NHS England Core Standards for Emergency preparedness, resilience and responsev3.0

The attached EPRR Core Standards spreadsheet has 6 tabs: EPRR Core Standards tab - with core standards nos 1 - 37 (green tab) Pandemic Influenza :- with deep dive questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16 (blue) tab) HAZMAT/ CBRN core standards tab: with core standards nos 38- 51. Please note this is designed as a stand alone tab (purple tab) HAZMAT/ CBRN equipment checklist: designed to support acute and ambulance service providers in core standard 43 (lilac tab) MTFA Core Standard: designed to gain assurance against the MTFA service specification for ambulance service providers only (orange tab) HART Core Standards: designed to gain assurance against the HART service specification for ambulance service providers only (yellow tab). This document is V3.0. The following changes have been made : • Inclusion of Pandemic Influenza questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16 • Inclusion of the HART service specification for ambulance service providers and the reference to this in the EPRR Core Standards • Inclusion of the MTFA service specification for ambulance service providers and the reference to this in the EPRR Core Standards • Updated the requirements for primary care to more accurately reflect where they sit in the health economy • update the requirement for acute service providers to have Chemical Exposure Assessment Kits (ChEAKs) (via PHE) to reflect that not all acute service providers have been issued these by PHE and to clarify the expectations for acute service providers in relation to supporting PHE in the collection of samples

Core standard

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Evidence of assurance STFHT evidence

Self assessment RAG

Red = Not compliant with core

standard and not in the EPRR

work plan within the next 12

months.

Amber = Not compliant but

evidence of progress and in the

EPRR work plan for the next 12

months.

Action to be taken Lead Timescale

2015 Deep Dive

DD1

Organisation have updated their pandemic influenza arrangements to reflect

changes to the NHS and partner organisations, as well as lessons identified from

the 2009/10 pandemic including through local debriefing

Y Y

• updated planning arrangements reflect changes and learning

• version control indicates changes made and timeliness

Complete change of approach. Plan is informed by

Department of Health UK Influenza Pandemic

Preparedness Strategy (2011), NHS England Operating

Framework for Managing the Response to Pandemic

Influenza (2013) and PHE North East Centre Pandemic

Infuenza Operational Plan (2013).

Version 1.0 written in March and version 2.0 signed off by

BoD in August.

none n/a n/a

DD2

Organisations have developed and reviewed their plans with LHRP and LRF

partners

Y Y

• indication of the process used to develop updated

arrangements, including identification of organisations involved

in contributing or commenting on drafts

• agendas/ miniutes illustarting where the updated

arrangements have been discussed

Pandemic Flu was discussed with NTHFT, CDDFT, TEWV

and NHS England in a meeting prior to the LHRP sub

group on 10 March.

Pandemic Flu 2015, v 1.0, was sent to DDT LHRP Sub

Group for comment.

none n/a n/a

DD3

Organisations have undertaken a pandemic influenza exercise or have one

planned in the next six months

Y Y

• documentation related to exercise since the 2013 publication,

including lessons identified OR

• invitation letters/ documentation related to exercise scheduled

to take place in next six months, including an indication of how

lessons identified will be addressed

To set up and deliver an exercise based on the PHE off

the shelf exercise - EXERCISE Corvus.

Scheduled to take place on 6 November, in David

Kenward Lecture Theatre, JCUH. Invitations have been

sent out.

Feedback from all 4 sessions to be collated into a report to

go to EPC in January.

Deliver Corvus and present

learning to EPC in Jan 2016.

EPR Manager

DD4

Organisations have taken their plans to Boards / Governing bodies for sign off

Y Y

• Board/ Governing Body agenda or meeting papers indicating

updated pandemic influenza arrangements have been

discussed and/ or signed off

Circulated to ID consultants for comment in March.

Circulated to members of EPC prior to April meeting.

Acting Head of Nursing presented to Operational

Management Board - 18 Aug

Acting Head of Nursing presented at BoD - 25 Aug

(http://southtees.nhs.uk/about/board/meetings/2015-

2016/board-directors-august-2015/ )

none n/a n/a

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STHFT evidence

Self

assessme

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Red = Not

compliant

with core

standard

and not in

the EPRR

work plan

Action to be taken Lead Timescale

Q Core standard Clarifying information JCUH

FHN

Comm

hosp

Evidence of assurance

Preparedness

38 There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex) Arrangements include:

• command and control interfaces

• tried and tested process for activating the staff and equipment (inc. Step 1-2-3 Plus)

• pre-determined decontamination locations and access to facilities

• management and decontamination processes for contaminated patients and fatalities in line

with the latest guidance

• communications planning for public and other agencies

• interoperability with other relevant agencies

• access to national reserves / Pods

• plan to maintain a cordon / access control

• emergency / contingency arrangements for staff contamination

• plans for the management of hazardous waste

• stand-down procedures, including debriefing and the process of recovery and returning to

(new) normal processes

• contact details of key personnel and relevant partner agencies

Y Y • Being able to provide documentary evidence of a regular process for monitoring,

reviewing and updating and approving arrangements

• Version control

● Appendices to Major Incident Plan: Appendix

6 Incidents involving Chemical contamination,

Appendix 7 Incidents Involving Biological

Agents, Appendix 8 Incidents Involving

Radioactive contamination

● Major Incident Plan is revised at least

annually, unless organisational strucuture

changes, guidance changes, or procedures

need to be updated following an actual incident

or exercise

● Work closely with NEAS when they notify

A&E of numbers and conditions of casualties

● Communications via Twitter, and to LRF

partners

● Appendix 9 in the MIP details the national

stocks for which ambulance control room is

first point of contact and those for which it is

NHS England EPRR Duty Officer

39 Staff are able to access the organisation HAZMAT/ CBRN management plans. Decontamination trained staff can access the plan Y Y • Site inspection

• IT system screen dump

MIP is on the intranet and printed

A&E have action cards to follow

40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate

to the organisation.

• Documented systems of work

• List of required competencies

• Impact assessment of CBRN decontamination on other key facilities

• Arrangements for the management of hazardous waste

Y Y • Appropriate HAZMAT/ CBRN risk assessments are incorporated into EPRR risk

assessments (see core standards 5-7)

Procedures to follow are listed in the

Decontamination folder.

Only appropriately trained staff undertake

decontamination procedures.

Buddy / control in operation outside

decontamination room.

Risk assessments include self presenters

being sent outside to the Decontamination

room, no formal contact by clinical staff until

fully protected with appropriate PPE,

assessment of whether wet or dry

decontamination is appropriate (caustic

chemical or not), whether to initiate partial

lockdown. Section 1.4.2 of Appendix 6 lists

activities, a risk rating and the PPE which

should be worn.

Sources used to inform A&E of contaminants

involved: TOXBASE, PHE (North East, CRCE

and NPIS, NEAS and local COMAH site

operators.

41 Rotas are planned to ensure that there is adequate and appropriate decontamination

capability available 24/7.

Y • Resource provision / % staff trained and available

• Rota / rostering arrangements

At JCUH: All band 6s and 7s have now been

trained, so there are always suitably trained

staff on each rota. Some 6s and 7s have been

trained but are going through annual refresher

training, Autumn 2015. Medics being trained by

Lt Col Paul Hunt at his sessions. Other band

5s trained in suiting up (25 of these members

of staff).

42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/

CBRN incident and this specialist advice is available 24/7.

• For example PHE, emergency services. Y Y • Provision documented in plan / procedures

• Staff awareness

Appendix 6 in MIP (section 1.8) refers to

TOXBASE. Decontamination file includes

details for TOXBASE, PHE (North East Centre,

CRCE and NPIS).

Decontamination Equipment

43 There is an accurate inventory of equipment required for decontaminating patients in

place and the organisation holds appropriate equipment to ensure safe decontamination

of patients and protection of staff.

• Acute and Ambulance service providers - see Equipment checklist overleaf on separate tab

• Community, Mental Health and Specialist service providers - see Response Box in

'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community

Care Facilities' (NHS London, 2011) (found at:

http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-

primary-and-community-care.pdf)

• Initial Operating Response (IOR) DVD and other material: http://www.jesip.org.uk/what-will-

jesip-do/training/

Y Y • completed inventory list (see overleaf) or Response Box (see Preparation for

Incidents Involving Hazardous Materials - Guidance for Primary and Community

Care Facilities (NHS London, 2011))

(see Equipment Checklist tab)

44 The organisation has the expected number of PRPS suits (sealed and in date) available

for immediate deployment should they be required (NHS England published guidance

(May 2014) or subsequent later guidance when applicable)

There is a plan and finance in place to revalidate (extend) or replace suits that are reaching the

end of shelf life until full capability of the current model is reached in 2017

Y n/a Email trail from EPR Manager to Brian

Simpson and Maxime Hewitt-Smith in Finance.

