement media-handling and public communication plans

Direct planning and operations beyond the immediate response in order to facilitate the recovery process

Chairing the SCG will normally fall to the police. In some circumstances it may be more appropriate for another agency to take the lead (for instance, the local authority may take the lead in the recovery phase). The strategic level is normally located away from the incident, at police facilities. Alternate sites may be used depending on the location and type of incident. Depending on the nature, extent and severity of the major incident, either the regional tier or central government may become involved. The SCG will then become the primary interface with these other levels of response. Only the SCG will authorise the release of casualty figures.

The SCG will normally include the following:

Police: Incident Commander

Fire: Senior Commander

Ambulance: Director

Local authorities: A Chief Executive (or their representative) from the affected local authorities

NHS: A Senior Manager from NHS England or designated officer from an NHS organisation to represent NHS services


Scientific and Technical Cell (STAC) Chair:

Public Health Consultant, Public Health England

Others: Depending on the type of the incident


5 Alerting

Southern Health NHS Foundation Trust (SHFT) would be alerted to a major incident via the alert cascade.

Significant Incident or Major Incident, Standby or Declared

CCG System On-call Director will inform: NHS ENGLAND (WESSEX) 1st ON-CALL

NHS England (Wessex) will: 1. PRIORITISE AND INFORM

OTHER PROVIDERS AND

CCGs FOR:

a. ACTION

b. INFORMATION.

2. INFORM NHS ENGLAND

(SOUTH)

3. INFORM NHS ENGLAND

COMMS

SIGNIFICANT OR MAJOR

INCIDENT, DECLARED OR

STANDBY

Other NHS Provider Organisation will inform: 1. AMBULANCE CONTROL

2. CCG SYSTEM ON-CALL

DIRECTOR

PUBLIC HEALTH ISSUES

Ambulance Control will also inform: 4. PUBLIC HEALTH ENGLAND

CENTRE ON-CALL

5. LOCAL AUTHORITY

DIRECTOR OF PUBLIC

HEALTH ON-CALL

Ambulance Trust Ambulance Control will inform: 1. ALL HOSPITALS THAT

WILL RECEIVE

CASUALTIES

2. NHS ENGLAND (WESSEX)

3. 111 CENTRE MANAGER

When there are

When there is a


3. ‘Top-down’ Cascade by NHS England

5.1 Request to a member of Southern Health NHS Foundation Trust staff

Should any member of SHFT staff receive a request for support directly from an acute (receiving) hospital, or an ambulance service, the person receiving the call will immediately contact the Director on Call who will make the decision on whether to activate the Incident response Plan( Major Incident Plan).

5.2 Southern Health NHS Foundation Trust declaration of a major incident The Chief Operating Officer, any member of the Executive Team, and the Director on Call may activate this Major Incident Plan regardless of any formal alerting message by either declaring a Major Incident or Major Incident Standby. In the event of the Major Incident or Major Incident Standby being declared the NHS England, Area Team Director on Call would be informed immediately. Such action may be taken when it is apparent that an incident or perceived threat may demand the implementation of special arrangements or when a spontaneous response by members of the public results in the presentation of major incident casualties at any SHFT health care setting e.g. community hospital or minor injuries unit.

NHS England (Wessex)

Ambulance Services

CCGs

Other Blue Light Services

Non-Blue Light Service LRF

Partners

Acute Hospitals

Primary Care

Non-acute and non-NHS commissioned

services

NHS England (South)


5.3 Alerting messages The agreed national alerting messages for the NHS are:

NHS Message Application Major incident standby Alerts the NHS that a major incident may

need to be declared. Organisations should make preparatory arrangements appropriate to the incident.

Major incident declared Organisations need to activate their major incident plan and mobilise additional resources

Major incident cancelled Message cancels either of the above messages

Scene evacuation complete

Message from the Ambulance Service to the Trusts to inform them that no more casualties are at the scene

Major incident stand down

It is the responsibility of each Trust to determine when it is appropriate for them to stand down

6 Southern Health NHS Foundation Trust major incident response 6.1 On call arrangements

To ensure there is a clear, defined structure for advice and the provision of support to staff out of hours, and at any time in the event of a major incident, SHFT has a Director on Call and the following Divisional and Area Managers On Call 24 hours a day 7 days a week:

Mental Health and Learning Disability

ISD West

ISD NE

ISD SE

OPMH Inpatients

TQ At Home

Estates/Hard FM

Communications In addition SHFT has an informal arrangement for IT support.

