{"text_format":"1","workbook":"xlsx","n_sheets":8,"sheets":["Control","EPRR Core Standards","Deep Dive Investigation","Action Plan","Interoperable Capabilities","Core Criteria","Deep Dive Criteria","LookUp"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":8,"comments":4,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Control","index":0,"n_rows":41,"n_cols":9,"rows_kept":41,"cut":false,"hidden":false,"merged":[[1,2,1,5],[6,7,8,7],[6,8,8,8]]}
[]
[null,"Please select type of organisation:","ALL ORGANISATION TYPES",null,null,null,{"$f":"IF(Dropdown=\"NHS Ambulance Service Providers\",3,FALSE)","v":false},null,"Publishing Approval Reference: 000719"]
[null,"Click button to format the workbook",null,null,null,null,null,null,1]
[]
[null,"Core Standards","Total standards applicable","Fully compliant","Partially compliant","Non compliant",null,"Overall assessment:",{"$f":"IF(AND(D17=0,E17=0,F17=0),\"Self-assessment not started\",IF(D17=C38,B38,IF(D17>=C39,B39,IF(D17>=C40,B40,B41))))","v":"Self-assessment not started"}]
[null,"Governance",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B6)","v":6},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B6,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B6,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B6,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0}]
[null,"Duty to risk assess",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B7)","v":2},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B7,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B7,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B7,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Interoperable capabilities:",{"$f":"IF(AND(D32=0,E32=0,F32=0),\"Self-assessment not started\",IF(D32=D38,B38,IF(D32>=D39,B39,IF(D32>=D40,B40,B41))))","v":"Self-assessment not started"}]
[null,"Duty to maintain plans",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B8)","v":11},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B8,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B8,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B8,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0}]
[null,"Command and control",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B9)","v":2},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B9,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B9,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B9,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0}]
[null,"Training and exercising",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B10)","v":4},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B10,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B10,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B10,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0}]
[null,"Response",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B11)","v":7},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B11,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B11,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B11,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Instructions:"]
[null,"Warning and informing ",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B12)","v":4},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B12,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B12,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B12,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Step 1: If you see a yellow ribbon at the top of the page and a button asking you to 'Enable Content' please do so."]
[null,"Cooperation",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B13)","v":7},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B13,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B13,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B13,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Step 2: Select the type of organisation from the drop-down at the top of this page"]
[null,"Business Continuity",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B14)","v":11},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B14,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B14,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B14,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Step 3: Click on the 'Format Workbook' button."]
[null,"Hazmat/CBRN   ",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B15)","v":12},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B15,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B15,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B15,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Step 4: Complete the Self-Assessment RAG in the 'EPRR Core Standards' tab"]
[null,"CBRN Support to acute Trusts",{"$f":"COUNTIF('EPRR Core Standards'!$D:$D,$B16)","v":7},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B16,'EPRR Core Standards'!$I:$I,Control!D$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B16,'EPRR Core Standards'!$I:$I,Control!E$5)","v":0},{"$f":"COUNTIFS('EPRR Core Standards'!$D:$D,$B16,'EPRR Core Standards'!$I:$I,Control!F$5)","v":0},null,"Step 5: Complete the Self-Assessment RAG in the 'Deep dive' tab"]
[null,"Total",{"$f":"SUM(C6:C16)","v":73},{"$f":"SUM(D6:D16)","v":0},0,0,null,"Step 6: Ambulance providers only: Complete the Self-Assessment in the 'Interoperable capabilities' tab"]
[null,null,null,null,null,null,null,"Step 7: In the Action Plan tab, click on the 'Format Action Plan' button."]
[null,"Deep Dive","Total standards applicable","Fully compliant","Partially compliant","Non compliant"]
["Deep Dive  \nCyber Security","Cyber Security",{"$f":"COUNTIF('Deep Dive Investigation'!$D:$D,Control!$A20)","v":11},{"$f":"COUNTIFS('Deep Dive Investigation'!$D:$D,Control!$A20,'Deep Dive Investigation'!$I:$I,Control!D$19)","v":0},{"$f":"COUNTIFS('Deep Dive Investigation'!$D:$D,Control!$A20,'Deep Dive Investigation'!$I:$I,Control!E$19)","v":0},{"$f":"COUNTIFS('Deep Dive Investigation'!$D:$D,Control!$A20,'Deep Dive Investigation'!$I:$I,Control!F$19)","v":0}]
[]
[]
[null,"Total",{"$f":"SUM(C20:C20)","v":11},{"$f":"SUM(D20:D20)","v":0},0,0]
[]
[null,"Interoperable capabilities","Total standards applicable","Fully compliant","Partially compliant","Non compliant"]
[null,"HART",{"$f":"COUNTIF('Interoperable Capabilities'!$B:$B,Control!$B26)","v":32},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B26,'Interoperable Capabilities'!$F:$F,Control!D$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B26,'Interoperable Capabilities'!$F:$F,Control!E$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B26,'Interoperable Capabilities'!$F:$F,Control!F$25)","v":0}]
[null,"SORT",{"$f":"COUNTIF('Interoperable Capabilities'!$B:$B,Control!$B27)","v":40},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B27,'Interoperable Capabilities'!$F:$F,Control!D$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B27,'Interoperable Capabilities'!$F:$F,Control!E$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B27,'Interoperable Capabilities'!$F:$F,Control!F$25)","v":0}]
[null,"MassCas",{"$f":"COUNTIF('Interoperable Capabilities'!$B:$B,Control!$B28)","v":14},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B28,'Interoperable Capabilities'!$F:$F,Control!D$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B28,'Interoperable Capabilities'!$F:$F,Control!E$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B28,'Interoperable Capabilities'!$F:$F,Control!F$25)","v":0}]
[null,"C2",{"$f":"COUNTIF('Interoperable Capabilities'!$B:$B,Control!$B29)","v":36},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B29,'Interoperable Capabilities'!$F:$F,Control!D$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B29,'Interoperable Capabilities'!$F:$F,Control!E$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B29,'Interoperable Capabilities'!$F:$F,Control!F$25)","v":0}]
[null,"JESIP",{"$f":"COUNTIF('Interoperable Capabilities'!$B:$B,Control!$B30)","v":13},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B30,'Interoperable Capabilities'!$F:$F,Control!D$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B30,'Interoperable Capabilities'!$F:$F,Control!E$25)","v":0},{"$f":"COUNTIFS('Interoperable Capabilities'!$B:$B,Control!$B30,'Interoperable Capabilities'!$F:$F,Control!F$25)","v":0}]
[]
[null,"Total",{"$f":"SUM(C26:C30)","v":135},{"$f":"SUM(D26:D30)","v":0},{"$f":"SUM(E26:E30)","v":0},{"$f":"SUM(F26:F30)","v":0}]
[]
[]
[]
[]
[null,null,"Core standards","Interoperable capabilities"]
[null,"Fully compliant",{"$f":"100%*C17","v":73},{"$f":"100%*C32","v":135}]
[null,"Substantially compliant",{"$f":"ROUND(89%*C17,0)","v":65},{"$f":"ROUND(89%*C32,0)","v":120}]
[null,"Partially compliant",{"$f":"ROUND(77%*C17,0)","v":56},{"$f":"ROUND(77%*C32,0)","v":104}]
[null,"Non compliant"]

{"sheet":"EPRR Core Standards","index":1,"n_rows":84,"n_cols":13,"rows_kept":84,"cut":false,"hidden":false,"merged":[]}
["Action Plan","Lookup","Ref","Domain","\nStandard name","\nStandard Detail","Supporting Information - including examples of evidence\n","\n\n\nOrganisational Evidence\t\n\n\n\n\n","Self assessment RAG\n\nRed (not compliant) = Not compliant with the core standard. The organisation’s work programme shows compliance will not be reached within the next 12 months.\n\nAmber (partially compliant) = Not compliant with core standard. However, the organisation’s work programme demonstrates sufficient evidence of progress and an action plan to achieve full compliance within the next 12 months.\n\nGreen (fully compliant) = Fully compliant with core standard.","Action to be taken","Lead","Timescale","Comments"]
[{"$f":"IF(OR(LEFT($C2,6)=\"Domain\",$I2=LookUp!$A$3,$I2=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A1)+1,\"\")","v":1},1,{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B2,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 1 - Governance"},{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B2,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B2,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B2,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B2,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C3,6)=\"Domain\",$I3=LookUp!$A$3,$I3=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A2)+1,\"\")","v":""},{"$f":"IFERROR(IF(B2+1>MAX('Core Criteria'!$C:$C),\"\",B2+1),\"\")","v":2},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B3,'Core Criteria'!$C:$V,2,FALSE)))","v":1},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B3,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B3,'Core Criteria'!$C:$V,4,FALSE)))","v":"Senior Leadership"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B3,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has appointed an Accountable Emergency Officer (AEO) responsible for Emergency Preparedness Resilience and Response (EPRR). This individual should be a board level director within their individual organisation, and have the appropriate authority, resources and budget to direct the EPRR portfolio. \n\n"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B3,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence \n• Name and role of appointed individual\n• AEO responsibilities included in role/job description"}]
[{"$f":"IF(OR(LEFT($C4,6)=\"Domain\",$I4=LookUp!$A$3,$I4=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A3)+1,\"\")","v":""},{"$f":"IFERROR(IF(B3+1>MAX('Core Criteria'!$C:$C),\"\",B3+1),\"\")","v":3},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B4,'Core Criteria'!$C:$V,2,FALSE)))","v":2},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B4,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B4,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR Policy Statement "},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B4,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has an overarching EPRR policy or statement of intent.\n\nThis should take into account the organisation’s:\n• Business objectives and processes\n• Key suppliers and contractual arrangements\n• Risk assessment(s)\n• Functions and / or organisation, structural and staff changes.\n\n"},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B4,'Core Criteria'!$C:$V,20,FALSE)))","v":"The policy should: \n• Have a review schedule and version control\n• Use unambiguous terminology\n• Identify those responsible for ensuring policies and arrangements are updated, distributed and regularly tested and exercised\n• Include references to other sources of information and supporting documentation.\n\nEvidence \nUp to date EPRR policy or statement of intent that includes:\n• Resourcing commitment\n• Access to funds\n• Commitment to Emergency Planning, Business Continuity, Training, Exercising etc.\n\n"}]
[{"$f":"IF(OR(LEFT($C5,6)=\"Domain\",$I5=LookUp!$A$3,$I5=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A4)+1,\"\")","v":""},{"$f":"IFERROR(IF(B4+1>MAX('Core Criteria'!$C:$C),\"\",B4+1),\"\")","v":4},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B5,'Core Criteria'!$C:$V,2,FALSE)))","v":3},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B5,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B5,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR board reports"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B5,'Core Criteria'!$C:$V,5,FALSE)))","v":"The Chief Executive Officer ensures that the Accountable Emergency Officer discharges their responsibilities to provide EPRR reports to the Board, no less than annually. \n\nThe organisation publicly states its readiness and preparedness activities in annual reports within the organisation's own regulatory reporting requirements"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B5,'Core Criteria'!$C:$V,20,FALSE)))","v":"These reports should be taken to a public board, and as a minimum, include an overview on:\n• training and exercises undertaken by the organisation\n• summary of any business continuity, critical incidents and major incidents experienced by the organisation\n• lessons identified and learning undertaken from incidents and exercises\n• the organisation's compliance position in relation to the latest NHS England EPRR assurance process.\n\nEvidence\n• Public Board meeting minutes\n• Evidence of presenting the results of the annual EPRR assurance process to the Public Board \n• For those organisations that do not have a public board, a public statement of readiness and preparedness activities."}]
[{"$f":"IF(OR(LEFT($C6,6)=\"Domain\",$I6=LookUp!$A$3,$I6=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A5)+1,\"\")","v":""},{"$f":"IFERROR(IF(B5+1>MAX('Core Criteria'!$C:$C),\"\",B5+1),\"\")","v":5},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B6,'Core Criteria'!$C:$V,2,FALSE)))","v":4},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B6,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B6,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR work programme "},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B6,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has an annual EPRR work programme, informed by:\n• current guidance and good practice\n• lessons identified from incidents and exercises \n• identified risks \n• outcomes of any assurance and audit processes\n\nThe work programme should be regularly reported upon and shared with partners where appropriate. "},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B6,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Reporting process explicitly described within the EPRR policy statement\n• Annual work plan"}]
[{"$f":"IF(OR(LEFT($C7,6)=\"Domain\",$I7=LookUp!$A$3,$I7=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A6)+1,\"\")","v":""},{"$f":"IFERROR(IF(B6+1>MAX('Core Criteria'!$C:$C),\"\",B6+1),\"\")","v":6},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B7,'Core Criteria'!$C:$V,2,FALSE)))","v":5},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B7,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B7,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR Resource"},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B7,'Core Criteria'!$C:$V,5,FALSE)))","v":"The Board / Governing Body is satisfied that the organisation has sufficient and appropriate  resource to ensure it can fully discharge its EPRR duties."},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B7,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• EPRR Policy identifies resources required to fulfil EPRR function; policy has been signed off by the organisation's Board\n• Assessment of role / resources\n• Role description of EPRR Staff/ staff who undertake the EPRR responsibilities\n• Organisation structure chart \n• Internal Governance process chart including EPRR group"}]
[{"$f":"IF(OR(LEFT($C8,6)=\"Domain\",$I8=LookUp!$A$3,$I8=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A7)+1,\"\")","v":""},{"$f":"IFERROR(IF(B7+1>MAX('Core Criteria'!$C:$C),\"\",B7+1),\"\")","v":7},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B8,'Core Criteria'!$C:$V,2,FALSE)))","v":6},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B8,'Core Criteria'!$C:$V,3,FALSE)))","v":"Governance"},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B8,'Core Criteria'!$C:$V,4,FALSE)))","v":"Continuous improvement "},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B8,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has clearly defined processes for capturing learning from incidents and exercises to inform the review and embed into EPRR arrangements. "},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B8,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Process explicitly described within the EPRR policy statement \n• Reporting those lessons to the Board/ governing body and where the improvements to plans were made\n• participation within a regional process for sharing lessons with partner organisations"}]
[{"$f":"IF(OR(LEFT($C9,6)=\"Domain\",$I9=LookUp!$A$3,$I9=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A8)+1,\"\")","v":2},{"$f":"IFERROR(IF(B8+1>MAX('Core Criteria'!$C:$C),\"\",B8+1),\"\")","v":8},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B9,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 2 - Duty to risk assess   "},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B9,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B9,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B9,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B9,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C10,6)=\"Domain\",$I10=LookUp!$A$3,$I10=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A9)+1,\"\")","v":""},{"$f":"IFERROR(IF(B9+1>MAX('Core Criteria'!$C:$C),\"\",B9+1),\"\")","v":9},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B10,'Core Criteria'!$C:$V,2,FALSE)))","v":7},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B10,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to risk assess"},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B10,'Core Criteria'!$C:$V,4,FALSE)))","v":"Risk assessment"},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B10,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has a process in place to regularly assess the risks to the population it serves. This process should consider all relevant risk registers including community and national risk registers.  "},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B10,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Evidence that EPRR risks are regularly considered and recorded\n• Evidence that EPRR risks are represented and recorded on the organisations corporate risk register\n• Risk assessments to consider community risk registers and as a core component, include reasonable worst-case scenarios and extreme events for adverse weather"}]
[{"$f":"IF(OR(LEFT($C11,6)=\"Domain\",$I11=LookUp!$A$3,$I11=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A10)+1,\"\")","v":""},{"$f":"IFERROR(IF(B10+1>MAX('Core Criteria'!$C:$C),\"\",B10+1),\"\")","v":10},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B11,'Core Criteria'!$C:$V,2,FALSE)))","v":8},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B11,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to risk assess"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B11,'Core Criteria'!$C:$V,4,FALSE)))","v":"Risk Management"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B11,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has a robust method of reporting, recording, monitoring, communicating, and escalating EPRR risks internally and externally "},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B11,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• EPRR risks are considered in the organisation's risk management policy \n• Reference to EPRR risk management in the organisation's EPRR policy document "}]
[{"$f":"IF(OR(LEFT($C12,6)=\"Domain\",$I12=LookUp!$A$3,$I12=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A11)+1,\"\")","v":3},{"$f":"IFERROR(IF(B11+1>MAX('Core Criteria'!$C:$C),\"\",B11+1),\"\")","v":11},{"$f":"IF($B12=\"\",\"\",IF(VLOOKUP($B12,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B12,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 3 - Duty to maintain Plans"},{"$f":"IF($B12=\"\",\"\",IF(VLOOKUP($B12,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B12,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B12=\"\",\"\",IF(VLOOKUP($B12,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B12,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B12=\"\",\"\",IF(VLOOKUP($B12,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B12,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B12=\"\",\"\",IF(VLOOKUP($B12,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B12,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C13,6)=\"Domain\",$I13=LookUp!$A$3,$I13=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A12)+1,\"\")","v":""},{"$f":"IFERROR(IF(B12+1>MAX('Core Criteria'!$C:$C),\"\",B12+1),\"\")","v":12},{"$f":"IF($B13=\"\",\"\",IF(VLOOKUP($B13,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B13,'Core Criteria'!$C:$V,2,FALSE)))","v":9},{"$f":"IF($B13=\"\",\"\",IF(VLOOKUP($B13,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B13,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B13=\"\",\"\",IF(VLOOKUP($B13,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B13,'Core Criteria'!$C:$V,4,FALSE)))","v":"Collaborative planning"},{"$f":"IF($B13=\"\",\"\",IF(VLOOKUP($B13,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B13,'Core Criteria'!$C:$V,5,FALSE)))","v":"Plans and arrangements have been developed in collaboration with relevant stakeholders  including emergency services and health partners to enhance joint working arrangements and to ensure the whole patient pathway is considered."},{"$f":"IF($B13=\"\",\"\",IF(VLOOKUP($B13,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B13,'Core Criteria'!$C:$V,20,FALSE)))","v":"Partner organisations collaborated with as part of the planning process are in planning arrangements\n\nEvidence\n• Consultation process in place for plans and arrangements\n• Changes to arrangements as a result of consultation are recorded"}]
[{"$f":"IF(OR(LEFT($C14,6)=\"Domain\",$I14=LookUp!$A$3,$I14=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A13)+1,\"\")","v":""},{"$f":"IFERROR(IF(B13+1>MAX('Core Criteria'!$C:$C),\"\",B13+1),\"\")","v":13},{"$f":"IF($B14=\"\",\"\",IF(VLOOKUP($B14,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B14,'Core Criteria'!$C:$V,2,FALSE)))","v":10},{"$f":"IF($B14=\"\",\"\",IF(VLOOKUP($B14,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B14,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B14=\"\",\"\",IF(VLOOKUP($B14,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B14,'Core Criteria'!$C:$V,4,FALSE)))","v":"Incident Response"},{"$f":"IF($B14=\"\",\"\",IF(VLOOKUP($B14,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B14,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has effective arrangements in place to  define and respond to Critical and Major incidents as defined within the EPRR Framework."},{"$f":"IF($B14=\"\",\"\",IF(VLOOKUP($B14,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B14,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current (reviewed in the last 12 months)\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C15,6)=\"Domain\",$I15=LookUp!$A$3,$I15=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A14)+1,\"\")","v":""},{"$f":"IFERROR(IF(B14+1>MAX('Core Criteria'!$C:$C),\"\",B14+1),\"\")","v":14},{"$f":"IF($B15=\"\",\"\",IF(VLOOKUP($B15,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B15,'Core Criteria'!$C:$V,2,FALSE)))","v":11},{"$f":"IF($B15=\"\",\"\",IF(VLOOKUP($B15,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B15,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B15=\"\",\"\",IF(VLOOKUP($B15,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B15,'Core Criteria'!$C:$V,4,FALSE)))","v":"Adverse Weather"},{"$f":"IF($B15=\"\",\"\",IF(VLOOKUP($B15,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B15,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has effective arrangements in place for adverse weather events. "},{"$f":"IF($B15=\"\",\"\",IF(VLOOKUP($B15,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B15,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national UK Health Security Agency (UKHSA) & NHS guidance and Met Office or Environment Agency alerts \n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n• reflective of climate change risk assessments\n• cognisant of extreme events e.g. drought, storms (including dust storms), wildfire. "}]
[{"$f":"IF(OR(LEFT($C16,6)=\"Domain\",$I16=LookUp!$A$3,$I16=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A15)+1,\"\")","v":""},{"$f":"IFERROR(IF(B15+1>MAX('Core Criteria'!$C:$C),\"\",B15+1),\"\")","v":15},{"$f":"IF($B16=\"\",\"\",IF(VLOOKUP($B16,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B16,'Core Criteria'!$C:$V,2,FALSE)))","v":12},{"$f":"IF($B16=\"\",\"\",IF(VLOOKUP($B16,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B16,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B16=\"\",\"\",IF(VLOOKUP($B16,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B16,'Core Criteria'!$C:$V,4,FALSE)))","v":"Infectious disease"},{"$f":"IF($B16=\"\",\"\",IF(VLOOKUP($B16,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B16,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has arrangements in place to respond to an infectious disease outbreak within the organisation or the community it serves, covering a range of diseases including High Consequence Infectious Diseases."},{"$f":"IF($B16=\"\",\"\",IF(VLOOKUP($B16,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B16,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nAcute providers should ensure their arrangements reflect the guidance issued by DHSC in relation to FFP3 Resilience in Acute setting incorporating the FFP3 resilience principles. https://www.england.nhs.uk/coronavirus/secondary-care/infection-control/ppe/ffp3-fit-testing/ffp3-resilience-principles-in-acute-settings/ "}]
[{"$f":"IF(OR(LEFT($C17,6)=\"Domain\",$I17=LookUp!$A$3,$I17=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A16)+1,\"\")","v":""},{"$f":"IFERROR(IF(B16+1>MAX('Core Criteria'!$C:$C),\"\",B16+1),\"\")","v":16},{"$f":"IF($B17=\"\",\"\",IF(VLOOKUP($B17,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B17,'Core Criteria'!$C:$V,2,FALSE)))","v":13},{"$f":"IF($B17=\"\",\"\",IF(VLOOKUP($B17,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B17,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B17=\"\",\"\",IF(VLOOKUP($B17,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B17,'Core Criteria'!$C:$V,4,FALSE)))","v":"New and emerging pandemics  "},{"$f":"IF($B17=\"\",\"\",IF(VLOOKUP($B17,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B17,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation and reflecting recent lessons identified, the organisation has arrangements in place to respond to a new and emerging pandemic "},{"$f":"IF($B17=\"\",\"\",IF(VLOOKUP($B17,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B17,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C18,6)=\"Domain\",$I18=LookUp!$A$3,$I18=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A17)+1,\"\")","v":""},{"$f":"IFERROR(IF(B17+1>MAX('Core Criteria'!$C:$C),\"\",B17+1),\"\")","v":17},{"$f":"IF($B18=\"\",\"\",IF(VLOOKUP($B18,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B18,'Core Criteria'!$C:$V,2,FALSE)))","v":14},{"$f":"IF($B18=\"\",\"\",IF(VLOOKUP($B18,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B18,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B18=\"\",\"\",IF(VLOOKUP($B18,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B18,'Core Criteria'!$C:$V,4,FALSE)))","v":"Countermeasures"},{"$f":"IF($B18=\"\",\"\",IF(VLOOKUP($B18,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B18,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has arrangements in place \nto support an incident requiring countermeasures or a mass countermeasure deployment\n\n\n"},{"$f":"IF($B18=\"\",\"\",IF(VLOOKUP($B18,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B18,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nMass Countermeasure arrangements should include arrangements for administration, reception and distribution of mass prophylaxis and mass vaccination. \n\nThere may be a requirement for Specialist providers, Community Service Providers, Mental Health and Primary Care services to develop or support Mass Countermeasure distribution arrangements. Organisations should have plans to support patients in their care during activation of mass countermeasure arrangements. \n\nCommissioners may be required to commission new services to support mass countermeasure distribution locally, this will be dependant on the incident."}]
[{"$f":"IF(OR(LEFT($C19,6)=\"Domain\",$I19=LookUp!$A$3,$I19=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A18)+1,\"\")","v":""},{"$f":"IFERROR(IF(B18+1>MAX('Core Criteria'!$C:$C),\"\",B18+1),\"\")","v":18},{"$f":"IF($B19=\"\",\"\",IF(VLOOKUP($B19,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B19,'Core Criteria'!$C:$V,2,FALSE)))","v":15},{"$f":"IF($B19=\"\",\"\",IF(VLOOKUP($B19,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B19,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B19=\"\",\"\",IF(VLOOKUP($B19,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B19,'Core Criteria'!$C:$V,4,FALSE)))","v":"Mass Casualty "},{"$f":"IF($B19=\"\",\"\",IF(VLOOKUP($B19,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B19,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has effective arrangements in place to respond to incidents with mass casualties. \n\n"},{"$f":"IF($B19=\"\",\"\",IF(VLOOKUP($B19,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B19,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nReceiving organisations should also include a safe identification system for unidentified patients in an emergency/mass casualty incident where necessary. "}]
[{"$f":"IF(OR(LEFT($C20,6)=\"Domain\",$I20=LookUp!$A$3,$I20=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A19)+1,\"\")","v":""},{"$f":"IFERROR(IF(B19+1>MAX('Core Criteria'!$C:$C),\"\",B19+1),\"\")","v":19},{"$f":"IF($B20=\"\",\"\",IF(VLOOKUP($B20,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B20,'Core Criteria'!$C:$V,2,FALSE)))","v":16},{"$f":"IF($B20=\"\",\"\",IF(VLOOKUP($B20,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B20,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B20=\"\",\"\",IF(VLOOKUP($B20,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B20,'Core Criteria'!$C:$V,4,FALSE)))","v":"\nEvacuation and shelter"},{"$f":"IF($B20=\"\",\"\",IF(VLOOKUP($B20,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B20,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has arrangements in place to  evacuate and shelter patients, staff and visitors.    "},{"$f":"IF($B20=\"\",\"\",IF(VLOOKUP($B20,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B20,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C21,6)=\"Domain\",$I21=LookUp!$A$3,$I21=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A20)+1,\"\")","v":""},{"$f":"IFERROR(IF(B20+1>MAX('Core Criteria'!$C:$C),\"\",B20+1),\"\")","v":20},{"$f":"IF($B21=\"\",\"\",IF(VLOOKUP($B21,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B21,'Core Criteria'!$C:$V,2,FALSE)))","v":17},{"$f":"IF($B21=\"\",\"\",IF(VLOOKUP($B21,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B21,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B21=\"\",\"\",IF(VLOOKUP($B21,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B21,'Core Criteria'!$C:$V,4,FALSE)))","v":"Lockdown"},{"$f":"IF($B21=\"\",\"\",IF(VLOOKUP($B21,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B21,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance, regulation and legislation, the organisation has arrangements in place to control access and egress for patients, staff and visitors to and from the organisation's premises and key assets in an incident. "},{"$f":"IF($B21=\"\",\"\",IF(VLOOKUP($B21,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B21,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C22,6)=\"Domain\",$I22=LookUp!$A$3,$I22=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A21)+1,\"\")","v":""},{"$f":"IFERROR(IF(B21+1>MAX('Core Criteria'!$C:$C),\"\",B21+1),\"\")","v":21},{"$f":"IF($B22=\"\",\"\",IF(VLOOKUP($B22,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B22,'Core Criteria'!$C:$V,2,FALSE)))","v":18},{"$f":"IF($B22=\"\",\"\",IF(VLOOKUP($B22,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B22,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B22=\"\",\"\",IF(VLOOKUP($B22,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B22,'Core Criteria'!$C:$V,4,FALSE)))","v":"Protected individuals"},{"$f":"IF($B22=\"\",\"\",IF(VLOOKUP($B22,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B22,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has arrangements in place to respond and manage  'protected individuals' including Very Important Persons (VIPs),high profile patients and visitors to the site. "},{"$f":"IF($B22=\"\",\"\",IF(VLOOKUP($B22,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B22,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C23,6)=\"Domain\",$I23=LookUp!$A$3,$I23=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A22)+1,\"\")","v":""},{"$f":"IFERROR(IF(B22+1>MAX('Core Criteria'!$C:$C),\"\",B22+1),\"\")","v":22},{"$f":"IF($B23=\"\",\"\",IF(VLOOKUP($B23,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B23,'Core Criteria'!$C:$V,2,FALSE)))","v":19},{"$f":"IF($B23=\"\",\"\",IF(VLOOKUP($B23,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B23,'Core Criteria'!$C:$V,3,FALSE)))","v":"Duty to maintain plans"},{"$f":"IF($B23=\"\",\"\",IF(VLOOKUP($B23,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B23,'Core Criteria'!$C:$V,4,FALSE)))","v":"Excess fatalities "},{"$f":"IF($B23=\"\",\"\",IF(VLOOKUP($B23,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B23,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has contributed to, and understands, its role in the multiagency arrangements for excess deaths and mass fatalities, including mortuary arrangements. This includes arrangements for rising tide and sudden onset events."},{"$f":"IF($B23=\"\",\"\",IF(VLOOKUP($B23,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B23,'Core Criteria'!$C:$V,20,FALSE)))","v":"Arrangements should be: \n• current\n• in line with current national guidance\nin line with DVI processes\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "}]
