STRATEGIC EMERGENCY AND BUSINESS CONTINUITY PLAN

Transcription

1 ` Shrewsbury and Telford Hospital NHS Trust STRATEGIC EMERGENCY AND BUSINESS CONTINUITY PLAN This is a live document and will be regularly updated. Holders of this document should ensure that they have an up to date copy. Reference Number: Version Number: COR. Final v.1 Plan Owner: Trish Rowson- Director of Service Delivery Plan Author: J.C. Gallimore Date last updated: To be Ratified by: Trust Board Date Ratified: Date issued: Review date: SATH-Corporate Emergency and BCM Plan/DraftVersion.014/Dec.2008/ME/JCG

2 DOCUMENT VERSION CONTROL This Shrewsbury and Telford Hospitals NHS Trust Strategic Business Continuity Plan will be reviewed on an annual basis as a minimum and in circumstances that would require a review (e.g. following an incident or exercise, new methods or procedures or a change in critical activities). Version Number Date Author Description of Change COR. Final v J.C. Gallimore Post consultation update Date DOCUMENT DISTRIBUTION INSERT TRUST NAME Area/Appointment PLAN OWNER This plan is owned by Trish Rowson, Director of Service Delivery who is responsible for ensuring that it remains up to date. The plan owner is also responsible for ensuring that the plan and the resources required are made available for testing. 2 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

3 CHIEF EXECUTIVES FOREWORD The incidence of an emergency or severe disruption to Trust services is relatively rare. However, if an emergency or disruption occurs it could have a significant impact on the provision of heath services within Shrewsbury and Telford Hospital NHS Trust. It is vital that the Trust are prepared and can respond at short notice, providing a co-ordinated range of emergency, mid-term and long-term responses to any emergency or disruption. The Strategic Emergency and Business Continuity Plan describes the Trust s Strategic and Divisional command and control structures required to manage the effects of a disruption across the Shrewsbury and Telford Hospitals. This plan has been produced to unite Trust arrangements for; Anticipating, Assessing, Preventing, Preparing, Responding and Recovering from the potential hazards/threats and their consequences in line with partner organisations. As the Chief Executive Officer of Shrewsbury and Telford Hospital NHS Trust, I have the responsibility for ensuring that this organisation s response to an emergency or disruption to services of the Trust and resultant business continuity management is built on the principle duties of the Civil Contingencies Act 2004 (CCA) and its accompanying guidance. Tom Taylor Chief Executive, Tom Taylor, Shrewsbury and Telford hospital NHS Trust Signed: Dated: SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 3

4 Serial Item Page 1. PLAN INTRODUCTION Policy Statement Scope 6 Fig. 1 SaTH NHS Trust Strategic Emergency & Business Continuity Plan Structure Objectives of the Plan Plan Review Training and Exercise Definitions of Emergencies and Disruptions 8/9/10 2. REPORTING AND DECLARING DISRUPTIVE INCIDENTS Levels of Disruption Contact List 11 Fig. 2 Notification Flow Chart SERVICE CONTINUITY PLANNING THROUGH THE ORGANISATION Management of Threats Testing the Plan Plan Preparation BUSINESS IMPACT ANALYSIS MINIMISING RISK 15 6 RECOVERY PROCEDURES AND RECOVERY PHASE Corporate Command and Control Centre Establishment Communications Estates and Facilities Information Technology Transport Financial, Insurance and Legal Matters Human Resources and Staff Counselling 18 7 SALVAGE OPERATIONS TESTING AND UPDATING THE PLAN STAND DOWN PROCEDURE GLOSSARY OF TERMS AND ABBREVIATIONS 20 4 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

5 11. APPENDICES EMERGENCY AND BUSINESS CONTINUITY MANAGEMENT Checklist Summary of Plan, Invocation and responsible people Decision/Action Cards 22 Decision/Action Card 1 Chair of Strategic Command and Control Group 23/24 Decision/Action Card 2 Director of Service Delivery or Nominated Deputy 25 Decision/Action Card 3 Head of Communications 26 Decision/Action Card 4 Senior Administration Officer 27 Decision/Action Card 5 Call Taker/Loggist (Strategic and Divisional Control) 28 Decision/Action Card 6 Divisional Managers 29/30 Decision/Action Card Continuation Sheet Plan Checklists Invoking The Strategic Business Continuity Plan Checklist Premises Checklist Human Resources Checklist Information Technology Checklist Telecommunications Checklist Communication Checklist Salvage Checklist Key Staff Form Needed To Get Service Up and Running Useful Contacts Inventory Computer System Back-up and Restoration Details Criteria For Temporary Accommodation/Equipment Arrangements For Reciprocal Support Review and Testing Schedule Forms 47 Form 1 Log of Decisions and Actions 48 Form 2 Contact Details For All Staff 49 Form 3 Paper Based Records 50 Form 4 Log of Expenditure Decisions and Commitments RISK SUMMARY Risk Summary Overview Risk Management Process BIA SUMMARY REPORT 55 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 5

