healthy wirral - whole system integration update

Healthy Wirral - Whole System Integration Update - September 2017

Meeting Board of Directors Date 6 September 2017 Agenda item 12 Lead Director Val McGee, Chief Operating Officer Author(s) Val McGee, Chief Operating Officer

To Approve

To Note

To Assure

Link to the Board Assurance Framework (strategic risks) Please mark against the principal risk(s) - does this paper constitute a mitigating control?

Our Patients and Community Our People Our Performance

Quality and safety including addressing

inequalities is not maintained or improved

Lack of, or ineffective engagement and 2-way communication with staff

& governors

Failure to respond to system changes and the requirements of the NHS Five Year Forward View

Patient experience is not systematically collected, reported or acted upon

Failure to maintain a competent, engaged and resilient workforce that

feels trusted, listened to and valued at work within a changing environment

Failure to deliver the efficiency programme

and achieve all the relevant financial statutory duties

Inability to deliver the benefits of integration

within the defined timescales

Failure to provide quality training and supervision

and opportunities for career development for

all staff

Inability to sustain performance against

contractual and financial targets

Link to strategic objectives & goals - 2017-19

Please mark against the strategic goal(s) applicable to this paper Our Patients and Community - To be an outstanding trust, providing the highest levels of safe and person-centred care

We will deliver outstanding, safe care every time

We will provide more person-centred care

We will improve services through integration and better coordination

Our People - To value and involve skilled and caring staff, liberated to innovate and improve services

We will improve staff engagement

We will advance staff wellbeing

We will enhance staff development

Our Performance - To maintain financial sustainability and support our local system

We will grow community services across Wirral, Cheshire & Merseyside

We will increase efficiency of corporate and clinical services

We will deliver against contracts and financial requirements

Link to the Organisational Risk Register (Datix)

Has an Equality Impact Assessment been completed?

Yes No

Paper history Submitted to Date Brief Summary of Outcome

Regular report submitted to Board

Healthy Wirral - Whole System Integration Update September 2017

Purpose 1. This paper describes a number of strategic activities across the health and social care system

which the Wirral Community NHS Foundation Trust (WCFT) is central in leading and supporting whilst ensuring an equality of partnership delivery and sustainability. At the same time, working with other community partners ensuring a strong out of hospital focus and clear leadership as work progresses in the development of an Accountable Care System (ACS).

Executive Summary 2. These activities support the delivery of the Trust’s strategic objectives and integrated business

plan, and also support the commissioners’ strategic intentions and wider system resilience. These developments ensure that service delivery is integrated, that patient care is optimised and that patient experience is enhanced. This work and focus demonstrates our strength as a strong and credible partner as we move to an Accountable Care System (ACS).

3. WCFT is either leading on or is a significant partner on a number of integration initiatives

across the health and social care economy. This places the Trust in a strong position as we develop towards an ACS. The paper also demonstrates the progress made in a number of key areas of integration, notably the opportunities afforded to the Trust by the transfer of Adult Social Care.

4. This paper is to assure the Board of Directors of our strategic relationships, our support of the wider health and social care system and our key place in Healthy Wirral, which impacts on the strategic direction, quality and service delivery of Trust’s activities and demonstrates our unique position in the health and social care system.

Areas of focus 5. The paper discusses the key areas of activity which have taken place across the health and

social care system on the integration agenda. The points to highlight are the priorities that have been agreed by system leaders to support the expected improvement in the 4 hour target at the Accident & Emergency Department (A&E) at Wirral University Teaching Hospital (WUTH), the emerging model and process within the Older Person (50 plus) care programme which is a cornerstone in establishing an ACS, the strengthening of relationships with Primary Care and the work programme moving forward following the successful transfer of Adult Social Care into the Trust.

Board action 6. The paper is to assure the Board of the commitment the Trust has to integration across a

number of work streams and with key partners across the health and social care system. 7. The Board of Directors are asked to be assured. Val McGee Chief Operating Officer 31 August 2017

Healthy Wirral Update Department of Health - Department for Communities and Local Government paper 1. Recent correspondence from the Department of Health and the Department for Communities

and Local Government describe measures to tackle delayed transfer for care and being clear of expectations in advance of winter.

2. The Government via the budget announced an additional £2bn funding for adult social care

and all systems have been asked to agree spending plans. Wirral has agreed these via the Better Care Fund.

3. The Government is clear that there are three priorities for this money:

• Meet adults social care needs • Reduce pressure on the NHS, including supporting more people to be discharged from

hospital when they are ready; and • Ensure that the local social care provider market is supported.

4. The Government’s mandate to NHS England for 2017/2018 regarding Delayed Transfer of

care (DToC) is to reduce the national delayed transfer rate to 3.5% by September 2017. The most recent actual performance against target nationally was 4.9%.

5. In 2016/2017 there were a total of 10,301 lost bed days in WUTH which equates to an

average of 28.2 beds per day (4.2%).

6. The CCG plan was submitted in June 2017 indicating an intention to achieve the 3.5% target.

7. Since the submission the DToC data for Wirral was: • April 4.5% • May 4.6% • June 6.4% (this represents an additional 13 beds per day being blocked)

8. This is a mixture of patients waiting for assessments to be completed, patients waiting for

care packages and residential and nursing home placements.

9. The delays are a mixture of both Health and Social care delays, and some are joint. 10. The Better Care Fund for 2017-2019 is due to be submitted on the 11 September 2017.

11. There is significant investment in community services to ensure that there are alternatives to

hospital admission and robust and safe discharge process. There is continued investment in the Rapid Community Service, Intermediate services and maintenance of social care. There are newly commissioned services for T2A (bed bad and community home first models of care), growth in domiciliary care, Green car and the development of the trusted assessor role in care homes and domiciliary care. There is also funding available for Winter planning and Contingency.

12. The first draft of the winter plan is due to be submitted in the 8 September 2017. WCFT staff

are working on the elements of the plan that the trust is responsible for.

Wirral Partners Board

13. There was no meeting of the Healthy Wirral Partners Board in August.

14. At the meeting in July, Price Waterhouse Cooper were thanked for bringing the system leaders to a place where there was agreement that the Healthy Wirral Partners Board should have an independent chair. That work would take place on establishing a governance structure which includes a sub structure where the work of the Senior Change Team, specifically working on the 50 plus modelling work would report.

15. Significant progress has been made on understanding the components required to develop the Older People Live Well - 50 plus, 53-9-4-1 model and a high level action plan has been agreed. These components include:-

• Pathways that recognise whole health and care system that enables the effective and efficient flow of people, information and resources.

• Information sharing enabled by positive working relationships and effective IT so that care is fully coordinated.

• Asset-focused culture

• Engagement with patients and service users, their carers, families and wider communities

• Multi-disciplinary primary, community, social care and mental health teams

• Pathway and initiative development including the identification of a professional forum to ensure there is clinical leadership to drive the transformation.

