Roster Management. Target Audience. Who Should Read This Policy. All staff where rostering can be used to support the delivery of Trust services

Transcription

1 Roster Management Who Should Read This Policy Target Audience All staff where rostering can be used to support the delivery of Trust services Version 1.0 October 2016

2 Ref. Contents Page 1.0 Introduction Purpose Objectives Process Rules of Effective E-Rostering Procedures connected to this Policy Links to Relevant Legislation Links to Relevant National Standards Links to other Key Policies Roles and Responsibilities for this Policy Training Equality Impact Assessment Data Protection and Freedom of Information Monitoring this Policy is Working in Practice 15 Appendices 1.0 Additional Rules of Effective Rostering Roster Management Report - Key Performance Indicators Rostering Compliant Questionnaire Roster Management Timetable Generation of Rosters Roster Management Timetable Payroll (Monthly) 26 Version 1.0 October

3 Explanation of terms used in this policy Trust - Black Country Partnership NHS Foundation Trust Unit - Unit/Ward/Department/Area Service Manager - Individual with line manager responsibility for the Manager of Unit Manager - Unit Manager with overall, financial responsibility for the unit/roster Roster Creator - Individual responsible for producing the roster e.g. Team Leaders/ Deputy Team Leaders or Unit Manages Unavailability - Staff that are unavailable for rostered shifts due to non-clinical activity i.e. annual leave, study days, sickness, other non-clinical work. This is also classed as non effectives Request - Employee generated request for a non-working day or annual leave Personal Pattern - A formal agreement of a set pattern of shifts for a given individual in line with Flexible working arrangements (IWL) Over Contracted Hours (XX-) - Hours worked above those contracted to be worked over a 4 week period Under Contracted Hours (XX) - Employee working less than contracted hours over a 4 week period Additional Duties - Any duties allocated that are in excess of the agreed budgeted staffing establishments for the unit Unfilled Duties - Duties within the agreed budgeted staffing establishments that have not been filled within the produced roster Finalisation - this task is undertaken by the Unit Manager. This process locks down the shifts worked, absences, sickness and any non-effectives for a roster, to enable reporting & payment Headroom - Percentage added onto the budgeted establishments to allow for non-effectives (Unavailability) Overtime - Time worked in addition to one's normal working hours Version 1.0 October

4 1.0 Introduction In order to meet demand placed upon our services, the Trust is required to make arrangements to efficiently and effectively manage the deployment of its workforce. In doing so it must continue to deliver care which is of the highest quality to its service users. This policy for the management and production of staff rosters will be used in conjunction with the Trusts MAPS Health Roster System. The rostering principles within the policy can and should be applied to all staff groups being rostered across Black Country Partnership NHS Foundation Trust. The Trust supports the principles embedded in the Health and Wellbeing Agenda regarding work/life balance, flexible working and family friendly working, set against the need to ensure safe levels of staffing to maximise the quality of patient care and services and reduce clinical and non-clinical risk. Flexible rostering supports flexible working practices already adopted in many areas of the Trust. Relevant policies to be read in conjunction with this policy e.g. flexible working can be found on the Trust s Intranet. 2.0 Purpose This policy also aims to: Establish the Trust s requirements for rostered staff who deliver Trust services. Outline the rostering rules to facilitate clinically safe and effective rosters Detail principles which underpin the approach to rostering across the Trust Outline the responsibilities of managers and members of staff to produce flexible, fair and equitable rosters across the Trust Outline procedures to be followed for the formulation, production and authorisation of duty rosters 3.0 Objectives The overarching principles and objectives underpinning the Trust wide electronic rostering system are to maximise the effective management of the Trusts staffing resource in order to: Enhance opportunities for continuous improvement in patient experience over a 24 hour period by delivery of a high quality and clinically safe service Ensure safe staffing for all departments using fair and consistent rosters by making use of the clear visibility of staff contracted hours and availability Minimise clinical and non-clinical risk by managing and scheduling for the appropriate level and skill mix of staffing Ensure that for Clinical areas the required number of in-patient beds are safely staffed to meet elective and emergency demand Ensure that for non-clinical areas the required numbers of staff are rostered to allow safe and effective services to meet Trust-wide Standards and optimum working practices Provide effective management of staffing establishments, thereby driving efficiencies in the workforce across all services Improve planning of clinical and non-clinical working days e.g. annual leave, sickness and study leave Improve monitoring of sickness and absence across the Trust, generating comparisons, identifying trends and priorities for action. Minimise bank & agency usage whilst maintaining safe staffing Version 1.0 October 2016