6 SECTION ONE 1. PLAN INTRODUCTION All NHS Organisations, as set out in the Civil Contingencies Act 2004 (CCA), are required to maintain plans to ensure they can: 1. Continue to exercise their civil protection functions 2. Continue to perform their ordinary functions to a minimal acceptable level The CCA places a statutory duty on Shrewsbury and Telford Hospital NHS Trust, as a Category 1 Responder, to have in place a plan (or series of plans) that set out the actions, roles and responsibilities for preventing, where possible, or recovering from disruptive incidents that have the potential to seriously impede the Trusts ability to provide its critical services. 1.1 POLICY STATEMENT Planning for emergencies and continuity of business will enable the recovery of the Trusts business critical services in the event of a minor/major disruption. The Emergency and Business Continuity Management framework consists of this Strategic overarching plan to co-ordinate the overall recovery effort and a number of other service specific plans for support functions and critical business services. Shrewsbury and Telford Hospital NHS Trust will take all reasonable steps to ensure that in the event of an emergency or service interruption, essential services are maintained and normal services restored as soon as possible. To ensure the above it is our policy to have in place robust emergency, business continuity and service continuity plans that are regularly reviewed and tested. 1.2 SCOPE This plan describes: The structure and process for Strategic Emergency and Business Continuity Management within the Trust (Figure 1) The actions to be taken by the first individual to detect a possible emergency or disruptive incident or an incident that has already occurred, that is likely to cause disruption to the Trusts time critical services; The roles and responsibilities of the Trust Management Team The list of tasks to be carried out The necessary reference information to support the actions detailed in the task lists Recovery processes to ensure timely return to normal service delivery 6 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

7 Figure 1- SaTH Strategic Business Continuity Plan Framework Shrewsbury and Telford Hospitals NHS Trust Strategic Emergency and Business Continuity Plan Structure DIVISION 1 Service Continuity Plan DIVISION 2 Service Continuity Plan DIVISION 3 Service Continuity Plan Departmental Service Continuity Plan Departmental Service Continuity Plan Departmental Service Continuity Plan Departmental Service Continuity Plan Departmental Service Continuity Plan Departmental Service Continuity Plan FINANCE HUMAN RESOURCES TRANSPORT COMMUNICATIONS FACILITIES ESTATES IT CORPORATE SERVICE CONTINUITY PLANS EVENT SPECIFIC PLANS FUEL CONTINGENCY PLAN MAJOR ACCIDENT PLAN SERIOUS UNTOWARD INCIDENT INFECTION OUTBREAK PLAN SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 7

8 1.3 OBJECTIVES OF THE PLAN The plan will ensure: The Trust s policies and procedures regarding incidents are implemented The safety of staff, patients and visitors Timely and suitable responses to every disruptive incident and/or threat to the well being of staff, patients and visitors Business Continuity requirements are quickly identified and implemented Human, physical, financial and information assets of the Trust are protected Honest communication with the Trust s stakeholders and other interested parties That the Trust can demonstrate that it has maintained responsibility and effective control of a disruption and that such management will enhance its credibility and reputation Sufficient resources are identified and made available The management of the crisis is reviewed after the event to ensure lessons for improvements are identified and implemented 1.4 PLAN REVIEW It is the responsibility of the Plan Owner to ensure that this document is amended to reflect any changes to the Trust procedures, which affect the contents of this document. This plan will be reviewed by Trust Management Team every 12 months or earlier if a change in circumstances takes place. 1.5 TRAINING AND EXERCISE It is the responsibility of the Plan Owner to ensure that appropriate members of staff are aware of the contents of this document and their role in any disruption where the Emergency and Business Continuity Plans are invoked. The Plan Owner will be responsible for the facilitation, formulation and delivery of an annual training and exercise programme for this plan and its supporting documents and procedures. 1.6 DEFINITION OF EMERGENCIES AND DISRUPTIONS Incidents that are likely to disrupt the delivery of the services of the Trust can be broadly grouped into two categories and three levels of incident (Tables 1 and 2), which will provide the benchmark on which to judge the level of response required to manage an incident and return critical services back to a pre-determined level of normality: Category 1 External Environment Incidents outside the Trust e.g. Utilities Failure, Terrorism and Severe weather conditions Category 2 Internal Environment Incidents created within the Trust e.g. systems failure and loss of key or high numbers of staff Level 1 Local Disruption A local incident, that is not an emergency, and does not cause serious physical threat to people or property. Results are likely to be limited disruption to services and would pose no threat to the reputation of the Trust. 8 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

