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					                              Ridgeway Partnership
                              Oxfordshire Learning Disability NHS Trust

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      EMERGENCY PREPAREDNESS POLICY
                   AND
           MAJOR INCIDENT PLAN




Review date                 April 2011

Authorisation date          January 2009



Author(s)     Brian Aveyard

                                                                          January 2009 Edition




            In the event of a major incident, contact the local on call Senior Manager
                                                Page 1 of 19
                            Ridgeway Partnership
                            Oxfordshire Learning Disability NHS Trust

                                       CONTENTS

1.    Objectives of Emergency Preparedness Policy & Major Incident Plan

2.    Definition of a major incident

3.    Responsibility of the Trust

4.    Responsibilities of staff

5.    Standing arrangements to support delivery of the Major Incident Plan

6.    Response to an emergency

Response to a major incident occurring within the Trust

7.    Phase I – immediate action (within 1 hour)

8.    Phase 2 – Transitional Period (within 12 hours)

9.    Stand down

10.   Restoration Stage

11.   Communications

12.   Independent activation

13.   Preservation of forensic evidence

14.   The Emergency Control Centre

15.   Switchboard

16.   Response to an major incident occurring outside of the Trust

17.   Training

18.   Testing the plan

19.   Reviewing procedures

20.   Other key related policies and statutory requirements




          In the event of a major incident, contact the local on call Senior Manager
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                               Ridgeway Partnership
                               Oxfordshire Learning Disability NHS Trust



1.     Objectives of the Emergency Preparedness Policy & Major Incident Plan

1.1      The NHS Executive requires Trusts to have plans in place to respond to
incidents outside their normal experience. An essential element of the plan must be
the development of procedures to ensure good co-ordination and control, as well as
to establish rapid staff and management call-out schemes and access to additional
facilities. Regular review of the plans, ensuring staff are clear of what to do and their
responsibilities and use of exercises are essential to maintaining confidence and
preparedness in the plans.

1.2     The purpose of this plan is to provide a considered response to emergency
situations that the Trust may experience and on the basis that the Trust is not an
acute NHS Trust nor is it a provider of emergency NHS health services. It aims to
provide guidance to management on their role and responsibilities in order to
minimise disruption, and maintain the continuity of existing services.

1.3     This plan complements the Trust’s Incident Reporting and Management
Policy. It does not replace separate reporting procedures to be followed for incidents
involving defective medicinal products and clinical incidents. Neither does it
supersede the statutory requirements to notify official bodies of certain incidents,
such as Riddor. The plan will be underpinned by local emergency plans for both
clinical (e.g. evacuation plans) and service areas (e.g. IT disaster plans).

1.4    The Trust’s Chief Executive accepts overall responsibility for Emergency
Preparedness and Major Incident Planning, and demonstrates this by signing this
document as a Trust Policy. The Specialist Health Services Director, the Supported
Lifestyles Director, the Director of Finance and the Director of Human Resources are
responsible for leading major incident planning within their directorates.

2.     Definition of a Serious Incident

2.1    A major incident may be defined as an event that would seriously affect the
       Trust’s ability to deliver some, or all, of its services, or attract significant legal,
       media or other interest, which if not managed may result in loss of the Trust’s
       reputation or assets. For example:

                    •   Fire, explosion or flood (or other natural disaster)
                    •   Major utility failure e.g. electricity, water, gas etc.
                    •   Major staffing failure
                    •   Major outbreak of infection
                    •   Significant communication failure
                    •   Bomb scares
                    •   Hostage situation
                    •   Major threat of violence to staff, service users or visitors
                    •   Other major disruption of whatever cause affecting buildings or
                        services e.g. severe weather, fuel crisis

2.2    A Senior Manager is a manager that reports directly to a Director of service.
           In the event of a major incident, contact the local on call Senior Manager
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                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust



2.3    The Trust may require the assistance of other Trusts and Social Services and
other organisations to contain the incident. The Trust may also receive requests to
support another Trust that is managing a major incident. Procedures and systems
shall be in place to respond to such needs (see major Incident policy).

