THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST BUSINESS CONTINUITY PLAN

Transcription

1 THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST BUSINESS CONTINUITY PLAN APRIL 2012 Version No: 2 Issue Status: awaiting Trust Board approval Date of Ratification: 11th April 2012 Ratified by: Risk Management Committee Policy Author(s): Stuart Coalwood Asst Director of External Compliance & Quality Assurance Policy Owner: Camilla Wiley, Director of Nursing Review Frequency: 2 yearly Last Review: May 2012 Next Review: May 2014 POLICY AWARENESS People who need to know this policy in detail People who need to have a broad understanding of this policy People who need to know this policy exists All on call staff All staff All staff CHANGE CONTROL DETAILS Date: Dd/mm/yy Version Description Reason for changes May 2012 VO2 Updated Plan Updated Plan January 2009 V01 New Plan New Plan Location: RNOH Intranet 1

2 Contents 1 Definitions 3 2 Regulatory and strategic context 4 3 Publication and distribution 5 4 Plan review 5 5 Background 5 6 Aim of this plan 5 7 Plan objectives 6 8 How the objectives will be met: preparation and planning 6 9 Business Impact Analysis 6 10 Categorisation of services 7 11 Risk assessment 7 12 Incident identification 7 13 Incident declaration and plan invocation 8 14 Business Continuity Incident Control Room(s) Incident management Building evacuation and acceptance of displaced people and services Human resources Information and communications technology (ICT) Essential service resumption or relocation Essential supplies and equipment Communication Department and service response plans Stand down Recovery and debrief Appendices

3 To be read in conjunction with: The Emergency plan Influenza pandemic and winter pressures plan Department and service business continuity plans Severe Weather plan Transport disruption plan Heatwave plan Fuel shortage plan The aim of this plan is to ensure that the Royal National Orthopaedic Hospital NHS Trust has a Business Continuity Management programme which ensures that statutory obligations are met, and which supports its vision and mission. Date: 1 st April Definitions 1.1 For the purposes of this document an emergency is defined as: An actual or impending situation that may cause injury, loss of life, destruction of property or cause the interference, loss or disruption of an organisation s normal business operations to such an extent that it poses a threat. 1.2 For the purposes of this document Business Continuity Management (BCM) is defined as: an holistic management process that identifies potential impacts that threaten an organisation and provides a framework for building resilience and the capability for an effective response that safeguards the interests of its key stakeholders, reputation, brand and value creating activities. 1.3 For the purposes of this document a Business Continuity Management Plan (BCMP) is defined as: A clearly defined and documented plan for use at the time of a Business Continuity Emergency, Event, Incident and/or Crisis (E/I/C). Typically a plan will cover all the key personnel, resources, services and actions required to manage the BCM process. 3

4 2 Regulatory and strategic context 2.1 BCM is a legal requirement for Primary Care Trusts, Acute Trusts and Acute Foundation Trusts, as Category 1 responders under the Civil Contingencies Act 2004 (CCA) and the Civil Contingencies Act 2004 (Contingency Planning) Regulations The Health and Social Care Act 2008 (Regulated Activities) Regulations 2009, 6 (Regulations 9(2) and 24) which came into force on April 1st 2010, provide the statutory basis for the Care Quality Commission s Essential Standards of Quality and Safety, 4B, 6D and 10E, which require healthcare providers to put in place arrangements for the management of emergencies and the development and maintenance of contingency plans to maintain services. 2.3 The Operating Framework for the NHS in England sets out the Department of Health s expectations regarding emergency preparedness and business continuity. 2.4 The Business Continuity Institute sets out Good Practice Guidelines which are recognised as the industry standard under BS The Department of Health Interim Strategic National Guidance 2008 recommends that all NHS organisations aspire to comply with the requirements of this standard. 2.5 The clinical vision of the Royal National Orthopaedic Hospital NHS Trust is to provide the scale and range of specialty surgery and rehabilitation to ensure clinical outcomes appropriate to a world class service. The volume and complexity of work undertaken by the Trust enable our staff to become leaders in their professional field and we offer training to cascade clinical practice in orthopaedics and rehabilitation throughout the NHS. The RNOH will also provide a vision and network of expert and exceptional support for trauma services. The clinical vision of the Royal National Orthopaedic Hospital NHS Trust is to be a world leading clinical centre of excellence for translational research, multi-disciplinary education and treatment of complex neuromusculoskeletal disease ; the mission of the Royal National Orthopaedic Hospital NHS Trust is to be the Specialist Orthopaedic Hospital of choice by providing outstanding patient care, research and education. In order for this vision and mission to be met it will be necessary to ensure that effective plans are in place to identify risks to service continuity, and ensure that effective plans are in place to mitigate those risks. 2.6 This document should be read in association with the approved the Royal National Orthopaedic Hospital NHS Trust Business Continuity Management Policy. 4

