Independent Assurance External evidence that risks are being effectively managed (e.g. planned or received audit reviews)

Transcription

1 Total Risk Score Total Risk Score SHA Risk Matrix Risk Matrix Trust Details Name of Trust: NHS Address: Francis Crick House Post Code: NN3 6BF Name of Chief Executive: John Parkes Name of Person to contact at trust: Emergency Planning Team Contact Tel number and of person above: Date Matrix approved by Trust Board: I confirm this is a true and accurate risk matrix for emergency preparedness at the above named trust (Signature of Chief Executive) 1 Planning for and delivering an effective response to specific threats and hazards (Highlevel potential risks that are unlikely to be fully resolved and require ongoing control) Risk Score 17 Low 811 Med 12 & above High The systems and processes in place that mitigate this risk / What we are doing to manage the risk and how this is evidenced how and when will this be reported to the Board i.e. include dates of planned Board reports External evidence that risks are being effectively managed (e.g. planned or received audit reviews) Where an additional system or process is needed, or evidence of effective management of the risk is lacking How the identified gap is to be addressed and how the risk is to be diminished(include lead person and end date) Anticipated Risk Score After Completed 17 Low 811 Med 12 & above High Note in all instances the white paper causes significant uncertainty in seeking to progress planning e.g. uncertainty over staff availability across the health economy and liquidation/merging of key health agencies (e.g. public health, HPA, PCTs) Potential Risk 1.1 Winter/Severe cold weather (including consideration of needs of specific community institutions such as care homes) (note A) Priority NHS and social care sites have been provided to the NLRF and NCC for inclusion in the winter gritting plan. BC / Board. Updated winter/severe cold weather plan A document was produced in Dec 2009 this will need to be reviewed in advance of the start of winter NHS East Midlands Risk Assessment Matrix Page 1 of Scores used to calculate the Total National Risk Register and based upon a reasonable worstcase scenario. The scores remain the same despite measures listed being in place. The measures will not mitigate the impact of weather risks, only enable our preparedness to respond to them.

2 Total Risk Score Total Risk Score Potential Risk SHA Risk Matrix 1.2 Pandemic Flu (note B) 1.3 Human Infectious disease outbreaks incl norovirus & vaccination strategies (excl pandemic flu see 1.2) 1.4 Fuel Disruption arrangements for remote working plan NLRF Pandemic Framework (draft) ACP plan (2009) Vaccination plan (2009) Outbreak plan NLRF Countywide response plan Essential staff identified. in place to establish TLS requirements for primary / Board and/or associated groups. Completion of review of pandemic plans Ongoing. NLRF Pandemic framework has been released for consultation this document will underpin all local pandemic planning. Review of operational plans is ongoing (e.g. mass vaccination, antiviral distribution, antiviral collection points. Note: national DESs covering the H1N1 pandemic have now expired). None This is a lower priority risk at this time. A review of the outbreak plan is not programmed to begin this year to other priorities. An effective review will be difficult to undertake with the uncertainty over the future role of agencies such as the HPA and Public Health. Board and/or associated groups. Review of plan and data forms part of Resilience Forum's ongoing 1096 NHS East Midlands Risk Assessment Matrix Page 2 of Scores used to calculate the Total National Risk Register and based upon a reasonable worstcase scenario. The scores remain the same despite measures listed being in place. The measures will not mitigate the impact of a pandemic, only enable our preparedness to respond to it As before a generic response is given based upon the National Risk Register. Ideally an individual assessment should be produced for each infectious disease that would cause a significant risk to the community/organisation as the probability and impact of each disease varies considerably. We have not included "vaccination strategies" within this assessment as this should be considered a separate issue Scores used to calculate the Total National Risk Register and based upon a reasonable worstcase scenario. The scores remain the same despite measures listed being in place.