3.    Responsibility of the Trust

3.1     The Trust Board has a duty of care to both service users and staff to conduct
its activities in a safe and effective manner. The Chief Executive is responsible for
ensuring assessment of foreseeable risks to staff and public and to have adequate
written procedures and plans in place for dealing with major incidents. It is also the
Chief Executives responsibility to ensure robust mechanisms are in place to alert and
mobilise staff, to assess the impact, and to respond to any incident. Executive
Directors are accountable to the Chief Executive for implementation of policy and to
ensure that staff are competent and equipped to respond to an incident. Executive
Directors should also ensure that post-incident procedures (including provision of
operational de-briefing and counselling services where appropriate) are managed
effectively.

3.2      It should be emphasised that a significant failure by a Trust to plan for or
respond to a major incident or emergency could lead to a breach of the law, either
civil or criminal.

3.3   This Major Incident Plan will be reviewed on an annual basis.

4.    Responsibilities of staff

4.1     It is the responsibility of all managers to ensure that all staff have been made
aware of their roles and responsibilities in the event of an emergency. To ensure that
all staff have read the plan and are aware of what steps they need to take should an
emergency or major incident occur. Periodic monitoring of staff awareness of their
individual roles should be carried out.

It is the responsibility of the identified senior managers to ensure on-call rotas
systems are structured appropriately and that those systems are being utilised
appropriately. Should staff who have been given specific responsibilities in the event
of an emergency be absent for any reason or leave the Trust employ, deputies or
new named staff must be appointed and the details amended in the departmental
plan.

4.2    It is the responsibility of all staff to make themselves aware of the actions
expected of them in such an emergency. However, Health & Safety Regulations
should be taken into account at all times and staff should not take any action likely to
result in personal injury or harm. For example in the event of a fire it is staff
members’ responsibility to alert/raise the alarm, evacuate the premises and alert the
emergency services.



           In the event of a major incident, contact the local on call Senior Manager
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                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust

If someone is left in the building the Fire Brigade should be alerted when they arrive
– the staff member should not try to re-enter the building him/herself – the Fire
Brigade are trained and equipped to deal with the situation.

4.3   If staff indicated their availability to be called upon in the event of a major
      incident they should ensure that their line manager is aware of any changes
      to their availability, location, or contact numbers.

5.    Standing Arrangements to support delivery of the Major Incident Plan

5.1   The following standing arrangements will be put in place and maintained on a
      regular basis.

Major Incident Plan: -     This Plan constitutes a corporate policy document, which
                           will be supported by detailed Individual Emergency plans
                           for each directorate

Major Incident             Major Incident manuals containing the policy document,
Manuals: -                 any supporting information and local emergency plans will
                           be available for each property and service. A manager will
                           be identified in each area / location to maintain the
                           manual.

Major Incident Control     A major Incident Control Pack containing relevant
Pack: -                    information and reporting documentation for the Control
                           Team (refer to box 4) will be placed in the reception at
                           Slade House. ‘On Call’ Senior Managers will also hold
                           copies of the Pack as part of the ‘On Call’ Pack.

Designated Emergency
Contact Point: -            The designated emergency contact point to alert on-call
                            staff of a potential major incident during office hours is
                            the Slade switchboard 01865 747455.

                           THE SWITCHBOARD WILL ALERT THE ON-CALL
                           SENIOR MANAGER WHO WILL BE RESPONSIBLE
                           FOR INITIATING THE MAJOR INCIDENT PROCEDURE.
                           OUT OF HOURS CONTACT WILL BE VIA THE
                           EXISTING ON CALL ARRANGEMENTS THROUGHOUT
                           THE TRUST.


If the nature of the incident requires one or more of the Emergency
services to attend a 999 call is the first priority action to be taken.

Responsible Persons: - All on-call senior managers are deemed responsible
                       persons in determining if an incident will be escalated to a
                       Major Incident. At the time of the incident the on-call

           In the event of a major incident, contact the local on call Senior Manager
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                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust

                           officer for the relevant service area is also designated as a
                           responsible person for supporting the implementation of
                           the Major Incident procedures at the location of the major
                            incident

Control Centre: -          The control centre will normally be located at the
                           Reception of Slade House. In the event Slade House
                           being unavailable the control centre would then be at the
                           Oxford Clinic. There will be a nominated Officer to support
                           the Control Team at a control centre in the event of an
                           Emergency.

