Emergency, Preparedness, Resilience and Response (EPRR) 2023-24 Annual Report

1 Introduction

The purpose of this paper is to provide an overview of the Emergency Preparedness, Resilience and Response (EPRR) work carried out between April 2023 and June 2024 in order to report to July 2024 Trust Management Board meeting (being held on 1 August 2024).

2 Governance

2.1 Accountable Emergency Officer

In line with NHS E EPRR requirements, the trust has an Accountable Emergency Officer (AEO) and this role is filled by Emma McGuigan, Chief Operating Officer.

2.2 Emergency Preparedness and Resilience Group (EPRG)

The Emergency Preparedness and Resilience Group (EPRG) meets quarterly; chaired by the Chief Operating Officer or Deputy and consists of representatives from:

Each Network (via their Emergency Preparedness Champions – see section 2.4)
Bed Hub
Communications
Estates and Facilities
Health and Safety
Infection Prevention and Control
Digital
Information Governance
Matrons and Senior Nurses
Medicines Management
Medical Directorate
Risk / Governance
Security
LSC ICB (EPRR)

The Group reviews the following key aspects of EPRR at each meeting:

Group composition
The annual work plan
Exercises (see section 5.2)
EPRR Risks (see section 7)
Incidents (see section 8)
Training (see section 5.1)
EPRR related updates from Digital and Estates
External updates from the Local Health Resilience Partnership (LHRP)

The role of the group is to oversee all aspects of emergency planning, business continuity and incident response. During this period the EPRG reported into the Clinical Standards Group but in early 2024 to the Trust Management Board. Group attendance at meetings is high.

2.3 EPRR Team

The EPRR team consists of a Head of EPRR, who joined the trust in May 2021 plus both a full time permanent Emergency Preparedness Support Worker, a full time fix term contact Emergency Preparedness Support Officer plus full time PA support.

2.4 Network support

The utilisation of network Emergency Preparedness (EP) Champions, introduced in 2021, has greatly enhanced the support for emergency preparedness across the trust with EP Champions in place across the five networks and an EP lead for the duty matron group and a dedicated EP lead within the Bed Hub. Their role is to support actions such as ensuring business continuity plans are reviewed, tested and updated, attend the EPRG, support work such as on the NHSE EPRR Core Standards Assessment, ensure staff from their areas participate in training and attending exercises plus support ad-hoc work such as defining key telephone numbers and the production of the network system prioritisation matrix in conjunction with Digitals’ Disaster Recovery Plan.

The Bed Hub are also supporting On Call managers with training sessions on the role of the bed bub, on call managers roles and responsibilities and undertaking key weekend tasks such as a sitrep to the ICB. The Matrons EP Champion is also supporting on review work such as the On Call handbook, contents of the on call training ensuring the out of hours provision is aligned to trust escalation and command and control procedures.

2.5 Corporate support

The Head of EPRR meets regularly with representatives from Digital and Communications to ensure that plans and arrangements are robust and relevant matters such as systems outages and communications issued during incidents are respectively managed. The remaining corporate teams, such as IPC, HR, Pharmacy and Risk and Governance report into each EPRG regarding the status of their Business Continuity plan, support the annual Core Standards process (see section 3) and are invited to attend major exercises.

2.6 Extreme weather group

To support the EPRG, a subgroup has been established and meets four times a year to plan for potential but likely effects of increased prolonged temperatures in the summer time and the effects of cold weather on staff, patients and our buildings. The Group’s work included establishing which buildings were “too hot” and / or “too cold” and ensuring the necessary reviews have been undertaken with Estates. The trust Major Incident Plan (MIP 005 Extreme Weather Plan) is reviewed by the group and tested including at Exercise Bono in November which included an element of severe weather affecting buildings and staff. Additionally, Exercise Dante was run in June focussing on prolonged heat and its effects on staff, patients and services.

The benefits of this group were yielded in winter 2024 during three cases of severe weather on 16 and 22 January and 8 July in the Lancashire and South Cumbria area (including snow) in order to ascertain any impacts (travel disruption, damage to buildings etc.) to our patients and staff via invoking our incident response process deployed through the network managers of the day and supported by the Emergency Preparedness Champions. The process quickly established there was minimum impact and we were maintaining “business as usual”.

