1. business and industrial

THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST
BUSINESS CONTINUITY PLAN
APRIL 2012
Version No: 2 Issue Status: awaiting Trust Board approval
Date of Ratification: 11th April 2012 Ratified by: Risk Management Committee
Policy Author(s):
Stuart Coalwood Asst Director of External Compliance & Quality Assurance
Policy Owner: Camilla Wiley, Director of Nursing
Review Frequency: 2 yearly
Last Review: May 2012
Next Review: May 2014
POLICY AWARENESS
People who need to know this
policy in detail
People who need to have a broad
understanding of this policy
People who need to know this
policy exists
All on call staff
All staff
All staff
CHANGE CONTROL DETAILS
Date:
Dd/mm/yy
Version
Description
Reason for
changes
May 2012
January 2009
VO2
V01
Updated Plan
New Plan
Updated Plan
New Plan
Location: RNOH Intranet
1
Contents
1 Definitions
3
2 Regulatory and strategic context
4
3 Publication and distribution
5
4 Plan review
5
5 Background
5
6 Aim of this plan
5
7 Plan objectives
6
8 How the objectives will be met: preparation and planning
6
9 Business Impact Analysis
6
10 Categorisation of services
7
11 Risk assessment
7
12 Incident identification
7
13 Incident declaration and plan invocation
8
14 Business Continuity Incident Control Room(s)
10
15 Incident management
11
16 Building evacuation and acceptance of displaced people and services
13
17 Human resources
14
18 Information and communications technology (ICT)
14
19 Essential service resumption or relocation
14
20 Essential supplies and equipment
15
21 Communication
15
22 Department and service response plans
18
23 Stand down
18
24 Recovery and debrief 1
19
19
5
25 Appendices
20-37
2
To be read in conjunction with:
•
The Emergency plan
•
Influenza pandemic and winter pressures plan
•
Department and service business continuity plans
•
Severe Weather plan
•
Transport disruption plan
•
Heatwave plan
•
Fuel shortage plan
The aim of this plan is to ensure that the Royal National Orthopaedic Hospital NHS Trust has
a Business Continuity Management programme which ensures that statutory obligations are
met, and which supports its vision and mission.
Date: 1st April 2012
1
Definitions
1.1
For the purposes of this document an emergency is defined as:
An actual or impending situation that may cause injury, loss of life, destruction of
property or cause the interference, loss or disruption of an organisation’s normal
business operations to such an extent that it poses a threat.
1.2
For the purposes of this document Business Continuity Management (BCM) is
defined as:
an holistic management process that identifies potential impacts that threaten an
organisation and provides a framework for building resilience and the capability
for an effective response that safeguards the interests of its key stakeholders,
reputation, brand and value creating activities.
1.3
For the purposes of this document a Business Continuity Management Plan
(BCMP) is defined as:
A clearly defined and documented plan for use at the time of a Business
Continuity Emergency, Event, Incident and/or Crisis (E/I/C). Typically a plan will
cover all the key personnel, resources, services and actions required to manage
the BCM process.
3
2
Regulatory and strategic context
2.1
BCM is a legal requirement for Primary Care Trusts, Acute Trusts and Acute
Foundation Trusts, as Category 1 responders under the Civil Contingencies Act
2004 (CCA) and the Civil Contingencies Act 2004 (Contingency Planning)
Regulations 2005.
2.2
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2009,6
(Regulations 9(2) and 24) which came into force on April 1st 2010, provide the
statutory basis for the Care Quality Commission’s Essential Standards of Quality
and Safety, 4B, 6D and 10E, which require healthcare providers to put in place
arrangements for the management of emergencies and the development and
maintenance of contingency plans to maintain services.
2.3
The Operating Framework for the NHS in England 2012-2013 sets out the
Department of Health’s expectations regarding emergency preparedness and
business continuity.
2.4
The Business Continuity Institute sets out Good Practice Guidelines which are
recognised as the ‘industry standard’ under BS 25999. The Department of
Health Interim Strategic National Guidance 2008 recommends that ‘all NHS
organisations aspire to comply with the requirements’ of this standard.
2.5
The clinical vision of the Royal National Orthopaedic Hospital NHS Trust is ’to
provide the scale and range of specialty surgery and rehabilitation to ensure
clinical outcomes appropriate to a world class service. The volume and
complexity of work undertaken by the Trust enable our staff to become leaders
in their professional field and we offer training to cascade clinical practice in
orthopaedics and rehabilitation throughout the NHS. The RNOH will also
provide a vision and network of expert and exceptional support for trauma
services’. The clinical vision of the Royal National Orthopaedic Hospital NHS
Trust is ‘to be a world leading clinical centre of excellence for translational
research, multi-disciplinary education and treatment of complex neuromusculoskeletal disease’; the mission of the Royal National Orthopaedic
Hospital NHS Trust is to be the Specialist Orthopaedic Hospital of choice by
providing outstanding patient care, research and education. In order for this
vision and mission to be met it will be necessary to ensure that effective plans
are in place to identify risks to service continuity, and ensure that effective plans
are in place to mitigate those risks.
