Nurse Rostering Policy

Transcription

1 Nurse Rostering Policy Reference Number: 156 Author & Title: Elizabeth Cowdrey Clinical Co-ordinator Responsible Director: Director of HR Review Date: 2016 Ratified by: Claire Buchanan Director of HR Date Ratified: 05 October 2013 Version: 1 Related Policies & Guidelines: Maternity, Paternity & Parental Leave Policy Appraisal Policy Temporary Staffing Policy Working Life Balance Policy Managing Health and Sickness Policy Secondary Employment Policy Fixed Term Contract Policy Author: Elizabeth Cowdrey Page 1 of 22

2 Index: 1. Policy Summary 3 2. Policy Statements 4 3. Definition of Terms Used 4 4. Duties and Responsibilities 5 Employees 5 5. Procedure Rostering Rules General Study Leave Sick leave Skill mix The Production of Roster Poor Rostering Monitoring Compliance 15 Key performance indicators Review References 15 Appendix 1: Roster Process Quick Guide 16 Appendix 2: 12 Golden Rules for good Roster Management 17 Ratification Assurance Statement 20 Consultation Schedule 21 Equality Impact: (A) Assessment Screening 22 Equality Impact: (B) Full Analysis Error! Bookmark not defined. Amendment History Issue Status Date Reason for Change Authorised Author: Elizabeth Cowdrey Page 2 of 22

3 1. Policy Summary The Trust is committed to delivering safe, quality patient care by demonstrably effectively managing its resources, including its workforce. The purpose of this policy is to outline the parameters for effective rostering in conjunction with the Trust s electronic rostering system, RosterPro Central (RPC), to ensure that the Trust s patients are consistently cared for by staff who have been effectively and equitably deployed in line with service need, agreed staffing levels and, wherever possible, to reflect the requests of individual employee s with regards to the off duty, to ensure a work life balance. This policy also outlines those occasions when use of the Trust s flexible workforce may be considered, by clearly identifying where shortages in the workforce may adversely impact on the maintenance of appropriate staffing levels. This policy is designed to enable maximum utilisation of the RosterPro Central system to ensure that the Trust is able to adequately report upon the utilisation of its workforce to demonstrate its effective use of public monies in its delivery of patient care and compliance with the standards outlined by the Care Quality Commission (CQC), including Outcome 21: Records Essential Standards of Quality and Safety. The purpose of this Policy is: To ensure safe/appropriate staffing for all departments using fair and consistent off duties. To minimise clinical risk associated with the level and skill mix of nurse staffing levels. To give all staff the opportunity to self-roster in line with Improving Working Lives. However this should be set against the need to ensure safe levels of staffing to maximise the quality of patient care and reduce clinical and nonclinical risk. To improve planning of clinical and non-clinical non-effective working days (e.g. annual leave, sickness and study leave). To provide effective management of inpatient (hereafter referred to as nursing establishments), thereby driving efficiencies in the nursing workforce across wards and departments. To improve the utilisation of existing staff and reduce bank and agency spend by giving Managers and Senior Managers clear visibility of staff contracted hours. To improve monitoring of sickness and absence by department and/or individual, generating comparisons, identifying trends and priorities for action. To provide guidelines for the effective use of (RPC) when linking to ESR for purpose of paying staff. Author: Elizabeth Cowdrey Page 3 of 22

