Operational Document
| Document Owner | , Registered Manager – |
| Classification | CONFIDENTIAL – Internal Use Only |
| Distribution | All managers, senior staff, and on-call personnel. Copies held at each service location and in grab bags. |
| CRITICAL NOTICE This is a live operational document. If you are reading this during an actual incident, follow the procedures exactly. Do not improvise. Contact details must be updated immediately when changes occur. |
QUICK REFERENCE: EMERGENCY CONTACTS
Keep this page accessible at all times. Post a copy by each telephone.
| Service | Contact | Number |
| Emergency Services | Police / Fire / Ambulance | 999 |
| NHS 111 | Non-emergency health advice | 111 |
| Registered Manager | ||
| Duty Manager (On-Call) | [Current duty manager name] | [Mobile number] |
| Safeguarding Lead | ||
| Health & Safety Officer | ||
| Local Authority Safeguarding | [LA name] | [24-hour number] |
| CQC Emergency Contact | CQC National Contact Centre | 03000 616161 |
| Commissioner On-Call | [Commissioner name] | [Emergency number] |
| Gas Emergency | National Gas Emergency Service | 0800 111 999 |
| Electricity Emergency | [Supplier name] | [24-hour number] |
| Water Emergency | [Water company] | [24-hour number] |
| Emergency Pharmacy | [Pharmacy name] | [24-hour number] |
| Insurance Claims | [Insurance company] | [24-hour claims line] |
| Emergency Repairs | [Contractor name] | [24-hour number] |
PLAN ACTIVATION: DECISION TREE
| WHEN TO USE THIS PLAN This Business Continuity Plan must be activated whenever a disruptive incident threatens or affects service delivery. If in doubt, activate the plan – it is better to stand down later than to delay essential response. |
STEP 1: Assess the Situation
Answer the following questions:
1. Is there an immediate threat to life or safety? (Fire, medical emergency, violence, gas leak, etc.)
→ If YES: Call 999 immediately, then activate this plan
2. Are service users affected or at risk?
→ If YES: Continue to Step 2
3. Can normal service continue without interruption?
→ If NO: Continue to Step 2
STEP 2: Classify Incident Severity
| Level | Description | Action Required |
| Level 1 MINOR | Localised incident, minimal impact, manageable with normal resources. Examples: Single staff absence, minor equipment failure, brief utility interruption (<1 hour) | Manage using standard procedures. Document in incident log. No plan activation required. |
| Level 2 MODERATE | Significant disruption affecting multiple service users or requiring coordination. Examples: Multiple staff absence, equipment failure affecting care delivery, utility outage 1-6 hours | Notify Duty Manager and Registered Manager. Activate relevant sections of this plan. Implement contingency measures. |
| Level 3 MAJOR | Severe incident threatening service delivery across site or prolonged period. Examples: Fire/flood, pandemic outbreak, complete utility failure, mass staff absence, safeguarding emergency | ACTIVATE FULL PLAN IMMEDIATELY. Convene incident management team. Notify all stakeholders including CQC and commissioners. |
STEP 3: Take Immediate Actions
For Level 2 or Level 3 incidents:
1. Ensure immediate safety of all service users and staff
2. Call emergency services if required (999)
3. Notify Duty Manager (if not already on site)
4. Notify Registered Manager
5. Start Incident Log (see Appendix A)
6. Go to relevant incident response procedure in Section 5
CONTENTS
Quick Reference: Emergency Contacts
Plan Activation: Decision Tree
Section 1: Introduction and Purpose
Section 2: Plan Ownership and Maintenance
Section 3: Incident Management Structure
Section 4: Communication Procedures
Section 5: Incident Response Procedures
5.1 Fire
5.2 Flood
5.3 Severe Weather – Snow/Ice
5.4 Severe Weather – Extreme Heat
5.5 Gas Leak
5.6 Electricity Outage
5.7 Water Supply Failure
5.8 IT System Failure / Cyber Attack
5.9 Pandemic / Infectious Disease Outbreak
5.10 Mass Staff Absence
5.11 Serious Safeguarding Incident
5.12 Death of Service User
5.13 Loss of Key Personnel
5.14 Major Supplier Failure
Section 6: Recovery and Stand-Down Procedures
Section 7: Testing and Exercising Schedule
Appendices:
Appendix A: Incident Log Template
Appendix B: Staff Contact List
Appendix C: Service User Emergency Information
Appendix D: External Stakeholder Contacts
Appendix E: Supplier and Contractor Contacts
Appendix F: Emergency Equipment and Supplies Inventory
Appendix G: Alternative Accommodation Register
Appendix H: Notification Templates
Appendix I: Site-Specific Information
Appendix J: Decision-Making Checklists
1. Introduction and Purpose
This Business Continuity Plan is the operational document that supports the Business Continuity Policy of . While the Policy sets out our strategic approach and governance framework, this Plan provides the practical, step-by-step procedures that staff must follow during disruptive incidents.
