Rostering Policy & Procedure for Non Clinical Staff

Transcription

1 SH HR 02 Rostering Policy & Procedure for Non Clinical Staff Summary: The purpose of this policy is to ensure the effective utilisation of the workforce through efficient rostering and staff management Keywords (minimum of 5): (To assist policy search engine) Target Audience: e-rostering, Roster Policy, Rostering Process, Leave management, Roster Creator, Roster Approver All non clinical employees of Southern Health NHS Foundation Trust Next Review Date: March 2018 Approved by: Ratified by: JCNC SHFT Board Trust Board Date of meeting: 27/03/12 Date of meeting: 25/09/12 Date issued: July 2013 Author: Sponsor: Lara Fox, Programme for e-rostering & Temporary Resourcing Helen Albericci, e-rostering Team Andrea Glover, Deputy Director of HR 1

2 Version Control Change Record Date Author Version Page Reason for Change Lara Fox & Helen 1.0 Albericci Julia Hinton 2 5 Carers leave replaced by special leave as per Special Leave Policy Julia Hinton 2 8, 15, 16 Update in the way performance metrics provided to Senior Line s Julia Hinton 2 8, 9 Staff Bank Office changed to NHSP Julia Hinton 2 12, 13, Revised names of policy referred to Julia Hinton 2 14 Bank staff will no longer be managed through MAPS Healthroster Julia Hinton 2 16 Revised training requirements Julia Hinton 2 16, 17 Change in associated documents Tom Weeks 2 20 Revised quick guide process Julia Hinton 2 22 Revised example of a roster calendar 15/5/17 2 Review date extended from July to August /8/17 2 Review date extended to December /11/17 2 Review date extended to March 2018 Reviewers/contributors Name Position Version Reviewed & Date 2

3 CONTENTS Page 1. Introduction 4 2. Scope 4 3. Communication 4 4. Definitions 5 5. Duties/ responsibilities 6 6. Main policy content 8 7. Equality & Diversity Performance Management Training requirements Monitoring compliance Policy review Associated documents 16 Appendices A1 Healthroster Reports 17 A2a Quick Guide to Producing Rosters (Flowchart) 19 A2b Quick Guide to Producing Rosters (Table) 20 A2c Example of Roster Timetable 21 3 Checklist for Validating & Approving Rosters 22 4 Annual Leave Algorithm 23 5 e-rostering KPI Thresholds 24 6 Training Needs Analysis (TNA) 25 7 Equality Impact Assessment (EqIA) 26 8 Policy Implementation Plan 34 3

4 1. Introduction: SHFT recognises the value of its workforce and is committed to supporting staff to provide high quality services and patient care. Whilst acknowledging the need to balance the effective provision of service with supporting staff to achieve an appropriate work life balance, it is recognised that the Trust needs to be able to respond to changing service requirements. A flexible, efficient and robust rostering system is key to achieving this objective. 1.1 Purpose: The purpose of this policy is to ensure the effective utilisation of the non clinical workforce through efficient rostering by:- improving the utilisation of existing staff and reducing bank and agency spend by giving Unit/Team s clear visibility of staff contracted hours ensuring that rosters are fair, consistent and fit for purpose, with the appropriate skill mix, in order to ensure high quality services and standards of care providing accurate management information regarding the establishment thereby driving efficiencies in the workforce across units/departments improving the monitoring and management of sickness and absence by department and/ or individual, generating comparisons, identifying trends and priorities for action improving the planning of non-effective working days e.g. annual leave and study leave enabling the legal requirements of the European Working Time Directive to be balanced with the needs of service delivery providing a mechanism for reporting against set Trust Key Performance Indicators (KPIs) facilitating the payment of staff through data being entered at source ensure staff feel valued as a resource by ensuring a fair and equitable system to manage working time 2. Scope of Policy This policy is for use by all non clinical staff using MAPS Healthroster (or other rostering processes) and their line management 3. Communication Unit based local guidelines should be displayed and made readily available to all staff. The Trust policy is available on the intranet where it can be downloaded / saved to shared drives. Local guidelines and the SHFT Roster Policy & Procedure for Clinical Staff should be made available to staff as part of their induction 4

