WESTON AREA HEALTH NHS TRUST

TRUST BOARD MEETING

OPEN SESSION

TUESDAY 4 NOVEMBER 2014

EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE (EPRR) ANNUAL REPORT

  1. Background
  2. This report identifies work undertaken to ensure thattheTrustis compliantwith thestatutoryduties placedupon it as a‘Category-1Responder’under theCivilContingenciesAct–2004.

1.2The Trust is also required to comply with theNHSEmergency Preparedness Resilience and Response Framework and Core Standards.

1.3This report addresses the following areas:

  • EPRR Core Standards
  • EPRR Self Assessment and Assurance Framework
  • EPRR Policies, Plans and Response Resources
  • Heatwave Planning
  • Chemical Biological Radiological and Nuclear (CBRN) Planning
  • Business Continuity
  • Training and Exercising
  • Ebola Response
  1. EPRRCore Standards
  2. EPRR remains a key priority for the NHS and forms part of the NHS Standard Contract and through this, the NHS Commissioning Board Emergency Planning Framework- (2013).

2.2The NHS had published core standards for (EPRR) in 2013 all of which are an underpinning requirement for all NHS funded organisations.

2.3A revised set of core standards was issued in July 2014, which includes 13 core standards specific to Chemical Biological Radiological and Nuclear (CBRN) response.

2.4The expectation ofWeston Area Health NHS Trustis, that as an NHS Funded Organisation, the Trust is able to demonstrate compliance with core standards and that plans and arrangements are in place to effectively and robustly respond to a wide range of incidents and emergencies,which may impact upon the health of the population or affect patient care.

  1. EPRR Self-Assessment and Assurance Framework
  2. In Late 2013 meetings between the North Somerset Clinical Commissioning Group, NHS England Local Area Team and the Trustanalysed self assessments undertaken by the EPRR Lead in post at that time, to highlight areas requiring improvement, in order to close gaps in the delivery of EPRR by the Trust.

3.2The EPRR assurance process undertaken through self assessment highlighted a challenging programme of work for the trust in order to achieve required compliance with the NHS EPRR agenda.

3.3Follow up meetings between the North Somerset Clinical Commissioning Group, NHS England Local Area Team and the Trust noted the following specific areas of concern and a RAG rating of Red for the following areas:

  • Lack of trained and dedicated EPRR resource to deliver a robust EPRR programme
  • Lack of appropriate governance arrangements for EPRR
  • Lack of EPRR specific training for on-call Directors and Managers
  • Out of date Major Incident Plan
  • Lack of Business Continuity Planning
  • Lack of EPRR Specific Risk Assessments
  • Lack of an EPRR training and exercising programme
  • Lack of a detailed EPRR Workplan

3.4The above resulted in the Trust putting in place a 0.4 WTE experienced Emergency Planning Lead, holding a DipHEP; effective from the 23 April 2014.

3.5EPRR governance arrangements were improved to ensure that:

  • A formal multi disciplinary Emergency Planning and Business Continuity Group was in place with formal Terms of Reference; chaired by the Accountable Emergency Officer.
  • EPRR Risks are subject to formal scrutiny by the Risk Management Committee.
  • The Audit and Assurance Committee receives update reports on EPRR delivery.
  • A specific EPRR electronic folder has been created with access provided to key Trust personnel.
  • The Trust’s Accountable Emergency Officer attends the LHRP strategic Planning Group.
  • The Trust EPRR Lead attends the LHRP Tactical Planning Group, CBRN Group, and Acute Trusts Group.

3.6A review of outstanding EPRR requirements has been undertaken in order to develop an agreed, prioritised EPRR Workplan.

3.7EPRR specific Risk Assessments have been undertaken (delivery of EPPR); also EPRR specific Risk Assessments relating to the Risk and Threats faced by the Trust as an Avon and Somerset Local Resilience Forum and LHRP member.

3.8The Trust was required to undertake a further assurance Self Assessment in September 2014; the work undertaken from 23 April 2014 to September 2014 resulted in a measurable improvement in EPRR delivery capability, with the Trust is now not RAG rated Red in any compliance area.

3.9The 2013/14 NHS England Local Area Team RAG summary scorecard is detailed at AppendixA.

3.10TheSeptember 2014 NHS England Local Area TeamRAG summary scorecard is detailed at AppendixB.

3.11The September 2014 NHS England Local Area Team CBRN/HAZMAT Outcome document is detailed at AppendixC.

3.12The EPRR Lead also completed the Trusts Internal Emergency Planning and Business Continuity Audit, originally set in motion in 2012. Outstanding actions have now been completed with the Major Incident Plan issued and Business Continuity implementation well underway.

