HSSOP06 Provide Corporate Business Continuity Plan by Provide Community

Corporate Business Continuity Plan v9

Version: V9

Ratified by: Finance & Investment Committee

Date ratified: 03/01/2024

Job Title of author: Nicky Mclean

Emergency Preparedness Resilience & Response (EPRR) Manager

Reviewed by Committee or Expert Group Property Heath & Safety Steering Group

1. Introduction

This plan provides the overarching procedures for managing business disruptions, regardless of cause, to ensure that, at a minimum, the organisation is able to provide its critical functions and prioritise service recovery. As per the Business Continuity Policy, the organisation will endeavour to manage disruptions at the lowest level practicable, starting with team leaders/managers, who will escalate any additional resource requests directly to their appropriate continuity lead. The plan can be activated in response to a business continuity incident, critical incident or in support of a major incident. The Business Continuity procedures will only activate the abridged Major Incident command and control structure in the event of an actual or threatened disruption to a critical or essential function and/or where it is likely that mutual aid of some form will need to be requested. However, in the event of an internal or external major incident it is likely that the business continuity procedures will be invoked in support of the incident response.

The plan is not a standalone plan and where relevant should be used in conjunction with the organisation’s emergency preparedness plans;

• Major Incident Plan

• Service Business Continuity Plans

• IT Disaster Recovery Plan

2. Purpose

The aim of this plan is to ensure that PROVIDE can respond to disruptions to its business in a way that ensures that statutory obligations are met, and supports its overall vision and mission.

The objectives of this plan are to ensure:

1. PROVIDE is compliant with its legal and regulatory obligations;

2. Critical and essential activities and services are identified, protected and ensure their continuity;

3. Stakeholder requirements are understood and can be delivered;

4. Staff, service users and the public are properly communicated with;

5. Staff receive adequate support in the event of a disruption;

6. The PROVIDE supply chain is secure and resilient

3. Definitions

The following terms and definitions have been sourced from ISO22301: Social security –Business continuity management systems – Requirement and the Civil Contingencies Act (CCA).

Term Definition

Activity

Business continuity

Business Continuity Incident

Business Continuity Plan

Business Impact Analysis (BIA)

Process or set of processes undertaken by an organisation (or on its behalf) that produces or supports one or more products and services

Capability of the organisation to continue to delivery of products or services at acceptable predefined levels following a disruptive incident

A business continuity incident is an event or occurrence that disrupts an organisation’s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implanted until services can return to an acceptable level.

Documented procedures that guide organisations to respond, recover, resume and restore to a pre-defined level of operation following disruption

Process of analysing activities and the effect that a business disruption might have upon them.

Category One Responder As defined in the CCA Category One responders are those organisations at the core of emergencyresponse such as emergency services and local authorities and are subject to the full set of civil protection duties. This includes all Acute Trusts and Ambulance Trusts, UKHSA, ICBs and NHS England. Although not listed, as a community and mental health provider PROVIDE is expected to plan and respond to incidents in the same way as category one responders.

Category Two Responder As defined in the CCA Category Two responders are co-operating bodies (Clinical, Commissioning Groups (CCGs) Health & Safety Executive, transport and utility companies).

Civil Contingencies Act 2004 (CCA)

Critical Incident

The Civil Contingencies Act 2004 (CCA) delivers a single framework for the protection of civil protection in the UK.

The Act divides responder organisations into two categories; Category One and Category Two depending on the extent of their involvement in civil protection work

A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions

Invocation Act of declaring that the business continuity arrangements need to be put into effect in order to continue delivery of key products or services

Major Incident

Maximum Tolerable Period of Disruption (MTPD)

Recovery time objective (RTO)

A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented.

Time it would take for adverse impacts, which might arise as a result of not providing a product/service or performing an activity, to become unacceptable

Period of time following an incident within which product or service must be resumed, or activity must be resumed or resources must be recovered

(the RTO must be less time than the time MTPD)

4. Duties

4.1

Chief Executive

The Chief Executive has the overall responsibility for emergency preparedness, resilience and response (EPRR) and is accountable to the Board for ensuring that systems are in place to facilitate an effective incident response including the continuity of critical/essential services

4.2 Accountable Emergency Officer (AEO)

The Health Chief Executive Officer is the nominated Accountable Emergency Officer (AEO) who is responsible for ensuring the full implementation of the organisation’s Business Continuity Policy (on behalf of the Chief Executive). The AEO may be called upon to help in the response of any incident that result in the corporate (this) plan being invoked.

4.3

Emergency Preparedness Resilience & Response Manager

The Emergency Preparedness Resilience & Response (EPRR) Manager is responsible for assisting the AEO in implementing the Business Continuity Policy and where available may be asked to provide advice during the incident response.

4.4

All staff

All staff have a role to play in business continuity in raising alerts, assisting service leads/managers in keeping the service running as normal as possible, and being flexible in their working arrangements.