5 4. Definitions A number of terms are defined below to assist understanding:- Non-effective working days: relates to days that staff are not available for the roster i.e. annual leave, study days, management days, sickness, paternity leave, maternity and special leave, etc. One request: one shift, including rostered days off Temporary: Bank and other temporary staff e.g. agency staff Substantive: Staff who have a permanent or fixed term contract. Not bank or agency staff. Variations in shifts: differing start and finish times to regular shifts. Personal patterns are those specific to individual staff members and are contractual Contingent workforce: A member of staff recruited and managed by an external organisation who works in conjunction with functional teams but the contract is with the external organisation and is time-limited e.g. agency staff, NHS Professionals. Unit: ward, department or team Management days / Working days: office / administration days for nursing staff, usually ward / unit managers and deputies WTE: Whole time equivalent Planned roster: the initial roster produced four/six weeks prior to start date Headroom Allowance: the % built into budgets to cover planned absence. Within each Ward/Unit/Team, Headroom Allowance should be included in the unit budget to cover expected absence. The guidelines on the percentage of the staffing budget are as follows: Annual Leave 14% Sickness - 3% Working Day i.e. Management day, non-clinical day - 2% Study Days 2% Maternity / paternity leave and other special leave 3% However, in TQtwentyone all absence cover is calculated separately for each service area at a current rate of 21%. This is broken down into Annual Leave of 12%, Sickness 4%, Training 4% and Other 1%. Performance management: relates to the management of effective and efficient rosters through Roster Analysis, ensuring Key Performance Indicators (KPIs) are being considered before approval. 5

6 5. Duties / Responsibilities 5.1 Staff are responsible for: Attending work as per their duty roster Adhering to the requirements set out by the roster policy Being reasonable and flexible with their roster requests and being considerate to their colleagues within the rules set out by the Trust Notifying the unit manager of changes to a planned or worked shift, giving sufficient notice in advance of the planned shift Notifying the unit manager of changes to personal details, e.g. address, telephone number, etc. Ensuring that correct personal details are displayed on Employee on Line. Any inaccurate information should be immediately reported to the Unit and escalated to HR for any necessary ESR updates Requesting shifts, study days and annual leave using Employee On Line 5.2 Roster Approvers (Unit / Department s) are responsible for: ensuring that a quality roster is produced, maintained and finalised in line with the Key Performance Indicators and within specified timeframes ensuring that their expenditure does not exceed the allocated budget in all wards, units and departments the appropriate and effective staffing of the unit even if they do not directly undertake the task of producing the duty roster ensuring that there are enough staff in the right place at the right time, based on the agreed and funded skill mix, with the required competencies, to meet the needs of the service the level 1 and/or 2 approval of each roster: by approving rosters, Unit s are confirming that all entries are accurate and are a true record of hours/shifts worked. Under no circumstances should rosters be approved if inaccuracies are apparent. If rosters are knowingly approved with inaccurate information, this will be treated as fraud against the employer. The NHS Counter Fraud Service will be notified and this may be considered as gross misconduct in accordance with the Disciplinary Policy and Procedures which could lead to summary dismissal. nominating a Roster Creator and deputy and ensuring that these staff are appropriately trained the fair and equitable allocation of annual leave and study leave considering all roster requests from staff, ensuring fairness and equity in working patterns ensuring that all staff are aware of the local guidelines and Trust wide policies for rostering. Escalating issues to the project team or e-rostering office Informing the e-rostering team when system users or staff leave the unit or Trust: this will ensure accurate rosters with joiner and leaver dates communicated in a timely manner and system users identified and trained as required within units. 6

7 Protecting personal log in details (including passwords) to ensure security of the system and no unauthorised access. 5.3 Roster Creators are responsible for:- The creation of all rosters (in line with Key Performance Indicators). In their absence the designated deputy is responsible for roster creation. The day to day management of rosters including updating shift swaps, adding noneffectives, adding overtime or excess hours etc and ensuring these changes are completed in a timely manner Publishing rosters within specified timeframes Roster Creators may also be responsible for approving rosters as appropriate, in the absence of a nominated approver. By approving rosters, the roster creator/approver is confirming that all entries are accurate and are a true record of hours/shifts worked. Under no circumstances should rosters be approved if inaccuracies are apparent. If rosters are knowingly approved with inaccurate information, this will be treated as fraud against the employer. The NHS Counter Fraud Service will be notified and this may be considered as gross misconduct in accordance with the Disciplinary Policy and Procedures which could lead to summary dismissal Informing the e-rostering team when system users or staff leave the unit or Trust: this will ensure accurate rosters with joiner and leaver dates communicated in a timely manner and system users identified and trained as required within units. Protecting personal log in details (including passwords) to ensure security of the system and no unauthorised access. 5.4 Roster Administrators are responsible for:- producing the Trust wide Roster Calendar monitoring rosters on completion and reporting against KPIs, feeding back to the appropriate managers where better rostering could improve the utilisation of the clinical workforce ensuring the Healthroster system remains appropriately configured setting up new users for MAPS and Employee on Line with log in details and passwords adding and removing unit staff from the Healthroster system to reflect current establishment and HR changes providing support and ongoing training to the Healthroster users liaising with the Healthroster IT Support Team to resolve system issues as required. 5.5 Senior Line s are responsible for:- Approving and finalising the Unit/Team duty roster in absence of Roster Approver (where agreed) approving all shifts where temporary staff are requested providing guidance and support to the Ward/Unit/Team or designated other in the creation of duty rosters, using the Key Performance Indicators as a reference 7