1.1 Purpose of This Document
This Plan enables staff to:
• Respond quickly and effectively to business continuity incidents
• Access critical contact information rapidly
• Follow tested procedures for common incident scenarios
• Make informed decisions under pressure
• Maintain service user safety and care standards during disruption
• Coordinate with external agencies and stakeholders
• Document actions taken for post-incident review
1.2 Scope
This Plan covers all operational aspects of business continuity management for supported living services. It applies to all staff, all service locations, and all service users.
The Plan addresses internal incidents (staffing, premises, equipment failures) and external threats (weather, utilities, pandemics, supplier failures) that could disrupt service delivery.
1.3 When to Use This Plan
This Plan should be activated for any Level 2 (Moderate) or Level 3 (Major) incident as defined in the Decision Tree. Staff discovering potential incidents must notify the Duty Manager immediately.
The Duty Manager has authority to activate relevant sections of this Plan without waiting for senior management approval in time-critical situations. The Registered Manager must be notified as soon as practicable.
1.4 How to Use This Plan
During an incident:
1. Refer to the Decision Tree to classify incident severity
2. Use the Quick Reference page to contact key personnel
3. Go directly to the relevant procedure in Section 5
4. Follow the steps sequentially – do not skip steps
5. Start an Incident Log immediately (Appendix A)
6. Document all decisions and actions as you proceed
2. Plan Ownership and Maintenance
2.1 Document Owner
The Registered Manager, , is the owner of this Business Continuity Plan and is accountable for ensuring it remains current, accurate, and effective.
2.2 Review and Update Schedule
This Plan must be reviewed and updated:
| Frequency | Review Requirement |
| Every 6 months (minimum) | Full document review including contact details, procedures, and appendices. Update version number and review date. |
| Monthly | Verify emergency contact numbers remain current. Update duty manager on-call rota. Check emergency supplies expiry dates. |
| After each incident | Update procedures based on lessons learned. Revise any information found to be outdated or inaccurate during actual use. |
| After exercises/tests | Incorporate improvements identified during testing. Update procedures that proved unclear or inadequate during exercises. |
| When changes occur | Immediately update for staff changes, new service users, premises modifications, supplier changes, or regulatory requirement changes. |
2.3 Distribution and Access
Copies of this Plan are held:
• In the manager’s office at each service location (printed and accessible 24/7)
• In the emergency grab bag at each service location
• On the organisation’s shared drive (electronic version)
• With all on-call managers (electronic copy on mobile device)
• At head office (master copy)
All staff receive training on the location of this Plan and how to access it during emergencies.
2.4 Version Control
Each update to this Plan requires:
• Version number increment (e.g., 1.0 to 1.1 for minor updates, 1.0 to 2.0 for major revisions)
• Update date recorded on cover page
• Change log maintained documenting what was updated and why
• All copies replaced with current version within 5 working days
• Old versions destroyed or clearly marked ‘SUPERSEDED’
3. Incident Management Structure
Effective incident response requires clear command and control structures. This section defines who does what during business continuity incidents.