9 Level 2 Minor Disruption Incidents that could pose an actual threat to people and property, but not seriously affect the overall functioning of the Trust. They may have legal ramifications or threaten the reputation of the Trust, and might include the isolation or evacuation of part of a building or buildings, with the assistance of the Emergency Services. Level 3 Major Disruption Incidents causing a significant disruption to the Trust s operations may affect an entire building or a number of buildings, staff, patients or visitors, with the escalation potential to require the intervention of the Emergency Services, who are likely to take operational control of the incident. External Incident Level 1 (Local) Level 2 (Minor) Level 3 (Major) Natural Emergencies causing building damage/collapse Minor structural damage. No evacuation necessary Minor structural damage. Evacuation and limited relocation necessary Major structural damage. Evacuation and relocation necessary Severe Weather conditions e.g. excessive rain, snow, wind, ice, extreme cold or heat Flooding Civil Disorder Utility Supply Water, Gas or Electricity failure - > 1 working day Health Epidemics No building damage. Some staff absence. Minor disruption to normal services. Minor damage to rooms, no loss of equipment or documents. Little or no disruption Disruption to normal Trust services. Some staff absence. Affecting <5% Trust property. Little or no disruption. Disruption to normal services. Some staff absence. Minor building damage/serious disruption to normal services. Significant staff absence. Medium damage to rooms and equipment. Some damage to documents. Remedial work and relocation necessary. Serious disruption to normal services. Significant staff absence/inability to use facilities. Affecting 10-30% of Trust premises, but no sensitive service areas/sites. Minor disruption Serious disruption to normal services. Significant staff absence. Table 1- Examples of External Disruption and Recommended Level Benchmarks Internal Incident Level 1 (Local) Level 2 (Minor) Level 3 (Major) Fire Minor damage to rooms, no relocation necessary. Little/no information loss. Room(s) out of use temporarily. Medium damage, loss of some accommodation can recognise to cover internally. Little loss of information. Serious building damage. Serious disruption to critical services. Significant staff absence. Wide-spread relocation necessary Major damage to rooms, equipment and information sources. Serious disruption to facilities. Prolonged serious disruption to normal services and significant number of staff unable to use facilities. Affecting >30% of the Trust premises and sensitive Service areas/sites. Serious disruption. Legionella. Pandemic Flu outbreaks. Major damage to the Trust infrastructure. Significant information loss. Relocation necessary. Explosions Small localised blast Can be isolated. Small to medium blast, minor damage. No release of toxic/flammable substances. Medium/major blast. Major damage and disruption. Gas Leaks Minor leak in small/large building. Evacuation. Major leak in small/large building. Evacuation. Major leak causing explosion. Major damage and disruption Bomb Threats Suspicious parcels. Isolate and inform Head of Service. Evacuation may be required. Following serious threats by known activists. Isolate and evacuate. Involves police. Adverse public interest Interest by local press only. Significant local interest Press and other media Extensive Regional/National interest Press and other media Computer system failure greater than one day Affecting <5% of the Trust. Affecting 10-30% of the Trust but no sensitive service/sites affected. Affecting >30% Trust and sensitive Service/sites. Death of staff or multiple serious injuries 1 death/several injured. Local press interest. Regulatory investigation. Possible prosecution Table 2: Examples of Internal Disruption and Recommended Level Benchmarks Multiple deaths or injuries. Regulatory investigation. Significant adverse media interest. Possible prosecution. SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 9

10 Tables 1 and 2 illustrate examples of the types of incidents that could arise. Indication of severity will provide guidance for those officers involved in the management of the incident as to how to manage it most effectively. The list is not exhaustive representing a small proportion of the potential hazards/threats. Continual reviews of hazards/threats, which have the potential to cause disruption to the Trust, are monitored by means of information sharing with other Category 1 Responders 10 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

11 SECTION REPORTING AND DECLARING EMERGENCY AND DISRUPTIVE INCIDENTS (Figure 2- Notification Flow Chart) The detection of any emergency or disruptive incident or event during office hours which could impact on the normal operations of the Trust should be communicated to the Chief Executive or Director of Service Delivery by ringing Royal Shrewsbury Hospital switchboard Out of hours: the contact will be the On Call Duty Director by calling the same number. Level 1 Local Disruption The member of staff managing the incident should inform the relevant Director and/or Divisional Manager who will assess the severity of the incident and its possible consequences. If the incident is unlikely to escalate beyond Level 1 status, then control of the incident will be done locally. Level 2 Minor Disruption Where the incident is deemed to be Level 2 by the Director and/or Divisional Manager then the Trust s Management Team will be informed of the incident immediately and of the decision to manage the incident centrally or locally. Level 3 Major Disruption Where the incident is deemed to be Level 3 by the Chief Executive/Duty Director all other Directors and Divisional Managers must be informed immediately. The decision to convene the SATH Strategic Command and Control Group to manage the Level 3 incident is designated to the Chief Executive/Duty Director and will depend on his/her assessment of the threat to the wellbeing of staff, patients or visitors; damage to property or disruption to operations. 2.2 CONTACT LIST A key contact list is held by the Chief Executive, On Call Directors, Divisional Managers and Heads of Department and switchboard. If the incident occurs outside normal office hours telephone the switchboard at Royal Shrewsbury Hospital and ask for the Executive Director on Call SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 11