Procedures: -              Procedure notes on action in the event of a fire will be
                           clearly displayed in all areas. Each area should have a
                           response to fire including evacuation procedures relevant
                           to that site. Procedures will be reviewed and amended as
                           necessary annually.

Important Phone            A list of important phone numbers will form a section of
numbers:                   the Major Incident Control Pack and will be updated on a
                           regular basis.

Emergency exits and        Emergency exits and Evacuation points will be identified
Evacuation Points: -       and clearly signed in all OLDT owned or leased premises.
                           Access will be regularly tested and a log of these tests
                           kept centrally.

6.    Response to an Emergency

6.1   The initial response to an incident is very important as it may prevent it
      becoming an emergency. Laminated Action Cards will form part of the Major
      Incident Control Pack and Major Incident Manuals giving explicit, sequential
      action to be taken in the event of a Major Incident.

6.2   There will be different levels of response in terms of time probably as follows:
      • Immediate (within 1 hour)
      • Transitional (within 12 hours)
      • Restoration

6.3   Each phase is likely to be of different duration and will require different
      responses and operational expertise. Each of the three phases requires
      defined response roles for: -
      •   Operational Tasks
      •   Overall incident Co-ordination
      •   The Co-ordination of support from in house services.
      •   The Co-ordination of external support
      •   Dealing with the media.

           In the event of a major incident, contact the local on call Senior Manager
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                                Ridgeway Partnership
                                Oxfordshire Learning Disability NHS Trust

6.4      Responses to perceived incident or emergencies should not circumvent
         established procedures such as Fire Alarms. The Major Incident Procedures
         will be used to provide additional support to the process.

6.5      The Trust will normally be alerted to a Major Incident through internal
         systems, but may also be alerted through external systems e.g. Strategic
         Health Authority.

Response to requests for assistance from local Acute Mental Healthcare and
Community Trusts or other outside agencies must be reported to the ‘On Call’ senior
manager.

The ‘On Call’ senior manager will decide the level of response to such requests.

RESPONSE TO A MAJOR INCIDENT OCCURRING WITHIN THE TRUST

If an incident occurs within the Trust the following procedure should be followed:

7        Phase 1. Immediate action (within the 1st Hour)

7.1      Reporting a potential Major Incident

If an incident occurs within the Trust, including those involving the emergency
services, the person discovering the situation should follow normal emergency
procedures. If the situation cannot be contained locally (this may involve liaison with
attending emergency services), the following procedure should be followed.

BOX 1
The most senior person on duty should:
•     Alert the Slade switchboard (during normal working hours 01865 747455, the on-
      call senior manager out of hours), stating that a potential need to start the Major
      Incident Procedure is being reported. The switchboard / on-call senior manager
      will ask the caller the following specific details, noting them in the Incident
      Reporting Log (see ‘On-call’ pack):
          Name, position, contact phone number, nature of incident, when incident occurred,
          location of incident, whether there are any physical casualties, emergency services
          involved, brief indication of current situation.
          The switchboard will ask the caller to keep the contact number free, as much as
          possible until contact has been made by the Senior ‘On Call’ Manager.
• The person who reported the incident should remain in control at the incident site
  until the on officer or senior ‘On Call’ Manager arrives.

BOX 2
Switchboard will immediately alert the :
•     On Call officer to take control of the site, or as near as possible to the site, of the
      incident.
•     On-call senior manager alerting them of the potential Major Incident and giving

              In the event of a major incident, contact the local on call Senior Manager
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                                Ridgeway Partnership
                                Oxfordshire Learning Disability NHS Trust


      the name of the on-call officer assessing the situation. The on-call senior
      manager is not expected on site at this stage but should wait further information
      from the On Call officer.
•     Registered Social Landlord (in the event of a building emergency)

BOX 3
The ‘On Call’ officer (in liaison with the Estates On Call Manager and any
emergency services on site) will
• Assess the situation
• Confirm whether or not the incident can be managed locally
• Contact ’On call’ senior manager to appraise them of the position.