2.6
This document should be read in association with the approved the Royal
National Orthopaedic Hospital NHS Trust Business Continuity Management
Policy.
4
3
Publication and distribution
3.1
4
5
The Civil Contingencies Act 2004 permits Category 1 responders to restrict the
publication of plans and prohibit the publication of sensitive information and
personal data. It advises publication only where there is a positive benefit in
doing so and where the benefits of disclosure are in the public interest. Sections
of this plan which relate to confidential telephone numbers and locations are
therefore considered exempt from the requirements of the Freedom of
Information Act 2000, and distribution of the full information contained within
these sections will therefore be restricted to the Royal National Orthopaedic
Hospital NHS Trust staff responsible for responding to Business Continuity
Incidents.
Plan review
4.1
The plan will be kept under constant review by the Director of Nursing (the
document Owner) and amended when there are changes in legislation or
internal arrangements, or as a result of improvements identified through
exercises.
4.2
The plan will be subject to formal review by the Risk Management Committee at
an interval not exceeding three years.
4.3
Technical and detail changes (such as changes of address or telephone
number, or references to legislation) will be made by the Director of Nursing who
will notify the relevant staff of the changes made and update the Document
Control Panel.
4.4
Significant changes to BCM operations will be approved by the Emergency
Planning Committee.
Background
5.1
A sound BC Plan (or set of plans) provides reasonable assurance to the Board
and evidence for internal and external auditors and inspecting/reviewing bodies.
It also makes good business sense:
•
•
•
•
6
for the public we serve
for our staff
for our partners
for those who commission services from us
Aim of this plan
6.1
The aim of this plan is to ensure that the Royal National Orthopaedic Hospital
5
NHS Trust has a BCM programme which ensures that statutory obligations are
met, and which supports its vision and mission.
7
Plan objectives
Objective 1 To ensure that the Royal National Orthopaedic Hospital NHS Trust
is compliant with its legal and regulatory obligations
Objective 2 To ensure that key products and services are identified and
protected, ensuring their continuity
Objective 3 To ensure that there is an effective incident management capability
Objective 4 To ensure that staff are trained to respond effectively to an incident
or disruption through appropriate exercising
Objective 5 To ensure that stakeholder requirements are understood and can
be delivered
Objective 6 To ensure that staff are properly communicated with and receive
adequate support in the event
of a disruption
Objective 7 To ensure that the Royal National Orthopaedic Hospital NHS Trust
supply chain is secured
8
How the objectives will be met: preparation and planning
8.1
9
A forward work plan has been developed and will be implemented by the
Director of Nursing.
Business Impact Analysis
9.1
BIA has been carried out on all category A and B services (see s.11 below) and
all essential corporate functions. These assessments are detailed in the
individual plans for departments and services.
9.2
It is recognised that the Maximum Tolerable Period of Disruption (MTPD)
identified as part of the BIA process might be affected by the workload of the
service at the time of the incident. For example, some services may be limited or
redefined during the summer or school holiday periods or financial year end
deadlines. Seasonal Activity should also be documented in individual
Department and service plans.
6
10
Categorisation of services
10.1
All services have been categorised into categories A, B or C, as follows:
See Appendix 10
11
Risk assessment
Generic risk assessment
11.1
Generic risks have been identified, and assessed using the matrix in the Royal
National Orthopaedic Hospital NHS Trust Guide for Assessors and Planners.
The Royal National Orthopaedic Hospital NHS Trust risk register also identifies
high or medium risks in the following areas which could impact on Business
Continuity. Responsibility for each risk area has been assigned to a Director:
Activity-specific risk assessment
11.2
12
Activity-specific risk assessment has been carried out on all services and all
essential corporate functions. :
Incident identification
12.1
An incident or set of circumstances which might present a risk to the continuity
of a service might be identified by any member of staff. When an incident or set
of circumstances which might present a risk to the continuity of a service is
identified, it is important that the person identifying the incident knows what to
do. In the initial stages, this will involve making sure that the right people have
been informed – see diagram overleaf.
12.2
In the event of a minor incident, or one that can be dealt with using normal
services and resources, local managers and staff will deal with it.
7
Negligible:
limited local impact
•
Take any remedial action it is safe to take
•
Report to line manager
•
Follow service or department Business
Continuity Plan
•
if available and necessary
•
Notify head of service/ department
•
Follow service or department Business
Minor:
Disruption to a
Continuity Plan
Category C service
Major:
Disruption to a
•
Notify on-call Director
•
Follow service or department Business
Continuity Plan
Category B service
Catastrophic:
•
Notify on-call Director
•
Declare a major incident or major incident
standby
Disruption to a
•
Category A service
13
Follow major incident plan and or service or
department
•
Business Continuity Plan
Incident declaration and plan invocation
Normal working hours
13.1
During normal working hours, in the event of a Major or Catastrophic incident, or
set of circumstances which might present a risk to the continuity of a Category A
or B service, an incident can be declared and the plan invoked by the Director
with responsibility for the service affected.