3 Total Risk Score Total Risk Score SHA Risk Matrix Potential Risk care services. 1.5 Heatwave NLRF framework in place. operational plan in place. Heatwave planning group established April Environmental hazards (including flooding) / Board and/or associated groups. Review of plan and data forms part of Resilience Forum's ongoing 0 Resilience Forum has recently begun to undertake development of a MultiAgency Flood Plan. NHS is actively engaged in the work group. We are procuring licences for a GIS mapping tool to assist with our own assessment of flood risk and other known Environmental Hazards (e.g. Scott Bader, Wellingborough). The data will be used to develop a health economy asset risk register, and to assist with the prioritisation of planning and assessment of commissioned service business continuity management systems Scores used to calculate the Total Community Risk Register rather than the National Risk Register. Locally we reviewed the worstcase scenario given and felt the probability of it occurring was less than that provided. The scores remain the same despite measures listed being in place as no measures can be taken to reduce the probability, and measures taken are unlikely to alter the impact significantly. 0 We consider this a poor risk definition. Flooding and Environmental Hazards should be treated as a separate risks; Environmental Hazards covers a spectrum of risks from industrial incidents to pollution or CBRN incidents. No single assessment is available; all are covered by individual assessments on the community risk register. Flooding is considered a very high risk for the county, but the assessment of the full impact on the local health economy is yet to be completed. The risk of Environmental Hazards varies according to type 1096 NHS East Midlands Risk Assessment Matrix Page 3 of 7

4 SHA Risk Matrix 2 Developed and tested plans for the NHS to respond to significant/specific challenges Plan 2.1 Clinically led surge plans, including for adult and paediatric critical care (Note C) 2.2 Ability for NHS Trust to respond to a Major incident in a local prison/secure hospital 2.3 Delivering an effective response to business disruption including disruption to supply chain and Business Continuity (Note D) 2.4 NHS supporting the response to incidents where there are mass fatalities 2.5 NHS supporting a response to any disruptive challenge where high numbers of casualties are incurred 2.6 Ability of Trust to deliver services throughout the Olympic Games & associated Olympic events to be held in 2012 The systems and processes in place to be able to respond to this challenge Acute trust responsibility, we would coordinate response if required. Not applicable to a Commissioning PCT BCM arrangements being developed. NLRF & PMB review mass fatalities programme Controls / or How are we managing External evidence Are there any How the identified gap the systems and that the additional is to be addressed processes and how this is systems/processes systems/processes (Include lead person evidenced how and are being needed? and end date) when will this be reported effectively to the Board i.e. include managed (e.g. dates of planned Board planned or reports received audit reviews) Not applicable to a commissioning PCT. However, we know our acute trusts have plans in place. Direct operational response is not applicable to a Commissioning PCT. However we will be acting as the coordinator for the local health economy. Commissioners have established links with local prison and secure training facilities. the Committee Engagement when requested SHA assessment took place in July the Attendance at the NLRF BC Group Being developed. Development of Business Continuity forms a major part of the An external consultant has been recruited to deliver the project. NLRF / PMB NLRF plan is under development. Lead = County Council and Police None Awaiting final version of regional mass casualty framework. Regional mass casualty framework is still under review. No work will progress until this is completed. See comment See comment See comment See comment See comment of the white paper is still being assessed, however it is anticipated that the PCT will have been reduced to minimum staffing levels and service provision to coincide with handover to GP consortia NHS East Midlands Risk Assessment Matrix Page 4 of 7