8 Notifying the Divisional Management Accountant of any additional hours agreed above the required staffing resource. Regular review of unit/locality/divisional performance metrics found in Director Performance Review (DPR) Dashboards supplied by the Information Analyst Team. Producing analysis reports on staffing, expenditure and quality in their area of responsibility using DPR Dashboards Ensure recommendations made by the e-rostering Team/Project via reports are followed through and managed effectively Demonstrating efficiencies/benefits realisation in roster costs at specified periods through MAPS/Healthroster reporting systems 5.6 Division Management Accountant is responsible for:- agreeing and signing off the agreed staffing resource for each Unit/Team with the Divisional reviewing the KPIs that affect the use of resources with the Divisional to ensure that the non clinical workforce is being managed efficiently. 6. Main policy content 6.1 Producing Rosters The publication of working rosters will take place simultaneously across all departments in the Trust using Healthroster. A Roster Calendar will be produced by the Roster Administrator which will set timeframes for the rostering process. These must be adhered to in order to ensure accuracy of scheduling and pay. There will be 13 rosters per year. The Roster Calendar is available through the e-rostering web page All rosters must commence on a Sunday and published a minimum of four weeks in advance in accordance with the Trust Roster Calendar. This will enable staff to better manage their personal arrangements and to NHSP sufficient time to fill any vacant shifts. All rosters should be composed to adequately cover set hours. If staff are working non standard shifts such as late starts, this should be entered into the system to ensure accuracy of hours worked and avoid misinterpretation. A Quick Guide to Producing Rosters and example Roster Calendar is in appendix Validation and Approval The Roster Creator undertakes the Level 1 validation and approval process using the roster analysis information. The Roster Approver (Unit/Team ) completes the Level 2 validation and approval process and will approve the roster if it meets the defined parameters. The approval of rosters must take into account the roster analysis information and KPIs. 8

9 Within some teams, the Roster Creator and Approver may be the same person. However, it is recommended a deputy Creator/Approver is also nominated and trained. If a roster is rejected by the Roster Approver, an should be sent to the Roster Creator indicating why it was rejected, adding a note to the roster bar for reference. A checklist for validating and approving rosters is in appendix Changes to Published Rosters Whilst it is acknowledged that this task may be delegated, it is the responsibility of the Roster Approver (Unit/Team manager) to ensure that rosters are amended and kept up to date with additional shifts and non-effective work shifts i.e. sickness, no shows, study leave, etc. All changes made, after the roster has been approved, will be clearly marked on the system for audit purposes and if this has an impact on the booking of temporary staff, immediately communicated to NHSP. Shift changes should be kept to a minimum. Staff are responsible for negotiating their own changes once the roster is completed. These changes must be approved by the Unit/Team. All updates to the roster must be made as soon as practically possible after occurrence, taking into consideration Payroll deadlines (this includes changes to shifts, times of attendance, late finishes, sickness and annual leave). The actual worked roster must be verified by the Unit/Team weekly and finalised to ensure data is available for payroll. It is the Unit/Team s responsibility to ensure appropriate staff have access and are trained to make these changes. 6.4 New Staff New substantive staff (permanent and fixed term) may have a supernumerary period. This may be for a minimum of two weeks and will be assessed on an individual basis, taking into consideration the requirements of the department/directorate. New staff should work with their mentor during the supernumerary period, to ensure that their induction is completed and objectives are planned. After this they should plan to work with their mentor twice a week to complete objectives and competencies. 6.5 Staffing and Skill Mix An agreed and funded staffing baseline is essential to delivering high quality care. Each Unit/Team should have an agreed total number of staff and skill mix for each shift, approved by Senior Line Management. The establishment should be reviewed at least annually, with the budget setting and workforce planning process. Skill Mix and establishment reviews may happen more frequently if a need / risk is identified. 6.6 Flexible Working The Trust is committed to the principles laid down by the NHS national initiative of Improving Working Lives (IWL), i.e. work-life balance; flexible working and family friendly working (refer to Trust Flexible Working Policy). 9

10 The Trust will seriously consider requests for flexible working, but may on occasion be unable to agree to requests of individuals if their proposed working pattern cannot be accommodated within service needs. Service needs will take priority when creating a roster and achieving safe staffing numbers and an appropriate skill mix is essential. Flexible working arrangements must be documented and reviewed bi annually. 6.7 Requests All staff will use the Employee on Line system to make requests for all types of leave or absence (including study days/training courses). Unit/Team s are responsible for training their staff in the use of Employee on Line and ensuring they are using it for communicating Requests. Where staff have the provision of requesting specific shifts, a maximum number of requests will be calculated according to individual s hours of work (table 1) In extenuating circumstances staff may exceed their request allocation verbally to their line manager. Staff Hours per Week Total number of requests per 4 week roster hours 6 requests hours 5 requests hours 4 requests hours 3 requests 7 12 hours 2 requests 1 6 hours 1 request Please note: The granting of requests cannot be guaranteed All requests will be considered in the light of service needs and the Unit/Team will endeavour, as far as possible, to meet individual requests. However, it cannot be assumed that the roster will be developed to accommodate all requests, including high priority requests, as service needs will take priority. The Unit/Team is responsible for approving all requests. Personal patterns are not to be considered as requests. Fairness in the allocation of requests will be monitored using the appropriate league tables. 6.8 Shift Patterns The number of consecutive standard day shifts recommended for staff to work is 5. All staff must have 24 hours rest in every seven days OR 48 hours rest in every 14 days. Staff must not work more than an average of 48 hours per week over 17 week period, in line with the European Working Time Directive (EWTD). 6.9 Breaks During Shifts The NHS standard working week is 37.5 hours exclusive of breaks. 10