4 2. Policy Statements All new employees will be made aware of this Policy through the Induction Process and supported by Managers and Supervisors, through the management communication process. This Policy recognises the importance of engaging staff in designing an effective roster for the delivery of safe patient care and the maintenance of a work life balance. This Policy reflects the requirements of both the Working Time Regulations (1998) and the Trust s Work Life Balance Policy, which provides detailed guidance on flexible working options within the Trust. In addition, the utilisation of RosterPro Central recognises the need for impartial and equitable rostering to take place within the Trust, with time clearly allocated for essential professional development (Study Leave) and rest periods (Annual Leave) to ensure that the workforce is supported to have an appropriate work life balance and in line with service needs. 3. Definition of Terms Used Actual: The activity that took place during the shift, e.g. employee was sick when rostered to work & should be retrospectively recorded as such. Electronic Staff record (ESR): The NHS Staff record system used by Payroll. Fixed Pattern: A set working pattern which is replicated each week without exception. Headroom: Additional allowance within a budget equal to 22% to fund cover for the absence of substantive members of staff due to planned Study Leave, Annual Leave etc. Non-Effective Working Days: Days that staff are not available for the roster i.e. Leave, Study days, sickness. One Request: One day of duties/shift (e.g. Early or a Long Day where appropriate). Permanent: Employees who hold a substantive contract of employment with the Trust which has no end date and which has a set number of hours per week/year. Author: Elizabeth Cowdrey Page 4 of 22

5 Temporary: Employees who hold a fixed term contract with the Trust or workers employed through the Bank or an Agency to undertake work on behalf of the Trust. RReporter: The reporting element of RosterPro Central. RosterPro Central (RPC): The Trust s E-Rostering software system. Rroster: The self-service interface which allows staff to electronically submit a selfroster for approval. R-Link: The software that links RosterpPro Central and ESR to enable payments to be made against information entered into RosterPro Central. Variations in shifts: differing start and finish times to regular shifts. Weekend Shifts: Friday Night, Saturday day or night, Sunday day or night and Bank Holidays. Whole Time Equivalent (WTE): Full Time Work, 37.5 hours per week for Agenda for Change Staff; 40 hours per week (10 Programmed Activities) for Medical & Dental Staff.. 4. Duties and Responsibilities 4.1 Employees Employees are expected to make all reasonable efforts to support effective rostering by requesting those shifts which would support them to have an appropriate work life balance. Employees should use the (RPC) for off duty requests via RRoster. These requests will be considered in the light of service needs. Whilst the Department Manager will be flexible in trying to accommodate as many requests as possible, service requirements and equity for other staff members must be taken into account first before applying these. Fixed shift patterns are not considered as requests but may be part of an agreed flexible working pattern for review on a 6 monthly basis. Employees are responsible for ensuring that they appropriately plan their annual leave and study leave to ensure that they maintain their skills and receive sufficient rest throughout the year. However, employees are reminded that requests for annual leave and study leave are requests until they have been approved and no bookings or arrangements should be made until or unless their request is formally approved. Author: Elizabeth Cowdrey Page 5 of 22

6 Employees must provide at least 8 weeks notice should they wish to take more than one week s annual leave, and may not carry over more than one week s (pro rata) annual leave into the next annual leave year. Employees rostered for a shift wishing to change their off duty post publication may do so by a fair swap which should be made with another member of staff of the same grade that meets the Rostering Manager s approval. Inappropriate shift requests, not in line with the Working Time Regulations (WTR), will not be considered by the Department Manager. The Working Time Regulations require: - maximum working hours 48 hours per week averaged over 17 weeks - a rest period of 11 hours in each 24 hour period unless compensatory rest is provided as soon as is practicable - uninterrupted rest period of 35 hours (including the 11 hours daily rest) in a 7 day period or averaged over 2 weeks Employees are required to undertake any shift which is not contrary to their contractual status as it appears on the published roster; this includes long shift, short, split shifts, nights and weekends. 4.2 Roster Managers Roster Managers are individuals identified as the designated employee responsible for the development of a roster in line with this policy and within the timescales outlined in their relevant departmental protocol. 4.3 Department Manager (Budget Holder) The Budget Holder is responsible for ensuring that their expenditure does not exceed the allocated budget each month and year for their specified area(s). The Budget Holder is responsible for undertaking the monitoring and approval of the off duty on completion whether or not it is them who produce's the roster. The Budget Holder is responsible for the first line approval/rejection of all shifts where temporary staff are requested prior to those requests being escalated as per the Temporary Staffing Policy. The Budget Holder is accountable for the effective maintenance and management of the RosterPro Central system within their department, including the inputting of up to date information including actuals and reporting from the system to demonstrate effective use of resources. Author: Elizabeth Cowdrey Page 6 of 22