[{"$f":"IF(OR(LEFT($C24,6)=\"Domain\",$I24=LookUp!$A$3,$I24=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A23)+1,\"\")","v":4},{"$f":"IFERROR(IF(B23+1>MAX('Core Criteria'!$C:$C),\"\",B23+1),\"\")","v":23},{"$f":"IF($B24=\"\",\"\",IF(VLOOKUP($B24,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B24,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 4 - Command and control"},{"$f":"IF($B24=\"\",\"\",IF(VLOOKUP($B24,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B24,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B24=\"\",\"\",IF(VLOOKUP($B24,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B24,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B24=\"\",\"\",IF(VLOOKUP($B24,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B24,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B24=\"\",\"\",IF(VLOOKUP($B24,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B24,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C25,6)=\"Domain\",$I25=LookUp!$A$3,$I25=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A24)+1,\"\")","v":""},{"$f":"IFERROR(IF(B24+1>MAX('Core Criteria'!$C:$C),\"\",B24+1),\"\")","v":24},{"$f":"IF($B25=\"\",\"\",IF(VLOOKUP($B25,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B25,'Core Criteria'!$C:$V,2,FALSE)))","v":20},{"$f":"IF($B25=\"\",\"\",IF(VLOOKUP($B25,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B25,'Core Criteria'!$C:$V,3,FALSE)))","v":"Command and control"},{"$f":"IF($B25=\"\",\"\",IF(VLOOKUP($B25,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B25,'Core Criteria'!$C:$V,4,FALSE)))","v":"On-call mechanism"},{"$f":"IF($B25=\"\",\"\",IF(VLOOKUP($B25,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B25,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has resilient and dedicated mechanisms and structures to enable 24/7 receipt and action of incident notifications, internal or external. This should provide the facility to respond to or escalate notifications to an executive level. "},{"$f":"IF($B25=\"\",\"\",IF(VLOOKUP($B25,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B25,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Process explicitly described within the EPRR policy statement\n• On call Standards and expectations are set out\n• Add on call processes/handbook available to staff on call\n• Include 24 hour arrangements for alerting managers and other key staff.\n• CSUs where they are delivering OOHs business critical services for providers and commissioners"}]
[{"$f":"IF(OR(LEFT($C26,6)=\"Domain\",$I26=LookUp!$A$3,$I26=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A25)+1,\"\")","v":""},{"$f":"IFERROR(IF(B25+1>MAX('Core Criteria'!$C:$C),\"\",B25+1),\"\")","v":25},{"$f":"IF($B26=\"\",\"\",IF(VLOOKUP($B26,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B26,'Core Criteria'!$C:$V,2,FALSE)))","v":21},{"$f":"IF($B26=\"\",\"\",IF(VLOOKUP($B26,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B26,'Core Criteria'!$C:$V,3,FALSE)))","v":"Command and control"},{"$f":"IF($B26=\"\",\"\",IF(VLOOKUP($B26,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B26,'Core Criteria'!$C:$V,4,FALSE)))","v":"Trained on-call staff"},{"$f":"IF($B26=\"\",\"\",IF(VLOOKUP($B26,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B26,'Core Criteria'!$C:$V,5,FALSE)))","v":"Trained and up to date staff are available 24/7 to manage escalations, make decisions and identify key actions\n"},{"$f":"IF($B26=\"\",\"\",IF(VLOOKUP($B26,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B26,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Process explicitly described within the EPRR policy or statement of intent\n\nThe identified individual:  \n• Should be trained according to the NHS England EPRR competencies (National  Minimum Occupational Standards) \n• Has a specific process to adopt during the decision making \n• Is aware who should be consulted and informed during decision making \n• Should ensure appropriate records are maintained throughout.\n• Trained in accordance with the TNA identified frequency."}]
[{"$f":"IF(OR(LEFT($C27,6)=\"Domain\",$I27=LookUp!$A$3,$I27=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A26)+1,\"\")","v":5},{"$f":"IFERROR(IF(B26+1>MAX('Core Criteria'!$C:$C),\"\",B26+1),\"\")","v":26},{"$f":"IF($B27=\"\",\"\",IF(VLOOKUP($B27,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B27,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 5 - Training and exercising"},{"$f":"IF($B27=\"\",\"\",IF(VLOOKUP($B27,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B27,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B27=\"\",\"\",IF(VLOOKUP($B27,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B27,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B27=\"\",\"\",IF(VLOOKUP($B27,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B27,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B27=\"\",\"\",IF(VLOOKUP($B27,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B27,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C28,6)=\"Domain\",$I28=LookUp!$A$3,$I28=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A27)+1,\"\")","v":""},{"$f":"IFERROR(IF(B27+1>MAX('Core Criteria'!$C:$C),\"\",B27+1),\"\")","v":27},{"$f":"IF($B28=\"\",\"\",IF(VLOOKUP($B28,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B28,'Core Criteria'!$C:$V,2,FALSE)))","v":22},{"$f":"IF($B28=\"\",\"\",IF(VLOOKUP($B28,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B28,'Core Criteria'!$C:$V,3,FALSE)))","v":"Training and exercising"},{"$f":"IF($B28=\"\",\"\",IF(VLOOKUP($B28,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B28,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR Training "},{"$f":"IF($B28=\"\",\"\",IF(VLOOKUP($B28,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B28,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation carries out training in line with a training needs analysis to ensure staff are current in their response role."},{"$f":"IF($B28=\"\",\"\",IF(VLOOKUP($B28,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B28,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Process explicitly described within the EPRR policy or statement of intent\n• Evidence of a training needs analysis\n• Training records for all staff on call and those performing a role within the ICC \n• Training materials\n• Evidence of personal training and exercising portfolios for key staff\n"}]
[{"$f":"IF(OR(LEFT($C29,6)=\"Domain\",$I29=LookUp!$A$3,$I29=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A28)+1,\"\")","v":""},{"$f":"IFERROR(IF(B28+1>MAX('Core Criteria'!$C:$C),\"\",B28+1),\"\")","v":28},{"$f":"IF($B29=\"\",\"\",IF(VLOOKUP($B29,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B29,'Core Criteria'!$C:$V,2,FALSE)))","v":23},{"$f":"IF($B29=\"\",\"\",IF(VLOOKUP($B29,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B29,'Core Criteria'!$C:$V,3,FALSE)))","v":"Training and exercising"},{"$f":"IF($B29=\"\",\"\",IF(VLOOKUP($B29,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B29,'Core Criteria'!$C:$V,4,FALSE)))","v":"EPRR exercising and testing programme "},{"$f":"IF($B29=\"\",\"\",IF(VLOOKUP($B29,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B29,'Core Criteria'!$C:$V,5,FALSE)))","v":"In accordance with the minimum requirements, in line with current guidance, the organisation has an exercising and testing programme to safely* test incident response arrangements, (*no undue risk to exercise players or participants, or those  patients in your care)"},{"$f":"IF($B29=\"\",\"\",IF(VLOOKUP($B29,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B29,'Core Criteria'!$C:$V,20,FALSE)))","v":"Organisations should meet the following exercising and testing requirements: \n• a six-monthly communications test\n• annual table top exercise \n• live exercise at least once every three years\n• command post exercise every three years.\n\nThe exercising programme must:\n• identify exercises relevant to local risks\n• meet the needs of the organisation type and stakeholders\n• ensure warning and informing arrangements are effective.\n\nLessons identified must be captured, recorded and acted upon as part of continuous improvement. \n\nEvidence\n• Exercising Schedule which includes as a minimum one Business Continuity exercise\n• Post exercise reports and embedding learning"}]
[{"$f":"IF(OR(LEFT($C30,6)=\"Domain\",$I30=LookUp!$A$3,$I30=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A29)+1,\"\")","v":""},{"$f":"IFERROR(IF(B29+1>MAX('Core Criteria'!$C:$C),\"\",B29+1),\"\")","v":29},{"$f":"IF($B30=\"\",\"\",IF(VLOOKUP($B30,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B30,'Core Criteria'!$C:$V,2,FALSE)))","v":24},{"$f":"IF($B30=\"\",\"\",IF(VLOOKUP($B30,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B30,'Core Criteria'!$C:$V,3,FALSE)))","v":"Training and exercising"},{"$f":"IF($B30=\"\",\"\",IF(VLOOKUP($B30,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B30,'Core Criteria'!$C:$V,4,FALSE)))","v":"Responder training"},{"$f":"IF($B30=\"\",\"\",IF(VLOOKUP($B30,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B30,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has the ability to maintain training records and exercise attendance of all staff with key roles for response in accordance with the Minimum Occupational Standards.\n\nIndividual responders and key decision makers should be supported to maintain a continuous personal development portfolio including involvement in exercising and incident response as well as any training undertaken to fulfil their role\n"},{"$f":"IF($B30=\"\",\"\",IF(VLOOKUP($B30,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B30,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Training records\n• Evidence of personal training and exercising portfolios for key staff"}]
[{"$f":"IF(OR(LEFT($C31,6)=\"Domain\",$I31=LookUp!$A$3,$I31=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A30)+1,\"\")","v":""},{"$f":"IFERROR(IF(B30+1>MAX('Core Criteria'!$C:$C),\"\",B30+1),\"\")","v":30},{"$f":"IF($B31=\"\",\"\",IF(VLOOKUP($B31,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B31,'Core Criteria'!$C:$V,2,FALSE)))","v":25},{"$f":"IF($B31=\"\",\"\",IF(VLOOKUP($B31,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B31,'Core Criteria'!$C:$V,3,FALSE)))","v":"Training and exercising"},{"$f":"IF($B31=\"\",\"\",IF(VLOOKUP($B31,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B31,'Core Criteria'!$C:$V,4,FALSE)))","v":"Staff Awareness & Training"},{"$f":"IF($B31=\"\",\"\",IF(VLOOKUP($B31,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B31,'Core Criteria'!$C:$V,5,FALSE)))","v":"There are mechanisms in place to ensure staff are aware of their role in an incident and where to find plans relevant to their area of work or department.\n\n"},{"$f":"IF($B31=\"\",\"\",IF(VLOOKUP($B31,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B31,'Core Criteria'!$C:$V,20,FALSE)))","v":"As part of mandatory training \nExercise and Training attendance records reported to Board"}]
[{"$f":"IF(OR(LEFT($C32,6)=\"Domain\",$I32=LookUp!$A$3,$I32=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A31)+1,\"\")","v":6},{"$f":"IFERROR(IF(B31+1>MAX('Core Criteria'!$C:$C),\"\",B31+1),\"\")","v":31},{"$f":"IF($B32=\"\",\"\",IF(VLOOKUP($B32,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B32,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 6 - Response "},{"$f":"IF($B32=\"\",\"\",IF(VLOOKUP($B32,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B32,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B32=\"\",\"\",IF(VLOOKUP($B32,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B32,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B32=\"\",\"\",IF(VLOOKUP($B32,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B32,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B32=\"\",\"\",IF(VLOOKUP($B32,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B32,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C33,6)=\"Domain\",$I33=LookUp!$A$3,$I33=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A32)+1,\"\")","v":""},{"$f":"IFERROR(IF(B32+1>MAX('Core Criteria'!$C:$C),\"\",B32+1),\"\")","v":32},{"$f":"IF($B33=\"\",\"\",IF(VLOOKUP($B33,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B33,'Core Criteria'!$C:$V,2,FALSE)))","v":26},{"$f":"IF($B33=\"\",\"\",IF(VLOOKUP($B33,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B33,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B33=\"\",\"\",IF(VLOOKUP($B33,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B33,'Core Criteria'!$C:$V,4,FALSE)))","v":"Incident Co-ordination Centre (ICC) "},{"$f":"IF($B33=\"\",\"\",IF(VLOOKUP($B33,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B33,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has in place suitable and sufficient arrangements to effectively coordinate the response to an incident in line with national guidance. ICC arrangements need to be flexible and scalable to cope with a range of incidents and hours of operation required.\n\nAn ICC must have dedicated business continuity arrangements in place and must be resilient to loss of utilities, including telecommunications, and to external hazards.\n\n ICC equipment should be  tested  in line with national guidance or after a major infrastructure change to ensure functionality and in a state of organisational readiness.\n\nArrangements should be supported with access to documentation for its activation and operation."},{"$f":"IF($B33=\"\",\"\",IF(VLOOKUP($B33,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B33,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Documented processes for identifying the location and establishing an ICC\n• Maps and diagrams\n• A testing schedule\n• A training schedule\n• Pre identified roles and responsibilities, with action cards\n• Demonstration ICC location is resilient to loss of utilities, including telecommunications, and external hazards\n• Arrangements might include virtual arrangements in addition to physical facilities but must be resilient with alternative contingency solutions. \n"}]
[{"$f":"IF(OR(LEFT($C34,6)=\"Domain\",$I34=LookUp!$A$3,$I34=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A33)+1,\"\")","v":""},{"$f":"IFERROR(IF(B33+1>MAX('Core Criteria'!$C:$C),\"\",B33+1),\"\")","v":33},{"$f":"IF($B34=\"\",\"\",IF(VLOOKUP($B34,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B34,'Core Criteria'!$C:$V,2,FALSE)))","v":27},{"$f":"IF($B34=\"\",\"\",IF(VLOOKUP($B34,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B34,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B34=\"\",\"\",IF(VLOOKUP($B34,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B34,'Core Criteria'!$C:$V,4,FALSE)))","v":"Access to planning arrangements"},{"$f":"IF($B34=\"\",\"\",IF(VLOOKUP($B34,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B34,'Core Criteria'!$C:$V,5,FALSE)))","v":"Version controlled current response documents are available to relevant staff at all times. Staff should be aware of where they are stored and should be easily accessible.  "},{"$f":"IF($B34=\"\",\"\",IF(VLOOKUP($B34,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B34,'Core Criteria'!$C:$V,20,FALSE)))","v":"Planning arrangements are easily accessible - both electronically and local copies "}]
[{"$f":"IF(OR(LEFT($C35,6)=\"Domain\",$I35=LookUp!$A$3,$I35=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A34)+1,\"\")","v":""},{"$f":"IFERROR(IF(B34+1>MAX('Core Criteria'!$C:$C),\"\",B34+1),\"\")","v":34},{"$f":"IF($B35=\"\",\"\",IF(VLOOKUP($B35,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B35,'Core Criteria'!$C:$V,2,FALSE)))","v":28},{"$f":"IF($B35=\"\",\"\",IF(VLOOKUP($B35,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B35,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B35=\"\",\"\",IF(VLOOKUP($B35,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B35,'Core Criteria'!$C:$V,4,FALSE)))","v":"Management of business continuity incidents"},{"$f":"IF($B35=\"\",\"\",IF(VLOOKUP($B35,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B35,'Core Criteria'!$C:$V,5,FALSE)))","v":"In line with current guidance and legislation, the organisation has effective arrangements in place to respond to a business continuity incident (as defined within the EPRR Framework). "},{"$f":"IF($B35=\"\",\"\",IF(VLOOKUP($B35,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B35,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Business Continuity Response plans\n• Arrangements in place that mitigate escalation to business continuity incident\n• Escalation processes"}]
[{"$f":"IF(OR(LEFT($C36,6)=\"Domain\",$I36=LookUp!$A$3,$I36=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A35)+1,\"\")","v":""},{"$f":"IFERROR(IF(B35+1>MAX('Core Criteria'!$C:$C),\"\",B35+1),\"\")","v":35},{"$f":"IF($B36=\"\",\"\",IF(VLOOKUP($B36,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B36,'Core Criteria'!$C:$V,2,FALSE)))","v":29},{"$f":"IF($B36=\"\",\"\",IF(VLOOKUP($B36,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B36,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B36=\"\",\"\",IF(VLOOKUP($B36,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B36,'Core Criteria'!$C:$V,4,FALSE)))","v":"Decision Logging"},{"$f":"IF($B36=\"\",\"\",IF(VLOOKUP($B36,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B36,'Core Criteria'!$C:$V,5,FALSE)))","v":"To ensure decisions are recorded during business continuity, critical and major incidents, the organisation must ensure:\n1. Key response staff are aware of the need for creating their own personal records and decision logs to the required standards and storing them in accordance with the organisations' records management policy.\n2. has 24 hour access to a trained loggist(s) to ensure support to the decision maker"},{"$f":"IF($B36=\"\",\"\",IF(VLOOKUP($B36,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B36,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Documented processes for accessing and utilising loggists\n• Training records"}]
[{"$f":"IF(OR(LEFT($C37,6)=\"Domain\",$I37=LookUp!$A$3,$I37=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A36)+1,\"\")","v":""},{"$f":"IFERROR(IF(B36+1>MAX('Core Criteria'!$C:$C),\"\",B36+1),\"\")","v":36},{"$f":"IF($B37=\"\",\"\",IF(VLOOKUP($B37,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B37,'Core Criteria'!$C:$V,2,FALSE)))","v":30},{"$f":"IF($B37=\"\",\"\",IF(VLOOKUP($B37,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B37,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B37=\"\",\"\",IF(VLOOKUP($B37,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B37,'Core Criteria'!$C:$V,4,FALSE)))","v":"Situation Reports"},{"$f":"IF($B37=\"\",\"\",IF(VLOOKUP($B37,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B37,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has processes in place for receiving, completing, authorising and submitting situation reports (SitReps) and briefings during the response to incidents including bespoke or incident dependent formats."},{"$f":"IF($B37=\"\",\"\",IF(VLOOKUP($B37,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B37,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Documented processes for completing, quality assuring, signing off and submitting SitReps\n• Evidence of testing and exercising\n• The organisation has access to the standard SitRep Template"}]
[{"$f":"IF(OR(LEFT($C38,6)=\"Domain\",$I38=LookUp!$A$3,$I38=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A37)+1,\"\")","v":""},{"$f":"IFERROR(IF(B37+1>MAX('Core Criteria'!$C:$C),\"\",B37+1),\"\")","v":37},{"$f":"IF($B38=\"\",\"\",IF(VLOOKUP($B38,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B38,'Core Criteria'!$C:$V,2,FALSE)))","v":31},{"$f":"IF($B38=\"\",\"\",IF(VLOOKUP($B38,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B38,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B38=\"\",\"\",IF(VLOOKUP($B38,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B38,'Core Criteria'!$C:$V,4,FALSE)))","v":"Access to 'Clinical Guidelines for Major Incidents and Mass Casualty events’"},{"$f":"IF($B38=\"\",\"\",IF(VLOOKUP($B38,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B38,'Core Criteria'!$C:$V,5,FALSE)))","v":"Key clinical staff (especially emergency department) have access to the ‘Clinical Guidelines for Major Incidents and Mass Casualty events’ handbook."},{"$f":"IF($B38=\"\",\"\",IF(VLOOKUP($B38,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B38,'Core Criteria'!$C:$V,20,FALSE)))","v":"Guidance is available to appropriate staff either electronically or hard copies"}]
[{"$f":"IF(OR(LEFT($C39,6)=\"Domain\",$I39=LookUp!$A$3,$I39=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A38)+1,\"\")","v":""},{"$f":"IFERROR(IF(B38+1>MAX('Core Criteria'!$C:$C),\"\",B38+1),\"\")","v":38},{"$f":"IF($B39=\"\",\"\",IF(VLOOKUP($B39,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B39,'Core Criteria'!$C:$V,2,FALSE)))","v":32},{"$f":"IF($B39=\"\",\"\",IF(VLOOKUP($B39,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B39,'Core Criteria'!$C:$V,3,FALSE)))","v":"Response"},{"$f":"IF($B39=\"\",\"\",IF(VLOOKUP($B39,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B39,'Core Criteria'!$C:$V,4,FALSE)))","v":"Access to ‘CBRN incident: Clinical Management and health protection’"},{"$f":"IF($B39=\"\",\"\",IF(VLOOKUP($B39,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B39,'Core Criteria'!$C:$V,5,FALSE)))","v":"Clinical staff have access to the ‘CBRN incident: Clinical Management and health protection’ guidance. (Formerly published by PHE)"},{"$f":"IF($B39=\"\",\"\",IF(VLOOKUP($B39,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B39,'Core Criteria'!$C:$V,20,FALSE)))","v":"Guidance is available to appropriate staff either electronically or hard copies"}]
[{"$f":"IF(OR(LEFT($C40,6)=\"Domain\",$I40=LookUp!$A$3,$I40=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A39)+1,\"\")","v":7},{"$f":"IFERROR(IF(B39+1>MAX('Core Criteria'!$C:$C),\"\",B39+1),\"\")","v":39},{"$f":"IF($B40=\"\",\"\",IF(VLOOKUP($B40,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B40,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 7 - Warning and informing"},{"$f":"IF($B40=\"\",\"\",IF(VLOOKUP($B40,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B40,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B40=\"\",\"\",IF(VLOOKUP($B40,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B40,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B40=\"\",\"\",IF(VLOOKUP($B40,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B40,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B40=\"\",\"\",IF(VLOOKUP($B40,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B40,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C41,6)=\"Domain\",$I41=LookUp!$A$3,$I41=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A40)+1,\"\")","v":""},{"$f":"IFERROR(IF(B40+1>MAX('Core Criteria'!$C:$C),\"\",B40+1),\"\")","v":40},{"$f":"IF($B41=\"\",\"\",IF(VLOOKUP($B41,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B41,'Core Criteria'!$C:$V,2,FALSE)))","v":33},{"$f":"IF($B41=\"\",\"\",IF(VLOOKUP($B41,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B41,'Core Criteria'!$C:$V,3,FALSE)))","v":"Warning and informing "},{"$f":"IF($B41=\"\",\"\",IF(VLOOKUP($B41,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B41,'Core Criteria'!$C:$V,4,FALSE)))","v":"Warning and informing"},{"$f":"IF($B41=\"\",\"\",IF(VLOOKUP($B41,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B41,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation aligns communications planning and activity with the organisation’s EPRR planning and activity.\n\n"},{"$f":"IF($B41=\"\",\"\",IF(VLOOKUP($B41,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B41,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Awareness within communications team of the organisation’s EPRR plan, and how to report potential incidents.\n• Measures are in place to ensure incidents are appropriately described and declared in line with the NHS EPRR Framework.\n• Out of hours communication system (24/7, year-round) is in place to allow access to trained comms support for senior leaders during an incident. This should include on call arrangements.\n• Having a process for being able to log incoming requests, track responses to these requests and to ensure that information related to incidents is stored effectively. This will allow organisations to provide evidence should it be required for an inquiry. \n"}]
[{"$f":"IF(OR(LEFT($C42,6)=\"Domain\",$I42=LookUp!$A$3,$I42=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A41)+1,\"\")","v":""},{"$f":"IFERROR(IF(B41+1>MAX('Core Criteria'!$C:$C),\"\",B41+1),\"\")","v":41},{"$f":"IF($B42=\"\",\"\",IF(VLOOKUP($B42,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B42,'Core Criteria'!$C:$V,2,FALSE)))","v":34},{"$f":"IF($B42=\"\",\"\",IF(VLOOKUP($B42,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B42,'Core Criteria'!$C:$V,3,FALSE)))","v":"Warning and informing "},{"$f":"IF($B42=\"\",\"\",IF(VLOOKUP($B42,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B42,'Core Criteria'!$C:$V,4,FALSE)))","v":"Incident Communication Plan"},{"$f":"IF($B42=\"\",\"\",IF(VLOOKUP($B42,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B42,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has a plan in place for communicating during an incident which can be enacted."},{"$f":"IF($B42=\"\",\"\",IF(VLOOKUP($B42,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B42,'Core Criteria'!$C:$V,20,FALSE)))","v":"• An incident communications plan has been developed and is available to on call communications staff\n• The incident communications plan has been tested both in and out of hours\n• Action cards have been developed for communications roles\n• A requirement for briefing NHS England regional communications team has been established\n• The plan has been tested, both in and out of hours as part of an exercise.\n• Clarity on sign off for communications is included in the plan, noting the need to ensure communications are signed off by incident leads, as well as NHSE (if appropriate). "}]
[{"$f":"IF(OR(LEFT($C43,6)=\"Domain\",$I43=LookUp!$A$3,$I43=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A42)+1,\"\")","v":""},{"$f":"IFERROR(IF(B42+1>MAX('Core Criteria'!$C:$C),\"\",B42+1),\"\")","v":42},{"$f":"IF($B43=\"\",\"\",IF(VLOOKUP($B43,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B43,'Core Criteria'!$C:$V,2,FALSE)))","v":35},{"$f":"IF($B43=\"\",\"\",IF(VLOOKUP($B43,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B43,'Core Criteria'!$C:$V,3,FALSE)))","v":"Warning and informing "},{"$f":"IF($B43=\"\",\"\",IF(VLOOKUP($B43,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B43,'Core Criteria'!$C:$V,4,FALSE)))","v":"Communication with partners and stakeholders "},{"$f":"IF($B43=\"\",\"\",IF(VLOOKUP($B43,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B43,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has arrangements in place to communicate with patients, staff, partner organisations, stakeholders, and the public before, during and after a major incident, critical incident or business continuity incident."},{"$f":"IF($B43=\"\",\"\",IF(VLOOKUP($B43,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B43,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Established means of communicating with staff, at both short notice and for the duration of the incident, including out of hours communications\n• A developed list of contacts in partner organisations who are key to service delivery (local Council, LRF partners, neighbouring NHS organisations etc) and a means of warning and informing these organisations about an incident as well as sharing communications information with partner organisations to create consistent messages at a local, regional and national level.\n• A developed list of key local stakeholders (such as local elected officials, unions etc) and an established a process by which to brief local stakeholders during an incident\n• Appropriate channels for communicating with members of the public that can be used 24/7 if required \n• Identified sites within the organisation for displaying of important public information (such as main points of access)\n• Have in place a means of communicating with patients who have appointments booked or are receiving treatment. \n• Have in place a plan to communicate with inpatients and their families or care givers.\n• The organisation publicly states its readiness and preparedness activities in annual reports within the organisations own regulatory reporting requirements"}]
[{"$f":"IF(OR(LEFT($C44,6)=\"Domain\",$I44=LookUp!$A$3,$I44=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A43)+1,\"\")","v":""},{"$f":"IFERROR(IF(B43+1>MAX('Core Criteria'!$C:$C),\"\",B43+1),\"\")","v":43},{"$f":"IF($B44=\"\",\"\",IF(VLOOKUP($B44,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B44,'Core Criteria'!$C:$V,2,FALSE)))","v":36},{"$f":"IF($B44=\"\",\"\",IF(VLOOKUP($B44,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B44,'Core Criteria'!$C:$V,3,FALSE)))","v":"Warning and informing "},{"$f":"IF($B44=\"\",\"\",IF(VLOOKUP($B44,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B44,'Core Criteria'!$C:$V,4,FALSE)))","v":"Media strategy"},{"$f":"IF($B44=\"\",\"\",IF(VLOOKUP($B44,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B44,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has arrangements in place to enable rapid and structured communication via the media and social media"},{"$f":"IF($B44=\"\",\"\",IF(VLOOKUP($B44,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B44,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Having an agreed media strategy and a plan for how this will be enacted during an incident. This will allow for timely distribution of information to warn and inform the media \n• Develop a pool of media spokespeople able to represent the organisation to the media at all times.\n• Social Media policy and monitoring in place to identify and track information on social media relating to incidents.\n• Setting up protocols for using social media to warn and inform\n• Specifying advice to senior staff to effectively use  social media accounts whilst the organisation is in incident response "}]
[{"$f":"IF(OR(LEFT($C45,6)=\"Domain\",$I45=LookUp!$A$3,$I45=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A44)+1,\"\")","v":8},{"$f":"IFERROR(IF(B44+1>MAX('Core Criteria'!$C:$C),\"\",B44+1),\"\")","v":44},{"$f":"IF($B45=\"\",\"\",IF(VLOOKUP($B45,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B45,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 8 - Cooperation "},{"$f":"IF($B45=\"\",\"\",IF(VLOOKUP($B45,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B45,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B45=\"\",\"\",IF(VLOOKUP($B45,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B45,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B45=\"\",\"\",IF(VLOOKUP($B45,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B45,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B45=\"\",\"\",IF(VLOOKUP($B45,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B45,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C46,6)=\"Domain\",$I46=LookUp!$A$3,$I46=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A45)+1,\"\")","v":""},{"$f":"IFERROR(IF(B45+1>MAX('Core Criteria'!$C:$C),\"\",B45+1),\"\")","v":45},{"$f":"IF($B46=\"\",\"\",IF(VLOOKUP($B46,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B46,'Core Criteria'!$C:$V,2,FALSE)))","v":37},{"$f":"IF($B46=\"\",\"\",IF(VLOOKUP($B46,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B46,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B46=\"\",\"\",IF(VLOOKUP($B46,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B46,'Core Criteria'!$C:$V,4,FALSE)))","v":"LHRP Engagement "},{"$f":"IF($B46=\"\",\"\",IF(VLOOKUP($B46,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B46,'Core Criteria'!$C:$V,5,FALSE)))","v":"The Accountable Emergency Officer, or a director level representative with delegated authority (to authorise plans and commit resources on behalf of their organisation) attends Local Health Resilience Partnership (LHRP) meetings."},{"$f":"IF($B46=\"\",\"\",IF(VLOOKUP($B46,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B46,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Minutes of meetings\n• Individual members of the LHRP must be authorised by their employing organisation to act in accordance with their organisational governance arrangements and their statutory status and responsibilities."}]
[{"$f":"IF(OR(LEFT($C47,6)=\"Domain\",$I47=LookUp!$A$3,$I47=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A46)+1,\"\")","v":""},{"$f":"IFERROR(IF(B46+1>MAX('Core Criteria'!$C:$C),\"\",B46+1),\"\")","v":46},{"$f":"IF($B47=\"\",\"\",IF(VLOOKUP($B47,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B47,'Core Criteria'!$C:$V,2,FALSE)))","v":38},{"$f":"IF($B47=\"\",\"\",IF(VLOOKUP($B47,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B47,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B47=\"\",\"\",IF(VLOOKUP($B47,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B47,'Core Criteria'!$C:$V,4,FALSE)))","v":"LRF / BRF Engagement"},{"$f":"IF($B47=\"\",\"\",IF(VLOOKUP($B47,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B47,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation participates in, contributes to or is adequately represented at Local Resilience Forum (LRF) or Borough Resilience Forum (BRF), demonstrating engagement and co-operation with partner responders. "},{"$f":"IF($B47=\"\",\"\",IF(VLOOKUP($B47,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B47,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Minutes of meetings\n• A governance agreement is in place if the organisation is represented and feeds back across the system"}]
[{"$f":"IF(OR(LEFT($C48,6)=\"Domain\",$I48=LookUp!$A$3,$I48=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A47)+1,\"\")","v":""},{"$f":"IFERROR(IF(B47+1>MAX('Core Criteria'!$C:$C),\"\",B47+1),\"\")","v":47},{"$f":"IF($B48=\"\",\"\",IF(VLOOKUP($B48,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B48,'Core Criteria'!$C:$V,2,FALSE)))","v":39},{"$f":"IF($B48=\"\",\"\",IF(VLOOKUP($B48,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B48,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B48=\"\",\"\",IF(VLOOKUP($B48,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B48,'Core Criteria'!$C:$V,4,FALSE)))","v":"Mutual aid arrangements"},{"$f":"IF($B48=\"\",\"\",IF(VLOOKUP($B48,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B48,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has agreed mutual aid arrangements in place outlining the process for requesting, coordinating and maintaining mutual aid resources. These arrangements may include staff, equipment, services and supplies. \n\nIn line with current NHS guidance, these arrangements may be formal and should include the process for requesting Military Aid to Civil Authorities (MACA) via NHS England."},{"$f":"IF($B48=\"\",\"\",IF(VLOOKUP($B48,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B48,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Detailed documentation on the process for requesting, receiving and managing mutual aid requests\n• Templates and other required documentation is available in ICC or as appendices to IRP\n• Signed mutual aid agreements where appropriate"}]
[{"$f":"IF(OR(LEFT($C49,6)=\"Domain\",$I49=LookUp!$A$3,$I49=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A48)+1,\"\")","v":""},{"$f":"IFERROR(IF(B48+1>MAX('Core Criteria'!$C:$C),\"\",B48+1),\"\")","v":48},{"$f":"IF($B49=\"\",\"\",IF(VLOOKUP($B49,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B49,'Core Criteria'!$C:$V,2,FALSE)))","v":40},{"$f":"IF($B49=\"\",\"\",IF(VLOOKUP($B49,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B49,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B49=\"\",\"\",IF(VLOOKUP($B49,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B49,'Core Criteria'!$C:$V,4,FALSE)))","v":"Arrangements for multi area response"},{"$f":"IF($B49=\"\",\"\",IF(VLOOKUP($B49,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B49,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has arrangements in place to prepare for and respond to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas."},{"$f":"IF($B49=\"\",\"\",IF(VLOOKUP($B49,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B49,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Detailed documentation on the process for coordinating the response to incidents affecting two or more LHRPs\n• Where an organisation sits across boundaries the reporting route should be clearly identified and known to all "}]
[{"$f":"IF(OR(LEFT($C50,6)=\"Domain\",$I50=LookUp!$A$3,$I50=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A49)+1,\"\")","v":""},{"$f":"IFERROR(IF(B49+1>MAX('Core Criteria'!$C:$C),\"\",B49+1),\"\")","v":49},{"$f":"IF($B50=\"\",\"\",IF(VLOOKUP($B50,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B50,'Core Criteria'!$C:$V,2,FALSE)))","v":41},{"$f":"IF($B50=\"\",\"\",IF(VLOOKUP($B50,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B50,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B50=\"\",\"\",IF(VLOOKUP($B50,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B50,'Core Criteria'!$C:$V,4,FALSE)))","v":"Health tripartite working"},{"$f":"IF($B50=\"\",\"\",IF(VLOOKUP($B50,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B50,'Core Criteria'!$C:$V,5,FALSE)))","v":"Arrangements are in place defining how NHS England, the Department of Health and Social Care and UK Health Security Agency (UKHSA) will communicate and work together, including how information relating to national emergencies will be cascaded. "},{"$f":"IF($B50=\"\",\"\",IF(VLOOKUP($B50,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B50,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Detailed documentation on the process for managing the national health aspects of an emergency"}]