11 Contracted hours (whether full time or part time) are exclusive of breaks. All breaks are unpaid. NB. Where the Trust has agreed local arrangements for paid breaks in specific areas these agreements will be subject to regular six month reviews to ensure clarity and fairness All shifts of more than six hours and up to 12 hours must include a minimum of 20 minutes unpaid break. However, for staff well being and rostering purposes, we would recommend a minimum of a 30 minute unpaid break. The Ward/Unit/Team or person in charge and the individual are responsible for ensuring that breaks are taken. If breaks are unable to be taken at an agreed time due to clinical need, they should be taken as soon after this point as possible. Breaks should not be taken as TOIL. Breaks should not be taken at the end of a shift, as their purpose is to provide rest time during the shift Staff Redeployment During staff shortages it is accepted that staff may be required to work in other areas for short-term periods (eg. Two days) to provide a safe and efficient service. The Senior or other designated person for each area is responsible for the redeployment of staff within the division to meet service requirements. Out of hours, this decision will be made by the Clinical Site / On-call manager. It is accepted that in the event of a major incident or significant event; staff will be redeployed, taking into consideration their skills and competencies, to provide the best patient care. The Healthroster system will be used to manage workforce redeployment in the event of a major incident or significant event. If staff are required to move from their base SHFT will meet transport costs Non-Effective Working Days Annual Leave: Annual leave is allocated in hours for all AfC members of staff or as per terms and conditions of other Trust contracts. For staff rostered within MAPS Healthroster, annual leave must be calculated in hours. The Roster Approver (Unit/Team ) is responsible for approving all annual leave, in accordance with the Trust s guidance on annual leave. Each member of staff is responsible for booking their annual leave in accordance with the Trust s annual leave policy through Employee on Line. The trust target for percentage of staff on leave at any one time is 14%. However, it is recognised that in small departments such percentages are unachievable. Nonetheless the principle of not having a high volume of staff on annual leave at the same time applies. Each department should calculate how many staff must be given annual leave in any one week, with a defined limit (see appendix 4 for the annual leave algorithm). An agreed number will be set and must be adhered to. Staff should be made aware of the need to maintain this number constantly throughout the year. This number should not be met by way 11

12 of requests. The Unit/Team will allocate leave following discussions with the staff concerned. Annual leave needs to be booked in advance before rosters are approved ie at least eight weeks, except in exceptional circumstances. A maximum of 14 consecutive calendar days of annual leave can be requested. Any more than this will need special approval from the Senior. Annual leave provides individuals with a chance to relax and recuperate and the Trust actively promotes staff taking all of their statutory leave entitlement each year. Under the European Working Time Directive, all Trust employees must take a minimum of 28 days annual leave (pro-rata according to the number of days worked including bank holidays). A worker with a substantive contract may not work a flexible shift on bank on their nominated day of annual leave from the substantive contract (until the minimum annual leave entitlement has been taken). These Leave days may need to be evidenced by the employee in case of audit by the Trust as part of its responsibilities as an employer. In the event that operational reasons require the individual to attend work during annual leave, then the annual leave should be cancelled and taken at a later date. Guide for Duty Roster Creators Where possible, all leave should be planned and booked well in advance to support efficient workforce planning. Staff should take 25% of their leave each quarter throughout the leave year as follows:- 25% of leave taken 1st quarter, 50% next two quarters, 25% last quarter If annual leave is not booked and is to be taken ad hoc, it is an individual s responsibility to ensure it is used before 31 st March. In exceptional circumstances, a maximum of five days annual leave may be carried forward into the next annual leave year at 31 st March if authorised in advance by Line Management. Any other leave not taken will be lost. The carryover of leave should be considered in accordance with the Anuual Leave Policy and Special Leave Policies. Annual leave must be booked before a roster is planned. Annual leave requested after this can only be given if staffing levels permit near to the day. Annual leave requests that exceed the documented acceptable level for the department will not be approved School Holidays and Bank Holidays The amount of annual leave taken during school and bank holidays should remain within the 11% -17% range with exception of term time contracts. Discussions should be encouraged between those requesting time off so that each member of staff has an equal chance of 12