5 SHA Risk Matrix Plan 2.7 Developed and tested plans to provide a response to Chemical, Biological, Radiological or Nuclear incident (deliberate or accidental), including decontamination of affected individuals (Note E) 2.8 Developed and tested plans for the NHS to evacuate patients from healthcare settings. Controls / or See comment See comment See comment See comment See comment As a commissioning PCT we do not have an operational response role but would be coordinating the local health response. Several staff have undergone STAC training this year; a local course was held in the absence of an HPA or SHA course. We are actively engaged in the NLRF CBRN Group. A local CBRN plan, including site specific plans is being developed following a review of the existing plan this year. It should be available within the next month. We are awaiting the development of regional template for self presenters at primary care establishments. The work is being undertaken by colleagues in Derbyshire. See comment See comment See comment See comment See comment As a commissioning PCT we do not own or run healthcare premises, rather commission the service from other trusts. We are aware that partners are looking at their evacuation plans. 3 Processes Process 3.1 Arrangements to ensure planning for emergencies and integrated emergency management embedded within the Trust 3.2 Effective leadership & Clear Command and Control of the NHS to manage any disruptive challenge The systems and processes in place to demonstrate this Attendance at NLRF and appropriate submeetings. MIP Training & awareness sessions delivered STAC training MIP Training and awareness sessions delivered / How are we managing the systems and processes and how this is evidenced how and when will this be reported to the Board i.e. include dates of planned Board reports Health MOU recognising as the local lead for External evidence that the systems/processes are being effectively managed (e.g. planned or received audit reviews) Minutes of meetings from the NLRF and/or PMB and other linked groups. External audit. Exercise feedback. Minutes of meetings from the NLRF and/or PMB and other linked groups. External audit. Are there any additional systems/processes needed? How the identified gap is to be addressed (Include lead person and end date) Major incident exercise and training scheduled for end Exercise Watermark scheduled for March Key staff attending relevant training sessions (e.g. STAC October 2010) Major incident exercise and training scheduled for end Exercise Watermark scheduled for March Key staff attending relevant training sessions (e.g. STAC October 2010) 1096 NHS East Midlands Risk Assessment Matrix Page 5 of 7

6 SHA Risk Matrix Process / planning and response for the whole health economy. Exercise feedback. 3.3 Trust Agreement and understanding of "Lead PCT" model in the East Midlands 3.4 Emergency preparedness competencies for relevant NHS staff embedded in the organisation 3.5 Plans for staff training to support emergency preparedness 3.6 Plans for exercising and incorporating any lessons identified (both within the NHS and multiagency partners) Signed agreement in place with local health economy. Key staff have been identified and training delivered. Key staff have been identified and training delivered. Training programme forms part of the EP work programme Training & Exercise group identifies lessons to be learned. PCT represented on group and ensures feedback into PCT plans. Health MOU recognising as the local lead for planning and response for the whole health economy. Competency forms part of the employment process. Active engagement in NLRF Training and Exercise Group Ask the other trusts. Recognition of our role forms an integral part of all training sessions and plans. Until the release of the white paper, was developing facilities at Francis Crick House to be the secondary MultiAgency Coordination Centre for use if Police HQ were unavailable (i.e. in a terrorist incident, or healthspecific incident such as a pandemic or infectious disease outbreak). This work has now stopped as due to the uncertain future of the organisation and the nonviability if we are to cease to exist by Lack of guidance Ongoing training programme. on adoption of National Occupational Standards for Emergency Planning. Meeting minutes. Ongoing training programme. Meeting minutes. Ongoing training and exercise programme. Competencies have been developed nationally by Skills for Justice in consultation with the Emergency Planning Society. It is unclear whether these are to be formally adopted yet NHS East Midlands Risk Assessment Matrix Page 6 of 7

7 SHA Risk Matrix Process 3.7 Resilient Public Health on call systems 3.8 Communication and media plans in line with the Civil Contingencies Act 2004 Regional oncall system administered by the HPA NLRF media plan in place media plan ongoing with Comms Team. representation at the NLRF Comms meeting. / Regional oncall system administered by the HPA Regional oncall An independent None. system assessment of the administered by effectiveness the HPA should be carried out e.g. by SHA. Meeting minutes. Ongoing review of plans in line with NLRF NOTES A Winter/Severe cold weather All Trusts have been asked to submit Winter Resilience Plans to SHA. B Pandemic Flu All Trusts have been asked to submit refreshed Pandemic Flu Plans (note separate pandemic flu plans are not required if incorporating into winter resilience plans) C Clinically led surge plans, including for adult and paediatric critical care Outcomes of a review by SHA of Hospital Trusts Critical Care plans have been sent to Trusts in June 2010 & Trusts asked to refresh and update plans by 10th September D Delivering an effective response to business disruption including disruption to supply chain All Trusts have been asked to complete a self assessment of Business Continuity by 16 July Following on from the assessment, an action plan is requested by 10th September 2010 and Business Continuity E Chemical, Biological, Radiological or Nuclear release Acute Trusts with A&E Departments are participating in the annual CBRN Audit process commencing in September NHS East Midlands Risk Assessment Matrix Page 7 of 7