Trust Board of Directors. Monitor Compliance Framework N/A N/A N/A N/A YES. The Board is asked to:

Transcription

1 NLG(15)286 DATE 30 June 2015 REPORT FOR Trust Board of Directors REPORT FROM Wendy Booth, Director of Performance Assurance & Trust Secretary CONTACT OFFICER Graham Jaques, Resilience Manager, Trustwide and Operations Centre Manager, SGH SUBJECT Emergency Preparedness, Resilience and Response BACKGROUND DOCUMENT (IF ANY) Civil Contingencies Act 2004 NHS Operating Framework Monitor Compliance Framework NHS England Core Standards for Emergency Preparedness, Resilience and Response NLG(14)266: Emergency Preparedness, Resilience & Response Annual Report for 2014 / 15 REPORT PREVIOUSLY CONSIDERED BY & DATE(S) N/A EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) The report provides assurance on the Trust s Emergency Preparedness, Resilience & Response arrangements including the work programme for 2015/16 HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? N/A HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? N/A ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? NO IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? N/A ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? NO WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? YES ACTION REQUIRED BY THE BOARD The Board is asked to: note the current compliance against the NHS England Core Standards for EPRR note the Training Programme note the Work Programme for the coming year 2015/16

2 1.0 Background and Introduction Northern Lincolnshire and Goole NHS Foundation Trust (NLAG), in common with other NHS organisations, has a duty to protect and promote the health of the community, including at times of emergency. As a Category 1 responder under the Civil Contingencies Act 2004, the Trust has a legal obligation to plan for and respond to any incident with major consequences for health or health services, in partnership with other parts of the NHS, the emergency services and local authorities. 2.0 NHS Emergency Preparedness, Resilience and Response (EPRR) Assurance NLAG is required to undertake an annual self-assessment against the NHS England Core Standards for EPRR. These core standards cover all aspects of the Trust s EPRR work, including the Trust s statutory obligations under the Civil Contingencies Act A self-assessment was completed during September 2014 culminating in a statement of compliance and an action plan for identified gaps being taken to the Trust Board in October The self-assessment submitted to NHS England via the Trust Board, demonstrated the Trust s current compliance against the 37 core standards for overall preparedness and the 14 core standards specific for Hazardous Materials / Chemical, Biological, Radiological and Nuclear (HAZMAT / CBRN) preparedness as detailed below: Compliance with 37 Core Standards for Overall Preparedness Compliance Description of Compliance Number of Core Standards Not Applicable Not applicable to the Trust 4 Green Arrangements in place now 31 Amber Draft or scheduled on action plan 2 Red Arrangements not in place or scheduled 0 Compliance with 14 Core Standards for HAZMAT / CBRN Preparedness Compliance Description of Compliance Number of Core Standards Not Applicable Not applicable to the Trust 0 Green Arrangements in place now 7 Amber Draft or scheduled on action plan 7 Red Arrangements not in place or scheduled 0 Based on this self-assessment, the Trust Board approved a statement of compliance submission as Full compliance, which meets the criteria The plans and work programme in place appropriately address all the core standards that the organisation is expected to achieve. An action plan (attached at Appendix A) was created for the nine Amber core standards and its progress is monitored and reviewed through the Emergency Preparedness, Resilience and Response Steering Group. Four of the nine actions have been completed while the remaining five are in progress. 3.0 Testing, Training and Working Together with Local Partner Agencies As a Category 1 responder, NLAG must carry out training and exercising of our emergency plans and contribute towards collaborative exercising of local partner agencies emergency plans. The EPRR Training Programme (attached at Appendix B) lists the internal and external training and exercises completed over the past two years and those planned within the next three years. In addition to this list, an EPRR Awareness session is part of the Trust Corporate Induction delivered to all new employees of the Trust. Page 2 of 17