2.7 External group participation

2.7.1 Local Health Resilience Partnership

The Trust AEO or Deputy attends Local Health Resilience Partnership (LHRP) meetings. These are chaired by the ICB and held quarterly.

2.7.2 Multi-agency Local Resilience Forum (LRF)

The LSC Local Resilience Forum (LRF) consists of agencies etc. such as Police, Fire, Ambulance, UKHSA, and Local Authority and, on behalf of NHS trusts, the ICB. The LRF has a number of sub-groups and LSCft are an active participant of the Humanitarian and Voluntary sub-group along with the likes of the Red Cross and Local Authority and the Head of EPRR attends.

2.7.3 North of England Mental Health Group

LSCft is part of an information sharing group of mental health trusts including:

Cheshire and Wirral Partnership
Merseycare
Pennine Care
Bradford District Care
Leeds and York Partnership
Rotherham Doncaster and South Humber
Sheffield Health and Social Care
NHS Midlands and Lancashire Commissioning Support Unit

The group meets three times a year with the aim of group to allow the EPRR leads of Mental Health providers within the NHS in the North of England to exchange information and best practice discuss issues of mutual interest and pursue specific pieces of work to assist in the delivery of effective emergency planning and business continuity arrangements in member organisations.

2.7.4 North West Emergency Accommodation Plan

This is a dedicated plan (North West Emergency Accommodation Plan for Secure Services (NWEAPSS)) established alongside a number of other North West Mental Health Trusts and third party provides via a memorandum of understanding.

Aimed at providing contingency and support allowing for the transfer of patients to temporary accommodation for between 12 and 72 hours following a major incident requiring full evacuation of a unit.

The plan is originally just for Secure Services only (i.e. the Guild) but is being expanded to include the following M/H areas:

CAMHS Tier
Learning Disability
Secure Services – Low beds
Secure Services – Medium beds
Adult: Acute, PICU, Rehab, Eating Disorder
Substance Misuse
Brain injury
Deaf Specialist
Specialist Perinatal

The secure services part of the plan was tested (Exercise Cascada) in June 2022 with a further multi-trust exercise being scheduled for Q4 2024 / Q1 2025. LSCft are also conducting an exercise of the plan for the Guild on 29th October 2024.

The aim of the plan is for trusts that are not able to re-house patients if a denial of access occurs and cannot be consumed within that trust’s inpatient capacity. The signed up members of the group (see below) will convene to support each other regarding beds, staffing and transport.

Cygnet Health Care
Cheshire and Wirral Partnership NHS Foundation Trust
Elysium Healthcare
Greater Manchester Mental Health NHS Foundation Trust
Lancashire and South Cumbria NHS Foundation Trust
Mersey Care NHS Foundation Trust
Priory Healthcare
Pennine Care NHS Foundation Trust
Alder Hey Children’s Hospital Trust

Although the scenario has not been tested, Exercise Cascada demonstrated that organisations working together will be able to support each other for mutually beneficial support.

However, it must be understood that a full evacuation of an inpatient area / set of wards is a significant concern (low probability but a high-impact risk) and we have MIP 018 – Shelter and Evacuation Plan have undertaken a series of business continuity and evacuation walk through for each inpatient site (see section 5.2).

2.7.5 National Performance Advisory Group (NPAG) for EPRR

Since 2021 The Head of EPRR has been the Chair of National Performance Advisory Group (NPAG) for EPRR. 30 organisations from all corners of England are members

The group aims to facilitate networking with peers and partners to support organisations in delivering Emergency Preparedness, Resilience and Response (EPRR) agenda. To share information with like-minded groups and individuals. (This information to include: policies, guidance documents, organisational details, cost saving initiatives, performance information). As well as to use the group as a networking facility between meetings supported by the NPAG Network function as well as developing the EPRR Network ‘resource library’. Additionally, to facilitate improved performance and aim to demonstrate value for money in the delivery of a resilient organisation whilst identifying good practice and develop service improvements.

Core standards for EPRR 2023-24

As in previous years, the Trust was required to self-assess its compliance with the NHS Emergency Planning, Resilience and Response Annual Assurance framework. For the year 2023-2024. It should be noted that this year’s process saw a significant change in process with NHSE requiring full evidential information against each submission. For example, copies of business continuity plans, exercise reports, terms of references, training records and meeting agendas and minutes.