13.2
Where more than one service is affected, any one of the responsible Directors
can decide to declare an incident and invoke the plan, in order to mobilise an
effective response across the organisation and ensure the involvement of
partners where required.
Out of hours
8
13.3
In the event of a Major or Catastrophic incident, or set of circumstances which
might present a risk to the continuity of a Category A or B service, which occurs
outside normal working hours, the on-call Director can decide to declare a
Business Continuity Incident (BCI), and invoke the plan, in order to mobilise an
effective response across the organisation and ensure the involvement of
partners where required.
Contacting the on-call director
Telephone the switchboard
0208 954 2300
...and ask for the on-call director to be called
If for any reason the switchboard is not available then ring Page One on ...
0844 822 2888
...ask for pager Royal National Orthopaedic Hospital NHS Trust and provide a short message on
request, which must include: a contact name and telephone number
Pass on as much information as you can, including :
•
Type of incident
•
The current and projected impact of the incident
•
How many casualties/fatalities are involved
•
The level of media interest
•
Your ability to cope – any additional support or resources required
•
Which other agencies/partners are involved in the incident
•
Any other information that you think is relevant
Invocation
13.4
To declare a BCI the responsible Director should:
•
•
•
•
13.5
Start the incident log
Notify the Chief Executive. The on-call Director will act as the BC
Manager (BCM) in the initial stages of the response
Notify the Director with line management responsibility for each service
or department affected
Notify the Communications Lead
The Trust response must keep pace with the pace of the incident itself, in order
to exert control. It might be necessary to convene a Business Continuity Team
9
out of office hours and to operate it on a 24/7 basis. Up to date contact details
and reserves for the BCT members will be maintained by the ANYWHERE NHS
TRUST Emergency Planning Team and will be available to all on-call Directors.
Alerting NHS London
13.6
NHS London must be notified whenever this plan is invoked:
Call 0844 822 2888
NHSØ1 (NHS London Manager) or
LONØ1 (NHS London Communications Manager)
Pass on as much in for mation as you can , including :
•
Type of incident
•
The current and projected impact of the incident
•
How many casualties/fatalities are involved
•
The level of media interest
•
Your ability to cope – any additional support or resources required
•
Which other agencies/partners are involved in the incident
•
Any other information that you think is relevant
14
Business Continuity Incident Control Room (S)
14.1
Refer to the Emergency Management Plan for locations and set up details.
14.2
In the event of an incident which requires both a response to an emergency and
a BC response the teams should be located in different control rooms in order to
maintain their separate focus. An agreement should be reached with the major
incident team as to the location of the BC team and good communications links
established between the two teams.
14.3
The BCM should chose a suitable location based on the following criteria:
•
•
•
•
•
14.4
Health & Safety
Accessibility
Availability of IT and communications
Toilets and hand washing
Availability of food and drinks
The BCM will ensure that regular rest breaks are taken, refreshment facilities
are available and that staff are rotated on a regular basis.
10
15
Incident management
INCIDENT MANAGER ACTION CARD
FIRST PHASE
1
Start the incident log
2
3
Convene a Business Continuity Team if required
Inform all relevant staff of the incident and what needs to be done immediately
4
Relocate to the BCI room
5
Inform all staff on how to contact the team or how messages will be broadcast
6
Notify the Chief Executive if necessary
7
8
Address immediate staff concerns
Ensure that staff are briefed about the incident and given clear instructions on whether they
should relocate or go home, and when they are expected to return
9
Inform neighbouring NHS organisations / local authority/ social services if necessary
10
Prioritise existing work using the Local Business Continuity Plans
11
Supervise effective management of the incident
12
Hold regular meetings with the Business Continuity Team (frequency depends on the nature
and severity of the situation) and ensure that staff are briefed
13
Ensure that the health and safety of staff is prioritised
14
Take regular breaks and hand over to another member of staff
15
Assess and monitor responses
16
Ensure that you have a good overview of the tasks being carried out by Business Continuity
Team members, leads and their staff
17
Authorise the stand down
18
Ensure debrief meetings are arranged
19
Write up the log notes and final report
20
Review use of emergency procedures, business continuity plans and update where necessary
11
Once the main priorities have been dealt with, you might consider scaling down the Business
Continuity Team, or hand over to another member of staff to deal with the medium and long
term issues, or the day-to-day recovery of the incident.
If an incident is going to go on for more than 4–8 hours, establish a rota for staff within the
team and regular hand over for the BC Manager role.