• Population health and risk model

• Hospital consultants and specialist mental health services to be involved in the development of the model to consider the benefits of delivering secondary care services in either a locality or hub structure.

• Information sharing

• Volunteers, community groups and third sector organisations to support the wellbeing agenda.

16. The Healthy Wirral Executive Group met on the 8 August and discussed the following:-

• Healthy Wirral Outcomes Framework which is to be included in the commissioning prospectus to be finalised by November 2017. Following this further work will be undertaken to add more specific metrics, indicators and measures to the outcomes in the prospectus.

• Discussions took place on the Antimicrobial resistance scheme.

• The group agreed to support the psychiatry liaison bid and for the CCG to commission the enhanced service direct with Cheshire and Wirral Partnership Trust.

• Urgent care redesign – There was an update on the case for change, draft document to be shared with the group for comments, before submission to NHS(E) and NHSI prior to consultation.

• Update on the Older People Live Well - 50 plus - 53-9-4-1 model.

17. Wirral Providers Forum - this has recently been established to ensure that providers are in a

strong position to influence commissioning intentions which will be set out in the outcomes prospectus that the commissioners are developing by November 2017.

Integrated Health and Social Care 18. Following the successful transfer of Adult Social care staff and services to the Trust on the

1 June 2017, work continues on the mobilisation plan. The pieces of work are categorised under the following sections:-

19. Governance

• An internal project team meets fortnightly to oversee the mobilisations plans and to provide assurance against the delivery action plan with risk and issue management.

• The Council have established a Partnership Governance Board chaired by the portfolio holder for Health and Care. First meeting agreed terms of reference and discussed the quality impacts of the Key Performance Indicators (KPI’s).

20. Contract Monitoring

• Contract monitoring meetings have been held monthly since the transfer date. Commissioners have recognised the progress made on performance reporting and early performance improvements.

• There is a forecast overspend on the Community Care Budget and the Trust has produced high level actions on saving opportunities whilst maximising individual independence and maintaining quality.

21. Estates and IT mobilisation

• Most staff moves have been completed with the move of the West Wirral social care team to West Kirby and the Warrens scheduled over the next few weeks.

• The implementation of a single number for access to community health and social care is planned for the 19 September 2017.

Urgent Care Priorities 22. Following discussion with regulators, senior leaders from across the health and social care

system have agreed a set of priorities in order to improve the A&E target of patients waiting no longer than four hours. These priority areas are linked to the 9 point A&E plan.

23. Priority 1 - Implementation of clinical streaming at the front door with a task and finish group to support the implementation of phase 1 and to develop a preferred model and cost by November 2017. • Phase 1 - commence 4 September 2017 • GP cover 8am-7pm Monday to Friday ( in hours) • ANP/ENP cover 7 days • Outcome to prevent non admitted minor breaches • Phase 3 - development of Urgent Treatment centres.

24. Priority 2 - Consistent and complete implementation of SAFER throughout the hospital

ensuring that 33% of patients are discharged before midday – to be in place by March 2018.

25. Priority 3 - Implementation and expansion of the Transfer to Assess model (T2A), which will support timely discharge for patients who require on-going assessments, in the right environment, whilst maintaining independence by transferring earlier from the hospital setting, reducing the impact of deconditioning.

• Pilot commenced on 22 August on Wards 22 and 23 with attendance at board rounds, which enables the Multi-Disciplinary Team (MDT) to plan ahead for potential discharges for either Home First Community provision or bed based Transfer to Assess.

• Revised specifications and discussion regarding fees rates with providers

• Revised staffing model agreed

• Revised model, approach and pathways (including cultural challenges)

• Revised Key Performance Indicators( KPI’s)

• Capacity modelling across the system underway

26. Priority 4 - Expansion of admission avoidance schemes, including maximising the impact across the system of the acute visiting service/Green Car and the Rapid Community service. As well as increasing the opportunities to divert away from ED via North West Ambulance Service (NWAS).

27. Priority 5 - Investment in Domiciliary Care, by implementing the Trusted Assessor role and provider led reviews.

Care Navigation/Enhanced Single Point of Access (SPA)

28. The development of an integrated health and social care “front of house” facility which is accessible to professionals, forming part of a larger integrated Gateway that serves the whole population of Wirral continues.

29. Significant progress has been made in enhancing the integrated gateway with the following achievements:-

• Work continues on pathway redesign and discussions have taken place around which other services can be accessed via the SPA. There is a challenge to enhance the gateway further.

• Meetings have taken place to discuss pathways and processes in the implementation of Cardio Vascular Disease (CVD) in SPA. The service lead is developing a workforce structure to support this.

• Telehealth and Teletriage – The aim of the project is to support care homes in determining the right clinical care pathway for their patients. Two additional nurse clinicians have been appointed and the service has been launched with 8 care homes. This has now extended to 2 further care homes where training has been cascaded. The service is working with all parties to redefine the process and is accessing the support of IT to achieve this. There are a further 22 care homes identified to go live as part of phase 2.

A&E Delivery Boards and Urgent Care 30. NHSI and NHSE have developed a 9 point plan for A&E Delivery Boards to implement.

There is an expectation that there is improved performance at pace and ahead of winter. All partners across the system have a responsibility to ensure that the plan is applied and to tight timescales.

31. The 9 points to the plan are described below and the work associated with each aspect of

the plan is in progress. The Community Trust and its staff are crucial in supporting the shift in the system to reduce the number of people attending A&E.

1. GP Streaming by October 2017 - Phase 1 in place by 4 September 2017, Phase 2,

developed with 6-8 weeks. Phase 3 is aligned to the Urgent Care review and consultation by the CCG on the future of Urgent Care and the development of Urgent Treatment Centres.

2. Patient Flow - Transfer to Access, Trusted assessor, 7 day discharge capability - this is a major transformation plan, the pilot on 2 wards in WUTH commenced on 22 August 2017.

3. Reduction in stranded patients in the hospital and linked to DTOC – work is on-going

to understand the categories of patients on the list for discharge, these include stranded patients, those which are a delayed transfer of care and those that are on the complex list requiring complex care packages. A weekly meeting is held to develop system care planning for those who have been in hospital the longest.

4. NHS 111- streaming to other clinicians not A&E - contact has been made with UC24, the out of hours provider in Liverpool with the agreement that a group of providers from across Mersey and part of Cheshire would meet to start to plan for the future of out of hours services and to look at opportunities to support resilience across a wider footprint.

5. 24 hour specialist for Mental Health presentations in A&E - Cheshire and Wirral Partnership Trust were successful in a bid to for additional resources to provide 24 liaison support in A&E.

6. Increased GP accessible appointments.

7. Clinical contact for GP calls from care homes - tele-triage model. Phase 1 of the model has been successfully implemented into 10 care homes.

8. Standardisation of Walk-in Centres, Urgent Care Centres to Urgent Treatment Centres - This forms part of the CCG plans for Urgent Care and will be part of a formal consultation with current providers and stakeholders scheduled for November 2017.

