proportionate to the size and scope of the organisation. organisation to meet the requirements of these core standards. DUTY TO ASSESS RISK 5 Assess the risk, at least annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions. Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving risk assessments. Version control. Consulting widely with relevant internal and external stakeholders during risk evaluation and analysis stages. Assurances from suppliers which could include: statements of commitment to BC; accreditation; and business continuity plans. Sharing appropriately once risk assessment(s) completed. 6 There is a process to ensure that the risk assessment(s) is in line with the organisational, other relevant parties, community and national risk registers. 7 There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners. DUTY TO MAINTAIN PLANS – EMERGENCY PLANS AND BUSINESS CONTINUITY PLANS 8 Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. Arrangements include how to continue your organisation's critical activities in the event of an emergency or business continuity incident. Relevant are in place.
9 Ensure that are prepared in line with current guidance and good practice which includes (refer to clarifying information on pages 13 and 14): Being able to provide documentary evidence that plans are regularly monitored, reviewed and systematically updated, based on sound assumptions. Being able to provide evidence of an approval process for emergency plans and documents. Asking peers to review and comment on your plans via consultation. Using identified good practice examples to develop emergency plans. Adopting plans which are flexible, allow for the unexpected and can be scaled up or down. Version control and change process controls. List of contributors. References and list of sources. Evidence that patients, staff and relatives are supported, before, during and after an incident (including counselling and mental health services). 10 Emergency and business continuity reflect clear activation processes. Major incident action cards are available. Director on-call rota available in relation to emergency planning. Evidence of communication cascades. 11 Arrangements include a debrief process so as to identify learning and inform future arrangements. COMMAND AND CONTROL (C2) 12 On-call staff responsible for incident response must meet identified competencies and key knowledge and skills. Training is delivered at the level for which the individual is expected to operate (i.e. operational/ bronze, tactical/ silver and strategic/gold). For example strategic/gold level leadership is delivered via the 'Strategic Leadership in a Crisis' course and other similar courses.
18 Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents. Communication strategy and action cards available INFORMATION SHARING – MANDATORY REQUIREMENTS 19 Arrangements contain information sharing protocols to ensure appropriate communication with partners. Where possible, channelling formal information requests through as small as possible a number of known routes. Sharing information via the Emergency Preparedness Group and the Health Emergency Planning Forum. Social networking tools may be of use here. CO-OPERATION 20 Organisations actively participate in or are represented at an Emergency Preparedness Group at least once every six months. Attendance at or receipt of minutes from relevant Emergency Preparedness Group meetings that meetings take place and membership is quorat. Taking lessons learned from all resilience activities. Establish mutual aid agreements. Identifying useful lessons from your own practice and learned from collaboration with other responders and strategic thinking and using the Emergency Preparedness Group and the Health Emergency Planning Forum to share them with colleagues. Having a list of contacts among both Cat. 1 and Cat 2. responders within the Emergency Preparedness Group area. 21 Demonstrate active engagement and with other category 1 and 2 responders in accordance with the NI Civil Contingencies Framework. 22 Arrangements include how mutual aid agreements will be requested, and maintained. 23 Arrangements outline the procedure for responding to incidents which affect two or more Trust areas. 24 Arrangements demonstrate how organisations support PHA/HSCB/BSO locally in discharging its emergency planning functions and duties through the Joint Emergency Response Plan.
HAZMAT CBRN CORE STANDARDS Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) response core standards (NB this is designed as a alone sheet) Evidence of Assurance Self-assessment RAG Red = Not compliant with core standard and not in the EP work plan within the next 12 months. Amber = Not compliant but evidence of progress and in the EP work plan for the next 12 months. Green = fully compliant with core standard. Action to be taken Lead Timescale PREPAREDNESS 29 There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex). Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving arrangements. Version control. 30 Staff are able to access the organisation HAZMAT/ CBRN management plans. Site inspection. IT system screen dump. 31 HAZMAT/ CBRN decontamination risk assessments are in which are appropriate to the organisation. Appropriate HAZMAT/ CBRN risk assessments are incorporated into emergency planning risk assessments (see EP core standards 5-7). 32 Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7. Resource provision / % staff trained and available. Rota / rostering arrangements. 33 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. Provision documented in plan / procedures. awareness. DECONTAMINATION EQUIPMENT 34 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. Completed inventory list (see overleaf). 35 The organisation has the expected number of PRPS (sealed and in date) available for immediate deployment should they be required (HSC CBRN Decontamination Guidance for at Hospitals – July 2015). 36 There are routine checks carried out on the decontamination equipment including: A) Suits B) C) Pump
E28 RAM GENE monitors (x2 per Emergency Department and/or HART team) E29 Hooded paper suits E30 Goggles E31 FFP3 Masks – for HART personnel only E32 Overshoes & Gloves Appendix 1 – Clarifying information in relation to the EP Core Standards EP CORE STANDARD CLARIFYING INFORMATION HSC Trusts PHA/ HSCB/ BSO NIAS NIFRS NIBTS NIGALA NISCC GOVERNANCE 1. Y Y Y Y Y Y Y 2. Lessons identified from your organisation and other partner organisations. HSC organisations, and providers of HSC-funded care, treat emergency planning (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s) - lessons identified from exercises, emergencies and business continuity incidents - restructuring and changes in the organisations - changes in key personnel - changes in guidance and policy Y Y Y Y Y Y Y 3. Arrangements are put in place for emergency plans which: • Have a change control process and version control. Y Y Y Y Y Y Y