13 being granted annual leave. Annual leave requests for school holidays will be shared equally amongst those making requests Christmas and New Year This period will be treated as all other weeks in terms of leave. Each department will determine how the usual level of leave will be allocated using the annual leave algorithm. All requests for Christmas / New Year annual leave should be made by 1st October and agreed locally. Staff should be notified if their leave request has been approved by the end of October. Where Bank/Agency staff are utilised, to ensure cost effectiveness and continuity of care shifts over the Christmas / New Year periods should be filled by existing staff. In exceptional circumstances only, shifts may be sent to Bank. Fairness in allocating leave over Christmas and New Year will be ensured using the appropriate league tables within MAPS Healthroster. These leagues will enable s to monitor which staff have worked over the previous five years, enabling fair allocation of shifts over the Christmas and New Year period Study Leave Study leave will be assigned in line with Mandatory and Statutory requirements and the Trust s guidance on study leave. The Ward/Unit/Team should: o Utilise the available number of study leave days in each roster o Prioritise mandatory training requirements for staff which may include induction, updates, etc. o Produce roster ensuring staff have the required mandatory training In accordance with standard working days, study days/shifts should not exceed 7.5 hours. External courses funded by the Trust may exceed 7.5 hours if agreed by Line Management and recorded within MAPS Healthroster. For study days less than 7.5 hours, the shift times with MAPS Healthroster should be adjusted accordingly so that work time is not lost. Staff should make up these hours at the earliest opportunity (ideally that day if possible) Sickness Absence Sickness Absence will be managed in accordance with the Trust s Managing Sickness Policy and Procedure. Sickness must be communicated by telephone to the Unit/Team or nominated deputy as agreed in the Trust s Managing Sickness Policy and in line with local reporting arrangements. Following a period of short term sick leave a member of staff must not work any additional hours for a period of one week (i.e. any hours over their contracted hours). This period may be extended dependent upon individual circumstances following discussions with Occupational Health, HR and staff-side. There may be exceptional circumstances where, in order to meet the needs of the service, it may be necessary to allow a member of staff to work additional hours following a period of sickness. 13

14 Following a period of long term sick leave, the Unit/Team should seek advice from Occupational Health about when an individual may resume working additional hours. Sickness absence should be considered in accordance with the Managing Sickness Policy and Procedure Time Off in Lieu Any time worked by staff over and above their contracted hours should be sanctioned by the Unit/Team and recorded on the roster. Any time claimed back, via time owing must be recorded and approved by the Unit/Team. These shifts should be allocated on the roster as Non Effective Leave Time Owing and the include work time box must be unchecked Unplanned System Failure Action in the Event of System Failure To enable business continuity in the event of system failure, it is necessary that the roster is printed after each update. This will ensure that each ward always has hard-copy access to the most up to date version of the roster. In the unlikely event that staff are unable to access Healthroster the hard copy roster will be updated by hand until such time as the system is available. Unexpected system failure, requiring rollback to previous uncorrupted files update of situation will be sent ASAP after event. Make note of changes made to live system since the last backup, and make these changes on the paper roster. Maintain paper roster for ongoing changes. updates will be sent, including the time and date of system restore file View roster, make changes required. Contact Roster Administrator if support is required 6.13 Accessibility and reasonable adjustments for all employees Support will be provided for employees who, for any reason, cannot access this document in its current form or cannot provide a written statement of complaint. This may be provided by a colleague, Human Resources, a Trade Union or other employee representative. Employees who would prefer a more accessible easy read format of this document are advised to contact the Human Resources team. Alternatively, in cases where the employee has difficulty in reading or interpreting the written documents that make up this policy and any associated correspondence, or where English is not their first language, the employee's manager should arrange to have such documents explained orally. 14

15 Where the employee indicates that they would prefer to discuss the matter with a person of the same or similar age, gender, sexual orientation, disability, race, religion or belief; the Human Resources team will arrange this whenever possible. All the meetings scheduled throughout this procedure should be arranged in venues which are accessible for all employees and where the meeting will not be disturbed and will remain confidential. The meeting may, therefore, possibly be held away from the workplace. Reasonable adjustments may be needed for an employee with a disability (and possibly for the employee representative). For example the provision of a support worker or advocate with knowledge of the disability and its effects. 7. Equality & Diversity SHFT is committed to the principles of Equality & Diversity. No patient or any other person referred to in this policy will receive unfair treatment on the grounds of age, colour, ethnic or national origins, religious and political beliefs, gender, marital status, sexual orientation, disability or trade union membership 8. Performance Management 8.1 Key Performance Indicators Baseline assessments of KPI s should be undertaken by the Trust for each ward prior to the implementation of Healthroster. Progress towards meeting the Trusts target performance measures will be reported to the monthly performance meeting and by exception to the Director of Clinical Delivery & Excellence. A top level report will be provided to the Trust Board and all Senior Management throughout the Trust Service area s/directorates to update the organisation on the efficiency and effectiveness of the clinical workforce. It is the Roster Creator/Approvers responsibility to regularly check and cross reference KPI s on the e-rostering web page. 8.2 Performance Reports A number of reports can be produced by Healthroster to support performance management (Appendix 1). These should be generated on a monthly basis by either the Senior Clinician/Divisional for distribution on a monthly basis and reviewed alongside DPR Dashboards at relevant divisional and Locality meetings. 9. Training Requirements 9.1 Core Training for Roster Creators & Approvers (for full implementation of system) or Core Training for New Starters (those learning the system post system implementation). 9.2 Refresher Workshops 9.3 Employee on Line e-learning 15