9. North West Ambulance Service (NWAS) - See and Treat and Hear and Treat model. End to end Therapy Redesign 32. Work has commenced with partners on a review of the whole pathway for therapy services

from the community into the hospital. This is a collaborative piece of work between WUTH, Cheshire and Wirral Partnership Trust (CWP) WCT, working around the Shift left, Homefirst principles.

Development of Respiratory and Diabetes Pathways 33. Work continues on the pilots where some of the early indications are that patient satisfaction

is high, access and referral to the new clinics are increasing and there is good evidence of partnership working across providers within Wirral to continue to improve services. Funding has been approved for both services until the April 2018.

Primary Care Relationships 34. Primary Care colleagues from the 2 federations are involved in the plans for Older People’s

service transformation along with all partners across Wirral. This is helping with relationships, understanding of roles and pressures and also gives insight on where the federation leads see primary care within those plans.

35. Positive conversations have taken place between Directors of the Community Trust and the

Chair of the Federations around their approach to joint working going forward. 36. There has been good joint working with the Primary Care Wirral Federation around a future

model for phlebotomy. 37. Work continues on the development of the Older People Live Well - 50 plus - 53-9-4-1

model.

Wirral Community Trust and Wirral University Hospital Trust - Executive to Executive meeting 38. Two meetings have taken place in July and August 2017 with the main purpose to provide a

framework where both Trusts can collaborate and provide leadership and oversight for joint work related to the development of an ACS which will:-

• Improve Health Outcomes for Wirral residents • Improve people’s experience of health care • Improve the experience of colleagues who deliver health care services • Make better use of resources for health and care

Conclusion 39. As the local health and care economy comes under increasing pressure and scrutiny by the

regulators around the imperative that there is improvement in the 4 hours target, the Trust has to ensure that the services that provide out of hospital alternatives are used to the absolute optimum.

40. The Trust continues to be an important and valuable partner within the local health and social

care economy, and wider with the development of STP’s across a wider Wirral and Cheshire and Cheshire and Merseyside footprint.

41. This month’s report evidences the progress that has been made across a number of projects

which are related to integration, partnership and collaborative working across many layers within the health and social care system. It is complex, multi-faceted.

42. Integration is the cornerstone of our care model and the Trust is ideally placed to lead. Our

staff are integral in delivering the different care models and the ICCH’s are becoming an increasingly key focus for community care delivery. This will be augmented further by the work the Trust is supporting on the Older People Live Well - 50 plus - 53-9-4-1 model and will form detailed work with social care colleagues now that they have formally transferred to the Trust. We have to communicate and demonstrate what our strengths are in delivering services, both nationally and locally, in partnership for the future. The added value that the Trust contributes is a holistic view of patients and their trust in us, multidisciplinary team working, knowledge of our communities, strong leadership for consensus and partnership and a willingness to embrace new relationships and collaborative working.

43. The Board of Directors are asked to be assured that the Trust is instrumental in Healthy

Wirral and therefore a key partner in developing accountable care especially around integration, urgent care, commissioning and primary care agenda’s which ensures the delivery of a high quality service which enhances patient care and patient experience.

Val McGee Chief Operating Officer August 2017

Quarterly Communications, Marketing and Engagement Strategy Update for Reporting Period April to June 2017

Meeting Board of Directors Date 6 September 2017 Agenda item 13 Lead Director Alison Hughes, Director of Corporate Affairs Author(s) Jane Loughran, Head of Communications and Marketing

To Approve

To Note

To Assure




inequalities is not maintained or

improved


& governors


Patient experience is not systematically

collected, reported or acted upon


feels trusted, listened to


and achieve all the relevant financial


Please mark against the strategic goal(s) applicable to this paper Our Patients and Community - To be an outstanding trust, providing the highest levels of safe and person-centred care We will deliver outstanding, safe care every time


We will improve services through integration and better coordination

Our People - To value and involve skilled and caring staff, liberated to innovate and improve services

We will improve staff engagement







2

and valued at work within a changing environment

statutory duties





all staff





Yes No


Quarterly reported submitted to board.

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Quarterly Communications, Marketing and Engagement Activity Report for April to June 2017

Purpose 1. The purpose of this paper is to provide the Board with an update on the implementation

of the Communications, Marketing and Engagement Strategy.

2. The Strategy provides assurance of the processes in place to ensure achievement of communications, marketing and engagement objectives which support the organisation’s approach to the delivery of its vision and values.

Executive Summary 3. The key elements of the strategy are delivered through five communications and

marketing themes:

• brand management • internal communications and engagement • external communications and engagement • crisis and incident management • delivering quality services and value for money

4. This update provides assurance to the Trust Board regarding the Communications, Marketing and Engagement Strategy measures for reporting period April to June 2017 (see appendix 1).

5. The Communications, Marketing and Engagement Strategy is due to be revised in 2017, following the development of the Organisational Strategy and the update of the Business Strategy.

6. It is anticipated that a board workshop will be held in November to identify the priorities for the Strategy and develop the key messages for the annual cycle.

7. The final Communications, Marketing and Engagement Strategy and accompanying Implementation Plan will be scheduled to be presented at Board in January 2018 for final approval.

8. In the interim, the Quarterly Communications, Marketing and Engagement Update will consist of an activity report for the reporting period. The reporting cycle for 2017-18 is therefore as follows:

• September 2017 Board Meeting: Quarter One Activity Report

• November 2017 Board Meeting: Quarter Two Activity Report

• January 2018 Board Meeting: Communications, Marketing and Engagement Strategy and Implementation Plan Approval

• March 2018 Board Meeting: Quarter Three Strategy Update Report

• May 2018: Board Meeting: Quarter Four Strategy Update Report

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Summary of Key Quarter 1 Activity

9. A continued high-level of support was given to the Health and Social Care Integration project to prepare for mobilisation. This included producing regular ‘health and social care’ staff bulletins to ensure transferring staff were kept informed and involved. A ‘Welcome Breakfast’ event was also organised for new social care staff and trust colleagues. Over 100 staff attended and feedback was hugely positive, with social care staff reporting it had facilitated a smooth transition and fostered enthusiasm and excitement for the new integrated working.

10. One Member of Parliament (MP) visit was facilitated this quarter. Margaret Greenwood visited the Phlebotomy service in West Kirby. The MP for West Wirral was impressed with the service and spoke to satisfied patients.

11. A number of media enquiries were dealt with, including a Daily Mail enquiry on the NHS cyber-attack, a Health service Journal (HSJ) and GP Pulse enquiry about the trust’s GP Out of Hours agency spend, another HSJ enquiry about the trust’s involvement in Wirral Primary and Acute Care Systems, and an enquiry from the Liverpool Echo regarding fire safety and cladding.

12. Expert advice was provided to Directors and Services regarding the Purdah guidelines. The Purdah period was extended following the announcement of the snap election. The communications team worked with NHS Improvement to identify how the regular Wirral Globe column could be continued, without breaching the Purdah requirements.