24 in date: last refitted Nov 2014, to be refitted

22 & 23 October

45 There are routine checks carried out on the decontamination equipment including:

A) Suits

B) Tents

C) Pump

D) RAM GENE (radiation monitor)

E) Other decontamination equipment

There is a named role responsible for ensuring these checks take place Y n/a A) Suits have not been used in an incident.

They are reboxed by Respirex engineer at the

extension service. Last service was 27 Nov

2014.

B & C) NO. Rely on mass decontamination at

scene and the use of our fixed

decontamination unit.

D) Monthly checks carried out by HCA (review

sheet ,maintained)

E) Decontamination room on daily cleaning /

maintenance schedule

Hazardous materials (HAZMAT) and chemical, biological, radiolgocial and nuclear (CBRN) response core standards

(NB this is designed as a stand alone sheet)

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STHFT evidence

Self

assessme

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Red = Not

compliant

with core

standard

and not in

the EPRR

work plan

Action to be taken Lead Timescale

Q Core standard Clarifying information JCUH

FHN

Comm

hosp

Evidence of assurance

Hazardous materials (HAZMAT) and chemical, biological, radiolgocial and nuclear (CBRN) response core standards

(NB this is designed as a stand alone sheet)

46 There is a preventative programme of maintenance (PPM) in place for the maintenance,

repair, calibration and replacement of out of date Decontamination equipment for:

A) Suits

B) Tents

C) Pump

D) RAM GENE (radiation monitor)

E) Other equipment

Y n/a Suirs as per Respirex extension schedule

Ramgene - see later

47 There are effective disposal arrangements in place for PPE no longer required. (NHS England published guidance (May 2014) or subsequent later guidance when applicable) Y n/a Following New guidance 2 June 2015

Training

48 The current HAZMAT/ CBRN Decontamination training lead is appropriately trained to

deliver HAZMAT/ CBRN training

Y n/a Sue Murphy (Department Manager), and

previously CBRN lead and Rebecca Ashby,

current CBRN training lead previously trained

by NEAS.

Senior Sister Karen Wood, the training lead

was trained by NARU in May 2015.

49 Internal training is based upon current good practice and uses material that has been

supplied as appropriate.

• Documented training programme

• Primary Care HAZMAT/ CBRN guidance

• Lead identified for training

• Established system for refresher training so that staff that are HAZMAT/ CBRN

decontamination trained receive refresher training within a reasonable time frame (annually).

• A range of staff roles are trained in decontamination techniques

• Include HAZMAT/ CBRN command and control training

• Include ongoing fit testing programme in place for FFP3 masks to provide a 24/7 capacity and

capability when caring for patients with a suspected or confirmed infectious respiratory virus

• Including, where appropriate, Initial Operating Response (IOR) and other material:

http://www.jesip.org.uk/what-will-jesip-do/training/

Y Y • Show evidence that achievement records are kept of staff trained and refresher

training attended

• Incorporation of HAZMAT/ CBRN issues into exercising programme

Rebecca Ashby is the designated lead for

CBRN.

Training day covers donning and doffing VHF

PPE and PRPS suits, wet and dry

decontamination and how to deal with patients.

The NARU IOR DVD is shown as part of the

training day

Planned in for Minor Injuries Unit staff to be

trained - RA to go to them

Minor Injuries have NHS England: Self

presenters pdf (April 2015) and access to the

North West London resources.

Exercise Diamond (Tues 16 June) - did self

presenters for anhyrous ammonia in a doctors

clinical session that day at same time as

exercise at Wilton was taking place.

Exercise Three Cathedrals (TEWV scheduled

to take place 9 Oct)- scenario and chemical

details shared with RA for inclusion in JCUH

A&E training progamme

Training for Minor Injury

staff to be complete by

December 2015

A&E CBRN

Training LeadDec-15

50 The organisation has sufficient number of trained decontamination trainers to fully

support it's staff HAZMAT/ CBRN training programme.

Y n/a 3 mentioned above Rebecca Ashby, CBRN lead

Karen Wood, Training lead

Sue Murphy, Department Manager

51 Staff that are most likely to come into first contact with a patient requiring

decontamination understand the requirement to isolate the patient to stop the spread of

the contaminant.