On-call Director
• Activate plan and BCI team
• Set recovery strategy
• Authorise expenditure
• Brief CEO
Information and communication technology lead
• Identify equipment and infrastructure requirements
• Identify suppliers
• Recommend priority for I&CT recovery
Human resources lead
• Advise on workforce law and policy
• Collate absence reporting and redeployment
• Payroll
• Co-ordinate staff family liaison where required
Communications lead
• Communications with staff, patients, media, partners, stakeholders
• Co-ordination of call centre activation, website communication, intranet information
Estates and facilities lead
• Accommodation
• Site clean up
• Building contractors
• Legal advice
12
• Health and Safety
• Mobile Phones
Service representatives as required (examples only)
• Primary care
• Public Health
• Therapies
• Nursing
Support team
• Admin: logging; note taking; call handling
Call centre
• As per Emergency Management Plan
Intelligence team
• Gathering and analysing data and information
• Internal and external situation reporting
ACTION CARD
BUSINESS CONTINUITY TEAM MEMBER
1
Attend the BC Control Room as required
2
Discuss with the BCM if you are required to attend the incident room in order to carry out your role. You might
need to be at the site of the incident in the first instance
3
You might be requested to assist with the following
16
Building evacuation and acceptance of displaced people and services
Evacuation
16.1
Follow fire evacuation procedures and alarms.
16.2
If there is a risk of explosion (i.e. if a credible bomb threat has been received)
responsible managers should consider the safest distance to establish an
Assembly Point until advised by the Fire Brigade and Police. Debris from an
explosion may cause damage over a wider area than a controlled fire. Staff and
13
visitors must be directed to a safe Assembly Point.
16.3
No person will re-enter a building unless notified that is safe to do so by the Fire
Brigade.
16.4
Business Continuity Team should ensure that, following an incident, the building
is assessed by competent estates and facilities staff or external contractors to
assure safety before resuming services.
Displaced members of the public: external incident
17
18
16.5
Staff in community premises may be asked to provide immediate shelter for
people evacuated by the emergency services.
16.6
Trained nursing or first aid staff should be alerted to deal with displaced people
and offer refreshment and communications until a suitable reception centre can
be set up in conjunction with the local council.
16.7
If necessary a triage system should be set up and liaison with the ambulance
service established.
Human resources
17.1
The BCI Team must consider staff health, safety and welfare, both during the
incident and in the recovery period.
17.2
Health & Safety will take priority in ensuring staff do not return to work before it
is safe to do so. The number of hours which staff work must be strictly controlled
and where necessary shift systems developed.
17.3
If a building or service is to remain closed for a period of time, staff will be
concerned about their pay, conditions and what they are required to do in the
meantime.
17.4
Counselling and rehabilitation services may be required for staff who may have
witnessed a traumatic event or suffered stress from dealing with its aftermath.
The HR and Communications leads should ensure that these matters are
addressed.
Information and communications technology (ICT)
18.1
19
In the event of a major incident, certain IT functions will be critical to the Royal
National Orthopaedic Hospital NHS Trust response. The Business Continuity
Plan for IT details arrangements for ensuring business continuity in the event of
a significant incident.
Essential service resumption or relocation
19.1
There are various options to consider for the resumption of a service or
relocation of a service due to loss of building or denial of access. These will be
14
affected by:
•
•
•
the availability of suitably skilled staff
resources
the ability of those receiving the service to travel to alternative
locations
19.2
When re-allocating staff it will be necessary to take into account the
Management of Staff in Emergency Situations: Joint Management & Staff Side
Agreement (see Appendices).
19.3
The BCI team will consider a range of recovery options.
OPTION
Budge up
OPTION
Portable premises e.g. portakabins
Can the service share resources?
Displacement
Priority services displace non-affected
Outsourcing arrangements: service provided
by another NHS body or private partner
low priority services i.e. category A
displaces category C
Remote working
Can some staff work effectively from a
Re-skill/ upskill staff and move into different
roles or request staff from another NHS
body or private partner
home base with the right ICT support?
Reciprocal arrangements
Relocate the service to a local hospital
Share with other NHS trusts
Third party alternative
Do nothing – service is allowed to
Local authority, commercial partner
become redundant
or social enterprise
20
Essential supplies and equipment
20.1
Essential services requiring re-location will arrange for the transport or delivery
of essential supplies and equipment in accordance with their Business
15
Continuity Plans, in liaison with the estates and facilities team.
21
Communication
21.1
The purpose of the communication plan is set out in the diagram below:
21.2
The Communications Lead will implement the communications plan and ensure
that communications with the general public and the media are managed
appropriately. Communications plans will follow Cabinet Office guidance.
21.3
The BCT will agree:
•
•
•
21.4
Overall Communication Objectives are to:
•
•
21.5
Method of communication
Frequency and timing of press releases
Method for sending press statements
provide accurate, timely and consistent advice to staff, the public
and partner organisations aid understanding of the incident
explain what the healthcare community can and cannot do to
respond to the incident and reduce the impact on the community
All contact with the press during office hours will be diverted through the Royal
National Orthopaedic Hospital NHS Trust Communications Team. The Royal
National Orthopaedic Hospital NHS Trust target audiences could include:
16
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Staff
Commissioners
Other local NHS organisations
Local non-NHS organisations
Voluntary, community and religious organisations
The media
Local MPs and Council members
Local businesses
Schools colleges and nurseries
Managers of nursing homes, residential care establishments and day
centres
Local emergency services
Patients and patient representative groups
The general public (via news media and other communication tools)
NHS London
The Department of Health
Communication to staff
21.6
Messages to staff must be:
•
•
•
Honest
Consistent
Timely
21.7
Briefly describe the problem to staff; don’t speculate, if you do not know, say so.