7.2      Instigating the Major Incident Procedure

If the situation cannot be managed locally the ‘On Call’ SENIOR MANAGER will go
to the site to take control and instigate the Major Incident Procedure.
BOX 4
The Senior Manager will:
  • Confirm the Major Incident
  • Establish a control centre at the most appropriate designated area.
  • Establish the Control Team consisting of:
         On-call Senior Manager
         On-call officer of the service area
         Alert members of County-wide Communications Unit to provide Press and
         Media support
         Open and maintain a log of activity

It is essential that good, accurate records are kept of all administrative decisions
together with any relevant documentation. This is important for organisational
learning purposes and should a claim be brought against the Trust as a result of
injury or death these documents would come under close scrutiny.

BOX 5
The Control Team under instruction from the on-call senior manager will:
•     Define the problem, extent of disruption, consequences and probable implications
•     Maintain the log of events
•     Agree objectives for the next 3 hours or so
•     Agree second meeting for around 3 hours later
•     Mobilise other on call staff as appropriate
•     Alert the North East Oxfordshire Primary Care Trust
•     Alert the Thames Valley Strategic Health Authority
•     Alert other Trusts as necessary
•     Secure site; if emergency services are in attendance they will assume control of
      the incident, this will limit the actions necessary to secure the site, but may
      require Trust staff to assist in identification of water, gas and electrical equipment.

              In the event of a major incident, contact the local on call Senior Manager
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                               Ridgeway Partnership
                               Oxfordshire Learning Disability NHS Trust

                                                                               st
•  Establish short/long term solutions, suitable area for immediate 1 aid/minor
   injury treatment.
• Liase with other agencies as necessary
• Report to Executive Directors
• Provide press statements as necessary
At all times the Control Team will liase with any emergency services involved.

8.       Phase 2 - Transitional Period (within 12 Hours)

BOX 6
The Control Team will
• Appoint on the site manager with overall control
• Establish “bed finding” teams as required to deal with the incident
• Identify a holding site prior to arrival of transportation if necessary
• Mobilise transport services for evacuation if necessary (internal, ambulance,
   social services)
• Establish service user tracking log
• Source equipment if required
• Alert additional staff as required
• Ensure access to personnel and medical records in the event of needed to
   contact next of kin
• Alert pharmacy for replacement drugs
• Contact County Emergency Planning Officer (CEPO)
• Determine timescale to restoration phase
• Plan for restoration
• Source staff and service user support
• Provide regular and accurate updates to the media as required

Generic Evacuation Contingencies

When considering the solution to the various risks or problems identified, in
particularly if there is a requirement to evacuate, the Control Team should consider
the following generic contingencies.

Evacuation

     • Sharing existing inpatient areas
     • Sharing Community Homes
     • Use of Health Centres or Clinics (weekends only)
     • Taking over local accommodation
     • Sharing/converting office accommodation
     • Use of other Trust premises (acute/community/mental healthcare)
     • Use of properties accessed through Social Services and the County Emergency
       Planning Department
     • Service users staying with staff overnight
     • Use of Day Centre (check knock on effect)
     • Use of portable buildings obtained by Facilities
             In the event of a major incident, contact the local on call Senior Manager
                                                 Page 9 of 19
                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust

  • Putting people back into their homes with support i.e. discharge from inpatient
    services
  • Use of Nursing Residential homes (through Care Management & Social
    Services)

Other contingencies

  • Use of Learning Disability Teams as back-up staff on Trust sites
  • Liaison with Police, Fire, Ambulance and service users transport
  • Contact with Public Utilities
  • Contact with PCT’s and Strategic Health Authority
  • Infection Control
  • Security of site and safe access
  • Identification of people in charge (Luminescent Jackets)
  • Communication - mobile phones
  • Knock on effect of dispersed service users to: - Catering, nurses, transport,
    hotel services, medication delivery and replacement if lost.
  • Additional telecom facilities via BT (Time delay e.g. 4hours)

Reception Centres/Holding areas

There is likely to be a lead in time before sufficient transport resources are available
for an evacuation. A list of predetermined indoor evacuation assembly points should
an urgent evacuation be required will be available, both on and off site.

Monitoring of staff assisting at the incident

In the event of a prolonged incident in excess of 7 hours, a central log of the hours
worked by staff directly in relation to the incident needs to be set up. Staff should
work no more than 3-4 hours without a break, and no more than 7 hours in total
including handover time. The Nominated Site Manager will inform the Control Team
at the beginning and end of each shift of the staff deployed. The Control Team will
be responsible for ensuring that staffs exposed to trauma do not work any longer
than seven hours duration in any twenty-four hour period and have access to
support/counselling if required.