• Including, where appropriate, Initial Operating Response (IOR) and other material:

http://www.jesip.org.uk/what-will-jesip-do/training/

• Community, Mental Health and Specialist service providers - see Response Box in

'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community

Care Facilities' (NHS London, 2011) (found at:

http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-

primary-and-community-care.pdf)

Y Y ●As evidenced in Ebola preparations, A&E

Receptionists know to make patient walk

outside to the front of the Decontamination

Room. Clinical staff alerted to get PPE from

the cupboard or PRPS suits located on the

consultant corridor and enter the

Decontamination Room on the instruction of

their control.

HAZMAT CBRN equipment list - for use by Acute and Ambulance service providers in relation to Core Standard 43.

No Equipment Equipment model/ generation/ details etc. Self assessment RAG

Red = Not in place and not in

the EPRR work plan to be in

place within the next 12

months.

Amber = Not in place and in

the EPRR work plan to be in

place within the next 12

months.

Green = In place.

EITHER: Inflatable mobile structure

E1 Inflatable frame Y

E1.1 Liner Y

E1.2 Air inflator pump Y

E1.3 Repair kit Y

E1.2 Tethering equipment Y

OR: Rigid/ cantilever structure

E2 Tent shell N/a n/a

OR: Built structure

E3 Decontamination unit or room Yes

AND:

E4 Lights (or way of illuminating decontamination area if dark) Yes

E5 Shower heads Yes

E6 Hose connectors and shower heads Taps on outside of decontamination room

E7 Flooring appropriate to tent in use (with decontamination basin if

needed)n/a

E8 Waste water pump and pipe n/a

E9 Waste water bladder n/a

PPE for chemical, and biological incidents

E10 The organisation (acute and ambulance providers only) has the

expected number of PRPS suits (sealed and in date) available for

immediate deployment should they be required. (NHS England

published guidance (May 2014) or subsequent later guidance when

applicable).

24 sealed and in date (refitted Nov 2014; next refit is

booked for 22 & 23 Oct 2015)

E11 Providers to ensure that they hold enough training suits in order to

facilitate their local training programmeyes, 3

Ancillary

E12

A facility to provide privacy and dignity to patients

Screens to be used outside in ambulance bay for dry

decontamination, then Decontamination Room for wet

decontamination.

E13 Buckets, sponges, cloths and blue roll Yes

E14 Decontamination liquid (COSHH compliant) Yes

E15 Entry control board (including clock) Yes: placed in corridor

E16 A means to prevent contamination of the water supply Can be collected but not in a bund

E17Poly boom (if required by local Fire and Rescue Service) n/a

E18 Minimum of 20 x Disrobe packs or suitable equivalent (combination

of sizes) Yes - next room round (relatives room)

E19 Minimum of 20 x re-robe packs or suitable alternative (combination

of sizes - to match disrobe packs)Yes - next room round (relatives room)

E20 Waste bins 60 litre burn bins and yellow bags

Disposable gloves Yes

E21 Scissors - for removing patient clothes but of sufficient calibre to

execute an emergency PRPS suit disrobetoughcuts

E22 FFP3 masks Yes

E23 Cordon tape Yes

E24 Loud Hailer Yes

E25 Signage Hang on red tape and door

E26 Tabbards identifying members of the decontamination team Yes (Major Incident cupboard)

E27 Chemical Exposure Assessment Kits (ChEAKs) (via PHE): should

an acute service provider be required to support PHE in the

collection of samples for assisting in the public health risk

assessment and response phase of an incident, PHE will contact

the acute service provider to agree appropriate arrangements. A

Standard Operating Procedure will be issued at the time to explain

what is expected from the acute service provider staff. Acute

service providers need to be in a position to provide this support.

(Reference to letter from PHE: NHS England Gateway

reference 02719, 16 Dec 2014)

We do not have ChEAK Kits. However the trust has

supported and will continue to support PHE in the

collection of samples for assisting in the public health

risk assessment and response phase of an incident.

Radiation

E28 RAM GENE monitors (x 2 per Emergency Department and/or HART

team)yes x2

E29 Hooded paper suits yes -in emergency cupboard

E30 Goggles yes

E31 FFP3 Masks - for HART personnel only n/a : HART personnel only

E32 Overshoes & Gloves yes