13. Information was provided to support a review of the Communications and Marketing Team and to explore capacity issues. The review is now complete and the information will be used as part of the forthcoming strategy development, to help prioritise work streams.

14. Collaborative work with Wirral University Teaching Hospital was continued, to review messages around urgent care and identify how the trust communications team could support capacity issues in the hospital Emergency Department. Messages were shared about alternative places to seek medical help and on-going reminders about self-care.

15. Partnership working was undertaken with Joint Union Staff Side (JUSS) to raise its profile and encourage more staff to become JUSS representatives. A recruitment campaign was delivered which has resulted in more than 12 additional new representatives.

16. A high-level of support was given to the development, launch and implementation of Wellbeing Week. A suite of marketing materials were designed. These were significantly different to any other campaign the trust has run, and were very positively received. Over the course of the week, 67 wellbeing events took place. Over 150 feedback forms were submitted, all of which were positive. 79 staff participated in the ‘Step Challenge’ and exceeded the target 8,500,000 steps. 34 members of staff from across the trust volunteered to become Wellbeing Champions. Over 100 employees made wellbeing pledges.

17. Continued support was given to Sexual Health Wirral to develop clinic posters and a new website. This requires on-going support and will require further marketing and promotion once new website functions are available for patients to use.

18. A high-level of support was provided to corporate projects, including to the development of the new strategic objectives and the trust’s new ‘I Statements’. A one page document was created to share the objectives with staff. Support was also given to the development and delivery of ‘Organisational Update’ presentations, training for on-call

5

managers, the development of a recruitment pack for the Associate Director of Social Care and on-going contribution to the Leadership for All Group.

19. Five hundred free cakes were sourced from a local company to celebrate International Nurses Day. These were delivered to nursing staff at all bases across Wirral and Cheshire East to thank the trust’s nursing staff and celebrate the work they do.

20. The Summer edition of the ForYou magazine was produced.

Signing the social care contract Over 100 new staff attend the social care welcome event

Marketing campaign for Wellbeing Week Physiotherapy wellbeing flashmob

Cake celebrations for International Nurses Day ForYou summer magazine

21. Additional internal communications projects:

• The weekly Chief Executive’s blog was published • The monthly Executive Brief was produced • Trust materials were updated to adhere to NHS England’s new branding guidelines

6

• A template was developed for a Health and Social Care bulletin • Screensavers included appraisals, sustainability, wellbeing week and JUSS • The Freedom to Speak Up Guardians were promoted • A campaign was launched to promote the trust’s sustainability programme • On-going support was provided to the Leadership For All programme

22. Additional external projects:

• The fortnightly Wirral Globe column was published • Support was given to the Tissue Viability Day, including development of promotional

material and support at the event itself. • Marketing materials were developed including:

o Heart support materials o Health visitors flyer o Speech and language thickening and texture leaflets o Membership bottles o Cheshire East flyers o Chlamydia testing leaflets and instructions o Infection, Prevention and Control posters o Cheshire East Livewell materials o Breastfeeding Awareness Month materials o Wheelchair Service information o Dementia resources leaflets

Membership water bottles Cardio fit advertising JUSS recruitment screensaver

23. Staff Awards / Nominations

There were no staff nominated for external awards this quarter.

Conclusion 24. The communications and marketing activity this quarter ensured the trust’s corporate

responsibilities were delivered whilst also supporting business development, internal communications and the achievement of the new strategic objectives.

25. The priorities for the next quarter will include:

• Implementing recommendations from the communication and marketing review • Developing a new communications and marketing strategy and associated

implementation plan • Piloting a new media monitoring process

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• Drafting a tender to develop the new website • Mapping the next ForYou magazine and exploring distribution via schools • Providing on-going support to the mobilisation of social care • Continued collaborative working with other NHS organisations to support urgent care • Review of organisational briefings • Planning for Archbishop visit • Planning for art exhibition • Delivering the Trust’s Annual Members Meeting

Board Action

26. The Board of Directors is asked to note the content of this report which provides a quarter one activity update for the Communications and Marketing Strategy.

27. The Board of Directors is asked to be assured of the progress made to date regarding implementation of the Communications, Marketing and Engagement Strategy and to be assured that the reputation of the trust is being managed effectively both in relation to proactive and reactive activities.

Alison Hughes Director of Corporate Affairs Contributors: Jane Loughran, Head of Communications and Marketing 30 August 2017

Appendix 1 Communications, Marketing and Engagement Strategy Measures Previous quarter

This quarter Annual target

Brand Management Projects Staff Awards event delivered

3 MP visits facilitated ForYou magazine started Brand review continued

ForYou magazine produced Sexual Health Wirral materials and website branding 1 MP visit facilitated NHS England’s new branding guidelines were implemented

NA

Internal Communications Weekly e-bulletin Issued = 13

StaffZone view in period = 859 Issued = 13 StaffZone view in period= 794

Target = 50 Achieved = 54

Blogs Blogs issued = 13 Chief Executive’s Wirral Globe column: 8 Chief Executive’s weekly CE blog: 11 Director of HR: 1 Director of Operations and Performance: 1 Director of Business Strategy: 1

Blogs issued = 9 Chief Executive’s Wirral Globe Column: 6 Chief Executive’s weekly blog: 9

N/A

Staff Zone

No. of users (previously reported as visits) = 8006 No. of sessions = 75,012* Most popular sections: Home, webmail, ESR self-service, human resources, templates and tools, room booking, e-learning, staff directory, A-Z services *Sessions = the total number of times staffzone has been accessed.

No. of users (previously reported as visits) = 8220 No. of sessions = 77,148 Most popular sections: Home, webmail, ESR self-service, learning and development, e-learning, room booking human resources, staff directory, A-Z services, Datix

N/A

Projects / campaigns

• Health and Social Care Integration

• Freedom to Speak Up promotion

• Sustainability communications plan

• Wellbeing week

• Health and social care integration • Wellbeing week • Communications and Marketing Team review • JUSS recruitment • International nurses day

N/A

9

External communications AGM / Annual report feedback

2015 AGM satisfaction = 95.37% 2015 annual report views: 215

2016 AGM satisfaction: % no data due to sample size 2016 annual report views: 295

95% satisfaction

Press releases

Issued = 4 • Staff awards success • Sexual Health Wirral • Health and Social Care Integration • Phlebotomy service

Issued = 4

• Health and Social Care Integration • Cheshire East Celebration Event • Tissue Viability Study Day • Breastfeeding month

Annual increase

2016/17 = 42 2015/16 = 38

Trust magazine Issued = 1 Issued = 1 Next edition due winter 2018 2 issues Media Enquiries 3:

• 2 x HSJ requests for finance figures. Signposted to Board papers when published.