16 10. Monitoring Compliance 10.1 E Rostering data (including Key Performance Indicators, Safety, Skill Mix, Efficiency, Leave Management and Staff Leagues) will be collected and analysed by the E Rostering Project Team, Ward/Unit s and Modern Matrons on a monthly basis E Rostering Rule Breakages will also be monitored on a monthly basis to ensure all staff are treated fairly in the allocation of shifts and leave management Data will also be available through DPR Dashboards distributed to Locality s and Divisional Directors as required (quarterly reviews recommended). Data reports will be escalated to Board Level as appropriate 10.4 Subsequently, the data will be used to inform and improve policies, as well as provide recommendations for improving working practices. Human Resources will provide relevant reports, based on this data, to the Board and the Joint Consultative and Negotiating Committee (JCNC) The policy and processes contained in the documents will be in place for three years following approval of a review and amendments. An earlier review can take place should exceptional circumstances arise resulting from this policy; in whole or in part, being insufficient for the purpose outlined in Section 1, and/or if there are legislative changes 11. Policy Review The policy will be reviewed in July Associated Documents This policy must be read in conjunction with the following documents:- NHS Terms and Conditions of Employment which includes guidance for annual leave Managing Sickness Policy and Procedure Annual Leave Policy Special Leave Policy & Procedure Maternity, Paternity and Adoption Leave Policy Preceptorship guidelines Healthroster documentation Bullying and Harassment Policy and Procedure Staff Handbook Performance and Development Review Policy Operational policy for discharge, bed and clinical site management Any other relevant ward / unit documents 16

17 Appendix 1: Healthroster Reports Report Master group Roster reports Report Name Additional duties Cancelled duties KPI Roster Effectiveness by grade type Roster Effectiveness Annual report Staff unsocial hours Unfilled duties Unfilled duties projected bank costs Details of report Usage of report Report access Frequency If duties have been allocated over agreed demand Duties that have been cancelled High level report, containing: % of lost contracted hours % of over contracted hours % of additional duties % of unfilled duties % of non-effective working days % of requests % of contracted staff by WTE % of vacancies % of bank requests on a weekend/night duty % of lost / over contracted hours, vacant shifts Fairness and efficiency graphs Allocation of duties by person, number of unsocial shifts allocated Number of vacant shifts (also in hours) Based on number of vacant shifts and bank costs Divisional Business Meeting/Performan ce Review Divisional Business Meeting/Performan ce Review Divisional Business Meeting/Performan ce Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review / Financial Management Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area Senior Clinician / Locality/Area / Management Accountant Monthly Monthly Monthly Monthly Quarterly Quarterly Monthly Monthly Sickness reports Sickness report by day of the week Sickness report by day of the week Sickness trends for Wards / individuals As above with further detail Divisional Business Meeting/ Performance Review / Trust Board Divisional Business Meeting/ Performance Senior Clinician / Locality/Area / Trust Board / HR s Senior Clinician / Locality/Area / HR Monthly Monthly 17

18 Unavailability report and person Review s Sickness report by grade type Overall % based on registered / unregistered grading Sickness report by person Sickness report by person and reason Sickness report by reason Unavailability breakdown by grade type Unavailability breakdown by person Unavailability breakdown by week Sickness report for each person Sickness report for each person and reason Overall sickness by reason Details % unavailable e.g. sickness, maternity leave As above, by person As above, by week Divisional Business Meeting/ Performance Review / Trust Board Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review / Trust Board Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Divisional Business Meeting/ Performance Review Senior Clinician / Locality/Area / Trust Board / HR s Senior Clinician / Locality/Area / HR s Senior Clinician / Locality/Area / HR s Senior Clinician / Locality/Area / Trust Board / HR s Senior Clinician / Locality/Area / HR s Senior Clinician / Locality/Area Senior Clinician / Locality/Area Monthly Monthly Monthly Monthly Monthly Monthly Monthly 18