6.2 Role of Director on Call, Divisional Managers on Call and Area Managers on Call See section 4.6.


6.3 Authority In hours the Divisional Manager and out of hours the Divisional Manager on Call has the authority to declare a Red incident affecting an Essential Service or an Amber incident affecting a service which could be scaled down if necessary (See Business Continuity Management Policy). In hours the Chief Operating Officer or any member of the Executive Team, and out of hours the Director on Call has the authority to declare a Major Incident or Major Incident Standby and authorise the establishment of the SHFT Incident Coordination Centre (ICC). The alerting system described in section 5 would then be followed. In the event of a Major Incident both in an out of hours the Director on Call, Chief Operating Officer, or any member of the Executive Team, acting as Incident Commander, has normal executive levels of authority including:

The deployment of resources

The authorisation of expenditure

6.4 Establishment of the Southern Health NHS Foundation Trust Incident coordination Centre (ICC) In the event of a major incident or emergency SHFT will establish an ICC which will function to:

Support the Incident Director to manage the SHFT response to the incident

Provide the main link between NHS England and SHFT

Provide the central hub for information and coordination of activities and actions

Provide the central hub for communicating with other health providers and multi-agency partners

Maintain regular contact with any SHFT representative at the Strategic or Tactical Co-ordinating Groups

The primary location of the ICC will be in Meeting Room 8, Sterne 7,Tatchbury. A back-up ICC at NHS England (Wessex) HQ, Oakley Road, Southampton is also available if the main ICC becomes unavailable. Details for accessing these locations are contained in the Director on Call Information Pack. The Incident Director will decide on the scale of the response and mobilise the Divisions required to form the ICC. A summary of the ICC Teams, their roles and membership are outlined in the table below.

Team Role Membership

Executive Incident Team

Assess impact and risks

Decision making

Maintain decision log

Set strategic aims and objectives for SHFT in line with the multi agency Strategic Coordinating Group objectives

Incident Commander (SHFT Gold)

Communications Lead

EPRR Advisor (if available)

Decision Loggist

Minute Taker

Other as required


Incident Coordination Centre Team

Provide the central hub for information and coordination of activities and actions

Maintain a master log of information

Maintain a commonly recognised information picture (CRIP)

Maintain a service pressures dashboard allowing a strategic overview of service pressures

Manage the running of the ICC

Be the main point of contact for SHFT services and external partners

Answer incoming calls and monitor the major incident email account

ICC Manager (SHFT Silver)

ICC Room Coordinator (responsible for managing the ICC and for establishing suitable rotas)

ICC Support Officer

Information Manager

Information Support Officer

Call handlers

Divisional on Call managers

Operational management of SHFT services

Divisional on Call managers

Communications Team

Maintain internal communications

Work closely with NHS partners and other multiagency partners communication leads to implement the appropriate media and communications response

In collaboration with partners monitor media and respond

Communications Managers

Communications Support Officers

Recovery Team

Focus on recovery issues

Plan return to normal working

Finance Manager

Finance Support Officers

To ensure the continuity of the ICC during the period of a major incident response a number of staff will need to be utilised. A full list of staff trained or possessing the necessary skills to perform particular roles e.g. loggist, in the ICC is maintained by


the Head of Risk and Business Continuity and the Business Continuity and Emergency Preparedness Officer. An ICT expert is available on call to manage any technical problems.