Control Team “shifts” should last no longer than 12 hours and the support to the
Control Team will develop a rota, including nominated site manager, in order to
achieve this.

The Control Team will be responsible for the operational debriefing of Nominated
Site Managers who will be responsible for the operational debriefing of all staff that
they are managing and supervising. Debriefing sessions will be held at the end of
every shift, therefore all staff will receive an operational debriefing session before
going off duty. This should include an assessment of their support/counselling
needs.



           In the event of a major incident, contact the local on call Senior Manager
                                              Page 10 of 19
                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust

Use of Voluntary Organisations

The Control Team will make the decision to or not to establish contact with voluntary
agencies for assistance.

Different Faiths managerial staffs are reminded that the different faiths have their
own customs that need to be respected when considering the potential solutions.

9.    Stand - Down

The emergency Control Team will determine when the stand-down from the
emergency procedures will be activated, and who will be responsible for ensuring
that all parties are informed.

10. Restoration Phase

BOX 7
Under the guidance of the Chief Executive / designated Executive Directors
• Arrangements for repair or re-build
• Ensure minimum repair standards are satisfactorily met
• Arrangements for transport to return service users
• Close down temporary accommodation
• Collect and return of equipment
• Undertaken operational debriefing and draft a final report to the Executive team
• Ensure staff/service user support mechanisms are in place for as long as needed

It should be noted that the psychosocial effect of a major incident on an individual
could last for up to 2 years, or in some cases, even longer.

11.   Communications
All communications will be instigated/co-ordinated through the Control Team. No
communications should go out to staff giving direction without it being agreed by the
Control Team. Levels of communications to be considered are:
• Internal
• External
• Media handling – only a member of the Countywide Communications Group
  (Press Officer) or the nominated Executive will act as spokesperson for the Trust.
• Have / should family members of service users and / or staff been contacted prior
  to statements being released to the media

It should be noted that service users affected by the incident should be
informed before the media, and dependent upon the circumstances and the
service users needs, relatives prior to the media.

Details of major emergency involving the police or ambulance service is likely to be
quickly picked up by the media.

           In the event of a major incident, contact the local on call Senior Manager
                                              Page 11 of 19
                                Ridgeway Partnership
                               Oxfordshire Learning Disability NHS Trust

Staff will be reminded that individual members of staff are not to make
statements without explicit authorisation from the responsible Executive
Director or the Chief Executive.

The Executive Director, the nominated Executive Director or Senior Manager will act
as the media liaison officer. The person managing the incident will need to record of
events from the time the serious incident is reported must be kept. This is essential,
as it is easy in the mist of a major incident to forget details of when an incident was
reported, when decisions were taken, why they were taken, who made those
decisions and what decisions were made. It will also act as a briefing document to
others who may subsequently take over the management of a major incident.
Other records that should be considered for completion (dependent upon the nature
and circumstances of the event) are:

•     Completion of accident, incident forms
•     Security of records – This is the responsibility of the Incident manager
•     Copying medical records if they are needed for on-going treatment
•     Taking statements from those involved in the incident (legible, signed and timed)
•     Provision of up to date reports to the Senior on-call manager and litigation advisor

Other parties that may need informing of the event / incident. Examples of these
are:- GP’s, NHS executive regional office, Health Authorities, PCT’s, PCG’s, and
other trusts, Community Health Councils, NHS Litigation Authority, Police, Coroner,
Social Services, Medical Devices Agency, HSE, Public / Health Department, and
Trust Legal Advisors.

12.      Independent Activation

In certain situations the senior officer or manager on site may activate the plan, i.e.
where it is apparent due to severe weather or an environment hazard that immediate
action is required. In these circumstances special arrangements may be agreed
locally and the senior manager on call informed as soon as possible after the event.

13.      Preservation of Forensic Evidence

In the event of a major fire, suspected terrorist incidents or death, the senior on-call
manager or the nominated site manager, in the absence of the senior on-call
manager, will be responsible for liaison with the Police concerning the need to
preserve forensic evidence. This will include restricting access into any areas
affected until cleared by the Police. This may require providing details of everyone
on site.

