SOUTH EAST COAST AMBULANCE. EPRR Assurance Audit Report

Transcription

1 SOUTH EAST COAST AMBULANCE EPRR Assurance Audit Report September 2015

2 Date Version Author Notes Josh Tarling SECSU Contents Assurance Visit... 3 Audit Details... 3 Areas investigated... 3 Audit Results... 4 Audit Narrative... 5 Page 2

3 Assurance Visit South East CSU Business Resilience Team conducted a visit to South East Coast Ambulance to conduct an audit of their Emergency Planning Response and Recovery (EPRR) preparedness against the NHS England EPRR Core Standards. The purpose of the visit was to enable SECAmb to provide assurance to their commissioner as to the level of their preparedness Audit Details Date of audit 08 September 2015 Location of Audit Auditors Provider representatives Coxheath Josh Tarling (SECSU) on behalf of Swale CCG Andy Cashman, Anne Harvey Areas Investigated The audit looked for evidence against the cores standards identified by NHS England as being required to be in place by Acute Healthcare Providers. The four investigated areas were: EPRR Core Standards Pandemic Influenza deep dive additional standards HazMat/ CBRN Core Standards HazMat/ CBRN Equipment Checklist MTFA Core Standards HART Core Standards MTFA Marauding Terrorist Firearms Attack HART Hazardous Area Response Team CBRN Chemical, Biological, Radiological and Nuclear Page 3

4 Audit Results SECAmb were able to provide evidence to demonstrate the following rates of compliance: Green (full compliance) Amber (plans to address gaps on annual work programme) Red (significant gaps with no plans to address) EPRR Core Standards 33/35 2/35 0/35 Pandemic Flu Deep Dive standards Hazmat/ CBRN Standards Hazmat/ CBRN equipment check 0/4 3/4 1/4 13/13 0/13 0/13 29/29 0/29 0/29 MTFA Core Standards 18/19 1/19 0/19 HART Core Standards 20/21 1/21 0/21 Full audit results are appended to this report. Based on the NHS England levels of assurance below we conclude that South East Coast Ambulance meets the requirements for Substantial compliance, noting the specific points about the pandemic flu planning arrangements in the next section. Compliance Level Full Substantial Partial Evaluation and Testing Conclusion Arrangements are in place that appropriately addresses all the core standards that the organisation is expected to achieve. The Board has agreed with this position statement. Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Non-compliant Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance. Page 4

5 Pandemic Flu Planning SECAmb appears to score poorly in relation to the pandemic flu deep dive questions however the posed questions do not necessarily demonstrate the preparedness of the organisation in relation to this specific threat. SECAmb are not included in the LHRP Pandemic Flu Plan and are not tasked with specific responsibilities. The organisation was also not invited to the last LHRP Pandemic Flu exercise. The organisations response to a pandemic flu incident is well covered by its other surge, escalation, major incident and business continuity procedures. In discussions with the auditor during the assurance process SECAmb agreed to add an appendix to their major incident plan outlining any specific information for a flu pandemic. It is the conclusion of this audit that the score is therefore not an accurate reflection of SECAmb s ability to respond to and support the response to a pandemic flu incident and should be considered in this context. Audit Narrative SECAmb continue to demonstrate high levels of compliance against the EPRR core standards. The Commissioner can be assured that the trust has in place all necessary and reasonable measures to respond appropriately to both external major incidents and internal business continuity and service disruptions. All identified gaps in compliance have a plan to resolve these within this year. In addition SECAmb have been identified as a source of good practice across the south east regarding its internal reporting and oversight of EPRR arrangements including its post incident procedures for debrief and identifying lessons. SECAmb have also instigated a programme of upskilling their paramedic practitioners to provide additional resilience in the event of an MFTA type incident. Page 5