3.1 Incident Management Team Roles
| Role | Responsibilities During Incident |
| Incident Commander (Registered Manager) | Overall command and strategic decision-making for Level 3 incidents. Authorises plan activation and stand-down. Liaison with CQC, commissioners, and external agencies. Resource allocation decisions. Media communications if required. Declares major incident status. Convenes incident management team meetings. Ensures all regulatory notifications completed. |
| Operations Lead (Duty Manager) | On-site operational coordination. Immediate incident assessment and initial response. Staff deployment and rota management. Direct service user welfare oversight. Implementation of tactical procedures. Liaison with emergency services on scene. Real-time decision-making for operational issues. Situation reporting to Incident Commander. Safety of site and personnel. |
| Safeguarding Lead | Assessment of safeguarding implications. Liaison with local authority safeguarding team. Coordination of safeguarding referrals. Monitoring vulnerable service user welfare during incident. Advising incident management team on safeguarding considerations. Ensuring protection measures maintained throughout. |
| Health & Safety Officer | Health and safety risk assessment during incident. Premises safety evaluation. Coordination of emergency repairs. PPE and safety equipment provision. RIDDOR reporting if applicable. Liaison with utilities and contractors. Environmental health considerations. Safe systems of work during disruption. |
| Communications Lead | Internal staff communications and briefings. Family and advocate notifications. Commissioner updates and liaison. External stakeholder communications. Media handling (in consultation with Incident Commander). Maintenance of communication log. Ensuring accessible communications for service users. Managing incoming enquiries. |
| Data Protection Officer | Protection of personal data during incident. Assessment of data security risks. Coordination of data breach response if applicable. ICO notification if required. Emergency access to critical records. Advising on lawful information sharing. Maintaining data protection compliance during response. |
| Logistics Coordinator | Procurement of emergency supplies. Coordination of transport and accommodation. Supplier liaison and emergency orders. Equipment sourcing and deployment. Financial tracking of incident costs. Administration support to incident management team. Documentation and record management. |
3.2 Incident Management Team Activation
For Level 2 incidents: Duty Manager coordinates response with support from relevant functional leads as needed (e.g., Health & Safety Officer for premises issue).
For Level 3 incidents: Full Incident Management Team convenes. Incident Commander determines meeting location and frequency (initially hourly, reducing as situation stabilises). Virtual meetings via video call acceptable if safe to do so.
3.3 Incident Management Team Meeting Structure
Each incident management team meeting follows this structure:
1. Situation Update: Operations Lead reports current status, service user welfare, immediate risks, resources deployed, and actions taken since last meeting.
2. Functional Reports: Each functional lead provides brief update on their area (safeguarding, health & safety, communications, data protection, logistics).
3. Decision-Making: Incident Commander leads discussion of options, decisions required, resource needs, and priority actions for next period.
4. Task Assignment: Clear allocation of actions with named responsible person and deadline for each task.
5. Next Meeting Time: Incident Commander sets next meeting time (or confirms meeting schedule if regular intervals agreed).
6. Documentation: All meetings documented in Incident Log with decisions, actions, and rationales recorded.
4. Communication Procedures
Effective communication is critical during business continuity incidents. This section provides step-by-step procedures for communicating with all stakeholders.
4.1 Internal Staff Communications
Step-by-Step Procedure:
STEP 1: Immediate Notification (First 30 Minutes)
• Duty Manager notifies all staff currently on duty via face-to-face briefing
• Provide: What has happened, current status, immediate actions required, where to get updates
• Answer questions and address concerns
STEP 2: Wider Staff Notification (First 2 Hours)
• Communications Lead activates staff cascade (see Appendix B for staff contact list)
• Contact off-duty staff via: Text message (for rapid dissemination), followed by phone call (for key personnel), email (for detailed information)
• Message content: Incident summary, impact on service, staffing requirements, reporting instructions, contact number for queries
STEP 3: Regular Updates (Throughout Incident)
• Frequency: Minimum twice per shift initially, reducing to daily as situation stabilises
• Methods: Staff briefings at handover, text message updates, notice board postings, email summaries
• Content: Situation update, changes to procedures, staffing arrangements, service user welfare, expected duration, questions answered
STEP 4: Stand-Down Notification
• Formal notification to all staff that normal operations have resumed
• Thank staff for their efforts and flexibility
• Provide details of any ongoing measures or follow-up actions
4.2 Service User and Family Communications
Step-by-Step Procedure:
STEP 1: Immediate Service User Communication (First 30 Minutes)
• Gather service users in common area if safe to do so
• Explain situation in calm, reassuring, accessible language
• Use visual supports, easy read materials if available
• Emphasise: They are safe, staff are here to help, what will happen next, how long it might last
• Allow time for questions and provide emotional support
• For service users with communication needs: Use their preferred method (Makaton, pictures, communication aids)
STEP 2: Family Notification (First Hour)
• Communications Lead coordinates family notifications using contact details from care plans (Appendix C)
• Priority order: Families of most vulnerable service users first, then all other families
• Notification method: Phone call (preferred), followed by email if unable to reach by phone
• Message content: What has happened, current situation, how their relative is (specific reassurance), actions being taken, expected impact, contact number for queries, when next update will be provided
STEP 3: Ongoing Updates to Service Users and Families
• Service users: Regular verbal updates at meals and during routine care interactions. Visual timeline if incident prolonged. Involvement in decisions about their care where appropriate.