5 3 Publication and distribution 3.1 The Civil Contingencies Act 2004 permits Category 1 responders to restrict the publication of plans and prohibit the publication of sensitive information and personal data. It advises publication only where there is a positive benefit in doing so and where the benefits of disclosure are in the public interest. Sections of this plan which relate to confidential telephone numbers and locations are therefore considered exempt from the requirements of the Freedom of Information Act 2000, and distribution of the full information contained within these sections will therefore be restricted to the Royal National Orthopaedic Hospital NHS Trust staff responsible for responding to Business Continuity Incidents. 4 Plan review 4.1 The plan will be kept under constant review by the Director of Nursing (the document Owner) and amended when there are changes in legislation or internal arrangements, or as a result of improvements identified through exercises. 4.2 The plan will be subject to formal review by the Risk Management Committee at an interval not exceeding three years. 4.3 Technical and detail changes (such as changes of address or telephone number, or references to legislation) will be made by the Director of Nursing who will notify the relevant staff of the changes made and update the Document Control Panel. 4.4 Significant changes to BCM operations will be approved by the Emergency Planning Committee. 5 Background 5.1 A sound BC Plan (or set of plans) provides reasonable assurance to the Board and evidence for internal and external auditors and inspecting/reviewing bodies. It also makes good business sense: for the public we serve for our staff for our partners for those who commission services from us 6 Aim of this plan 6.1 The aim of this plan is to ensure that the Royal National Orthopaedic Hospital 5

6 NHS Trust has a BCM programme which ensures that statutory obligations are met, and which supports its vision and mission. 7 Plan objectives Objective 1 To ensure that the Royal National Orthopaedic Hospital NHS Trust is compliant with its legal and regulatory obligations Objective 2 To ensure that key products and services are identified and protected, ensuring their continuity Objective 3 To ensure that there is an effective incident management capability Objective 4 To ensure that staff are trained to respond effectively to an incident or disruption through appropriate exercising Objective 5 To ensure that stakeholder requirements are understood and can be delivered Objective 6 To ensure that staff are properly communicated with and receive adequate support in the event of a disruption Objective 7 To ensure that the Royal National Orthopaedic Hospital NHS Trust supply chain is secured 8 How the objectives will be met: preparation and planning 8.1 A forward work plan has been developed and will be implemented by the Director of Nursing. 9 Business Impact Analysis 9.1 BIA has been carried out on all category A and B services (see s.11 below) and all essential corporate functions. These assessments are detailed in the individual plans for departments and services. 9.2 It is recognised that the Maximum Tolerable Period of Disruption (MTPD) identified as part of the BIA process might be affected by the workload of the service at the time of the incident. For example, some services may be limited or redefined during the summer or school holiday periods or financial year end deadlines. Seasonal Activity should also be documented in individual Department and service plans. 6

7 10 Categorisation of services 10.1 All services have been categorised into categories A, B or C, as follows: See Appendix Risk assessment Generic risk assessment 11.1 Generic risks have been identified, and assessed using the matrix in the Royal National Orthopaedic Hospital NHS Trust Guide for Assessors and Planners. The Royal National Orthopaedic Hospital NHS Trust risk register also identifies high or medium risks in the following areas which could impact on Business Continuity. Responsibility for each risk area has been assigned to a Director: Activity-specific risk assessment 11.2 Activity-specific risk assessment has been carried out on all services and all essential corporate functions. : 12 Incident identification 12.1 An incident or set of circumstances which might present a risk to the continuity of a service might be identified by any member of staff. When an incident or set of circumstances which might present a risk to the continuity of a service is identified, it is important that the person identifying the incident knows what to do. In the initial stages, this will involve making sure that the right people have been informed see diagram overleaf In the event of a minor incident, or one that can be dealt with using normal services and resources, local managers and staff will deal with it. 7

8 Negligible: limited local impact Minor: Disruption to a Category C service Major: Disruption to a Category B service Catastrophic: Disruption to a Category A service Take any remedial action it is safe to take Report to line manager Follow service or department Business Continuity Plan if available and necessary Notify head of service/ department Follow service or department Business Continuity Plan Notify on-call Director Follow service or department Business Continuity Plan Notify on-call Director Declare a major incident or major incident standby Follow major incident plan and or service or department Business Continuity Plan 13 Incident declaration and plan invocation Normal working hours 13.1 During normal working hours, in the event of a Major or Catastrophic incident, or set of circumstances which might present a risk to the continuity of a Category A or B service, an incident can be declared and the plan invoked by the Director with responsibility for the service affected Where more than one service is affected, any one of the responsible Directors can decide to declare an incident and invoke the plan, in order to mobilise an effective response across the organisation and ensure the involvement of partners where required. Out of hours 8