19 Appendix 2a: Quick Guide to Producing Rosters Where required, open e- request period using Employee On Line Request period available for staff to complete, with a stated closing date Analyse, approve and publish roster Analyse roster to assess effectiveness, make relevant changes to ensure within defined parameters e.g. unavailability and approve. Pass roster approved by Unit/Team Leader to Senior Clinician for 2 nd level analysis and approval. Work and Manage roster Enter changes on to Healthroster as they occur e.g. shift swaps, sickness, leave, and time owing. Week 1 Week 3 Week 4 Week 4-8 Week 9-12 Produce roster Close requests, print staff hours report, produce roster, using all available hours. Lead Time Fill shortfalls - Send vacant shifts to be filled to NHSP where required. Once filled cancel vacant shift in MAPS with a reason of NHSP. Enter all approved changes to planned roster, swaps, late leave requests, etc Finalise Roster Finalise worked roster for payroll (Monthly) 19

20 Appendix 2b: Quick Guide to Producing Rosters Process Use the Trust standard roster dates Open the roster for shift requests using Employee On-Line (in units where shift request system utilised). Close the roster to requests, approve requests and add / approve any other non-effective periods (annual leave, study days etc ) Run the autoroster Fill any remaining staff hours with vacant shifts, adjusting duty times where necessary. Review roster analyser data, ensuring good balance of staff across 4 week period and all staff hours are used. Staff unavailability should be within the specified parameters, if it is not the roster should be reviewed and amendments made before reviewing the analysis data. Approve the roster ready for second level approval Roster Approver/Unit to review roster and Roster Analyser to ensure all staff hours used and metrics are within defined parameters Roster Approver/Unit to complete second level approval Publish roster If there are still gaps in the roster, plan to fill them with temporary staff where required or appropriate Responsibility Roster Creator Roster Creator Roster Creator Roster Creator Roster Creator Roster Creator Roster Creator Roster Approver/Unit Roster Approver/Unit Roster Creator Unit 20

21 Appendix 2c: Example of Roster Timetable 4 Week Work Period ACTION DEADLINE ACTION DEADLINE ACTION ACTION Pay Period DEADLINE From To Open New Roster Close to Staff Requests Run Auto Roster Full Approval by Print & Display Finalise Unit From To Unit Finalised 31-Mar Apr Feb Feb Feb Feb Mar-13 Weekly 01-Apr Apr May Apr May Mar Mar Mar Mar Mar-13 Weekly 01-May May Jun May Jun Apr Apr Apr Apr Apr-13 Weekly 01-Jun Jun Jul Jun Jul Apr May May May May-13 Weekly 01-Jul Jul Aug-13 21

22 Appendix 3: Checklist for Validating and Approving Rosters Action The Roster has been created 4 weeks before off duty commences Check All shifts have an agreed total number of staff and skill mix as shown by the establishment templates The off duty is within the budget for the ward No more than 5 standard shifts days/nights are worked consecutively to a maximum of 7 if specifically requested Hours carried forward are as near to 0 as possible Roster Effectiveness Indicators Fairness and Safety Indicators Check Effectiveness Tab for: Over Contracted Hours are as near to 0 as possible Lost Contracted Hours are as near to 0 as possible The reason for Additional Shifts Overtime Hours are as near as possible to 0 Requests are not greater that the requirements of the policy according to hours worked. Shifts with Warnings are acceptable The policy rules are not being broken by viewing my Roster Stats and reviewing the Rule/Violation column The reason for rules being broken have been reviewed Annual Leave is evenly distributed and is consistent with the % calculated for the unit EWTD is considered and not violated Requirements v Availability Staff Unavailability there should be 0 warnings Filled Shifts there should be 0 Optional and Additional Shifts unless agreed prior to the creation of the roster Personal Patterns are still valid (confirm every 3 months) 22

23 Appendix 4: Annual Leave Algorithm A Unit has 21 WTE. The percentage of staff on annual leave at any time is 14.0% Therefore: 21 x = WTE You would need to try and allocate approximately 3 members of staff per week on leave to achieve balance over the year. The number of WTE in post can be viewed in Healthroster by using the details pane under My Staff Details. Please note: This number is based on WTE in post; therefore as staff join and/or leave you will need to recalculate the above. 23