3 Emergency plans must be validated through an exercise every three years as a minimum unless a live incident occurs when the emergency plan is implemented and a post-incident report is completed. Section 5.0 within this report refers to live incidents that have provided the appropriate validation for specific emergency plans. During 2014, the Emergency ning Department has developed and created a scenario based table top exercise toolkit consisting of a visual hospital footprint and detailed scenarios providing a realistic incident experience for clinical and non-clinical participants. Four table top exercises have been delivered, focusing on the Trust s Emergency Department response to a large scale incident within our area (a train derailment on the Scunthorpe to Grimsby line involving 50 casualties of varying severities of injury). All four exercises were well attended with positive feedback received that the training enhanced the participant s knowledge of the Major Incident, the overall Trust response and their individual role in responding to an incident. NLAG hosted a Strategic Leadership in a Crisis course in October 2014 which was attended by Executive Directors from NLAG and neighbouring NHS organisations. The nationally recognised course provides Directors with an overview of the legislation supporting EPRR within the NHS, decision making during an incident and what to expect if they have to attend a multi-agency Strategic Coordinating Group. The Major Incident was also a primary focus in this year s On-Call Director and On-Call Senior Manager Training Sessions. An internally designed and delivered Loggist course was introduced within the Trust during 2014 with 36 members of staff from across the Trust volunteering to undertake the training and be part of a call out register to support an Incident Coordination Centre during an incident, the value of which has been recognised during live incidents as detailed section 5.0. In respect of partnership working with Local Partner Agencies, NLAG is represented at the Local Resilience Forum, the Local Resilience Forum s Sub-Groups, the Yorkshire and Humber Major Incident Practitioners Group, and the Local Health Resilience Partnership. 4.0 Emergency Preparedness, Resilience and Response - Work Programme The EPRR Work Programme (Appendix C) provides a high level overview of the work to be carried out over the coming three years. The EPRR Work Programme will continue to develop in line with the ever changing guidance and legislation to ensure the Trust maintains its compliance and readiness to respond to an incident. 5.0 Incidents Implementation of Emergency s Over the past 12 months, some of Trust s emergency plans have been activated to support the response to live incidents or as part of the preparedness actions to prevent an incident from occurring. Emergency Date Description of Incident Heatwave July 2014 The Met Office issued a Level 2 Heatwave Alert and the Heatwave was implemented for level 2 actions Major Incident Incident Coordination Centre Manual 04/10/2014 Water pipe leak at SGH causing water tanks to run dry resulting in no running water on site Major Incident declared and plan implemented to assist the management and response to the incident 04/10/2014 As above Incident Coordination Centre established to provide a command and control function to support the response Page 3 of 17

4 Significant Incident 26/11/2014 Core switch failure at SGH causes the entire IT network and systems to fail Trustwide Significant Incident declared and plan implemented to assist the management and response to the incident Business Continuity s Oct-Nov 2014 Industrial Action by seven unions resulted in two strikes and several weeks of action short of strike Business Continuity s were used to identify critical and noncritical services and supported the re-allocation of resources 6.0 Summary and Next Steps In summary, there continues to be a considerable amount of work in developing the Trust s EPRR arrangements. The Trust s EPRR arrangements were scrutinised by East Coast Audit Consortium in their Internal Audit Report, completed during March 2014, demonstrating that the Trust has significant assurance. There maintains a high level of focus and priority nationally and with the developing national guidance due to the expanding range of threats and events which the Trust must be prepared for, it is essential that there is a continued focus on the Trust s emergency preparedness and business continuity arrangements which should be seen as an on-going corporate priority. It is important that the Trust maintains and continues to advance the reputation in the EPRR arena that has been developed over the last three years. 7.0 Trust Board Action Required The Board is asked to: note the current compliance against the NHS England Core Standards for EPRR and the action plan in response to those actions which are ongoing (Appendix A) note the Training Programme (Appendix B) note the Work Programme (Appendix C) for the coming year 2015/16 Page 4 of 17

5 Appendix A Action for Compliance with NHS England Core Standards for EPRR Action Last Updated: 02/06/2015 Core Standard Core Standard Description Reference 8 Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resource and capacity. Improvement Required To Achieve Compliance Action To Deliver Improvement Deadline Have arrangements for Corporate and service level business continuity (aligned to current nationally recognised BC standards) Service-level BC s need to align to new ISO standards New guidance has been purchased. Review and update BC template December 2014 Completed BCP template reviewed, updated and live on SharePoint Have arrangements for - Evacuation Evacuation All Directorates to review and update their Service-level BC s when structural changes have been implemented Develop and approve a Hospital Full and Partial Site Evacuation March 2015 Ongoing All Directorates in process of updating BCPs March 2015 Ongoing Draft of plan in development 16 Those on-call must meet identified competencies and key knowledge and skills of staff Strategic Leadership in a Crisis course for On-Call Directors Strategic Leadership in a Crisis Course to be held for Trust Executive Directors (booked for 17 th October 2014) October 2014 Completed Course held on 17/10/14 Page 5 of 17