5 Provide continuous improvement in the utilisation of existing staff and a reduction in bank and agency spend, making use of best practice identified both locally and nationally across all wards and departments, both clinical and nonclinical 4.0 Process This policy is for use by all areas within the Trust to assist with the production of optimised best practice and safe staffing rosters using the 'Trust's healthroster System. Annually, the Manager/ Service Manager, in conjunction with the finance lead for the area is responsible for the sign-off of a safe and financially achievable roster template, clearly indicating the precise numbers of staff required on each shift. The Manager is responsible for ensuring that expenditure does not exceed the approved establishment budget in all wards/clinics, units and departments under their control. Once agreed the ward/department template may not be changed without authorisation from each of the following: The Manager Service Manager Finance Manager Bank and Rostering Rostering templates and budgeted establishments will be reviewed at monthly Manager meetings with the Finance lead for the area. To assist in this review, a roster management report will be produced by the Bank and Rostering Team for each group Service Manager. Effective roster management and efficient use of resources will form part of each manager s objectives and appraisal. The Manager is responsible for nominating a Roster Creator and deputy and ensuring that they receive appropriate training to undertake the task. The Manager is ultimately responsible and accountable for the 1 st line approval and subsequent publication of rosters that are compliant with the principles set out in this policy and in line with the Roster Management Timetable (Appendix 4). Rosters will need to be produced in line with the Roster Management timetable (Appendix 5). The Escalation process will apply if rosters are submitted/ generated late (Appendix 4). The Manager is responsible for ensuring that the roster is appropriately prepared for production (Appendix 5) by updating the following information where necessary: Continuing episodes of unavailability e.g. sickness, maternity, study leave etc. Annual leave to be taken within the roster period, with the aim of 15% of staff on leave every week, with the manager being held to account for non-compliance. Other headroom factors to be considered also when producing rosters. Changes to staff details e.g. new starters, leavers, change in hours or working patterns (Input by HealthRoster Team) Formal changes in flexible working agreements, occupational health restrictions in line with agreed review periods. Version 1.0 October

6 As rosters are worked, any necessary changes should be made in line with Management guidelines. Rosters should be updated and maintained daily for the previous day to avoid error. If rosters are printed they must reflect the electronic roster at all times. Rosters must be finalised daily for the previous day in preparation for payroll. If not completed on time, this may be detrimental to staff. Any time worked over contracted hours or time-owing taken MUST be recorded and approved by the unit manager on Health-Roster. Any unused contracted hours must be rostered into the shift pattern of any affected individuals within the current roster period, providing the hours equate to a full shift. Managers will perform a six-monthly Rostering Audit of their area in conjunction with the Bank and Rostering Team and Finance Managers. Bank/agency staff MUST only be used if there is no alternative method of covering duties using substantive staff contracted hours. Staff with unused hours within the rota should be requested to fulfil these hours on another unit before the use of bank and agency. Where possible this should be arranged in advance in order to allow reasonable notice of the move to be given. Where substantive staff have been absent due to a period of sickness and are on a phased return into the workplace, they must not undertake Excess Hours/Overtime or undertake Bank Shift assignments during the phased return period. For further information please contact Human Resources. If unfilled duties cannot be filled using substantive staff contracted hours then approval must be gained for the following: Excess hours for substantive staff Bank Staff Agency staff The following authorisation list is provided for Information: Staff Group Proposed Working Approval Required Part-Time staff Where their contracted Unit / Ward Manager hours and additional hours are equal to or less than 37.5 hrs. per week Substantive Staff ( Full To be paid overtime rate Service Manager or Above Time Staff (up to and including Band 7 Staff) Bank Staff All Proposed Shifts Unit / Ward Manager Agency Staff All proposed shifts Service Manager or Above Staff employed on a substantive or bank contract by the Trust, are not permitted to work on an Agency basis at any Trust site. Version 1.0 October

7 4.1 Rules of Effective E-Rostering The following provides rules for managers to assist in the management and production of optimised and safe rosters. Further supporting detail can be found in Appendix Service Needs All rosters will be patient quality and safety/demand focused and all decisions made with patient safety and service needs prioritised. The Trust supports the principles embedded in Improving Working Lives (IWL) regarding work life balance, flexible working and family friendly working. These principles however must be set against the need to ensure on-going and consistently safe staffing levels to maximise the quality of patient care and reduce clinical and non-clinical risk. The Trust will seriously consider formal requests for flexible working, but has a right to decline them if the request cannot be accommodated into the service needs. These must be agreed in line with the Flexible Working Policy and reviewed regularly by the Unit / Ward Manager as per policy. Achieving adequate staffing numbers and skill mix is the main priority. All other factors are secondary to this including requests and working preferences. Staff may request like for like swaps via the Manager if there is no negative impact on roster effectiveness. The Trust will continuously review best practice both locally and nationally in order to benefit from continuous improvement best practice and service innovations for the benefit of patients and staff alike. The Trust will undertake a bi-annual Safe Staffing Audit which will inform the skill mix and safe staffing numbers in clinical areas, in line with current guidance Unavailability (Non-Effectives) i.e. Unavailability must be controlled and measured within approved budgeted allowances. Budgeted allowances as a percentage (%) of contracted hours are as follows: Annual Leave Annual Leave optimum level is 15% of each grade requirement each week (11% to 17% leverage) and should be appropriately apportioned based on skills mix requirements for each week. [Whilst these tolerances provide guidance it must be noted that consecutive months at each end of the tolerance scale may lead to safe staffing and patient quality issues and budget overspend]. In addition, staff should aim to take leave consistently throughout the year to provide regular breaks from work. Staff should aim to take 25% of their leave each quarter. Employee Online provides staff with a measure of this for their information and guidance. For more details please contact the Bank & Rostering Team Version 1.0 October