• Families: Daily update during first 3 days, then frequency agreed with each family. Text message for brief updates. Phone call for significant developments. Email for detailed information. Face-to-face meeting if serious incident.
STEP 4: Post-Incident Follow-Up
• Inform service users and families when normal operations resumed
• Thank families for their patience and understanding
• Invite feedback on how incident was handled
• Provide emotional support to service users who found incident distressing
4.3 Commissioner and Local Authority Notifications
Refer to Section 13.2 of the Business Continuity Policy for notification matrix (what incidents require notification and within what timeframe).
Step-by-Step Procedure:
STEP 1: Determine Notification Requirement
• Incident Commander (or Duty Manager if Incident Commander not yet involved) reviews incident against notification matrix
• Identifies: Which stakeholders must be notified, timeframe for notification (immediate, same day, 5 days, routine)
STEP 2: Prepare Notification
• Use template from Appendix H
• Include: Date and time of incident, nature of incident, number of service users affected, immediate actions taken, anticipated duration and impact, support required (if any), named contact person for further information, next update schedule
STEP 3: Send Notification
• Immediate notifications: Telephone call followed by email confirmation
• Same-day notifications: Email during working hours, telephone out of hours
• Use contact details from Appendix D (External Stakeholder Contacts)
STEP 4: Document Notification
• Record in Incident Log: Who was notified, when, by what method, content of notification
• File copy of notification
STEP 5: Provide Updates
• Commissioner: Daily update during first 3 days of major incident, then as agreed or when significant developments occur
• Local Authority Safeguarding: As required by specific case or as requested by safeguarding team
4.4 CQC Statutory Notifications
Certain incidents require statutory notification to CQC under Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 18.
Notifiable incidents include:
• Death of service user (Regulation 16)
• Serious injury to service user (Regulation 18)
• Safeguarding incidents or allegations (Regulation 18)
• Outbreak of notifiable disease (Regulation 18)
• Events affecting the running of the service (Regulation 18) – includes: fire, flood, service disruption, inability to maintain safe staffing
Notification must be made without delay – typically within 24 hours for deaths, as soon as reasonably practicable for other notifiable events.
Notification Procedure:
1. Log into CQC Provider Portal: www.cqc.org.uk/provide
2. Select ‘Submit a notification’
3. Complete online notification form with full incident details
4. Print confirmation and file with incident documentation
5. If portal unavailable: Telephone CQC on 03000 616161
5. Incident Response Procedures
This section provides detailed step-by-step procedures for responding to specific business continuity scenarios. Each procedure follows the same format: immediate actions, assessment, response, communication, and recovery.
| IMPORTANT These procedures are templates. During actual incidents, use professional judgement to adapt procedures to specific circumstances. Service user safety is always the top priority. |
5.1 FIRE EMERGENCY
| SEVERITY LEVEL: 3 (MAJOR) Fire presents immediate life-threatening risk. Emergency services must be called immediately. Full evacuation may be required. |
IMMEDIATE ACTIONS (First 5 Minutes):
□ CALL 999 IMMEDIATELY – request Fire Service
State: ‘Fire at [full address]’, ‘[number] people in building’, ‘vulnerable adults present’
□ Activate fire alarm if not already sounding
□ Begin EVACUATION immediately following fire evacuation plan
• Assist service users to nearest safe exit
• Take grab bag containing PEEPs and emergency contacts
• Close doors behind you
• DO NOT use lifts
• DO NOT stop to collect belongings
• DO NOT re-enter building
□ Proceed to assembly point (see site plan in Appendix I)
□ Account for ALL service users and staff using PEEP folder
• Identify any missing persons immediately
• Inform fire service on arrival of any missing persons and last known location
□ Keep service users warm, calm, and together at assembly point
• Provide reassurance and emotional support
• Monitor for signs of shock or injury
• Request ambulance if any injuries
ASSESSMENT PHASE (5-30 Minutes):
□ Duty Manager takes command at assembly point
□ Liaise with Fire Service Incident Commander
• Confirm all persons accounted for
• Provide building information: layout, hazards, oxygen/medication storage, mobility of occupants
• Follow Fire Service instructions
□ Start Incident Log (Appendix A)
□ Notify Registered Manager immediately
□ Assess likely duration before re-entry possible
• Small fire, quickly extinguished: May re-enter within hours once Fire Service declares safe
• Significant fire: May require days/weeks before premises habitable
• Severe fire: Premises may be uninhabitable for months
□ Make immediate accommodation decision:
• If brief incident (<2 hours): Can service users wait at assembly point or nearby safe location?