  1. EPRR Policies, Plans and Response Resources
  2. The EPRR Lead has drafted and the Trust’sExecutive Management Group has ratified the following documents since May 2014.
  • WAHT – EPRR Policy
  • WAHT – Business Continuity Framework
  • WAHT – Department/Team Business Continuity Plan (template)
  • WAHT Heatwave Plan

4.2All the above have been uploaded onto the Trust’sDocument Management System, under a specific EPRR heading, this will happen to all Trust EPRR documents as they are drafted and formally approved.

4.3Additionally the Trust’s Major Incident Plan (Including Action Cards) has been reviewed and updated.

4.4The Trust’s Heatwave and CBRN Plans were made standalone.

4.5The Trust’s Incident Control Room(Executive Board Room - Brent Knoll) has had improvements made to available facilities:

  • Plans are now located in the EPRR Resource cupboard.
  • A satellite TV receiver has been installed to receive news broadcasts.
  • The Trust’s Resilience Email account has been setup and key members of staff given access to it, as an add-on mailbox.
  • The Incident Control Room - Standard Operating Procedure (SOP) has been reviewed and updated.
  • The Trust now has access to the Cabinet Offices Secure Extranet- ‘Resilience Direct; login details are detailed within the SOP and a copy sits in the on-call Managers electronic folder.
  1. Heatwave Planning
  2. The Trust’s Heatwave Plan from 2013 and actions undertaken/arising from response to last year’s Heatwave, was reviewed by the Trust’s Emergency Planning and Business Continuity Group, in order to meet the revised national Heatwave Plan for England 2014.

5.2The National Heatwave Plan 2014 now clarifies responsibilities and actions for healthcare organisations, local authorities and professionals in the light of the changes made in 2013 to health and social care, separating actions for commissioners, providers, professional staff and the wider community.

5.3The Heatwave Plans continue to be under pinned by a system of Met Office and NHS heatwave alerts, with changes to emphasis for long term planning for heatwaves throughout the year, with an additional alert level ‘0’ added to reflect this requirement.

5.4The Trust’s EPRR Lead redrafted the 2013 Plan incorporating lessons learnt, including action cards for key personnel/departments, ready for use in the 2014 heatwave period 1 June – 15 September.

5.5This Plan was ratified by the Executive Management Group and uploaded to the Trust’s Document Management System.

5.6No Major issues arose during this summer’s heatwave response period.

  1. Chemical, Biological, Radiological and Nuclear (CBRN) Planning
  2. The Trust’s CBRN Plan was previously issued as a part of the Major Incident Plan, however in order to simplify the Major Incident plan, the CBRN Plan was removed, reviewed (including input from the Trust’s CBRN trainers) and reformatted, before uploading to the Trust’s DMS.

6.2The Trust undertook a CBRN self assessment as part of the September 2014 EPRR assurance process. This entailed a SWAST/NHS England physical audit of the Trust CBRN plan, facilities and allocated resources.

6.3The SWAST - CBRN Audit Report is detailed at AppendixC and some minor changes to administrative requirements were identified, along with some small items of equipment, there were no major issues identified by the Audit.

6.4CBRN specific training for staff in the Emergency Department is delivered by two members of staff.

6.5The same two members of staff also manage the CBRN response equipment, supported by the EPRR Lead.

  1. Business Continuity
  2. Revised EPRR Core Standards issued in July 2014 states:

‘NHS organisations and providers of NHS funded care must have suitable, proportionate and up to date plans which set out how they will maintain prioritised activities when faced with disruption from identified local risks; for example, severe weather, IT failure, an infectious disease, a fuel shortage or industrial action.

7.2The Trust’s EPRR Lead had applied principles detailed for ISO-22301, following a review of the Trust’s BCM process, undertaken on handover in May 2014.

  • The Trust EPRR Lead has drafted and had ratified by the Executive Management Group a WAHT – Business Continuity Framework document and a Department/Team Business Continuity Plan (template).

7.3Work is underway with identified Department/Team Business Continuity Leads, for the drafting of individual Team plans, using the template provided by the EPRR Lead. Initial work undertaken has involved the Emergency Care Division, Planned Care Division and IM&T.

7.4This involves some 80 plus local Teams within the Trust, with six drop in training sessions allocated and over 30, 1:1 sessions with Leads undertaken to-date.

7.5Each initially submitted Local Team / Department Business Continuity Plan will be reviewed by the EPRR Lead, assisted by the Trust’s Security Advisor, before final sign off with the Divisional Leads.

  1. Training and Exercises
  2. An EPRR Training Needs Analysis for the Trust has been developed by the EPRR Lead.

8.2A Key area of training identified are Induction / refresher for all staff as part of statutory/mandatory training delivered by the Trust’s Training Department. This was implemented in July 2014 through the viewing of a specially made Trust Major Incident DVD.