8 Sickness Sickness levels should be at 5% or below the current Trust target figure (Trust Target for Sickness is 4.5%) Training Study leave levels should be no greater than 5% Other Maternity levels greater than 1% will have an impact upon service delivery. Other non-clinical duties such as management days, meetings and supernumerary duties for staff other than the Unit Manager should be no greater than 1%. All unavailability should be no greater that 25% (Headroom) Any rosters with non-effectives (Unavailability) above 25% will have a negative impact on the unit s ability to meet service needs and therefore should be escalated to service managers as part of the roster performance management process. Managers will find it helpful to calculate the appropriate whole time equivalent (WTE) figures for both Annual Leave and Study Leave for each period, in order to balance allocation and distribution of these fairly and equitably across the year Budgets All rosters must be produced within previously approved budget limits. Any instances of not achieving this will be escalated to the appropriate Service manager. The healthroster system provides an operational guide as to the measure of roster cost against roster budget. The roster cost and roster budget within the system is a measure based on mid-point of salary plus enhancements with no on-costs included. To minimise the risk of overspend and produce rosters that are cost effective the principles of this policy must be followed. In particular attention should be paid to the allocation of shifts at night and weekends to substantive staff and avoid the use of bank/agency staff. In addition to overall spend against budget, (agreed and signed off by the unit manager and the departmental finance manager), detailed information regarding the use of bank/agency staff and variable pay should be measured taking into account all other KPIs to ensure these staffing options are being used only when absolutely necessary and appropriate Safety Safety is measured through the following metrics: Unfilled Roster This is a measure of shifts that are required to be filled to maintain safe staffing levels, but where coverage has not been possible Shifts without Charge Cover This is a measure of shifts that are required to be filled to maintain safe staffing levels, but where coverage has not been possible. Version 1.0 October

9 Shifts Missing Skills This is a measure for those units that have a skill mix requirement that is more specific than registered/unregistered ratio. Examples of this would be a MAPA skill mix Skill Mix This is a ratio measure of registered and unregistered staff to allow units to be measured against their skill mix requirements Effectiveness Effectiveness is measured through the following metrics: Over and Unused Contracted Hours A measure of how many hours over and under the total contracted hours, have been used by the unit over the roster period. Over contracted hours should be kept to a minimum to ensure appropriate and safe working patterns for staff. Unused contracted hours should be identified to ensure they are used across the Trust site as an alternative to variable pay and temporary staffing. In each circumstance, the manager must ensure that a plan is in place to achieve a zero balance within two further roster periods Additional Duties An additional duty is one that has been allocated to an individual in excess of the budgeted establishment and despite the safe staffing levels for that shift having already been reached. Additional duty hours are direct roster cost pressure/ inefficiency and should be removed through the alternative use of staff substantive hours such as a staff move to cover an unfilled duty on another unit or allocation of mandatory study leave. Ability to create additional duties can be restricted if needed or directed by the service manager Wrong Grade Type This is a measure of the number of shifts that have been set to a required grade type that have been allocated to an individual of a different grade type. The impact of this on skill mix and cost should be analysed and appropriate action taken to resolve issues Fairness The following metrics can provide a measure of the fairness of the roster: Requests Percentage (%) Requested shifts should be recorded on healthroster, a review of requests should be regularly undertaken, so these can be monitored. A measure of the % of roster that is made up of staff requests. This metric should be used to assess the potential impact of staff requests on the roster effectiveness and to provide a measure to staff of their influence on roster production Duties with Warnings Percentage (%) A measure of the % of the roster where the unit s rules have been not been able to be accommodated. Further analysis of the occurrence of specific rule breakages Version 1.0 October