6 41 HAZMAT / CBRN - Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7 A&E Department rotas to ensure CBRN trained staff cover on each shift Ensure systems in place that offers assurance that adequate CBRN trained staff cover is on each shift March 2015 Ongoing New CBRNe/HAZMAT Training programme being designed and rolled out during HAZMAT / CBRN There is an accurate inventory of equipment required for decontaminating patients in palace and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff 5 additional PRPS required across Trust to meet minimum 24 PRPS per A&E Obtain 5 additional PRPS December 2014 Completed Unable to secure PRPS from other Trusts. Emergency Departments have ordered additional suits 15 more disrobe and re-robe packs required at each A&E to meet minimum requirement Purchase 30 additional disrobe kits Purchase 30 additional re-robe kits December 2014 Completed Equipment purchased. Kits made up and delivered Loud hailer needed at SGH A&E SGH A&E to purchase a loud hailer December 2014 Completed Purchased and in A&E Chemical Equipment Assessment Kits (ChEAKs) needed at each site? Guidance unclear Seek clarification on requirements for ChEAKs September 2014 Completed ChEAKs Kits not available for Acute Trusts so N/A Page 6 of 17

7 44 HAZMAT / CBRN The organisation has the expected number of PRPS suites (sealed and in date) available for immediate deployment should they be required 5 additional PRPS required across Trust to meet minimum 24 PRPS per A&E Obtain 5 additional PRPS December 2014 Completed Unable to secure PRPS from other Trusts. Emergency Departments have ordered additional suits 48 HAZMAT / CBRN The current HAZMAT / CBRN decontamination training lead is appropriately trained to deliver HAZMAT / CBRN training CBRN Lead Nurses need to have a training or assessing qualification Check CBRN Lead Nurses training or assessing qualifications September 2014 Ongoing - Medicine Group checking current qualifications 49 HAZMAT / CBRN Internal training is based upon current practice and uses material that has been supplied as appropriate HAZMAT / CBRN training session needs to incorporate the Trust CBRN and new JESIP IOR guidance Review and revise HAZMAT / CBRN Training March 2015 Ongoing New CBRNe/HAZMAT Training programme being designed and rolled out during HAZMAT / CBRN The organisation has sufficient number of trained decontamination trainers to fully support its staff HAZMAT / CBRN training programme Ensure adequate staff are trained to manage a HAZMAT / CBRN incident Review the Trust s current position with HAZMAT / CBRN training September 2014 Ongoing All A&E staff to receive updated training when new training programme rolled out 51 HAZMAT / CBRN Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant A&E Reception staff to receive Step guidance A&E Reception staff to receive Step guidance September 2014 Completed Training provided to DPOWH and SGH A&E Receptionists Page 7 of 17

8 Appendix B Emergency Preparedness, Resilience and Response Training Programme 2015/16 Date Training Training Type Provided By NLAG Attendance Multi-Agency 21/04/2013 Op Spring - SGH Live Decontamination Exercise Live NLAG A&E, EP, Ops 11/06/2013 Advanced Casualty Clearing Station (ACCS) Exercise Live YAS EP, A&E 19/06/2013 Heatwave Exercise Table Top NLAG 04/09/2013 Partial Site Evacuation Live 12/09/2013 Chemical Fatality Multi-agency Training Live 24/10/2013 Astral Climb - Military Nuclear Transport Exercise Live Northallerton Hospital Humberside Police HM Armed Forces Ops, Comms, Matrons, Pharmacists, EP EP EP, A&E EP NLAG, HF&RS, HP, NHS NY&H YAS, NLAG, NHS Eng, HF&RS NLAG NLAG as Observers only NLAG as Observers only NLAG as Observers only 25/10/2013 YAS Safety Advisory Seminar Training YAS EP YAS, NLAG, LA, Police 14/11/2013 North Lincolnshire Winter / Surge Exercise Table Top NLAG EP, Ops, Community & Therapy NLAG, NLC 17/12/2013 North East Lincolnshire Winter / Surge Exercise Discussion NEL CCG EP, Ops NEL Health Partners 25/11/ /01/ /01/2014 Hospital Major Incident Medical Management and Support (HMIMMS) Major Incident Switchboard Cascade Test - Office Hours - DPOWH Major Incident Switchboard Cascade Test - Office Hours - SGH Course ALSG EP Yorkshire & Humber Region Health Practical NLAG EP, Switchboard NLAG only Practical NLAG EP, Switchboard NLAG only 24/03/2014 EPS Branch Study Day Training EPS EP EPS Branch Page 8 of 17