6.5 Associated Plans and Action cards Associated Plans and Action Cards providing detailed information and instructions concerning emergency situations and procedures, functional roles and responsibilities applicable to specific post holders have been developed. The use of the associated Plans and Action Cards is important to ensure that risk reduction and contingency arrangements are in place and that once a major incident has been declared procedures are followed after activation of this plan. SHFT has the following plans and action cards:

Major Incident Action Cards

Flood Response Plan and Action Cards

Fuel Shortage Plan and Action Cards

Heat Wave Plan and Action Cards

Potassium Iodate Tablet distribution in response to a nuclear emergency Action Cards ( Soton safe and Portssafe plans)

Seasonal and Pandemic Influenza Plan and Action Cards SHFT Plans and Action Cards are available to the Director on Call, and held in the ICC.

6.6 Mass casualty response Mass Casualty Incidents could result in a large number of immediate casualties Mass casualty scenarios differ from conventional major incidents in terms of scale, duration, intensity, and the probability that there will be other compounding factors such as loss of services/infrastructure, shortage of essential supplies or the possibility of civil disruption. They are likely to involve greater numbers, both in terms of casualties and fatalities, and could involve either incidents occurring simultaneously, or at multiple sites (either in close proximity or more widely spread). The Hampshire and Isle of Wight (HIOWLRF ) and Thames Valley (TVLRF) Local Resilience Forums hold Mass Casualty Plans which details the LRF response to a mass casualty incident and describes the coordination of components of the response i.e. triage, transport, treatment, and logistics support. Activation of the plan will occur when a major incident exceeds LRF response capabilities based on the following triggers:

Dynamics of the incident

Nature and severity of the injuries

Availability of medical resources

Loss of a main hospital facility

Large influx of patients from out of county A mass casualty incident will be declared by the Ambulance Incident Commander based on their scene assessment. The Ambulance Emergency Operations Centre will then contact NHS England, South Executive on Call who will confirm details with the Ambulance Service, that a mass casualty incident has occurred, and inform NHS England, Area Team, Director on Call.


A mass casualty event will be subject to the normal command and control structures of responding organisations. In the early stages of any mass casualty incident, all organisations are expected to manage their individual responses within their own major incident plans. In a mass casualty scenario SHFT will be required to activate its Major Incident Plan and implement its ICC structures focusing on:

Reviewing and creating bed and treatment capacity to receive discharged patients from acute (receiving) hospitals

Prioritising patients according to local plans to free up capacity and staff

Provision of care to suitable patients i.e. stabilised casualties needing early treatment but where delay is acceptable and treatment at minor injuries units is appropriate (P2 patients) and stabilised casualties requiring treatment but where a longer delay is acceptable (more serious P3 patients)

Providing minor injury units / treatment centres away from acute hospitals

Responding to the wider system requirements by supporting emergency responders and local A&E departments with clinical and nursing staff

Assisting the police, local authorities and voluntary aid sector, as requested

Ensuring that a continuing health service is provided to those unaffected SHFT minor injuries units are normally open from 0800 to 2200 but they have the potential to remain open 24 hours if necessary. This will need to be agreed with the SHFT Incident Commander and NHS England, Area Team and CCG(s) Executive Directors on Call. A specific Action Card for use in these scenarios has been developed and forms part of the Director on Call Information Pack. In addition action cards have been developed at Area/Service and Divisional level. It is vital that SHFT implements appropriate measures to ensure the protection of its staff, patients and visitors, and its properties and assets.

6.7 Mutual aid Responding to a major or catastrophic incident can quickly overwhelm the initial responding NHS organisation and even a small incident confined to one PCT area requires the Acute, Ambulance, Community and Mental Health response. In some cases mutual aid may be required between this local group of NHS organisations. The HIOW Mutual Aid Document is being developed to allow NHS staff to work in other NHS locations other than their employing Trust during a major incident. All organisations across HIOW have been consulted on the document, and it is currently in the process of going through high-level sign-off. This document deals with the issue of staff indemnity. It establishes an agreed framework for:

The request of mutual aid by any NHS organisations within the NHS England, South in response to a major incident or emergency

Arrangements to supply assets/resources to a requesting NHS organisation

Arrangements for the receipt of assets/resources within an NHS organisation that have been supplied by another NHS organisation

Criteria for the implementation of mutual aid are set within the following parameters:


The requesting NHS organisation must have declared a major incident for their organisation in response to an incident which meets the definition under the Civil Contingencies Act (CCA) 2004

The requesting organisation must have ensured they have attempted all possible redeployment of resources within their organisation and prioritisation of services to manage the incident

The NHS organisation requesting mutual aid can no longer manage the incident response with the full deployment of their resources/assets and prioritisation of their own services

When an NHS organisation or health economy is potentially or actually unable to maintain safe level of health critical services either through lack of physical or human resources

The NHS England, South Incident Response Team with support from the NHS England Major Incident Control Centre will coordinate the provision of mutual aid arrangements between local health communities as required. Multi-agency requests and offers of mutual aid will be managed through established coordination arrangements.

7. Stand down

The Incident Commander in consultation with the Incident Team will determine the time for the declaration of the Trust ‘Stand Down’ from the major incident. This decision will not necessarily coincide with receipt of notification of stand down by other Trusts in the NHS.

7.1 Debrief

The Head of Risk and Business Continuity will work with Divisional, Area and Service Managers to ensure that staff involved in the major incident have had the opportunity to attend a debrief immediately following the incident (hot debrief), and that this is followed up by a thorough debrief shortly after the incident. This allows staff involved in the major incident the chance to discuss their views and opinions, to talk about their role, and to identify ways of modifying and improving the Major Incident Plan and response. SHFT will follow the debriefing strategy and guidance detailed in the Hampshire and the Isle of Wight Local Resilience Forum Debriefing Guidance.

Lessons learnt from the activation and usage of the Major Incident Plan will be captured and documented at the debrief to enhance organisational learning. All actions from lessons learnt will be given a completion deadline and action owner and will be monitored to completion by the Emergency Planning Team. A full report of any major incident will be taken to the Board detailing lessons learnt and progress on any improvement actions identified.

8. Recovery Recovery is an integral part of the major incident management process. It is characterised as the process of rebuilding, restoring and rehabilitating the community following an emergency. The challenges posed by the recovery process will depend on the nature, scale and severity of an emergency. Every recovery process is different and in order to be truly effective, the process will require multi-agency working. All sectors of the community will need to be engaged including the


voluntary and private sectors. The process may take months or even years to complete, requiring the implementation of short, medium and long term strategies. As soon as the initial major incident response phase is over the SHFT Incident Commander will establish a Recovery Team so that the main focus of the management of the incident moves to returning SHFT services to normal as soon as is practicable. Essential Services will be prioritised. Generally the Recovery Team will be led by the Director of Finance.

9. Record keeping and preservation of documents 9.1 Record Keeping/Completion of Logs 9.1.1 Master Log

The Incident Coordination Centre (ICC) Manager is responsible for ensuring that all information entering the Southern Health NHS Foundation Trust (SHFT) ICC during a major incident is logged. This includes all incoming phone calls, faxes and emails. The ICC manager is responsible for identifying a designated loggist to fulfil this role.

9.1.2 Decision Log

The Incident Commander/Director on Call is responsible for ensuring that a record of the key corporate decisions taken during a major incident is kept. This includes the rational for the decision. The decision log is signed by the Incident Commander after each key decision is reached. The Incident Commander is responsible for identifying a designated loggist to fulfil this role.

9.1.3 Action Log All members of the SHFT ECC must keep a record of:

Instructions received

Actions taken

Other relevant information If the Incident Commander, ICC Manager or an EMT member is relieved during the major incident, the log is signed and passed to the relief. At the end of the major incident all logs are given to the Head of Risk and Business Continuity. SHFT Log Books and Message Forms for use in the event of a major incident are available at the ECC and in On Call Managers Information Packs.

9.2 Preservation of documents Following a major incident SHFT may be required to provide evidence to an appropriate enforcement agency, for example:

The Health & Safety Executive

A Judicial inquiry

A Coroner's inquest

The Police


A Civil Court hearing compensation claims In the course of any or each of these, the Trust may be obliged, or advised, to give access to documents produced prior to, during, and as a result of the incident. Documents could be paper documents, photographs, audio and videotapes, internal and external email, and any information held on a computer. Under no circumstances must any document that relates or may in any way relate to the incident, be destroyed, amended, held back or mislaid. The vital message Preserve and Protect- needs to be spread very quickly during a major incident and must reach those who might quite unknowingly hold significant documents. The Head of Risk and Business Continuity will issue appropriate instructions and guidance on procedures to be adopted in the immediate aftermath of a major incident to preserve all documentation.