[{"$f":"IF(OR(LEFT($C51,6)=\"Domain\",$I51=LookUp!$A$3,$I51=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A50)+1,\"\")","v":""},{"$f":"IFERROR(IF(B50+1>MAX('Core Criteria'!$C:$C),\"\",B50+1),\"\")","v":50},{"$f":"IF($B51=\"\",\"\",IF(VLOOKUP($B51,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B51,'Core Criteria'!$C:$V,2,FALSE)))","v":42},{"$f":"IF($B51=\"\",\"\",IF(VLOOKUP($B51,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B51,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B51=\"\",\"\",IF(VLOOKUP($B51,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B51,'Core Criteria'!$C:$V,4,FALSE)))","v":"LHRP Secretariat"},{"$f":"IF($B51=\"\",\"\",IF(VLOOKUP($B51,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B51,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has arrangements in place to ensure that the Local Health Resilience Partnership (LHRP) meets at least once every 6 months."},{"$f":"IF($B51=\"\",\"\",IF(VLOOKUP($B51,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B51,'Core Criteria'!$C:$V,20,FALSE)))","v":"• LHRP terms of reference\n• Meeting minutes\n• Meeting agendas"}]
[{"$f":"IF(OR(LEFT($C52,6)=\"Domain\",$I52=LookUp!$A$3,$I52=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A51)+1,\"\")","v":""},{"$f":"IFERROR(IF(B51+1>MAX('Core Criteria'!$C:$C),\"\",B51+1),\"\")","v":51},{"$f":"IF($B52=\"\",\"\",IF(VLOOKUP($B52,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B52,'Core Criteria'!$C:$V,2,FALSE)))","v":43},{"$f":"IF($B52=\"\",\"\",IF(VLOOKUP($B52,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B52,'Core Criteria'!$C:$V,3,FALSE)))","v":"Cooperation"},{"$f":"IF($B52=\"\",\"\",IF(VLOOKUP($B52,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B52,'Core Criteria'!$C:$V,4,FALSE)))","v":"Information sharing "},{"$f":"IF($B52=\"\",\"\",IF(VLOOKUP($B52,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B52,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has an agreed protocol(s) for sharing appropriate information pertinent to the response with stakeholders and partners, during incidents.\n"},{"$f":"IF($B52=\"\",\"\",IF(VLOOKUP($B52,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B52,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Documented and signed information sharing protocol\n• Evidence relevant guidance has been considered, e.g. Freedom of Information Act 2000, General Data Protection Regulation 2016, Caldicott Principles, Safeguarding requirements and the Civil Contingencies Act 2004"}]
[{"$f":"IF(OR(LEFT($C53,6)=\"Domain\",$I53=LookUp!$A$3,$I53=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A52)+1,\"\")","v":9},{"$f":"IFERROR(IF(B52+1>MAX('Core Criteria'!$C:$C),\"\",B52+1),\"\")","v":52},{"$f":"IF($B53=\"\",\"\",IF(VLOOKUP($B53,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B53,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 9 - Business Continuity"},{"$f":"IF($B53=\"\",\"\",IF(VLOOKUP($B53,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B53,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B53=\"\",\"\",IF(VLOOKUP($B53,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B53,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B53=\"\",\"\",IF(VLOOKUP($B53,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B53,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B53=\"\",\"\",IF(VLOOKUP($B53,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B53,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C54,6)=\"Domain\",$I54=LookUp!$A$3,$I54=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A53)+1,\"\")","v":""},{"$f":"IFERROR(IF(B53+1>MAX('Core Criteria'!$C:$C),\"\",B53+1),\"\")","v":53},{"$f":"IF($B54=\"\",\"\",IF(VLOOKUP($B54,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B54,'Core Criteria'!$C:$V,2,FALSE)))","v":44},{"$f":"IF($B54=\"\",\"\",IF(VLOOKUP($B54,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B54,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B54=\"\",\"\",IF(VLOOKUP($B54,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B54,'Core Criteria'!$C:$V,4,FALSE)))","v":"BC policy statement"},{"$f":"IF($B54=\"\",\"\",IF(VLOOKUP($B54,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B54,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has in place a policy which includes a statement of intent to undertake business continuity.  This includes the commitment to a Business Continuity Management System (BCMS) that aligns to the ISO standard 22301."},{"$f":"IF($B54=\"\",\"\",IF(VLOOKUP($B54,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B54,'Core Criteria'!$C:$V,20,FALSE)))","v":"The organisation has in place a policy which includes intentions and direction as formally expressed by its top management.\nThe BC Policy should:                              \n• Provide the strategic direction from which the business continuity programme is delivered.                                                   \n• Define the way in which the  organisation will approach business continuity.                      \n• Show evidence of being supported, approved and owned by top management.                    \n• Be reflective of the organisation in terms of size, complexity and type of organisation.                       \n• Document any standards or guidelines that are used as a benchmark for the BC programme.\n• Consider short term and long term impacts on the organisation including climate change adaption planning"}]
[{"$f":"IF(OR(LEFT($C55,6)=\"Domain\",$I55=LookUp!$A$3,$I55=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A54)+1,\"\")","v":""},{"$f":"IFERROR(IF(B54+1>MAX('Core Criteria'!$C:$C),\"\",B54+1),\"\")","v":54},{"$f":"IF($B55=\"\",\"\",IF(VLOOKUP($B55,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B55,'Core Criteria'!$C:$V,2,FALSE)))","v":45},{"$f":"IF($B55=\"\",\"\",IF(VLOOKUP($B55,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B55,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B55=\"\",\"\",IF(VLOOKUP($B55,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B55,'Core Criteria'!$C:$V,4,FALSE)))","v":"Business Continuity Management Systems (BCMS) scope and objectives "},{"$f":"IF($B55=\"\",\"\",IF(VLOOKUP($B55,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B55,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has established the scope and objectives of the BCMS in relation to the organisation, specifying the risk management process and how this will be documented.\n\nA definition of the scope of the programme ensures a clear understanding of which areas of the organisation are in and out of scope of the BC programme."},{"$f":"IF($B55=\"\",\"\",IF(VLOOKUP($B55,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B55,'Core Criteria'!$C:$V,20,FALSE)))","v":"BCMS should detail: \n• Scope e.g. key products and services within the scope and exclusions from the scope\n• Objectives of the system\n• The requirement to undertake BC e.g. Statutory, Regulatory and contractual duties\n• Specific roles within the BCMS including responsibilities, competencies and authorities.\n• The risk management processes for the organisation i.e. how risk will be assessed and documented (e.g. Risk Register), the acceptable level of risk and risk review and monitoring process\n• Resource requirements\n• Communications strategy with all staff to ensure they are aware of their roles\n• alignment to the organisations strategy, objectives, operating environment and approach to risk.                                         \n• the outsourced activities and suppliers of products and suppliers.                                     \n• how the understanding of BC will be increased in the organisation "}]
[{"$f":"IF(OR(LEFT($C56,6)=\"Domain\",$I56=LookUp!$A$3,$I56=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A55)+1,\"\")","v":""},{"$f":"IFERROR(IF(B55+1>MAX('Core Criteria'!$C:$C),\"\",B55+1),\"\")","v":55},{"$f":"IF($B56=\"\",\"\",IF(VLOOKUP($B56,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B56,'Core Criteria'!$C:$V,2,FALSE)))","v":46},{"$f":"IF($B56=\"\",\"\",IF(VLOOKUP($B56,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B56,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B56=\"\",\"\",IF(VLOOKUP($B56,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B56,'Core Criteria'!$C:$V,4,FALSE)))","v":"Business Impact Analysis/Assessment (BIA) "},{"$f":"IF($B56=\"\",\"\",IF(VLOOKUP($B56,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B56,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation annually assesses and documents the impact of disruption to its services through Business Impact Analysis(es).\n\n"},{"$f":"IF($B56=\"\",\"\",IF(VLOOKUP($B56,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B56,'Core Criteria'!$C:$V,20,FALSE)))","v":"The organisation has identified prioritised activities by undertaking a strategic Business Impact Analysis/Assessments. Business Impact Analysis/Assessment is the key first stage in the development of a BCMS and is therefore critical to a business continuity programme.\n\nDocumented process on how BIA will be conducted, including:\n• the method to be used\n• the frequency of review\n• how the information will be used to inform planning \n• how RA is used to support.\n\nThe organisation should undertake a review of its critical function using a Business Impact Analysis/assessment. Without a Business Impact Analysis organisations are not able to assess/assure compliance without it. The following points should be considered when undertaking a BIA:                                   \n• Determining impacts over time should demonstrate to top management how quickly the organisation needs to respond to a disruption.\n• A consistent approach to performing the BIA should be used throughout the organisation.\n• BIA method used should be robust enough to ensure the information is collected consistently and impartially. \n"}]
[{"$f":"IF(OR(LEFT($C57,6)=\"Domain\",$I57=LookUp!$A$3,$I57=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A56)+1,\"\")","v":""},{"$f":"IFERROR(IF(B56+1>MAX('Core Criteria'!$C:$C),\"\",B56+1),\"\")","v":56},{"$f":"IF($B57=\"\",\"\",IF(VLOOKUP($B57,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B57,'Core Criteria'!$C:$V,2,FALSE)))","v":47},{"$f":"IF($B57=\"\",\"\",IF(VLOOKUP($B57,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B57,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B57=\"\",\"\",IF(VLOOKUP($B57,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B57,'Core Criteria'!$C:$V,4,FALSE)))","v":"Business Continuity Plans (BCP)"},{"$f":"IF($B57=\"\",\"\",IF(VLOOKUP($B57,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B57,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has  business continuity plans for the management of incidents. Detailing how it will respond, recover and manage its services during disruptions to:\n• people\n• information and data\n• premises\n• suppliers and contractors\n• IT and infrastructure\n\n                                                                  "},{"$f":"IF($B57=\"\",\"\",IF(VLOOKUP($B57,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B57,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented evidence that as a minimum the BCP checklist is covered by the various plans of the organisation.\n  \nEnsure BCPS are Developed using the ISO 22301 and the NHS Toolkit.  BC Planning is undertaken by an adequately trained person and contain the following:                                                           • Purpose and Scope                                          \n• Objectives and assumptions                             \n• Escalation & Response Structure which is specific to your organisation.                                                      \n• Plan activation criteria, procedures and authorisation.                                                \n• Response teams roles and responsibilities.                                          \n• Individual responsibilities and authorities of team members.                                                   \n• Prompts for immediate action and any specific decisions the team may need to make.                                  \n• Communication requirements and procedures with relevant interested parties.                                  \n• Internal and  external interdependencies.                \n• Summary Information of the organisations prioritised activities.                                                \n• Decision support checklists                            \n• Details of meeting locations                                   \n• Appendix/Appendices "}]
[{"$f":"IF(OR(LEFT($C58,6)=\"Domain\",$I58=LookUp!$A$3,$I58=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A57)+1,\"\")","v":""},{"$f":"IFERROR(IF(B57+1>MAX('Core Criteria'!$C:$C),\"\",B57+1),\"\")","v":57},{"$f":"IF($B58=\"\",\"\",IF(VLOOKUP($B58,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B58,'Core Criteria'!$C:$V,2,FALSE)))","v":48},{"$f":"IF($B58=\"\",\"\",IF(VLOOKUP($B58,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B58,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B58=\"\",\"\",IF(VLOOKUP($B58,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B58,'Core Criteria'!$C:$V,4,FALSE)))","v":"Testing and Exercising"},{"$f":"IF($B58=\"\",\"\",IF(VLOOKUP($B58,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B58,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has in place a procedure whereby testing and exercising of Business Continuity plans is undertaken on a yearly basis as a minimum, following organisational change or as a result of learning from other business continuity incidents."},{"$f":"IF($B58=\"\",\"\",IF(VLOOKUP($B58,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B58,'Core Criteria'!$C:$V,20,FALSE)))","v":"Confirm the type of exercise the organisation has undertaken to meet this sub standard:                         \n• Discussion based exercise                                                        \n• Scenario Exercises                                           \n• Simulation Exercises                                        \n• Live exercise                                                   \n• Test                                                                   \n• Undertake a debrief\n\nEvidence\nPost exercise/ testing reports and action plans"}]
[{"$f":"IF(OR(LEFT($C59,6)=\"Domain\",$I59=LookUp!$A$3,$I59=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A58)+1,\"\")","v":""},{"$f":"IFERROR(IF(B58+1>MAX('Core Criteria'!$C:$C),\"\",B58+1),\"\")","v":58},{"$f":"IF($B59=\"\",\"\",IF(VLOOKUP($B59,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B59,'Core Criteria'!$C:$V,2,FALSE)))","v":49},{"$f":"IF($B59=\"\",\"\",IF(VLOOKUP($B59,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B59,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B59=\"\",\"\",IF(VLOOKUP($B59,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B59,'Core Criteria'!$C:$V,4,FALSE)))","v":"Data Protection and Security Toolkit"},{"$f":"IF($B59=\"\",\"\",IF(VLOOKUP($B59,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B59,'Core Criteria'!$C:$V,5,FALSE)))","v":"Organisation's Information Technology department certify that they are compliant with the Data Protection and Security Toolkit on an annual basis. "},{"$f":"IF($B59=\"\",\"\",IF(VLOOKUP($B59,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B59,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Statement of compliance\n• Action plan to obtain compliance if not achieved"}]
[{"$f":"IF(OR(LEFT($C60,6)=\"Domain\",$I60=LookUp!$A$3,$I60=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A59)+1,\"\")","v":""},{"$f":"IFERROR(IF(B59+1>MAX('Core Criteria'!$C:$C),\"\",B59+1),\"\")","v":59},{"$f":"IF($B60=\"\",\"\",IF(VLOOKUP($B60,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B60,'Core Criteria'!$C:$V,2,FALSE)))","v":50},{"$f":"IF($B60=\"\",\"\",IF(VLOOKUP($B60,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B60,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B60=\"\",\"\",IF(VLOOKUP($B60,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B60,'Core Criteria'!$C:$V,4,FALSE)))","v":"BCMS monitoring and evaluation "},{"$f":"IF($B60=\"\",\"\",IF(VLOOKUP($B60,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B60,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation's BCMS is monitored, measured and evaluated against established Key Performance Indicators. Reports on these and the outcome of any exercises, and status of any corrective action are annually reported to the board."},{"$f":"IF($B60=\"\",\"\",IF(VLOOKUP($B60,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B60,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Business continuity policy\n• BCMS\n• performance reporting\n• Board papers"}]
[{"$f":"IF(OR(LEFT($C61,6)=\"Domain\",$I61=LookUp!$A$3,$I61=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A60)+1,\"\")","v":""},{"$f":"IFERROR(IF(B60+1>MAX('Core Criteria'!$C:$C),\"\",B60+1),\"\")","v":60},{"$f":"IF($B61=\"\",\"\",IF(VLOOKUP($B61,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B61,'Core Criteria'!$C:$V,2,FALSE)))","v":51},{"$f":"IF($B61=\"\",\"\",IF(VLOOKUP($B61,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B61,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B61=\"\",\"\",IF(VLOOKUP($B61,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B61,'Core Criteria'!$C:$V,4,FALSE)))","v":"BC audit"},{"$f":"IF($B61=\"\",\"\",IF(VLOOKUP($B61,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B61,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has a process for internal audit, and outcomes are included in the report to the board.\n\nThe organisation has conducted audits at planned intervals to confirm they are conforming with its own business continuity programme. "},{"$f":"IF($B61=\"\",\"\",IF(VLOOKUP($B61,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B61,'Core Criteria'!$C:$V,20,FALSE)))","v":"• process documented in EPRR policy/Business continuity policy or BCMS aligned to the audit programme for the organisation\n• Board papers\n• Audit reports\n• Remedial action plan that is agreed by top management.                                                      \n• An independent business continuity management audit report.                                   \n• Internal audits should be undertaken as agreed by the organisation's audit planning schedule on a rolling cycle.    \n• External audits should be undertaken  in alignment with the organisations audit programme"}]
[{"$f":"IF(OR(LEFT($C62,6)=\"Domain\",$I62=LookUp!$A$3,$I62=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A61)+1,\"\")","v":""},{"$f":"IFERROR(IF(B61+1>MAX('Core Criteria'!$C:$C),\"\",B61+1),\"\")","v":61},{"$f":"IF($B62=\"\",\"\",IF(VLOOKUP($B62,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B62,'Core Criteria'!$C:$V,2,FALSE)))","v":52},{"$f":"IF($B62=\"\",\"\",IF(VLOOKUP($B62,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B62,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B62=\"\",\"\",IF(VLOOKUP($B62,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B62,'Core Criteria'!$C:$V,4,FALSE)))","v":"BCMS continuous improvement process"},{"$f":"IF($B62=\"\",\"\",IF(VLOOKUP($B62,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B62,'Core Criteria'!$C:$V,5,FALSE)))","v":"There is a process in place to assess the effectiveness of the BCMS and take corrective action to ensure continual improvement to the BCMS. "},{"$f":"IF($B62=\"\",\"\",IF(VLOOKUP($B62,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B62,'Core Criteria'!$C:$V,20,FALSE)))","v":"• process documented in the EPRR policy/Business continuity policy or BCMS\n• Board papers  showing evidence of improvement\n• Action plans following exercising, training and incidents\n• Improvement plans following internal or external auditing\n•Changes to suppliers or contracts following assessment of suitability \n\nContinuous Improvement can be identified via the following routes:                                                                     \n• Lessons learned through exercising.                \n• Changes to the organisations structure, products and services, infrastructure, processes or activities.                                     \n• Changes to the environment in which the organisation operates.                                        \n• A review or audit.                                               \n• Changes or updates to the business continuity management lifecycle, such as the BIA or continuity solutions.                                            \n• Self assessment                                                        \n• Quality assurance                                               \n• Performance appraisal                                       \n• Supplier performance                                         \n• Management review                                         \n• Debriefs                                                            \n• After action reviews                                          \n• Lessons learned through exercising or live incidents    "}]
[{"$f":"IF(OR(LEFT($C63,6)=\"Domain\",$I63=LookUp!$A$3,$I63=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A62)+1,\"\")","v":""},{"$f":"IFERROR(IF(B62+1>MAX('Core Criteria'!$C:$C),\"\",B62+1),\"\")","v":62},{"$f":"IF($B63=\"\",\"\",IF(VLOOKUP($B63,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B63,'Core Criteria'!$C:$V,2,FALSE)))","v":53},{"$f":"IF($B63=\"\",\"\",IF(VLOOKUP($B63,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B63,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B63=\"\",\"\",IF(VLOOKUP($B63,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B63,'Core Criteria'!$C:$V,4,FALSE)))","v":"Assurance of commissioned providers / suppliers BCPs "},{"$f":"IF($B63=\"\",\"\",IF(VLOOKUP($B63,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B63,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has in place a system to assess the business continuity plans of commissioned providers or suppliers; and are assured that these providers business continuity arrangements align and are interoperable with their own. \n"},{"$f":"IF($B63=\"\",\"\",IF(VLOOKUP($B63,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B63,'Core Criteria'!$C:$V,20,FALSE)))","v":"• EPRR policy/Business continuity policy or BCMS outlines the process to be used and how suppliers will be identified for assurance\n• Provider/supplier assurance framework\n• Provider/supplier business continuity arrangements\n\nThis may be supported by the organisations procurement or commercial teams (where trained in BC) at tender phase and at set intervals for critical and/or high value suppliers"}]
[{"$f":"IF(OR(LEFT($C64,6)=\"Domain\",$I64=LookUp!$A$3,$I64=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A63)+1,\"\")","v":""},{"$f":"IFERROR(IF(B63+1>MAX('Core Criteria'!$C:$C),\"\",B63+1),\"\")","v":63},{"$f":"IF($B64=\"\",\"\",IF(VLOOKUP($B64,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B64,'Core Criteria'!$C:$V,2,FALSE)))","v":54},{"$f":"IF($B64=\"\",\"\",IF(VLOOKUP($B64,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B64,'Core Criteria'!$C:$V,3,FALSE)))","v":"Business Continuity"},{"$f":"IF($B64=\"\",\"\",IF(VLOOKUP($B64,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B64,'Core Criteria'!$C:$V,4,FALSE)))","v":"Computer Aided Dispatch "},{"$f":"IF($B64=\"\",\"\",IF(VLOOKUP($B64,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B64,'Core Criteria'!$C:$V,5,FALSE)))","v":"Manual distribution processes for Emergency Operations Centre / Computer Aided Dispatch systems are in place and have been fully tested annually, with learning identified, recorded and acted upon"},{"$f":"IF($B64=\"\",\"\",IF(VLOOKUP($B64,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B64,'Core Criteria'!$C:$V,20,FALSE)))","v":"• Exercising Schedule\n• Evidence of post exercise reports and embedding learning"}]
[{"$f":"IF(OR(LEFT($C65,6)=\"Domain\",$I65=LookUp!$A$3,$I65=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A64)+1,\"\")","v":10},{"$f":"IFERROR(IF(B64+1>MAX('Core Criteria'!$C:$C),\"\",B64+1),\"\")","v":64},{"$f":"IF($B65=\"\",\"\",IF(VLOOKUP($B65,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B65,'Core Criteria'!$C:$V,2,FALSE)))","v":"Domain 10 - CBRN"},{"$f":"IF($B65=\"\",\"\",IF(VLOOKUP($B65,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B65,'Core Criteria'!$C:$V,3,FALSE)))","v":""},{"$f":"IF($B65=\"\",\"\",IF(VLOOKUP($B65,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B65,'Core Criteria'!$C:$V,4,FALSE)))","v":""},{"$f":"IF($B65=\"\",\"\",IF(VLOOKUP($B65,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B65,'Core Criteria'!$C:$V,5,FALSE)))","v":""},{"$f":"IF($B65=\"\",\"\",IF(VLOOKUP($B65,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B65,'Core Criteria'!$C:$V,20,FALSE)))","v":""}]
[{"$f":"IF(OR(LEFT($C66,6)=\"Domain\",$I66=LookUp!$A$3,$I66=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A65)+1,\"\")","v":""},{"$f":"IFERROR(IF(B65+1>MAX('Core Criteria'!$C:$C),\"\",B65+1),\"\")","v":65},{"$f":"IF($B66=\"\",\"\",IF(VLOOKUP($B66,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B66,'Core Criteria'!$C:$V,2,FALSE)))","v":55},{"$f":"IF($B66=\"\",\"\",IF(VLOOKUP($B66,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B66,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B66=\"\",\"\",IF(VLOOKUP($B66,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B66,'Core Criteria'!$C:$V,4,FALSE)))","v":"Governance"},{"$f":"IF($B66=\"\",\"\",IF(VLOOKUP($B66,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B66,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has identified responsible roles/people for the following elements of Hazmat/CBRN:\n- Accountability - via the AEO\n- Planning\n- Training\n- Equipment checks and maintenance \nWhich should be clearly documented"},{"$f":"IF($B66=\"\",\"\",IF(VLOOKUP($B66,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B66,'Core Criteria'!$C:$V,20,FALSE)))","v":"Details of accountability/responsibility are clearly documented in the organisation's Hazmat/CBRN plan and/or Emergency Planning policy as related to the identified risk and role of the organisation\n\n"}]
[{"$f":"IF(OR(LEFT($C67,6)=\"Domain\",$I67=LookUp!$A$3,$I67=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A66)+1,\"\")","v":""},{"$f":"IFERROR(IF(B66+1>MAX('Core Criteria'!$C:$C),\"\",B66+1),\"\")","v":66},{"$f":"IF($B67=\"\",\"\",IF(VLOOKUP($B67,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B67,'Core Criteria'!$C:$V,2,FALSE)))","v":56},{"$f":"IF($B67=\"\",\"\",IF(VLOOKUP($B67,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B67,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B67=\"\",\"\",IF(VLOOKUP($B67,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B67,'Core Criteria'!$C:$V,4,FALSE)))","v":"Hazmat/CBRN risk assessments "},{"$f":"IF($B67=\"\",\"\",IF(VLOOKUP($B67,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B67,'Core Criteria'!$C:$V,5,FALSE)))","v":"Hazmat/CBRN risk assessments are in place which are appropriate to the organisation type\n\n"},{"$f":"IF($B67=\"\",\"\",IF(VLOOKUP($B67,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B67,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence of the risk assessment process undertaken - including - \ni) governance for risk assessment process\nii) assessment of impacts on staff\niii) impact assessment(s) on estates and infrastructure - including access and egress\niv) management of potentially hazardous waste\nv) impact assessments of Hazmat/CBRN decontamination on critical facilities and services"}]
[{"$f":"IF(OR(LEFT($C68,6)=\"Domain\",$I68=LookUp!$A$3,$I68=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A67)+1,\"\")","v":""},{"$f":"IFERROR(IF(B67+1>MAX('Core Criteria'!$C:$C),\"\",B67+1),\"\")","v":67},{"$f":"IF($B68=\"\",\"\",IF(VLOOKUP($B68,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B68,'Core Criteria'!$C:$V,2,FALSE)))","v":57},{"$f":"IF($B68=\"\",\"\",IF(VLOOKUP($B68,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B68,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B68=\"\",\"\",IF(VLOOKUP($B68,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B68,'Core Criteria'!$C:$V,4,FALSE)))","v":"Specialist advice for Hazmat/CBRN  exposure"},{"$f":"IF($B68=\"\",\"\",IF(VLOOKUP($B68,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B68,'Core Criteria'!$C:$V,5,FALSE)))","v":"Organisations have signposted key clinical staff on how to access appropriate and timely specialist advice for managing patients involved in Hazmat/CBRN incidents"},{"$f":"IF($B68=\"\",\"\",IF(VLOOKUP($B68,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B68,'Core Criteria'!$C:$V,20,FALSE)))","v":"Staff are aware of the number / process to gain access to advice through appropriate planning arrangements. These should include ECOSA, TOXBASE, NPIS, UKHSA\n\nArrangements should include how clinicians would access specialist clinical advice for the on-going treatment of a patient"}]
[{"$f":"IF(OR(LEFT($C69,6)=\"Domain\",$I69=LookUp!$A$3,$I69=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A68)+1,\"\")","v":""},{"$f":"IFERROR(IF(B68+1>MAX('Core Criteria'!$C:$C),\"\",B68+1),\"\")","v":68},{"$f":"IF($B69=\"\",\"\",IF(VLOOKUP($B69,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B69,'Core Criteria'!$C:$V,2,FALSE)))","v":58},{"$f":"IF($B69=\"\",\"\",IF(VLOOKUP($B69,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B69,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B69=\"\",\"\",IF(VLOOKUP($B69,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B69,'Core Criteria'!$C:$V,4,FALSE)))","v":"Hazmat/CBRN    planning arrangements "},{"$f":"IF($B69=\"\",\"\",IF(VLOOKUP($B69,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B69,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has up to date specific Hazmat/CBRN plans and response arrangements aligned to the risk assessment, extending beyond IOR arrangements, and which are supported by a programme of regular training and exercising within the organisation and in conjunction with external stakeholders\n\n"},{"$f":"IF($B69=\"\",\"\",IF(VLOOKUP($B69,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B69,'Core Criteria'!$C:$V,20,FALSE)))","v":" Documented plans include evidence of the following:\n•\tcommand and control structures \n•\tCollaboration with the NHS Ambulance Trust to ensure Hazmat/CBRN plans and procedures are consistent with the Ambulance Trust’s Hazmat/CBRN  capability\n•\tProcedures to manage and coordinate communications with other key stakeholders and other responders\n•\tEffective and tested processes for activating and deploying Hazmat/CBRN staff and Clinical Decontamination Units (CDUs) (or equivalent)\n•\tPre-determined decontamination locations with a clear distinction between clean and dirty areas and demarcation of safe clean access for patients, including for the off-loading of non-decontaminated patients from ambulances, and safe cordon control\n•\tDistinction between dry and wet decontamination and the decision making process for the appropriate deployment\n•\tIdentification of lockdown/isolation procedures for patients waiting for decontamination\n•\tManagement and decontamination processes for contaminated patients and fatalities in line with the latest guidance\n•\tArrangements for staff decontamination and access to staff welfare\n•\tBusiness continuity  plans that ensure the trust can continue to accept patients not related/affected by the Hazmat/CBRN incident, whilst simultaneously providing the decontamination capability, through designated clean entry routes\n•\tPlans for the management of hazardous waste\n•\tHazmat/CBRN plans and procedures include sufficient provisions to manage the stand-down and transition from response to recovery and a return to business as usual activities\n•\tDescription of process for obtaining replacement PPE/PRPS - both during a protracted incident and in the aftermath of an incident"}]
[{"$f":"IF(OR(LEFT($C70,6)=\"Domain\",$I70=LookUp!$A$3,$I70=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A69)+1,\"\")","v":""},{"$f":"IFERROR(IF(B69+1>MAX('Core Criteria'!$C:$C),\"\",B69+1),\"\")","v":69},{"$f":"IF($B70=\"\",\"\",IF(VLOOKUP($B70,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B70,'Core Criteria'!$C:$V,2,FALSE)))","v":59},{"$f":"IF($B70=\"\",\"\",IF(VLOOKUP($B70,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B70,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B70=\"\",\"\",IF(VLOOKUP($B70,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B70,'Core Criteria'!$C:$V,4,FALSE)))","v":"Decontamination capability availability 24 /7 "},{"$f":"IF($B70=\"\",\"\",IF(VLOOKUP($B70,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B70,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has adequate and appropriate wet decontamination capability that can be rapidly deployed to manage self presenting patients, 24 hours a day, 7 days a week (for a minimum of four patients per hour) - this includes availability of staff to establish the decontamination facilities\n\nThere are sufficient trained staff on shift to allow for the continuation of decontamination until support and/or mutual aid can be provided - according to the organisation's risk assessment and plan(s)\n\nThe organisations also has plans, training and resources in place to enable the commencement of interim dry/wet, and improvised decontamination where necessary.\n"},{"$f":"IF($B70=\"\",\"\",IF(VLOOKUP($B70,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B70,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented roles for people forming the decontamination team -  including Entry Control/Safety Officer\nHazmat/CBRN trained staff are clearly identified on staff rotas and scheduling pro-actively considers sufficient cover for each shift\nHazmat/CBRN trained staff working on shift are identified on shift board\n\nCollaboration with local NHS ambulance trust and local fire service - to ensure Hazmat/CBRN plans and procedures are consistent with local area plans\n\nAssessment of local area needs and resource"}]
[{"$f":"IF(OR(LEFT($C71,6)=\"Domain\",$I71=LookUp!$A$3,$I71=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A70)+1,\"\")","v":""},{"$f":"IFERROR(IF(B70+1>MAX('Core Criteria'!$C:$C),\"\",B70+1),\"\")","v":70},{"$f":"IF($B71=\"\",\"\",IF(VLOOKUP($B71,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B71,'Core Criteria'!$C:$V,2,FALSE)))","v":60},{"$f":"IF($B71=\"\",\"\",IF(VLOOKUP($B71,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B71,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B71=\"\",\"\",IF(VLOOKUP($B71,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B71,'Core Criteria'!$C:$V,4,FALSE)))","v":"Equipment and supplies"},{"$f":"IF($B71=\"\",\"\",IF(VLOOKUP($B71,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B71,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff. There is an accurate inventory of equipment required for decontaminating patients. \n\nEquipment is proportionate with the organisation's risk assessment of requirement - such as for the management of non-ambulant or collapsed patients\n\n• Acute providers - see Equipment checklist: https://www.england.nhs.uk/wp-content/uploads/2018/07/eprr-decontamination-equipment-check-list.xlsx \n• Community, Mental Health and Specialist service providers - see guidance 'Planning for the management of self-presenting patients in healthcare setting': https://webarchive.nationalarchives.gov.uk/20161104231146/https://www.england.nhs.uk/wp-content/uploads/2015/04/eprr-chemical-incidents.pdf\n"},{"$f":"IF($B71=\"\",\"\",IF(VLOOKUP($B71,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B71,'Core Criteria'!$C:$V,20,FALSE)))","v":"This inventory should include individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment).\n\nThere are appropriate risk assessments and SOPs for any specialist equipment\n\nAcute and ambulance trusts must maintain the minimum number of PRPS suits specified by NHS England (24/240). These suits must be maintained in accordance with the manufacturer’s guidance. NHS Ambulance Trusts can provide support and advice on the maintenance of PRPS suits as required.\n\nDesignated hospitals must ensure they have a financial replacement plan in place to ensure that they are able to adequately account for depreciation in the life of equipment and ensure funding is available for replacement at the end of its shelf life.  This includes for PPE/PRPS suits, decontamination facilities etc."}]