• Sky news – request for spokesperson re locum costs. Approached all trusts. We did not provide

4 • HSJ enquiring about agency fees for our GP Out of Hours

Service • GP Pulse enquiring about agency fees for our GP Out of

Hours Service • HSJ enquiry for finance figures • Daily Mail enquiry on the NHS Cyber-attack • HSJ enquiry about the trusts involvement in Wirral PACs • Liverpool Echo regarding fire safety and cladding

N/A

Website

No. visitors = 46,565 (cf 151,392 in 2016) (cf 152,457 in 2015) (cf 128,010 in 2014) (cf 29,630 in 2013) Page views: 97,658 (cf 410,486 in 2016) (cf 527,914 in 2015) (cf 531,065 in 2014) (cf 96,918 in 2013) GP section visitors: 832

No. visitors = 44,786 Page views: 92,719 GP section visitors: 585 Popular sections: Home, Walk-in centres, services A-Z, St Catherine’s Health Centre, Sexual Health Wirral, Phlebotomy Service, vacancies, Victoria Central Health Centre

Target = 5% increase =

10

Popular sections: Home, Walk-In Centres, St Catherine’s Health Centre, Services A-Z, Phlebotomy Service, current vacancies, Sexual Health

Advertising • Waiting magazine – sexual health None N/A

Publications None this quarter None this quarter Twitter (corporate)

No. followers : 1256 No. tweets: 3252

No. followers : 1384 No. tweets: 4322

Patient material • Nutrition & Dietetics questionnaires • Cheshire East 0-19 certificates • Wirral 0-19 Parents to be materials (9

leaflets updated) • Speech and language high risk foods

leaflet • Speech and language listening for

sounds – final amends • Quality and Governance patient

experience questionnaires • Quality and Governance patient safety

newsletter template • Fire safety in the home leaflet • Fit club certificates • Wirral school nurses letter • GP factsheet for Nutilis Clear • Wirral 0-19 service leaflet updated • Wirral 0-19 weaning group invite • Wirral 0-19 portion plate • Self care medicines pop-up

• Infection Prevention and Control: C. Diff patient leaflet, hand washing poster, children’s hand hygiene poster, Wirral care homes poster

• 0-19 Wirral: school letters, ‘You in Mind’ flyers, pupil panel certificates, breastfeeding awareness month posters, flyers, twitter images, red book updates

• 0-19 Cheshire East: minor illness poster, Poynton health visiting flyer

• Sexual Health Wirral: clinic times poster, Chlamydia leaflet and instructions, chlamydia workshop flyer, pocket timetable amends

• Heart Support: roller banners • Cheshire East Livewell: posters, flyers • Speech and Language: Thickening fluids, texture and

mashed leaflets, sound cue leaflets, vowel cue cards, A$ word cards

• Wirral heartbeat: pedometer artwork, new logo, half mile marker posters

• Specialised dental services: fluoride varnish leaflet • Wheelchair services: contact cards, service user folder,

repair booklet • Community nursing: dementia leaflet • Continence service: catheter passport amends

N/A

Projects / campaigns

• Sexual Health Wirral mobilisation • Cheshire East Livewell marketing

materials • Phlebotomy PR •

• Sexual Health Wirral mobilisation • Cheshire East Livewell marketing • Cardio fit (Heart Support)

N/A

11

Crisis & incident communications • Urgent Care messages • Urgent care messages N/A

Workforce Race Equality Standard (WRES)

Meeting Board of Directors Date 6 September 2017 Agenda item 14 Lead Director Jo Harvey, Director of HR & Organisational Development Author(s) Sophie Hunter, Equality & Diversity Manager

To Approve

To Note

To Assure






& governors











all staff






We will improve services through integration and better coordination Our People - To value and involve skilled and caring staff, liberated to innovate and improve services We will improve staff engagement









Yes No


No previous history

Workforce Race Equality Standard (WRES) Update Purpose 1. The purpose of this presentation is to ensure that the Board are up to date with the principle,

requirements and progress of the WRES at the Trust in accordance with the obligations of the Quality Contract 2017/18.

Board action 2. The Board of Directors is asked to note and be assured of compliance and progress. Sophie Hunter Equality & Diversity Manager 1 September 2017

Workforce Race Equality Standard (WRES) 2017 Presented by: Sophie Hunter, Equality and Diversity Manager

What is it?

The Workforce Race Equality Standard is a set of metrics that look for inconsistences regarding opportunity between White British and BME NHS staff. The metrics address the question….are you more likely to face barriers to career progression if you are a BME NHS staff member? There is evidence presented by NHS England, that there is unfair bias Between BME and White British staff with regards to: • Career opportunities • Likelihood of disciplinary • Lack of Continuing Professional Development/investment in Career development • Protection and support in cases of staff or patient abuse

Why does it matter?

“We know that care is far more likely to meet the needs of all the patients we’re here to serve when NHS leadership is drawn from diverse communities across the country, and

when all our frontline staff are themselves free from discrimination. These new mandatory standards will help NHS organisations to achieve these important goals.”

Simon Stevens, Chief Executive of NHS England,

https://www.youtube.com/watch?v=G44C9yn-oo0 Each Trust is expected to produce and complete an action plan each July.

Our Quality Contract 2017/2018 requires that the Board are kept up to date with the Trusts WRES progress, and that WCT provide them with evidence of this every 6 months.

https://www.youtube.com/watch?v=G44C9yn-oo0

WCT 2016 WRES Results

WCT WRES Action Plan 2017/2018

Emergency Preparedness, Resilience and Response (EPRR) Annual Report and self-assessment against the EPRR Core Standards 2017/18

Review of Major Incident Plan

Meeting Trust Board of Directors Date 6 September 2017 Agenda item 15

Lead Director David Hammond, Interim Director of Business Development & Strategy, Accountable Emergency Officer (AEO)

Author(s) Mick Blease, Emergency Planning Lead and Security Manager

To Approve

To Note

To Assure






& governors








within the defined


and opportunities for


contractual and financial




We will improve services through integration and better coordination Our People - To value and involve skilled and caring staff, liberated to innovate and improve services We will improve staff engagement







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timescales career development for all staff

targets



Yes No


Trust Board November 2015 To Assure and Approve Trust Board November 2016 To Assure and Approve

Emergency Preparedness, Resilience and Response (EPRR) Annual

Report and self-assessment against the EPRR Core Standards 2017/18 Review of Major Incident Plan

Purpose 1. The purpose of this paper is to:

• Through the EPRR annual report, provide assurance to the Board on the trust’s state of readiness to respond to threats and hazards and major disruptive events that may impact on the delivery of its services

• Provide its annual self-assessment against EPRR core standards with associated workplan for approval

• Provide the reviewed Major Incident Plan for approval

Annual EPRR report and Self-Assessment against EPRR core standards 2. The attached EPRR report (Appendix 1) identifies work undertaken to ensure that the trust

is compliant with statutory requirements placed upon it as a category 1 responder under the Civil Contingencies Act (CCA) 2004.

3. The report also outlines the current position of emergency preparedness against the 2017/18

EPRR core standards. These are the minimum standards for emergency preparedness, resilience and response that the trust and other organisations must meet.