9 28/03/2014 Strategic Leadership in a Crisis Course External Trainer EP, COO Regional Health Partners 25/04/2014 Phillips66 Humber Refinery COMAH Exercise Table Top Phillips66 & LA EP, A&E LRF Mulit-agency 14/05/2014 Loggist Training Session - SGH Training NLAG Loggists NLAG only 02/06/2014 Loggist Training Session - DPOWH Training NLAG Loggists NLAG only 23/06/2014 Loggist Training Session - SGH Training NLAG Loggists NLAG only 25/06/2014 Major Incident Training Session - SGH Training NLAG On-Call Managers NLAG only 02/07/2015 Major Incident Training Session - DPoWH Training NLAG On-Call Managers NLAG only 20/09/ /10/2014 Major Incident Switchboard Cascade Test - Out of hours - DPOWH Major Incident Switchboard Cascade Test - Out of hours - SGH Practical NLAG EP, Switchboard NLAG only Real Incident - Water Loss Major Incident NLAG Switchboard NLAG only 02/07/2014 Major Incident Training Session - DPOWH Training NLAG On-Call Managers NLAG only 07/07/2014 Loggist Training Session - DPOWH Training NLAG Loggists NLAG only 27/08/2014 Loggist Training Session - DPOWH Training NLAG Loggists NLAG only 10/09/2014 Loggist Training Session - SGH Training NLAG Loggists NLAG only 22/09/2014 Major Incident - Table Top - DPOWH Table Top NLAG Medicine, ECC, EP NLAG only 02/10/2014 Major Incident Training Session - SGH Training NLAG 04/10/2014 Major Incidnet - Live 13/10/2014 ICC Test - DPOWH 13/10/2014 ICC Test - SGH Real Incident - Water Loss Major Incident Real Incident - Industrial Action Real Incident - Industrial Action NLAG On-Call Directors and Managers Trustwide Response NLAG only NLAG Trustwide Response NLAG only NLAG Trustwide Response NLAG only 22/10/2014 Major Incident - Table Top - DPOWH Table Top NLAG Medicine, ECC, EP NLAG only 23/10/2014 Emergency Blood Stock Shortage Table Top NLAG Multiple Depts NLAG only 05/11/2014 Major Incident Training Session - DPOWH Training NLAG On-Call Director NLAG only 11/12/2014 Major Incident - Table Top - SGH Table Top NLAG Medicine, EC, EP NLAG only 07/01/2015 Major Incident - Table Top - SGH Table Top NLAG Medicine, EC, EP NLAG only NLAG, EMAS, HF&RS, AW Page 9 of 17

10 11/02/2015 Major Incident Training Session - SGH Training NLAG On-Call Managers NLAG only 19/03/2015 Major Incident Training Session - SGH Training NLAG On-Call Managers NLAG only 07/05/2015 ICC Setup Test - DPOWH Practical NLAG EP NLAG only Before Jul-15 ICC Setup Test - SGH Practical NLAG EP NLAG only Before Jul-15 Major Incident Switchboard Cascade Test - Office Hours - DPOWH Practical NLAG Switchboard NLAG only Before Jul-15 Before Jul-15 Major Incident Switchboard Cascade Test - Office Hours - SGH Major Incident Switchboard Cascade Test - Out of hours - DPOWH Practical NLAG Switchboard NLAG only Practical NLAG Switchboard NLAG only Before Jul-15 Major Incident Switchboard Cascade Test - Out of hours - SGH Practical NLAG Switchboard NLAG only To Be Confirmed Site Evacuation - Table Top - DPOWH Table Top NLAG TBC NLAG only To Be Confirmed Site Evacuation - Table Top - SGH Table Top NLAG TBC NLAG only To Be Confirmed Site Evacuation - Table Top - GDH Table Top NLAG TBC NLAG only To Be Confirmed Site Evacuation - Multi-agency Live NLAG TBC LRF Mulit-agency To Be Confirmed Adverse Weather Exercise Table Top NLAG TBC TBC To Be Confirmed Major Incident - Table Top Table Top NLAG TBC NLAG only To Be Confirmed Pandemic Flu Table Top TBC TBC Before Mar-16 Mass Vaccination / Treatment Table Top NLAG TBC NLAG only TBC - Potentially LHRP Led Before Apr-16 CBRN - Live - DPOWH Live NLAG TBC LRF Mulit-agency Before Apr-16 CBRN - Live - SGH Live NLAG TBC LRF Mulit-agency Before Jun-16 Heatwave Table Top NLAG TBC NLAG only Before Oct-17 Major Incident - Live Live NLAG TBC NLAG only Page 10 of 17

11 Appendix C Emergency Preparedness, Resilience and Response Work Programme Key: Green - Completed Amber - Within Month of Deadline Red - Overdue Deadline Light Blue - Not Near Deadline Subject Task Deadline Status Notes CBRN CBRN/HAZMAT Review plan incorporating latest national guidance on dry decontamination 31/03/2015 Ongoing Standard Review Due July To be reviewed and updated early due to new national guidance on dry decontamination DPOW Exercise SGH Exercise CBRN/HAZMAT Training Live Decontamination exercise at DPOW Live Decontamination exercise at SGH Review and update training programme 31/04/2016 Future 31/04/2016 Future 31/03/2015 Ongoing Initial meeting has taken place with DPOWH and SGH Emergency Departments to agree approach to update of training package. Training package in development. Learning outcomes identified and training plan agreed PRPS Ensure minimum of 24 PRPS at each A&E Site Disrobe and Re- Robe Kits Receptionist Step 123+ Training COMAH Data Sheets Major Incident Major Incident Ensure minimum of 20 Disrobe and 20 Re-Robe kits at each A&E Site Provide interim training for A&E Receptionists on Step 123+ Update COMAH Data Sheets Review plan 30/11/2016 Future 31/12/2014 Completed Additional PRPS ordered and awaiting delivery 31/12/2014 Completed Equipment for disrobe and re-robe kits purchased. Packs assembled and delivered 30/09/2014 Completed 3/4 of DPOWH Receptionists trained during September and November SGH Receptionist session took place during November A&E's able to request further ad-hoc sessions as required. 31/10/2014 Completed All COMAH Data Sheets updated and uploaded on to the EPRR website Page 11 of 17

12 Major Incident Training Sessions Major Incident Table Top Exercises Create an MIP / EP training session and organise dates for through the year Create an MIP table top exercise and organise a dates for delivery at both DPOWH and SGH 31/06/2014 Completed Major Incident training sessions for On-Call Directors and Senior Manager completed. Regular dates for 2015 to be set for staff invites 31/06/2014 Completed Table top toolkit created and tested. Two exercises at DPOWH completed and two at SGH arranged Major Incident Trustwide Table Top Trustwide table top to cover all Directorates Incident Coordination Centre DPOW Major Incident Cupboard SGH Major Incident Cupboard Incident Coordination Centre Manual On-Call Director and Senior Manager Training Review and ensure sufficiently stocked Review and ensure sufficiently stocked 31/07/2016 Ongoing 31/04/2015 Completed 31/04/2015 Completed Review plan 30/11/2016 Future Create and deliver major incident training session to On-Call Directors and Senior Managers 31/12/2014 Completed Sessions delivered at DPOWH and SGH Strategic Leadership in a Crisis Course Personal Logbooks for Directors Neighbouring Hospitals Info Pack Loggist Training Refresher Sessions Organise and host the SLIC course for NLAG Directors Design personal logbooks for Directors Create info pack on neighbouring hospitals for the ICC Provide refresher sessions for loggists 31/10/2014 Completed Course hosted at DPOWH on 17/10/ /03/2016 Future 31/10/2015 Ongoing Information gathering in progress. Document templates created and being populated 31/05/2017 Future Page 12 of 17

13 EPRR Steering Group Terms of Reference Business Continuity s Business Continuity Policy Business Continuity Template Service-Level Business Continuity s Business Continuity Tests Directorate Critical Services Overview s Adverse / Cold Weather Adverse Weather (Community Services) National Cold Weather Review TOR 31/03/2016 Future Review policy 30/04/2016 Future Update BCP template to bring in line with ISO Ensure Service-Level BCPs are reviewed and updated Validate BCPs through scenario testing Update Directorate Overview BCPs Review Community Service impact and incorporate guidance Ensure relevant actions can be activated during Cold Weather Alerts 31/12/2014 Completed Additional sections added to template and new template live from January /03/2015 Ongoing Review reminder sent to all BC Reps with instructions on how to update their BCPs. Deadline given of 31st March Deadline extended to 30th April and additional support offered 31/12/2014 Completed BCPs tested under real conditions during the industrial action on 13th and 20th October /09/2015 Future Rest Centres Rest Centre Review plan 30/09/2017 Future To be completed after Service-Level BCPs have been updated. 30/09/2014 Ongoing Discussions to take place on whether a separate Adverse Weather is still required 31/12/2014 Completed National plan checked. Community Services confident that actions can be implemented during Cold Weather Alerts Heat Wave Heatwave Review plan 31/07/2016 Future Page 13 of 17