10 Training Requirements Southern Health NHS Foundation Trust (SHFT) is required to train staff to participate in major incidents to ensure that staff:

Understand the role they are to fulfil in the event of an incident

Have the necessary competencies to fulfil that role As a minimum standard, all staff will receive as part of their induction training awareness of Major Incident and Business Continuity Management, and the role they and SHFT play in major incident planning and response. All On Call Managers will receive Major Incident training on joining an On Call Rota and annually thereafter. Identified administrators will receive loggist training. The Training Needs Analysis details training needs from general awareness to specific training for staff with key roles. In addition appropriate training will be delivered as and when required. This could be in response to new or updated central government guidance or in response to lessons learnt as a result of major incidents either locally or nationally. The training need analysis will be conducted yearly and the training programme reviewed accordingly.

11 Exercising programme As a minimum requirement Southern Health NHS Foundation Trust (SHFT) is required to undertake the following:

A communications cascade test at least every 6 months to test the major incident alert and activation process. This will take place both in and out of hours

A table top exercise at least every year

A live exercise every 3 years

Setting up of the Incident Coordination Centre – annually


The Head of Risk and Business Continuity is responsible for ensuring that an exercising programme is developed to ensure that SHFT meets these requirements and that records of the exercises are maintained.

12 Monitoring Compliance 12.1 The EPRR Working Group will monitor compliance with the Trust’s major incident

management arrangements through the Exercising Programme and following any major incidents or emergencies

12.2 Exceptions against the standards defined in this policy will be reported to the

Assurance and Risk Committee 12.3 Major Incident management compliance will be included in the Annual Report for

Business Continuity and Resilience to the Assurance and Risk Committee.

13 Policy review

This policy will be reviewed within 3 years of it being approved or at any point within this time to reflect organisational change, changes in legislation and/or guidance or following a major incident or emergency.

14 Associated Documents

The following Southern Health NHS Foundation Trust (SHFT) policies and strategies are associated documents to this policy:

Business Continuity Management Policy

An Emergency Event: Guidelines on Managing the Workforce Issues

Health & Safety Policy

Investigation, Analysis and Learning Policy

Policy on Policy Management

Policy for Managing Incidents

Security and Management of Violence and Aggression Policy

Security Management Procedure

Risk Management Policy

Risk Management Strategy 15 Supporting References

Civil Contingencies Act 2004 and the Civil Contingencies Act 2004 (Contingency Planning) regulations 2005

NHS Commissioning Board EPRR Guidance 2013

NHS Commissioning Board Core Standards in EPRR

NHS Commissioning Board Command & Control Framework 2013

Humanitarian Assistance Guidance

PD 25222 Guidance to Supply Chain Continuity

ISO 22301 Societal Security – Business Continuity Management

ISO 22313 Societal Security – Business Continuity Systems Guidance

PAS 2015- Framework for Health Service Resilience

Skills for Justice Standards for EPRR


Health and Social Care Act 2008 (Regulated Activities) Regulations 2009

Care Quality Commission’s Essential Standards of Quality and Safety

Responding to Emergencies: The UK Central Government Response. Concept of Operations 2010

NHS Resilience PAS 2015: Guidance for NHS-funded organisations 2010

Department of Health: Mass casualties Incidents – A framework for planning

Health and Social Care Act 2012


Appendix 1 Training Needs Analysis (CURRENTLY UNDER REVIEW)

If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process.

Training Programme

Frequency

Major Incident Management Awareness

Once at Induction

All on Call Managers

Once on joining an on call rota and annually thereafter

Strategic leadership for Directors on Call

Annually

Media spokesperson and media and communications in an emergency for Directors on Call and Communications Team

Every two years

Loggist training Every two years


Appendix 2: Equality Impact Assessment Equality Impact Assessment (or ‘Equality Analysis’) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law.