12 Figure 2: Notification Flow Chart Incident identified Has the incident occurred during office hours? Yes Contact Chief Executive, Directors and Divisional Managers No On Call Duty Director to be informed Director or Divisional Manager to be notified Inform Trust s Management Team Assess the severity of the incident and its possible consequences Level 1 Escalation unlikely. Control the incident locally Inform Director of Service Delivery Level 2 Inform the following: 1. Chief Executive 2. Directors 3. Divisional Manager Decision taken to manage the incident centrally or locally Level 3 Inform the following: 1. Chief Executive 2. Directors 3. Divisional Manager Decision taken to invoke the Trust Strategic Command and Control Group 12 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

13 SECTION 3 3. SERVICE CONTINUITY PLANNING THROUGH THE ORGANISATON 3.1 MANAGEMENT OF THREATS Service interruption caused by the threats referred in Tables 1 and 2 are ever-present within every organisation, regardless of its size. The potential consequences, of such disasters will be reduced with comprehensive business continuity plans. Failure to identify and manage the significant threats could cause: Inability to maintain services to the public Damage the reputation of the Trust Failure to protect the Trust s assets (people, finance and property) Failure to meet legal or regulatory requirements Precautions must be taken in all areas of the organisation to reduce the risks involved, whilst accepting that elimination of risks completely is virtually impossible and the organisation is always vulnerable to the actions of others. 3.2 TESTING OF THE PLAN It is essential that all Divisions and Services of the Trust have a Service Continuity Plan prepared and tested. The plan will enable a service to anticipate incidents that could affect its critical functions and processes and ensure that it responds in a planned, rehearsed and successful manner. As a local NHS Trust: The public will expect plans to be in place to ensure continuity of service Staff, commissioners and stakeholders expect management to be in control and seen to be in control Staff, and suppliers expect it to protect their livelihoods The reputation of the Trust is at risk if continuity of services does not happen. Whilst insurance helps to reduce the financial impact of such disasters, the true value of loss is usually many times greater than the insured value. Having a tested plan indicates that the Trust is taking appropriate steps to mitigate risks and losses. As a Category 1 Responder under the Civil Contingencies Act (2004) Service Continuity is a Statutory Duty. The Act requires procedures to be in place to ensure that the Trust can continue to deliver services to the community and fulfil its statutory duties without interruption. SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 13

14 3.3 PLAN PREPARATION The preparation of a successful Emergency and Business Continuity Plan and supporting Service Continuity Plans are summarised as a series of steps: Identify an Executive Director responsible for the Development, Implementation, Testing, Exercising and Maintaining the Plan Identify the Critical and Essential Services of the Trust at both Corporate and Divisional levels of the organisation Complete the Risk Analysis and Business Impact Analysis defining the major risks of disruption to services and the effect that these risks could have Using the Risk Registers and Impact Analysis information complete Risk Minimisation Action Plans to identify all actions and resources required to minimise the risk of a major disruption to services from possible events. All Business Impact Analysis documents and associated Action Plans will be signed off by the relevant Divisional Manager or Director Develop and Implement Procedures and associated Action Cards for the Recovery Phase of an Incident and Salvage Operations if required Service Continuity Plans for all Divisions and Departments include: a) Identification of staff to do key tasks b) Call out list of the key staff required to recover identified critical and essential services after a disruption. c) Action Cards for the Divisions and Departments d) Contact list for external organisations such as suppliers and local organisations e) Back-up arrangements for computer held data, including basic instructions of how the data is restored. f) List of temporary accommodation criteria and possible alternative accommodation for each service. g) List and contact details of departments/offices/divisions and organisations that may offer use of facilities in an emergency. h) Schedule of testing and exercising of the component parts of the plan. i) Identification of financial resources required in the event of a major disruption and the financial planning required. The Trust Strategic Emergency and Business Continuity Plan and supporting Service Continuity Plans should be accessible on Trust intranet to allow flexibility to customise service continuity plans. 14 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