7 The Budget Holder is responsible for informing the System Administrator of any new starters/leavers/changes to staff terms and conditions as soon as possible. This information must be input on to (RPC) in advance of the change date by the System Administrator. The New Staff Details Form (Appendix 3) must be completed to ensure accuracy and the details must be cross checked against ESR. The Budget Holder is responsible for ensuring shifts are verified for payment within the Payroll deadlines in line with counter fraud guidelines. The Department Manager is responsible for ensuring that breaks are facilitated. 4.4 Staffing Solutions Staffing Solutions are responsible for the administration and maintenance of RPC for both temporary staff bookings and E-Rostering. Where a temporary staffing solution cannot be identified, Staffing Solutions are responsible for flagging this in a timely way to the relevant manager. Staffing Solutions are responsible for populating and updating (RPC) with all relevant staff information. 4.5 Matrons/Divisional Managers The relevant Matron/Divisional Manager will undertake the monitoring and approval of the Departments roster on completion and approve shifts where agency staff are requested and when requests for bank staff exceed the agreed set parameters as per Temporary Staffing Policy. 4.6 E-Rostering System Administrator The E-Rostering System Administrator is responsible for the training of all employees and Roster Managers in the use of (RPC) Rostered Staff Training: All rostered staff must be trained as part of their local induction to use the selfservice interface (RRoster). Staff must be shown how to make requests electronically for working shifts and planned absence in their permanent role. All RRoster users must be aware of: The priority weighting of requests The request notification period The request confirmation process Author: Elizabeth Cowdrey Page 7 of 22

8 4.6.2 Roster Managers Training: Roster Managers must be as a minimum trained to undertake: The development of a planned roster The confirmation of RRoster requests The notification of shortages The entry of actuals (what actually happened within the roster i.e. sickness) The accurate Verification of actuals to ensure accurate payment of staff via the ESR interface The use of RReporter, an electronic tool that can report on information entered onto (RPC) such as annual leave and sickness 5. Procedure Departments should have local department based protocols on staffing covering: Optimum staffing levels (number of staff) and skill mix (experience of staff required) by duty and by day and by night. Local process for annual and study leave requests. Local reporting requirements for sickness absence in accordance with Managing Health and Sickness Policy. Christmas and key bank holiday roster requirements. Department specific requirements and specific competencies/skills required of staff needed to be on duty at any given time. The maximum number of requests that can be considered for day s off/annual leave on any single date. How far in advance requests can be entered, in order to ensure that new staff joining the team have a fair chance of adding their requests. 5.1 Rostering Rules General All rosters must start on a Monday and should be produced ideally 6-8 weeks in advance. There is an assumption within the Trust that under Agenda for Change (AfC) the annual leave percentage in any Ward Nursing roster period will not exceed 14.2%. Statutory/mandatory training and sickness is set at 5.5% and an additional 2.3% is given for backfill which is to take account of additional AfC annual leave allowances. This equates to a headroom percentage of 22% for Ward Nursing budgets. This must be taken into account when producing a roster along with the less predictable non-effective working days such as Author: Elizabeth Cowdrey Page 8 of 22