14.      The Emergency Control Centre

14.1     Location and Role

An Emergency Control Centre will normally be established in the reception, Slade
House or at the Oxford Clinic. The Control Centre will be the focal point for all liaison,

             In the event of a major incident, contact the local on call Senior Manager
                                                Page 12 of 19
                             Ridgeway Partnership
                             Oxfordshire Learning Disability NHS Trust

co-ordination, and control matters. A Major Incident Control Pack will be kept at both
designated sites at all times.

14.2   Staffing

The Control Team when assembled will remain in the control centre to collate and
disseminate information necessary for decision making and the issue of instructions.
A site manager will be nominated to act for the Control Team at the site of the
incident. In the event of Slade Reception being out of commission a subsidiary
switchboard will be established at the Oxford Clinic.

14.3   Record Keeping

The Control Team will be responsible for ensuring that a proper record is kept of the
incidents and the decisions taken. A follow up report for the Executive Directors will
be required within 24 hours of the incident first being reported. A final report to the
Executive Directors will be expected within two weeks of the official ‘stand-down’
reviewing both the incident itself and the effectiveness of the Major Incident
Procedure, and making recommendations for action to be taken including changes to
the Incident Plan.

15.    Switchboard

In the event of the Slade switchboard being put out of commission, a subsidiary
switchboard may be established at the Oxford Clinic site if failure of Slade system is
localised. As a contingency, the Trust will also have arrangements in place with
Littlemore Mental Health Centre to provide switchboard services if these cannot be
provided on site.

16.    Response to a Major Incident occurring outside of the Trust

The Trust may be requested to assist in the event of a serious incident occurring in
another organisation or within the community. All requests for assistance from
external agencies should be dealt with by the ‘On Call’ senior manager. The
response may involve call for additional back up staff or accommodation.

The ‘On Call’ senior manager, in liaison with other senior Trust staff, will decide
whether the Trust is in the position to respond.

17.    Training

As appropriate, staff will receive adequate training to enable them to carry out the
Major Incident plan with confidence during an emergency. Each department
manager will be expected to consider how they can best achieve a clear
understanding of awareness, procedures, and responsibilities for their staff in
readiness for dealing with an emergency. New members of staff will be made aware
of the Plan through induction training.



           In the event of a major incident, contact the local on call Senior Manager
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                               Ridgeway Partnership
                               Oxfordshire Learning Disability NHS Trust




18.   Testing the Plan

The major incident plan will be comprehensively tested at least every three years.

19.   Review Procedures

The Major Incident Plan will be reviewed following an incident and at regular intervals
not exceeding 2 years including tabletop exercise.

20.   Other key related policies and statutory requirements

         •        Counter Fraud and Corruption
         •        The Concerns and complaints procedure
         •        The Health and Safety at work Act 1974 (copies available for
                  inspection in Human Resources Department.
         •        Managing of Challenging Behaviour
         •        Risk Assessment and Management Pack
         •        Grievance Policy
         •        Accident, Incident and Near Misses Reporting policy
         •        Information Security Policy
         •        Disciplinary Policy
         •        Risk Management Policy
         •        Human Bites
         •        Client risk assessments
         •        Infection control policy
         •        Medications policy
         •        Whistle Blowing policy
         •        Fire Policy
         •        Root Cause Analysis Investigations Guide book
         •        Complaints policy
         •        Claims management Policy & Procedures

Please refer to policies and procedures manual for detail of the above and other key
major policies.




             In the event of a major incident, contact the local on call Senior Manager
                                                Page 14 of 19
                                                Ridgeway Partnership
                                                Oxfordshire Learning Disability NHS Trust


                                                Ridgeway Partnership
                                              Equality Impact Assessment

Policy/Function Name:                    Emergency Preparedness Policy

Names of persons completing Assessment:                           Brian Aveyard
                                                 (Please print names

Lead Director for Policy/Function:                                Brian Aveyard

Date of Policy/ Function: January 2009                            Date Policy/Function assessed: January 2009

Policy/Function review date April 2011

When completed this Assessment should be attached to the policy/function and distributed accordingly.


   The main aims and impacts of the
                                                                         Brief description/explanation
           policy/function

1. What is the purpose          of   the To enable the organisation and its varied operational directorates to respond
policy/function/development?             in a structured and coordinated manner to emergencies disrupting continued
                                         service delivery to service users.