9 13.3 In the event of a Major or Catastrophic incident, or set of circumstances which might present a risk to the continuity of a Category A or B service, which occurs outside normal working hours, the on-call Director can decide to declare a Business Continuity Incident (BCI), and invoke the plan, in order to mobilise an effective response across the organisation and ensure the involvement of partners where required. Contacting the on-call director Telephone the switchboard and ask for the on-call director to be called If for any reason the switchboard is not available then ring Page One on ask for pager Royal National Orthopaedic Hospital NHS Trust and provide a short message on request, which must include: a contact name and telephone number Type of incident Pass on as much information as you can, including : The current and projected impact of the incident How many casualties/fatalities are involved The level of media interest Your ability to cope any additional support or resources required Which other agencies/partners are involved in the incident Any other information that you think is relevant Invocation 13.4 To declare a BCI the responsible Director should: Start the incident log Notify the Chief Executive. The on-call Director will act as the BC Manager (BCM) in the initial stages of the response Notify the Director with line management responsibility for each service or department affected Notify the Communications Lead 13.5 The Trust response must keep pace with the pace of the incident itself, in order to exert control. It might be necessary to convene a Business Continuity Team 9

10 out of office hours and to operate it on a 24/7 basis. Up to date contact details and reserves for the BCT members will be maintained by the ANYWHERE NHS TRUST Emergency Planning Team and will be available to all on-call Directors. Alerting NHS London 13.6 NHS London must be notified whenever this plan is invoked: Call NHSØ1 (NHS London Manager) or LONØ1 (NHS London Communications Manager) Pass on as much in for mation as you can, including : Type of incident The current and projected impact of the incident How many casualties/fatalities are involved The level of media interest Your ability to cope any additional support or resources required Which other agencies/partners are involved in the incident Any other information that you think is relevant 14 Business Continuity Incident Control Room (S) 14.1 Refer to the Emergency Management Plan for locations and set up details In the event of an incident which requires both a response to an emergency and a BC response the teams should be located in different control rooms in order to maintain their separate focus. An agreement should be reached with the major incident team as to the location of the BC team and good communications links established between the two teams The BCM should chose a suitable location based on the following criteria: Health & Safety Accessibility Availability of IT and communications Toilets and hand washing Availability of food and drinks 14.4 The BCM will ensure that regular rest breaks are taken, refreshment facilities are available and that staff are rotated on a regular basis. 10

11 15 Incident management 1 Start the incident log INCIDENT MANAGER ACTION CARD FIRST PHASE 2 Convene a Business Continuity Team if required 3 Inform all relevant staff of the incident and what needs to be done immediately 4 Relocate to the BCI room 5 Inform all staff on how to contact the team or how messages will be broadcast 6 Notify the Chief Executive if necessary 7 Address immediate staff concerns 8 Ensure that staff are briefed about the incident and given clear instructions on whether they should relocate or go home, and when they are expected to return 9 Inform neighbouring NHS organisations / local authority/ social services if necessary 10 Prioritise existing work using the Local Business Continuity Plans 11 Supervise effective management of the incident 12 Hold regular meetings with the Business Continuity Team (frequency depends on the nature and severity of the situation) and ensure that staff are briefed 13 Ensure that the health and safety of staff is prioritised 14 Take regular breaks and hand over to another member of staff 15 Assess and monitor responses 16 Ensure that you have a good overview of the tasks being carried out by Business Continuity Team members, leads and their staff 17 Authorise the stand down 18 Ensure debrief meetings are arranged 19 Write up the log notes and final report 20 Review use of emergency procedures, business continuity plans and update where necessary 11

12 Once the main priorities have been dealt with, you might consider scaling down the Business Continuity Team, or hand over to another member of staff to deal with the medium and long term issues, or the day-to-day recovery of the incident. If an incident is going to go on for more than 4 8 hours, establish a rota for staff within the team and regular hand over for the BC Manager role. On-call Director Activate plan and BCI team Set recovery strategy Authorise expenditure Brief CEO Information and communication technology lead Identify equipment and infrastructure requirements Identify suppliers Recommend priority for I&CT recovery Human resources lead Advise on workforce law and policy Collate absence reporting and redeployment Payroll Co-ordinate staff family liaison where required Communications lead Communications with staff, patients, media, partners, stakeholders Co-ordination of call centre activation, website communication, intranet information Estates and facilities lead Accommodation Site clean up Building contractors Legal advice 12