9 maternity/paternity leave. If this is not considered, rosters may not be produced within budget Study Leave Study leave will be assigned in line with Mandatory and Statutory requirements and in line with local arrangements. All requests and authorisation of study leave should be recorded on the Learning Agreement form in the Access to Study Leave policy. The Department Manager should: Utilise the available number of study leave days in each roster. Prioritise mandatory training requirements for staff which may include induction, updates etc. Produce a roster ensuring staff have attended the required mandatory training Sick leave All sickness absences should be managed as per The Managing Health and Sickness Policy. If off-duty days follow on from sick days, the Department Manager or Deputy must be kept informed of recovery and unless notified, off-duty days will be re-classified as sick leave and must be entered as sick days within (RPC). If a member of staff has taken sick leave, it is good practice to work 1 week or 37.5 hours pro rata of rostered shifts before agreeing to work any additional hours, in order to allow time to recover Skill mix Each area must have an agreed total number of staff and skill mix for each duty. A joint decision on this must be reached with the Assistant Directors of Nursing/Assistant Divisional Managers/Matrons and Department Managers. Agreed numbers and skill mix must be achievable within the department budgeted establishment. Each area must have an agreed basic level of staff with specific competencies on each duty. In areas where the workload is known to vary according to the day of the week staff numbers and skill mix should reflect this. The off duty of senior staff must be compatible with their commitment to any bleep holder s/manager s rota. Author: Elizabeth Cowdrey Page 9 of 22

10 Consideration should be given to flexible working, however, this needs to be fair and equitable to all staff and should be regularly reviewed (refer to Trust Flexible Working Policy). Staff may be required to work a variety of shifts and shift patterns as agreed with their Department Manager. All staff if required to do so should work nights, unless by prior agreement with their Department Manager and a valid reason recorded in their staff personnel records. If there is a valid reason this must be reviewed on an annual basis and documented as above. Staff may work long shifts, short shifts, split shifts or a combination of both in order to meet the department and clinical requirements. Variations to these shifts may be worked but must be agreed with the Department Manager. A written record of the shift agreement will be kept and published as part of department policies for all variations in shifts, and will be reviewed as agreed. All shifts of 6 hours or longer must include a 30 minute unpaid break. Breaks must not be taken at the beginning or end of a shift, as their purpose is to provide rest time during the shift. This is a legal requirement in line with Working Time Regulations. There must be a designated nurse in charge for each shift who has been identified as having the required skills and competencies for a coordinating role or for delegation of those duties whilst maintaining accountability. Senior ward staff should work opposite shifts. Senior Sister/Charge Nurse should generally work 4-5 week-day shifts per week dependent on the specific needs of their department. The maximum number of consecutive standard day shifts recommended for staff to work is 5. Staff may work more than this by local agreement but Department Managers should ensure that staff have at least one whole day off every week, or two days a fortnight The maximum number of consecutive 12 hour shifts (days or nights) recommended for staff to work is 4. Where staff work 12 hour shifts, no more than 7x12 hour shifts should be worked in a 14 day period. Clinical staff may have a minimum of one weekend off per 4 week roster, in normal circumstances. Additional weekends off can be rostered if the ward requirements allow. Nights should be consecutive where possible. There should be a minimum of 48 hours off after being rostered a night shift. Senior Sister/Charge Nurse should not generally work nights except when specifically required to do so and with the approval of the Matron. Author: Elizabeth Cowdrey Page 10 of 22

11 Student nurses should be rostered as supernummery and with their mentor where possible and for 2 days per week as a minimum. If their mentor is unavailable, an associate mentor should be allocated. Annual leave must be allocated in hours for all members of staff. The Department Manager or designated Deputy must approve or decline all annual leave. Each department should calculate how many staff e.g. registered and non-registered nurses must be given annual leave in any one week. An agreed number needs to be set and adhered to (local policy) giving consideration to current department vacancies. Only in exceptional circumstances can annual leave be given over this agreed level. Staff should be made aware of the need to maintain this number constantly throughout the year. Should this number not be met, by way of requests, the Department Manager will allocate leave following discussion with the staff concerned. No holiday bookings or travel arrangements should be made until the Department Manager has sanctioned the annual leave requested. All staff are encouraged to book their annual leave in advance. It is an individual s responsibility to ensure all their annual leave is used before the end of their annual leave year. Annual leave must be booked or cancelled before a roster is published. Annual leave requested after this can only be given if staffing levels permit near to the day. Periods of annual leave of 1 week or greater must be booked at least 8 weeks in advance and authorised by the Department Manager. In principle, 50% of leave should have been taken by staff by the end 6 month period. It is expected that staff should only have 25% of their leave outstanding at the commencement of the final 3 months of the annual leave year except: By prior arrangement with the Line Manager; Due to the needs of the service; As a result of ill health/maternity leave. No holiday bookings should be made until the Department Manager has sanctioned the annual leave requested. All annual leave will be agreed by the Department Manager within 1 month or earlier if possible. Ad hoc annual leave must be agreed as soon as possible. Requests for leave during school holidays may present additional pressures. The set amount of leave whether annual or study leave etc. should not be increased during these weeks. Discussions should be encouraged between those requesting half terms off so that each member of staff has an equal chance of being granted annual leave. Annual leave requests for school holidays must be shared equitably. Author: Elizabeth Cowdrey Page 11 of 22