Redeployment or Relocation

In the event of a business disruption, the organisation expects staff to be flexible in their working practices. This may include the requirement to work at home or at a location other than their usual workplace. Examples include:

• Working at another site managed by Provide (e.g. if the site where they normally work is inaccessible due to the incident);

• Working at or near the site of the major/critical incident;

• Working in a different department or service;

• Working at an acute hospital or at a site managed by an external partner

Changes to Working Hours

If the disruption has caused a ‘DECLARED’ Major, Critical or Business Continuity Incident, staff may be invited to temporarily change their working hours. This could include:

• Asking part time staff to temporarily increase their contractual hours;

• Asking staff who work flexible hours to temporarily alter them;

• Allowing staff to work hours in excess of 48 hours per week;

• Allowing staff who have recently retired to assist the response;

• Suspending and/or cancelling pre-booked leave or training

4.4 Heads of Service/Service Leads (Operational/Bronze)

Heads of Service/Service Leads Role (action card BC3)

Heads of Service/Service leads keep their business as usual role in a business disruption and are responsible for the coordination of the team and functions for which they are usually responsible. All Heads of Service/service leads need to be aware of their team’s essential and critical activities. In working hours, they or their nominated deputy are also the first point of contact to manage any incident or disruption that requires extra resources

in any of the named teams or functions. Out of hours, this function will be completed by the most senior staff member on site/duty

Heads of Service/Service Leads Responsibilities

The main responsibilities of the service leads are to:

• Coordinate team response

• Ensure incident is escalated as appropriate

• Ensure business continuity actions listed within service plans are completed

• Consider asking part time staff to temporarily increase their contractual hours;

• Consider asking staff to cancel any non-urgent meetings

• Consider asking staff to cancel annual leave.

• Ensure that Business Continuity Planning is activated and resourced appropriately to maintain all critical functions, working towards restoration of normal services

• Ensure that Business Continuity Plans are cascaded to appropriate staff within their remit.

4.5 Assistant Director

(Tactical/Silver)

Assistant Director/Manager On-Call (action card BC2)

The role of the Director/Assistant Director or manager on-call (Tactical/Silver if a major/critical incident has been declared) is to coordinate the business continuity measures across the organisation.

Associate Director/Manager On-call (Tactical/Silver) Responsibilities

The main responsibilities of the Director/Associate Director/Manager On-call are to:

• Liaise with the Continuity Leads (if available) to gain an overview of the status of the services in the organisation

• Ensure situation reports are completed and returned within agreed timeline

• Agree all internal mutual aid requests

• Ensure that all affected services lower priority activities are regularly reviewed to check that due to the type and length of the incident their priority rating has not increased (i.e. time critical activities)

• Review all external mutual aid requests and escalate as appropriate

• Inform the Director On-call of any disruption to any critical/essential services and the actions being taken to resume them to business as usual levels; and

• Escalate any requests for resources from outside of the organisation to the Director on-call

4.6 Director on-call/Strategic (gold) commander

Director On-call/Strategic (Gold) Commander Role (action card BC1)

The Director on-call (or Strategic (Gold) Commander if a major incident has been declared) sets the strategic direction for the organisations response and provides final oversight and approval for the logs, authorises external situation reports, mutual aid arrangements and communications

Director On-call/Strategic (Gold) Commander Responsibilities

The main responsibilities of the Director On-call are to:

• Invoke business continuity arrangements for the organisation

• Activate the Major Incident Procedures if the disruption has reached the thresholds to be considered a major incident;

• If major incident status thresholds are not met to consider invoking the corporate business continuity (this) plan and forming an incident response team to monitor response and update the ICB and/or commissioners;

• Ensure the commissioner(s) is informed of any disruption to the ‘critical/essential services’ and the steps being taken to return them to business as usual levels’;

• Feed requests for additional resources into the relevant directorates or relevant Integrated Care Board (ICB), NHS England Team and/or commissioners

5. Consultation and Communication

This policy has been reviewed by the Property, Health & Safety Steering Group and ratified by the Finance and Investment Committee (FIC).

6. Monitoring

NHS England EPRR Annual Assurance Process

All NHS organisations and providers of NHS funded care are held to account by NHS England for having effective EPRR processes and systems in place. An annual assurance process is used by NHS England to seek assurance that organisations are prepared to respond to an emergency and have the resilience in place to continue to provide safe patient care during a major incident or business continuity event. The indicators are set against the EPRR core standards and an action plan is agreed against any standard that is assessed as requiring improvement. Progress against the action plan is monitored through Senior Leadership Team (SLT).

Business continuity or major/critical incidents will be monitored by the EPRR manager through SLT and any lessons identified will be considered for changes to EPRR practice.

Internal Audit Programme

Provides internal auditors may also choose to audit the organisations business continuity arrangements on an annual basis. Any resulting recommendations from the audit will be monitored through the Finance and Investment Committee

7. Business Disruption Response Flowchart

On notification of an incident, the Director on-call should assess the situation and decide on the action to be taken; this could be to maintain a watching brief as appropriate mitigating actions are in place or to declare a business critical or business continuity incident

8. Understanding the business continuity priority ratings

The categories below are in line with Provides risk management policy and also identify the Maximum Tolerable Periods of Disruption (MTPD). In a disruption or major incident, the organisation will not be expected to keep all its services operating at business as usual levels; instead, it will proritise service delivery to ensure the continuation of its critical activities (as at Appendix B). To achieve this, staff and resources from lesser priority services may be redeployed elsewhere within the organisation. For continuity and recovery decision making processes the priorities are defined as –

Risk Levels

Example descriptors

• Function can be suspended for up to 1 week

• Minimal injury requiring no/minimal intervention or treatment No time off work required

• Peripheral element of treatment or service sub-optimal Informal complaint/inquiry

Low (1)

(Negligible)

Medium (2) (Minor)

• Short-term low staffing level that temporarily reduces service quality (<1 day)

• No or minimal impact or breech of guidance/ statutory duty

• Rumours. Potential for public concern

• Insignificant cost increase/ schedule slippage. Small loss. Risk of claim remote.