4. To comply with the national requirements the Trust is required by the Local Health Resilience

Partnership (LHRP) to: • Undertake a self-assessment against the revised core standards identifying the level of

compliance • Submit an action plan addressing any areas of improvement • Complete the a statement of compliance identifying the organisations overall level of

compliance • Present the outcomes to Board

5. The trust has undertaken its 2017/18 self-assessment against required areas of the NHS England Core Standards for EPRR. Following self-assessment, the organisation has demonstrated ‘Green’ compliance with 45 Core standards and ‘Amber’ compliance with 5 Core standards. Overall, this indicates Substantial Compliance against the core standards.

Major Incident Plan review 6. Consistent with the requirements of the Civil Contingencies Act 2004, the EPRR framework

and Standard NHS contract, as a category 1 responder, the trust must have emergency plans that make explicit how the organisation will respond in the event of an emergency or major incident.

7. The Major Incident Plan has been subject to its regular annual review with minor changes

made to Authorising Officer, Author and a note regarding the ongoing review of rest centre roles and responsibilities. (The plan accompanies the papers as a separate document for review and approval.)

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Board Action 8. The Board of Directors is asked to:

• Note the annual EPRR Report and be assured that arrangements in relation to EPRR are in place and comply with statutory requirements.

• Approve the outcome of the 2017/18 self-assessment process, the associated action plan to allow the associated compliance return to NHSE.

• Approve the Major Incident Plan.

David Hammond Interim Director of Business Development and Strategy (Accountable Emergency Officer) Contributor: Mick Blease, EPRR Lead and Security Manager 30 August 2017

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Appendix 1

Emergency Preparedness, Resilience and Response (EPRR) Report

Introduction The report identifies the work undertaken to ensure that Wirral Community NHS Foundation Trust is compliant with the statutory requirements placed upon it by:

• The Civil Contingencies Act (CCA) 2004 • Terms and conditions of the NHS Standard Contract for Emergency Planning • NHS England core standards for Emergency Preparedness Resilience and Response

(EPRR) The purpose of the annual report is to provide an overview of

• The trust’s state of readiness to respond to the challenges, threats, hazards and major disruptive events that may impact on the delivery of its services or require a wider community response.

• Describe our response to incidents which have occurred in 2016/17 • Outline the work that has been undertaken in the last 12 months

The report is sectioned as follows:

1. Planning 2. Training and Exercising 3. Response 4. Partnership Working 5. Priorities for 2017/18

1. Planning 1.1 Accountable Emergency Officer /Emergency Preparedness Officer

Under the EPRR framework, the trust is required to be represented at the Local Health Resilience Partnership (LHRP) for Merseyside by the Accountable Emergency Officer (AEO). In July the role was transferred from Phil Clow Director of Business Development & Strategy to David Hammond, Interim Director of Business Development & Strategy.

Mick Blease was appointed the Trust Emergency Preparedness officer after the previous incumbent, Amanda Adams, left the organisation. Mick Blease attends the LHRP practitioners meeting.

1.2 Major Incident Plan

In line with the requirements of the Civil Contingencies Act 2004, the EPRR framework and Standard NHS contract, as a category 1 responder, the trust must have emergency plans that make explicit how the organisation will respond in the event of an emergency or major incident. The Major Incident Plan has been subject to its regular annual review with the following changes made • Updates to Authorising Officer • Updates to Author • Comment relating to review of rest centre roles and responsibilities.

The plan is attached as separate document for approval as part of EPRR annual submission.

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1.3 Business Continuity Planning WCT has a legal and contractual duty to develop robust Business Continuity arrangements which set out how the trust will maintain critical functions if there is a major emergency or disruption. Business Continuity plans are in place at both the service and divisional level. To provide a consistent methodology and format across the trust, a Business Continuity Policy aligned to ISO22301 (International standard for Business Continuity Management) has been developed. Divisions have updated their plans in the new format. Monitoring of progress in completing plans takes place within the Resilience Group.

1.4 Resilience Group

The Resilience Group has met on a quarterly basis throughout 2017. It is now chaired by the EPRR lead. The group includes representation from corporate services and clinical divisions. Future meetings will also be attended by Adult Social Care Following its integration with the Trust in June 2017.

1.5 Heatwave and Cold Weather Alert Planning Both the Heatwave Plan and Cold Weather Plan have been subject to annual review, informed by national guidance. The trust subscribes to alerts which provide advance notification when temperature thresholds are likely to be reached. In the event of adverse weather, communications plans include providing both staff and the public with key messages and advice. A review in 2017/18 will amalgamate these two plans into a single ‘Adverse Weather Plan’

1.6 On Call Manager Process

The trust has a well-established On Call Manager process to respond to incidents both in and out of hours via a dedicated phone and contact number. To support this:

• The On Call pack for On Call Managers is reviewed on a quarterly basis by the Resilience Group. It is available on StaffZone to those performing the role, plus administrators. This enhances information accessibility and the resilience of the organisation.

• On Call incident logs are completed on Datix, allowing for more effective management of incidents. Reporting and analysis of On Call incidents takes place at the Resilience Group and within On Call Manager training.

• The rota was increased in June 2017 from 11 participants to 14 with the inclusion of the three divisional managers. The rota is available on StaffZone and issued to WUTH switchboard as a back-up.

• Following the integration with Adult Social Care, a decision was made for the ‘On Call’ element of this process to remain with the Emergency Duty Team until 31 March 2018 to support local authority resilience.

• The On Call rota will be subject to a full review during Q3 2017/18, based on the need to prepare for including social care services. Any identified changes to the rota will be implemented from 1 April 2018.

1.7 Counter Terrorism

The current threat from International Terrorism is SEVERE (an attack is highly likely). There have been a number of tragic events in the United Kingdom and on the continent during the past 12 months. Close liaison has taken place with the LHRP and Counter Terrorist Police. Key messages to staff concerning preparedness and security are communicated in Staff Bulletin, StaffZone and training.

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Lockdown operations have taken in place at St Catherine’s Health Centre and the Walk in Centre at Victoria Central Health Centre, both based on a marauding terrorist attack and both were successful. The Government produced ‘Run Hide Tell’ video has now been included with in the Conflict Resolution training programme.

1.8 Plan Development

The following plans have been reviewed and updated in the past 12 months: • CBRN • Fuel Plan • Heatwave • Cold Weather • Pandemic flu

The Community Outbreak and Mass Vaccination plan is currently under review. This review follows an audit conducted by the NHS England on all community outbreak plans in the Mersey and Cheshire regions. All plans were identified as insufficient in the area of medication, the sourcing, the prescribing and administrating of those medications.

2. Training and Exercising 2.1 EPRR Training Matrix

An EPRR training matrix summarising training requirements for specific role holders and areas of delivery has been prepared and approved at the Learning & Development Group. The matrix is reviewed annually.

2.1.1 Risk and Business Continuity training This course aims to assist understanding of the principles of Risk Management and Business Continuity Planning .The training is aimed at operational band 7 and those with line management and/or responsibility for a service area/business continuity plans.

