Incident Response Plan

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Incident Response Plan

Version 1.0

Date Issued: September 2010

Review Date: September 2010

Approved By: EMT

1.0 Introduction

The purpose of this document is to outline SWYPFT’s (the Trust) organisational response to major incidents both internal and external. Whilst this will include the extraordinary type of incident described above it is principally about local events may disrupt the Trust’s services.

2.0 Background

The Civil Contingencies Act 2004 (CCA) creates a need to review our emergency preparedness arrangements. Mental Health Trusts are not designated in the Act, as either category 1 or 2 responders and consequently have no statutory duties other than an implied one ‘to cooperate with those who do.’

3.0 Purpose and Scope

This plan seeks to define an incident response structure that enables an effective response and recovery from disruptions

During an incident there should be a simple and quickly formed structure that will enable the organisation to:

·  Confirm the nature and extent of the incident

·  Take control of the situation

·  Contain the incident

·  Communicate with stakeholders

The same structure should trigger an appropriate business continuity response.

4.0 What is a Major Incident?

For practical purposes, the criterion to be used by the Trust to identify a ‘major incident’ is; ‘Any requirement for service provision above a level which can be contained within existing services’

In responding to the Major Incident the Trust will aim to:

§  save life

§  prevent the escalation of the situation

§  relieve suffering

§  safeguard the environment

§  protect property

§  facilitate criminal investigation and judicial, public, technical or other inquiries

§  inform the public

§  promote self help and recovery

§  restore normality as soon as possible

5.0 Principles of dealing with a Major Incidents

The response to a major incident should be based on the following phases:

Phase 1 (…the initial response) This phase is about establishing the scope of the incident, gathering relevant information and disseminate it to those people who need to be involved

Phase 2 (Containment) Prevent exacerbation and escalation. The focus moves to caring for those affected, evacuation, welfare, staff briefing, public information etc.

Phase 3 (Resolution and Recovery) Concerns restoration, returning the situation to normal and understanding lessons learned. Co-ordinating the long-term response including, support for victims and the reinstatement of the affected area.

5.1 Definitions

The term “emergency” is used consistently throughout The Civil Contingencies Act to encompass ‘all disruptive challenges that require the use of assets beyond the scope of normal operations and require a special deployment’.

The term “major incident” is commonly used by emergency services personnel to describe events or situations which would constitute an emergency as defined in the Act; this is the threshold of event or situation that will initiate a response under their major incident plans. These terms refer to the same threshold and are interchangeable.

The British Standard for Business Continuity (NHS 25999) defines an incident as a ‘situation that might be, or could lead to, a business disruption, loss, emergency or crisis

6.0 Roles and Responsibilities

6.1 Trust Board

Trust Board will be responsible for approving The Incident Response Plan

6.2 Chief Executive

The Chief Executive of the Trust has ultimate responsibility for Emergency management within the organisation and:

·  must ensure that there are effective systems in place for compliance with the Care Quality Commission’s Core Standard 24.

·  Must ensure that a Lead Director is identified

6.3 Lead Director (Emergency Management)

The Lead Director (Director of Business Development and Planning) will have overall responsibility for Incident Management and is directly accountable for ensuring the continued success of this capability. In addition, the Lead Director will;

·  chair the Emergency Management TAG

·  Make an Annual Report to the Trust Board

6.4 Trust- Wide Action Group (Emergency Management TAG)

The Emergency Management TAG has responsibility for:

o  ensuring that the policy is disseminated to Directors

o  monitoring compliance

o  reporting progress to Risk Management and Governance Committee

o  communicating relevant messages to all staff

6.5 Executive Directors

Executive Directors will support the Lead Director to ensure that the policy is embedded in the organisation

6.6 Emergency Planning Lead

·  Implement and maintain Business Continuity programme

·  Undertake training with Business Continuity Leads

·  Act as a resource for Business Continuity Leads

6.7 District Director

District Directors have responsibility for ensuring that the policy is disseminated and implemented within their area of responsibility.