8.3A requirement exists for all Trust on-call Directors and Managers to undertake specific EPRR training and exercising. This will be arranged from January 2015 as the Trust’s Incident Control Room and the required plans and SOPs are now in place.

8.4Exercising will take the form of Tabletop Exercises and Incident Control Room walkthroughs, around a specific scenario.

8.5The Trust is planning to undertake a multi-agency decontamination exercise with Avon Fire and Rescue Service, in April 2015.

  1. EBOLA

Ebola Response Activity

9.1From August 2014, NHS England and Public Health England have issued guidance and updates to the Trust for Ebola preparedness.

9.2Initial Guidance issued, included a ‘Viral Haemorrhagic Fevers Risk Assessment Algorithm’ and a document entitled ‘Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence’.

9.3Regular updates are received by the Trust, via the Microbiologists, Head of Communication and EPRR routes.

9.4As a result of case of Ebola occurring outside Africa; the Department of Health and Cabinet Office cancelled a scheduled National Pandemic Flu Exercise for the week commencing 13 October 2014, substituting an Ebola response exercise.

9.5On 10 October 2014, NHS England called a short notice Ebola desktop exercise for NHS and partner agencies in the Southwest, to be held in Bristol on 15 October 2014.

9.6The Trust’s EPRR Lead arranged short notice attendance from:

  • Emergency Department Matron, plus one Emergency Department Nurse and one Emergency Nurse Practitioner (both CBRN Trainers); two Infection Control Nurses and the EPRR Lead.

Trust’s Ebola Response Working Group

9.7The Trust EPRR called a meeting of an Ebola Response Working Group for Thursday 16 October 2014.

9.8The purpose of the meeting was to ensure the Trust’s Ebola response measures were understood and resources allocated.

9.9This meeting was well attended and a meeting schedule going forward was set up.

9.10The second Ebola Response Working Group meeting took place on Wednesday 22 October 2014, with progress reported as detailed below.

Sn: / Action / By / Being Progressed
(Y/N) / Completed (Y/N)
1. / Discuss Emergency Department Consultant lead for EBOLA with the Medical Director / Director of Nursing / Y
2. / ENP – Glenda Lenaghan requires support in role as ED Ebola lead. / Emergency Department– Head of Nursing and Matron, Infection Control Nurses and EPRR Lead.
Additional support available as required from Consultant Microbiologist and Director of Nursing. / Y
3. / Check when redrafted policy (VHF) was issued. / IC-18 Pol ‘Management of Viral Haemorrhagic Fevers’ was issued in August –2014.
Dr Ram Lakshmipathy, Consultant Medical Microbiologist retains responsibility for amendments. / Y
4. / Authorising Director for any new or reissued Trust EBOLA policies. / Director of Nursing (DIPC) / Y
5. / Responsibility for drafting Trust Ebola response procedures. / ENP Glenda Lenaghan / Y
6. / Storage of Ebola Related guidance or communication to the Trust / Glenda Lenaghan (ENP) with support from the EPRR Lead, Rod Dewar.
Ensure stored in the x-drive EBOLA folder (to be setup by IM&T). / Y
7. / TNA required Identifying members of staff that require specific training; (e.g. EBOLA response, PPE, waste disposal, lockdown). / Glenda Lenaghan (ENP) and Emergency Department Matron. / Y
8. / Delivery of Ebola specific training for ED Staff / Glenda Lenaghan (ENP) with support from Emergency Department Matron and Infection Control. / Y
9. / Responsibility for Initial arrival assessment of suspect Ebola patient (training required). / Trained Triage Nurse from the Emergency Department. / Y
10. / Identification of any Microbiologist Training requirements. / Consultant Microbiologist / Y
11. / Sample transportation container required in ED. / Consultant Microbiologist / Y
12. / Identification of Isolation facilities (Rooms 9 & 10) ED Department / Glenda Lenaghan / Infection Control Nurse / EPRR Lead / Y
13. / Are isolation room’s neutral pressure. / Infection Control Nurse, Selena Luff / Y
14. / Walkthrough of possible routes into the Emergency Department. / ENP Glenda Lenaghan/ Infection Control Nurse and EPRR Lead / Y
15. / Investigate Provision of Telephone in Isolation Room with Pete Dunstone. / Emergency Nurse Practitioner, Glenda Lenaghan / Y
16. / Identification for PPE - Ebola specific requirements. / ENP Glenda Lenaghan/ Infection Control Nurse and EPRR Lead. / Y
17. / Order required PPE – utilising Taunton (MPH) order codes if possible. / ENP Glenda Lenaghan / Infection Control Nurse / Y
18. / Identify EPRR budget code for PPE. / ENP Glenda Lenaghan / Infection Control Nurse / Y
19. / Identify the PPE regime to be utilised and include in the Ebola procedure. / A Single tier PPE approach will be used from the outset of presentation of patient. / Y
20. / Ebola procedure to include clear (approved) Resus guidance. / ENP Glenda Lenaghan. / Y
21. / Escalation arrangements to be clearly defined as part of Ebola response procedure. / ENP – Glenda Lenaghan / EPRR Lead. (MI, BC, CBRN plans and on call arrangements) / Y
22. / As part of the Ebola response arrangements identify clinical leads for each shift (consultants / Sisters) and provide any additional training required along with ongoing situation briefings. / ED matron / HoN / ENP – Glenda Lenaghan / Y
23. / Requirement to test (exercise) trust response arrangements.
  1. The triage process with emphasis on identification of possible EBOLA.
  2. The Isolation Process.
  3. The escalation process (in Ed and to On Call Directors / Managers).
  4. The PPE Process.
  5. The Communication process – with Microbiologists and PHE.
  6. Communication process internal for staff, external with NHS England / CCG.
  7. Waste management process.
/ ED matron / HoN / ENP – Glenda Lenaghan / EPRR lead / facilities Manager / Y
24. / Arrangements for Ebola communication to staff
(FAQ / Changes in advice etc...) / ECD managers / HoN/ Ops Director / Head of comms. / Y