The Standards were grouped under the following 10 domains:

Governance
Duty to risk assess
Duty to maintain plans
Command and Control
Training and exercising
Response
Warning and Informing
Cooperation
Business Continuity
Hazmat / Chemical, Biological, Radiological and Nuclear (CBRN)

There were 58 core standard questions. The process adopted for the core standards (CS) was:

Initial completion by the Head of EPRR supported by the EPRR Project Worker
Review and input by the Emergency Preparedness Champions
Presented at the Emergency Preparedness & Resilience Group
Reviewed by the COO/AEO
ICB Head of EPRR review

From there, the LSCft submission to NHSE E was at the following substantial level:

Green 53
Amber 5
Red 0

Final agreement reached of:

Green 6
Amber 52
Red 0

A paper was presented to TMB in January 2024 that outlined the full EPRR plan to improve the current CS score including the formation of a Core Standards Working Group chaired by the Deputy COO that reports into the COO/AEO and the EPRG.

Current Position:

A working Group chaired by the Deputy COO meets on a regular basis working to:

Work through the 2023/24 NHSE feedback.
Ensure that where gaps in information were identified will now be included or plans laid out on how to achieve over time.
Corporate teams are ensuring their aspects of the core standards are being improved (Comms, Estates, H&S, HR, IPC and Security).
EPRR policies and plans have been reviewed and agreed at EPRG.
Provide regular feedback to the chair to ensure we are on track for a potential September submission.

Full compliance will not be achieved in 2024 however, we anticipate significant progress on a number of standards with a full update being presented to the September EPRG. As of 22nd July 2024 the process and timescales for submission to the ICB have not been advised by NHSE although the complete process including NHS E submission at a national level is 27th December 2024.

Mersey Internal Audit Agency Report

In July 2023 LSCft commissioned an EPRR review with the final report agreed and issued in February 2024. The overall objective was: to review and evaluate the arrangements in place in relation to emergency planning, considering local and national guidance, and the degree to which plans have been tested.

Overall, the review found that the controls in place were designed to support effective EPRR and Business Continuity processes with some improvements required in the operating effectiveness of the controls, in particular action plans arising from exercises and incidents have not been fully completed, with actions outstanding for significant periods.

The overall assurance was moderate with one red (high), four amber (medium), five yellow (low) RAG rated objectives.

The actions from the report are incorporated into the “Summary of Exercises and Incidents - Action Plans” report that is a standard agenda item on each meeting of the EPRG.

Since the report, six actions have been fully completed (including the red action), two are on course to for completion by their due dates and two have their actions deferred (Revised Business Continuity Plan template and HAZMAT / CBRN training) until December 2024 and June 2025 as per agreement via TMB.

4 Incident Management

The Trust has robust incident management processes in place which were fine tuned during our Covid response. These principles have been employed during several outages* with all Executive On Call and Directors On Call undertaking specific incident commander training.

During 2023/24 the Winter Resilience Group ran weekly meetings, chaired by the Deputy Coo / Director of Ops for C&W to ensure matters such as any increases sickness, wide system pressures and we had Christmas and New Year’s plans were in place. The group met less frequently in this period than in 2022/23 evidencing less overall combined pressures. This group will convene again for 2024/25 commencing in October.

*Refer to Section 7 for details of specific incident that have required EPRR command and control or support to the networks. Also to Section 5 for details of role specific training e.g. in incident management skills such as the Head of EPRR’s incident commander training.

4.1 Incident management plans

The current list of major incident plans is contained in Appendix 1, including details of their current position.

4.2 Incident coordination centres (ICCs)

The Trust has an ICC for each of the networks plus for the tactical (silver) command and strategic (gold) command. These facilities are tested quarterly with the support of the Emergency Preparedness Champions. A list of the ICCs is included B.