As this training was delivered by the trust’s Risk Manager (who has left the organisation), the Learning & Development group will be engaged to ascertain how best to deliver this training in future.

2.1.2 On Call Manager training All On Call Managers have attended specific training relative to the role of On Call Manager training. Two refresher and update sessions for On Call Managers were delivered in December 2016 and in June 2017 and included a review of EPRR command and control structures in Merseyside. Other training topics included:

• Overview of trust arrangements

• On call processes detailed in the on call pack

• Establishing the Incident coordination centre.

• Communication tools available to On Call Managers

• Overview of recent incidents and lessons learnt

• Integration with Adult Social Care

2.1.3 FFP3 Respirator training In February 2017 an additional 8 staff received training in Fit Testing of FFP3 respirators, required to respond to an outbreak of a suspected or confirmed infectious respiratory virus. They are now equipped with the knowledge to train others. Additional resource is due to be identified in order for these staff to cascade training across the organisation.

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2.1.4 NHS Health Emergency Planning Diploma (HEPDIP) The trust’s Emergency Planning Lead is working towards the Health Emergency Planning Diploma course, delivered by Loughborough University. The final stage of the programme takes place in April 2018.

2.2 Tests and Exercises

The trust is required to ensure plans have been appropriately tested, conducting: • A live exercise every 3 years • A table top exercise annually. • Communications test every 6 months The trust has conducted a number of internal exercises and participated in a number of external tests and exercises as detailed below.

Date Type Topic Attendees Internal Exercises 19/07/2017 Trust

Table top - live

Pandemic Flu. On Call Managers Representatives from divisions and corporate services

09/05/2016 Trust Table top

Exercise Argus - Counter Terrorism delivered by Merseyside Police.

On Call Managers Representatives from divisions and corporate services

External Exercises 10/11/2017 Table Top Influenza

CHAMPS Flu event Mick Blease Claire Sherratt (IPC)

22/02/2017 Table Top Flood exercise, hosted by Merseyside Fire and Rescue

Mick Blease

Internal Training 21/07/16 Trust

Training Suspicious Packages

Clinic coordinators

External Training 22/01/17 WUTH Wirral Escalation Plan,

Exercise OPEL

Mick Blease Helen Lundy Julian Eyre Anne Cartwright Tracey Orr

19/01/17 WUTH Wirral Escalation Plan Exercise Exercise OPEL

Mick Blease Helen Lundy David Hammond Ann Barlow

2.2.1 Training and Exercise programme The trust is required to complete a live exercise within a three year period that can test elements of the emergency planning measures in place. The occurrence of an incident that has tested the effectiveness of elements of the plans in that period may also show compliance in this area.

In 2016/17 there were three live exercises conducted in the trust. There were also two incidents that have tested emergency planning. All of these exercises and incidents have been subject to internal ‘After Action Reviews’ in order to identify any areas for improvement. The incident referencing the gas blast in New Ferry was also subject of an external review involving all concerned parties.

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Date Exercise/Incident Details 26/08/16 Incident Maggot infestation disrupting services at Eastham

Walk In centre 27/10/16 Live Exercise Lockdown of St Catherine’s Health centre 15/02/17 Live Exercise CBRN Response Exercise at VCHC Walk In

Centre 22/03/17 Live Exercise Lockdown of VCHC Walk In Centre 25/03/17 Incident Gas Blast in New Ferry, required a trust response

to assist in reception of patients at WUTH and assistance at rest centre.

2.2.2 Communication tests Regular testing of the on call phone response has taken place throughout the year. All calls have been answered and completed with the specified time frame. Following consultation with other providers this process will be developed with a view of testing the required response to specific incidents.

2.2.3 Incident Control Centre (Major Incident Room) The Trust is required to maintain appropriate incident control centre facilities to control and co-ordinate the response to an emergency. Incident Control Centres have now been established at St Catherine’s Health Centre and a backup facility at the Walk in Centre at WUTH. Regular monthly checks take place of the resources and the Major Incident Plan updated with the new room layout and contact phone numbers.

3. Response 3.1 Maggot infestation, Eastham Clinic

On 26 August 2016, Eastham Clinic was closed due to an infestation of maggots. The closure caused serious disruption to the Walk in Centre services operated by the organisation. Business Continuity plans were utilised in order to ensure services delivered from the building continued at other locations. It was strongly believed that a local food outlet was responsible for the infestation due to poor disposal methods of foodstuffs. Pest control measures were put in place to resolve the situation. The incident also received media attention that was dealt with by the communications department. The building was reopened 11 days after the initial closure and normal service was resumed.

3.2 Cyber Attack

On 12 May 2017, a cyber-attack affected over 40 NHS organisations across the country. Although referred to as the NHS Cyber Attack, the NHS only accounted for a small percentage of businesses affected. On notification of the virus, trust IT staff swiftly put in measures to ensure that the services delivered by the trust were able to continue unaffected. IT staff ensured the latest software technology was installed to assist in protecting the trust against this and future attacks.

3.3 Terrorist incident, MEN Arena

On 22 May 2017 a terrorist attack occurred at the Manchester Arena at the Ariane Grande concert that resulted in the death of 22 people and many injured, both physically and mentally. Although there was no direct response required at the time of the incident there were a number of ancillary actions required relating to increased security at our premises and emotional support for those affected by the incident.

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3.4 New Ferry gas blast On the evening of 25 March 2017 a blast occurred in the area of New Ferry which caused large scale damage and injured 34 individuals. A Major Incident was declared by the North West Regional Operating Control Centre and WUTH. The On Call Manager was alerted and support mechanisms were put in place for the trust to support the Accident & Emergency department at WUTH. Further trust involvement was required to support activities at a rest centre, established to support displaced residents. Debriefs have been recognised that communication concerning the setting up of the rest centre could have been improved and processes have been reviewed. The incident preceded the trust integration with Adult Social Care. A similar incident now would mean that trust social care staff would be required to manage the rest centre. A task and finish group has been established by the local authority with regard to its emergency planning and the management of rest centres will form part of the group’s work plan. WCT is represented at the group by the AEO, EPRR lead and Deputy Director of Operations.

4. Partnership Working

The trust actively participates in the following multi-agency groups to ensure a proactive and co-ordinated approach to informing and sharing best practice:

• Local Health Resilience Partnership (LHRP) - Executive Groups for both Merseyside and Cheshire, attended by accountable emergency officers

• LHRP Practitioners Group – Working group for both Merseyside and Cheshire attended by emergency planning leads

• Wirral Emergency Planning Group – Multi-agency working group attended by both industry, category 1 and 2 responders to review resilience arrangements and public events across Wirral

• WUTH Emergency Planning Team Meeting

5. Assurance

Under the CCA 2004, the trust has legal responsibilities in 6 specific areas: • Co-operating with other responder organisations • Risk assessment • Emergency planning • Communicating with the public • Sharing information with local responder organisations • Business continuity plans to ensure that services can continue to deliver their functions in

the event of an emergency so far as its reasonably practicable

Compliance against the EPRR requirements of the CCA 2004 is monitored via an annual self-assessment exercise the results of which are required to be submitted to trust board for approval before submission to NHS England. Organisations are expected to state an overall assurance rating as to whether they are fully, substantially, partially or non-compliant with the NHS EPRR Core Standards.