Rod Dewar

Health and Safety/ EPRR Lead

17 September 2018

K:\Board Papers\Board Papers 2014\4 November 2014\Open\Agenda Item 955 14 Emergency Preparedness Resilience and Response Annual Report.docx

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AppendixA: BNSSSG Resilience Indicators- 2013/14 EPRR Assurance Process

AppendixB: BNSSG Resilience Indicators-September 2014 EPRR Assurance Process

AppendixC:CBRN/Hazmat Audit Outcome Document – September 2014 EPRR Assurance Process

Acute Trust: Weston General Hospital
Date: 11th September 2014 - 09.30 hrs
Trust representatives: Rod Dewar (EPRR Lead), David Watkins (ED CBRN Trainer)
SWAST representative: Philip Russell
Others present: Kate Bradley (NHS England)
Core Standard / Evidence shown / Standard Met? / Feedback/Recommendations
Preparedness
There is an organisation specific Hazmat/CBRN plan (or dedicated annex). / CBRN plan is in a draft state, and is due to be released at the end of Sept 2014. / Will be fully compliant when plan is released.
Staff is able to access the Hazmat/CBRN management plans. / All plans are available on the trusts intranet. / Will be fully compliant when plan is released.
HAZMAT/ CBRN decontamination risk assessments are in place which is appropriate to the organisation. / All risk assessments are within the EPRR risk assessments. They will complete some specific CBRN/Decontamination risk assessments. / To develop specific CBRN/Decontamination risk assessments.
Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7. / Trained staff is drawn from ED staff, and they have the correct amount of cover on duty 24/7.
Staff on-duty knows who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7. / There are folders with specialist advice numbers held within them.
Decontamination Equipment
There is an accurate inventory of equipment required for decontaminating patients in place and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff. / No inventory currently available. / They will create an equipment inventory.
The organisation has the expected number of PRPS suits (sealed and in date) available for immediate deployment should they be required (NHS England published guidance (May 2014) or subsequent later guidance when applicable) / 24 live PRPS.
There are routine checks carried out on the decontamination equipment including:
A) Suits
B) Tents
C) Pump
D) RAM GENE (radiation monitor)
E) Other decontamination equipment / Routine checks on equipment are carried out by the CBRN leads, routinely.
There is a preventative programme of maintenance (PPM) in place for the maintenance, repair, calibration and replacement of out of date Decontamination equipment for:
A) Suits
B) Tents
C) Pump
D) RAM GENE (radiation monitor)
E) Other equipment / The manufacturers will deal with equipment such as the tent, and the PRPS. The Ram Gene is maintained by Med. Physics. All other maintenance is completed through the estates department.
There are effective disposal arrangements in place for PPE no longer required. / No PPE has been disposed of. Out of date PRPS will be utilised for training.
Training
The current HAZMAT/ CBRN Decontamination training lead is appropriately trained to deliver HAZMAT/ CBRN training / They are appropriately trained. / The trainers would welcome some refresher training for themselves.
Internal training is based upon current good practice and uses material that has been supplied as appropriate. / Reviewed the training package, and it is based on current best practice.
The organisation has sufficient number of trained decontamination trainers to fully support its staff HAZMAT/ CBRN training programme. / The trust has 2 trainers
Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant. / Requirement is understood. They currently use a cubicle to isolate / Suggestion was made about possibly using a toilet near reception for the use of isolating a patient.

17 September 2018