12 No more than 1 working week pro rata of annual leave may be carried forward to the following leave year and only in exceptional circumstances and only by agreement with the Department Manager. Where an employee works more than their contracted hours with the agreement of their Manager and consequently accrues Time Off In Lieu (TOIL) this must be taken within three months and should be recorded as TOIL on RosterPro Central by the Roster Manager Contracted hours not used over a 4 week roster period should not exceed 1% 5.2 The Production of Roster Staff should refer to (appendix 1) - Roster Process Quick Guide. The following steps should create a roster that is safe and cost effective and should be followed in conjunction with the 12 golden rules for rostering (Appendix 2). Assemble all necessary information. Assess the establishment for the department and review the process for recruitment. Assess and review all current custom & practice agreements Know and understand the local policies and best practice for planning rosters. Roster Managers should inform their team 3 days before the next roster is primed to enable any last minute requests. Roster Managers must check the self-roster requests on the RRoster. Roster Managers approve or decline the requests in line with the local process for the approval of working and non-working requests. Roster Managers enter fixed shift patterns before the production of the main off duty. Create the roster on (RPC), if this is not done by the Department Manager it must go to them prior to completion. All off duties should be composed to adequately cover 24 hours if required, utilising permanent staff proportionately across all shifts. Shifts with a high priority on (RPC) must be filled first, i.e. nights and weekends or locally recognised high priority shifts e.g. Theatre days. The Department Managers must check the roster does not exceed budgeted establishment. The Roster Managers must make any changes in consultation with staff members. The Department Managers check the proposed off duty for skill mix and cover. The Department Managers review the roster and highlight potentially unsafe shifts: 1. Vacant shifts which have no cover; i.e. shifts for which temporary staff appear to be needed; Author: Elizabeth Cowdrey Page 12 of 22

13 2. Any of the agreed parameters that have been exceeded, such as staffing levels or skill levels. The Department Managers and Matron/Assistant Divisional Managers discuss options of using appropriate staff from within the division/local area, rather than temporary staff, to cover gaps. Where there are more staff than available shifts for a roster period, the Department Managers will offer any extra staff to another unit within their area who may be short of staff. If this is happening regularly then the skill mix should be reviewed. Department Managers authorise the roster by completing it. Unfilled duties which may require temporary staff will be reviewed by the Department Managers to ascertain how many vacant shifts are in fact essential for the safe running of the department/service. The Roster Managers identify shortages and notify authorised planned bank shifts electronically to Staffing Solutions office. A single copy of the roster is printed for all staff to view at least 4-6 weeks prior to the roster start date. This will enable staff to better manage their personal arrangements. The Roster Managers review and adapt the roster in a timely manner whilst it is in use, notifying new additional authorised bank shifts electronically to Staffing Solutions. The Roster Managers enter actual information live and no later than one week following the roster being worked. 5.3 Poor Rostering Where a Roster Manager or Budget Holder consistently generate and/or approve rosters which are over budget or outside the agreed parameters with regards to skill mix, these rosters will be reviewed by the Deputy Divisional Manager/Assistant Director of Nursing, Matron and Department Manager who will complete a full departmental review including skill mix; current vacancies, clinical need/workload, following which recommendations may be made with regard to further training or a revised approach to rostering with a view to recouping the previous excess expenditure. Where issues persist, after the third month, continuing overspends will be reported to the Executive Management Team for consideration and review via the Divisional Managers. Any department highlighted by the Executive Management Team as consistently overspending on the staffing budget for 3 consecutive months will be notified to the RosterPro team. Any identified performance issues will be dealt with via the Trust Managing Performance process. Author: Elizabeth Cowdrey Page 13 of 22