24 Appendix 5: E Rostering KPI Threshold Table Group Headroom Effectiveness Key Performance Indicator Unit Amber Threshold Red Threshold Trust Target Overall Downtime Limit Percentage 25% Overall Downtime Limit Percentage 22% (exc. parenting) Sickness % Percentage 3 7% 3% Annual Leave Activation Percentage 7 14% (staff required of each grade type before min and max thresholds examined) Annual Leave Minimum Percentage 11% n/a % Annual Leave Maximum Percentage 17% n/a % Study Day % Percentage 5% 7% 2% Working Day % Percentage 3% 4% 2% Parenting % Percentage 5% 7% 3% Time worked % Percentage 100% 100% Staff Utilisation Hours Rostering Over Contracted Hours Percentage 1.5% 2% Effectiveness % (4 weekly) Unused Contracted Percentage 1.5% 2.0% Hours % (4 weekly) Additional Duties (Hours, Count weekly) Bank / Agency Usage - Percentage 5 10 Hours % Bank Fill Rate % Percentage n/a n/a Duties Assigned To Count 0 3 Wrong Grade Type Bank Required Duty Hours Hours Fairness Duties with Warnings % Percentage 20% 30% Requested Roster % Percentage 30% 40% Granted Requests Count Establishment Percent of Demand Bank Requested % Percentage 5% 10% Post Vacancies WTE WTE 3% 5% Redeployed People Hours Hours Staff With Working Restrictions % Percentage 30% 40% Effort Total Rostered Duty Hours Hours Total Number Of Rostered Duties Count Budgeted Whole Time Equivalent Hours Hours Cost Cost of budgeted WTE Pounds Cost of planned WTE Pounds % Over Budget Percentage 5% 10% 24

25 APPENDIX 6 LEAD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Deputy Head of LEAD or LEAD Strategic Education Lead) before the policy goes through Policy Board. Training Programme Frequency Course Length Delivery Method Trainer(s) Existing workshops agreed with LEaD and already in place. No further training needs identified at this stage. As specified within training objectives As specified within training objectives As specified within training objectives As specified within training objectives Directorate Division Target Audience Adult Mental Health As specified in current training objectives MH/LD ICS Learning Disabilities Older Persons Mental Health Specialised Services TQtwentyone Adults Children s & Wellbeing As specified in current training objectives As specified in current training objectives As specified in current training objectives As specified in current training objectives As specified in current training objectives As specified in current training objectives Recording Attendance As specified within training objectives Strategic & Operational Responsibility As specified within training objectives Corporate Services Dental All (HR, Finance, Governance, Estates etc.) As specified in current training objectives As specified in current training objectives

26 APPENDIX 7 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on different groups within the community For guidance and support in completing this form please contact a member of the Equality and Diversity team on Name of policy/service/project/plan: SHFT Rostering Policy & Procedure for Non Clinical Staff Policy Number: SH HR 02 Department: HR Lead officer for assessment: Date Assessment Carried Out: Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Provide brief details of the scope of the policy being reviewed, for example: Is it a new service/policy or review of an existing one? Is it a national requirement? Answers / Notes The purpose of this policy is to ensure the effective utilisation and management of the non clinical workforce through efficient rostering. The policy will be delivered by team/unit managers, senior management, HR and the e-rostering team The intended outcome is full compliance by all staff with the policy This policy relates to all non clinical staff within SHFT who are utilising or captured within the e- Rostering system. The policy is new and has been developed form the HCHC rostering policy for clinical staff

27 APPENDIX 7 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool 2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions 2.1 What is the equalities profile of the team delivering the service/policy? The team fully reflects the diversity profile of the organisation 2.2 What equalities training have staff received? Trust equality & Diversity training within staff induction and as required thereafter 2.3 What is the equalities profile of service users? Services are available to all staff 2.4 What other data do you have in terms of service users or staff? (e.g. results of customer satisfaction surveys, consultation findings). Are there any gaps? 2.5 What engagement or consultation has been undertaken as part of this EIA and with whom? Data, research and information that you can refer to Staff Database LEaD Database N/A Training satisfaction questionnaires which are complied and reviewed quarterly. Use of Employee on Line Quality Audits Specialist reports available within MAPS Healthroster See next answer

28 APPENDIX 7 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool What were the results? 2.6 If you are planning to undertake any consultation in New Starter Packs and the future regarding this service or policy, how will action lists you include equalities considerations within this? Data gathering sheets Post Training Sign Offs Satisfaction questionnaires Quality Audits Training In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this.

29 APPENDIX 7 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool Age Positive impact (including examples of what the policy/service has done to promote equality) The system promotes fairer rostering, promoting staff well being and compliance with EWTD. Negative Impact Apprehension around new IT systems possibly resulting in lack of engagement Action Plan to address negative impact Actions to overcome problem/barrier Comprehensive training programme with flexibility to cater for all levels of IT knowledge. Resources required e-rostering Team Responsibility Target date Project Ongoing Reports and Staff Leagues are available (e.g. for nights worked, weekends worked, Christmas periods worked, on calls etc ) so that managers can ensure an even spread of the less desirable shifts and Regular workshops available through LEaD SHFT e- Rostering User Groups quarterly for staff support network e-rostering Team e-rostering Team Project Project Ongoing Ongoing

30 APPENDIX 7 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool working periods. Allows staff greater control, visibility and self management of leave and non effectives through Employee on Line (EOL). E-rostering Champions nominated and available for support e-rostering Champions Project Ongoing Improves payroll accuracy Reduces administration time spent on timesheets and less room for error Disability a/a Accessibility Workplace Assessment Unit/Team Prior to core training Gender Reassignment a/a Access to Work Scheme Marriage and Civil a/a