• If extended incident (>2 hours): Alternative accommodation required immediately
RESPONSE ACTIONS (30 Minutes – 24 Hours):
□ Communications:
• Telephone all families (use contact list in Appendix C) – inform of fire, confirm service user safe, explain temporary arrangements
• Notify commissioner immediately (Appendix D contacts)
• Submit CQC statutory notification via Provider Portal
• Notify insurance company claims line (Appendix D)
• Brief all staff via text message with situation update
□ Alternative Accommodation (if required):
• Refer to Alternative Accommodation Register (Appendix G)
• Priority options: (1) Vacant beds in our other services, (2) Partner provider emergency beds, (3) Hotel/serviced accommodation, (4) Family homes (with consent)
• Contact providers in priority order until accommodation secured
• Arrange transport to accommodation
• Ensure staff accompany service users to provide continuity of care
□ Essential Items:
• If Fire Service allows brief escorted re-entry: Collect medications, care records, essential personal items
• If no re-entry possible: Emergency prescriptions from pharmacy (use Appendix E contacts), temporary care records created from backup, essential items purchased (clothing, toiletries)
□ Staffing:
• Recall additional staff to maintain ratios in temporary accommodation
• Brief staff on temporary arrangements and location
• Ensure 24-hour coverage maintained
□ Service User Welfare:
• Monitor service users for signs of trauma or distress
• Provide emotional support and reassurance
• Maintain familiar routines as far as possible
• Consider whether counselling support required
• Update care plans with temporary arrangements
RECOVERY PHASE (Days to Weeks):
□ Premises Assessment:
• Obtain Fire Investigation Report
• Commission structural survey if significant fire damage
• Obtain quotes for repairs/restoration
• Submit insurance claim with full documentation
• Determine realistic timeline for premises restoration
□ Long-Term Accommodation Planning:
• If restoration will take >4 weeks: Identify longer-term accommodation options
• Involve service users and families in decisions
• Update commissioners on accommodation plans
• Arrange personal belongings replacement
□ Post-Incident Actions:
• Conduct post-incident review (see Section 6.3)
• Review and update fire risk assessment
• Enhance fire safety measures if investigation identifies improvements
• Staff debriefing and counselling if required
• Thank staff for their response
KEY CONTACTS FOR FIRE INCIDENTS:
Emergency Services: 999
Registered Manager:
Health & Safety Officer:
Insurance Claims: [number]
Commissioner Emergency: [number]
Alternative Accommodation (see Appendix G)
5.9 PANDEMIC / INFECTIOUS DISEASE OUTBREAK
| SEVERITY LEVEL: 3 (MAJOR) Pandemics and outbreaks can affect service delivery for weeks or months. Requires sustained response with enhanced infection control, potential staff shortages, and restrictions on normal activities. |
IMMEDIATE ACTIONS (First 24 Hours):
□ Confirm outbreak/pandemic status
• Government pandemic announcement: Activate pandemic response immediately
• Service-level outbreak (2+ cases of infectious disease): Contact local Health Protection Team for advice
• Single case of notifiable disease: Notify Public Health England, local authority, CQC
□ Implement enhanced infection control measures IMMEDIATELY
• All staff don PPE: Fluid-resistant surgical masks, gloves, aprons (upgrade to FFP2/3 masks if aerosol-generating procedures)
• Increase hand hygiene frequency: Before and after every service user contact
• Enhanced cleaning: High-touch surfaces cleaned hourly, full deep clean daily
• Open windows for ventilation where possible
□ Isolate affected service users (if outbreak within service)
• Move symptomatic service users to single rooms if available
• If single rooms not available: Cohort affected service users together, separate from non-affected
• Dedicated staff for affected zone (no cross-over between zones)
• Post signage on doors indicating isolation precautions
□ Restrict admissions and visiting
• Suspend new admissions until outbreak controlled