• Loss/interruption of >1 hour Minimal or no impact on the environment

• Function can be suspended for up to 3 days

• Minor injury or illness requiring minor intervention Requiring time off work for <3 days Increase in length of hospital stay (LoS) by 1–3 days

• Overall treatment or service sub-optimal. Formal complaint (stage 1). Local resolution. Single failure to meet internal standards

• Low staffing level that reduces service quality. Breech of statutory legislation.

• Local media coverage – short-term reduction in public confidence Elements of public expectation not being met

• <5 per cent over project budget. Schedule slippage. Claim less than £10,000

• Loss/interruption of >8 hours. Minor impact on environment

• Function can be suspended for up to 24 hours

• Moderate injury requiring professional intervention. Requiring time off work for 4–14 days Increase in LoS by 4–15 days RIDDOR reportable incident

High (3) (Moderate)

Essential (4) (Major)

• Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) Repeated failure to meet internal standards Major patient safety implications

• Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1day) Low staff morale Poor staff attendance for mandatory/key training

• Single breech in statutory duty. Challenging external recommendations/ improvement notice. Local media coverage – long-term reduction in public confidence

• 5-10 per cent over project budget. Schedule slippage. Claim/s - £10,000-£100,000

• Loss/interruption of >1 day. Moderate impact on environment

• Function can be suspended for up to 12 hours

• Major injury leading to long-term incapacity/ disability. Time off work for >14 days. Increase in LoS by >15 days Mismanagement of patient care with long-term effects

• Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Critical report

• Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff No staff attendance for mandatory/key training

• Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report

• National media coverage with <3 days service well below reasonable public expectation

• Non-compliance with national 10–25 per cent over project budget. Schedule slippage.

• Claim(s) between £100,000 and £1 million Purchasers failing to pay on time

• Loss/interruption of >1 week Major impact on environment

• A function that be suspended for up to 4 hours

• Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients

• Incident leading to totally unacceptable level or quality of treatment/service. Gross failure of patient safety. Inquest/ ombudsman inquiry. Gross failure to meet national standards

Critical (5) (Catastrophic)

• Non-delivery of key objective/service due to lack of staff. Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training

• Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

• National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence

• Incident leading >25 per cent over project budget Schedule slippage

• Loss of contract/ payment by results Claim(s) >£1 million

• Permanent loss of service or facility Catastrophic impact on environment

9. Command and Control Arrangements

9.1 Initial assessment

Following the initial assessment, it will be necessary for more detailed impact assessments and information gathering to be undertaken. This information should be used to ensure the most appropriate management system is used to control and respond to the incident.

The business continuity plan will operate under a Strategic, Tactical, Operational (Gold/Silver/Bronze) command structure. Strategic (Gold) will provide strategic oversight and trigger activity under the plan. Tactical (Silver) will develop the specific actions needed, will oversee implementation and report to the Strategic Team (Gold). Operational (Bronze) leads will carry out actions required.

In some incidents, it may be necessary to establish a response group without declaring an incident where there is a perceived threat from an event or hazard, which may or may not be realised. This allows the development of mitigation actions prior to any impact occurring. Such events may include industrial action or civil disturbances.

9.2 Invocation

Disruptions to service delivery do occur and are often dealt with quickly and effectively by managers, it is important that when a disruption is likely to be extended and / or involve more than one service or one of the major sites that all managers understand the correct procedure to be followed.

The criteria below has been developed to provide uniformity across Provide in relation to escalating a service disruption upward through the chain of command. In most cases these will be adequate as a guide for managers however there will be occasions when the event falls outside of criteria, but is so serious that action will still be required, in these instances the respective manager should consult with their Manager/Head of Service or Director on-call

Is the service disruption:

• Likely to result in the death of patients as a result of a lack of direct clinical intervention for longer than a period of 72 hours; or

• Involves a disruption to any of the critical services beyond the capacity of normal management frameworks to resolve; or

• Involves the loss or partial loss of one or more major facilities.

then the Service Manager is to take all actions as set out in their Service Business Continuity Plan and notify their Head of Service lead who in turn will notify the Associate Director and then the Director. The decision to activate the corporate business continuity (this) plan lies with Director On-call who may request advice from the Accountable Emergency Officer (AEO) and/or EPRR Manager as required.

9.3 Incident Coordination Centres (ICC)

The organisation has dedicated Incident Coordination Centres (ICC). A dedicated ICC should be set up and used wherever possible; however, it is acknowledged that there will be circumstances when this is not possible because either staff cannot physically get to an incident coordination centre or the ICC is being utilised to coordinate the major incident

response. Dependent on the incident it may also be more practicable to have a virtual ICC The Director on-call will decide the location of the ICC and ensure that contact details are forwarded to all necessary internal and external partners.

9.4 Stand down

The Provide Director on-call is responsible for issuing the business continuity incident ‘STAND DOWN’ instruction. This is when the organisation has completed its response and normal working arrangements are now re-instated. The Director on-call is responsible for ensuring that all necessary parties are informed that the incident has been stood down.

9.5 Record Keeping and Situation Reporting

Record keeping

A debrief, inquiry or legal proceedings may occur after any incident and the recording of data and collection of information will be used to inform the subsequent incident debrief report

For this reason all teams should ensure:

• Their decision(s)/actions are recorded/logged; where possible a loggist should be appointed

• Where mobile phones are used and not recorded the content of the conversations should be recorded where possible

• The completed forms and any original documentation should be kept securely as it may be required in any subsequent debrief or inquiry.