13 Health and Safety Mobile Phones Service representatives as required (examples only) Primary care Public Health Therapies Nursing Support team Admin: logging; note taking; call handling Call centre As per Emergency Management Plan Intelligence team Gathering and analysing data and information Internal and external situation reporting 1 Attend the BC Control Room as required ACTION CARD BUSINESS CONTINUITY TEAM MEMBER 2 Discuss with the BCM if you are required to attend the incident room in order to carry out your role. You might need to be at the site of the incident in the first instance 3 You might be requested to assist with the following 16 Building evacuation and acceptance of displaced people and services Evacuation 16.1 Follow fire evacuation procedures and alarms If there is a risk of explosion (i.e. if a credible bomb threat has been received) responsible managers should consider the safest distance to establish an Assembly Point until advised by the Fire Brigade and Police. Debris from an explosion may cause damage over a wider area than a controlled fire. Staff and 13

14 visitors must be directed to a safe Assembly Point No person will re-enter a building unless notified that is safe to do so by the Fire Brigade Business Continuity Team should ensure that, following an incident, the building is assessed by competent estates and facilities staff or external contractors to assure safety before resuming services. Displaced members of the public: external incident 16.5 Staff in community premises may be asked to provide immediate shelter for people evacuated by the emergency services Trained nursing or first aid staff should be alerted to deal with displaced people and offer refreshment and communications until a suitable reception centre can be set up in conjunction with the local council If necessary a triage system should be set up and liaison with the ambulance service established. 17 Human resources 17.1 The BCI Team must consider staff health, safety and welfare, both during the incident and in the recovery period Health & Safety will take priority in ensuring staff do not return to work before it is safe to do so. The number of hours which staff work must be strictly controlled and where necessary shift systems developed If a building or service is to remain closed for a period of time, staff will be concerned about their pay, conditions and what they are required to do in the meantime Counselling and rehabilitation services may be required for staff who may have witnessed a traumatic event or suffered stress from dealing with its aftermath. The HR and Communications leads should ensure that these matters are addressed. 18 Information and communications technology (ICT) 18.1 In the event of a major incident, certain IT functions will be critical to the Royal National Orthopaedic Hospital NHS Trust response. The Business Continuity Plan for IT details arrangements for ensuring business continuity in the event of a significant incident. 19 Essential service resumption or relocation 19.1 There are various options to consider for the resumption of a service or relocation of a service due to loss of building or denial of access. These will be 14

15 affected by: the availability of suitably skilled staff resources the ability of those receiving the service to travel to alternative locations 19.2 When re-allocating staff it will be necessary to take into account the Management of Staff in Emergency Situations: Joint Management & Staff Side Agreement (see Appendices) The BCI team will consider a range of recovery options. OPTION OPTION Budge up Portable premises e.g. portakabins Can the service share resources? Displacement Priority services displace non-affected Outsourcing arrangements: service provided by another NHS body or private partner low priority services i.e. category A displaces category C Remote working Can some staff work effectively from a home base with the right ICT support? Reciprocal arrangements Re-skill/ upskill staff and move into different roles or request staff from another NHS body or private partner Relocate the service to a local hospital Share with other NHS trusts Third party alternative Local authority, commercial partner Do nothing service is allowed to become redundant or social enterprise 20 Essential supplies and equipment 20.1 Essential services requiring re-location will arrange for the transport or delivery of essential supplies and equipment in accordance with their Business 15

16 Continuity Plans, in liaison with the estates and facilities team. 21 Communication 21.1 The purpose of the communication plan is set out in the diagram below: 21.2 The Communications Lead will implement the communications plan and ensure that communications with the general public and the media are managed appropriately. Communications plans will follow Cabinet Office guidance The BCT will agree: Method of communication Frequency and timing of press releases Method for sending press statements 21.4 Overall Communication Objectives are to: provide accurate, timely and consistent advice to staff, the public and partner organisations aid understanding of the incident explain what the healthcare community can and cannot do to respond to the incident and reduce the impact on the community 21.5 All contact with the press during office hours will be diverted through the Royal National Orthopaedic Hospital NHS Trust Communications Team. The Royal National Orthopaedic Hospital NHS Trust target audiences could include: 16