5 Training and exercising

5.1 Training

A comprehensive set of training is being undertaken from 2023 and into 2024 that includes:

NHSE Tactical or Health Commander Awareness Training – all Director On Call and Executive attend a MS Teams half day session delivered by NHSE.
Incident Commander Training – The Head of EPRR provides training to equip all Director On Call and Executives with the tools with some practical examples of responding to an incident including forming and running an Incident Management Team.
Decision Loggist Training – each network plus staff from corporate and Executive office are nominated and undergo training by the Head of EPRR on the key supporting role to the Incident Commander of a Decision Loggist.
Legal Aspects of EPRR – LSCft have utilised the specialist skills of Barrister Graham Watson to deliver face to face training to Executives and Directors on Call around all legal aspects of EPRR including the Civil Contingencies Act, debriefing, Logging and public enquiries.
Media training – a number of Executives plus some Directors on call and the Head of EPRR attended a one day training session delivered by Ex BBC journalist on the importance of dealing with the media including experience of being in front of the camera.
EPRR Awareness training for the Bed Hub - a programme has started with team members of the bed hub to enhance their awareness around EPRR, On call and incident response given their importance as a ley 24/7 365 operation and their role if we encounter any incidents.
Cyber Awareness – a personation was delivered in June 2024 to 16 persons from the Board and Executive Team.

As part of the new core standards requirements an individual training portfolio is required for each Executive and Director on call. These are in production and will be rolled across LSCft by the end of August 2024 forming a key requirement under the core standards.

5.2 Exercises

The following exercises were undertaken in the period with learning and actions added to the “Summary of Exercises and Incidents - Action Plans” report that is a standard agenda item on each meeting of the EPRG.

2023 – Major exercises

Exercise Avalon (OPEL 4) – 23rd May 2023
Exercise Camelot (OPEL 4) – 15th August 2023
Exercise Bono (Digital outage and extreme weather) – 21st November 2023

Exercise Bono was an off-site exercise with over 60 participants.

2023/24 – business continuity exercises including post evacuation*

Exercise Skylark – Avondale Unit at Royal Preston Hospital, 15th February 2023
Exercise Whalley – Whalley in-patient site, 25th October 2023
Exercise Pathfinders – Orchard in-patient site, 28th November 2023
Exercise Cherrytree – Duxbury Unit at Chorley Hospital, 24th January 2024
Exercise Little Marton - The Harbour, 19th February 2024
Exercise Cashmere - Dova & Ramsey units at Furness General, 20th February 2024
Exercise Medlar – Wesham unit, 11th June 2024
Exercise Edge - Scarisbrick & Lathom units at Ormskirk Hospital, 27th June 2024

Further scheduled exercise include:

Exercise Plover – The Cove – 25th July 2024
Exercise Romney – Kentmere at Westmoreland Hospital – 4th September 2024
Exercise Stones – Guild Lodge, 29th October 2024
Exercise Diablo – whole trust off site exercise – scenario secret until the exercise! 6th November 2024

Note: Exercise Dynamo was completed on 14th December 2022 for Hillview and Pendleview.

6 On-call arrangements

LSCft operates a three-tier on call process consisting of:

Senior Manager On Site
On Call Director
Executive On Call

Also, as part of the 2023/24 Core Standards requirements all new On Call persons that are Directors on Call and Executive On Call must complete a NHS E Commander Training Portfolio that details all training undertaken plus evidence of competency (via undertaking training or responding to incidents). The portfolio is being rolled out to the relevant persons by the Head of EPRR via the Incident Commander Training session.

To support On Call managers the On Call Handbook and On Call On a Page are regularly reviewed and re-issued. Additionally, On Call Manger workshops are held there times a year in order to share on call experiences and best practice.

All new On Call managers undertook an initial training session with the Head of EPRR and this has been extended to all matrons and senior nurses. Specific training sessions are also underway for all our Matrons and Senior nurses on escalation, business continuity, incident management and the on call process. All new matrons will be enrolled in this training as they come into post.

7 Risk management

Emergency preparedness risks are considered at each EPRG meeting and three risks are maintained through the group supported by Head of Risk:

Industrial Action - Rating of 15
Power Outages - Rating of 15
Critical IT Systems - Rating of 12

An annual wider review of LSCft’s risk alongside those of the UK’s National Risk register and the Lancashire and the Cumbria Local Resilience Forum (LRF) risks.