• All notes of meetings and decisions made by the incident response team should be recorded/logged as they are being made.

Situation Reporting (SitRep)

In response to an incident we may be asked by the ICB, NHS England and/or commissioners for regular updates, which may be through the completion of SitReps. The Director on-call or formally delegated person(s) will decide what information is required, will collate and authorise all returns.

10.Specific Strategies

10.1 Loss of premises strategy

The organisation operates its services out of a range of premises across Essex. This includes buildings it owns and maintains and those it rents from other public and private sector organisations.

The response to loss of premises will depend on the type of premises affected, the type of equipment needed, and the priority of the services running out of it. In general, alternative office and clinic space is more easily sourced than inpatient wards where mutual aid from other NHS providers may be called upon. When responding to a loss of premises the service lead should assess the priority of the service running out of it and in the case of inpatient areas, escalate it as soon as possible. It should be noted that a partial and/or total evacuation of an inpatient area will trigger the declaration of a Major Incident

If the building the team or function operates out of is lost, or there is a denial of access, then the following options should be considered for resumption:

• Agile working – able to work flexibly within the community or from home

• Budge up – share premises and resources with another service

• Displacement – Higher priority services to displace non-affected lower priority services

• Reciprocal arrangements – share premises or outsource to other NHS providers (mutual aid).

• Third Party Alternative – team or function go to a local authority, commercial partner or social enterprise property.

• Portable Premises – Portacabins.

The organisation has a number of premises and a large number of staff are able to work agilely.

Each service business continuity plan has identified alternative working locations or arrangements.

10.2

Loss of utility services strategy

The loss of a utility service may make accommodation temporarily unfit for purpose and an extended long-term loss of essential utilities may require the relocation of staff. In the case of inpatient areas, a partial and/or total evacuation will trigger the declaration of a Major Incident.

The general actions that all Heads of Service/Service leads should take for loss of the major utilities can be found in their business continuity plans.

10.2.1 Electricity

Electricity is the most critical of the utility supplies as the loss of power supply has the potential to be catastrophic for many aspects of the organisation’s business. Without electricity most office-based functions will come to an immediate standstill, therefore standby generators support the electricity supply to all the organisation’s main buildings. Nevertheless, an extended interruption to electricity supply will undoubtedly cause impacts on service provision especially as loss of power will often result in disruptions to water and gas supplies as these may depend on electrically operated pumps or relays.

A prolonged and wide scale loss of electricity could be a major incident for the organisation and as such, major incident arrangements are likely to be activated alongside business continuity arrangements with all non-critical or essential activities being scaled back or suspended.

10.2.2

Gas/ Heating

The loss of gas or heating will generally affect inpatient areas more than office or clinic areas and the impacts will depend on the weather. However, in the worst case an extended loss of heating in a period of cold weather could require the relocation of inpatient areas. In the event of loss of gas heating, additional blankets should be sourced from stock and from other inpatient areas and electric heaters can be sourced from the Estates team.

10.2.3 Water

Initially the loss of mains water for drinking purposes is relatively easily to address by sourcing bottled water from existing, or alternative, suppliers, using hand gels instead of water and reducing the use of toilets as much as possible. However, the loss of mains water for hygiene is potentially more problematic, particularly inpatient and frontline service areas. Hospital sites are recognised as priority sites by Water Companies for restoration of services; however, it could take some time for water supply to be restored (possibly up to 8 hours). The Estates team will maintain liaison with the relevant water company and ensure the organisation is regularly updated

In a situation where there is a prolonged loss of mains water the organisation will scale back or suspend activities to decrease the overall need for water and will work with water companies to ensure water bottles, bowsers, and tankers reach the high priority inpatient areas.

10.3 Loss of information technology

The loss of information technology, may change the way in which services are delivered but it, should not stop any of the services the Group delivers. Service leads should ensure staff are aware of their Business Continuity Plans should there be a network failure

The Technology Team currently provide core services between the hours of 0800 to 1600 Monday to Friday, outside of these hours the team can be reached by the on-call manager where appropriate.

The Groups Infrastructure is distributed between two geographically dispersed datacentres and back up of data is kept off site in a secure location. Important applications that are stored in these data centres are virtualised and replicated to enable business continuity and failover to the other datacentre.

All Group data including that held on laptops and memory sticks is encrypted for security purposes and the Group network is regularly subjected to vulnerability tests.

All services have within their own plans, identified the systems required to perform their critical activities. The IT department have a disaster recovery plan in place which details the procedures to ensure that critical systems are restored as quickly as possible in priority order. This is tested at least annually through real life use or exercises

10.4 Loss of staff strategy

Shortages of staff can happen for many different reasons - from pandemic influenza to industrial disputes to severe weather negatively affecting the transport system. However, regardless of cause, continuity leads will ensure that critical priority areas have adequate staffing even if that means scaling back or suspending lesser priority activities. If the loss of staff is widespread and is likely to continue for a prolonged period then the Strategic (Gold) Director should consider activating the Provide Major Incident Plan so that further workforce management strategies can be put in place including the invocation of the redeployment process ([previously described in section 4.4 of this plan) and the following:

• Cancelling meetings and training

• Asking part time staff to temporarily increase their contractual hours

• Asking staff who work flexible hours to temporarily alter them

• Allowing staff to work hours in excess of 48 hours per week.

• Allowing staff who have recently retired to assist the response.

• Suspending and cancelling pre-booked leave.

• Retraining staff to be able to support essential and critical services.