15 SECTION FOUR 4. BUSINESS IMPACT ANALYSIS (APPENDIX 11) The Corporate and Service Level Business Impact Analysis and Risk Assessment exercises, to assess the potential for disruption to services, will be undertaken annually to include significant risk areas e.g. loss of premises and key staff in an accident, a strike, fuel crisis or infection outbreak. The list of functions undertaken by the Trust will be updated as required and reviewed annually by the Business Continuity Planning Team and endorsed by the Trust Board. This list includes those functions critical/essential to the Trust ability to provide overall service(s) e.g. ability to provide contact point for public, ability to contact other organisations etc. Additionally, the resources required for operating these functions are defined. The list is in priority order. Resources include staff, accommodation, plant, equipment, furnishings, communications, computers, material, stationery, call centre/switchboard, procedure documents, special measures for special artefacts or equipment etc. Hazards identification (an event or situation which can cause harm) to each critical function e.g. fire destroying a building, damage to infrastructure (tools and equipment etc) or flu pandemic (up to 50% reduction in staff numbers) will be updated as required and reviewed annually, with associated Risk Assessment exercise, by the Business Continuity Planning Team and endorsed by the Trust Board. SECTION FIVE 5. MINIMISING RISK 5.1 The principal aim of risk management is to help services achieve their objectives by assessing and mitigating (controlling) their risks. The objective is to ensure that risk of significant incidents are eliminated, avoided, made less likely and made less costly. 5.2 Many risks can never be eliminated, but it is important to reduce the likelihood of incidents occurring and to reduce the cost of them if they do occur, through comprehensive business continuity planning. An example of where effective Risk Minimisation techniques may have prevented massive loss can be found in the report on the fire at the Norwich City Library that took place on 1st August A simple short circuit in an electric light fitting above a display case caused a fire that resulted in the loss of valuable library stocks and the complete destruction of a largely irreplaceable and unique collection of American literature and memorabilia. The subsequent inquiry into the fire resulted in several recommendations designed to limit the loss sustained in any future such incident. These recommendations included: Introduction of a 'defects book' system Accelerated electrical testing programme Identification of highly flammable fixtures and fittings Annual inspection of electrical apparatus Safety assessment of new buildings and extensions Installations of smoke detectors and sprinkler systems Fire proof compartmentalisation of buildings Identification of valuable contents in buildings for priority salvage Pre-prepared emergency salvage plans for buildings SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 15

16 SECTION SIX 6. RECOVERY PROCEDURES AND RECOVERY PHASE Success of the recovery procedures and recovery phase following disruption will be dependant upon the implementation of a comprehensive set of Corporate, Divisional and Departmental Service Continuity Plans as described in Section 1. These plans will be continuously updated as required and reviewed by the Business Continuity Planning Team annually. 6.1 CORPORATE COMMAND AND CONTROL CENTRE ESTABLISHMENT A Corporate Command and Control Centre will be established on the site of the Trust considered to be most appropriate for the management of the disruption. These will be: Room 229 Royal Shrewsbury Hospital, Corporate Offices, Shrewsbury Division 2 Managers Office, Management Centre Princess Royal Hospital, Telford Decision/Action Cards and Checklists for the initial management of the disruption will be used to ensure implementation of the relevant Service Continuity Plans (Appendix 11.2) 6.2 COMMUNICATIONS The rapid establishment of a clear line of communication with all interested parties and partners is important to ensure support from all in the rapid recovery of the services affected and successful implementation of the Business Continuity Plans of the Trust Telecommunications Any disruption to Trust telecommunication services need to be acknowledged and reported to the Executive responsible and alternative arrangements will be identified and implemented at the earliest opportunity Media liaison Depending upon the nature of the disruption to service, there may be a degree of media interest and demands for information. The Head of Communications should be kept fully informed of all significant actions during the recovery process Staff briefings Any major disruption and subsequent recovery methods will profoundly affect the staff involved. It is of the utmost importance to keep staff fully informed of the situation at regular intervals and to utilise their expertise to aid the recovery process Public Information Information for the public will outline any disruption to services and alternative arrangements where appropriate for in-patients, visitors and all other service users of services affected or likely to be affected Organisational Briefings To inform and regularly update interested organisations outside the Trust in the identification and progress of the disruption and the identified Business Continuity plans to be implemented. The organisations include NHS Commissioners of Trust services (PCT s), NHS West Midlands, West Midlands Ambulance Service and Local Authorities. 16 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

17 6.3 ESTATES The Estates service continuity plan will remain the responsibility of the Head of Estates who has overall responsibility for Trust properties Relocation of staff Identification of alternative accommodation for key personnel will be largely undertaken within the Trust with help from, neighbouring Trusts, PCT Provider Services and Local Authorities. Other alternative accommodation could be made available in the form of relocating staff/clients into existing directorate accommodation, sister hospital accommodation, unoccupied Trust offices, sharing accommodation available within the directorate, and setting up portable buildings. Agreed reciprocal support arrangements with neighbouring sites and organisations will be updated as required and reviewed annually Equipment and Inventories Inventories of all equipment and replacement arrangements for all Divisions are available through the Estates Department. A list of sources of temporary replacement furniture/equipment that could be utilised in an emergency will be kept updated as required and reviewed annually within the Estates Department. 6.4 INFORMATION TECHNOLOGY Computer Services has its own system for the protection and recovery of computer data held on the mainframe, however, there will be a substantial quantity of vital information held on individual stand alone personal computers. The agreed system of back-up and protection for all computer data during the recovery phase of Business Continuity will be outlined in the IT Business Continuity Plan. Close and ongoing consultation with the Computer Operations section on all IT matters such as recovery, prioritisation, home working, p.c. requirements will be undertaken through the Business Continuity Planning Team reviews. 6.5 TRANSPORT There may be a significant movement of patients, staff and equipments required during the recovery phase of the Business Continuity Plan. Consideration should be given to the transport requirements if the service needs to be re-located to another site. There will be a need for vehicles, labour and coordination. If patients require to be moved this will require collaboration of West Midlands Ambulance Service. If, for service reasons, it is convenient to move to a more distant office in the Trust, then the needs of staff required to travel to the new location should be considered. This may entail some provision of transport or a car sharing scheme. SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 17

18 6.6 FINANCIAL, INSURANCE AND LEGAL MATTERS Staff responsible for Trust Insurance matters must be kept informed at all stages of a disruption to ensure that any requirements set down by the Trust insurers are adhered to. Additionally, the Director of Corporate Affairs should be kept advised of the situation to ensure that any legal issues are being addressed. It is likely that any disruption to services would result in an increase in expenditure and budgetary considerations, whilst they may not be considered paramount, they should be carefully monitored throughout the recovery process HUMAN RESOURCES AND STAFF COUNSELLING The disruption caused by a major emergency can be very disturbing for staff. The loss of years of work, personal possessions, vital notes and records etc. will have a detrimental effect on morale. It is important that staff concerns are acknowledged and that a structured return to normal service is made. A positive and constructive attitude to the recovery phase should be encouraged. In some cases, it may be appropriate to arrange for counselling sessions for individuals and/or groups to ease concerns. SECTION SEVEN 7 SALVAGE OPERATIONS 7.1 An Executive Director and Senior Manager will be designated responsible for overseeing any salvage matters required 7.2 After the incident has occurred, there may be a need for a salvage operation to take place. The Fire and Rescue Service are the lead emergency service on salvage matters during the incident and in the immediate aftermath. Information about the whereabouts of key documents/equipment in departments will help them prioritise their salvage efforts. However, in the longer term divisions/departments and/or other organisations may be in a better position to assist. 7.3 The recovery and safe keeping of documents will be of major concern and it may be necessary to let this aspect of the recovery process be dealt with by experts from specialist document recovery firms. It is possible to salvage and restore documents/equipment that have been damaged by charring, smoke, mould, water etc. The cost of restoration, per item, should be weighed against the cost of replacement. However, some documents are irreplaceable and restoration is the only option in this case. Contacting a specialist recovery firm quickly is very important. These specialists employ measures such as air-drying and vacuum freezing to stop any further damage occurring to documents whilst measures are taken to recover either the document or the information contained within. 18 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

19 SECTION EIGHT 8. TESTING AND UPDATING THE PLAN 8.1 The Shrewsbury and Telford Hospital NHS Trust Strategic Emergency and Business Continuity Plan will be reviewed annually following an annual tabletop scenario. 8.2 Component parts of the plan will be tested on an annual basis e.g. Call Out systems using a phased approach to ensure that the plan is kept alive and up to date. Some of the components of the plan will be unsuitable for testing e.g. the salvage procedures in which case testing by simulation will be considered. A test schedule for the Strategic Emergency and Business Continuity Plan will be developed annually. A Service Continuity Test Plan will be developed indicating how and when each element of the plan will be tested. 8.3 Resources will be identified to ensure the plan is implemented, tested and reviewed on an annual basis including briefing of staff at both induction and annually. 8.4 Many Service Continuity Plans fail when tested, often because of incorrect assumptions, oversights or changes in equipment or personnel. Testing will assist the identification of these issues and will keep the plan fresh in the minds of the relevant staff. 8.5 Responsibility for updating the plan is held by the Director of Service Delivery. 8.6 There may be several events which would occasion a re-assessment of the plan before the annual review. Examples of such events are: Acquisition of new equipment, or upgrading of operational systems New problem detection and control technology e.g. fire detection New environmental control technology Staff or organisational changes Changes of contractors or suppliers Changes of addresses or telephone numbers Changes to Service processes Changes in operating practices Changes in legislation 8.7 In the case of significant change before the annual review, all plan holders will be notified of the changes to be made in their documents. SECTION NINE 9. STAND-DOWN PROCEDURES 9.1 DECISION TO STAND DOWN Once the Command and Control Group is in session it is the responsibility of the Chair of the Command and Control Group, when circumstances permit, to plan the strategy for stand down. This may involve a phased process with acknowledgement that certain activities may have to continue for some time (under Emergency and Business Continuity Plans) e.g. media relations and long term welfare requirements to staff and patients. 9.2 COMMUNICATION OF STANDOWN DECISION Stand down decisions will be communicated to all relevant Stakeholders. SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 19