8 Incidents experienced

8.1 Incidents responded to

The Trust Emergency Preparedness has supported a number of significant number of incidents during the period demonstrating effective command and control arrangements. These include:

Fire at inpatient unit (Pendleview) and IT outage – 25/12/23
Weather disruption (potential) – 16&22/01/24 and 08/02/24
Guild in-patient flood – 08/03/24
Guild in-patient unit fire alarms – 13/03/24
Knife incident at outpatient area – 28/03/24
Virgin Media – 06/05/24 (Avondale unit)
Virgin Media – 08/05/24 (wider issue including other Trusts)

The actions and any learnings from incidents are collated via debriefs (EPRR and local service / key supporting areas such as Digital) and added to the “Summary of Exercises & Incidents - Action Plans” report that is a standard agenda item on each meeting of the EPRG.

8.2 Industrial action (IA)

During the period the Trust has prepared and planned to industrial actions from the following:

British Medical Association (BMA) – both Junior and Senior Doctors
Chartered Society of Physiotherapy
Royal College of Nursing (RCN)
Unison
Unite

There were over twenty periods of IA that the EPRR team and the Medical Directorate coordinated an IA Working Group consisting of representatives from

HR
Comms
all networks
Bed Management and Patient Flow Service
Digital
ePMA
Estates
Finance
Health and Safety
Improvement and Compliance
IPC (Infection Prevention & Control)
Learning and Development
Meds Management
Physiotherapy

Work is currently underway regarding GP industrial action that is likely to commence in August.

Note: at the 2023 Trust Annual Awards Ceremony the Corporate Team of the year award was won by the EPRR and Medical Directorate for their work in coordinating cover rotas and the command and control process enacted over each period of IA.

9 Covid public inquiry

In 2022 the trust has deemed it prudent to start to prepare for independent Public Inquiry into the Government and public sector response to the Covid-19 pandemic. This will include all government departments including Health. A Senior Responsible Officer (SRO) - Chief Strategy & Improvement Officer) was appointed: Ursula Martin, Chief Strategy & Improvement Officer) and the formation of a working group (LSCft Covid-19 Public Inquiry Working Group). Membership of the group includes:

Business Intelligence Unit
Clinical Ethics Group
Communications
Data Protection / Information Governance
Digital
EPRR Team
Estates & Facilities
Finance
HR
Infection Prevention Control
Pharmacy
Procurement
Tactical (Silver) Incident Command

The purpose of the group is to provide the Executive and Board with assurance in relation to our preparedness and resilience to provide and respond to the request of the Public Inquiry.
To ensure LSCft are able to respond to the requests of the Public Inquiry including the need to prepare to provide our fullest support and transparency to any requests for information, and maintain a full clear set of records.

Freedom of Information Requests

The Emergency Preparedness team received three FOI requests during the period:

2603 - The number of cancelled, delayed or missed appointments at your Trust as a result of British Medical Association strikes w/c 11th - 15th April 2023?
2836 - How much have you spent on agency staff during days in which industrial action was taken by staff in your trust since 1st December 2022?
3232 - Which LSCFT teams are currently in Business Continuity Management and from what date?

All the above were agreed with the COO and communicated to the Trust’s Freedom of Information team.

Areas of work identified for 2024-2025

A detailed training programme continues to be rolled out with the following objectives achieved by the end of 2024:

All Executives and Directors On Call have attended the following mandatory training:

NHSE’s Principles of Health Command
Legal Aspects of emergency preparedness
The Role of an Incident Commander

Following agreement via TMB the Chemical, Biological, Radiological and Nuclear (CBRN) and Hazardous Materials (HAZMAT) elements of the NHS E Core standards.

A computer based training package (CBT) for EPRR is in development that all staff will be mandated to complete.

10 Summary

The Board is asked to note the contents of the report.