6.8 All Staff

All staff members are responsible for:

·  co-operating with the development and implementation of Trust policies as part of their normal duties and responsibilities

·  for reporting any adverse experience or difficulties in implementing this policy or where practice is not in accordance with this policy

7.0 Invoking the plan

7.1 Declaring an incident ‘Major’

The responsibility for declaring a situation a ‘Major Incident’ rests with the Chief Executive or nominated deputy. Where possible this should be done in consultation with another member of the core Executive Director Team.

The immediate response will differ depending on whether the incident occurs during or outside normal working hours:

During Office Hours: At the point where an untoward incident/denial of service occurs, or an identified risk is realised, routine line management reporting of the incident should proceed as normal (i.e. The key responsibility will be with the relevant General Manager, or nominated deputy)

If, in the judgement of the General Manager (or nominated deputy), the incident is so serious that is cannot be contained, they will, as a matter of urgency, notify the Chief Executive’s office.

Out of Office Hours: The responsibilities of the General Manager in this process will be vested in the On-Call Manager (SEE Appendix I).

At the point where a Major Incident is declared out of hours, the On-Call Manager will become the DUTY INCIDENT MANAGER.

The person immediately responsible at the site of the incident i.e. Ward/Unit Manager, Modern Matron; Team Leader will become the SITE MANAGER

The Major Incident Plan is designed for full activation both during and out of normal office hours. However, most incidents do not require the implementation of the full procedure (i.e. minor or very short term incidents involving one or two Services would probably not warrant such activation) and in such instances, the Duty Incident Manager, in consultation with the Chief Executive could consider implementing a more restricted response.

Care must be exercised by the Duty Incident Manager not to underestimate the potential impact of any incident. He/she should also consider the possibility of the incident being dealt with under normal Service procedures (i.e. ‘Business as Usual’). The procedure will need to be adjusted according to circumstances.

NB. Occasionally the Trust may be notified of potential disruptions to its services from outside sources (e.g. Fuel protests), determining the Trusts response to such warnings is the responsibility of the Chief Executive, in consultation with members of the Core Executive Team

7.2 Levels of response

The planned response to any major incident reflects the model used by the emergency services and which is becoming used more commonly by NHS organisations. Rather than prescribing an approach for every type of emergency, this model describes a process of managing any major incident.

The full activation of the Major Incident Procedure is described below.

7.3 Core Executive Team (Gold Level)

This is the strategic level of command (referred to as “gold” level by Emergency Services) and will formulate overall policy and would only be established in the most serious incidents.

Meetings will take place away from the site and would normally be attended by:

§  Chief Executive

§  Director of Operations and Nursing

§  Director of Human Resources

§  Director of Public Affairs (Communications)

§  Duty Incident Manager (Optional)

§  Emergency Planning Lead (Advisory)

The initial meeting of this group will take place as soon as is reasonably possible following the declaration of a major incident.

The meeting should be recorded or verbatim notes prepared. This ensures an Incident Log is maintained and provides a record of all strategic decisions.

The initial meeting should consider;

§  Frequency of subsequent meetings

§  Co-opting additional members/expertise to the core team

§  Internal/External communication Strategy

§  Notification of partner organizations

§  First reports from the Duty Incident Manager and relevant Services on actions taken, resources/staff committed, additional resources needed/requested and problems encountered and anticipated

§  Other urgent matters

7.4 Incident Management Team (Silver Level)

This tactical level group will determine the priority in allocating resources, will plan and co-ordinate the overall response and obtain other resources as required.

The Duty Incident Officer will chair the Incident Management Team meetings. The meeting should be recorded or verbatim notes prepared. This ensures an Incident Log is maintained and provides a record of all decisions.

The incident Management Team will include:

§  Facilities Manager

§  Administration Manager

§  Head Porter

§  Fleet Manager

§  Staff Counselling

§  Pastoral Care

§  Psychological Therapies

§  The site manager (Optional - in an advisory capacity

The main functions of the Incident Management Team are to:

§  Ensure the incident is contained

§  Co-ordinate the activities of Trust services,

§  Liaise with other agencies and to respond to and prioritise all requests for resources.