17 Staff Commissioners Other local NHS organisations Local non-nhs organisations Voluntary, community and religious organisations The media Local MPs and Council members Local businesses Schools colleges and nurseries Managers of nursing homes, residential care establishments and day centres Local emergency services Patients and patient representative groups The general public (via news media and other communication tools) NHS London The Department of Health Communication to staff 21.6 Messages to staff must be: Honest Consistent Timely 21.7 Briefly describe the problem to staff; don t speculate, if you do not know, say so Tell staff what actions you need from them, whether you need them to stay and help or to go home If you are sending staff home, make sure they know who to contact for information when they can return or where they should report to instead If staff are going to be off for more than a few days, ensure that they are informed if it will affect their pay and conditions, staff may be unduly worried if they feel they will be financially penalised (see staff agreement, Appendices) Ensure key staff attend regular briefings so that they can disseminate information Don t rely on to relate key messages not all staff have access or read their regularly Use key points to display messages; reception areas, main access points, refreshment areas or toilets are good places to get information across to a wide range of staff Consider setting up a helpline number for staff this can be used by the Business Continuity Team to provide recorded information or allow staff to update their availability or answer queries. 17

18 Communication with external media See Appendices for a template script for media enquiries. Spokespeople All communications must be issued by an appropriate spokesperson. The designated spokesperson will vary according to the audience and / or the subject matter as well as the availability of relevant experts Spokesperson selection should use key strengths, so for example messages about avoiding and treating Pandemic Flu should come from a doctor, whilst messages about changes in service delivery should come from the CEO. Press briefings and statements All media briefings should follow the following guidelines (see Template, Appendices) Make sure your own staff and other relevant audiences are fully informed, ideally just prior to informing the media Keep to the facts with short simple statements Be open, maintain regular contact, especially with established media contacts Issue updates at agreed times and establish format for briefings e.g. questions taken at the end of statements. Demonstrate concern Demonstrate control of the situation and take assertive action Take questions but only answer when sure of the facts, otherwise promise to investigate and respond later or pass to the relevant supporting spokesman Announce conclusion of the incident as positively and quickly as possible Move the story on if possible issue a new, positive story as soon as possible after the incident but be aware of local sensitivities to something too overt Do not speculate Do not apportion blame NB: For Pandemic Flu see Pandemic Flu Communications Plan 22 Department and service response plans 22.1 All Category A and B services and all essential Corporate functions listed in Appendix 5 have local Business Continuity Plans. These plans are held: 23 Stand down By the manager of the affected department or service. These plans will be held: in hard copy in the department or service base, and on a data stick, off site, by the department or service manager and deputy By the Emergency Planning Officer On a secure section of the Trust Intranet 23.1 The BCM will decide when the incident response can be stood down, in 18

19 consultation with the BCT and the Chief Executive, as necessary. 24 Recovery and debrief 19

20 Appendix 1: Business continuity team meeting agenda 1 Introductions Check for absences Confirm covering officers ACTION NOTES 2 Actions from the previous meeting NOTES 3 Reported disruptions to ANYWHERE NHS TRUST services NOTES 4 Reported disruptions to partner services NOTES 5 Reports from primary care NOTES 6 Reports on public health matters NOTES 7 Human resources/staff welfare NOTES 8 Estates and facilities NOTES 20

21 9 IT and telecommunications NOTES 10 Communications NOTES 11 NHS London NOTES 12 Other partners/stakeholders NOTES 13 Any other business NOTES 14 Date, time and location of next meeting NOTES 21

22 Appendix 2: Decision log template Date Time Recorded by Description of matter to be decided Options Outcome/actions Reasons for decision 22

23 Appendix 3: Action log template ACTION INITIATED ACTION DETAIL ACTION COMPLETED COMMENTS DATE TIME WHO BY? WHO TO? DATE TIME 23

24 Appendix 4: Damage calculation worksheet: costs ADDITIONAL STAFFING COSTS DESIGNATION (staff, nurse, admin, porter etc) NUMBERS OF ADDITIONAL STAFF PAY BAND ADDITIONAL HOURS COST 24

25 Appendix 5: Damage calculation worksheet: additional equipment costs EQUIPMENT TYPE SUPPLIER NUMBER REQUIRED PURCHASE COST HIRE/LEASE COST TOTAL COST COST CODE 25

26 Appendix 6: Cost of building replacement or repair ITEM SUPPLIER/ CONTRACTOR DESCRIPTION OF WORK TOTAL COST COST CODE 26