Name of policy/service/project/plan:

Major Incident Policy

Policy Number:

SH NCP 56

Department:

Quality and Governance

Lead officer for assessment:

Head of Risk and Business Continuity

Date Assessment Carried Out:

March 2013

1. Identify the aims of the policy and how it is implemented. Key questions Answers / Notes

Briefly describe purpose of the policy including How the policy is delivered and by

whom Intended outcomes

This Major Incident policy has been developed to provide the framework by which Southern Health NHS Foundation Trust (SHFT) will prepare for, respond to and recover from a major incident or emergency regardless of cause thus ensuring SHFT meets it’s emergency preparedness and response responsibilities. The Head of Business Continuity and Resilience has lead operational responsibility for the implementation of the policy. The Policy is publically available on the Trust Web site and Staff Intranet.


2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and

voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about

them Recommendations of external inspections or audit reports

Key questions

Data, research and information that you can refer to

2.1 What is the equalities profile of the team delivering the service/policy?

All staff members, contractors, visitors and volunteers should comply with this Policy. The Trust’s Equality and Diversity team report on workforce equality monitoring data on an annual basis and this information is available if required.

2.2 What equalities training have staff received?

All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment

2.3 What is the equalities profile of service users?

The Trust’s Equality and Diversity team report on Trust patient equality data profiling on an annual basis and this information is available if required.

2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps?

The Quality and Safety Committee is a Sub-Committee of the Trust Board, and therefore has a responsibility to receive and scrutinise assurance, and provide onward assurance to the assurance and Audit Committees and Trust Board. It monitors business continuity management as part of risk management processes to ensure that these are working correctly. Delegated responsibility for specific areas of business continuity management is held by the following groups:

Local Divisional / Directorate / Business


and Governance Groups

Health and Safety Committee

Trust Business Continuity and Resilience Group

2.5 What internal engagement or consultation

has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/Staff

This Section requires completion following completion of the Policy consultation. The EIA will be sent out as part of the policy consultation process.

2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations

The Trust has embraced the Equality Delivery System and will drive forward a strong engagement plan to involve and communicate with staff and patients so that they can share their skills and expertise on key issues on affecting service delivery.


In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this:

Positive impact (including examples of what the policy/service has done to promote equality)

Negative Impact Action Plan to address negative impact

Actions to overcome problem/barrier

Resources required

Responsibility Target date

Age Appropriate action is taken to ensure that the work environment is conducive to the needs of all our staff and service users.

No negative impacts have been identified at this stage of screening

Disability

The Trust will support staff with a disability and provide reasonable adjustments Personal Emergency Evacuation Plans (PEEP’S) are available to ensure the safety to staff and patients. The Trust has conducted Disability Access Audits on its services The Trust will provide appropriate interpreting and translation services to respond to requests for

There is a potential negative impact in making assumptions about the health and safety implications of a person’s disability as it might not make a difference to business continuity management. People hiding a disability that might have business continuity implications.

The equality and diversity team will provide support and guidance to the Trust.

Equality and Diversity Team. Estates Department.


information in alternative formats.

Gender Reassignment

The ethical framework used by the Trust will ensure each staff member’s and patient’s privacy and confidentiality are preserved.

No negative impacts have been identified at this stage of screening.

Marriage and Civil Partnership

No negative Impacts identified at this stage of screening.

Pregnancy and Maternity

The Trust will ensure risk assessments are undertaken for all new and expectant mothers to ensure preventative measures are undertaken where significant risks to business continuity are identified.

No negative impacts have been identified at this stage of screening.

Race The Trust responds positively to requests of information in alternative formats. The Equality and diversity Lead can be contacted for information on Interpreting and Translation services.


Religion or Belief


Sex No negative Impacts identified at this stage


of screening.

Sexual Orientation

The ethical framework used by the Trust will ensure each patient’s privacy and confidentiality are preserved.


Date post:	20-Jun-2018
Category:	Documents
Upload:	truongphuc
View:	216 times
Download:	0 times