21.8
Tell staff what actions you need from them, whether you need them to stay and
help or to go home.
21.9
If you are sending staff home, make sure they know who to contact for
information when they can return or where they should report to instead.
21.10
If staff are going to be off for more than a few days, ensure that they are
informed if it will affect their pay and conditions, staff may be unduly worried if
they feel they will be financially penalised (see staff agreement, Appendices).
21.11
Ensure key staff attend regular briefings so that they can disseminate
information.
21.12
Don’t rely on email to relate key messages – not all staff have access or read
their email regularly.
21.13
Use key points to display messages; reception areas, main access points,
refreshment areas or toilets are good places to get information across to a wide
range of staff.
21.14
Consider setting up a helpline number for staff – this can be used by the
Business Continuity Team to provide recorded information or allow staff to
update their availability or answer queries.
17
Communication with external media
21.15
See Appendices for a template script for media enquiries.
Spokespeople
21.16
All communications must be issued by an appropriate spokesperson. The
designated spokesperson will vary according to the audience and / or the
subject matter as well as the availability of relevant experts.
21.16.1 Spokesperson selection should use key strengths, so for example messages
about avoiding and treating Pandemic Flu should come from a doctor, whilst
messages about changes in service delivery should come from the CEO.
Press briefings and statements
21.17
All media briefings should follow the following guidelines (see Template,
Appendices)
•
•
•
•
•
•
•
•
•
•
•
22
Make sure your own staff and other relevant audiences are fully informed,
ideally just prior to informing the media
Keep to the facts with short simple statements
Be open, maintain regular contact, especially with established media contacts
Issue updates at agreed times and establish format for briefings – e.g. questions
taken at the end of statements. Demonstrate concern
Demonstrate control of the situation and take assertive action
Take questions but only answer when sure of the facts, otherwise promise to
investigate and respond later or pass to the relevant supporting spokesman
Announce conclusion of the incident as positively and quickly as possible
Move the story on – if possible issue a new, positive story as soon as possible
after the incident but be aware of local sensitivities to something too overt
Do not speculate
Do not apportion blame
NB: For Pandemic Flu see Pandemic Flu Communications Plan
Department and service response plans
22.1
All Category A and B services and all essential Corporate functions listed in
Appendix 5 have local Business Continuity Plans. These plans are held:
•
•
•
23
By the manager of the affected department or service. These plans will
be held:
– in hard copy in the department or service base, and
– on a data stick, off site, by the department or service manager and
deputy
By the Emergency Planning Officer
On a secure section of the Trust Intranet
Stand down
23.1
The BCM will decide when the incident response can be stood down, in
18
consultation with the BCT and the Chief Executive, as necessary.
24
Recovery and debrief
19
Appendix 1: Business continuity team meeting agenda
1
• Introductions
• Check for absences
• Confirm covering officers
ACTION
NOTES
2
Actions from the previous meeting
NOTES
3
Reported disruptions to ANYWHERE NHS TRUST services
NOTES
4
Reported disruptions to partner services
NOTES
5
Reports from primary care
NOTES
6
Reports on public health matters
NOTES
7
Human resources/staff welfare
NOTES
8
Estates and facilities
NOTES
20
9
IT and telecommunications
NOTES
10
Communications
NOTES
11
NHS London
NOTES
12
Other partners/stakeholders
NOTES
13
Any other business
NOTES
14
Date, time and location of next meeting
NOTES
21
Appendix 2: Decision log template
Date
Time
Recorded by
Description of matter to be decided
Options
1
2
3
4
5
6
Outcome/actions
Reasons for decision
22
Appendix 3: Action log template
ACTION
DETAIL
ACTION INITIATED
DATE
TIME
WHO BY?
WHO TO?
ACTION COMPLETED
DATE
COMMENTS
TIME
23
Appendix 4: Damage calculation worksheet: costs
ADDITIONAL STAFFING COSTS
DESIGNATION
(staff, nurse, admin,
porter etc)
NUMBERS OF
ADDITIONAL STAFF
PAY BAND
ADDITIONAL
HOURS
COST
24
Appendix 5: Damage calculation worksheet: additional equipment costs
EQUIPMENT
TYPE
SUPPLIER
NUMBER
REQUIRED
PURCHASE
COST
HIRE/LEASE
COST
TOTAL COST
COST CODE
25
Appendix 6: Cost of building replacement or repair
ITEM
SUPPLIER/
CONTRACTOR
DESCRIPTION
OF WORK
TOTAL COST
COST CODE
26
Appendix 7: Media response
1 It is essential that advice be sought as soon as possible whether or not there has been any
press interest, and that there is liaison with the NHS London communications team.
2 Provide information concerning the Royal National Orthopaedic Hospital NHS Trust’s role
and the response by members of the Royal National Orthopaedic Hospital NHS Trust’s
staff. Do not discuss other elements of the response and do not criticise individuals or
organisations.