• Providing staff with overnight accommodation. Consider requesting mutual aid support from alternative providers or the third and voluntary sectors

Agency and temporary staff may also be used. However, if the staff shortage is due to a pandemic, then it is recognised that agency staff may not be available.

10.5 Supplies resilience

As part of each services business continuity plan, each service has identified key resources, partners and suppliers. For supplies that are required to maintain critical activities services have where possible identified alternative sourcing arrangements.

The Procurement Team hold a list of all suppliers and require suppliers to have effective business continuity plans in place. Suppliers will be asked to produce a copy of their business continuity plan to ensure its viability. In the event of a business continuity incident the Procurement Team may be asked to provide a core information service for obtaining any relevant goods and services required in the response and recovery. The team will provide a stores and supplies focal point for staff during the incident.

In addition, Sainsbury’s has an Emergency Assistance Policy, which states that they would supply emergency services (including the NHS), local authorities and voluntary organisations with the necessary supplies in the event of a major incident. Support will be provided by any store so long as it is occupied, even if the store is closed to the public. It should also be noted that the majority of all alternative large supermarkets have been recorded as having assisted NHS healthcare providers in supplying goods in response to an incident and as such can be contacted to assist if appropriate.

10.6 Mutual aid

The NHS England Emergency Preparedness and Resilience Framework states that successful response to incidents has demonstrated that joint working can resolve very difficult problems that fall across organisational boundaries’ and that ‘mutual aid arrangements should exist between NHS funded organisations and also their partner organisations and these should be regularly reviewed and updated.’

It is recognised that requests for mutual aid may need to be made at the time of the incident. If this is the case the mutual aid protocol as at Appendix B will be followed

The Director, who will in turn inform the Director on-call, will agree all internal directorate mutual aid requests. All external requests for mutual aid will be authorised by the Director on-call.

11.Communications

The Provide Communications Team or if unavailable an appropriately senior and qualified member of staff will take responsibility for accurate and timely communications.

To ensure that all messages provided are consistent and accurate the communications lead will have responsibility for liaising with the following communications offices for the following agencies;

• MSE ICB

• NHS England East

• The Department of Health & Social Care (DHSC)

• Media specialists for Strategic (GOLD) Command (if not NHS England)

• Partner organisations including those with the Mid & South Essex (MSE Community Collaborative

• Emergency services

It is vital that staff are kept up to date with accurate information about the incident, not only for their own information but also to share with service users, patients and visitors. All

communications with staff will be mindful of the personal, as well as the professional, impact of the incident.

11.1 Communications Resources

The following systems are in place for communications during an incident:

• PROVIDE 24/7 call centre that is able to notify all senior staff of a ‘DECLARED’ Major Incident

• Generic Email address PROVIDE.ep@nhs.net

• Mass messaging system

Located in the ICC and electronically on the on call shared drive are:

• Registers of key internal and external contact numbers;

• List of key contacts in non-statutory/voluntary organisations;

• Site addresses and maps for all services/buildings.

All services and teams are responsible for maintaining a register of the current contact details for their staff for use during major incidents and other emergencies

11.1 Internal Communications

It is vital that staff are kept up to date with accurate information about the incident, not only for their own information but also to share with service users, patients and visitors. All communications with staff will be mindful of the personal, as well as the professional, impact of the incident. Even if we don’t have all the details of the incident, its important to make staff aware and ensure them that information will be provided as soon as possible, adding time frames where relevant.

Staff who are on call to respond to an incident

The Director on-call declaring the incident shall have responsibility for contacting staff on call to respond. This may be personally, or by asking another Director to make the appropriate calls or through Carecall

Staff who are

duty and

site at the time of the incident

The Communications and Media Manager will draft core messages / Frequent Questions and Answer (FAQs) pages which will be shared with staff via:

• Email – the ‘PROVIDE Communications’ email address will be used to send out information to all staff, using the distribution lists used for the weekly update. Information will be sent at regular intervals as required (e.g. every hour). Information should not be sent out from any other source, to avoid confusion. All email communication will invite questions to the provide.communications@nhs.net address, so that FAQs can be answered in subsequent messages on or on the intranet as appropriate.

• Intranet – the organisation’s Intranet, Community Platform, will be updated regularly (will be dependent on incident severity and longevity) with the latest messages sent out by email and answers to FAQs. A banner can also be added to the home page as a quick link to information relating to the incident.

• All staff mass SMS messaging system

• Telephone – where electronic means of communication are not available; the telephone will be used to contact key contact points for verbal cascade within their Divisions. Divisional leads may therefore need to identify ‘runners’ at each site to help distribute information and instructions to staff.

• Microsoft Teams – subject tothe nature of the incident, an all colleague message/group can be set up on Microsoft Teams with one way information (locked down so staff cannot reply if required)

Staff who are off duty and off site

In the event of a DECLARED major incident, staff may be away from their office base, working at a remote site, working in the community or off duty. All staff therefore have the responsibility for contacting their office base as soon as they are made aware of a major incident. This is so that they can:

• Assure their manager of their personal safety;

• Inform their manager of their location;

• Receive instructions from their manager about any changes to their duties arising from the incident.

There may be circumstances in which the organisation issues a public appeal for staff to attend, seeks assistance from neighbouring Trusts/providers or where staff living locally make their way to the site to help. In these cases the appropriate teams will establish a staff reception points where such staff can be registered and deployed as appropriate

11.2 External Communications Communications with External Agencies

When declaring a business continuity the PROVIDE Incident Director will ensure that the MSE ICB, NHSE, and all other relevant external agencies are informed. A direct dial point of contact and email address should be set up. This direct dial line can be a mobile phone number. External agencies should not be phoning Carecall, as this will lead to delays in relaying information.