27 Appendix 7: Media response 1 It is essential that advice be sought as soon as possible whether or not there has been any press interest, and that there is liaison with the NHS London communications team. 2 Provide information concerning the Royal National Orthopaedic Hospital NHS Trust s role and the response by members of the Royal National Orthopaedic Hospital NHS Trust s staff. Do not discuss other elements of the response and do not criticise individuals or organisations. 3 The Royal National Orthopaedic Hospital NHS Trust s BC communications strategy will be managed by the Incident Team or the Business Continuity Team. 4 Do not speculate on the cause of any incident 5 Secrecy is sometimes necessary during covert threats or responses. This is for both police and security reasons, but also because fear can often be more dangerous than any threat posed by such an event. Be extremely careful if contacted by the Media about an incident. DO NOT confirm that an incident has occurred unless it is clearly in the public domain, and never comment on the presence of VIP or suspects within NHS facilities. 6 The Chair, Chief Executive or Director of Public Health will usually be the lead public figure representing the PCT. All persons undergoing media interviews or releasing press statements should be fully trained. Template script for initial media enquiries 7 A major incident has been declared by (if it has) 8 The Royal National Orthopaedic Hospital NHS Trust is working alongside other healthcare services, the local authority and the emergency services to ensure that a co-ordinated response is undertaken to deal with this incident and maintain normal health services where possible. 9 Further information will be issued at XXXXhrs and will be available on our website at 10 Once more information is available: Press Information 11 Statement on incident at (name site) 12 the Royal National Orthopaedic Hospital NHS Trust has implemented special business plans following an incident at (location, time, and date). 13 Describe what has happened (flood, criminal activity, IT failure,). Be clear if there are or are not any injuries to staff or public. If there are injuries, where are they being treated? How 27

28 many staff are affected? 14 Our response: e.g. Additional staff have been called in to enable us to provide care for all patients; a help line has been set up (telephone number). 15 The Royal National Orthopaedic Hospital NHS Trust staff are working hard to ensure that regular services are operating again as soon as possible and ensuring there is minimal disruption to patient care. Give details of when The Royal National Orthopaedic Hospital NHS Trust expect the department activity to be returned to normal. 16 Advice to the public: e.g. visit GP, don t turn up at the clinic, give location of where they can go for treatment, phone NHS Direct, ring help line, look at our website (give address) etc. 17 Time of next press release (don t leave it too long) 18 For information please contact the press office on (give telephone number, which should always be staffed, and an address) 28

29 Appendix 8: List of GP practices and contacts GP PRACTICE CONTACT NO. WATLING MEDICAL CENTRE STANMORE 42 London Road Stanmore Middlesex HA74NU SHOPWICK SURGERY Everett Court Romeland Elstree WD63BJ THE STANMORE SURGERY 71 Elm Park Stanmore Middx HA74AU STANMORE PARK MEDICAL CENTRE William Drive Stanmore Park Middlesex HA74FZ SHOPWICK SURGERY New Bushey Surgery Windmill Street Bushey Heath WD231NB JAI MEDICAL CENTRE 114 Edgwarebury Lane Edgware Middlesex Herts HA88NB FURBANK IDJ California Lane Bushey Hertfordshire WD231EZ LANE END MEDICAL GROUP 2 Penshurst Gardens Edgware Middlesex HA89GJ DR PINTO & PARTNERS 39 Penshurst Gardens Edgware Middlesex HA89TN

30 Appendix 9: Essential services: corporate Finance, procurement and performance General description of work carried out Urgent Payment Requests (including patient monies administration) Debtors Control Financial Management Financial Accounting Cashiering Service Overseas and Out of Area treatment patients identification Costing (SLR / Reference Costs) Commissioning / Contracting If normal business is disrupted Prioritise urgent payment requests (including patient monies administration) Inform NHS NCL if any financial regulations may be breached Maintain core financial functions, work with the Emergency Management Team to manage budgets and finances during the pandemic including emergency funding for alternative contracts (e.g. food, staffing, equipment and transport) Ensure payroll services are maintained Enable payments for extra-ordinary items (e.g. transport costs for staff, agency staff payments) Estates and facilities General description of work carried out Provision of Estates and Facilities management Commissioning of subcontractors and support staff Maintenance, refurbishment and rebuild of Trust properties If normal business is disrupted Allocate representative to Emergency Management Team Respond to Estates issues, prioritise provision of utilities, services, repairs etc Report on status of Trust infrastructure Link with local organisations to ensure priority restoration of services Co-ordinate a rota for the role of Utilities Co-ordinator on the Emergency Management Team Prioritise utilities, food and fuel for use within the Trust Human resources General description of work carried out Provision of Human Resources for the Trust including: Staff Bank Electronic Staff Records (ESR) Central System Recruitment Criminal Records Bureau (CRB) Checks Data collection and reporting Personnel Files Training Trust Induction 30