14 At the point of escalation to the Executive Team, a process review will then be initiated by the RosterPro team. This will be a joint exercise between the Assistant Divisional Manager/Department Manager/Roster Manager/Divisional Accountant and the RosterPro team. The Department Manager will make available to the RosterPro team any existing flexible working arrangements already agreed and in place and information on when they were last reviewed. The RosterPro team will assess the last 4 rosters and discuss/assess with the Department Manager the criteria used for producing the roster. The next 4 week roster will be produced as a joint exercise and the performance reviewed. If there is a consistent reduction in overspend over the 4 week period, the Department Manager/Roster Manager will produce the next 4 weeks using the same criteria and again the performance will be reviewed by the whole group. If there is no improvement the RosterPro team will then produce the roster for the following 4 weeks and again the rosters will be reviewed against budget. If there is still no ability to produce a roster within budget, the RosterPro team will produce a report to go to the Executive Management Team highlighting the issues and reasons for overspend. These may include things like poor skill mix; high level of vacancies; inappropriate budget setting. Author: Elizabeth Cowdrey Page 14 of 22

15 6. Monitoring Compliance Compliance with these guidelines will be monitored through the E- rostering Project Board monthly meetings. Key performance indicators Key performance indicators and parameters will be set and monitored using (RPC) system reports. Monthly reports will be generated by Staffing Solutions and disseminated to senior management teams in medical and surgical division. Bi-Monthly reporting to nursing workforce planning group outlining performance, issues and risks Quarterly update to strategic workforce committee as part of the workforce strategy update. 7. Review This policy will be in effect for three years, unless otherwise stated. Prior to the third anniversary of the policy the author will be asked to review it and make any necessary changes prior to further ratification. 8. References Flexible workforce: strategic planning to reduce costs and improve quality. NHS Employers, November 2010 Controlling the use of temporary staff through large scale workforce change NHS Employers, January Electronic Rostering: Helping to improve workforce productivity.a guide implementing electronic rostering in your Workplace. NHS Employers, October 2007 Improving working lives. Department of Health,October 2000 Five high impact actions to effectively manage your temporary workforce. NHS Employers, April 2012 Standards for better health. Department of Health, July 2004 Working Time Regulations Agenda For Change Author: Elizabeth Cowdrey Page 15 of 22

16 Appendix 1: Roster Process Quick Guide Start All rotas are to be generated on Roster system All staff set up on roster including fixed shift patterns All Staff request shifts/annual leave Via RRoster 6-8 Weeks before requirement Duty Roster inputted to roster system Department Manager completes roster Identify Shortages and Notify electronically to bank Entry of Actuals inputted by Roster Manager live or before the end of each current roster week Entry of Actuals verified and signed off On completion of the rota period prior to payroll deadlines Manpower information generated And forwarded to HR/Finance Finish Author: Elizabeth Cowdrey Page 16 of 22