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5.1 Core standards assessment 2016/17

Following the self-assessment process of 2016/17 an action plan was developed in order to target areas for improvement identified through that process. All actions have been completed. The action plan is shown at Appendix 2.

5.2 Core standards assessment 2017/18

The trust has completed the required self-assessment of the new EPRR core standards for 2017/18. Of the 50 standards attributable to a community service provider, 45 have been assessed as Green and 5 as Amber. This represents Substantial Compliance. The action plan generated as a result of the self-assessment exercise has been attached at Appendix 3.

5.3 Deep dive assessment

In addition to the assessment against the core standards, each year a ‘deep dive’ is conducted into a specific area. This year the focus is on governance arrangements. Two areas for further action are identified in Appendix 3. NB The deep dive is developmental and the results of this are not included in the Core Standards assurance.

6. Priorities for 2017/18

The key emergency planning and business continuity priorities for the trust in 2017/18 are outlined in in the EPRR work plan which is monitored via the Resilience Group.

Mick Blease Emergency Planning Lead September 2017

Appendix 2 Progress report on actions identified in the 2016/17 self-assessment exercise Organisation: Wirral Community NHS Foundation Trust

Plan owner: Phil Clow, Director of Business Development & Strategy

Core Standard reference

Core Standard description Improvement required to achieve compliance Action to deliver improvement Deadline

EPRR Core Standards identified as Amber Rated

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Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive): " Utilities, IT and Telecommunications Failure

Review IT and Estates Plans required following transfer of CSU and consolidation of estates

Ensure agenda item at Estates Management Group and I+MT Group. Identify potential risks to IT and estates infrastructure. Consider critical alarms. Develop Plans and action cards Review arrangements at VCH and conduct risk assessment. Consider main and generator failure – organise exercise with estates and divisions.

Identify critical alarms and develop action cards for estates critical alarms.

COMPLETE

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Standards identified as compliant but areas for improvement identified

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Arrangements include a debrief process so as to identify learning and inform future arrangements

Although the requirement to conduct debrief is included within the MIP there is no set template.

Develop one page After Action Review ‘How to’ guidance and template for services following a business continuity incident to ensure a debrief is appropriately conducted. Incorporate into on call managers pack and best practice.

COMPLETE

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Arrangements contain information sharing protocols to ensure appropriate communication with partners.

Information sharing arrangements in place a number of local health economy partners. Developing briefing for on call managers and update in on call manager training

Discuss at Information Governance Group Develop guidance for on call managers and update in on call manager training

COMPLETE

Business Continuity and Fuel Deep Dive Standards identified as Amber Rated

DD1 Organisation has undertaken a Business Impact Assessment

BIAs have been conducted at service level as part of the EPRR work programme this year. BIAs required to be completed for both the Divisions and Organisation.

Meet with Divisional leads to develop BIAs Develop organisational BIA COMPLETE

DD3

There is a plan in place for the organisation to follow to maintain critical functions and restore other functions following a disruptive event.

Plan required updating following work on BC plans and Board approval Review Plan and submit for Board approval COMPLETE

DD5

The Accountable Emergency Officers has ensured that their organisation, any providers they commission and any sub-

Requests for business continuity plans to be incorporated into e-tendering software. Retrospective assessment of existing contracts prioritising on the basis of risk.

Modify e-tendering template to include BC plans. Review existing contracts and prioritise

COMPLETE

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contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance which may supersede this.

level of risk to the organisation. Request BC Plans and review

Business Continuity and Fuel Deep Dive Standards identified as Compliant but areas for further improvement Identified

DD2

Organisation has explicitly identified its Critical Functions and set Minimum Tolerable Periods of disruption for these

On-going programme of work. Plans require review and validation with services and also by scheduling of BC exercise

Review of service Business Continuity Plans Testing of BC plans incorporated into exercise programme

COMPLETE

HAZMAT CBRN Core standards identified as Amber Rated

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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.

Require audit and exercise to confirm assurance

Conduct audit of arrangements Walk through exercise scheduled Q3 to review arrangements and promote awareness

COMPLETE

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Appendix 3 Actions identified in the 2017/18 self-assessment exercise Organisation: Wirral Community NHS Foundation Trust

Plan owner: David Hammond, Interim Director of Business Development &Strategy



Deep Dive regarding governance arrangements (not included in assessment of EPRR Core Standards compliance)

DD1

The organisation has published the results of the 2016/17 NHS EPRR assurance process in their annual report.

Previous annual reports have not included results of EPRR assurance process

Arrangements to be made with the Communications Department to include a summary of 2017/18 assurance process to be included in the relevant annual report.

31.10.17

DD2

The organisation has an identified, active Non-executive Director/Governing Body Representative who formally holds the EPRR portfolio for the organisation.

Identify NED to include EPRR within portfolio to be involved in /informed re EPRR planning.

31.10.17

EPRR Core Standards

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Duty to maintain plans. 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, re Corporate & Service Level Business Continuity

Corporate and Business Continuity Policy to be in place.

Template for Business Continuity policy to be reviewed and approved at committe. 31.10.17

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11 As above, re Severe Weather NB, whilst compliant (Green) an action is in place for further development

Amalgamate Cold Weather plan and Heatwave plan into a Severe Weather Plan. 01.02.18

17 As above, re Community Outbreak Plan

Following audit conducted by NHS England there is a requirement to review the policy to ensure that there are clearer guidelines with regards to medication issues.

Review plan with partners include CCG and Public Health England. Review to focus on medication issues during a community outbreak. In particular the procurement of the medication the prescribing and administration of that medication.

01.10.17

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Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

In addition to the notes made at Core Standard 8 above, BC Plans from the IT, HR, Communications, and Quality and Governance Departments.

Reminders provided and support offered. AEO to raise the non-compliance with submission of BC plan with the Executive Leadership Team if required.

01.11.17

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Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident.

To identify additional Loggists and to arrange suitable training for those loggists

Arrange for Comm’s to seek volunteers to perform the role of a loggist at the time of a Major Incident by utilising the staff bulletin. Once staff have been identified arrange for training of those individuals in order that they are able to perform the role.

31.03.17

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Arrangements ensure the ability to communicate internally and externally during communication equipment failures

NB, whilst compliant (Green) an action is in place for further development

Arrange for On Call Managers phone to be have MT PASS facility allowing phone to switch to another network in the event of a failure of a given network.

31.01.18

Haz Mat standards

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HAZMAT/ CBRN decontamination risk assessments are in place, which are appropriate to the organisation.

CBRN Plan to include specific reference to Risk Assessments

Review CBRN plan and ensure that decontamination Risk Assessments are in included.

31.12.17

healthy wirral - whole system integration update

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