31 If normal business is disrupted Maintain provision of Staff Bank Access ESR system for staff essential contact details Assist with requests for staff redeployment Assist Emergency Management Team with HR issues Nursing, Clinical Governance & Risk Emergency Planning including pandemic influenza and business continuity Responding to Care Quality Commission compliance Monitoring and responding to incidents and cascading alerts, internal and external through established reporting system: Serious Untowards Incidents (SUIs) 2 hours Incidents 24 hours Investigations 60 days Monitoring complaints / claims and cascading alerts within regulatory timeframes Cascading legal issues Infection Control Risk Register Safeguarding Children policies and procedures See incident policy for external reporting requirements (e.g. RIDDOR, SHA, PCT (STEIS), HPA, NPSA) SUI Incident reporting needs to be carried out within 2 hours update NHS London SHA if unable to process SUIs General incidents should be reported within 24 hours Ensure complaints are acknowledged within two working days Review current regulatory requirements and prioritise workloads, inform regulatory bodies of expected duration of disruption Press and communications General description of work carried out Communications Media Liaison Publication of internal & external newsletters Publication of corporate documents If normal business is disrupted Provide communication material on behalf of the Trust to staff, service users and local responding organisations Update the Trust s website and intranet site Act on a rota basis as the Communications Lead for the Emergency Management Team Co-ordinate communications on behalf of the Trust Liaise with Dept of Health led communications teams 31

32 IM&T General description of work carried out Provision and maintenance of Trust hardware and software, network and internet connection ICT Helpdesk Patient Administration System If normal business is disrupted Refer to ICT Continuity Plan Liaise with the Emergency Management Team in order to prioritise provision, repair and maintenance of the ICT system Arrange/enable additional remote access service accounts as directed by EMT for offsite working. Implement additional databases or systems to allow the Trust to collect data for internal and external situation reports 32

33 CATEGORY B CATEGORY A Appendix 10: Categorisation of clinical services See Local Templates See Local Templates 33

34 CATEGORY C See Local Templates 34

35 Appendix 11: Management of staff in emergency situations: Joint Management and Staff Side Agreement 1 Introduction 1.1 In an emergency there might be a necessity to reallocate and redeploy staff without warning and without consultation. This might include asking staff to undertake duties outside their normal professional area. Additional staff could also be required, sourced from a pool of volunteers and retirees. 1.2 Current job descriptions and employment contracts allow some leeway in the ability to allocate existing staff other tasks or work, whereas permanent or very long term redeployment would require consultation under the Worklife Balance Policy. 1.3 This paper sets out the agreement between Staff Side and Management regarding the safeguards and rules that would apply if Royal National Orthopaedic Hospital NHS Trust needed to manage staff in the event of an emergency. These arrangements would only apply in an emergency, major incident, major transport or weather crisis or a serious infectious disease outbreak. 2 Existing staff Redeployment/Reallocation of Work 2.1 In an emergency where staff may need to be redeployed or work may need to be reallocated, managers will assess whether it is necessary for staff to report to their normal place of work and whether there is a need to redeploy staff or reallocate work. In deciding this managers will, wherever possible: Direct staff to sites which are accessible Allocate staff work with which they are familiar The location of staff, their access to public/private transport, any reasonable constraints on their flexibility, as appropriate Depending on service requirements, the feasibility of staff being able to work at a different NHS site closer to home, either to undertake the same or different work, including for other NHS bodies Depending on service requirements, the feasibility of staff being able to work from home and undertake either the same or different work and the technology available to support this The duration of any arrangements and whether these will apply to the full contractual hours of the individual or part of their normal working hours The steps necessary to ensure that Royal National Orthopaedic Hospital NHS Trust complies with its legal obligation to ensure employee s health, safety and 35

36 welfare at work as far as is reasonably practicable and with its duty of care to others. In doing so, managers will take account of: Any known/stated restriction on work that could safely be undertaken by an individual on health grounds. This may include, for example, pregnancy and, in the case of a serious infectious disease, whether the individual had received any appropriate available vaccination. This risk will be assessed and determined on an individual basis Any training or professional qualification that would be a prerequisite to carrying out certain duties safely Any official communication from bodies government agencies, for example, advising against travel/other activity in all/some circumstances. The Trust will provide advice to staff on interpreting such communications. For example, workers providing essential services would normally be expected to travel to work if there were advice to refrain from non-essential travel Any other circumstance that may make working unreasonably unsafe. 2.2 Any staff who are exhibiting symptoms of serious infectious disease will be asked to report absent in accordance with current sickness procedure, or if already at work will be asked to go home and follow the normal reporting procedure, until the risk of infecting others has passed and they are well enough to return. For all other illnesses, no staff will be required to attend work if they are not fit enough to do so safely. Managers may seek Occupational Health advice regarding the fitness of staff and making adjustments to enable the early, safe return of staff where appropriate. Excess Travel Expenses 2.3 Any member of staff who is redeployed and incurs additional travel expenses will be reimbursed for the excess cost upon provision of the relevant receipts in the normal way. (As per NHS terms and conditions of the service handbook) Working Hours 2.4 Part time staff will be invited to increase their contractual hours for a specified period of time, however, they will not be obliged to do so. Staff on other flexible working arrangements may be asked to temporarily alter these arrangements in response to the emergency situation, if it is reasonable for them to do so. However, flexible working solutions may also enable as many staff to continue working as possible. This may include home working, childcare schemes/facilities, staff accommodation, and special travel arrangements (e.g. car pools). HR and managers will therefore continue to promote and agree flexible working options where possible. In an emergency situation, it will be important to ensure that staff continue to receive appropriate rest breaks or compensatory rest and that they are not asked to work more than 48 hours on average over a 17-week reference period, in accordance with the Working Time 36