• Restrict visiting to essential only (follow government/public health guidance)
• Screen all visitors: Temperature check, symptom questions, hand hygiene, PPE provision
□ Communications
• Notify all families immediately of outbreak/pandemic response activation
• Daily updates to families of affected service users
• Brief all staff on enhanced measures
• Notify local authority, commissioner, CQC
• Liaise with Health Protection Team for outbreak management guidance
□ Start Incident Log tracking:
• Number of affected service users and staff
• Symptom onset dates
• Testing results
• Infection control measures implemented
• Deaths if applicable
ASSESSMENT PHASE (24-72 Hours):
□ PPE Stock Assessment
• Count current PPE stock: Masks, gloves, aprons, eye protection, hand sanitiser
• Calculate daily usage rate based on enhanced IPC measures
• Determine how many days’ supply available
• If <14 days supply: Emergency order from suppliers (Appendix E)
• If supply chain disrupted: Contact local authority PPE coordination hub
□ Staffing Impact Assessment
• Count current staff absences due to illness/isolation
• Project potential absence rate (pandemic: assume 30-50% at peak)
• Identify which shifts cannot be covered with current available staff
• Activate staffing contingency measures (see below)
□ Service User Health Status
• Identify vulnerable service users: Severe learning disabilities, respiratory conditions, immunocompromised, elderly
• Ensure advance care plans up to date (DNACPR, treatment escalation plans)
• Liaise with GPs regarding high-risk individuals
• Implement twice-daily health monitoring for all service users
• Determine hospital admission thresholds in consultation with healthcare team
SUSTAINED RESPONSE ACTIONS (Ongoing During Pandemic):
□ Daily Infection Control Measures
• Morning briefing for all staff on current status and IPC requirements
• Twice-daily symptom screening of all service users: Temperature, cough, difficulty breathing, loss of taste/smell, other relevant symptoms
• Staff self-screening before each shift
• Any symptomatic person excluded immediately and tested if available
• Enhanced cleaning schedule maintained
• PPE audit: Spot checks of proper donning/doffing technique
□ Staffing Contingency Measures
• Extend shifts: Offer 12-hour instead of 8-hour shifts to reduce handovers
• Activate on-call staff and bank workers
• Request agency staff specifically trained in IPC
• Activate mutual aid agreements with partner providers (Appendix G)
• Redeploy managers and administrative staff to care duties
• Arrange staff accommodation on-site if available to reduce travel/infection risk
• Offer enhanced pay rates or time off in lieu to incentivise availability
• Support staff with childcare, shopping, transport if needed
□ Service User Wellbeing During Restrictions
• Establish video calling schedule for families (minimum twice weekly)
• Increase staff interaction time to compensate for restricted activities
• Meaningful activities within service setting: Arts and crafts, music, games, sensory activities
• Outdoor access where possible following distancing guidance
• Monitor mental health and emotional wellbeing closely
• Additional support for service users showing signs of distress or anxiety
• Maintain contact with advocates and ensure service user voice heard
□ Visiting Policy During Pandemic
• Follow current government guidance on visiting in care settings
• Balance infection control with human rights and service user wellbeing
• Essential visiting: End of life, severe distress without family contact, safeguarding
• Visiting protocols: Pre-visit health screening, PPE provision, designated visiting area, hand hygiene, time limits
• Window visits and garden visits as alternatives where appropriate
• Video calls facilitated by staff for those who cannot use technology independently
□ Vaccination Programme Support
• Liaise with GP practices/public health teams regarding vaccination clinics
• Facilitate vaccination of service users: Consent process, appointment attendance, post-vaccination monitoring
• Encourage staff vaccination: Information provision, appointment facilitation, address vaccine hesitancy