3 The Royal National Orthopaedic Hospital NHS Trust’s BC communications strategy will be
managed by the Incident Team or the Business Continuity Team.
4 Do not speculate on the cause of any incident
5 Secrecy is sometimes necessary during covert threats or responses. This is for both police
and security reasons, but also because fear can often be more dangerous than any threat
posed by such an event. Be extremely careful if contacted by the Media about an incident.
DO NOT confirm that an incident has occurred unless it is clearly in the public domain, and
never comment on the presence of VIP or suspects within NHS facilities.
6 The Chair, Chief Executive or Director of Public Health will usually be the lead public figure
representing the PCT. All persons undergoing media interviews or releasing press
statements should be fully trained.
Template script for initial media enquiries
7 A major incident has been declared by __________ (if it has)
8 The Royal National Orthopaedic Hospital NHS Trust is working alongside other healthcare
services, the local authority and the emergency services to ensure that a co-ordinated
response is undertaken to deal with this incident and maintain normal health services where
possible.
9 Further information will be issued at XXXXhrs and will be available on our website at
www.rnoh.nhs.uk
10 Once more information is available:
Press Information
11 Statement on incident at (name site)
12 the Royal National Orthopaedic Hospital NHS Trust has implemented special business plans
following an incident at (location, time, and date).
13 Describe what has happened (flood, criminal activity, IT failure,). Be clear if there are or are
not any injuries to staff or public. If there are injuries, where are they being treated? How
27
many staff are affected?
14 Our response: e.g. Additional staff have been called in to enable us to provide care for all
patients; a help line has been set up (telephone number).
15 The Royal National Orthopaedic Hospital NHS Trust staff are working hard to ensure that
regular services are operating again as soon as possible and ensuring there is minimal
disruption to patient care. Give details of when The Royal National Orthopaedic Hospital
NHS Trust expect the department activity to be returned to normal.
16 Advice to the public: e.g. visit GP, don’t turn up at the clinic, give location of where they can
go for treatment, phone NHS Direct, ring help line, look at our website (give address) etc.
17 Time of next press release (don’t leave it too long)
18 For information please contact the press office on (give telephone number, which should
always be staffed, and an email address)
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Appendix 8: List of GP practices and contacts
GP PRACTICE
CONTACT NO.
WATLING MEDICAL CENTRE STANMORE
42 London Road Stanmore Middlesex HA74NU
020 8958 4237
SHOPWICK SURGERY
Everett Court Romeland Elstree WD63BJ
0844 477 2400
THE STANMORE SURGERY
71 Elm Park Stanmore Middx HA74AU
020 8954 4151
STANMORE PARK MEDICAL CENTRE
William Drive Stanmore Park Middlesex HA74FZ
0208 951 3888
SHOPWICK SURGERY
New Bushey Surgery Windmill Street Bushey Heath WD231NB
0844 477 2400
JAI MEDICAL CENTRE
114 Edgwarebury Lane Edgware Middlesex Herts HA88NB
0300 033 7861
FURBANK IDJ
California Lane Bushey Hertfordshire WD231EZ
020 8386 8888
LANE END MEDICAL GROUP
2 Penshurst Gardens Edgware Middlesex HA89GJ
0844 375 6867
DR PINTO & PARTNERS
39 Penshurst Gardens Edgware Middlesex HA89TN
020 8958 3141
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Appendix 9: Essential services: corporate
Finance, procurement and performance
General description of work carried out
Urgent Payment Requests (including patient monies administration)
Debtors Control
Financial Management
Financial Accounting
Cashiering Service
Overseas and Out of Area treatment patients identification
Costing (SLR / Reference Costs)
Commissioning / Contracting
If normal business is disrupted
Prioritise urgent payment requests (including patient monies administration)
Inform NHS NCL if any financial regulations may be breached
Maintain core financial functions, work with the Emergency Management Team to manage budgets and
finances during the pandemic including emergency funding for alternative contracts (e.g. food, staffing,
equipment and transport)
Ensure payroll services are maintained
Enable payments for extra-ordinary items (e.g. transport costs for staff, agency staff payments)
Estates and facilities
General description of work carried out
Provision of Estates and Facilities management
Commissioning of subcontractors and support staff
Maintenance, refurbishment and rebuild of Trust properties
If normal business is disrupted
Allocate representative to Emergency Management Team
Respond to Estates issues, prioritise provision of utilities, services, repairs etc
Report on status of Trust infrastructure
Link with local organisations to ensure priority restoration of services
Co-ordinate a rota for the role of Utilities Co-ordinator on the Emergency Management Team
Prioritise utilities, food and fuel for use within the Trust
Human resources
General description of work carried out
Provision of Human Resources for the Trust including:
Staff Bank
Electronic Staff Records (ESR) Central System
Recruitment
Criminal Records Bureau (CRB) Checks
Data collection and reporting
Personnel Files
Training
Trust Induction
30
If normal business is disrupted
Maintain provision of Staff Bank
Access ESR system for staff essential contact details
Assist with requests for staff redeployment
Assist Emergency Management Team with HR issues
Nursing, Clinical Governance & Risk
Emergency Planning including pandemic influenza and business continuity
Responding to Care Quality Commission compliance
Monitoring and responding to incidents and cascading alerts, internal and external through established
reporting system:
Serious Untowards Incidents (SUIs) – 2 hours
Incidents – 24 hours
Investigations – 60 days
Monitoring complaints / claims and cascading alerts within regulatory timeframes
Cascading legal issues
Infection Control
Risk Register
Safeguarding Children policies and procedures
See incident policy for external reporting requirements (e.g. RIDDOR, SHA, PCT (STEIS), HPA, NPSA)
SUI Incident reporting needs to be carried out within 2 hours – update NHS London SHA if unable to
process SUIs
General incidents should be reported within 24 hours
Ensure complaints are acknowledged within two working days
Review current regulatory requirements and prioritise workloads, inform regulatory bodies of expected
duration of disruption
Press and communications
General description of work carried out
Communications
Media Liaison
Publication of internal & external newsletters
Publication of corporate documents
If normal business is disrupted
Provide communication material on behalf of the Trust to staff, service users and local responding
organisations
Update the Trust’s website and intranet site
Act on a rota basis as the Communications Lead for the Emergency Management Team
Co-ordinate communications on behalf of the Trust
Liaise with Dept of Health led communications teams
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IM&T
General description of work carried out
Provision and maintenance of Trust hardware and software, network and internet connection
ICT Helpdesk
Patient Administration System
If normal business is disrupted
Refer to ICT Continuity Plan
Liaise with the Emergency Management Team in order to prioritise provision, repair and maintenance of
the ICT system
Arrange/enable additional remote access service accounts as directed by EMT – for offsite working.
Implement additional databases or systems to allow the Trust to collect data for internal and external
situation reports
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Appendix 10: Categorisation of clinical services
CATEGORY A
See Local Templates
CATEGORY B
See Local Templates
33
CATEGORY C
See Local Templates
34
Appendix 11: Management of staff in emergency situations: Joint Management and Staff
Side Agreement
1
2
Introduction
1.1
In an emergency there might be a necessity to reallocate and redeploy staff
without warning and without consultation. This might include asking staff to
undertake duties outside their normal professional area. Additional staff could
also be required, sourced from a pool of volunteers and retirees.
1.2
Current job descriptions and employment contracts allow some leeway in the
ability to allocate existing staff other tasks or work, whereas permanent or very
long term redeployment would require consultation under the Worklife Balance
Policy.
1.3
This paper sets out the agreement between Staff Side and Management
regarding the safeguards and rules that would apply if Royal National
Orthopaedic Hospital NHS Trust needed to manage staff in the event of an
emergency. These arrangements would only apply in an emergency, major
incident, major transport or weather crisis or a serious infectious disease
outbreak.
Existing staff
Redeployment/Reallocation of Work
2.1
In an emergency where staff may need to be redeployed or work may need to
be reallocated, managers will assess whether it is necessary for staff to report to
their normal place of work and whether there is a need to redeploy staff or
reallocate work. In deciding this managers will, wherever possible:
2.1.1
Direct staff to sites which are accessible
2.1.2
Allocate staff work with which they are familiar
2.1.3
The location of staff, their access to public/private transport, any reasonable
constraints on their flexibility, as appropriate.
2.1.4
Depending on service requirements, the feasibility of staff being able to work at
a different NHS site closer to home, either to undertake the same or different
work, including for other NHS bodies.
2.1.5
Depending on service requirements, the feasibility of staff being able to work
from home and undertake either the same or different work and the technology
available to support this.
2.1.6
The duration of any arrangements and whether these will apply to the full
contractual hours of the individual or part of their normal working hours
2.1.7
The steps necessary to ensure that Royal National Orthopaedic Hospital NHS
Trust complies with its legal obligation to ensure employee’s health, safety and
35
welfare at work as far as is reasonably practicable and with its duty of care to
others. In doing so, managers will take account of:
2.1.8
Any known/stated restriction on work that could safely be undertaken by an
individual on health grounds. This may include, for example, pregnancy and, in
the case of a serious infectious disease, whether the individual had received any
appropriate available vaccination. This risk will be assessed and determined on
an individual basis.
2.1.9
Any training or professional qualification that would be a prerequisite to carrying
out certain duties safely
2.1.10
Any official communication from bodies government agencies, for example,
advising against travel/other activity in all/some circumstances. The Trust will
provide advice to staff on interpreting such communications. For example,
workers providing essential services would normally be expected to travel to
work if there were advice to refrain from non-essential travel.
2.1.11
Any other circumstance that may make working unreasonably unsafe.
2.2
Any staff who are exhibiting symptoms of serious infectious disease will be
asked to report absent in accordance with current sickness procedure, or if
already at work will be asked to go home and follow the normal reporting
procedure, until the risk of infecting others has passed and they are well enough
to return. For all other illnesses, no staff will be required to attend work if they
are not fit enough to do so safely. Managers may seek Occupational Health
advice regarding the fitness of staff and making adjustments to enable the early,
safe return of staff where appropriate.