2. Who is intended to benefit from the Senior managers and service managers responding to the occurrence of an
policy/ function/ development?         emergency.

(Who are the target group? Who will
benefit directly or indirectly?)




                                                                   Page 15 of 19
                                                   Ridgeway Partnership
                                                   Oxfordshire Learning Disability NHS Trust

  The main aims and impacts of the
                                                                            Brief description/explanation
          policy/function

3. Is there any adverse impact(s) from the The policy recognises the needs to communicate with both service users and
policy     function/   development      on family members and or legal guardian prior to information being shared in the
individuals from the following groups - public media environment.
service users, staff, carers, members of
the public - in relation to need, equal
treatment, inclusion/ exclusion - based
on:
   a) Age                                  None

   b) Gender (male/female)                 None

   c) Learning Disability                  Yes – staff are trained in meeting the communication needs of service users.

   d) Mental Health need                   Yes – staff are trained in meeting the communication needs of service users.

   e) Sensory Impairment                   None.

   f) Physical Disability                  In emergency situation the primary directive is to safeguard the overall well
                                           being of the service user, during evacuations a service user’s dignity may be
                                           compromised, however, this is a temporary necessity and covered within the
                                           restoration of normal services.

   g) Race, Ethnicity, Religion, Spiritual None
      belief (including other belief),
      Language or Culture

   h) Sexual Orientation                   None


                                                                    Page 16 of 19
                                                 Ridgeway Partnership
                                                 Oxfordshire Learning Disability NHS Trust

  The main aims and impacts of the
                                                                          Brief description/explanation
          policy/function
  i) Any Long Term condition               In emergency situation, the primary directive is to safeguard the overall well
                                           being of the service user, during evacuations a service user’s dignity and or
                                           comfort may be compromised, however, this is a temporary necessity and
                                           covered within the restoration of normal services.


4. Is responsibility shared with another The policy covers the whole of the organisation and its services.
department to deliver the policy/ function/
development? How is this managed?


5. Has anyone been involved in the This a structured response to legislative requirements with regard to the
development of the policy/ function/ Contingency Act 2004.
development?

If so, who, e.g. service users, staff, Executive Board have been asked to review the policy to ensure it reflects
professional groups, H&S Executive, both the organisations, service users and the governing legislative framework
stakeholders, partners?                requirements within the NHS.

How were they involved?

Should anyone else have been involved –
if so how will they now be consulted?


6. What information has helped towards This a structured response to legislative requirements with regard to the
the Equality Impact Assessment? E.g. Contingency Act 2004.
Audit reports, feedback from groups/
committees, surveys, etc.


                                                                  Page 17 of 19
                                                  Ridgeway Partnership
                                                  Oxfordshire Learning Disability NHS Trust

  The main aims and impacts of the
                                                                           Brief description/explanation
          policy/function

7. Which groups of service users, staff, Executive Board have been asked to review the policy to ensure it reflects
carers,   members       of   the  public, both the organisations, service users and the governing legislative framework
stakeholders, partners, have been requirements within the NHS.
consulted with during this assessment?

What information have they provided?        The original policy was reviewed by the H&S committee, the major changes
                                            to the policy reflect NHSLA standards regarding review and monitoring of
                                            implementation.


8. Is there any evidence that some There is no evidence to date that there are differing expectations form varied
people may have different expectations groups, as the policy is in response to statutory requirements governing the
of the policy/ function/ development? E.g. operation of the organisation.
different racial groups, people with a
disability, people with different religious
beliefs, or on the grounds of age, gender,
or sexuality.


9. Is more information required?            At present, no further information requirement has been identified.

 If so, what information and how will you
get it?




                                                                   Page 18 of 19
                                              Ridgeway Partnership
                                              Oxfordshire Learning Disability NHS Trust


10. Action Plan
What Action is required as Who is responsible for When will the action be When will the policy/ function
result of this assessment? implementing      this implemented by?         be re-assessed for any adverse
                           action?                                        impact?




Please send this form to Deborah Lawrenson, Company Secretary, for signing off and publishing on the Trust website.

This Assessment is completed and any adverse impacts have been identified and action agreed.

Name   Brian Aveyard                 th
                              Date 13 January 2009




                                                               Page 19 of 19

				
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