17 Appendix 2: 12 Golden Rules for good Roster Management 1. Off duty must be completed 6-8 weeks in advance of the start date. 2. Off duty must be available for staff to view 4-6 weeks in advance. 3. All off duties should be composed to adequately cover 24 hours utilising permanent staff proportionately across all shifts. 4. Shifts with a high priority on RosterPro Central must be filled first, i.e. nights and weekends or locally recognised high priority shifts. 5. All fixed pattern shifts should be entered before the production of the main off duty. 6. Off duty requests should be reviewed and agreed fairly whilst priority must always be given to service requirements rather than staff preferences. 7. The correct percentage of staff must be on annual leave for the period of the Roster whether requested or not. 8. Ward administration staff hours should also be entered as appropriate (as should any other hours that have an impact of the staff cost budget). 9. Following completion rosters must be reviewed by Department Manager to ensure: That the roster does not exceed budgeted establishment. That vacant shifts which have no cover; i.e. Shifts for which temporary staff are currently planned, or appear to be needed are appropriate and there are no potentially unsafe shifts. That option for using staff from within the local area/division has been looked at rather than temporary staff and overtime. That any of the agreed parameters have not been exceeded, such as staffing levels or skill levels. 10. Vacant shifts authorised for temporary staff cover have been notified to the Staffing Solutions office 4 weeks in advance. 11. Enter actual information live and at the latest the week following the roster being worked to effectively report on sickness and absences and adhere to payroll deadlines. Author: Elizabeth Cowdrey Page 17 of 22

18 12. The Roster must be reviewed in a timely manner whilst it is in use and any changes to the roster must be approved by the Department Manager/Deputy. Author: Elizabeth Cowdrey Page 18 of 22

19 Appendix 3 Staff Details For Roster-Pro Central Sections Marked with * are mandatory fields and must be completed Title Surname * Forename * NI DOB Sex Ward/Department * Post Title * Post Band * Start Date * Contracted Days Per Week NMC Pin No Contracted hours per week * Expiry Date Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Annual leave entitlement Fixed Shift Pattern Shift Bank holiday entitlement Hours Days Hours Days Office Use Only RRoster Access Date Set up Completed Publication date 19/07/2012 Authorship: Viki Webber Content Approved by: Liz Cowdrey Updated date 19/07/2012 version 1 Author: Elizabeth Cowdrey Page 19 of 22

20 Document Control Information Ratification Assurance Statement Dear Claire Please review the following information to support the ratification of the below named document. Name of document: Name of author: Rostering Policy Elizabeth Cowdrey Job Title: Clinical Co-ordinator I, the above named author confirm that: The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy; I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation; I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification; I will keep this Policy under review and ensure that it is reviewed prior to the review date. Signature of Author: Name of Person Ratifying this policy: Job Title: Claire Buchanan Director of HR Date: Signature: Date: 5 October 2013 To the person approving this policy: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building. The whole policy must be sent electronically to: ruh-tr.policies@nhs.net Author: Elizabeth Cowdrey Page 20 of 22

21 Consultation Schedule Name and Title of Individual Date Consulted Ward Managers June 2013 Matrons June 2013 Assistant Directors of Nursing June 2013 Roster Project Group Members June 2013 The following people have submitted responses to the consultation process: Name and Title of Individual Sharon Bonson Many Rumble Irene Richards Donna Little Neil Boyland Liz Richards Date Responded Name of Committee/s (if applicable) Date of Committee Author: Elizabeth Cowdrey Page 21 of 22

22 Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval. Person responsible for the assessment: Name: Elizabeth Cowdrey Job Title: Clinical Coordinator Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/No Comments Race Yes No Ethnic origins (including gypsies and travellers) Yes No Nationality Yes No Gender (including gender reassignment) Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Disability (learning disabilities, physical disability, sensory impairment and mental health problems) Yes No Is there any evidence that some groups are affected differently? Yes No If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No Is the impact of the document/guidance likely to be negative? Yes No If so, can the impact be avoided? Yes No What alternative is there to achieving the document/guidance without the impact? Yes No Can we reduce the impact by taking different action? Yes No If you answered NO to all the above questions, the assessment is now complete, and no further action is required. If you answered YES to any of the above please complete the Equality Impact: (B) Full Analysis Document name: Ref.: Issue date: Status: Author: Page 22 of 22