14 Emergency ning & Business Continuity Website Ebola ning and Guidance Section Training and Exercise Section New section required to include national and local guidance New section required to include TNAs, description of available training sessions and a training matrix Induction Training Induction Training Review presentation 31/12/2015 Future Training Program Training Programme Update training programme with 2014 courses completed and required training for next 3 years Mass Vaccination / Treatment Mass Vaccination / Treatment Review plan 30/04/2016 Future Mass Casualties Mass Casualties Create a Mass Casualties for NLAG that is consistent with the Humber Partial or Total Site Evacuation Site Evacuation Site Evacuation Exercise Create a Site Evacuation for partial and total site evacuation Organise and conduct a Site Evacuation Table top Exercise 31/10/2014 Completed Ebola section created, links and guidance added 31/08/2014 Completed Training section created including TNAs, session details and a training matrix spreadsheet Initial meeting held with other induction trainers in Oct /12/2014 Completed Training programme spreadsheet updated with all training carried out during 2014 (including real incidents that supersede training requirements) and the training schedule for the next 3 years 30/10/2014 Future Establish whether NLAG requires its own Mass Casualties or if regional plan is sufficient. Awaiting outcome from discussions with LHRP 31/03/2015 Ongoing Draft in development. Multi-agency meeting to agree response tool place during Feb Draft to be finalised and circulated for comments 30/11/2015 Future HPA Exercise Template reviewed and will be able to be used after being modified to meet specific requirements for our Trust Page 14 of 17

15 Trust EPRR Risk Register Procedure for EPRR Risk Assessments EPRR Risk Assessments EPRR Risk Assessment Annual Summary Report Training Needs Analysis Training Needs Analysis Complete TNA for Evac Pandemic Flu Pandemic Flu Significant Incident Significant Incident Review procedure 31/05/2017 Future Complete additional risk assessments Provide summary report to EPRRSG 30/09/2015 Future 31/07/2015 Future Review TNAs 01/03/2017 Future Complete TNAs and upload to training section Review the requirement for an illness specific plan 30/11/2015 Future 31/08/2015 Future Review plan 31/05/2017 Future Surge and Escalation Management Surge and Escalation Policy Review policy 30/09/2017 Future Investigations, Action s, Assurance Frameworks and Submissions NHS England Core Standards for EPRR Self- Assessment and Submission 2014 NHS England Core Standards for EPRR Action Complete self-assessment, gain Trust Board approval and submit to NHS England before deadline Monitor completion of actions To be completed once plan is approved 22/11/2014 Completed Self-assessment approved at Trust Board and submitted to NHS England Various (30/09/ /03/2015) Ongoing Page 15 of 17

16 SGH CBRN Post- Exercise Action Water Loss Major Incident Post- Incident Report IT Network Incident Post- Incident Report IT Network Incident Post- Incident Report Action Industrial Action Autumn Interim Report 2014 National Capabilities Survey NHS England Core Standards for EPRR Self- Assessment and Submission 2015 Resilience Direct Trust Access to Resilience Direct Trust Emergency s on Resilience Direct Ebola Coordinate Trust Action Coordinate and Distribute National and Local Guidance on Ebola Monitor completion of actions Create report and submit to EPRRSG Create report and submit to EPRRSG Monitor completion of actions Create report and submit to TGAC Complete survey and submit before deadline Complete self-assessment, gain Trust Board approval and submit to NHS England before deadline Gain relevant accesses to RD Upload relevant plans to RD Monitor completion of actions Coordinate and Distribute National and Local Guidance on Ebola 31/07/2013 Ongoing Actions 3, 7-13 have been completed. Actions 1, 2, 4-6 remain outstanding 31/12/2014 Completed Report complete and submitted to EPRRSG 30/01/2015 Completed Report completed and will be submitted to March's EPRRSG 31/03/2015 Completed 21/10/2014 Completed Interim report completed and submitted to TGAC 24/11/2014 Completed Survey completed and submitted 30/11/2015 Ongoing 30/09/2014 Completed 31/10/2015 Future Ongoing Ongoing Action plan to be monitored through EPRRSG Ongoing Ongoing National websites and Resilience Direct checked daily and new guidance documents uploaded on to Trust EPRR website when relevant Page 16 of 17

17 Ebola Live Exercise Create, organise and deliver Ebola live exercise 31/12/2014 Completed Exercise conducted on Saturday 22/11/2014 Page 17 of 17