[{"$f":"IF(OR(LEFT($C72,6)=\"Domain\",$I72=LookUp!$A$3,$I72=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A71)+1,\"\")","v":""},{"$f":"IFERROR(IF(B71+1>MAX('Core Criteria'!$C:$C),\"\",B71+1),\"\")","v":71},{"$f":"IF($B72=\"\",\"\",IF(VLOOKUP($B72,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B72,'Core Criteria'!$C:$V,2,FALSE)))","v":61},{"$f":"IF($B72=\"\",\"\",IF(VLOOKUP($B72,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B72,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B72=\"\",\"\",IF(VLOOKUP($B72,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B72,'Core Criteria'!$C:$V,4,FALSE)))","v":"Equipment - Preventative Programme of Maintenance"},{"$f":"IF($B72=\"\",\"\",IF(VLOOKUP($B72,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B72,'Core Criteria'!$C:$V,5,FALSE)))","v":"There is a preventative programme of maintenance (PPM) in place, including routine checks for the maintenance, repair, calibration (where necessary) and replacement of out of date decontamination equipment to ensure that equipment is always available to respond to a Hazmat/CBRN incident.\n\nEquipment is maintained according to applicable industry standards and in line with manufacturer’s recommendations\n\nThe PPM should include where applicable:\n- PRPS Suits\n- Decontamination structures \n- Disrobe and rerobe structures\n- Water outlets\n- Shower tray pump\n- RAM GENE (radiation monitor) - calibration not required\n- Other decontamination equipment as identified by your local risk assessment e.g. IOR Rapid Response boxes\n\nThere is a named individual (or role) responsible for completing these checks"},{"$f":"IF($B72=\"\",\"\",IF(VLOOKUP($B72,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B72,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented process for equipment maintenance checks included within organisational Hazmat/CBRN plan - including frequency required proportionate to the risk assessment\n• Record of regular equipment checks, including date completed and by whom \n• Report of any missing equipment\nOrganisations using PPE and specialist equipment should document the method for it's disposal when required \n\nProcess for oversight of equipment in place for EPRR committee in multisite organisations/central register available to EPRR\n\nOrganisation Business Continuity arrangements to ensure the continuation of the decontamination services in the event of use or damage to primary equipment \n\nRecords of maintenance and annual servicing\n\nThird party providers of PPM must provide the organisations with assurance of their own Business Continuity arrangements as a commissioned supplier/provider under Core Standard 53"}]
[{"$f":"IF(OR(LEFT($C73,6)=\"Domain\",$I73=LookUp!$A$3,$I73=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A72)+1,\"\")","v":""},{"$f":"IFERROR(IF(B72+1>MAX('Core Criteria'!$C:$C),\"\",B72+1),\"\")","v":72},{"$f":"IF($B73=\"\",\"\",IF(VLOOKUP($B73,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B73,'Core Criteria'!$C:$V,2,FALSE)))","v":62},{"$f":"IF($B73=\"\",\"\",IF(VLOOKUP($B73,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B73,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B73=\"\",\"\",IF(VLOOKUP($B73,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B73,'Core Criteria'!$C:$V,4,FALSE)))","v":"Waste disposal arrangements"},{"$f":"IF($B73=\"\",\"\",IF(VLOOKUP($B73,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B73,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation has clearly defined waste management processes within their Hazmat/CBRN plans\n"},{"$f":"IF($B73=\"\",\"\",IF(VLOOKUP($B73,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B73,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented arrangements for the safe storage (and potential secure holding) of waste\nDocumented arrangements - in consultation with other emergency services for the eventual disposal of:\n- Waste water used during decontamination\n- Used or expired PPE\n- Used equipment - including unit liners\n\nAny organisation chosen for waste disposal must be included in the supplier audit conducted under Core Standard 53"}]
[{"$f":"IF(OR(LEFT($C74,6)=\"Domain\",$I74=LookUp!$A$3,$I74=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A73)+1,\"\")","v":""},{"$f":"IFERROR(IF(B73+1>MAX('Core Criteria'!$C:$C),\"\",B73+1),\"\")","v":73},{"$f":"IF($B74=\"\",\"\",IF(VLOOKUP($B74,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B74,'Core Criteria'!$C:$V,2,FALSE)))","v":63},{"$f":"IF($B74=\"\",\"\",IF(VLOOKUP($B74,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B74,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B74=\"\",\"\",IF(VLOOKUP($B74,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B74,'Core Criteria'!$C:$V,4,FALSE)))","v":"Hazmat/CBRN    training resource"},{"$f":"IF($B74=\"\",\"\",IF(VLOOKUP($B74,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B74,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation must have an adequate training resource to deliver Hazmat/CBRN training which is aligned to the organisational Hazmat/CBRN plan and associated risk assessments\n\n\n\n"},{"$f":"IF($B74=\"\",\"\",IF(VLOOKUP($B74,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B74,'Core Criteria'!$C:$V,20,FALSE)))","v":"Identified minimum training standards within the organisation's Hazmat/CBRN plans (or EPRR training policy)\n\nStaff training needs analysis (TNA) appropriate to the organisation type - related to the need for decontamination\n\nDocumented evidence of training records for Hazmat/CBRN training - including for:\n- trust trainers - with dates of their attendance at an appropriate 'train the trainer' session (or update)\n- trust staff - with dates of the training that that they have undertaken\n\nDeveloped training programme to deliver capability against the risk assessment"}]
[{"$f":"IF(OR(LEFT($C75,6)=\"Domain\",$I75=LookUp!$A$3,$I75=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A74)+1,\"\")","v":""},{"$f":"IFERROR(IF(B74+1>MAX('Core Criteria'!$C:$C),\"\",B74+1),\"\")","v":74},{"$f":"IF($B75=\"\",\"\",IF(VLOOKUP($B75,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B75,'Core Criteria'!$C:$V,2,FALSE)))","v":64},{"$f":"IF($B75=\"\",\"\",IF(VLOOKUP($B75,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B75,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B75=\"\",\"\",IF(VLOOKUP($B75,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B75,'Core Criteria'!$C:$V,4,FALSE)))","v":"Staff training - recognition and  decontamination"},{"$f":"IF($B75=\"\",\"\",IF(VLOOKUP($B75,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B75,'Core Criteria'!$C:$V,5,FALSE)))","v":"The organisation undertakes training for all staff who are most likely to come into contact with potentially contaminated patients and patients requiring decontamination.\n\nStaff that may make contact with a potentially contaminated patients, whether in person or over the phone, are sufficiently trained in Initial Operational Response (IOR) principles and isolation when necessary. (This includes (but is not limited to) acute, community, mental health and primary care settings such as minor injury units and urgent treatment centres)\n\nStaff undertaking patient decontamination are sufficiently trained to ensure a safe system of work can be implemented"},{"$f":"IF($B75=\"\",\"\",IF(VLOOKUP($B75,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B75,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence of trust training slides/programme and designated audience\nEvidence that the trust training includes reference to the relevant current guidance (where necessary)\nStaff competency records\n\n"}]
[{"$f":"IF(OR(LEFT($C76,6)=\"Domain\",$I76=LookUp!$A$3,$I76=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A75)+1,\"\")","v":""},{"$f":"IFERROR(IF(B75+1>MAX('Core Criteria'!$C:$C),\"\",B75+1),\"\")","v":75},{"$f":"IF($B76=\"\",\"\",IF(VLOOKUP($B76,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B76,'Core Criteria'!$C:$V,2,FALSE)))","v":65},{"$f":"IF($B76=\"\",\"\",IF(VLOOKUP($B76,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B76,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B76=\"\",\"\",IF(VLOOKUP($B76,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B76,'Core Criteria'!$C:$V,4,FALSE)))","v":"PPE Access"},{"$f":"IF($B76=\"\",\"\",IF(VLOOKUP($B76,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B76,'Core Criteria'!$C:$V,5,FALSE)))","v":"Organisations must ensure that staff who come in to contact with patients requiring wet decontamination and patients with confirmed respiratory contamination have access to, and are trained to use, appropriate PPE. \n\nThis includes maintaining the expected number of operational PRPS available for immediate deployment to safely undertake wet decontamination and/or access to FFP3 (or equivalent) 24/7\n\n"},{"$f":"IF($B76=\"\",\"\",IF(VLOOKUP($B76,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B76,'Core Criteria'!$C:$V,20,FALSE)))","v":"Completed equipment inventories; including completion date \n\nFit testing schedule and records should be maintained for all staff who may come into contact with confirmed respiratory contamination\n\nEmergency Departments at Acute Trusts are required to maintain 24 Operational PRPS\n\n"}]
[{"$f":"IF(OR(LEFT($C77,6)=\"Domain\",$I77=LookUp!$A$3,$I77=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A76)+1,\"\")","v":""},{"$f":"IFERROR(IF(B76+1>MAX('Core Criteria'!$C:$C),\"\",B76+1),\"\")","v":76},{"$f":"IF($B77=\"\",\"\",IF(VLOOKUP($B77,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B77,'Core Criteria'!$C:$V,2,FALSE)))","v":66},{"$f":"IF($B77=\"\",\"\",IF(VLOOKUP($B77,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B77,'Core Criteria'!$C:$V,3,FALSE)))","v":"Hazmat/CBRN   "},{"$f":"IF($B77=\"\",\"\",IF(VLOOKUP($B77,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B77,'Core Criteria'!$C:$V,4,FALSE)))","v":"Exercising"},{"$f":"IF($B77=\"\",\"\",IF(VLOOKUP($B77,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B77,'Core Criteria'!$C:$V,5,FALSE)))","v":"Organisations must ensure that the exercising of Hazmat/CBRN plans and arrangements are incorporated in the organisations EPRR exercising and testing programme"},{"$f":"IF($B77=\"\",\"\",IF(VLOOKUP($B77,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B77,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence\n• Exercising Schedule which includes Hazmat/CBRN exercise\n• Post exercise reports and embedding learning"}]
[{"$f":"IF(OR(LEFT($C78,6)=\"Domain\",$I78=LookUp!$A$3,$I78=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A77)+1,\"\")","v":""},{"$f":"IFERROR(IF(B77+1>MAX('Core Criteria'!$C:$C),\"\",B77+1),\"\")","v":77},{"$f":"IF($B78=\"\",\"\",IF(VLOOKUP($B78,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B78,'Core Criteria'!$C:$V,2,FALSE)))","v":67},{"$f":"IF($B78=\"\",\"\",IF(VLOOKUP($B78,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B78,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B78=\"\",\"\",IF(VLOOKUP($B78,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B78,'Core Criteria'!$C:$V,4,FALSE)))","v":"Capability"},{"$f":"IF($B78=\"\",\"\",IF(VLOOKUP($B78,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B78,'Core Criteria'!$C:$V,5,FALSE)))","v":"NHS Ambulance Trusts must support designated Acute Trusts\n(hospitals) to maintain the following CBRN / Hazardous Materials \n(HazMat) tactical capabilities:\n\n• Provision of Initial Operational Response (IOR) for self presenting casualties at an Emergency Department including ‘Remove, Remove, Remove’ provisions. \n• PRPS wearers to be able to decontaminate CBRN/HazMat casualties.\n• ‘PRPS’ protective equipment and associated accessories.\n• Wet decontamination of casualties via Clinical Decontamination \nUnits (CDU’s), these may take the form of dedicated rooms or external structures but must have the capability to decontaminate both ambulant and non – ambulant casualties with warm water. \n• Clinical radiation monitoring equipment and capability.\n• Clinical care of casualties during the decontamination process.\n• Robust and effective arrangements to access specialist scientific advice relating to CBRN/HazMat incident response. \n\nThe support provided by NHS Ambulance Services must include, as a minimum, a biennial (once every two years) CBRN/HazMat capability review of the hospitals including decontamination capability and the provision of training support in accordance with the provisions set out in these core standards. "},{"$f":"IF($B78=\"\",\"\",IF(VLOOKUP($B78,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B78,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence predominantly gained through assessment and verification of training syllabus (lesson plans, exercise programme), ensuring all key elements in “detail”\" column are expressed in documentation. This will help determine:\n\n-\tIf IOR training is being received and is based on self-presenters to ED.\n-\tWhether PRPS training is being delivered.\n-\tTraining re: decontamination and clinical care of casualties.\n\nSpecific plans, technical drawings, risk assessments, etc. that outline:\n\n-\tThe acute Trusts’ CDU capability and how it operates.\n-\tIts provision of clinical radiation monitoring.\n-\tHow scientific advice is obtained (this could also be an interview question to relevant staff groups, e.g., ”\"what radiation monitoring equipment do you have, and where is it?”\n\nAny documentation provided as evidence must be in-date, and published (i.e., not draft) for it to be credible.\n\nDocumented evidence of minimum completion of biannual reviews (e.g., via a collated list)."}]
[{"$f":"IF(OR(LEFT($C79,6)=\"Domain\",$I79=LookUp!$A$3,$I79=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A78)+1,\"\")","v":""},{"$f":"IFERROR(IF(B78+1>MAX('Core Criteria'!$C:$C),\"\",B78+1),\"\")","v":78},{"$f":"IF($B79=\"\",\"\",IF(VLOOKUP($B79,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B79,'Core Criteria'!$C:$V,2,FALSE)))","v":68},{"$f":"IF($B79=\"\",\"\",IF(VLOOKUP($B79,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B79,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B79=\"\",\"\",IF(VLOOKUP($B79,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B79,'Core Criteria'!$C:$V,4,FALSE)))","v":"Capability Review"},{"$f":"IF($B79=\"\",\"\",IF(VLOOKUP($B79,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B79,'Core Criteria'!$C:$V,5,FALSE)))","v":"NHS Ambulance Trusts must undertake a review of the CBRN/HazMat capability in designated hospitals within their geographical region. \n\nDesignated hospitals are those identified by NHS England as having a CBRN/HazMat decontamination capability attached to their Emergency Department and an allocation of the national PRPS stock."},{"$f":"IF($B79=\"\",\"\",IF(VLOOKUP($B79,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B79,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented evidence of that review, including:\n\n-\tDates of review.\n-\tWhat was reviewed.\n-\tFindings of the review.\n-\tAny associated actions.\n-\tEvidence of progress/close-out of actions."}]
[{"$f":"IF(OR(LEFT($C80,6)=\"Domain\",$I80=LookUp!$A$3,$I80=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A79)+1,\"\")","v":""},{"$f":"IFERROR(IF(B79+1>MAX('Core Criteria'!$C:$C),\"\",B79+1),\"\")","v":79},{"$f":"IF($B80=\"\",\"\",IF(VLOOKUP($B80,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B80,'Core Criteria'!$C:$V,2,FALSE)))","v":69},{"$f":"IF($B80=\"\",\"\",IF(VLOOKUP($B80,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B80,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B80=\"\",\"\",IF(VLOOKUP($B80,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B80,'Core Criteria'!$C:$V,4,FALSE)))","v":"Capability Review Frequency"},{"$f":"IF($B80=\"\",\"\",IF(VLOOKUP($B80,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B80,'Core Criteria'!$C:$V,5,FALSE)))","v":"NHS Ambulance Trusts must formally review the CBRN/HazMat capability in each designated hospital biennially (at least once every two years). "},{"$f":"IF($B80=\"\",\"\",IF(VLOOKUP($B80,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B80,'Core Criteria'!$C:$V,20,FALSE)))","v":"Documented evidence of that review, including:\n\n-\tDates of review.\n-\tWhat was reviewed.\n-\tFindings of the review.\n-\tAny associated actions.\nEvidence of progress/close-out of actions."}]
[{"$f":"IF(OR(LEFT($C81,6)=\"Domain\",$I81=LookUp!$A$3,$I81=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A80)+1,\"\")","v":""},{"$f":"IFERROR(IF(B80+1>MAX('Core Criteria'!$C:$C),\"\",B80+1),\"\")","v":80},{"$f":"IF($B81=\"\",\"\",IF(VLOOKUP($B81,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B81,'Core Criteria'!$C:$V,2,FALSE)))","v":70},{"$f":"IF($B81=\"\",\"\",IF(VLOOKUP($B81,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B81,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B81=\"\",\"\",IF(VLOOKUP($B81,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B81,'Core Criteria'!$C:$V,4,FALSE)))","v":"Capability Review report"},{"$f":"IF($B81=\"\",\"\",IF(VLOOKUP($B81,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B81,'Core Criteria'!$C:$V,5,FALSE)))","v":"Following each formal review of the capability within a designated  hospital, the NHS Ambulance Trust must produce a report detailing the level of compliance against the standards set out in this document. That report must be provided to the designated hospital and the NHS England Regional EPRR Lead. \n\nCopies of all such reports must be retained by the NHS Ambulance Trust for at least 10 years and they must be made available to any inspections or audits conducted by the National Ambulance Resilience Unit (NARU) on behalf of NHS England."},{"$f":"IF($B81=\"\",\"\",IF(VLOOKUP($B81,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B81,'Core Criteria'!$C:$V,20,FALSE)))","v":"Evidence of those reports and that the designated hospital and NHSE EPRR Lead are in receipt of those.\n\nDip sample of last 10 years of reports, e.g., please provide reports from 2015, 2018, and 2022 to show adherence to the retention of reports for 10 years."}]
[{"$f":"IF(OR(LEFT($C82,6)=\"Domain\",$I82=LookUp!$A$3,$I82=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A81)+1,\"\")","v":""},{"$f":"IFERROR(IF(B81+1>MAX('Core Criteria'!$C:$C),\"\",B81+1),\"\")","v":81},{"$f":"IF($B82=\"\",\"\",IF(VLOOKUP($B82,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B82,'Core Criteria'!$C:$V,2,FALSE)))","v":71},{"$f":"IF($B82=\"\",\"\",IF(VLOOKUP($B82,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B82,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B82=\"\",\"\",IF(VLOOKUP($B82,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B82,'Core Criteria'!$C:$V,4,FALSE)))","v":"Train the trainer"},{"$f":"IF($B82=\"\",\"\",IF(VLOOKUP($B82,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B82,'Core Criteria'!$C:$V,5,FALSE)))","v":"NHS Ambulance Trusts must support each designated hospital in their region with training to support the CBRN/HazMat decontamination and PRPS capability. \n\nThat training will take the form of ‘train the trainer’ sessions so trainers based within the designated hospitals can then cascade the training to those hospital staff that require it."},{"$f":"IF($B82=\"\",\"\",IF(VLOOKUP($B82,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B82,'Core Criteria'!$C:$V,20,FALSE)))","v":"Written statement as to how this is achieved, which can then be further investigated during inspection.\n\nEvidence of training records and/or a documented training schedule. \n\nProvision of suitable training documentation – syllabus, lesson plans, etc., that shows the detail of training delivered."}]
[{"$f":"IF(OR(LEFT($C83,6)=\"Domain\",$I83=LookUp!$A$3,$I83=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A82)+1,\"\")","v":""},{"$f":"IFERROR(IF(B82+1>MAX('Core Criteria'!$C:$C),\"\",B82+1),\"\")","v":82},{"$f":"IF($B83=\"\",\"\",IF(VLOOKUP($B83,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B83,'Core Criteria'!$C:$V,2,FALSE)))","v":72},{"$f":"IF($B83=\"\",\"\",IF(VLOOKUP($B83,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B83,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B83=\"\",\"\",IF(VLOOKUP($B83,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B83,'Core Criteria'!$C:$V,4,FALSE)))","v":"Aligned training"},{"$f":"IF($B83=\"\",\"\",IF(VLOOKUP($B83,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B83,'Core Criteria'!$C:$V,5,FALSE)))","v":"Training provided by the NHS Ambulance Trust for this purpose must be aligned to national train the trainer packages approved by the National Ambulance Resilience Unit for CBRN/HazMat decontamination and PRPS capabilities."},{"$f":"IF($B83=\"\",\"\",IF(VLOOKUP($B83,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B83,'Core Criteria'!$C:$V,20,FALSE)))","v":"NARU can provide the latest version number of associated training packages. This can then be cross-referenced against lesson plans and training packages in acute Trusts to ensure up-to-date national training is being delivered."}]
[{"$f":"IF(OR(LEFT($C84,6)=\"Domain\",$I84=LookUp!$A$3,$I84=LookUp!$A$4),MAX('EPRR Core Standards'!A$1:A83)+1,\"\")","v":""},{"$f":"IFERROR(IF(B83+1>MAX('Core Criteria'!$C:$C),\"\",B83+1),\"\")","v":83},{"$f":"IF($B84=\"\",\"\",IF(VLOOKUP($B84,'Core Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B84,'Core Criteria'!$C:$V,2,FALSE)))","v":73},{"$f":"IF($B84=\"\",\"\",IF(VLOOKUP($B84,'Core Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B84,'Core Criteria'!$C:$V,3,FALSE)))","v":"CBRN Support to acute Trusts"},{"$f":"IF($B84=\"\",\"\",IF(VLOOKUP($B84,'Core Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B84,'Core Criteria'!$C:$V,4,FALSE)))","v":"Training sessions"},{"$f":"IF($B84=\"\",\"\",IF(VLOOKUP($B84,'Core Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B84,'Core Criteria'!$C:$V,5,FALSE)))","v":"Provision of training sessions will be arranged jointly between the NHS Ambulance Trust and their designated hospitals. Frequency, capacity etc will be subject to local negotiation."},{"$f":"IF($B84=\"\",\"\",IF(VLOOKUP($B84,'Core Criteria'!$C:$V,20,FALSE)=\"\",\"\",VLOOKUP($B84,'Core Criteria'!$C:$V,20,FALSE)))","v":"Clear evidence of documentation (e.g., a contract, MoU, or equivalent, that details how training is delivered to acute Trusts, how often, etc.)."}]

{"sheet":"Deep Dive Investigation","index":2,"n_rows":20,"n_cols":13,"rows_kept":20,"cut":false,"hidden":false,"merged":[[1,2,1,12]]}
[null,"Lookup","Ref","Domain","Standard","Deep Dive question","Supporting evidence- including examples of evidence\n","\n\n\nOrganisational Evidence - Please provide details of arrangements in order to capture areas of good practice or further development. (Use comment column if required)\n\n\n\n\n","Self assessment RAG\n\nRed (not compliant) = Not evidenced in EPRR arrangements.\n\nAmber (partially compliant) = Not evidenced in EPRR arrangements but have plans in place to include in the next 12 months. \n\nGreen (fully compliant) = Evidenced in plans or EPRR arrangements and are  tested/exercised as effective.","Action to be taken","Lead","Timescale","Comments"]
[{"$f":"MAX('EPRR Core Standards'!A:A)+1","v":11},1,{"$f":"IF($B2=\"\",\"\",IF(VLOOKUP($B2,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B2,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"Deep Dive - Cyber Security and IT related incident response (NOT INCLUDED WITHIN THE ORGANISATION'S OVERALL EPRR ASSURANCE RATING)"}]
[{"$f":"IF(OR($I3=LookUp!$A$3,$I3=LookUp!$A$4),MAX(A$1:A2)+1,\"\")","v":""},{"$f":"IFERROR(IF(B2+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B2+1),\"\")","v":2},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD1"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Cyber Security & IT related incident preparedness"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"Cyber security and IT teams support the organisation's EPRR activity including delivery of the EPRR work programme to achieve business objectives outlined in organisational EPRR policy.\n"},{"$f":"IF($B3=\"\",\"\",IF(VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B3,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"-Cyber security and IT teams engaged with EPRR governance arrangement and are represented on EPRR committee membership (TOR and minutes)\n- Shared understanding of risks to the organisation and the population it serves with regards to EPRR - organisational risk assessments and risk registers\n-Plans and arrangements demonstrate a common understanding of incidents in line with EPRR framework and cyber security requirements. \n-EPRR work programme\n-Organisational EPRR policy                                                                                                                                                                      "}]
[{"$f":"IF(OR($I4=LookUp!$A$3,$I4=LookUp!$A$4),MAX(A$1:A3)+1,\"\")","v":""},{"$f":"IFERROR(IF(B3+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B3+1),\"\")","v":3},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD2"},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Cyber Security & IT related incident response arrangements"},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The organisation has developed threat specific cyber security and IT related incident response arrangements with regard to relevant risk assessments and that dovetail with generic organisational response plans."},{"$f":"IF($B4=\"\",\"\",IF(VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B4,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"Arrangements should:\n-consider the operational impact of such incidents\n-be current and include a routine review schedule\n-be tested regularly\n-be approved and signed off by the appropriate governance mechanisms\n-include clearly identified response roles and responsibilities\n-be shared appropriately with those required to use them\n-outline any equipment requirements \n-outline any staff training needs\n-include use of unambiguous language\n-demonstrate a common understanding of terminology used during incidents in line with the EPRR framework and cybersecurity requirements.'"}]
[{"$f":"IF(OR($I5=LookUp!$A$3,$I5=LookUp!$A$4),MAX(A$1:A4)+1,\"\")","v":""},{"$f":"IFERROR(IF(B4+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B4+1),\"\")","v":4},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD3"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Resilient Communication during Cyber Security & IT related incidents"},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The organisation has arrangements in place for communicating with partners and stakeholders during cyber security and IT related incidents."},{"$f":"IF($B5=\"\",\"\",IF(VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B5,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"Arrangements should consider the generic principles for enhancing communications resilience:\n1. look beyond the technical solutions at processes and organisational arrangements\n2. identify and review the critical communication activities that underpin your response arrangements\n3. ensure diversity of technical solutions\n4. adopt layered fall-back arrangements\n5. plan for appropriate interoperability\n\nhttps://www.england.nhs.uk/wp-content/uploads/2019/03/national-resilient-telecommunications-guidance.pdf"}]
[{"$f":"IF(OR($I6=LookUp!$A$3,$I6=LookUp!$A$4),MAX(A$1:A5)+1,\"\")","v":""},{"$f":"IFERROR(IF(B5+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B5+1),\"\")","v":5},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD4"},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Media Strategy"},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The organisation has Incident communication plans and media strategies that include arrangements to agree media lines and the use of corporate and personal social media accounts during cyber security and IT related incidents"},{"$f":"IF($B6=\"\",\"\",IF(VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B6,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"- Incident communications plans and media strategy give consideration to cyber security incidents activities as well as clinical and operational impacts. \n- Agreed sign off processes for media and press releases in relation to Cyber security and IT related incidents. \n- Documented process for communications to regional and national teams\n- Incident communications plan and media strategy provides guidance for staff on providing comment, commentary or advice during an incident or where sensitive information is generated. "}]
[{"$f":"IF(OR($I7=LookUp!$A$3,$I7=LookUp!$A$4),MAX(A$1:A6)+1,\"\")","v":""},{"$f":"IFERROR(IF(B6+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B6+1),\"\")","v":6},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD5"},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Testing and exercising"},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The exercising and/ or testing of cyber security and IT related incident arrangements are included in the organisations EPRR exercise and testing programme."},{"$f":"IF($B7=\"\",\"\",IF(VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B7,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"- Evidence of exercises held in last 12 months including post exercise reports\n- EPRR exercise and testing programme "}]
[{"$f":"IF(OR($I8=LookUp!$A$3,$I8=LookUp!$A$4),MAX(A$1:A7)+1,\"\")","v":""},{"$f":"IFERROR(IF(B7+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B7+1),\"\")","v":7},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD6"},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Continuous Improvement"},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The organisation's Cyber Security and IT teams have processes in place to implement changes to threat specific response arrangements and embed learning following incidents and exercises"},{"$f":"IF($B8=\"\",\"\",IF(VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B8,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"- Cyber security and IT colleagues participation in debriefs following live incidents and exercises\n- lessons identified and implementation plans to address those lessons\n-agreed processes in place to adopt implementation of lessons identified\n- Evidence of updated incident plans post-incident/exercise"}]
[{"$f":"IF(OR($I9=LookUp!$A$3,$I9=LookUp!$A$4),MAX(A$1:A8)+1,\"\")","v":""},{"$f":"IFERROR(IF(B8+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B8+1),\"\")","v":8},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD7"},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Training Needs Analysis (TNA)"},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"Cyber security and IT related incident response roles are included in an organisation's TNA."},{"$f":"IF($B9=\"\",\"\",IF(VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B9,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"- TNA includes Cyber security and IT related incident response roles\n- Attendance/participant lists showing cybersecurity and IT colleagues taking part in incident response training."}]
[{"$f":"IF(OR($I10=LookUp!$A$3,$I10=LookUp!$A$4),MAX(A$1:A9)+1,\"\")","v":""},{"$f":"IFERROR(IF(B9+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B9+1),\"\")","v":9},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD8"},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"EPRR Training "},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The oranisation's EPRR awareness training  includes the risk to the organisation of cyber security and IT related incidents and emergencies"},{"$f":"IF($B10=\"\",\"\",IF(VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B10,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"-Cyber security and IT related incidents and emergencies included in  EPRR awareness training package"}]
[{"$f":"IF(OR($I11=LookUp!$A$3,$I11=LookUp!$A$4),MAX(A$1:A10)+1,\"\")","v":""},{"$f":"IFERROR(IF(B10+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B10+1),\"\")","v":10},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,2,FALSE)=\"\",\"\",VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,2,FALSE)))","v":"DD9"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,3,FALSE)=\"\",\"\",VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,3,FALSE)))","v":"Deep Dive  \nCyber Security"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,4,FALSE)=\"\",\"\",VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,4,FALSE)))","v":"Business Impact Assessments"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,5,FALSE)=\"\",\"\",VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,5,FALSE)))","v":"The Cyber Security and IT teams are aware of the organisations's critical functions and the dependencies on IT core systems and infrastrucure for the safe and effective delivery of these services"},{"$f":"IF($B11=\"\",\"\",IF(VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,6,FALSE)=\"\",\"\",VLOOKUP($B11,'Deep Dive Criteria'!$C:$V,6,FALSE)))","v":"-robust Business Impact Analysis including core systems\n-list of the organisations critical services and functions\n-list of the organisations core IT/Digital systems and prioritisation of system recovery"}]
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[{"$f":"IF(OR($I20=LookUp!$A$3,$I20=LookUp!$A$4),MAX(A$1:A19)+1,\"\")","v":""},{"$f":"IFERROR(IF(B19+1>MAX('Deep Dive Criteria'!$C:$C),\"\",B19+1),\"\")","v":""}]

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[null,"Overall self assesment rating:"]
[null,"Ref","Domain","\nStandard name","\nStandard Detail","Supporting Information - including examples of evidence\n","\n\n\nOrganisational Evidence\t\n\n\n\n\n","Self assessment RAG\n\nRed (not compliant) = Not compliant with the core standard. The organisation’s work programme shows compliance will not be reached within the next 12 months.\n\nAmber (partially compliant) = Not compliant with core standard. However, the organisation’s work programme demonstrates sufficient evidence of progress and an action plan to achieve full compliance within the next 12 months.\n\nGreen (fully compliant) = Fully compliant with core standard.","Action to be taken","Lead","Timescale","Comments"]
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{"sheet":"Interoperable Capabilities","index":4,"n_rows":160,"n_cols":10,"rows_kept":160,"cut":false,"hidden":true,"merged":[]}
["Ref","Domain","Standard","Detail","Organisational Evidence","Self assessment RAG\n\nRed (non compliant) = Not compliant with the core standard. The organisation’s EPRR work programme shows compliance will not be reached within the next 12 months. \n\nAmber (partially compliant) = Not compliant with core standard. However, the organisation’s EPRR work programme demonstrates sufficient evidence of progress and an action plan to achieve full compliance within the next 12 months.\n\nGreen (fully compliant) = Fully compliant with core standard.","Action to be taken","Lead","Timescale","Comments"]
["HART"]
["Domain: Capability"]
["H1","HART","HART tactical capabilities","Organisations must maintain the following HART tactical capabilities: \n\n• Hazardous Materials (HazMat) \n• Chemical, Biological Radiological, Nuclear, Explosives (CBRN) \n• High Consequence Infectious Disease (HCID) \n• Marauding Terrorist Attack \n• Water Operations \n• Safe Working at Height \n• Confined Space \n• Unstable Terrain \n• All-Terrain Vehicle Operations \n• Support to Security Operations\n\nThese represent both local and national capabilities that mitigate risks within the National Risk Register. They must be maintained even through periods of significant local or regional demand pressure."]
["H2","HART","National Capability Matrices for HART","Organisations must maintain the HART capabilities in compliance with the scope and interoperable specification defined within the National HART Capability Matrices."]
["H3","HART","Compliance with National Standard Operating Procedures","Organisations must ensure that HART units and their personnel remain compliant with the National Standard Operating Procedures (SOPs) during local and national deployments. It is the personal responsibility for each member of HART staff to access and know the content of the National Standard Operating Procedures (SOPs)"]
["Domain: Human Resources"]
["H4","HART","Staff competence","Organisations must ensure that operational HART personnel maintain the minimum levels of competence defined in the National HART Training Information Sheets, and corresponding sub-competencies."]