• Record vaccination status (with consent) to inform risk assessments
• Recognise vaccination as key preventive measure but respect individual choice
□ Regular Reporting and Communication
• Daily situation report to Registered Manager: Infection numbers, staff availability, PPE status, concerns
• Weekly report to commissioners (or as per contract requirements)
• Ongoing liaison with Health Protection Team during outbreak
• Regular updates to families (at least weekly, more frequently if service user affected)
• Staff briefings at each handover
RECOVERY PHASE:
□ Outbreak Declared Over (14 days since last case / pandemic restrictions lifted)
□ Gradual relaxation of measures
• Liaison with Health Protection Team regarding safe lifting of restrictions
• Phased return to normal visiting
• Resumption of community activities
• Maintain enhanced hand hygiene and cleaning as ‘new normal’
• PPE available for staff preference and seasonal illness prevention
□ Staff Wellbeing and Recovery
• Debriefing sessions for all staff
• Access to counselling services for those experiencing moral distress or burnout
• Thank and recognise staff efforts during pandemic
• Review and enhance staff support systems
• Address any ongoing anxiety or COVID-related trauma
□ Service User Recovery
• Support reintegration into community
• Address any social anxiety or fear developed during isolation
• Rebuild routines and community connections
• Review care plans and update goals
• Celebration and positive focus on return to normal activities
□ Organisational Learning
• Comprehensive post-incident review
• Update pandemic response plans based on lessons learned
• Review PPE stock levels and supply chain resilience
• Evaluate effectiveness of staffing contingencies
• Share learning with sector and commissioners
KEY CONTACTS FOR PANDEMIC RESPONSE:
Health Protection Team: [number]
Local Authority Public Health: [number]
GP Practices: [numbers]
NHS 111: 111
PPE Emergency Supplies: [number]
Staff Support Helpline: [number]
[PROCEDURES FOR SCENARIOS 5.2-5.8 AND 5.10-5.14 FOLLOW SAME FORMAT]
Each remaining scenario includes: Immediate Actions, Assessment Phase, Response Actions, Recovery Phase, and Key Contacts
6. Recovery and Stand-Down Procedures
Recovery begins as soon as the immediate crisis is stabilised. This section outlines how to safely return to normal operations and formally stand down business continuity arrangements.
6.1 Recovery Planning
The Incident Commander initiates recovery planning when:
• Immediate threat has passed
• Service users are safe and stable
• Essential services are functioning
• Path to normal operations is clear
Recovery Plan must address:
1. When normal operations can safely resume
2. What infrastructure or resource restoration is required
3. Whether temporary arrangements can be safely withdrawn
4. If any permanent changes to service delivery are needed
5. What support staff and service users require during transition
6.2 Stand-Down Decision
The Registered Manager (Incident Commander) has sole authority to declare stand-down. Stand-down criteria:
| Stand-Down Criteria | Evidence Required |
| Incident cause resolved | Premises safe, utilities restored, staffing adequate, outbreak controlled, etc. |
| Normal service delivery restored | Service users returned to usual accommodation, usual routines resumed, full activities programme restored |
| Emergency measures no longer required | Temporary arrangements stood down, emergency rotas ended, additional resources released |
| Service users and staff safe and well | No ongoing welfare concerns, emotional support needs addressed, health status stable |
| Stakeholders informed | CQC, commissioners, families notified of resolution |
6.3 Post-Incident Review
A formal post-incident review must be conducted within 2 weeks of stand-down for all Level 2 and Level 3 incidents.
Review participants: Incident Commander, Operations Lead (Duty Manager), all functional leads involved in response, frontline staff who responded, service user representatives or advocates (where appropriate)
Review questions:
1. What happened? Timeline and sequence of events
2. What worked well? Strengths and effective responses
3. What could be improved? Weaknesses and gaps identified
4. Were plans and procedures adequate? Did staff know what to do?
5. Were resources sufficient? Equipment, supplies, staffing
6. Was communication effective? Internal and external
7. Were service users adequately protected? Safety and wellbeing maintained?
8. What training needs identified? Skills or knowledge gaps
9. What changes needed to prevent recurrence? Risk controls
10. What updates required to this Plan?
Review outputs: Written report with findings and recommendations, action plan with responsible persons and deadlines, plan updates implemented, training needs addressed, good practice shared, staff recognition
7. Testing and Exercising Schedule
Regular testing ensures this Plan remains effective and staff are competent in emergency procedures. The following testing programme is mandatory:
| Test Type | Frequency | Purpose | Responsible |
| Contact List Verification | Monthly | Ensure all emergency contact numbers current | Duty Manager |
| Fire Drill | Every 6 months (minimum) | Practice evacuation procedures, test alarms, timing | Health & Safety Officer |
| Communication Exercise | Every 6 months | Test staff cascade and notification procedures | Communications Lead |
| Desktop Exercise | Annually | Tabletop scenario for management team, test decision-making | Registered Manager |
| Functional Exercise | Annually | Test specific procedure (utility failure, staff recall, etc.) | Duty Manager |
| Full Exercise | Every 3 years | Comprehensive test with external partners if possible | Registered Manager |
All tests and exercises must be: Scheduled in advance with participants notified, documented with evaluation report, followed by debrief identifying learning points, result in action plan to address gaps, inform plan updates and training
APPENDICES
| CRITICAL INFORMATION The appendices contain essential operational information required during incidents. Ensure all templates are completed accurately and updated regularly. |
APPENDIX A: Incident Log Template
This log must be started immediately when any Level 2 or Level 3 incident occurs. Record all decisions, actions, and communications in chronological order.
| Date | Time | Event/Action | Person | Outcome |
Continue on additional pages as needed. Logs can be hand-written during incident if IT systems unavailable.
APPENDIX B: Staff Contact List
| CONFIDENTIALITY This list contains personal contact details. Must be stored securely and only accessed for emergency purposes. Update immediately when staff join/leave or contact details change. |
| Name | Role | Mobile Number | Alternative Contact |
| Registered Manager | |||
| [Continue for all staff] |
Include: All permanent staff, regular bank staff, on-call managers, senior management team
Note: For key personnel (Registered Manager, Safeguarding Lead, Health & Safety Officer, Data Protection Officer), email addresses are included in the Alternative Contact column.
Staff Cascade Order: Senior managers contact duty managers, duty managers contact team leaders, team leaders contact their team members
APPENDIX C: Service User Emergency Information
For each service user, maintain current information:
• Full name and date of birth
• Emergency contact details (minimum 2 contacts with mobile and alternative numbers)
• GP name and contact details
• Critical medical information: Allergies, current medications, medical conditions
• Communication needs and preferences
• Mobility level and equipment required
• Specific anxieties or triggers during emergencies
• Personal Emergency Evacuation Plan (PEEP) summary
Keep printed copies in: Manager’s office, grab bag, with PEEPs
Update whenever: New admission, discharge, change in needs, contact details change
APPENDIX D: External Stakeholder Contacts
| Organisation | Department/Contact | Number / Email |
| CQC | National Contact Centre | 03000 616161 |
| Local Authority | [LA Name] Commissioning | [Number and email] |
| Local Authority | Adult Safeguarding Team | [24-hour number] |
| Local Authority | Emergency Planning | [Number and email] |
| Health Protection Team | [Local HPT] | [Number and email] |
| Insurance Company | [Company] Claims Dept | [24-hour claims line] |
| Legal Advisors | [Firm name] | [Number and email] |
APPENDICES E-J
The following additional appendices must be completed and attached to this Plan:
APPENDIX E: Supplier and Contractor Contacts – Pharmacy, food suppliers, PPE, utilities, emergency repairs, IT support, facilities management
APPENDIX F: Emergency Equipment and Supplies Inventory – Location and quantity of: First aid supplies, PPE stocks, emergency lighting, grab bags, communication equipment, generators/heaters
APPENDIX G: Alternative Accommodation Register – Contact details for: Our other services with potential capacity, Partner providers with mutual aid agreements, Hotels/serviced accommodation, Respite providers
APPENDIX H: Notification Templates – Pre-written templates for: CQC statutory notifications, Commissioner incident notifications, Family notification letters, Staff briefing messages, Media statements
APPENDIX I: Site-Specific Information – For each location: Floor plans with evacuation routes, Utility shut-off locations, Emergency assembly points, Site access codes, Nearest hospital, Local emergency services stations
APPENDIX J: Decision-Making Checklists – Quick reference checklists for: Evacuation go/no-go decision, Alternative accommodation selection, Staff recall activation, Plan invocation criteria, Stand-down criteria
END OF BUSINESS CONTINUITY PLAN
| PLAN MAINTENANCE This Plan is only effective if kept current. Review dates must be strictly observed. Contact details must be verified monthly. Report any inaccuracies immediately to the Registered Manager. |
For questions about this Plan or to report updates required, contact:
Registered Manager