20 SECTION TEN 10. GLOSSARY OF TERMS AND ABBREVIATIONS Category 1 Responders Core Responders to Emergencies responsible for working in partnership in multi-agency planning: Assessing the risk of emergencies occurring and use this to inform contingency planning Development, implementation and testing emergency plans Implementation of Business Continuity Management arrangements Implementation of arrangements to make information available to the public relating to civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency Sharing of information with other local responders to enhance co-ordination Co-operating with other local responders and enhance co-ordination and efficiency Provision of advice and assistance to business and voluntary organisations related to business continuity management Category 1 responders include Local Authorities, Emergency Services PCT s and NHS Acute Hospital Trusts Category 2 Responders Support Responders with a duty to co-operate Category 2 responders include Strategic Health Authorities and Mental Health Trusts. Responsible for: Planning for incidents affecting their organisations Co-operate and share pertinent information with Category 1 Responders and Category 2 partners Lead Responder LRF- A Category 1 Responder Organisation charged with carrying out a duty under the Act on behalf of a number of responder organisations, so as to co-ordinate it s delivery and to avoid unnecessary duplication. Local Resilience Forum A process for bringing together all the Category 1 and 2 Responders within a local police area for the purpose of facilitating co-operation in fulfillment of their duties under the Civil Contingencies Act Mutual Aid - An agreement between Category 1 and 2 responders and other organisations not covered by the Act, within the same sector and across boundaries, to provide assistance with additional resources during an incident which may go beyond the resources of a single organist ion SATH - Shrewsbury and Telford Hospital NHS Trust 20 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

21 SECTION ELEVEN 11. EMERGENCY AND BUSINESS CONTINUITY MANAGEMENT 11.1 Checklist - Summary of Plan Invocation and responsible people List Phase and tasks Responsible person ALERT & INCIDENT MANAGEMENT PHASE 1 Raising the alarm and incident management CEO or On Call Director 2 Invocation of Strategic Command and Control CEO or On Call Director MANAGEMENT AND RECOVERY PHASE Executive Director 3 Invoking the Service Continuity Plans Plan Owners 3.1 Divisional Plans Divisional Managers 3.2 Departmental Plans Head of Department 3.3 Communications and Telecommunications Adrian Osborne 3.4 Estates Chris Needham 3.5 Information Technology Nigel Appleton 3.6 Transport Mark Liquorice 3.7 Financial Plans Steve Shanahan 3.8 Insurance and Legal Julia Buckley 3.9 Human Resources William Raith 3.10 Clinical Governance Claire Jowett SALVAGE PHASE 4 Salvage procedures Identified Executive Director STAND-DOWN PHASE CEO or Deputy SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 21

22 11.2 Emergency and Corporate Service Continuity Plan Decision/ Action Cards CORPORATE SERVICE CONTINUITY PLAN DECISION/ACTION CARDS Site: Review Date: Issue No: Copies of this document are kept at: Plan Owner Name: Address: Tel no: Fax no: Keyholder(s) if outside normal office hours: 22 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

23 DECISION / ACTION CARD 1 Chair of Strategic Command and Control Group (CEO or Nominated Deputy) This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Confirm that the alert is a genuine Emergency and estimate the extent of disruption (E) Make decision to invoke SATH Strategic Emergency and Business Continuity Plan (E) Identify other members required for Strategic Command and Control Group (E) Instruct switchboard to call Strategic Command and Control Group members to RSH Room 229 (E) Assist in the setting up of Room 229 as Command and Control (E) Determine Strategy for dealing with disruption in normal way using the Strategic Business Continuity Plan (E) Complete Incident Notification Log Appendix 1 (E) Commence and maintain paper Incident Log until Electronic Log commenced (E) Notify other agencies as appropriate (E) Ensure staff/patient and public safety (E) Arrange for all patients and staff to be accounted for if necessary (E) Identify Media Room for SATH (C) Identify Lead organisation if required (E) Prepare to brief Strategic Command and Control Group: What happened, where and when: What was the effect: Who has been contacted/alerted: Appendix 2 STHA, LRF Gold, Shropshire & Telford and Wrekin PCTs. Emergency Services SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 23

24 DECISION / ACTION CARD 1 (CONTINUED) Chair of Strategic Command and Control Group (CEO or Nominated Deputy) This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (C) Contact lead organisation to receive local update on incident (E)Establish policy framework for overall management of the disruption (C) Request information regarding the effect of disruption on Trust inbound supplies (C) Consider the establishment of helpline for patients to enquire about services (C) Direct the planning beyond the immediate response in order to facilitate a timely recovery process Essential services Meeting and briefing timetable Conference calls etc. Public information 24 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