§  Communicate with Strategic and Operational level services

§  Ensure the welfare of the Staff involved

§  Ensure patients and their relatives are kept up to date with developments

7.5 Site Manager (Bronze Level)

The operational level (also referred to as “bronze” level) manager is sited at the scene of the incident. As responding agencies arrive at the scene they will liaise fully and continually with others.

The priorities are:

§  Containment of the incident/event

§  Safety

§  Ensuring adequate resources are available to deal any likely contingencies which might arise

§  Staff welfare

§  Service continuity

§  Communicating situations reports.

8.0 Emergency Contacts

Are available in the Directors On-Call folder

9.0 Incident Management

Incident Control Centre

A control centre has been identified which will act as a central point for incoming and outgoing information and decisions when a major incident is in progress.

The Core Executive Team will assemble at the nominated centre, at the discretion of the Chief Executive, to co-ordinate the Trust’s response to a major incident.

9.1 Incident Control Centre

Fieldhead Hospital

Education Department

Wakefield

Tel: 01924 327000 (Main Reception)

If the incident has attracted members of the media, a secure press room will be established in

Fieldhead Hospital

Communications Department

Wakefield

No members of the media should be allowed to enter the building or grounds unaccompanied.

10.0 Document Owner and Maintainer

The Trust’s Emergency Planning Lead.

11.0 Document Control

This document is Version 1.0 of the Trusts Incident Response Plan (previously titled ‘Major Incident and Business Continuity Plan) which will be submitted to the Executive for final approval. When approved, the Emergency Planning Lead will collate and store the originals as Version 1.0 of the Trusts Plan.

Minor updates will be notified to the Emergency Planning Lead and will lead to modification of the active version (ie 1.1, 1.2, 1.3 etc.)

Full or major review of the plan will be done under Executive scrutiny and will lead to new versions of the plan being activated (2.0, 3.0, 4.0 etc.)

The Plan will be reviewed as new guidance becomes available or subject to lessons learned.

Appendix I

SOUTH WEST YORKSHIRE PARTNERSHIP FOUNDATION TRUST

On-call Guidelines

SCOPE

This procedure applies to all clinical areas and staff of South West Yorkshire Partnership Foundation NHS Trust.

STATEMENT

In order that a twenty four hour system of organisation, management, administration and coordination of Trust services can be maintained, this procedure sets out the process for accessing a Manager or Director on-call, outside normal working hours (evenings, weekends, at night and during bank holidays) or in the event of a major incident.

RESPONSIBILITIES

It is the responsibility of the Trust to:

· Provide management at evenings, weekends, nights and bank holidays.

· Set out clearly the process for staff to access the on-call manager.

· Provide appropriate support to enable rapid response to implementation of the major incident plan.

It is the responsibility of the On-call Manager to:

·  Provide on-call managerial cover when rostered

·  Be accessible to staff when on-call

·  Provide advice, management guidance and support to staff when contacted for advice or help

·  To follow Trust procedures set out for action to be taken in emergencies

·  To report any incidents to the relevant Director or the Chief Executive as the situation requires, and as laid out in specific Trust procedures.

·  Be first contact if the Major Incident Plan is activated (this requires 24-hour contact access.)

·  To record all calls in the call log (appendix 1)

·  Deal with external enquiries where appropriate

·  Refer ALL media enquires to the On Call Director

·  Ensure Datix reports are submitted

It is the responsibility of the On-call Director to:

·  Be accessible to the On Call Manager

·  Escalate the response to an incident if necessary (in line with Incident Response Plan)

·  Notify internal stakeholders

·  Notify external stakeholders (e.g. SHA, other Trusts, PCT) if necessary.

·  Log calls (Appendix 1)

·  Respond to media enquires

PROCEDURE

The key principle of the On-call system is that there is a manager available outside normal working hours for staff to access when they need help or advice.

The On-call Manager should be contacted by the senior member of staff on duty at that time.

The On-call Manager should be contacted when a specific Trust procedure dictates, or when the senior member of staff on duty does not feel competent to take a decision without consulting the On-call Manager.

The On-call Director will usually be contacted by the On-call Manager

Contacting the On Call Manager/Director

The Trusts have separate On-call management arrangements in the following localities, they can be contacted in: