Document Control
Version 1
Name of Document NHS Guildford and Waverley CCG Incident Management Plan Version Date 1st December 2015
Owner Director of Governance and Compliance [Accountable Emergency Officer}
Author Deputy Director of Governance and Compliance [Emergency Planning Officer]
Next Review August 2016 by document Author GPMS OFFICIAL [Business in Confidence]
Document Location X:\Emergency Planning\Emergency planning\Incident Management Plan\GWCCG IMP v1 Dec 2015.docx Purpose
To explain how NHS Guildford and Waverley Clinical Commissioning Group will respond to a business continuity incident. NHS EPRR Core Standards require each NHS Funded
Organisation to have and maintain an Incident Management Plan
Change summary since last version First edition
Version 1 – Following approval at Governing Body on 24th November 2015
Distribution and Accessibility
This document will be made available to all staff via the Intranet
The document and any revisions will additionally be e-mailed to all on-call staff. Executive Directors should ensure that relevant staff are aware of the plan and the procedures.
Author Contact Details Mark Twomey
Deputy Director of Governance & Compliance 01483 405 424
INVOCATION OF THIS PLAN
Table of Contents
Document Control ... 2
1. Aim, purpose and background ... 4
2. Objectives ... 4
3. Scope ... 4
4. Planning Assumptions ... 5
5. Definitions ... 6
6. Invocation and alert levels ... 7
7. Decision making ... 7
7.1 Joint Decision Making Model ... 7
8. Incident Response Group ... 10
8.1 Group Composition ... 10
8.2 Recording and actions ... 11
8.3 Meeting Location ... 11
9. Communications ... 11
10. Information Governance ... 11
11. Specific risks, linking documents for mitigation and response ... 12
12. Logging, Reporting, VIPs and documentation ... 13
13. Stand-down, Recovery and de-brief ... 13
14. Plan Review and Publication ... 14
15. Training ... 14
16. Acknowledgements ... 14
Appendix ... 14
Appendix A - Glossary ... 15
Appendix B - Incident Response Group Meeting Template ... 16
Appendix C – Incident Report Form ... 17
1.
Aim, purpose and background
1.1 To explain how NHS Guildford and Waverley Clinical Commissioning Group will respond to a business continuity incident or other incident affecting the operation of the business.
1.2 The plan will align to the expectations as laid out in the NHS Commissioning Board Emergency Preparedness Framework 2013 and the NHS England EPRR Core Standards 2014.
1.3 NHS Guildford and Waverley CCG is a category two responder under the Civil Contingencies Act 2004. Under this legislation the CCG has a duty to co-operate and information share with other responders including NHS England, Public Health England, Acute Trusts and Foundation Trusts, which are category one responders. 1.4 This plan is complementary and should be read in conjunction with the CCG
Emergency Planning, Resilience and Response (EPRR) Policy, the GWCCG Emergency Response Directory and the Surrey Local Resilience Forum Major Incident Protocol (SMIP).
2.
Objectives
2.1 To explain the context of the plan.
2.2 To detail the incident alert levels and how the CCG plans to react and respond at the relevant alert levels.
2.3 To set out how the CCG will plan for, respond to and recover from an emergency, significant incidents or major incident.
2.4 How this plan links to local, regional and national risk registers and maintains continuity of key services when faced with disruption from either an identified local risk or via an internal incident and resume services which have been disrupted. 2.5 Align arrangements where appropriate to the ISO 22301 standard, as required by the
EPRR Core Standards and to incorporate where practicable the principles of the
Joint Emergency Services Interoperability Programme (JESIP).
3.
Scope
3.1 This plan will explain the processes to be used requiring a response to an incident. It is expected that minor disruption will be managed within directorates and business as usual processes.
3.2 This plan covers the areas and activities covered by the organisational business continuity policy.
4.
Planning Assumptions
4.1 This plan makes the following assumptions:
4.1.1 That the Duty Director on-call will take the leadership in the initial stages of a response. Details and expectation of this role are set out in the organisational on-call protocol.
4.1.2 Other staff may be called upon to support the response should the extent, scale, nature or duration of a given situation be above and beyond the capability of the on-call director to manage the situation.
4.1.3 If the incident duration passes 72 hours that business as usual resources will take over the running and management of an incident and be directed by the Executive Management Team (EMT) or a suitably appointed lead. EMT, or a nominated Executive Director, will assess the situation at this point and allocate resources going forward to manage the incident if not resolved within 72hrs.
4.1.4 That reasonable assumptions of community risk in the decision making are based on the Surrey Community Risk Register. In 2014/15 the very high risks identified for Surrey included major fluvial flooding, localised flooding of rivers and streams, a pandemic of infectious disease and an epidemic of infectious disease.
5.
Definitions
5.1 The NHS Commissioning Board Emergency Preparedness Framework 2013 defines a significant incident or emergency to be:
Any event that cannot be managed within routine service arrangements. Each require the implementation of special procedures and may involve one or more of the emergency services, the wider NHS or a local authority, a significant incident or emergency may include;
• Times of severe pressure, such as winter periods, a sustained increase in demand for services such as surge or an infectious disease outbreak that would necessitate the declaration of a significant incident however not a major incident;
• Any occurrence where the NHS funded organisations are required to implement special arrangements to ensure the effectiveness of the organisations internal response. This is to ensure that incidents above routine work but not meeting the definition of a major incident are managed effectively.
• An event or situation that threatens serious damage to human welfare in a place in the UK or to the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. The term ‘‘major incident’’ is commonly used to describe such
emergencies. These may include multiple casualty incidents, terrorism or national emergencies such as pandemic influenza.
• An emergency is sometimes referred to by organisations as a major incident. Within NHS funded organisations an emergency is defined as the above for which robust management arrangements must be in place.
5.2 A significant incident is when a NHS organisation’s own facilities and /or resources, or those of its neighbours, are overwhelmed.
6.
Invocation and alert levels
6.1 Upon realising the extent of a given situation, the on-call director should assess whether the incident reaches the threshold to be declared a significant or major incident.
7.
Decision making
7.1 Joint Decision Making Model
7.2 Actions, Information, Involvement and Mutual Aid Requests
7.2.1 Upon being informed of an incident, the on-call director should take details of the informant, the time and date of receiving the information, the details of the incident at that point and the expectations of the CCG. The on-call director should check back with the informant any details to ensure the details and expectations of the CCG have been recorded accurately.
7.2.2 The on-call director should then, based on the information received, assign an alert level (as per the NHS 2013 EPRR Framework).
Alert Activity Action Level
NHS CB Incident Levels
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1
A health related incident that can be responded to
and managed by local health provider
organisations that requires co-ordination by the
local CCG.
2
A health related incident that requires the
response of a number of health provider
organisations across an NHSCB area team
boundary and will require an NHSCB Area Team
to co-ordinate the NHS local support.
3
A health related incident, that requires the
response of a number of health provider
organisations across and NHSCB area teams
across an NHS CB region and requires NHS CB
Regional co-ordination to meet the demands of
the incident
4
A health related incident, that requires NHSCB
National co-ordination to support the NHS and
NHS CB response
7.2.3 Based on the information received and the alert level designated, the on-call director will notify the appropriate persons, providers and other stakeholders, including those listed below.
7.2.4 The on-call director will maintain a log of those notified, the time, date and any delay or messages needing to be left.
7.2.5 The on-call director may also be required to setup an Incident Control Centre (ICC) at the CCG HQ (Dominion House). The Break-out room of the 3rd Floor will be used for this purpose as it has a computer, screen, phone line and whiteboards as well as space for additional support.
7.3 Royal Surrey County Hospital
7.3.1 The Royal Surrey County Hospital should be officially notified through their on-call manager via their paging system. The manager on-call should confirm receipt of the notification and call the CCG to discuss next steps.
7.4 Community and Mental Health Providers
7.4.1 NHS Guildford and Waverley CCG has one main community provider – Virgin Care Limited. Virgin Care will be notified through their on-call manager.
7.4.2 NHS Guildford and Waverley CCG has one mental health provider – Surrey and Borders Partnership NHS Foundation Trust (SABP). SABP will be notified through their on-call manager.
7.4.3 Unless directed to do otherwise, for level 1 incidents, the providers should keep the CCG updated on key significant events or updates. Where the Area Team has become involved, updates maybe directed to NHS England for the purposes of ensuring information is passed to those in command and control of an incident in a timely and effective way.
7.5 Primary Care
7.5.1 NHS England is the commissioner of primary care. The lead responsibility rests with NHS England to contact primary care organisations however the CCG as a Category Two responder may be required to co-operate with NHS England as a Category One responder in discharging necessary actions and messages. Where an incident occurs during working hours, this could be discharged by business as usual lines as this is most likely to achieve a more effective outcome.
7.6 Out of Hours Primary Care
7.6.1 The out of hours primary care service for the CCG area is provided by Care UK. For any incident occurring out of hours, Care UK should be notified through their on-call manager.
7.7 NHS England South (South East) Area Team
7.7.1 NHS England Area Team is the first escalation point for emergencies and incidents. The Area Team provide the leadership in an incident for the NHS and will normally attend any Strategic Co-ordinating Group (SCG) (Gold) meeting if called.
7.7.2 During an incident it is important to keep the Area Team updated on anything of significance as the conduit to other parts of the command structure that may emerge and/or contract in accordance with the needs of an incident.
7.7.4 The Area Team may require support at SCG meetings if required, particularly for longer running incidents.
7.8 Surrey County Council
7.8.1 Surrey County Council operate a Duty Officer and Duty Manager system for
emergencies and incidents. All requests for information and services out of hours will be directed through the County Duty Officer.
7.9 Public Health England – Kent, Surrey and Sussex Centre
7.9.1 The Public Health England Centre has an on-call system which can be accessed through their on-call manager and the CCG should activate this in conjunction with NHS England as required.
7.10 Surrey Strategic Co-ordinating Group (SCG)
7.10.1 The Surrey SCG when convened will normally be at the Surrey Police Headquarters at Mount Browne, Sandy Lane, Guildford GU3 1HG
7.10.2 If the CCG director on-call is asked to attend, consideration should be given to taking a loggist or other manager in support.
7.11 Mutual Aid Requests
7.11.1 Mutual Aid requests during times of response will be decided at Executive level.
8.
Incident Response Group
8.1 Group Composition
8.1.1 The Incident Response Group (IRG), will principally be activated for CCG business continuity incidents however this function can be activated for incidents that would benefit from wider co-ordination in support of the on-call director. The group will normally comprise of a core membership but with additional members as required:
• One Member of the Executive Management Team (unless already the designated on-call director)
• On-Call Director
• Deputy Director of Governance & Compliance (unless already the designated on-call director)
• Estates and Facilities Manager
• Head of Information and Performance or deputy, representing the Finance
Directorate
• CCG Communications Manager
• Deputy Director of Clinical Commissioning or designated deputy • Head of Medicines Management
8.1.2 The Chair of the Group will normally be the Executive Director unless decided
otherwise, with the Deputy Director of Governance and Compliance in attendance as the Emergency Planning Officer.
8.2 Recording and actions
8.2.1 All meetings and actions of the Incident Response Group will be recorded by a trained loggist.
8.2.2 A generic template agenda should be used which can be found at Appendix B.
8.3 Meeting Location
8.3.1 The designated meeting location will be in the CCG Boardroom unless designated otherwise if Dominion House is available.
8.3.2 In the event that Dominion House is not available, an arrangement is in place for NHS Guildford and Waverley CCG to use the offices of NHS East Surrey CCG. This location can be activated through the NHS East Surrey CCG On-call.