["H5","HART","Protected training hours","l Training Information Sheets for HART. Organisations must ensure that operational HART personnel maintain the minimum levels of competence defined in the National HART Training Information Sheets, and corresponding sub-competencies. 1 – 4 H5 H5 Organisations must ensure that all operational HART personnel are provided with no less than 37.5 hours of protected training time every seven weeks. If designated training staff are used to augment the live HART team, they must receive the equivalent protected training hours within the seven-week period (in other words, training hours can be converted to live hours providing they are re-scheduled as protected training hours within the seven-week period). Organisations must ensure that all operational HART personnel are provided with no less than 37.5 hours of protected training time every seven weeks. If designated training staff are used to augment the live HART team, they must receive the equivalent protected training hours within the seven-week period (in other words, training hours can be converted to live hours providing they are re-scheduled as protected training hours within the seven-week period). If HART staff are given additional local skills and training requirements outside of the scope defined within the National HART Matrices, that local training must be provided in addition to the 37.5 hours protected for core HART training."]
["H6","HART","Training records ","Organisations must ensure that comprehensive training records are maintained for each member of HART in their establishment. These records must include; a record of mandated training completed, when it was completed, any outstanding training or training due and an indication of the individual’s level of competence across the HART skill sets. It must also include any restrictions in practice and corresponding action plans. Individual training records must directly cross reference the National Training Information Sheets."]
["H7","HART","Registration as Paramedics","All operational HART personnel must be professionally registered pre-hospital clinician. This will normally be an NHS paramedic, but this standard does not preclude the use of other NHS clinical professionals providing the Trust ensures the individuals have an appropriate level of pre-hospital experience and training. To ensure the appropriate clinical standard of care is maintained in accordance with the original DHSC mandate, the expectation is that the clinical level will be equivalent to or exceeding that of an NHS Paramedic."]
["H8","HART","Six operational HART staff on duty","Organisations must maintain a minimum of six operational HART staff on duty, per unit, at all times (24/7)"]
["H9","HART","Completion of Physical Competency Assessment","All HART applicants must be recruited in accordance with the minimum requirements set out in the national HART recruitment and selection manual. Local recruitment provisions can be added to this mandatory minimum as required by NHS Ambulance Trusts."]
["H10","HART","Mandatory six month completion of Physical Competency Assessment","All operational HART staff must undertake an ongoing Physical Competency Assessment (PCA) to the nationally specified standard every 6 months. Failure to achieve the required standard during these assessments must result in the individual being placed on restricted practice until they achieve the required standard. The Trust must then implement appropriate support for individuals on a restriction of practice."]
["H11","HART","Returned to duty Physical Competency Assessment","Any HART staff returning to work after a period of absence which exceeds 7 weeks must be subject to a formal review to ensure they receive sufficient catch up training and to ensure they are sufficiently fit (evidenced through the successful completion of a Physical Competency Assessment) and competent to continue with HART operational activity. It is the responsibility of the employing Trust to manage this process."]
["Domain: Administration"]
["H12","HART","Effective deployment policy","Organisations must maintain a local policy or procedure to ensure the effective prioritisation and deployment (or redeployment) of HART staff to an incident requiring the HART capabilities."]
["H13","HART","Identification appropriate incidents / patients","Organisations must maintain an effective process to identify incidents or individual patients, at the point of receiving a 999 call, that may benefit from the deployment of HART capabilities. Organisations must also have systems in place to ensure unreasonable delays in HART deployments are avoided."]
["H14","HART","Notification of changes to capability delivery","In any event that the organisation is unable to maintain the HART capabilities safely or if consideration is being given to locally reconfigure HART to support wider Ambulance operations, the organisation must notify the NARU On-Call Duty Officer and obtain national approval prior to any action being taken which may compromise the HART capability. \n\nWritten notification of any default of these core standards must also be provided to the Trust’s NHS England Regional EPRR Lead and the NARU Director within 14 days of the default or breach occurring."]
["H15","HART","Recording resource levels","Organisations must record HART resource levels, along with any restrictions of practice, and deployments on the nationally specified system. Resource levels must be updated on the system at least twice daily at shift change over even if the data is the same. Data recorded on the system must be in accordance with the requirements set by the National Ambulance Resilience Unit. Each Trust must have arrangements in place to ensure the required data is uploaded to the system even where HART staff may be deployed on an incident because the system is used to continually monitor the national state of readiness against national threats and risks."]
["H16","HART","Record of compliance with response time standards","Organisations must monitor and maintain accurate local records of their level of compliance with all HART core standards defined in this document. That must include accurate records of compliance with staffing levels and responses time standards for every HART deployment. \n\nOrganisations must comply and fully engage with any audits or inspections of the HART capabilities that are commissioned by NHS England. \n\nCompliance records must be made available for annual audits or inspections conducted by NHS England or NARU and must be made available to NHS commissioners or regulators on their request."]
["H17","HART","Local risk assessments","Organisations must maintain a set of local specific HART risk assessments which supplement the national HART risk assessments. These must cover specific local training venues or local activity and pre-identified local high-risk sites. The organisation must also ensure there is a local process to determine how HART staff should conduct a dynamic risk assessment at any live deployment. This should be consistent with the JESIP approach to risk assessment."]
["H18","HART","Lessons identified reporting","Organisations must have a robust and timely process to report any lessons identified following a HART deployment or training activity that may affect the interoperable service to NARU within 12 weeks using a nationally approved lessons database."]
["H19","HART","Safety reporting","Organisations must have a robust and timely written process to report to NARU any safety risks related to equipment, training or operational practice which may have an impact on the national interoperability of the HART service as soon as is practicable and no later than 24 hours of the risk being identified."]
["H20","HART","Receipt and confirmation of safety notifications","Organisations must have a written process to acknowledge and respond appropriately to any national safety notifications issued for HART by NARU or other relevant national body within 2 days of the notification being issued."]
["H21","HART","Change Request Process","Organisations must use the NARU coordinated Change Request Process before reconfiguring (or changing) any HART procedures, equipment or training that has been specified as nationally interoperable."]
["Domain: Response time standards"]
["H22","HART","Initial deployment requirement","Four HART personnel must be available or released and mobilised to respond locally to any incident identified as potentially requiring HART capabilities within 15 minutes of the call being accepted by the provider. This standard does not apply to pre-planned operations. \n\nThe standard will not apply if the nearest HART unit is already deployed dealing with a higher priority incident requiring HART capabilities. If the HART team is already deployed on an incident requiring specialist HART capabilities, the Trust must take steps to mobilise another HART team to the new incident (either from within its own geography or via national mutual aid) within 15 minutes of that call being received by the Trust."]
["H23","HART","Additional deployment requirement","Once a HART capability is confirmed as being required at the scene (with a corresponding safe system of work) organisations must ensure that six HART personnel are released and available to respond to scene within 10 minutes of that confirmation. The six includes the four already mobilised. \n\nConfirmation of this requirement would usually come from; the HART Team Leader based on information from the call, one of the four HART Operatives already mobilised or from other emergency service personnel (including Ambulance personnel) in attendance at the scene. \n\nDelays in the deployment of all six HART staff could create a direct risk to the application of a safe system of work at the scene."]
["H24","HART","Attendance at strategic sites of interest","Organisations maintain a HART service capable of placing six HART personnel on\u0002scene at strategic sites of interest within 45 minutes. \n\nThese sites were initially determined through the Model Response Doctrine which led to the strategic placement of HART units. The 45 minute standard is therefore primarily associated with key transport infrastructure and densely populated areas. Where a Trust through their LRF have identified additional strategic sites of interest which may be beyond a 45 minute HART response, the Trust must have local multi-agency plans to act as a contingency for a potentially delayed HART response. \n\nA delayed response will not breach this standard if the nearest live HART team is already deployed at an incident requiring specialist HART capabilities within the same region. If the HART Team is already deployed on an incident requiring specialist HART capabilities, the Trust must take steps to mobilise another HART team to the new incident (either from within its own geography or via national mutual aid) within 15 minutes of that call being received by the Trust."]
["H25","HART","HART Mutual aid","Organisations must ensure that their ‘on duty’ HART personnel and HART assets maintain a 30-minute notice to move to anywhere in the United Kingdom following a mutual aid request endorsed by NHS England or NARU. Trusts can also maintain the 30-minute notice to move by way of a recall to duty or on-call process (i.e. where members of the on-duty team are unable to deploy due to child care or personal commitments at the time of the notification). \n\nA delayed response will not breach this standard if the nearest live HART team is already deployed at an incident requiring specialist HART capabilities within the same region"]
["Domain: Logistics"]
["H26","HART","Capital depreciation and revenue replacement schemes ","Organisations must ensure appropriate capital depreciation and revenue replacement schemes are maintained locally to replace nationally specified HART equipment. \n\nThis must include maintaining capital provisions of at least £1.9 million depreciated over 5 years to maintain the HART fleet and incident ground equipment. \n\nInternal HART budgets and expenditure must be in accordance with the reference costs set nationally for HART units. Given that the HART capabilities are national as well as local, HART funding provision must not be reallocated internally away from HART within the express permission of NHS England (the National EPRR team)."]
["H27","HART","Interoperable equipment","Organisations must procure and maintain minimum levels of interoperable equipment specified in National Equipment Data Sheets. \n\nTo maintain minimum levels of interoperability, national interoperable equipment that has not be specified within National Equipment Data Sheets should not be utilised as part of the HART capabilities."]
["H28","HART","Equipment procurement via national buying frameworks ","Organisations must procure interoperable equipment using the national buying frameworks (where applicable) coordinated by NARU unless they can provide assurance that the local procurement is interoperable and meets the requirements of the National Equipment Data Sheets. \n\nAny locally procured equipment that does not have a National Equipment Data Sheet which has been procured locally to support the delivery of training, sits outside of the national safe system of work. Trusts must ensure that they have local risk assessments and governance provisions in place to manage the use of such equipment. Any such equipment must not be deployed at incidents in support of HART capabilities."]
["H29","HART","Fleet compliance with national specification","Organisations must ensure that the HART fleet and associated incident ground technology remain compliant with the national specification. \n\nNationally specified vehicles must conform to the national loading lists for each vehicle and the vehicles state of readiness must be updated on the national monitor systems. This will include national location tracking."]
["H30","HART","Equipment maintenance","Organisations must ensure that all HART equipment is maintained according to applicable standards and in line with manufacturers recommendations. This will include standards specified in the National Equipment Data Sheets and relevant associated BS or EN related standards (or equivalent)."]
["H31","HART","Equipment asset register","Organisations maintain an asset register of all HART equipment. Such assets are defined by their reference or inclusion within the Capability Matrix and National Equipment Data Sheets. This register must include; individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment)."]
["H32","HART","Capital estate provision","Organisations must maintain suitable estate provision for each HART unit which complies with the national estate specification as a minimum."]
["SORT"]
["Domain: Capability"]
["S1","SORT","Maintenance of national specified MTFA capability","NHS Ambulance Trusts must maintain a combined MTA (Marauding Terrorist Attack) and CBRN (Chemical Biological Radiological Nuclear) capability in accordance with national specifications. \n\nThese capabilities operate in support of Hazardous Area Response Team deployments when required."]
["S2","SORT","Compliance with safe system of work","NHS Ambulance Trusts must ensure that the SORT capabilities (MTA and CBRN) remain compliant with the national safe system of work specified by the National Ambulance Resilience Unit (NARU)."]
["S3","SORT","Interoperability","NHS Ambulance Trusts must ensure that the SORT capabilities (MTA and CBRN) remain nationally interoperable and confirm the scope of operational practice defined within national capability matrices published by NARU."]
["S4","SORT","Access to specialist scientific advice","Organisations have robust and effective arrangements in place to access specialist scientific advice relevant to the full range of CBRN incidents. All Commanders and NILOs / Tactical Advisors must be able to access this advice at all times (24/7)."]
["Domain: Human Resources"]
["S5","SORT","SORT establishment","NHS Ambulance Trusts must maintain a minimum establishment of 290 SORT trained staff. For compliance purposes this must be for at least 90% of the calendar year. \n\nTrusts should have 35 SORT staff on duty between the hours of 06:00 and 02:00 daily (365 days per year). Recall to duty programmes must be in addition to this on\u0002duty requirement. \n\nFor compliance monitoring and reporting the following provisions apply: \n• Trusts will not be penalised or deemed to be non-compliant if the number of SORT staff fluctuates between 30 and 35 during any given shift. \n• Less than 35 but more than 25 on up to 3 occasions per month = compliant. \n• Less than 30 and more than 25 on more than 3 occasions in any given month = non-compliant. \n• Less than 25 at any time = non\u0002compliant."]
["S6","SORT","Completion of a Physical Competency Assessment","All active SORT staff within each NHS Ambulance Trust must successfully complete a physical competence assessment every 12 months (annually). \n\nThe physical competence assessment must be conducted to the nationally specified standard (as specified by the National Ambulance Resilience Unit). \n\n‘Active’ staff means staff that are undertaking operational shifts where their numbers are being included within SORT staffing level data for the Trust.\n\nSORT staff that have not successfully completed a physical competency assessment within a 12 month period must be placed on a restriction of practice. They must not respond to an incident as a SORT operative whilst on such a restriction of practice and the Trust must have robust processes in place to ensure compliance with this provision. Staff on a restriction of practice for SORT must not be counted as part of the SORT on-duty staffing levels."]
["S7","SORT","Staff competency","NHS Ambulance Trusts must ensure that each individual SORT member of staff remains compliant with the competency standards defined within national Training Information Sheets (TIS’s) published by NARU for SORT staff and CBRN training is aligned to Skills for Health occupational standard EC25 – Decontaminate individuals affected by chemical, biological, radiological or nuclear incident. \n\nThis training requirement includes providing a minimum of 7 days training (minimum of 52.5 hours) every 12 months. This training must be split into at least two separate sessions per operative per annum (it cannot be delivered in a single consecutive training session or period)."]
["S8","SORT","Training records","NHS Ambulance Trusts must ensure that comprehensive training records are maintained for all SORT personnel in their establishment. These records must include; a record of mandated training completed aligned to the national Training Information Sheets (TISs), when it was completed, any outstanding training or training due and an indication of the individual’s level of competence across the SORT skill sets. It must also include any restrictions in practice and corresponding action plans."]
["S9","SORT","Provision of clinical training","NHS Ambulance Trusts are required to provide supportive training to statutory Fire and Rescue Services within their Trust geography that have a declared MTA capability. That supportive training must cover the clinical elements of the response and working jointly with Ambulance HART and SORT deployments for MTA incidents."]
["S10","SORT","Staff training requirements","NHS Ambulance Trusts must ensure that all frontline operational staff have received familiarisation training or briefing on how non-specialist / non-protected Ambulance responders should deal with an MTA incident. This should be included as part of annual mandatory training requirements. \n\nIt is recognised that Ambulance Trusts have various staff in training or on alternate duties at any point in time. Therefore, for compliance purposes, the Trust will be deemed to be compliant with this requirement providing it can evidence that over 80% of frontline staff have received the required familiarisation training when audited or inspected."]
["S11","SORT","Arrangements to manage staff exposure and contamination ","NHS Ambulance Trusts must ensure they have robust procedures in place to document all staff who may have become exposed or contaminated during incidents involving CBRN or hazardous materials. These procedures must include attendance at scene monitoring, exposure monitoring and post exposure management."]
["S12","SORT","CBRN Lead trainer","NHS Ambulance Trusts must have sufficient capacity of dedicated training or instructional staff for SORT to enable the Trusts to deliver and maintain the nationally specified training requirements each year."]
["S13","SORT","FFP3 access","NHS Ambulance Trusts must ensure that frontline staff who may come into contact with confirmed infectious respiratory viruses have access to FFP3 mask protection (or equivalent such as a Powered Respirator Protective Hood PRPH) and that they have been appropriately fit tested (where applicable). The specification and standards for this protection (including the Air Particulate Filtration) must comply with the provisions set out in the relevant national Equipment Data Sheet (EDS)."]
["S14","SORT","IOR training for operational staff ","NHS Ambulance Trusts must ensure that all frontline operational staff that may make contact with a contaminated patient are sufficiently trained in Initial Operational Response (IOR) principles of Remove Remove Remove. Organisations must maintain records to demonstrate how many staff are trained (and when the training occurred)."]
["Domain: Administration"]
["S15","SORT","Effective deployment policy","NHS Ambulance Trusts must maintain a local policy or procedure to ensure the effective identification of incidents or patients that may benefit from deployment of the SORT capability. These procedures must be aligned to the MTA Joint Operating Principles (produced by JESIP)."]
["S16","SORT","Identification appropriate incidents / patients","NHS Ambulance Trusts must have a local policy or procedure to ensure the effective prioritisation and deployment (or redeployment) of SORT personnel to an incident requiring the MTA or CBRN capability. This must include specific mechanisms to identify on-duty SORT staff and make them available to response to the incident as quickly as possible. These procedures must be aligned to relevant Joint Operating Principles (JOPs, produced by JESIP)."]
["S17","SORT","Change Management Process","NHS Ambulance Trusts must use the national Change Management Process coordinated by NARU before reconfiguring (or changing) any SORT procedures, equipment or training that has been specified as nationally interoperable."]
["S18","SORT","Record of compliance with response time standards","NHS Ambulance Trusts must monitor their compliance with the SORT core standards set out in this document. The Accountable Emergency Officer in each Trust is responsible to their Board for the levels of compliance against these standards. \n\nEach NHS Ambulance Trust must maintain accurate records of their compliance with the core standards set out in this document and make those records available during annual audits or inspections commissioned by NHS England. These records should also be made available to NHS commissioners and regulators on request."]
["S19","SORT","Notification of changes to capability delivery","SORT is both a national and regional capability. It provides critical mitigation to risks articulated in the risk register for the United Kingdom. \n\nNHS Ambulance Trusts must not take the SORT capability offline or reconfigure it locally without first obtaining permission from the National Ambulance Resilience Unit or NHS England’s national EPRR team. In the first instance, the discussion needs to be with the NARU On-Call Duty Officer. \n\nIn any event that the organisation is unable to maintain the SORT capability safely or if consideration is being given to locally reconfigure SORT to support wider Ambulance operations, the organisation must notify the NARU On-Call Duty Officer and obtain national approval prior to any action being taken which may compromise the SORT capability.\n\nWritten notification of any default of these core standards must also be provided to the Trust’s NHS England Regional EPRR Lead and the NARU Director within 14 days of the default or breach occurring."]
["S20","SORT","Recording resource levels","NHS Ambulance Trusts must record SORT resource levels, along with any restrictions of practice, and deployments on the nationally specified system. Resource levels must be updated on the system at least twice daily even if the data is the same. Data recorded on the system must be in accordance with the requirements set by the National Ambulance Resilience Unit. Each Trust must have arrangements in place to ensure the required data is uploaded to the system even where SORT staff may be deployed on an incident because the system is used to continually monitor the national state of readiness against national threats and risks."]
["S21","SORT","Local risk assessments","NHS Ambulance Trusts must maintain a set of local specific SORT risk assessments which supplement the national SORT risk assessments. These must cover specific local training venues or local activity and pre-identified local high-risk sites. The organisation may determine what locations are considered high-risk (often in conjunction with the LRF), but the assessment must be for/or include MTA and CBRN specific risks. The organisation must also ensure there is a local process to regulate how SORT staff conduct a dynamic risk assessment at any live deployment. This should be consistent with the JESIP approach to risk assessment."]
["S22","SORT","Lessons identified reporting","NHS Ambulance Trusts must have a robust and timely process to report any lessons identified following a SORT deployment or training activity that may affect the interoperable service to NARU within 12 weeks using the nationally approved lessons database. Note: the 12 weeks starts from resolution of the incident."]
["S23","SORT","Safety reporting","NHS Ambulance Trusts have a robust and timely process to report to NARU any safety risks related to equipment, training or operational practice which may have an impact on the national interoperability of the SORT service as soon as is practicable and no later than 24 hours of the risk being identified. \n\nReports must be made using the national safety alert system managed by NARU."]
["S24","SORT","Receipt and confirmation of safety notifications","NHS Ambulance Trusts have a process to acknowledge and respond appropriately to any national safety notifications issued for SORT by NARU within 2 days."]
["S25","CBRN","HAZMAT / CBRN plan","NHS Ambulance Trusts must ensure that their major or complex incident plans include specific provisions to manage a MTA or CBRN incident. These provisions must align to the national SORT matrices and operating procedures published by NARU. All SORT staff must have access to both the Trust plans and the national safe system of work provisions (including procedures, generic risk assessments etc) published by NARU and should be familiar with their contents. \n\nThese plans must also be aligned to the relevant JESIP / JOP provisions."]
["S26","SORT","SORT Audit and inspections","NHS Ambulance Trusts must comply and fully engage with any audits or inspections of the SORT capability that are commissioned by NHS England."]
["S27","SORT","SORT capability funding","NHS Ambulance Trusts must ensure that the national funding provided to support the SORT capability within Trusts is used to support the maintenance of that capability. The Trust must not redirect these funds and use them for other internal purposes within the express permission of NHS England or NARU."]
["Domain: Response time standards"]
["S28","SORT","SORT Readiness to deploy","NHS Ambulance Trusts must ensure their SORT capability remains at a high state of readiness to deploy to MTA or CBRN related incidents between the hours of 0600 and 0200 daily. \n\nOn receipt of an emergency call or notification by a partner agency of a potential incident involving CBRN or a marauding terrorist attack, NHS Ambulance Trusts must immediately identify all SORT staff on duty within their system and prepare to deploy those that are not committed or that can be made available from lower priority calls."]
["S29","SORT","SORT response time","Once a SORT capability is confirmed as being required at the scene (with a corresponding safe system of work) organisations must ensure that at least 30 SORT staff are allocated to respond to the incident (or a designated holding area) within 60 minutes. This includes the SORT staff that may have already been deployed and this can include off duty staff who have made themselves available through recall to duty. \n\nAny SORT staff available to respond in less than 60 minutes, must be responded as quicky as possible. The 60 minutes is the total envelope in which a minimum of 30 SORT responders must be assigned to the incident. \n\nThe NHS Ambulance Trust can use less SORT staff to resolve a smaller scale incident without breaching this standard, providing the decision is based on clear information or intelligence indicating that 30 staff would not be required due to the nature or scale of the incident. Any decision to limit the number of SORT responders sent to the incident must be approved by a Tactical or Strategic Commander and must be clearly documented. The decision will be subject to external review post incident."]
["S30","SORT","SORT Mutual Aid","NHS Ambulance Trusts must maintain their SORT capability at a state of readiness which is able to support a national deployment under mutual aid with reference to the national mutual aid policy. As an interoperable capability, it is nationally expected that Trusts provide SORT mutual aid when requested by NHS England, NARU or the National Ambulance Coordination Centre."]
["Domain: Logistics "]
["S31","SORT","PPE availability","NHS Ambulance Trusts must ensure that the nationally specified personal protective equipment is available for all operational SORT personnel and that the equipment remains compliant with the relevant national Equipment Data Sheets (EDSs)."]
["S32","SORT","Equipment procurement via national buying frameworks ","NHS Ambulance Trusts must procure SORT (MTA and CBRN) equipment specified in the SORT (MTA and CBRN) related Equipment Data Sheets and where applicable through the buying frameworks maintained by NARU. \n\nNHS Ambulance Trusts must also ensure sufficient financial provisions are in place to replace SORT equipment as specified by the relevant national Equipment Data Sheets. For MTA equipment, this should include an annual programme of rolling replacement."]
["S33","SORT","Equipment maintenance ","All SORT equipment must be maintained in accordance with the manufacturer’s recommendations and applicable national industry standards. \n\nThis must include a programme of regular inspections and preventative maintenance as specified in relevant national Equipment Data Sheets."]
["S34","SORT","SORT asset register ","NHS Ambulance Trusts must maintain an asset register of all SORT (MTA and CBRN) assets specified in the relevant national capability matrices and associated national Equipment Data Sheets. The register must include individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment)."]
["S35","SORT","PRPS  - minimum number of suits ","NHS Ambulance Trusts must maintain the minimum number of PRPS suits specified by NHS England and NARU. These suits must remain live and fully operational. Trusts must also ensure they have a financial / revenue replacement plan in place to ensure the minimum number of suits is maintained and replaced as required by the national Equipment Data Sheets."]
["S36","SORT","Individual / role responsible for SORT assets","NHS Ambulance Trusts must have a named individual or role that is responsible for ensuring SORT assets are managed appropriately."]
["S37","SORT","CBRN countermeasures","NHS Ambulance Trusts must ensure that they make CBRN countermeasures available for use by frontline Ambulance staff. This must include distribution of countermeasures across frontline assets in accordance with the specification and requirements defined within the relevant national matrix and Equipment Data Sheets (EDSs)."]
["S38","SORT","Water supply for clinical decontamintion","NHS Ambulance Trusts must ensure they have local or regional agreements and procedures in place to facilitate access to water supplies to carry out clinical decontamination. This may be achieved in conjunction with Fire and Rescue Services."]
["S39","SORT","Equipment Vehicles","Organisations must maintain a minimum of four vehicles to provide the MTA pooled equipment These vehicles should be replaced at a maximum of every 7 years. A minimum of 160 sets of pooled ballistic PPE and associated medical consumables must be available split over the organisations geographical area based on a local Trust assessment of risk."]
["S40","SORT","Equipment vehicle readiness","In conjunction with standards S29 and S30, MTA pooled equipment vehicles must be maintained at a high state of readiness to deploy. At least one asset must be mobilised within 15 minutes of a SORT response being confirmed as being required for an incident.  \n\nFailure to rapidly mobilise the equipment on these vehicles will delay the deployment of responders at the scene."]
["S41","SORT","Vehicle Tracking","NHS Ambulance Trusts must ensure that vehicles used to deploy interoperable capabilities can be tracked nationally by NARU via nationally approved systems. This includes the vehicles associated with the SORT capability that are used to transport either pooled MTA equipment or CBRN resources to the scene of an incident."]
["Mass Casualty Capability"]
["Domain: Capability Alignment Standards"]
["M1","MassCas","Mass casualty response arrangements ","NHS Ambulance Trusts must ensure they have plans and procedures in place that specifically cater for a mass casualty incident and that those provisions are aligned to the national framework or concept of operations for managing mass casualty incidents published by NHS England."]
["M2","MassCas","Arrangements to work with NACC","NHS Ambulance Trusts must have a procedure in place to work in conjunction with the National Ambulance Coordination Centre (NACC) in the event that national coordination is required or activated."]
["M3","MassCas","EOC arrangements ","NHS Ambulance Trusts must have effective and tested arrangements in place to ensure their Emergency Operations Centres (or equivalent) can communicate and effectively coordinate with receiving medical facilities (including designated Acute Trusts) within the first hour of mass casualty or major incident being declared."]
["M4","MassCas","Casualty management arrangements ","NHS Ambulance Trusts must have a Casualty Management Plan (CMP) (including patient distribution model) which has been produced in conjunction with Regional Trauma Networks and / or individual receiving facilities. These plans and arrangements must be exercised once a year. This can be by way of a table top or live exercise."]
["M5","MassCas","Casualty Clearing Station arrangements ","NHS Ambulance Trusts must maintain a capability to establish and appropriately resource a Casualty Clearing Station or multiple Casualty Collection Points at the location in which patients can receive further assessment, stabilisation and preparation on onward transportation / evacuation."]
["M6","MassCas","Management of non-NHS resource","NHS Ambulance Trust plans must include provisions to access, coordinate and, where necessary, manage the following additional resources, as part of the patient distribution model: \n• Patient Transportation Services \n• Private Providers of Patient Transport Services \n• Voluntary Ambulance Service Providers"]
["M7","MassCas","Mass Cas Audits and Inspections","NHS Ambulance Trusts must comply and fully engage with any audits or inspections of the mass casualties capability that are commissioned by NHS England."]
["Domain: Mass Casualty Equipment"]
["M8","MassCas","MCV accommodation","NHS Ambulance Trusts must maintain the number of mass casualty vehicles assigned to them by the National Ambulance Resilience Unit. \n\nThese vehicles must be maintained in compliance with the national specification and any guidance produced by NARU to ensure effective interoperability."]
["M9","MassCas","Maintenance and insurance ","NHS Ambulance Trusts must insure, mechanically maintain and regularly run the mass casualty vehicles. \n\nEach nationally specified mass casualty vehicle must be securely accommodated undercover (garaged) when not deployed and must be maintained with an appropriate shoreline / electrical feed. \n\nThe vehicle must be parked in a way that would facilitate rapid mobilisation and a high state of readiness. \n\nIn the event of a mass casualty vehicle being unavailable, within 2 hours the national electronic dashboard must be updated and the NARU On Call Duty Officer informed."]
["M10","MassCas","Mobilisation arrangements ","NHS Ambulance Trusts must maintain appropriate mobilisation arrangements for the vehicles which should include criteria to identify any incidents or events which may benefit from the deployment of the asset(s). \n\nTrusts must ensure that their mass casualty vehicle (MCV) assets maintain a 30-minute notice to move anywhere in the United Kingdom following a mutual aid request endorsed by NARU. An exception to this standard may be claimed if the MCV is already deployed at a local incident or is non\u0002operational."]
["M11","MassCas","Mass oxygen delivery system","NHS Ambulance Trusts must maintain the mass oxygen delivery system on the vehicles, in accordance with the manufacturers guidance (including regular servicing and maintenance)."]
["M12","MassCas","Drug and pharmaceutical stock management","In accordance with agreements and instructions from NHS England and local Pharmacy Leads, the drugs and pharmaceuticals which form part of the minimum nationally specified stock for each MCV must be appropriately and effectively maintained by the NHS Ambulance Trust."]
["M13","MassCas","Fleet compliance with national specification","NHS Ambulance Trusts must ensure that the minimum contents for each MCV (specified through the national load list) are maintained on the vehicle and remain fit for operational deployment / utilisation."]
["M14","MassCas","Compliance with safe system of work","NHS Ambulance Trusts must ensure that each MCV is managed in accordance with national procedures and other associated national safe system of work provisions."]
["Command and control (C2)"]
["Domain: Generic Standards "]
["C1","C2","Consistency with NHS England EPRR Framework","NHS Ambulance command and control must remain consistent with the NHS England EPRR Framework and wider NHS command and control arrangements. \n\nEach NHS Ambulance Trust must comply and fully engage with any audits or inspections of the command and control capability that are commissioned by NHS England."]
["C2","C2","Consistency with Standards for NHS Ambulance Service Command and Control.","NHS Ambulance command and control must be conducted in a manner commensurate to the legal and professional obligations set out in the National Command and Control Guidance published by NARU."]
["C3","C2","NARU notification process ","NHS Ambulance Trusts must notify the NARU On-Call Officer of any critical or major incidents active within their area that require the establishment of a full command structure (strategic commander down to functional roles) and utilisation of the Trusts interoperable capability assets to manage an incident. Notification should be made within the first 30 minutes of the incident whether additional resources are needed or not. In the event of a national emergency or where mutual aid is required by the NHS Ambulance Service, the National Ambulance Coordination Centre (NACC) may be established. Once established, NHS ambulance strategic commanders must ensure that their command and control processes have an effective interface with the NACC and that clear lines of communication are maintained."]
["C4","C2","AEO governance and responsibility ","The Accountable Emergency Officer in each NHS Ambulance Trust is responsible for ensuring compliance with these core standards and the provisions set out within the National Command and Control Guidance published by NARU. NHS Ambulance Trust Boards are required to provide annual assurance against these standards."]
["Domain: Resource"]
["C5","C2","Command role availability","NHS Ambulance Trusts must ensure that the command roles defined within the National Command and Control Guidance published by NARU are maintained and available at all times within their service area."]
["C6","C2","Support role availability ","NHS Ambulance Trusts must ensure that there is sufficient resource in place to provide each command level (strategic, tactical and operational) with the dedicated support roles set out in the National Command and Control Guidance published by NARU standards at all times."]
["C7","C2","Recruitment and selection criteria","NHS Ambulance Trusts must ensure there is an appropriate recruitment and selection criteria for personnel fulfilling command roles (including command support roles) that promotes and maintains the levels of credibility and competence defined in these standards. No personnel should have command and control roles defined within their job descriptions without a recruitment and selection criteria that specifically assesses the skills required to discharge those command functions. Those skills and the mandatory levels of competence are defined within the National Training Information Sheets for Command and the National Occupational Standards for Command. This standard does not apply to the Functional Command Roles assigned to available personnel at a major incident."]
["C8","C2","Contractual responsibilities of command functions ","Staff expected to discharge strategic, tactical, and operational command functions must have those responsibilities explicitly defined within their individual contracts of employment."]
["C9","C2","Access to PPE ","The NHS Ambulance Trust must ensure that each commander and each of the support functions have access to personal protective equipment and logistics necessary to discharge their role and function. To ensure interoperability at a national incident, this must include access to tabards that are compliant with the specification defined within the National Command and Control Guidance published by NARU."]
["C10","C2","Suitable communication systems ","The NHS Ambulance Trust must have suitable communication systems (and associated technology) to support its command and control functions. As a minimum this must support the secure exchange of voice and data between each layer of command with resilience and redundancy built in."]
["Domain: Decision making"]
["C11","C2","Risk management ","NHS ambulance commanders must manage risk in accordance with the method prescribed in the National Command and Control Guidance published by NARU and the JESIP principles."]
["C12","C2","Use of JESIP JDM","NHS ambulance commanders at all levels must use the JESIP Joint Decision Model (JDM) and apply JESIP principles during emergencies where a joint command structure is established."]
["C13","C2","Command decisions","NHS ambulance command decisions at all three levels must be made within the context of the legal and professional obligations set out in the National Command and Control Guidance published by NARU. \n\nTactical and operational commanders must utilise the national Standard Operating Procedures (SOPs) for command and associated safe system of work provisions."]
["Domain: Record keeping"]
["C14","C2","Retaining records ","All decision logs and records which are directly connected to a major or complex emergency must be securely stored and retained by the Ambulance Service for a minimum of 25 years."]
["C15","C2","Decision logging ","Commanders at all three levels (strategic, tactical and operational) must have access to an appropriate system of logging their decisions which conforms to national best practice. Ambulance Trusts are under a legal, professional and contractual obligation to ensure their commanders maintain appropriate decision logs."]
["C16","C2","Access to loggist ","Each level of command (strategic, tactical and operational) must be supported by a trained and competent loggist. A minimum of three loggists must be available to provide that support in each NHS Ambulance Service at all times. It is accepted that there may be more than one operational commander for multi-sited incidents. The minimum is three loggists but the Trust should have plans in place for additional logs to be kept by non\u0002trained loggists should the need arise."]
["Domain: Learning Lessons"]
["C17","C2","Lessons identified ","NHS Ambulance Trusts must ensure they maintain an appropriate system for identifying, recording, learning and sharing lessons from complex or protracted incidents in accordance with the wider EPRR core standards and that such learning is shared on the national systems produced by NARU and/or JESIP."]
["Domain: Competence"]
["C18","C2","Strategic commander competence - National Occupational Standards","Personnel that discharge the strategic commander function must maintain the minimum levels of competence defined in the National Training Information Sheets, and corresponding sub-competencies, for Command and Control. \n\nStrategic commanders must also ensure they maintain the standards of competence defined within the NHS England Minimum Occupational Standards for EPRR. \n\nStrategic commanders must ensure they are fully aware of the provisions in the National Command and Control Guidance published by NARU including the specific requirements of commanders and command functions."]
["C19","C2","Strategic commander competence - nationally recognised course","Personnel that discharge the strategic commander function must have successfully completed a nationally recognised strategic commander course (nationally recognised by NHS England / NARU). \n\nIndividuals must not be placed on an active command rota or fulfil strategic commander functions unless or until they can demonstrate the appropriate minimum level of qualification for that specific role as defined within the National Training Information Sheets."]
["C20","C2","Tactical commander competence - National Occupational Standards","Personnel that discharge the tactical commander function must maintain the minimum levels of competence defined in the National Training Information Sheets, and corresponding sub-competencies, for Command and Control. \n\nTactical commanders must also ensure they maintain the standards of competence defined within the NHS England Minimum Occupational Standards for EPRR. \n\nTactical commanders must ensure they are fully aware of the provisions in the National Command and Control Guidance published by NARU including the specific requirements of commanders and command functions. \n\nAmbulance service tactical commanders must have a good professional understanding of each interoperable capability and the tactical options available from these capabilities. They should not be reliant on tactical advisors or NILOs for this level of knowledge. Advisors provide highly technical or specialist advice but that should not be a substitute to a tactical commander understanding the capabilities under their command."]
["C21","C2","Tactical commander competence - nationally recognised course","Personnel that discharge the tactical commander function must have successfully completed a nationally recognised tactical commander course (nationally recognised by NHS England / NARU). Courses may be run nationally or locally but they must be recognised by NARU as being of a sufficient interoperable standard. Local courses should also cover specific regional risks and response arrangements. \n\nIndividuals must not be placed on an active command rota or fulfil tactical commander functions unless or until they can demonstrate the appropriate minimum level of qualification for that specific role as defined within the National Training Information Sheets."]
["C22","C2","Operational commander competence - National Occupational Standards","Personnel that discharge the operational commander function must maintain the minimum levels of competence defined in the National Training Information Sheets, and corresponding sub-competencies, for Command and Control. \n\nOperational commanders must also ensure they maintain the standards of competence defined within the NHS England Minimum Occupational Standards for EPRR. \n\nOperational commanders must ensure they are fully aware of the provisions in the National Command and Control Guidance published by NARU including the specific requirements of commanders and command functions. \n\nAmbulance service operational commanders must have a good professional understanding of each interoperable capability and the tactical options available from these capabilities. They should not be reliant on tactical advisors or NILOs for this level of knowledge. Advisors provide highly technical or specialist advice but that should not be a substitute to an operational commander understanding the capabilities under their command."]
["C23","C2","Operational commander competence - nationally recognised course","Personnel that discharge the operational commander function must have successfully completed a nationally recognised operational commander course (nationally recognised by NHS England / NARU). Courses may be run nationally or locally but they must be recognised by NARU as being of a sufficient interoperable standard. Local courses should also cover specific regional risks and response arrangements. \n\nIndividuals must not be placed on an active command rota or fulfil operational commander functions unless or until they can demonstrate the appropriate minimum level of qualification for that specific role as defined within the National Training Information Sheets."]
["C24","C2","Commanders - maintenance of CPD ","All strategic, tactical and operational commanders must maintain appropriate Continued Professional Development (CPD). \n\nThis CPD must be aligned to the relevant National Training Information Sheet for Command and the NHS England Minimum Occupational Standards for EPRR. \n\nThe core competency requirements defined within the relevant Training Information Sheet must be specifically referenced within the CPD portfolio maintained by the individual commander. \n\nIndividual CPD portfolios must demonstrate sufficient maintenance of skill and competence against the minimum requirements for the role."]
["C25","C2","Commanders - exercise attendance","All strategic, tactical and operational commanders must refresh their skills and competence by discharging their command role as a ‘player’ at a training exercise every 18 months. Attendance at these exercises will form part of the mandatory Continued Professional Development requirement and evidence must be included in the form of documented reflective practice for each exercise. Acceptable exercises can include the smaller scale exercises run by HART teams as part of their regular training or they can include larger multiagency exercises, including table top exercises. The requirement to attend an exercise in any 18 month period can be negated by discharging the individuals specific command role at a relevant live incident providing documented reflective practice is completed post incident. Relevant live incidents are those where the commander has discharged duties in their command role as part of the incident response, such as delivering briefings, use of the JDM, making decisions appropriate to their command role, deployed staff, assets or material, etc. \n\nFailure to demonstrate and document these command functions at an exercise or live incident within an 18 month period must result in the individual being immediately suspended from their command duties until such time as they are able to fulfil this mandatory competency requirement."]
["C26","C2","Training and CDP - suspension of non-compliant commanders ","Any ambulance service strategic, tactical or operational commander that has not maintained the competency requirements specified in the National Training Information Sheet applicable to their role, or that has not maintained the relevant continued professional development (CPD) obligations, must be immediately suspended from their command duties. They must be removed from any active command rota and must not discharge their command functions at an incident until such time as the minimum level of mandated competence can be fully demonstrated."]
["C27","C2","Assessment of commander competence and CDP evidence","Each NHS Ambulance Trust must have a process in place to check and verify that strategic, tactical and operational commanders are maintaining appropriate levels of CPD evidence and that they are maintaining the minimum levels of competence defined within the National Training Information Sheets. \n\nAs a minimum, this must include obtaining an annual signed declaration from all active commanders that they understand the obligations defined within these core standards and that they have maintained the minimum levels of competence and CPD defined within the relevant National Training Information Sheet. \n\nFurther to these annual declarations, each Ambulance Trust must undertake ‘dip sampling’ of multiple CPD portfolios from the strategic, tactical and operational command levels to verify the declarations being made. This assessment of randomly selected CPD portfolios should be undertaken by a suitably competent person, such as an Emergency Preparedness professional. \n\nThe Accountable Emergency Officer in each Ambulance Trust is responsible for ensuring that any commander at any level who has not been able to maintain the minimum competency requirements is immediately suspended from discharging command functions at an incident."]
["C28","C2","NILO / Tactical Advisor - training","Personnel that discharge a NILO or Tactical Advisor function must have completed a nationally recognised NILO or Tactical Advisor course (nationally recognised by NHS England / NARU)."]
["C29","C2","NILO / Tactical Advisor - CPD","Personnel that discharge the NILO or tactical advisor function must maintain an appropriate continued professional development portfolio to demonstrate their continued professional creditability and up-to\u0002date competence in the NILO or tactical advisor discipline."]
["C30","C2","Loggist - training ","Personnel that discharge the loggist function must have completed a loggist training course which covers the elements and requirements defined by the National Ambulance Service Command and Control Guidance published by NARU."]
["C31","C2","Loggist - CPD ","Personnel that discharge the loggist function must maintain an appropriate continued professional development portfolio to demonstrate their continued professional creditability and up-to-date competence in the discipline of logging."]
["C32","C2","Availability of Strategic Medical Advisor, Medical Advisor and Forward Doctor ","The medical director of each NHS ambulance service is responsible for ensuring that the strategic medical advisor, medical advisor and forward doctor roles are available at all times and that the personnel occupying these roles are credible and competent (guidance provided in the National Ambulance Service Command and Control Guidance published by NARU)."]
["C33","C2","Medical Advisor of Forward Doctor - exercise attendance ","Personnel that discharge the medical advisor or forward doctor roles must refresh their skills and competence by discharging their support role as a ‘player’ at a training exercise involving ambulance service interoperable capabilities every 18 months. Attendance at these exercises will form part of mandatory continued professional development and evidence must be included in the form of documented reflective practice for each exercise"]
["C34","C2","Commanders and NILO / Tactical Advisors - familiarity with the Joint Operating Procedures ","Commanders (strategic, tactical and operational) and the NILO and tactical advisors must ensure they are fully conversant with all Joint Operating Principles published by JESIP and that they remain competent to discharge their responsibilities in compliance with these principles"]
["C35","C2","Control room familiarisation with capabilities ","Control starts with receipt of the first emergency call, therefore emergency control room supervisors (or equivalent) must be aware of the ambulance service’s operational capabilities, including the interoperable capabilities, and the implications of utilising them. Control room supervisors must have a working knowledge of major incident procedures and the National Command and Control Guidance published by NARU to enable the initial steps to be taken (e.g. notifying the Trust command structure, wider alerting mechanisms, following action cards etc.)"]
["C36","C2","Responders awareness of NARU major incident action cards","Front line ambulance responders will often be, by default, the interim first commander at scene. So, all frontline operational ambulance staff must be aware of basic major incident principles, including their Trust’s major incident plan and the need to follow major incident action cards. They must all have access to such cards. \n\nAll frontline operational ambulance staff must be sufficiently competent to provide accurate information back to the control room and take the initial steps detailed on relevant major incident action cards safely and effectively."]
["JESIP Specific Core Standards"]
["J1","JESIP","Incorporation of JESIP doctrine","The JESIP doctrine must be incorporated into all organisational policies, plans and procedures relevant to a multi-agency emergency response within NHS Ambulance Trusts."]
["J2","JESIP","Operations procedures commensurate with Doctrine ","All NHS Ambulance Trust operational procedures must be interpreted and applied in a manner commensurate to the Joint Doctrine."]
["J3","JESIP","Review process ","All NHS Ambulance Trusts must have a timed review process for all procedures covering major or complex incidents to ensure they remain current and consistent with the latest version of the JESIP Joint Doctrine"]
["J4","JESIP","Access to JESIP products, tools and guidance","All NHS Ambulance Trusts must ensure that commanders and command support staff have access to the latest JESIP products, tools and guidance."]
["J5","JESIP","Awareness of JESIP - Responders ","All relevant front-line NHS ambulance responders attain and maintain a basic knowledge and understanding of JESIP to enhance their ability to respond effectively upon arrival as the first personnel on-scene."]
["J6","JESIP","Awareness of JESIP - control room staff ","NHS ambulance control room staff (dispatchers and managers) attain and maintain knowledge and understanding of JESIP to enhance their ability to manage calls and coordinate assets."]
["J7","JESIP","Training records - staff requiring training","NHS ambulance service providers must identify and maintain records of staff in the organisation who may require training or awareness of JESIP, what training they require and when they receive it."]
["J8","JESIP","Command function - interoperability command course","All staff required to perform a command role must have attended a one day, JESIP approved, interoperability command course."]
["J9","JESIP","Training records - annual refresh","All those who perform a command role should annually refresh their awareness of JESIP principles, use of the JDM and METHANE models by either the JESIP e\u0002learning products or another locally based solution which meets the minimum learning outcomes. Records of compliance with this refresher requirement must be kept by the organisation."]
["J10","JESIP","Commanders - interoperability command course","All active commanders (strategic, tactical and operational) are required to ensure that JESIP forms part of their ongoing continued professional development portfolios and evidence. This must include reflective practice that includes specific JESIP principles from an exercise or live incident every 18 months."]
["J11","JESIP","Participation in multiagency exercise ","At least every three years, all NHS ambulance commanders (at strategic, tactical and operational levels) must participate as a player in a joint exercise with at least Police and Fire Service command players where JESIP principles are applied."]
["J12","JESIP","Induction training ","All NHS Ambulance Trusts must ensure that JESIP forms part of the initial training or induction of all new operational staff."]
["J13","JESIP","Training records - 90% operational and control room staff are familiar with JESIP","All NHS Ambulance Trusts must maintain records and evidence which demonstrates that at least 90% of operational staff (that respond to emergency calls) and control room staff (that dispatch calls and manage communications with crews) are familiar with the JESIP principles and can construct a M/ETHANE message."]

{"sheet":"Core Criteria","index":5,"n_rows":84,"n_cols":22,"rows_kept":84,"cut":false,"hidden":true,"merged":[]}
["Selected Org Type",{"$f":"Control!$C$2","v":"ALL ORGANISATION TYPES"},"Selected Type","Ref","Domain","\nStandard name","\nStandard Detail","All Organisation Types","Acute Providers","Specialist Providers","NHS Ambulance Service Providers","Community Service Providers","Patient Transport Services","NHS111","Mental Health Providers","NHS England Region","NHS England National","Integrated Care Board","Commissioning Support Unit ","Primary Care Services - GP, community pharmacy","Other NHS funded organisations","Supporting Information - including examples of evidence\n"]
["Column",{"$f":"MATCH(B1,$D$1:$W$1,0)","v":5},{"$f":"IF(OR(LEFT($D2,6)=\"Domain\",VLOOKUP(D2,$D2:$U2,$B$2,FALSE)=\"Y\"),MAX(C$1:C1)+1,\"\")","v":1},"Domain 1 - Governance"]
[null,null,{"$f":"IF(OR(LEFT($D3,6)=\"Domain\",VLOOKUP(D3,$D3:$U3,$B$2,FALSE)=\"Y\"),MAX(C$1:C2)+1,\"\")","v":2},1,"Governance","Senior Leadership","The organisation has appointed an Accountable Emergency Officer (AEO) responsible for Emergency Preparedness Resilience and Response (EPRR). This individual should be a board level director within their individual organisation, and have the appropriate authority, resources and budget to direct the EPRR portfolio. \n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Evidence \n• Name and role of appointed individual\n• AEO responsibilities included in role/job description"]
[null,null,{"$f":"IF(OR(LEFT($D4,6)=\"Domain\",VLOOKUP(D4,$D4:$U4,$B$2,FALSE)=\"Y\"),MAX(C$1:C3)+1,\"\")","v":3},2,"Governance","EPRR Policy Statement ","The organisation has an overarching EPRR policy or statement of intent.\n\nThis should take into account the organisation’s:\n• Business objectives and processes\n• Key suppliers and contractual arrangements\n• Risk assessment(s)\n• Functions and / or organisation, structural and staff changes.\n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","The policy should: \n• Have a review schedule and version control\n• Use unambiguous terminology\n• Identify those responsible for ensuring policies and arrangements are updated, distributed and regularly tested and exercised\n• Include references to other sources of information and supporting documentation.\n\nEvidence \nUp to date EPRR policy or statement of intent that includes:\n• Resourcing commitment\n• Access to funds\n• Commitment to Emergency Planning, Business Continuity, Training, Exercising etc.\n\n"]
[null,null,{"$f":"IF(OR(LEFT($D5,6)=\"Domain\",VLOOKUP(D5,$D5:$U5,$B$2,FALSE)=\"Y\"),MAX(C$1:C4)+1,\"\")","v":4},3,"Governance","EPRR board reports","The Chief Executive Officer ensures that the Accountable Emergency Officer discharges their responsibilities to provide EPRR reports to the Board, no less than annually. \n\nThe organisation publicly states its readiness and preparedness activities in annual reports within the organisation's own regulatory reporting requirements","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","These reports should be taken to a public board, and as a minimum, include an overview on:\n• training and exercises undertaken by the organisation\n• summary of any business continuity, critical incidents and major incidents experienced by the organisation\n• lessons identified and learning undertaken from incidents and exercises\n• the organisation's compliance position in relation to the latest NHS England EPRR assurance process.\n\nEvidence\n• Public Board meeting minutes\n• Evidence of presenting the results of the annual EPRR assurance process to the Public Board \n• For those organisations that do not have a public board, a public statement of readiness and preparedness activities."]
[null,null,{"$f":"IF(OR(LEFT($D6,6)=\"Domain\",VLOOKUP(D6,$D6:$U6,$B$2,FALSE)=\"Y\"),MAX(C$1:C5)+1,\"\")","v":5},4,"Governance","EPRR work programme ","The organisation has an annual EPRR work programme, informed by:\n• current guidance and good practice\n• lessons identified from incidents and exercises \n• identified risks \n• outcomes of any assurance and audit processes\n\nThe work programme should be regularly reported upon and shared with partners where appropriate. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• Reporting process explicitly described within the EPRR policy statement\n• Annual work plan"]
[null,null,{"$f":"IF(OR(LEFT($D7,6)=\"Domain\",VLOOKUP(D7,$D7:$U7,$B$2,FALSE)=\"Y\"),MAX(C$1:C6)+1,\"\")","v":6},5,"Governance","EPRR Resource","The Board / Governing Body is satisfied that the organisation has sufficient and appropriate  resource to ensure it can fully discharge its EPRR duties.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• EPRR Policy identifies resources required to fulfil EPRR function; policy has been signed off by the organisation's Board\n• Assessment of role / resources\n• Role description of EPRR Staff/ staff who undertake the EPRR responsibilities\n• Organisation structure chart \n• Internal Governance process chart including EPRR group"]
[null,null,{"$f":"IF(OR(LEFT($D8,6)=\"Domain\",VLOOKUP(D8,$D8:$U8,$B$2,FALSE)=\"Y\"),MAX(C$1:C7)+1,\"\")","v":7},6,"Governance","Continuous improvement ","The organisation has clearly defined processes for capturing learning from incidents and exercises to inform the review and embed into EPRR arrangements. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• Process explicitly described within the EPRR policy statement \n• Reporting those lessons to the Board/ governing body and where the improvements to plans were made\n• participation within a regional process for sharing lessons with partner organisations"]
[null,null,{"$f":"IF(OR(LEFT($D9,6)=\"Domain\",VLOOKUP(D9,$D9:$U9,$B$2,FALSE)=\"Y\"),MAX(C$1:C8)+1,\"\")","v":8},"Domain 2 - Duty to risk assess   "]
[null,null,{"$f":"IF(OR(LEFT($D10,6)=\"Domain\",VLOOKUP(D10,$D10:$U10,$B$2,FALSE)=\"Y\"),MAX(C$1:C9)+1,\"\")","v":9},7,"Duty to risk assess","Risk assessment","The organisation has a process in place to regularly assess the risks to the population it serves. This process should consider all relevant risk registers including community and national risk registers.  ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Evidence that EPRR risks are regularly considered and recorded\n• Evidence that EPRR risks are represented and recorded on the organisations corporate risk register\n• Risk assessments to consider community risk registers and as a core component, include reasonable worst-case scenarios and extreme events for adverse weather"]
[null,null,{"$f":"IF(OR(LEFT($D11,6)=\"Domain\",VLOOKUP(D11,$D11:$U11,$B$2,FALSE)=\"Y\"),MAX(C$1:C10)+1,\"\")","v":10},8,"Duty to risk assess","Risk Management","The organisation has a robust method of reporting, recording, monitoring, communicating, and escalating EPRR risks internally and externally ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• EPRR risks are considered in the organisation's risk management policy \n• Reference to EPRR risk management in the organisation's EPRR policy document "]
[null,null,{"$f":"IF(OR(LEFT($D12,6)=\"Domain\",VLOOKUP(D12,$D12:$U12,$B$2,FALSE)=\"Y\"),MAX(C$1:C11)+1,\"\")","v":11},"Domain 3 - Duty to maintain Plans"]
[null,null,{"$f":"IF(OR(LEFT($D13,6)=\"Domain\",VLOOKUP(D13,$D13:$U13,$B$2,FALSE)=\"Y\"),MAX(C$1:C12)+1,\"\")","v":12},9,"Duty to maintain plans","Collaborative planning","Plans and arrangements have been developed in collaboration with relevant stakeholders  including emergency services and health partners to enhance joint working arrangements and to ensure the whole patient pathway is considered.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Partner organisations collaborated with as part of the planning process are in planning arrangements\n\nEvidence\n• Consultation process in place for plans and arrangements\n• Changes to arrangements as a result of consultation are recorded"]
[null,null,{"$f":"IF(OR(LEFT($D14,6)=\"Domain\",VLOOKUP(D14,$D14:$U14,$B$2,FALSE)=\"Y\"),MAX(C$1:C13)+1,\"\")","v":13},10,"Duty to maintain plans","Incident Response","In line with current guidance and legislation, the organisation has effective arrangements in place to  define and respond to Critical and Major incidents as defined within the EPRR Framework.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Arrangements should be: \n• current (reviewed in the last 12 months)\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D15,6)=\"Domain\",VLOOKUP(D15,$D15:$U15,$B$2,FALSE)=\"Y\"),MAX(C$1:C14)+1,\"\")","v":14},11,"Duty to maintain plans","Adverse Weather","In line with current guidance and legislation, the organisation has effective arrangements in place for adverse weather events. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Arrangements should be: \n• current\n• in line with current national UK Health Security Agency (UKHSA) & NHS guidance and Met Office or Environment Agency alerts \n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n• reflective of climate change risk assessments\n• cognisant of extreme events e.g. drought, storms (including dust storms), wildfire. "]
[null,null,{"$f":"IF(OR(LEFT($D16,6)=\"Domain\",VLOOKUP(D16,$D16:$U16,$B$2,FALSE)=\"Y\"),MAX(C$1:C15)+1,\"\")","v":15},12,"Duty to maintain plans","Infectious disease","In line with current guidance and legislation, the organisation has arrangements in place to respond to an infectious disease outbreak within the organisation or the community it serves, covering a range of diseases including High Consequence Infectious Diseases.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nAcute providers should ensure their arrangements reflect the guidance issued by DHSC in relation to FFP3 Resilience in Acute setting incorporating the FFP3 resilience principles. https://www.england.nhs.uk/coronavirus/secondary-care/infection-control/ppe/ffp3-fit-testing/ffp3-resilience-principles-in-acute-settings/ "]
[null,null,{"$f":"IF(OR(LEFT($D17,6)=\"Domain\",VLOOKUP(D17,$D17:$U17,$B$2,FALSE)=\"Y\"),MAX(C$1:C16)+1,\"\")","v":16},13,"Duty to maintain plans","New and emerging pandemics  ","In line with current guidance and legislation and reflecting recent lessons identified, the organisation has arrangements in place to respond to a new and emerging pandemic ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D18,6)=\"Domain\",VLOOKUP(D18,$D18:$U18,$B$2,FALSE)=\"Y\"),MAX(C$1:C17)+1,\"\")","v":17},14,"Duty to maintain plans","Countermeasures","In line with current guidance and legislation, the organisation has arrangements in place \nto support an incident requiring countermeasures or a mass countermeasure deployment\n\n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nMass Countermeasure arrangements should include arrangements for administration, reception and distribution of mass prophylaxis and mass vaccination. \n\nThere may be a requirement for Specialist providers, Community Service Providers, Mental Health and Primary Care services to develop or support Mass Countermeasure distribution arrangements. Organisations should have plans to support patients in their care during activation of mass countermeasure arrangements. \n\nCommissioners may be required to commission new services to support mass countermeasure distribution locally, this will be dependant on the incident."]
[null,null,{"$f":"IF(OR(LEFT($D19,6)=\"Domain\",VLOOKUP(D19,$D19:$U19,$B$2,FALSE)=\"Y\"),MAX(C$1:C18)+1,\"\")","v":18},15,"Duty to maintain plans","Mass Casualty ","In line with current guidance and legislation, the organisation has effective arrangements in place to respond to incidents with mass casualties. \n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required \n\nReceiving organisations should also include a safe identification system for unidentified patients in an emergency/mass casualty incident where necessary. "]
[null,null,{"$f":"IF(OR(LEFT($D20,6)=\"Domain\",VLOOKUP(D20,$D20:$U20,$B$2,FALSE)=\"Y\"),MAX(C$1:C19)+1,\"\")","v":19},16,"Duty to maintain plans","\nEvacuation and shelter","In line with current guidance and legislation, the organisation has arrangements in place to  evacuate and shelter patients, staff and visitors.    ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D21,6)=\"Domain\",VLOOKUP(D21,$D21:$U21,$B$2,FALSE)=\"Y\"),MAX(C$1:C20)+1,\"\")","v":20},17,"Duty to maintain plans","Lockdown","In line with current guidance, regulation and legislation, the organisation has arrangements in place to control access and egress for patients, staff and visitors to and from the organisation's premises and key assets in an incident. ","Y","Y","Y","Y","Y",null,null,"Y",null,null,null,null,"Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D22,6)=\"Domain\",VLOOKUP(D22,$D22:$U22,$B$2,FALSE)=\"Y\"),MAX(C$1:C21)+1,\"\")","v":21},18,"Duty to maintain plans","Protected individuals","In line with current guidance and legislation, the organisation has arrangements in place to respond and manage  'protected individuals' including Very Important Persons (VIPs),high profile patients and visitors to the site. ","Y","Y","Y","Y","Y",null,null,"Y",null,null,null,null,"Y","Y","Arrangements should be: \n• current\n• in line with current national guidance\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D23,6)=\"Domain\",VLOOKUP(D23,$D23:$U23,$B$2,FALSE)=\"Y\"),MAX(C$1:C22)+1,\"\")","v":22},19,"Duty to maintain plans","Excess fatalities ","The organisation has contributed to, and understands, its role in the multiagency arrangements for excess deaths and mass fatalities, including mortuary arrangements. This includes arrangements for rising tide and sudden onset events.","Y","Y","Y","Y","Y",null,null,"Y",null,null,null,null,"Y",null,"Arrangements should be: \n• current\n• in line with current national guidance\nin line with DVI processes\n• in line with risk assessment \n• tested regularly\n• signed off by the appropriate mechanism\n• shared appropriately with those required to use them\n• outline any equipment requirements \n• outline any staff training required "]
[null,null,{"$f":"IF(OR(LEFT($D24,6)=\"Domain\",VLOOKUP(D24,$D24:$U24,$B$2,FALSE)=\"Y\"),MAX(C$1:C23)+1,\"\")","v":23},"Domain 4 - Command and control"]
[null,null,{"$f":"IF(OR(LEFT($D25,6)=\"Domain\",VLOOKUP(D25,$D25:$U25,$B$2,FALSE)=\"Y\"),MAX(C$1:C24)+1,\"\")","v":24},20,"Command and control","On-call mechanism","The organisation has resilient and dedicated mechanisms and structures to enable 24/7 receipt and action of incident notifications, internal or external. This should provide the facility to respond to or escalate notifications to an executive level. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","• Process explicitly described within the EPRR policy statement\n• On call Standards and expectations are set out\n• Add on call processes/handbook available to staff on call\n• Include 24 hour arrangements for alerting managers and other key staff.\n• CSUs where they are delivering OOHs business critical services for providers and commissioners"]
[null,null,{"$f":"IF(OR(LEFT($D26,6)=\"Domain\",VLOOKUP(D26,$D26:$U26,$B$2,FALSE)=\"Y\"),MAX(C$1:C25)+1,\"\")","v":25},21,"Command and control","Trained on-call staff","Trained and up to date staff are available 24/7 to manage escalations, make decisions and identify key actions\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","• Process explicitly described within the EPRR policy or statement of intent\n\nThe identified individual:  \n• Should be trained according to the NHS England EPRR competencies (National  Minimum Occupational Standards) \n• Has a specific process to adopt during the decision making \n• Is aware who should be consulted and informed during decision making \n• Should ensure appropriate records are maintained throughout.\n• Trained in accordance with the TNA identified frequency."]
[null,null,{"$f":"IF(OR(LEFT($D27,6)=\"Domain\",VLOOKUP(D27,$D27:$U27,$B$2,FALSE)=\"Y\"),MAX(C$1:C26)+1,\"\")","v":26},"Domain 5 - Training and exercising"]
[null,null,{"$f":"IF(OR(LEFT($D28,6)=\"Domain\",VLOOKUP(D28,$D28:$U28,$B$2,FALSE)=\"Y\"),MAX(C$1:C27)+1,\"\")","v":27},22,"Training and exercising","EPRR Training ","The organisation carries out training in line with a training needs analysis to ensure staff are current in their response role.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• Process explicitly described within the EPRR policy or statement of intent\n• Evidence of a training needs analysis\n• Training records for all staff on call and those performing a role within the ICC \n• Training materials\n• Evidence of personal training and exercising portfolios for key staff\n"]
[null,null,{"$f":"IF(OR(LEFT($D29,6)=\"Domain\",VLOOKUP(D29,$D29:$U29,$B$2,FALSE)=\"Y\"),MAX(C$1:C28)+1,\"\")","v":28},23,"Training and exercising","EPRR exercising and testing programme ","In accordance with the minimum requirements, in line with current guidance, the organisation has an exercising and testing programme to safely* test incident response arrangements, (*no undue risk to exercise players or participants, or those  patients in your care)","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Organisations should meet the following exercising and testing requirements: \n• a six-monthly communications test\n• annual table top exercise \n• live exercise at least once every three years\n• command post exercise every three years.\n\nThe exercising programme must:\n• identify exercises relevant to local risks\n• meet the needs of the organisation type and stakeholders\n• ensure warning and informing arrangements are effective.\n\nLessons identified must be captured, recorded and acted upon as part of continuous improvement. \n\nEvidence\n• Exercising Schedule which includes as a minimum one Business Continuity exercise\n• Post exercise reports and embedding learning"]
[null,null,{"$f":"IF(OR(LEFT($D30,6)=\"Domain\",VLOOKUP(D30,$D30:$U30,$B$2,FALSE)=\"Y\"),MAX(C$1:C29)+1,\"\")","v":29},24,"Training and exercising","Responder training","The organisation has the ability to maintain training records and exercise attendance of all staff with key roles for response in accordance with the Minimum Occupational Standards.\n\nIndividual responders and key decision makers should be supported to maintain a continuous personal development portfolio including involvement in exercising and incident response as well as any training undertaken to fulfil their role\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• Training records\n• Evidence of personal training and exercising portfolios for key staff"]
[null,null,{"$f":"IF(OR(LEFT($D31,6)=\"Domain\",VLOOKUP(D31,$D31:$U31,$B$2,FALSE)=\"Y\"),MAX(C$1:C30)+1,\"\")","v":30},25,"Training and exercising","Staff Awareness & Training","There are mechanisms in place to ensure staff are aware of their role in an incident and where to find plans relevant to their area of work or department.\n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","As part of mandatory training \nExercise and Training attendance records reported to Board"]
[null,null,{"$f":"IF(OR(LEFT($D32,6)=\"Domain\",VLOOKUP(D32,$D32:$U32,$B$2,FALSE)=\"Y\"),MAX(C$1:C31)+1,\"\")","v":31},"Domain 6 - Response "]
[null,null,{"$f":"IF(OR(LEFT($D33,6)=\"Domain\",VLOOKUP(D33,$D33:$U33,$B$2,FALSE)=\"Y\"),MAX(C$1:C32)+1,\"\")","v":32},26,"Response","Incident Co-ordination Centre (ICC) ","The organisation has in place suitable and sufficient arrangements to effectively coordinate the response to an incident in line with national guidance. ICC arrangements need to be flexible and scalable to cope with a range of incidents and hours of operation required.\n\nAn ICC must have dedicated business continuity arrangements in place and must be resilient to loss of utilities, including telecommunications, and to external hazards.\n\n ICC equipment should be  tested  in line with national guidance or after a major infrastructure change to ensure functionality and in a state of organisational readiness.\n\nArrangements should be supported with access to documentation for its activation and operation.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Documented processes for identifying the location and establishing an ICC\n• Maps and diagrams\n• A testing schedule\n• A training schedule\n• Pre identified roles and responsibilities, with action cards\n• Demonstration ICC location is resilient to loss of utilities, including telecommunications, and external hazards\n• Arrangements might include virtual arrangements in addition to physical facilities but must be resilient with alternative contingency solutions. \n"]
[null,null,{"$f":"IF(OR(LEFT($D34,6)=\"Domain\",VLOOKUP(D34,$D34:$U34,$B$2,FALSE)=\"Y\"),MAX(C$1:C33)+1,\"\")","v":33},27,"Response","Access to planning arrangements","Version controlled current response documents are available to relevant staff at all times. Staff should be aware of where they are stored and should be easily accessible.  ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Planning arrangements are easily accessible - both electronically and local copies "]
[null,null,{"$f":"IF(OR(LEFT($D35,6)=\"Domain\",VLOOKUP(D35,$D35:$U35,$B$2,FALSE)=\"Y\"),MAX(C$1:C34)+1,\"\")","v":34},28,"Response","Management of business continuity incidents","In line with current guidance and legislation, the organisation has effective arrangements in place to respond to a business continuity incident (as defined within the EPRR Framework). ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Business Continuity Response plans\n• Arrangements in place that mitigate escalation to business continuity incident\n• Escalation processes"]
[null,null,{"$f":"IF(OR(LEFT($D36,6)=\"Domain\",VLOOKUP(D36,$D36:$U36,$B$2,FALSE)=\"Y\"),MAX(C$1:C35)+1,\"\")","v":35},29,"Response","Decision Logging","To ensure decisions are recorded during business continuity, critical and major incidents, the organisation must ensure:\n1. Key response staff are aware of the need for creating their own personal records and decision logs to the required standards and storing them in accordance with the organisations' records management policy.\n2. has 24 hour access to a trained loggist(s) to ensure support to the decision maker","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Documented processes for accessing and utilising loggists\n• Training records"]
[null,null,{"$f":"IF(OR(LEFT($D37,6)=\"Domain\",VLOOKUP(D37,$D37:$U37,$B$2,FALSE)=\"Y\"),MAX(C$1:C36)+1,\"\")","v":36},30,"Response","Situation Reports","The organisation has processes in place for receiving, completing, authorising and submitting situation reports (SitReps) and briefings during the response to incidents including bespoke or incident dependent formats.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Documented processes for completing, quality assuring, signing off and submitting SitReps\n• Evidence of testing and exercising\n• The organisation has access to the standard SitRep Template"]
[null,null,{"$f":"IF(OR(LEFT($D38,6)=\"Domain\",VLOOKUP(D38,$D38:$U38,$B$2,FALSE)=\"Y\"),MAX(C$1:C37)+1,\"\")","v":37},31,"Response","Access to 'Clinical Guidelines for Major Incidents and Mass Casualty events’","Key clinical staff (especially emergency department) have access to the ‘Clinical Guidelines for Major Incidents and Mass Casualty events’ handbook.","Y","Y","Y",null,null,null,null,null,null,null,null,null,null,null,"Guidance is available to appropriate staff either electronically or hard copies"]
[null,null,{"$f":"IF(OR(LEFT($D39,6)=\"Domain\",VLOOKUP(D39,$D39:$U39,$B$2,FALSE)=\"Y\"),MAX(C$1:C38)+1,\"\")","v":38},32,"Response","Access to ‘CBRN incident: Clinical Management and health protection’","Clinical staff have access to the ‘CBRN incident: Clinical Management and health protection’ guidance. (Formerly published by PHE)","Y","Y",null,null,null,null,null,null,null,null,null,null,null,null,"Guidance is available to appropriate staff either electronically or hard copies"]
[null,null,{"$f":"IF(OR(LEFT($D40,6)=\"Domain\",VLOOKUP(D40,$D40:$U40,$B$2,FALSE)=\"Y\"),MAX(C$1:C39)+1,\"\")","v":39},"Domain 7 - Warning and informing"]
[null,null,{"$f":"IF(OR(LEFT($D41,6)=\"Domain\",VLOOKUP(D41,$D41:$U41,$B$2,FALSE)=\"Y\"),MAX(C$1:C40)+1,\"\")","v":40},33,"Warning and informing ","Warning and informing","The organisation aligns communications planning and activity with the organisation’s EPRR planning and activity.\n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Awareness within communications team of the organisation’s EPRR plan, and how to report potential incidents.\n• Measures are in place to ensure incidents are appropriately described and declared in line with the NHS EPRR Framework.\n• Out of hours communication system (24/7, year-round) is in place to allow access to trained comms support for senior leaders during an incident. This should include on call arrangements.\n• Having a process for being able to log incoming requests, track responses to these requests and to ensure that information related to incidents is stored effectively. This will allow organisations to provide evidence should it be required for an inquiry. \n"]
[null,null,{"$f":"IF(OR(LEFT($D42,6)=\"Domain\",VLOOKUP(D42,$D42:$U42,$B$2,FALSE)=\"Y\"),MAX(C$1:C41)+1,\"\")","v":41},34,"Warning and informing ","Incident Communication Plan","The organisation has a plan in place for communicating during an incident which can be enacted.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• An incident communications plan has been developed and is available to on call communications staff\n• The incident communications plan has been tested both in and out of hours\n• Action cards have been developed for communications roles\n• A requirement for briefing NHS England regional communications team has been established\n• The plan has been tested, both in and out of hours as part of an exercise.\n• Clarity on sign off for communications is included in the plan, noting the need to ensure communications are signed off by incident leads, as well as NHSE (if appropriate). "]
[null,null,{"$f":"IF(OR(LEFT($D43,6)=\"Domain\",VLOOKUP(D43,$D43:$U43,$B$2,FALSE)=\"Y\"),MAX(C$1:C42)+1,\"\")","v":42},35,"Warning and informing ","Communication with partners and stakeholders ","The organisation has arrangements in place to communicate with patients, staff, partner organisations, stakeholders, and the public before, during and after a major incident, critical incident or business continuity incident.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Established means of communicating with staff, at both short notice and for the duration of the incident, including out of hours communications\n• A developed list of contacts in partner organisations who are key to service delivery (local Council, LRF partners, neighbouring NHS organisations etc) and a means of warning and informing these organisations about an incident as well as sharing communications information with partner organisations to create consistent messages at a local, regional and national level.\n• A developed list of key local stakeholders (such as local elected officials, unions etc) and an established a process by which to brief local stakeholders during an incident\n• Appropriate channels for communicating with members of the public that can be used 24/7 if required \n• Identified sites within the organisation for displaying of important public information (such as main points of access)\n• Have in place a means of communicating with patients who have appointments booked or are receiving treatment. \n• Have in place a plan to communicate with inpatients and their families or care givers.\n• The organisation publicly states its readiness and preparedness activities in annual reports within the organisations own regulatory reporting requirements"]
[null,null,{"$f":"IF(OR(LEFT($D44,6)=\"Domain\",VLOOKUP(D44,$D44:$U44,$B$2,FALSE)=\"Y\"),MAX(C$1:C43)+1,\"\")","v":43},36,"Warning and informing ","Media strategy","The organisation has arrangements in place to enable rapid and structured communication via the media and social media","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Having an agreed media strategy and a plan for how this will be enacted during an incident. This will allow for timely distribution of information to warn and inform the media \n• Develop a pool of media spokespeople able to represent the organisation to the media at all times.\n• Social Media policy and monitoring in place to identify and track information on social media relating to incidents.\n• Setting up protocols for using social media to warn and inform\n• Specifying advice to senior staff to effectively use  social media accounts whilst the organisation is in incident response "]
[null,null,{"$f":"IF(OR(LEFT($D45,6)=\"Domain\",VLOOKUP(D45,$D45:$U45,$B$2,FALSE)=\"Y\"),MAX(C$1:C44)+1,\"\")","v":44},"Domain 8 - Cooperation "]
[null,null,{"$f":"IF(OR(LEFT($D46,6)=\"Domain\",VLOOKUP(D46,$D46:$U46,$B$2,FALSE)=\"Y\"),MAX(C$1:C45)+1,\"\")","v":45},37,"Cooperation","LHRP Engagement ","The Accountable Emergency Officer, or a director level representative with delegated authority (to authorise plans and commit resources on behalf of their organisation) attends Local Health Resilience Partnership (LHRP) meetings.","Y","Y","Y","Y","Y",null,null,"Y","Y",null,"Y",null,null,"Y","• Minutes of meetings\n• Individual members of the LHRP must be authorised by their employing organisation to act in accordance with their organisational governance arrangements and their statutory status and responsibilities."]
[null,null,{"$f":"IF(OR(LEFT($D47,6)=\"Domain\",VLOOKUP(D47,$D47:$U47,$B$2,FALSE)=\"Y\"),MAX(C$1:C46)+1,\"\")","v":46},38,"Cooperation","LRF / BRF Engagement","The organisation participates in, contributes to or is adequately represented at Local Resilience Forum (LRF) or Borough Resilience Forum (BRF), demonstrating engagement and co-operation with partner responders. ","Y","Y","Y","Y","Y",null,null,"Y","Y",null,"Y",null,null,"Y","• Minutes of meetings\n• A governance agreement is in place if the organisation is represented and feeds back across the system"]
[null,null,{"$f":"IF(OR(LEFT($D48,6)=\"Domain\",VLOOKUP(D48,$D48:$U48,$B$2,FALSE)=\"Y\"),MAX(C$1:C47)+1,\"\")","v":47},39,"Cooperation","Mutual aid arrangements","The organisation has agreed mutual aid arrangements in place outlining the process for requesting, coordinating and maintaining mutual aid resources. These arrangements may include staff, equipment, services and supplies. \n\nIn line with current NHS guidance, these arrangements may be formal and should include the process for requesting Military Aid to Civil Authorities (MACA) via NHS England.","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y",null,"Y","Y","• Detailed documentation on the process for requesting, receiving and managing mutual aid requests\n• Templates and other required documentation is available in ICC or as appendices to IRP\n• Signed mutual aid agreements where appropriate"]
[null,null,{"$f":"IF(OR(LEFT($D49,6)=\"Domain\",VLOOKUP(D49,$D49:$U49,$B$2,FALSE)=\"Y\"),MAX(C$1:C48)+1,\"\")","v":48},40,"Cooperation","Arrangements for multi area response","The organisation has arrangements in place to prepare for and respond to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas.","Y",null,null,"Y",null,null,null,null,"Y","Y","Y",null,null,"Y","• Detailed documentation on the process for coordinating the response to incidents affecting two or more LHRPs\n• Where an organisation sits across boundaries the reporting route should be clearly identified and known to all "]
[null,null,{"$f":"IF(OR(LEFT($D50,6)=\"Domain\",VLOOKUP(D50,$D50:$U50,$B$2,FALSE)=\"Y\"),MAX(C$1:C49)+1,\"\")","v":49},41,"Cooperation","Health tripartite working","Arrangements are in place defining how NHS England, the Department of Health and Social Care and UK Health Security Agency (UKHSA) will communicate and work together, including how information relating to national emergencies will be cascaded. ","Y",null,null,null,null,null,null,null,null,"Y",null,null,null,null,"• Detailed documentation on the process for managing the national health aspects of an emergency"]
[null,null,{"$f":"IF(OR(LEFT($D51,6)=\"Domain\",VLOOKUP(D51,$D51:$U51,$B$2,FALSE)=\"Y\"),MAX(C$1:C50)+1,\"\")","v":50},42,"Cooperation","LHRP Secretariat","The organisation has arrangements in place to ensure that the Local Health Resilience Partnership (LHRP) meets at least once every 6 months.","Y",null,null,null,null,null,null,null,"Y",null,"Y",null,null,null,"• LHRP terms of reference\n• Meeting minutes\n• Meeting agendas"]
[null,null,{"$f":"IF(OR(LEFT($D52,6)=\"Domain\",VLOOKUP(D52,$D52:$U52,$B$2,FALSE)=\"Y\"),MAX(C$1:C51)+1,\"\")","v":51},43,"Cooperation","Information sharing ","The organisation has an agreed protocol(s) for sharing appropriate information pertinent to the response with stakeholders and partners, during incidents.\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Documented and signed information sharing protocol\n• Evidence relevant guidance has been considered, e.g. Freedom of Information Act 2000, General Data Protection Regulation 2016, Caldicott Principles, Safeguarding requirements and the Civil Contingencies Act 2004"]
[null,null,{"$f":"IF(OR(LEFT($D53,6)=\"Domain\",VLOOKUP(D53,$D53:$U53,$B$2,FALSE)=\"Y\"),MAX(C$1:C52)+1,\"\")","v":52},"Domain 9 - Business Continuity"]
[null,null,{"$f":"IF(OR(LEFT($D54,6)=\"Domain\",VLOOKUP(D54,$D54:$U54,$B$2,FALSE)=\"Y\"),MAX(C$1:C53)+1,\"\")","v":53},44,"Business Continuity","BC policy statement","The organisation has in place a policy which includes a statement of intent to undertake business continuity.  This includes the commitment to a Business Continuity Management System (BCMS) that aligns to the ISO standard 22301.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","The organisation has in place a policy which includes intentions and direction as formally expressed by its top management.\nThe BC Policy should:                              \n• Provide the strategic direction from which the business continuity programme is delivered.                                                   \n• Define the way in which the  organisation will approach business continuity.                      \n• Show evidence of being supported, approved and owned by top management.                    \n• Be reflective of the organisation in terms of size, complexity and type of organisation.                       \n• Document any standards or guidelines that are used as a benchmark for the BC programme.\n• Consider short term and long term impacts on the organisation including climate change adaption planning"]
[null,null,{"$f":"IF(OR(LEFT($D55,6)=\"Domain\",VLOOKUP(D55,$D55:$U55,$B$2,FALSE)=\"Y\"),MAX(C$1:C54)+1,\"\")","v":54},45,"Business Continuity","Business Continuity Management Systems (BCMS) scope and objectives ","The organisation has established the scope and objectives of the BCMS in relation to the organisation, specifying the risk management process and how this will be documented.\n\nA definition of the scope of the programme ensures a clear understanding of which areas of the organisation are in and out of scope of the BC programme.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","BCMS should detail: \n• Scope e.g. key products and services within the scope and exclusions from the scope\n• Objectives of the system\n• The requirement to undertake BC e.g. Statutory, Regulatory and contractual duties\n• Specific roles within the BCMS including responsibilities, competencies and authorities.\n• The risk management processes for the organisation i.e. how risk will be assessed and documented (e.g. Risk Register), the acceptable level of risk and risk review and monitoring process\n• Resource requirements\n• Communications strategy with all staff to ensure they are aware of their roles\n• alignment to the organisations strategy, objectives, operating environment and approach to risk.                                         \n• the outsourced activities and suppliers of products and suppliers.                                     \n• how the understanding of BC will be increased in the organisation "]
[null,null,{"$f":"IF(OR(LEFT($D56,6)=\"Domain\",VLOOKUP(D56,$D56:$U56,$B$2,FALSE)=\"Y\"),MAX(C$1:C55)+1,\"\")","v":55},46,"Business Continuity","Business Impact Analysis/Assessment (BIA) ","The organisation annually assesses and documents the impact of disruption to its services through Business Impact Analysis(es).\n\n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","The organisation has identified prioritised activities by undertaking a strategic Business Impact Analysis/Assessments. Business Impact Analysis/Assessment is the key first stage in the development of a BCMS and is therefore critical to a business continuity programme.\n\nDocumented process on how BIA will be conducted, including:\n• the method to be used\n• the frequency of review\n• how the information will be used to inform planning \n• how RA is used to support.\n\nThe organisation should undertake a review of its critical function using a Business Impact Analysis/assessment. Without a Business Impact Analysis organisations are not able to assess/assure compliance without it. The following points should be considered when undertaking a BIA:                                   \n• Determining impacts over time should demonstrate to top management how quickly the organisation needs to respond to a disruption.\n• A consistent approach to performing the BIA should be used throughout the organisation.\n• BIA method used should be robust enough to ensure the information is collected consistently and impartially. \n"]
[null,null,{"$f":"IF(OR(LEFT($D57,6)=\"Domain\",VLOOKUP(D57,$D57:$U57,$B$2,FALSE)=\"Y\"),MAX(C$1:C56)+1,\"\")","v":56},47,"Business Continuity","Business Continuity Plans (BCP)","The organisation has  business continuity plans for the management of incidents. Detailing how it will respond, recover and manage its services during disruptions to:\n• people\n• information and data\n• premises\n• suppliers and contractors\n• IT and infrastructure\n\n                                                                  ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Documented evidence that as a minimum the BCP checklist is covered by the various plans of the organisation.\n  \nEnsure BCPS are Developed using the ISO 22301 and the NHS Toolkit.  BC Planning is undertaken by an adequately trained person and contain the following:                                                           • Purpose and Scope                                          \n• Objectives and assumptions                             \n• Escalation & Response Structure which is specific to your organisation.                                                      \n• Plan activation criteria, procedures and authorisation.                                                \n• Response teams roles and responsibilities.                                          \n• Individual responsibilities and authorities of team members.                                                   \n• Prompts for immediate action and any specific decisions the team may need to make.                                  \n• Communication requirements and procedures with relevant interested parties.                                  \n• Internal and  external interdependencies.                \n• Summary Information of the organisations prioritised activities.                                                \n• Decision support checklists                            \n• Details of meeting locations                                   \n• Appendix/Appendices "]
[null,null,{"$f":"IF(OR(LEFT($D58,6)=\"Domain\",VLOOKUP(D58,$D58:$U58,$B$2,FALSE)=\"Y\"),MAX(C$1:C57)+1,\"\")","v":57},48,"Business Continuity","Testing and Exercising","The organisation has in place a procedure whereby testing and exercising of Business Continuity plans is undertaken on a yearly basis as a minimum, following organisational change or as a result of learning from other business continuity incidents.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Confirm the type of exercise the organisation has undertaken to meet this sub standard:                         \n• Discussion based exercise                                                        \n• Scenario Exercises                                           \n• Simulation Exercises                                        \n• Live exercise                                                   \n• Test                                                                   \n• Undertake a debrief\n\nEvidence\nPost exercise/ testing reports and action plans"]
[null,null,{"$f":"IF(OR(LEFT($D59,6)=\"Domain\",VLOOKUP(D59,$D59:$U59,$B$2,FALSE)=\"Y\"),MAX(C$1:C58)+1,\"\")","v":58},49,"Business Continuity","Data Protection and Security Toolkit","Organisation's Information Technology department certify that they are compliant with the Data Protection and Security Toolkit on an annual basis. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Evidence\n• Statement of compliance\n• Action plan to obtain compliance if not achieved"]
[null,null,{"$f":"IF(OR(LEFT($D60,6)=\"Domain\",VLOOKUP(D60,$D60:$U60,$B$2,FALSE)=\"Y\"),MAX(C$1:C59)+1,\"\")","v":59},50,"Business Continuity","BCMS monitoring and evaluation ","The organisation's BCMS is monitored, measured and evaluated against established Key Performance Indicators. Reports on these and the outcome of any exercises, and status of any corrective action are annually reported to the board.","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• Business continuity policy\n• BCMS\n• performance reporting\n• Board papers"]
[null,null,{"$f":"IF(OR(LEFT($D61,6)=\"Domain\",VLOOKUP(D61,$D61:$U61,$B$2,FALSE)=\"Y\"),MAX(C$1:C60)+1,\"\")","v":60},51,"Business Continuity","BC audit","The organisation has a process for internal audit, and outcomes are included in the report to the board.\n\nThe organisation has conducted audits at planned intervals to confirm they are conforming with its own business continuity programme. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• process documented in EPRR policy/Business continuity policy or BCMS aligned to the audit programme for the organisation\n• Board papers\n• Audit reports\n• Remedial action plan that is agreed by top management.                                                      \n• An independent business continuity management audit report.                                   \n• Internal audits should be undertaken as agreed by the organisation's audit planning schedule on a rolling cycle.    \n• External audits should be undertaken  in alignment with the organisations audit programme"]
[null,null,{"$f":"IF(OR(LEFT($D62,6)=\"Domain\",VLOOKUP(D62,$D62:$U62,$B$2,FALSE)=\"Y\"),MAX(C$1:C61)+1,\"\")","v":61},52,"Business Continuity","BCMS continuous improvement process","There is a process in place to assess the effectiveness of the BCMS and take corrective action to ensure continual improvement to the BCMS. ","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• process documented in the EPRR policy/Business continuity policy or BCMS\n• Board papers  showing evidence of improvement\n• Action plans following exercising, training and incidents\n• Improvement plans following internal or external auditing\n•Changes to suppliers or contracts following assessment of suitability \n\nContinuous Improvement can be identified via the following routes:                                                                     \n• Lessons learned through exercising.                \n• Changes to the organisations structure, products and services, infrastructure, processes or activities.                                     \n• Changes to the environment in which the organisation operates.                                        \n• A review or audit.                                               \n• Changes or updates to the business continuity management lifecycle, such as the BIA or continuity solutions.                                            \n• Self assessment                                                        \n• Quality assurance                                               \n• Performance appraisal                                       \n• Supplier performance                                         \n• Management review                                         \n• Debriefs                                                            \n• After action reviews                                          \n• Lessons learned through exercising or live incidents    "]
[null,null,{"$f":"IF(OR(LEFT($D63,6)=\"Domain\",VLOOKUP(D63,$D63:$U63,$B$2,FALSE)=\"Y\"),MAX(C$1:C62)+1,\"\")","v":62},53,"Business Continuity","Assurance of commissioned providers / suppliers BCPs ","The organisation has in place a system to assess the business continuity plans of commissioned providers or suppliers; and are assured that these providers business continuity arrangements align and are interoperable with their own. \n","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","Y","• EPRR policy/Business continuity policy or BCMS outlines the process to be used and how suppliers will be identified for assurance\n• Provider/supplier assurance framework\n• Provider/supplier business continuity arrangements\n\nThis may be supported by the organisations procurement or commercial teams (where trained in BC) at tender phase and at set intervals for critical and/or high value suppliers"]
[null,null,{"$f":"IF(OR(LEFT($D64,6)=\"Domain\",VLOOKUP(D64,$D64:$U64,$B$2,FALSE)=\"Y\"),MAX(C$1:C63)+1,\"\")","v":63},54,"Business Continuity","Computer Aided Dispatch ","Manual distribution processes for Emergency Operations Centre / Computer Aided Dispatch systems are in place and have been fully tested annually, with learning identified, recorded and acted upon","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"• Exercising Schedule\n• Evidence of post exercise reports and embedding learning"]
[null,null,{"$f":"IF(OR(LEFT($D65,6)=\"Domain\",VLOOKUP(D65,$D65:$U65,$B$2,FALSE)=\"Y\"),MAX(C$1:C64)+1,\"\")","v":64},"Domain 10 - CBRN"]
[null,null,{"$f":"IF(OR(LEFT($D66,6)=\"Domain\",VLOOKUP(D66,$D66:$U66,$B$2,FALSE)=\"Y\"),MAX(C$1:C65)+1,\"\")","v":65},55,"Hazmat/CBRN   ","Governance","The organisation has identified responsible roles/people for the following elements of Hazmat/CBRN:\n- Accountability - via the AEO\n- Planning\n- Training\n- Equipment checks and maintenance \nWhich should be clearly documented","Y","Y","Y","Y","Y",null,null,"Y",null,null,null,null,null,null,"Details of accountability/responsibility are clearly documented in the organisation's Hazmat/CBRN plan and/or Emergency Planning policy as related to the identified risk and role of the organisation\n\n"]
[null,null,{"$f":"IF(OR(LEFT($D67,6)=\"Domain\",VLOOKUP(D67,$D67:$U67,$B$2,FALSE)=\"Y\"),MAX(C$1:C66)+1,\"\")","v":66},56,"Hazmat/CBRN   ","Hazmat/CBRN risk assessments ","Hazmat/CBRN risk assessments are in place which are appropriate to the organisation type\n\n","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"Evidence of the risk assessment process undertaken - including - \ni) governance for risk assessment process\nii) assessment of impacts on staff\niii) impact assessment(s) on estates and infrastructure - including access and egress\niv) management of potentially hazardous waste\nv) impact assessments of Hazmat/CBRN decontamination on critical facilities and services"]
[null,null,{"$f":"IF(OR(LEFT($D68,6)=\"Domain\",VLOOKUP(D68,$D68:$U68,$B$2,FALSE)=\"Y\"),MAX(C$1:C67)+1,\"\")","v":67},57,"Hazmat/CBRN   ","Specialist advice for Hazmat/CBRN  exposure","Organisations have signposted key clinical staff on how to access appropriate and timely specialist advice for managing patients involved in Hazmat/CBRN incidents","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,"Y",null,"Staff are aware of the number / process to gain access to advice through appropriate planning arrangements. These should include ECOSA, TOXBASE, NPIS, UKHSA\n\nArrangements should include how clinicians would access specialist clinical advice for the on-going treatment of a patient"]
[null,null,{"$f":"IF(OR(LEFT($D69,6)=\"Domain\",VLOOKUP(D69,$D69:$U69,$B$2,FALSE)=\"Y\"),MAX(C$1:C68)+1,\"\")","v":68},58,"Hazmat/CBRN   ","Hazmat/CBRN    planning arrangements ","The organisation has up to date specific Hazmat/CBRN plans and response arrangements aligned to the risk assessment, extending beyond IOR arrangements, and which are supported by a programme of regular training and exercising within the organisation and in conjunction with external stakeholders\n\n","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null," Documented plans include evidence of the following:\n•\tcommand and control structures \n•\tCollaboration with the NHS Ambulance Trust to ensure Hazmat/CBRN plans and procedures are consistent with the Ambulance Trust’s Hazmat/CBRN  capability\n•\tProcedures to manage and coordinate communications with other key stakeholders and other responders\n•\tEffective and tested processes for activating and deploying Hazmat/CBRN staff and Clinical Decontamination Units (CDUs) (or equivalent)\n•\tPre-determined decontamination locations with a clear distinction between clean and dirty areas and demarcation of safe clean access for patients, including for the off-loading of non-decontaminated patients from ambulances, and safe cordon control\n•\tDistinction between dry and wet decontamination and the decision making process for the appropriate deployment\n•\tIdentification of lockdown/isolation procedures for patients waiting for decontamination\n•\tManagement and decontamination processes for contaminated patients and fatalities in line with the latest guidance\n•\tArrangements for staff decontamination and access to staff welfare\n•\tBusiness continuity  plans that ensure the trust can continue to accept patients not related/affected by the Hazmat/CBRN incident, whilst simultaneously providing the decontamination capability, through designated clean entry routes\n•\tPlans for the management of hazardous waste\n•\tHazmat/CBRN plans and procedures include sufficient provisions to manage the stand-down and transition from response to recovery and a return to business as usual activities\n•\tDescription of process for obtaining replacement PPE/PRPS - both during a protracted incident and in the aftermath of an incident"]
[null,null,{"$f":"IF(OR(LEFT($D70,6)=\"Domain\",VLOOKUP(D70,$D70:$U70,$B$2,FALSE)=\"Y\"),MAX(C$1:C69)+1,\"\")","v":69},59,"Hazmat/CBRN   ","Decontamination capability availability 24 /7 ","The organisation has adequate and appropriate wet decontamination capability that can be rapidly deployed to manage self presenting patients, 24 hours a day, 7 days a week (for a minimum of four patients per hour) - this includes availability of staff to establish the decontamination facilities\n\nThere are sufficient trained staff on shift to allow for the continuation of decontamination until support and/or mutual aid can be provided - according to the organisation's risk assessment and plan(s)\n\nThe organisations also has plans, training and resources in place to enable the commencement of interim dry/wet, and improvised decontamination where necessary.\n","Y","Y",null,null,null,null,null,null,null,null,null,null,null,null,"Documented roles for people forming the decontamination team -  including Entry Control/Safety Officer\nHazmat/CBRN trained staff are clearly identified on staff rotas and scheduling pro-actively considers sufficient cover for each shift\nHazmat/CBRN trained staff working on shift are identified on shift board\n\nCollaboration with local NHS ambulance trust and local fire service - to ensure Hazmat/CBRN plans and procedures are consistent with local area plans\n\nAssessment of local area needs and resource"]
[null,null,{"$f":"IF(OR(LEFT($D71,6)=\"Domain\",VLOOKUP(D71,$D71:$U71,$B$2,FALSE)=\"Y\"),MAX(C$1:C70)+1,\"\")","v":70},60,"Hazmat/CBRN   ","Equipment and supplies","The organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff. There is an accurate inventory of equipment required for decontaminating patients. \n\nEquipment is proportionate with the organisation's risk assessment of requirement - such as for the management of non-ambulant or collapsed patients\n\n• Acute providers - see Equipment checklist: https://www.england.nhs.uk/wp-content/uploads/2018/07/eprr-decontamination-equipment-check-list.xlsx \n• Community, Mental Health and Specialist service providers - see guidance 'Planning for the management of self-presenting patients in healthcare setting': https://webarchive.nationalarchives.gov.uk/20161104231146/https://www.england.nhs.uk/wp-content/uploads/2015/04/eprr-chemical-incidents.pdf\n","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"This inventory should include individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment).\n\nThere are appropriate risk assessments and SOPs for any specialist equipment\n\nAcute and ambulance trusts must maintain the minimum number of PRPS suits specified by NHS England (24/240). These suits must be maintained in accordance with the manufacturer’s guidance. NHS Ambulance Trusts can provide support and advice on the maintenance of PRPS suits as required.\n\nDesignated hospitals must ensure they have a financial replacement plan in place to ensure that they are able to adequately account for depreciation in the life of equipment and ensure funding is available for replacement at the end of its shelf life.  This includes for PPE/PRPS suits, decontamination facilities etc."]
[null,null,{"$f":"IF(OR(LEFT($D72,6)=\"Domain\",VLOOKUP(D72,$D72:$U72,$B$2,FALSE)=\"Y\"),MAX(C$1:C71)+1,\"\")","v":71},61,"Hazmat/CBRN   ","Equipment - Preventative Programme of Maintenance","There is a preventative programme of maintenance (PPM) in place, including routine checks for the maintenance, repair, calibration (where necessary) and replacement of out of date decontamination equipment to ensure that equipment is always available to respond to a Hazmat/CBRN incident.\n\nEquipment is maintained according to applicable industry standards and in line with manufacturer’s recommendations\n\nThe PPM should include where applicable:\n- PRPS Suits\n- Decontamination structures \n- Disrobe and rerobe structures\n- Water outlets\n- Shower tray pump\n- RAM GENE (radiation monitor) - calibration not required\n- Other decontamination equipment as identified by your local risk assessment e.g. IOR Rapid Response boxes\n\nThere is a named individual (or role) responsible for completing these checks","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,"Y",null,"Documented process for equipment maintenance checks included within organisational Hazmat/CBRN plan - including frequency required proportionate to the risk assessment\n• Record of regular equipment checks, including date completed and by whom \n• Report of any missing equipment\nOrganisations using PPE and specialist equipment should document the method for it's disposal when required \n\nProcess for oversight of equipment in place for EPRR committee in multisite organisations/central register available to EPRR\n\nOrganisation Business Continuity arrangements to ensure the continuation of the decontamination services in the event of use or damage to primary equipment \n\nRecords of maintenance and annual servicing\n\nThird party providers of PPM must provide the organisations with assurance of their own Business Continuity arrangements as a commissioned supplier/provider under Core Standard 53"]
[null,null,{"$f":"IF(OR(LEFT($D73,6)=\"Domain\",VLOOKUP(D73,$D73:$U73,$B$2,FALSE)=\"Y\"),MAX(C$1:C72)+1,\"\")","v":72},62,"Hazmat/CBRN   ","Waste disposal arrangements","The organisation has clearly defined waste management processes within their Hazmat/CBRN plans\n","Y","Y",null,null,null,null,null,null,null,null,null,null,null,null,"Documented arrangements for the safe storage (and potential secure holding) of waste\nDocumented arrangements - in consultation with other emergency services for the eventual disposal of:\n- Waste water used during decontamination\n- Used or expired PPE\n- Used equipment - including unit liners\n\nAny organisation chosen for waste disposal must be included in the supplier audit conducted under Core Standard 53"]
[null,null,{"$f":"IF(OR(LEFT($D74,6)=\"Domain\",VLOOKUP(D74,$D74:$U74,$B$2,FALSE)=\"Y\"),MAX(C$1:C73)+1,\"\")","v":73},63,"Hazmat/CBRN   ","Hazmat/CBRN    training resource","The organisation must have an adequate training resource to deliver Hazmat/CBRN training which is aligned to the organisational Hazmat/CBRN plan and associated risk assessments\n\n\n\n","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"Identified minimum training standards within the organisation's Hazmat/CBRN plans (or EPRR training policy)\n\nStaff training needs analysis (TNA) appropriate to the organisation type - related to the need for decontamination\n\nDocumented evidence of training records for Hazmat/CBRN training - including for:\n- trust trainers - with dates of their attendance at an appropriate 'train the trainer' session (or update)\n- trust staff - with dates of the training that that they have undertaken\n\nDeveloped training programme to deliver capability against the risk assessment"]
[null,null,{"$f":"IF(OR(LEFT($D75,6)=\"Domain\",VLOOKUP(D75,$D75:$U75,$B$2,FALSE)=\"Y\"),MAX(C$1:C74)+1,\"\")","v":74},64,"Hazmat/CBRN   ","Staff training - recognition and  decontamination","The organisation undertakes training for all staff who are most likely to come into contact with potentially contaminated patients and patients requiring decontamination.\n\nStaff that may make contact with a potentially contaminated patients, whether in person or over the phone, are sufficiently trained in Initial Operational Response (IOR) principles and isolation when necessary. (This includes (but is not limited to) acute, community, mental health and primary care settings such as minor injury units and urgent treatment centres)\n\nStaff undertaking patient decontamination are sufficiently trained to ensure a safe system of work can be implemented","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"Evidence of trust training slides/programme and designated audience\nEvidence that the trust training includes reference to the relevant current guidance (where necessary)\nStaff competency records\n\n"]
[null,null,{"$f":"IF(OR(LEFT($D76,6)=\"Domain\",VLOOKUP(D76,$D76:$U76,$B$2,FALSE)=\"Y\"),MAX(C$1:C75)+1,\"\")","v":75},65,"Hazmat/CBRN   ","PPE Access","Organisations must ensure that staff who come in to contact with patients requiring wet decontamination and patients with confirmed respiratory contamination have access to, and are trained to use, appropriate PPE. \n\nThis includes maintaining the expected number of operational PRPS available for immediate deployment to safely undertake wet decontamination and/or access to FFP3 (or equivalent) 24/7\n\n","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"Completed equipment inventories; including completion date \n\nFit testing schedule and records should be maintained for all staff who may come into contact with confirmed respiratory contamination\n\nEmergency Departments at Acute Trusts are required to maintain 24 Operational PRPS\n\n"]
[null,null,{"$f":"IF(OR(LEFT($D77,6)=\"Domain\",VLOOKUP(D77,$D77:$U77,$B$2,FALSE)=\"Y\"),MAX(C$1:C76)+1,\"\")","v":76},66,"Hazmat/CBRN   ","Exercising","Organisations must ensure that the exercising of Hazmat/CBRN plans and arrangements are incorporated in the organisations EPRR exercising and testing programme","Y","Y","Y",null,"Y",null,null,"Y",null,null,null,null,null,null,"Evidence\n• Exercising Schedule which includes Hazmat/CBRN exercise\n• Post exercise reports and embedding learning"]
[null,null,{"$f":"IF(OR(LEFT($D78,6)=\"Domain\",VLOOKUP(D78,$D78:$U78,$B$2,FALSE)=\"Y\"),MAX(C$1:C77)+1,\"\")","v":77},67,"CBRN Support to acute Trusts","Capability","NHS Ambulance Trusts must support designated Acute Trusts\n(hospitals) to maintain the following CBRN / Hazardous Materials \n(HazMat) tactical capabilities:\n\n• Provision of Initial Operational Response (IOR) for self presenting casualties at an Emergency Department including ‘Remove, Remove, Remove’ provisions. \n• PRPS wearers to be able to decontaminate CBRN/HazMat casualties.\n• ‘PRPS’ protective equipment and associated accessories.\n• Wet decontamination of casualties via Clinical Decontamination \nUnits (CDU’s), these may take the form of dedicated rooms or external structures but must have the capability to decontaminate both ambulant and non – ambulant casualties with warm water. \n• Clinical radiation monitoring equipment and capability.\n• Clinical care of casualties during the decontamination process.\n• Robust and effective arrangements to access specialist scientific advice relating to CBRN/HazMat incident response. \n\nThe support provided by NHS Ambulance Services must include, as a minimum, a biennial (once every two years) CBRN/HazMat capability review of the hospitals including decontamination capability and the provision of training support in accordance with the provisions set out in these core standards. ","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Evidence predominantly gained through assessment and verification of training syllabus (lesson plans, exercise programme), ensuring all key elements in “detail”\" column are expressed in documentation. This will help determine:\n\n-\tIf IOR training is being received and is based on self-presenters to ED.\n-\tWhether PRPS training is being delivered.\n-\tTraining re: decontamination and clinical care of casualties.\n\nSpecific plans, technical drawings, risk assessments, etc. that outline:\n\n-\tThe acute Trusts’ CDU capability and how it operates.\n-\tIts provision of clinical radiation monitoring.\n-\tHow scientific advice is obtained (this could also be an interview question to relevant staff groups, e.g., ”\"what radiation monitoring equipment do you have, and where is it?”\n\nAny documentation provided as evidence must be in-date, and published (i.e., not draft) for it to be credible.\n\nDocumented evidence of minimum completion of biannual reviews (e.g., via a collated list)."]
[null,null,{"$f":"IF(OR(LEFT($D79,6)=\"Domain\",VLOOKUP(D79,$D79:$U79,$B$2,FALSE)=\"Y\"),MAX(C$1:C78)+1,\"\")","v":78},68,"CBRN Support to acute Trusts","Capability Review","NHS Ambulance Trusts must undertake a review of the CBRN/HazMat capability in designated hospitals within their geographical region. \n\nDesignated hospitals are those identified by NHS England as having a CBRN/HazMat decontamination capability attached to their Emergency Department and an allocation of the national PRPS stock.","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Documented evidence of that review, including:\n\n-\tDates of review.\n-\tWhat was reviewed.\n-\tFindings of the review.\n-\tAny associated actions.\n-\tEvidence of progress/close-out of actions."]
[null,null,{"$f":"IF(OR(LEFT($D80,6)=\"Domain\",VLOOKUP(D80,$D80:$U80,$B$2,FALSE)=\"Y\"),MAX(C$1:C79)+1,\"\")","v":79},69,"CBRN Support to acute Trusts","Capability Review Frequency","NHS Ambulance Trusts must formally review the CBRN/HazMat capability in each designated hospital biennially (at least once every two years). ","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Documented evidence of that review, including:\n\n-\tDates of review.\n-\tWhat was reviewed.\n-\tFindings of the review.\n-\tAny associated actions.\nEvidence of progress/close-out of actions."]
[null,null,{"$f":"IF(OR(LEFT($D81,6)=\"Domain\",VLOOKUP(D81,$D81:$U81,$B$2,FALSE)=\"Y\"),MAX(C$1:C80)+1,\"\")","v":80},70,"CBRN Support to acute Trusts","Capability Review report","Following each formal review of the capability within a designated  hospital, the NHS Ambulance Trust must produce a report detailing the level of compliance against the standards set out in this document. That report must be provided to the designated hospital and the NHS England Regional EPRR Lead. \n\nCopies of all such reports must be retained by the NHS Ambulance Trust for at least 10 years and they must be made available to any inspections or audits conducted by the National Ambulance Resilience Unit (NARU) on behalf of NHS England.","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Evidence of those reports and that the designated hospital and NHSE EPRR Lead are in receipt of those.\n\nDip sample of last 10 years of reports, e.g., please provide reports from 2015, 2018, and 2022 to show adherence to the retention of reports for 10 years."]
[null,null,{"$f":"IF(OR(LEFT($D82,6)=\"Domain\",VLOOKUP(D82,$D82:$U82,$B$2,FALSE)=\"Y\"),MAX(C$1:C81)+1,\"\")","v":81},71,"CBRN Support to acute Trusts","Train the trainer","NHS Ambulance Trusts must support each designated hospital in their region with training to support the CBRN/HazMat decontamination and PRPS capability. \n\nThat training will take the form of ‘train the trainer’ sessions so trainers based within the designated hospitals can then cascade the training to those hospital staff that require it.","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Written statement as to how this is achieved, which can then be further investigated during inspection.\n\nEvidence of training records and/or a documented training schedule. \n\nProvision of suitable training documentation – syllabus, lesson plans, etc., that shows the detail of training delivered."]
[null,null,{"$f":"IF(OR(LEFT($D83,6)=\"Domain\",VLOOKUP(D83,$D83:$U83,$B$2,FALSE)=\"Y\"),MAX(C$1:C82)+1,\"\")","v":82},72,"CBRN Support to acute Trusts","Aligned training","Training provided by the NHS Ambulance Trust for this purpose must be aligned to national train the trainer packages approved by the National Ambulance Resilience Unit for CBRN/HazMat decontamination and PRPS capabilities.","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"NARU can provide the latest version number of associated training packages. This can then be cross-referenced against lesson plans and training packages in acute Trusts to ensure up-to-date national training is being delivered."]
[null,null,{"$f":"IF(OR(LEFT($D84,6)=\"Domain\",VLOOKUP(D84,$D84:$U84,$B$2,FALSE)=\"Y\"),MAX(C$1:C83)+1,\"\")","v":83},73,"CBRN Support to acute Trusts","Training sessions","Provision of training sessions will be arranged jointly between the NHS Ambulance Trust and their designated hospitals. Frequency, capacity etc will be subject to local negotiation.","Y",null,null,"Y",null,null,null,null,null,null,null,null,null,null,"Clear evidence of documentation (e.g., a contract, MoU, or equivalent, that details how training is delivered to acute Trusts, how often, etc.)."]

{"sheet":"Deep Dive Criteria","index":6,"n_rows":84,"n_cols":22,"rows_kept":84,"cut":false,"hidden":true,"merged":[[1,3,1,21]]}
["Selected Org Type",{"$f":"'Core Criteria'!B1","v":"ALL ORGANISATION TYPES"},"Selected Type","Ref","Domain","Standard","Deep Dive question","Supporting evidence- including examples of evidence\n","All Organisation Types","Acute Providers","Specialist Providers","NHS Ambulance Service Providers","Community Service Providers","Patient Transport Services","NHS111","Mental Health Providers","NHS England Region","NHS England National","Integrated Care Board","Commissioning Support Unit ","Primary Care Services - GP, community pharmacy","Other NHS funded organisations"]
["Column",{"$f":"MATCH(B1,$D$1:$V$1,0)","v":6},{"$f":"IFERROR(IF(OR(LEFT($D2,4)=\"Deep\",VLOOKUP(D2,$D2:$V2,$B$2,FALSE)=\"Y\"),MAX(C$1:C1)+1,\"\"),\"\")","v":1},"Deep Dive - Cyber Security and IT related incident response (NOT INCLUDED WITHIN THE ORGANISATION'S OVERALL EPRR ASSURANCE RATING)"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D3,4)=\"Deep\",VLOOKUP(D3,$D3:$V3,$B$2,FALSE)=\"Y\"),MAX(C$1:C2)+1,\"\"),\"\")","v":2},"DD1","Deep Dive  \nCyber Security","Cyber Security & IT related incident preparedness","Cyber security and IT teams support the organisation's EPRR activity including delivery of the EPRR work programme to achieve business objectives outlined in organisational EPRR policy.\n","-Cyber security and IT teams engaged with EPRR governance arrangement and are represented on EPRR committee membership (TOR and minutes)\n- Shared understanding of risks to the organisation and the population it serves with regards to EPRR - organisational risk assessments and risk registers\n-Plans and arrangements demonstrate a common understanding of incidents in line with EPRR framework and cyber security requirements. \n-EPRR work programme\n-Organisational EPRR policy                                                                                                                                                                      ","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D4,4)=\"Deep\",VLOOKUP(D4,$D4:$V4,$B$2,FALSE)=\"Y\"),MAX(C$1:C3)+1,\"\"),\"\")","v":3},"DD2","Deep Dive  \nCyber Security","Cyber Security & IT related incident response arrangements","The organisation has developed threat specific cyber security and IT related incident response arrangements with regard to relevant risk assessments and that dovetail with generic organisational response plans.","Arrangements should:\n-consider the operational impact of such incidents\n-be current and include a routine review schedule\n-be tested regularly\n-be approved and signed off by the appropriate governance mechanisms\n-include clearly identified response roles and responsibilities\n-be shared appropriately with those required to use them\n-outline any equipment requirements \n-outline any staff training needs\n-include use of unambiguous language\n-demonstrate a common understanding of terminology used during incidents in line with the EPRR framework and cybersecurity requirements.'","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D5,4)=\"Deep\",VLOOKUP(D5,$D5:$V5,$B$2,FALSE)=\"Y\"),MAX(C$1:C4)+1,\"\"),\"\")","v":4},"DD3","Deep Dive  \nCyber Security","Resilient Communication during Cyber Security & IT related incidents","The organisation has arrangements in place for communicating with partners and stakeholders during cyber security and IT related incidents.","Arrangements should consider the generic principles for enhancing communications resilience:\n1. look beyond the technical solutions at processes and organisational arrangements\n2. identify and review the critical communication activities that underpin your response arrangements\n3. ensure diversity of technical solutions\n4. adopt layered fall-back arrangements\n5. plan for appropriate interoperability\n\nhttps://www.england.nhs.uk/wp-content/uploads/2019/03/national-resilient-telecommunications-guidance.pdf","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D6,4)=\"Deep\",VLOOKUP(D6,$D6:$V6,$B$2,FALSE)=\"Y\"),MAX(C$1:C5)+1,\"\"),\"\")","v":5},"DD4","Deep Dive  \nCyber Security","Media Strategy","The organisation has Incident communication plans and media strategies that include arrangements to agree media lines and the use of corporate and personal social media accounts during cyber security and IT related incidents","- Incident communications plans and media strategy give consideration to cyber security incidents activities as well as clinical and operational impacts. \n- Agreed sign off processes for media and press releases in relation to Cyber security and IT related incidents. \n- Documented process for communications to regional and national teams\n- Incident communications plan and media strategy provides guidance for staff on providing comment, commentary or advice during an incident or where sensitive information is generated. ","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D7,4)=\"Deep\",VLOOKUP(D7,$D7:$V7,$B$2,FALSE)=\"Y\"),MAX(C$1:C6)+1,\"\"),\"\")","v":6},"DD5","Deep Dive  \nCyber Security","Testing and exercising","The exercising and/ or testing of cyber security and IT related incident arrangements are included in the organisations EPRR exercise and testing programme.","- Evidence of exercises held in last 12 months including post exercise reports\n- EPRR exercise and testing programme ","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D8,4)=\"Deep\",VLOOKUP(D8,$D8:$V8,$B$2,FALSE)=\"Y\"),MAX(C$1:C7)+1,\"\"),\"\")","v":7},"DD6","Deep Dive  \nCyber Security","Continuous Improvement","The organisation's Cyber Security and IT teams have processes in place to implement changes to threat specific response arrangements and embed learning following incidents and exercises","- Cyber security and IT colleagues participation in debriefs following live incidents and exercises\n- lessons identified and implementation plans to address those lessons\n-agreed processes in place to adopt implementation of lessons identified\n- Evidence of updated incident plans post-incident/exercise","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D9,4)=\"Deep\",VLOOKUP(D9,$D9:$V9,$B$2,FALSE)=\"Y\"),MAX(C$1:C8)+1,\"\"),\"\")","v":8},"DD7","Deep Dive  \nCyber Security","Training Needs Analysis (TNA)","Cyber security and IT related incident response roles are included in an organisation's TNA.","- TNA includes Cyber security and IT related incident response roles\n- Attendance/participant lists showing cybersecurity and IT colleagues taking part in incident response training.","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D10,4)=\"Deep\",VLOOKUP(D10,$D10:$V10,$B$2,FALSE)=\"Y\"),MAX(C$1:C9)+1,\"\"),\"\")","v":9},"DD8","Deep Dive  \nCyber Security","EPRR Training ","The oranisation's EPRR awareness training  includes the risk to the organisation of cyber security and IT related incidents and emergencies","-Cyber security and IT related incidents and emergencies included in  EPRR awareness training package","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D11,4)=\"Deep\",VLOOKUP(D11,$D11:$V11,$B$2,FALSE)=\"Y\"),MAX(C$1:C10)+1,\"\"),\"\")","v":10},"DD9","Deep Dive  \nCyber Security","Business Impact Assessments","The Cyber Security and IT teams are aware of the organisations's critical functions and the dependencies on IT core systems and infrastrucure for the safe and effective delivery of these services","-robust Business Impact Analysis including core systems\n-list of the organisations critical services and functions\n-list of the organisations core IT/Digital systems and prioritisation of system recovery","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D12,4)=\"Deep\",VLOOKUP(D12,$D12:$V12,$B$2,FALSE)=\"Y\"),MAX(C$1:C11)+1,\"\"),\"\")","v":11},"DD10","Deep Dive  \nCyber Security","Business Continuity Management System","Cyber Security and IT systems and infrastructure are considered within the scope and objectives of the organisation's Business Continuity Management System (BCMS)","-Reflected in the organisation's Business Continuity Policy\n-key products and services within the scope of BCMS\n-Appropriate risk assessments","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D13,4)=\"Deep\",VLOOKUP(D13,$D13:$V13,$B$2,FALSE)=\"Y\"),MAX(C$1:C12)+1,\"\"),\"\")","v":12},"DD11","Deep Dive  \nCyber Security","Business Continuity Arrangments ","IT Disaster Recovery arrangements for core IT systems and infrastructure are included with the organisation's Business Continuity arrangements for the safe delivery of critical services identified in the organisation's business impact assessments","- Business Continuity Plans for critical services provided by the organisation include core systems\n-Disaster recovery plans for core systems\n-Cyber security and IT departments own BCP which includes  contacts for key personnel outside of normal working hours                                                                                                     ","Y","Y","Y","Y","Y","Y","Y","Y",null,"Y","Y","Y","Y","Y"]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D14,4)=\"Deep\",VLOOKUP(D14,$D14:$V14,$B$2,FALSE)=\"Y\"),MAX(C$1:C13)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D15,4)=\"Deep\",VLOOKUP(D15,$D15:$V15,$B$2,FALSE)=\"Y\"),MAX(C$1:C14)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D16,4)=\"Deep\",VLOOKUP(D16,$D16:$V16,$B$2,FALSE)=\"Y\"),MAX(C$1:C15)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D17,4)=\"Deep\",VLOOKUP(D17,$D17:$V17,$B$2,FALSE)=\"Y\"),MAX(C$1:C16)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D18,4)=\"Deep\",VLOOKUP(D18,$D18:$V18,$B$2,FALSE)=\"Y\"),MAX(C$1:C17)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D19,4)=\"Deep\",VLOOKUP(D19,$D19:$V19,$B$2,FALSE)=\"Y\"),MAX(C$1:C18)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D20,4)=\"Deep\",VLOOKUP(D20,$D20:$V20,$B$2,FALSE)=\"Y\"),MAX(C$1:C19)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D21,4)=\"Deep\",VLOOKUP(D21,$D21:$V21,$B$2,FALSE)=\"Y\"),MAX(C$1:C20)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D22,4)=\"Deep\",VLOOKUP(D22,$D22:$V22,$B$2,FALSE)=\"Y\"),MAX(C$1:C21)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D23,4)=\"Deep\",VLOOKUP(D23,$D23:$V23,$B$2,FALSE)=\"Y\"),MAX(C$1:C22)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D24,4)=\"Deep\",VLOOKUP(D24,$D24:$V24,$B$2,FALSE)=\"Y\"),MAX(C$1:C23)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D25,4)=\"Deep\",VLOOKUP(D25,$D25:$V25,$B$2,FALSE)=\"Y\"),MAX(C$1:C24)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D26,4)=\"Deep\",VLOOKUP(D26,$D26:$V26,$B$2,FALSE)=\"Y\"),MAX(C$1:C25)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D27,4)=\"Deep\",VLOOKUP(D27,$D27:$V27,$B$2,FALSE)=\"Y\"),MAX(C$1:C26)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D28,4)=\"Deep\",VLOOKUP(D28,$D28:$V28,$B$2,FALSE)=\"Y\"),MAX(C$1:C27)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D29,4)=\"Deep\",VLOOKUP(D29,$D29:$V29,$B$2,FALSE)=\"Y\"),MAX(C$1:C28)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D30,4)=\"Deep\",VLOOKUP(D30,$D30:$V30,$B$2,FALSE)=\"Y\"),MAX(C$1:C29)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D31,4)=\"Deep\",VLOOKUP(D31,$D31:$V31,$B$2,FALSE)=\"Y\"),MAX(C$1:C30)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D32,4)=\"Deep\",VLOOKUP(D32,$D32:$V32,$B$2,FALSE)=\"Y\"),MAX(C$1:C31)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D33,4)=\"Deep\",VLOOKUP(D33,$D33:$V33,$B$2,FALSE)=\"Y\"),MAX(C$1:C32)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D34,4)=\"Deep\",VLOOKUP(D34,$D34:$V34,$B$2,FALSE)=\"Y\"),MAX(C$1:C33)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D35,4)=\"Deep\",VLOOKUP(D35,$D35:$V35,$B$2,FALSE)=\"Y\"),MAX(C$1:C34)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D36,4)=\"Deep\",VLOOKUP(D36,$D36:$V36,$B$2,FALSE)=\"Y\"),MAX(C$1:C35)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D37,4)=\"Deep\",VLOOKUP(D37,$D37:$V37,$B$2,FALSE)=\"Y\"),MAX(C$1:C36)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D38,4)=\"Deep\",VLOOKUP(D38,$D38:$V38,$B$2,FALSE)=\"Y\"),MAX(C$1:C37)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D39,4)=\"Deep\",VLOOKUP(D39,$D39:$V39,$B$2,FALSE)=\"Y\"),MAX(C$1:C38)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D40,4)=\"Deep\",VLOOKUP(D40,$D40:$V40,$B$2,FALSE)=\"Y\"),MAX(C$1:C39)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D41,4)=\"Deep\",VLOOKUP(D41,$D41:$V41,$B$2,FALSE)=\"Y\"),MAX(C$1:C40)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D42,4)=\"Deep\",VLOOKUP(D42,$D42:$V42,$B$2,FALSE)=\"Y\"),MAX(C$1:C41)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D43,4)=\"Deep\",VLOOKUP(D43,$D43:$V43,$B$2,FALSE)=\"Y\"),MAX(C$1:C42)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D44,4)=\"Deep\",VLOOKUP(D44,$D44:$V44,$B$2,FALSE)=\"Y\"),MAX(C$1:C43)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D45,4)=\"Deep\",VLOOKUP(D45,$D45:$V45,$B$2,FALSE)=\"Y\"),MAX(C$1:C44)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D46,4)=\"Deep\",VLOOKUP(D46,$D46:$V46,$B$2,FALSE)=\"Y\"),MAX(C$1:C45)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D47,4)=\"Deep\",VLOOKUP(D47,$D47:$V47,$B$2,FALSE)=\"Y\"),MAX(C$1:C46)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D48,4)=\"Deep\",VLOOKUP(D48,$D48:$V48,$B$2,FALSE)=\"Y\"),MAX(C$1:C47)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D49,4)=\"Deep\",VLOOKUP(D49,$D49:$V49,$B$2,FALSE)=\"Y\"),MAX(C$1:C48)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D50,4)=\"Deep\",VLOOKUP(D50,$D50:$V50,$B$2,FALSE)=\"Y\"),MAX(C$1:C49)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D51,4)=\"Deep\",VLOOKUP(D51,$D51:$V51,$B$2,FALSE)=\"Y\"),MAX(C$1:C50)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D52,4)=\"Deep\",VLOOKUP(D52,$D52:$V52,$B$2,FALSE)=\"Y\"),MAX(C$1:C51)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D53,4)=\"Deep\",VLOOKUP(D53,$D53:$V53,$B$2,FALSE)=\"Y\"),MAX(C$1:C52)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D54,4)=\"Deep\",VLOOKUP(D54,$D54:$V54,$B$2,FALSE)=\"Y\"),MAX(C$1:C53)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D55,4)=\"Deep\",VLOOKUP(D55,$D55:$V55,$B$2,FALSE)=\"Y\"),MAX(C$1:C54)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D56,4)=\"Deep\",VLOOKUP(D56,$D56:$V56,$B$2,FALSE)=\"Y\"),MAX(C$1:C55)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D57,4)=\"Deep\",VLOOKUP(D57,$D57:$V57,$B$2,FALSE)=\"Y\"),MAX(C$1:C56)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D58,4)=\"Deep\",VLOOKUP(D58,$D58:$V58,$B$2,FALSE)=\"Y\"),MAX(C$1:C57)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D59,4)=\"Deep\",VLOOKUP(D59,$D59:$V59,$B$2,FALSE)=\"Y\"),MAX(C$1:C58)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D60,4)=\"Deep\",VLOOKUP(D60,$D60:$V60,$B$2,FALSE)=\"Y\"),MAX(C$1:C59)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D61,4)=\"Deep\",VLOOKUP(D61,$D61:$V61,$B$2,FALSE)=\"Y\"),MAX(C$1:C60)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D62,4)=\"Deep\",VLOOKUP(D62,$D62:$V62,$B$2,FALSE)=\"Y\"),MAX(C$1:C61)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D63,4)=\"Deep\",VLOOKUP(D63,$D63:$V63,$B$2,FALSE)=\"Y\"),MAX(C$1:C62)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D64,4)=\"Deep\",VLOOKUP(D64,$D64:$V64,$B$2,FALSE)=\"Y\"),MAX(C$1:C63)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D65,4)=\"Deep\",VLOOKUP(D65,$D65:$V65,$B$2,FALSE)=\"Y\"),MAX(C$1:C64)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D66,4)=\"Deep\",VLOOKUP(D66,$D66:$V66,$B$2,FALSE)=\"Y\"),MAX(C$1:C65)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D67,4)=\"Deep\",VLOOKUP(D67,$D67:$V67,$B$2,FALSE)=\"Y\"),MAX(C$1:C66)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D68,4)=\"Deep\",VLOOKUP(D68,$D68:$V68,$B$2,FALSE)=\"Y\"),MAX(C$1:C67)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D69,4)=\"Deep\",VLOOKUP(D69,$D69:$V69,$B$2,FALSE)=\"Y\"),MAX(C$1:C68)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D70,4)=\"Deep\",VLOOKUP(D70,$D70:$V70,$B$2,FALSE)=\"Y\"),MAX(C$1:C69)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D71,4)=\"Deep\",VLOOKUP(D71,$D71:$V71,$B$2,FALSE)=\"Y\"),MAX(C$1:C70)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D72,4)=\"Deep\",VLOOKUP(D72,$D72:$V72,$B$2,FALSE)=\"Y\"),MAX(C$1:C71)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D73,4)=\"Deep\",VLOOKUP(D73,$D73:$V73,$B$2,FALSE)=\"Y\"),MAX(C$1:C72)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D74,4)=\"Deep\",VLOOKUP(D74,$D74:$V74,$B$2,FALSE)=\"Y\"),MAX(C$1:C73)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D75,4)=\"Deep\",VLOOKUP(D75,$D75:$V75,$B$2,FALSE)=\"Y\"),MAX(C$1:C74)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D76,4)=\"Deep\",VLOOKUP(D76,$D76:$V76,$B$2,FALSE)=\"Y\"),MAX(C$1:C75)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D77,4)=\"Deep\",VLOOKUP(D77,$D77:$V77,$B$2,FALSE)=\"Y\"),MAX(C$1:C76)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D78,4)=\"Deep\",VLOOKUP(D78,$D78:$V78,$B$2,FALSE)=\"Y\"),MAX(C$1:C77)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D79,4)=\"Deep\",VLOOKUP(D79,$D79:$V79,$B$2,FALSE)=\"Y\"),MAX(C$1:C78)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D80,4)=\"Deep\",VLOOKUP(D80,$D80:$V80,$B$2,FALSE)=\"Y\"),MAX(C$1:C79)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D81,4)=\"Deep\",VLOOKUP(D81,$D81:$V81,$B$2,FALSE)=\"Y\"),MAX(C$1:C80)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D82,4)=\"Deep\",VLOOKUP(D82,$D82:$V82,$B$2,FALSE)=\"Y\"),MAX(C$1:C81)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D83,4)=\"Deep\",VLOOKUP(D83,$D83:$V83,$B$2,FALSE)=\"Y\"),MAX(C$1:C82)+1,\"\"),\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(OR(LEFT($D84,4)=\"Deep\",VLOOKUP(D84,$D84:$V84,$B$2,FALSE)=\"Y\"),MAX(C$1:C83)+1,\"\"),\"\")","v":""}]

{"sheet":"LookUp","index":7,"n_rows":15,"n_cols":7,"rows_kept":15,"cut":false,"hidden":true,"merged":[]}
["Compliance",null,"Org Types",null,"Formats"]
["Fully compliant",null,"ALL ORGANISATION TYPES",null,"Blue",null,"Accent 1 lighter 60%"]
["Partially compliant",null,"Acute Providers",null,"Green",null,"Accent 6 lighter 60%"]
["Non compliant",null,"Specialist Providers",null,"Grey",null,"White Background 1 Darker 15%"]
["Not applicable",null,"NHS Ambulance Service Providers",null,"Dark Blue",null,"Accent 5 Darker 25%"]
[null,null,"Community Service Providers"]
[null,null,"Patient Transport Services"]
[null,null,"NHS111"]
[null,null,"Mental Health Providers"]
[null,null,"NHS England Region"]
[null,null,"NHS England National"]
[null,null,"Integrated Care Board"]
[null,null,"Commissioning Support Unit "]
[null,null,"Primary Care Services - GP, community pharmacy"]
[null,null,"Other NHS funded organisations"]