Communication with Service Users, Patients and the Public

It is important that information for service users, patients and the public is kept simple, clear, concise, accurate and consistent. They should also be timely.

Telephone helpline

Depending on the nature of the incident, it may be necessary to establish a telephone helpline or multiple helplines for staff and/or service users/public. The need for advice or support to be provided in different languages must also be considered. This will divert traffic away from the main switchboard to dedicated call handlers. It will also provide a destination for calls being made inappropriately to other known direct dial numbers.

Provide website & social media sites

The Provide Community website and social media accounts will be regularly updated (as appropriate to the incident) with information about the incident, and details of the telephone helpline if appropriate.

A banner can be added to the home page of the website with information on the incident, this can be updated as necessary.

Any proactive press statements will also go onto the Provide Community website and the Communications Team will drive the media to this information where appropriate.

Media Enquiries

Staff must not respond to any media questions directly, if approached by the media please refer them to the Communications Team.

All media enquiries will be referred to the Communications Team, who will keep the Strategic (Gold) Command up to date with the enquiries and support a written response for approval and then response. Strategic Command will inform the ICO and they will work with the Communications and Media Manager (or Director) to agree the response. The ICO will then agree the response with the Provide Incident Director. Before issuing any statements the ICO will ensure the information is consistent and accurate and where appropriate will check it against statements from the:

• Strategic (Gold) Command (if running);

• NHS England;

• ICB;

• Department of Health & Social Care (DHSC) media office;

• Media Leads for the emergency services and partner organisations

No member of staff other than the Communications and Media Manager, or somebody identified by the PROVIDE Incident Director (Gold) should discuss any aspect of the incident with the media unless expressly requested to do so

The Communications Team will respond to all media enquiries, which will also be logged.

Should the media attempt to enter any Provide sites they must be advised that they should leave and wait at the site/building perimeter. If available, it is advisable to identify a holding room for the media and ensure they are regularly updated

12.Recovery

12.1

Recovery plan

Recovery normally begins as the incident starts and runs in parallel with the response; the response should inform the recovery and form the basis for the recovery process. Activation of the PROVIDE Recovery Group will be carried out by the organisations Accountable Emergency Officer (AEO) or authorised deputy. It needs to be formed as soon as possible to influence the local recovery response. The communication cascade arrangements for the activation will also be via the AEO who will decide, depending on the emergency, who needs to be on this group

12.2 Post-incident recovery

Post-incident recovery planning starts at the first Provide Strategic (Gold) meeting where recovery issues are identified as part of the standing agenda and will be followed up at any subsequent Strategic (Gold) meetings. The Recovery Group will assess the disruption to the organisations operational functions caused by the incident, including any long-term implications and how to return to business as usual. This assessment will include:

• Effects on staffing (e.g. loss of staff through injury or sickness, impact of overtime worked by staff during the incident on staffing levels);

• Support needs of staff affected by the incident (including trauma support);

• Disruption caused to patient care;

• Disruption caused to other Provide functions;

• Damage inflicted to provide property or property the organisation shares;

• Financial losses;

• Future provision of services in the short, medium and long term.

An important part of the work of the Recovery Group, in the response phase of the incident, is to develop a recovery strategy. When restoring teams and functions that have been scaled down or suspended, a reassessment should be made of the recovery time objectives (using impact over time) to set the order for restoration and prioritisation of services.

The Chair of the Recovery Group, in discussion with the group members will decide when it is appropriate to stand-down the Group. The length of time that the Recovery Group is required to continue meeting will vary according to the nature and scale of the emergency.

12.3 Debrief

Within 48 hours of recovery, the Head of Service ending the response to a business disruption leads a ‘hot debrief’

12.3.1 A ‘hot debrief’ is:

• A process for learning lessons from the incident.

• A forum for staff to express up to two immediate issues which may concern them.

• An opportunity to thank staff.

A ‘hot debrief may help the organisation identify staff who may need further support but should NOT:

• be allowed to become over-emotional or confrontational.

• be used to criticise individuals.

• be overly detailed.

• be used to provide any form of post incident psychological support.

The hot debriefs should be minuted and last no more than an hour. Once the hot debriefs have been conducted a series of ‘Cold’ structured debriefs should be held

12.3.2 Cold debrief

The key aspects of a cold debrief are as follows;

• It should be held within 4 weeks of the incident

• It should include key players within Provide who were involved in the response to the incident

• It should address organisational issues, not personal or psychological issues

• It should look for both strengths and weaknesses and ideas for future learning

• It provides an opportunity to thank staff and provide positive feedback

• It may be facilitated by a range of people within Provide.

12.3.3 Multi-agency debrief

If a multiagency debrief is convened, the key aspects are as follows;

• It should address organisational issues, not personal or psychological issues

• It should look for both strengths and weaknesses and ideas for future learning

• It provides an opportunity to thank staff and provide positive feedback

• It may be facilitated by a partner agency.

12.3.4 Post Incident

Post Incident the following action will be undertaken;

• The post incident report will be completed

• Lessons identified from the incident will be developed into an action plan

• Lessons identified will be shared with our partners

• The Provide EPRR Manager will be responsible for collating and storing all the records, logs and reports associated with the incident.

12.4 Post incident psychosocial and mental healthcare

After a business continuity/Major Incident, Provide recognises the need to consider the psychosocial support an affected population would need and how that would be provided and by who. Provision of psychosocial care skills to assist patients, responders, families, friends and residents to meet their basic needs including their emotional and mental wellbeing will need to be provided

Traumatic events provoke strong reactions. These can include pride and professional satisfaction in responding well to a difficult task, a sense of purpose and solidarity, but also profound sadness, anger, rage and grief.

Any incident that causes fear and uncertainty may be accompanied by an increase in health concerns, anxiety and somatic symptoms in the public. Somatic symptoms are caused by the physiological response to anxiety – they are not ‘imaginary’ or ‘all in the mind’ – and can be easily confused by the persons themselves, and by health professionals, with symptoms of exposure

Provide staff should be aware of the psychological impact of traumatic incidents in their immediate post-incident care of survivors and offer practical, social and emotional support to those involved.

For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident should not be routine practice when delivering services

The organisation will take a stepped approach to psychosocial support that initially relies on informal support provided by families, communities, and colleagues. This support will progress, according to need, to the primary or occupational health and social care services and voluntary agencies that can provide psychosocial first aid. Any person who does not recover from immediate and short-term distress of the incident after the above measures then assessment and intervention services will be offered by the organisation through the usual referral pathways. Anyone assessed as requiring further primary or secondary mental healthcare services will be signposted or in the case of staff through Occupational Health Services.

12.5 Staff post incident counselling services

Information about counselling services is available from the Human Resources Department. Staff are also able to self-refer to Occupational Health or the Employee Assistance Programme (EAP) for counselling or support should they find it necessary. These services are available for all staff experiencing psychological distress for whatever reason.

12.6 Incident documentation

After a major/business continuity incident all documents including logs, notes, post-its, flip charts, electronic documents, memos, and message pads must be retained. Documents are to be sent to the EPRR manager as soon as possible after stand-down.

Appendix A – Action cards

Introduction to Action Cards

During a business disruption members of Provide staff may be asked to perform a key role on behalf of the organisation, these roles might be different from their usual responsibilities so action cards have been developed to support staff in this situation.

If the disruption lasts for more than 8 hours then it may be necessary for another member of staff to take over the action card role (because they are providing relief, or they have more localised appropriate experience) this can only happen after a full briefing has to been given, in writing, on the actions taken to-date and outstanding issues. Until this has taken place, the member of staff originally assigned to the action card will be considered as still in place and responsible for all actions associated with the role.

ACTION CARDS

BC1 – Director/Director on-call

BC2 - Assistant Director/Manager on-call

BC3 - Head of Service/Service lead

BUSINESS CONTINUITY PLAN ACTION CARD BC1

DIRECTOR ON-CALL

The business continuity plan may be activated when the major incident plan has been activated (including ‘Standby’) and/or there is an incident that has the potential to cause disruption and affect the organisations critical activities.

DIRECTOR ON-CALL ACTIONS

1 Gather information required to complete the METHANE report in the Director On-call pack

2 Determine from the METHANE report whether to put the organisation on Business Continuity, Critical or Major incident ‘STANDBY’ or ‘DECLARED’ status. (if major incident ‘STANDBY’ or ‘DECLARED’ refer to Major Incident Plan) and/or invoke the corporate business continuity plan.

3 Record your initial decision and rationale Business Continuity Plan invoked

4 Establish if an Incident Coordination Centre (ICC) is required and confirm location.

5 Liaise with Director/AD or if out of hours Manager on-call and agree actions

6 Alert key internal staff required to form incident response team. If set up develop a rota to ensure every member can be relieved after an appropriate period.

7 If business continuity plan is invoked contact MSE ICB and relevant commissioners to advise them of the situation.

8 Consider contacting key stakeholders and partners

9 Maintain a log of all decisions, reasons and actions taken

10 Establish internal situation reporting if required

11 Authorise all mutual aid requests

12 Continue to monitor the overall response

13 Ensure communications plan is in place

14 Lead the organisation on the restoration of services to normal levels of delivery

15 Ensure recovery arrangements are in place

16 Before standing down the business continuity response ensure arrangements are in place for debriefing

ASSISTANT DIRECTOR/MANAGER ON-CALL

On being alerted to

confirm details of incident and action being taken to mitigate the effects

with the Head of Service (if available) to gain an overview of the status of the service(s) in

log

that situation reports are completed and returned as agreed by the Director on-call

with the heads of service their business continuity plans to ensure all essential and critical activities

Ensure services are resourced appropriately to maintain all critical functions, working towards restoration of normal services.

Contribute to the incident debrief.

BUSINESS CONTINUITY PLAN ACTION CARD

HEAD OF SERVICE (Service lead)

OF SERVICE/MANAGER ON-CALL ACTIONS

1 On being made aware of an incident establish the nature of the incident and assess the impact on service activities.

If decision is made to invoke service business continuity plan contact; In hours – Line manager to escalate Out of hours – manager on-call

Start documenting information and actions

Keep staff briefed about the incident and give clear instructions, ensuring the health & safety of staff and patients.

Determine priorities and recovery objectives as set out in the business continuity plan to ensure that services return to business as usual as quickly as possible

Ensure that situation reports are completed and returned as agreed by the Assistant Director/ Director

Escalate where necessary requests for mutual aid 8 Ensure tasks being carried out to facilitate recovery are regularly monitored

Continue to monitor the response

Contribute to the incident debrief.

Appendix B – Critical Activities

All service level business continuity plans identify their essential and critical services. The information has been used to develop a BCP spreadsheet.

The business continuity spreadsheet codes each service as red, amber or green against the category table below

Red Services

Red services should only be those that operate 24/7 or 7 days per week. They will also include those services that support inpatients services even if they are M-F services as they would be supporting discharge such as therapies and medical or have on call/weekend cover functions in some areas

Each red service line will indicate the minimum staffing required to maintain the BCP critical /essential activities and if the BCP critical / essential activities would be maintained in 3 different scenarios staffing reduced by 10%, 25% or 50%.

Amber Services

This covers clinical services operating 9-5 Monday to Friday. The spreadsheet also indicates if the service was suspended for longer than 3-7 days what core activities need to be restarted/maintained and how many staff would be required to do this

Green Services

This covers most corporate services operating 9-5 Monday to Friday. The spreadsheet indicates if the service was suspended for longer than 3-7 days what core activities need to be restarted/maintained and how many staff would be required to do this.

A spreadsheet is available on the SharePoint on-call folder, in business continuity, MS Teams on-call channel or on request from the Provide EPRR Manager.

Appendix C – Mutual aid protocol

Mutual Aid Protocol

The NHSE Emergency Preparedness Resilience and Response (EPRR) Framework states that ‘successful response to incidents has demonstrated that joint working can resolve very difficult problems that fall across organisational boundaries. Mutual aid arrangements should exist between NHS funded organisations and also their partner organisations and these should be regularly reviewed and updated’.

The organisation has a number of mutual aid agreements already in place across the Essex region. However, it is recognised that requests for mutual aid may need to be made at the time of the incident. If this is the case the following protocol will be followed

Criteria

• The requesting organisation must have declared a major or critical incident or invoked their business continuity arrangements in response to an incident.

• The organisation requesting mutual aid can no longer manage the incident with the full deployment of their resources/assets and prioritisation of their services.

• When an organisation or health economy is potentially or actually unable to maintain safe level of health critical services either through lack of physical or human resources.

Types of mutual aid

- Equipment

- Human

- Capacity

- Key Personnel

- Advice Process

1. Request for mutual aid agreement will be made by the Director on-call or Office in Charge by the originating organisation.

2. The Director on-call from the requesting organisation will make contact with the potential mutual aid provider and identify a point of contact.

3. The Director on-call making the request will complete the mutual aid template as at appendix 1 of this protocol and forward a copy to the intended provider.

4. Any organisation receiving a request for mutual aid may as a consequence consider declaring a major incident. This alone should not be considered a reason to deny the request received.

5. The Director on-call will ensure that MSE ICB and NHSE East are advised of all mutual aid requests made or received.

6. For requests received the Director on-call will review the request and advise the originating organisation whether all or part of the request will be met or denied.

7. Agree an assembly point/delivery area and or a focal point where incoming resources will be met or received.

8. The responsibility for deploying mutual aid resources rests with the receiving organisation.

9. The receiving organisation is responsible for the command and control of all assets supplied by other organisations under the mutual aid agreements.

10. The receiving organisations should notify the supporting organisations when the need for support ends or can be reduced as soon as it is recognised.

11. All mutual aid requests with response and reason for decision must be logged.

12. The mutual aid requests should be time limited and monitored through the response and recovery to the incident.

13. Any organisation providing mutual aid but no longer able to do so, or only able to do in a limited capacity should notify the receiving organisation and relevant ICS and NHSE/regional team

14. The cost for mutual aid is normally based on the principle of ‘shared risk’ recognising the fact that the risk presented in major or business continuity incidents may be equal.

15. Any mutual aid provided between NHS provider organisations will be on the basis of shared risk and costs lie where they fall. Consequently there is normally no cross charging for mutual aid between organisations. However if the incident is a protracted one organisations may wish to discuss associated costs of supplying mutual aid

16. The organisations must ensure that all associated mutual aid costs are tracked and logged.

17. If we receive mutual aid the Director on-call will;

• Assume initial command for the incoming resources

• Manage deployment of incoming resources

• Maintain liaison with the supporting organisation

• Ensure that staff are appropriately briefed prior to being deployed on specific tasks

• Arrange hot debriefs for staff of the providing organisation and ensure staff are rotated back to their home organisation.

For large incidents that require a multiagency response it may be necessary for NHSE to coordinate all health mutual aid requests to ensure that the health sector does not become overwhelmed.

Organisations

The following list is not exhaustive but provides a list of PROVIDEs local resilience partners who may be able to supply resources to support our response.

• Ambulance Services for East of England.

• British Red Cross

• East Sussex and North Essex NHS Foundation Organisation (ESNEFT)

• Essex County Council

• Essex Partnership University NHS Trust (EPUT)

• ICBs for Mid & South Essex, North Essex and West Essex

• Local Councils for Basildon, Maldon, Southend, and Thurrock

• Mid and South Essex NHS Foundation Trust (MSE)

• NELFT

• NHS Property Services

• NHSE East

• Princess Alexandra Hospital NHS Trust

• St Johns Ambulance

• UK Health Security Agency (UKHSA)

• HCRG

Requesting organisation

Include contact name and details.

Date & Time

Request being made to

Emergency Mutual Aid Request

Mutual aid requested

This must be explicit including exact quantities, for how long and for what purpose.

Costs agreed

Where the mutual aid is to be sent to

Exact location must be included. Transport arrangements

Will transport be provided or is this being requested as well.

If transport has been arranged include details of what is being used –courier, ambulance taxi etc. Contact arrangements

Remember to include in and out of hours if appropriate.

Signature of Director on-call

A copy of this mutual aid agreement must be retained.