9.
Communications
9.1 Incidents may attract media interest and/or other stakeholders. Most communications will be handled by the CCG on-call director to stakeholders. Where media enquiries are involved, the CCG Communications Manager should be advised and will facilitate/ co-ordinate liaison with the media and other stakeholders.
9.2 Where an incident takes place out of hours, and the Communications Manager is not available, the Deputy Director of Governance and Compliance should be contacted in the first instance, followed by the Director of Governance and Compliance.
9.3 It is likely that incidents that involve media will be classed as level 2 incidents, where the Area Team Communications lead will take the primary ownership of the incident.
10.
Information Governance
11.
Specific risks, linking documents for mitigation and response
All Local Resilience plans are accessible through Resilience Direct.
Specific Risk Arrangements in place Action to consider
Severe Weather • SLRF Severe Weather Plan Actions to be agreed with NHS England
Pandemic Influenza
• GWCCG Pandemic Influenza Plan
• SLRF Pandemic Influenza Plan
Activate GWCCG Pandemic Flu Plan Refer to SLRF Plan Refer to NHS England
for dynamic advice at time of incident Fuel Disruption • GWCCG Incident Management Plan – • SLRF Fuel Plan Activate GWCCG Incident Management Plan Incident Response Group Surge and Escalation Management • In progress Infectious Disease Outbreak
Surrey LHRP Outbreak Plan Liaise with NHS
England around specific actions
Evacuation
SLRF Mass Evacuation Liaise with NHS
England around specific actions
Lockdown
CCG has a security Policy and lockdown covered within this plan
Liaise with NHS
England around specific actions Utilities, IT and Telecommunications Failure • GWCCG Incident Management Plan
• Emergency Response Directory • SLRF Telecommunications Plan
Liaise with NHS
England around specific actions
Excess Deaths/ Mass Fatalities
• SLRF Excess Deaths Plan • SLRF Mass Fatalities Plan • SCC Temporary Mortuary Plan • RSCH Business Continuity Plan
• GWCCG Incident Management Plan
Liaise with NHS
12.
Logging, Reporting, VIPs and documentation
12.1 Incidents of all natures will need to be logged by all roles involved. Where appropriate, the on-call director should consider the use of a loggist to ensure all information is captured and decisions can be made in order to ensure the effective and timely response to an incident.
12.2 The Incident report form found at appendix C should be used to note the incident and establish the type and extent. Noting the relevant information the form asks for will help inform the response, information required for decision making and be the basis for the convening of the incident response group in the case of a business continuity incident or a system call for other types of incident.
12.3 Once completed, all incident documentation should be returned to the Estates and Facilities Manager.
12.4 For level 2-4 incidents or other types of incidents for which the Local Resilience Forum is co-ordinating, there maybe further reporting required, sometimes daily or even more frequently. Some incidents, where the Cabinet Office Briefing Room (COBR) is in operation will require the completion of a Common Recognised Information Picture (CRIP). The CRIP reports often require information at short notice and may require data and information from providers that the CCG will need to collate.
12.5 During an incident it is possible that VIPs may visit aspects of the response, potentially including the scene of an incident or the co-ordination centre. On notification of any visits, the Chair and Chief Executive should be made aware and NHS England should be advised if not already aware.
13.
Stand-down, Recovery and de-brief
13.1 Stand-down for incidents only involving the CCG will be determined by the on-call Director. Incidents where the NHS England Area Team are involved will have a stand-down determined by the Area Team in consultation with other partners.
13.2 From the onset of an incident, consideration should also be given to the recovery phase of an incident and the earliest notification to other partners that may be required so that arrangements can be prepared. Consideration should be considered as an input to Strategic and Tactical Co-ordinating Groups.
14.
Plan Review and Publication
14.1 This plan will be reviewed by the Author and Owner annually or at a point of significant change.
14.2 The plan will be published on the CCG Intranet and Website.
15.