Excess Travel Expenses
2.3
Any member of staff who is redeployed and incurs additional travel expenses
will be reimbursed for the excess cost upon provision of the relevant receipts in
the normal way. (As per 17.29 NHS terms and conditions of the service
handbook)
Working Hours
2.4
Part time staff will be invited to increase their contractual hours for a specified
period of time, however, they will not be obliged to do so. Staff on other flexible
working arrangements may be asked to temporarily alter these arrangements in
response to the emergency situation, if it is reasonable for them to do so.
However, flexible working solutions may also enable as many staff to continue
working as possible. This may include home working, childcare
schemes/facilities, staff accommodation, and special travel arrangements (e.g.
car pools). HR and managers will therefore continue to promote and agree
flexible working options where possible. In an emergency situation, it will be
important to ensure that staff continue to receive appropriate rest breaks or
compensatory rest and that they are not asked to work more than 48 hours on
average over a 17-week reference period, in accordance with the Working Time
36
Regulations. The Trust will follow Department of Health Guidance as to whether
Working Time Regulations should be lifted during an emergency.
3
2.5
Annual leave requests may need to be more tightly controlled and staff might
not be able to take leave at the exact times they request, depending on service
needs. However, staff will remain entitled to take their annual leave allocation
and must take at least twenty days leave during the leave year, in accordance
with Working Time Regulations.
2.6
It will be important for both staff and managers to monitor working time and
ensure that excessive working time without appropriate rest does not occur, as
this could adversely affect staff health and wellbeing and therefore their ability to
remain at work to support colleagues and the running of services.
On-call payments
3.1
4
On call payments are payable to staff who are asked to be ‘on call’ to provide
emergency cover outside of the normal working day. To calculate entitlement to
on call the week is divided into 9 periods (night time Mon-Fri and 2 periods for
day and night at weekend).
Non-attendance at work
4.1
It will be important in an emergency situation to ensure that all staff able to work
do so as directed, to ensure services run smoothly and colleagues are not
unnecessarily overburdened by their absence. Unauthorised absence without
good reason will need to be dealt with.
4.2
Staff refusing to come into work should be offered unpaid or annual leave to
cover their absence. Depending on the circumstances and period involved,
management would have to use their discretion as to whether or not they need
to take further action. Following consideration of the circumstances, such
absence might be considered a breach of the employment contract that could
lead to disciplinary action following appropriate investigation, in accordance with
the Trust’s Disciplinary Policy and procedure.
4.3
Any disciplinary action taken under the Disciplinary Policy and Procedure should
be based on the facts of the individual case, as investigated and considered in
accordance with the procedure. Such action may lead to dismissal, depending
on the individual circumstances concerned. Depending on the availability of
resources and the duration of the emergency, disciplinary action might not be
taken until the emergency is over or resources enable the matter to be dealt
with.
4.4
In the event of staff absence due to caring responsibilities, current procedure will
be followed (see Work Life Balance Policy). Whether leave is granted with pay
will depend on the individual situation and will be at the discretion of
management.
4.5
In relation to redeployment/reallocation of work, if staff refuse to follow a
37
management request that is reasonable in the circumstances, this might lead to
disciplinary action being taken, in accordance with the Trust’s Disciplinary
Procedure. Again, such action might not be taken until the end of the
emergency or until resources allow the matter to be dealt with.
5
Staff support
5.1
6
To enable staff to continue working, it will be important to ensure they are
appropriately supported during and after an emergency. This could be in the
form of arrangements with other trusts who offer trauma counselling, the Right
Core Care Employee Assistance Programme, Occupational Health, or support
groups set up by other agencies. Managers will also play a key role in identifying
concerns, supporting their staff and ensuring their health, safety and well-being
at work.
Retirees/volunteers
Retirees
6.1
The Head of Human Resources is responsible for ensuring that arrangements
are in place to identify all retirees who have retired in the last three years, and
for ensuring that retirees will be contacted to see if they would be willing to be
entered on an emergency register of staff. All staff who have retired more than
six months ago will be health screened and CRB checked again and a reference
sought from their previous line manager. If professional registration or training
has lapsed, retirees will not be asked to undertake duties for which either would
be a requirement. Retirees would be engaged as Bank workers on the same
rates of pay as in operation for the Royal National Orthopaedic Hospital NHS
Trust Bank.
Volunteers
6.2
Volunteers are deemed to be helping out rather than fulfilling a discrete role and
will therefore not be paid (although travel expenses will be covered). Those
already on the volunteer register may be called upon in an emergency, and new
volunteers will need to be health and CRB screened with appropriate references
being taken up. The Royal National Orthopaedic Hospital NHS Trust will rely on
the testing and screening provided by volunteer agencies for potential
volunteers. Volunteers will be allocated roles according to their competence,
qualifications and skill.
Health & Safety Training
6.3
Retirees and volunteers will be required to attend a local induction/Health and
Safety training session to ensure the Royal National Orthopaedic Hospital NHS
Trust complies with its legal obligations. This training session will occur as soon
as possible after engagement.
38