37 Regulations. The Trust will follow Department of Health Guidance as to whether Working Time Regulations should be lifted during an emergency. 2.5 Annual leave requests may need to be more tightly controlled and staff might not be able to take leave at the exact times they request, depending on service needs. However, staff will remain entitled to take their annual leave allocation and must take at least twenty days leave during the leave year, in accordance with Working Time Regulations. 2.6 It will be important for both staff and managers to monitor working time and ensure that excessive working time without appropriate rest does not occur, as this could adversely affect staff health and wellbeing and therefore their ability to remain at work to support colleagues and the running of services. 3 On-call payments 3.1 On call payments are payable to staff who are asked to be on call to provide emergency cover outside of the normal working day. To calculate entitlement to on call the week is divided into 9 periods (night time Mon-Fri and 2 periods for day and night at weekend). 4 Non-attendance at work 4.1 It will be important in an emergency situation to ensure that all staff able to work do so as directed, to ensure services run smoothly and colleagues are not unnecessarily overburdened by their absence. Unauthorised absence without good reason will need to be dealt with. 4.2 Staff refusing to come into work should be offered unpaid or annual leave to cover their absence. Depending on the circumstances and period involved, management would have to use their discretion as to whether or not they need to take further action. Following consideration of the circumstances, such absence might be considered a breach of the employment contract that could lead to disciplinary action following appropriate investigation, in accordance with the Trust s Disciplinary Policy and procedure. 4.3 Any disciplinary action taken under the Disciplinary Policy and Procedure should be based on the facts of the individual case, as investigated and considered in accordance with the procedure. Such action may lead to dismissal, depending on the individual circumstances concerned. Depending on the availability of resources and the duration of the emergency, disciplinary action might not be taken until the emergency is over or resources enable the matter to be dealt with. 4.4 In the event of staff absence due to caring responsibilities, current procedure will be followed (see Work Life Balance Policy). Whether leave is granted with pay will depend on the individual situation and will be at the discretion of management. 4.5 In relation to redeployment/reallocation of work, if staff refuse to follow a 37

38 management request that is reasonable in the circumstances, this might lead to disciplinary action being taken, in accordance with the Trust s Disciplinary Procedure. Again, such action might not be taken until the end of the emergency or until resources allow the matter to be dealt with. 5 Staff support 5.1 To enable staff to continue working, it will be important to ensure they are appropriately supported during and after an emergency. This could be in the form of arrangements with other trusts who offer trauma counselling, the Right Core Care Employee Assistance Programme, Occupational Health, or support groups set up by other agencies. Managers will also play a key role in identifying concerns, supporting their staff and ensuring their health, safety and well-being at work. 6 Retirees/volunteers Retirees 6.1 The Head of Human Resources is responsible for ensuring that arrangements are in place to identify all retirees who have retired in the last three years, and for ensuring that retirees will be contacted to see if they would be willing to be entered on an emergency register of staff. All staff who have retired more than six months ago will be health screened and CRB checked again and a reference sought from their previous line manager. If professional registration or training has lapsed, retirees will not be asked to undertake duties for which either would be a requirement. Retirees would be engaged as Bank workers on the same rates of pay as in operation for the Royal National Orthopaedic Hospital NHS Trust Bank. Volunteers 6.2 Volunteers are deemed to be helping out rather than fulfilling a discrete role and will therefore not be paid (although travel expenses will be covered). Those already on the volunteer register may be called upon in an emergency, and new volunteers will need to be health and CRB screened with appropriate references being taken up. The Royal National Orthopaedic Hospital NHS Trust will rely on the testing and screening provided by volunteer agencies for potential volunteers. Volunteers will be allocated roles according to their competence, qualifications and skill. Health & Safety Training 6.3 Retirees and volunteers will be required to attend a local induction/health and Safety training session to ensure the Royal National Orthopaedic Hospital NHS Trust complies with its legal obligations. This training session will occur as soon as possible after engagement. 38