25 DECISION / ACTION CARD 2 Director of Service Delivery or Nominated Deputy This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Attend Room 229 RSH when informed Fuel disruption Strategic Group required (E) Contact Divisional Managers to inform of implementation of SATH Emergency and Business Continuity Plan and request situation reports for Divisions and Departments (E) Oversee setting up of Room 229 as Command and Control (E) Prioritise the demands of the divisions and departments within the Trust and allocate personnel and resources to meet requirements (E) Inform Divisional Managers of Essential services to be maintained when identified by Strategic Group (C) Oversee co-ordination of up to date database of essential users for Strategic Command and Control Room (E)Direct Trust operations beyond the immediate response to facilitate a timely recovery process (E) Deliver regular Situation Reports for Divisional Managers Briefing timetable SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 25

26 DECISION / ACTION CARD 3 Head of Communications This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Attend Room 229 RSH when informed Strategic Command and Control Group required (E) Assist in setting up of Room 229 as Command and Control (E) Prepare staff briefing informing of implementation of Strategic Command and Control Group and outline of Emergency or disruption (E) Prepare public briefing to inform of services which will be interrupted, continued and details of help-line numbers (if required) (C) Oversee implementation of helpline if required (E) Implement arrangements for communicating with professional partners and agree policy statements and briefing times with Strategic Command and Control Group (E) Information on current national, regional and local situation posted and updated daily on the SATH website (E) Information regarding arrangements for the delivery of services e.g. cancellation of services and re-location of services posted on SATH website and updated at least regularly (C) Consider use of local radio to deliver information re-service delivery changes 26 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

27 DECISION / ACTION CARD 4 Senior Administration Officer This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Attend Room 229 RSH when informed Fuel Disruption Strategic Group required (E) Assist in setting up of Room 229 as Command and Control (E) Commence and maintain Manual Incident Log (E) Identify loggist staff for Strategic Control Room and Divisional Manager support and facilitate rota and call in (E) Identify Documentation Disks and distribute to Call takers/loggists for Strategic Control and Divisional Controls Ensure Electronic Log commenced and maintained at earliest opportunity (E) Identify call handling staff for Strategic Command and Control and Divisional Manager support and facilitate rota and call in (E) Co-ordinate call in of additional staff as required (E) Identify and allocate call taker/ loggist for each Divisional Control (E) Receive log of received calls from call loggist and action Inform Chair of Strategic Group or relevant Group member of calls ensuring that all calls and messages are logged SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 27

28 DECISION / ACTION CARD 5 Call Takers /Loggists (Strategic and Divisional Control) This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Attend Room 229 RSH when informed Strategic Command and Control Group required (E) Assist in setting up of Room 229 as Command and Control (E) Move to allocated Control Room (Strategic or Divisional) (E) Identify Documentation Disk and commence and maintain Electronic log at earliest opportunity (E) Receive assistance calls Log and record the call and then pass it to the senior administrator (Strategic Control) or Divisional Manager (Divisional Control) for action 28 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG

29 DECISION / ACTION CARD 6 Divisional Managers This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Attend Room 229 RSH when informed Fuel Disruption Strategic Group required (E) Assist in setting up of Room 229 as Command and Control (E) Agree venue for Divisional Control Room (E) In collaboration with Strategic Command Group agree method of distribution of Temporary Logos, information and maps for essential users (E)Move to Divisional Control Room At least one of the Divisional Control Rooms will need to be at Princess Royal Hospital Telford (E) Commence and maintain Manual Incident Log until Electronic Log commenced (E) Prepare situation reports for Divisions and Departments for Strategic Command Team (E) Ensure database of essential users for Division is up to date and send the Strategic Command Group (E) Following identification of Trust Essential services prepare to cease nonessential services and re-allocate staff SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG 29

30 DECISION / ACTION CARD 6 Divisional Managers Cont. This action card is to be completed by the person responsible for the actions at the time the actions are completed. There are two types of actions: ** Essential (E)this type of action must be completed in all circumstances?? Consider (C) this type of action may or may not be required dependant upon the circumstance Action Contact Details/Other Info Remarks Date/Time Signature (E) Assess significant risks to service delivery and inform Strategic Command and Control Group (E) Determine Divisional priorities and allocate resources in accordance with these plans and task operational leads in departments (E) Prepare update briefing reports in line with requests from Strategic Command and Control Group (E) Ensure information regarding the disruption of Divisional services is accurately provided to the Strategic Command and Control Group to be disseminated to patients and public Strategic Command and Control Room: 30 SATH-Corporate Emergency and BCM Plan/Final Version.1/Dec.2008/JCG