Appendix 1

Trust major incident plans

Title	Description/Update
MIP001 - LSCFT Incident Response Plan	For use in the event of a significant disruption – critical or major incident Presented and agreed at the May 2024 EPRG.
MIP002 – Pandemic Flu Plan	This plan is currently undergoing review with the support of Infection Prevention and Control in order to refresh post covid and include wider pandemics then flu. Requires review.
MIP003 – Flood Plan	Reviews each LSCft premise / where we have staff located for any flood risks and ensure the relevant business continuity plans are updated accordingly. Requires review.
MIP004 – Disruption of Fuel Supply Plan	Ensures LSCft plans are aligned to national requirements. Requires review.
MIP005 – Extreme Weather Policy	Covers both hot and cold weather planning, including the Met Office weather warning process and with trust’s Extreme Weather Group convening four times a year to ensure plans are in pace. Presented and agreed at the May 2024 EPRG and tested at Exercise Bono and Exercise Dante.
MIP006 – Organisation Resilience a	Now part of MIP015 EPRR Policy
MIP007 – Staff Resilience Handbook	To assist all staff in EPRR. Presented and agreed at the March 2024 EPRG.
MIP008 – Emergency Transport Plan	In conjunction with our Bed Hub team. Presented and agreed at the May 2024 EPRG.
MIP009 – HAZMAT/CBRN Plan	Review of the plan to commence in December 2024.
MIP010 – Multi Agency Emergency Accommodation Pla	The LSCft section of a wider partnership plan with the likes of CWP, Merseycare, Pennine and Greater Manchester Care. To support in the event of an incident at a low or medium secure unit in-patient requiring patient relocation.
MIP011 – Water Disruption Guidance	To be reviewed.
MIP012 – Operation GLIDE Guidance	Supports MIP 010 specifically for the Guild being “Guild Lodge In-patient Decanting and Evacuation” flowchart. Presented and agreed at the May 2024 EPRG.
MIP013 – T4 CAMHS Emergency Accommodation Plan	See section 2.7.4
MIP014 – LSC Psychological Resilience Support Plan	Details what LSCft could provide in the event of a major incident requiring post event Psychological support. Presented and agreed at the May 2024 EPRG.
MIP015 – EPRR Policy	The overarching policy on EPRR was Presented and agreed at the May 2024 EPRG.
MIP016 – Mass Casualty Plan	Requires review.
MIP017 – Avian Flu Support Plan	Details what LSCft could provide in the event of a major incident requiring post event Avian flu support. Note: primary response is by UKHSA and other agencies. Presented and agreed at the December 2023 EPRG
MIP018 - Evacuation and Shelter Plan	Details what each in-patient unit’s business continuity plans are to support a significant loss of in-patients beds / wards. Presented and agreed at the May 2024 EPRG.
MIP019 – On Call Policy	Details the on call process for Senior Managers On Site, Directors On Call and Executive On call. Presented and agreed at the October 2023 EPRG.
MIP020 – LSCFT Incident Coordination Centre	Details all LSCft’s ICCs that can be utilised for command and control in a disruptive event. Presented and agreed at the May 2024 EPRG.
MIP021 – LSCFT Overarching Business Continuity Plan	Presented and agreed at the May 2024 EPRG.

Appendix B

Trust Incident Coordination Centres (ICC) are:

Corporate	Boardroom, Sceptre Point, Bamber Bridge, Walton Summit Centre, Preston PR5 6AW Trust Primary ICC
Central and West	Pathways Resource Centre, Room 12, First floor, St Aiden’s Road, Bamber Bridge, PR5 6GD
Specialist	Guild Lodge, Room 1, Whittingham Lane, Goosnargh, Preston, PR3 2JH
Fylde	The Harbour, Training Rooms 1 and 2, First Floor, Windmill Rise, Blackpool, FY4 4F
The Bay	North Barn, Conference Room, Pathfinders Drive Lancaster, LA1 4J
Pennine	Pendleview/ Hillview 2nd Floor, Seminar room, Royal Blackburn Hospital site, Haslingden Road, Blackburn, BB2 3HH

Appendix C

Item	March 2024	May 2024	Sept 2024	Dec 2024
Review Terms of Reference			√
Review of Group Composition			√	√
Committee Annual Report to Board			√
Review of Work Plan	√	√	√	√
Summary of Actions Raised from Exercises and Incidents	√	√	√	√
EPRR Core Standards Review	√	√	√	√
Review of current and emerging risks	√	√	√	√
Training/Exercise Program	√	√	√
Trust Major Incident Plans	√	√	√	√
Locality Business Continuity Plans - Each locality Emergency Preparedness Champion to present updates	√	√	√	√
Corporate Business Continuity Plans	√	√	√	√
On Call Update including Policy Review			√
External EPRR Updates	√	√	√	√
Lockdown and Security Update			√	√
NWEAP for Mental Health Services Update		√	√

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