Training
15.1 This Incident Management Plan will be used in all exercises to ensure validity and to inform updates and reviews.
15.2 All on-call directors will be trained on the plan as part of their induction and the plan will be made available to all staff via the intranet and advertised accordingly and with any subsequent updates.
16.
Acknowledgements
16.1 NHS Guildford and Waverley CCG would like to acknowledge the support of the Surrey County Council Emergency Management Team in helping provide materials in the interests of sharing best practice.
Appendix
A – Glossary
B – Incident Response Group Template agenda and considerations C – Incident Report Form
Appendix A - Glossary
CCG Clinical Commissioning Group
COBR Cabinet Office Briefing Room
CRIP Common Recognised Information Picture
EMT Executive Management Team
EPRR Emergency Planning, Resilience and Response
GWCCG NHS Guildford and Waverley Clinical Commissioning Group
ICC Incident Control Centre
IMP Incident Management Plan
JESIP Joint Emergency Services Interoperability Programme LHRP Local Health Resilience Partnership
MAGIC Multi Agency Gold Incident Command
NHS England The Commissioning Board of the NHS for England RSCH Royal Surrey County Hospital
SCC Surrey County Council
SCG Strategic Co-ordinating Group
SLRF Surrey Local Resilience Forum SMIP Surrey Major Incident Protocol
Appendix B - Incident Response Group Meeting Template
Agenda / Actions
To be chaired by the Executive Director / Director on-call Assign Note taker
1. Introduction of attendees, roles and responsibilities 2. Confirm the nature and extent of an incident
3. Allocate an incident alert level and review as appropriate at subsequent meetings 4. Urgent actions and decisions required
5. Confirm actions agreed
6. Ensure welfare of all staff at all times
7. Confirm resources required to facilitate an effective response
8. Communication – with all those involved in the incident and relevant stakeholders are informed and involved
9. Confirm time and date of next meeting
10. Confirm and communicate a ‘stand-down’ where appropriate 11. Commission a de-brief where appropriate.
If holding meeting by teleconference, consider:
• Participants calling in within a 5 minute window before meeting starts to avoid disruption
• All participants should engage their mute button when not talking to avoid background noise
• Follow ABC – Be Accurate, Brief and Concise
• Reminder this is not a normal conference call and the call should last 15-20 mins at the latest.
Key Questions:
• Have staff been affected in any way? (Consideration to the health and safety of staff, contractors and members of the public and patients)
• Have there been any loss of facilities? (Resources, access to buildings etc) • What is the impact if any resources have been affected?
Appendix C – Incident Report Form
INCIDENT REPORT FORM
Event / Incident Person Recording
Date Time Person Reporting Exec Director notified? Contact Number Chair notified?
EVENT / INCIDENT INFORMATION
COMMUNICATION
Who has beennotified and when Name and time of those informed NHS ENGLAND ACUTE COMMUNITY
OOH PRIMARY CARE MENTAL HEALTH Patients and Public RADIO PRACTICES TWITTER FACEBOOK WEBSITE Other Stakeholders
UPDATE
Appendix D – Invocation Flowchart
INCIDENT / EVENT / SITUATION
On-call Director informed
START LOG
Other CCG Contact informedAssessment of incident to be made and if necessary escalated to below. **Use Joint Decision Model Process**
• Confirm date and Time of Incident • Take name and contact details of caller
• Confirm who else has been informed. Is NHS England On-call aware – if so, who • Confirm expectations of caller
What level is the incident?
Level 1
Level 2-4
• Consider whether the incident can be managed within CCG resources. If so call Incident Response Group Meeting if appropriate and activate Business Continuity Plan
• If affecting the CCG economy, consider calling teleconference/ meeting with relevant stakeholders • Ensure NHS England is aware of incident
• NHS England On-call to lead response • CCG as Category two Responder to co-operate and support response
NHS Guildford and Waverley Clinical Commissioning Group 3rd Floor Dominion House