10 should be used to identify if the roster configuration is relevant to the service needs and also the impact of staff preferences on the ability to produce an effective roster. 5.0 Procedures connected to this Policy Standard Operating Procedure 1 (SOP 1) Safe Staffing Escalation 6.0 Links to Relevant Legislation Equality Act 2010 Equality Act came into force on 1 October 2010 and brought together over 116 separate pieces of legislation into one single Act to provide a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act simplifies, strengthens and harmonizes the current legislation to provide a new discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society. Employment Relations Act 2004 The Employment Relations Act 2004 is mainly concerned with collective labour law and trade union rights. It implements the findings of the review of the Employment Relations Act 1999, announced by the Secretary of State in July The centrepiece of the 1999 Act was the establishment of a statutory procedure for the recognition of trade unions by employers for collective bargaining purposes Human Rights Act 1998 One of the main laws protecting human rights in the UK, it contains a list of 16 rights (called articles) which belong to all people in the UK, and outlines several ways that these rights should be protected. These rights are drawn from the European Convention on Human Rights, which were developed by the UK and others in the aftermath of World War II. The Human Rights Act may be used by every person resident in the United Kingdom regardless of whether or not they are a British citizen or a foreign national, a child or an adult, a prisoner or a member of the public. The Human Rights Act has two main aims, to promote a culture of human rights by making sure that basic human rights underpin the workings of government at the national and local level and enabling access to human rights here at home, instead of only being able to go to the European Court of Human Rights It does this by placing a legal duty on all public authorities, including NHS organisations and staff and mental health tribunals carrying out public functions, to respect and protect human rights in everything that they do. This means that public authorities have legal responsibilities for respecting, protecting and fulfilling human rights. This duty is important in everyday situations because it enables individuals to challenge poor treatment and to negotiate better solutions. Trade Union and Labour Relations (Consolidation) Act 1999 The Act's effect is to: Define trade unions and state they are the subjects of legal rights and duties Protect the right of workers to organise into, or leave, a union without suffering discrimination or detriment Version 1.0 October

11 Provide a framework for a union to engage in collective bargaining for better workplace or business standards with employers Protect the right of workers in a union to take action, including strike action and industrial action short of a strike, to support and defend their interests, when reasonable notice is given, and when that action is "in contemplation or furtherance of a trade dispute" Part Time Workers Prevention of Less Favourable Treatment Regulations (2000) The Part-Time Workers (Prevention of Less Favourable Treatment) Regulations came into force on 1st July The Regulations make it unlawful for part-time workers to be treated less favourably than full-time workers. This means the following: 1. Part-time workers should receive the same hourly rate as full-timers. A lower hourly rate should only be given if it can be justified on objective grounds, e.g. performance related pay 2. Part-time workers should receive the same hourly rate for overtime once they have worked more than the normal full-time hours 3. Part-time workers should not to be excluded from training simply because they work part-time 4. Part-time workers have the same entitlement as full-timers to maternity / parental leave and annual leave on a pro rata basis. The calculations used and the length of service required should be the same for both part-time and fulltime staff 5. Part-time workers have the same entitlements to pensions, perks and sick pay on a pro rata basis as full-timers. This will include the same entitlement to bonuses, shift allowances etc. 6. Entitlement to written reasons for any treatment they consider less favourable under the Regulations. The employer must respond to a request by an employee for a written statement within 21 days Fixed Term Employees Prevention of Less Favourable Treatment Regulations (2001) This legislation, enacted on 1 st October 2002, was introduced to comply with the EU directive on Fixed Term Work. Its aim is to prevent employers from treating employees on fixed term contracts less favourably than similar permanent employees. It also imposes limits on the use of successive fixed term contracts. 6.1 Links to Relevant National Standards CQC Regulation 18: Staffing The intention of this regulation is to make sure that providers deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements described in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations To meet the regulation, providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times and the other regulatory requirements set out in this part of the above regulations. Staff must receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. They should be supported to obtain further qualifications and provide evidence, where required, to Version 1.0 October

12 the appropriate regulator to show that they meet the professional standards needed to continue to practise. CQC Regulation 19: Fit and Proper Persons Employed The intention of this regulation is to make sure that providers only employ 'fit and proper' staff who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity. To meet this regulation, providers must operate robust recruitment procedures, including undertaking any relevant checks. They must have a procedure for ongoing monitoring of staff to make sure they remain able to meet the requirements, and they must have appropriate arrangements in place to deal with staff who are no longer fit to carry out the duties required of them. Employing unfit people, or continuing to allow unfit people to stay in a role, may lead CQC to question the fitness of a provider. If CQC considers that a breach of this regulation is also be a breach of another regulation(s) that carries offence clauses, then we can move directly to prosecution without serving a Warning Notice. For example, in situations where the care and treatment is provided without the consent of a person using the service or someone lawfully acting on their behalf, and where it is unsafe, does not meet the person's nutritional needs, results in abuse, or puts the person at risk of abuse. 6.2 Links to other Key Policies Annual Leave policy The aim of the policy is to provide a uniform and equitable approach to the calculation of annual leave and bank holidays entitlements. A key principal is that to encourage appropriate work life balance employees should plan to take their full entitlements wherever practicable to do so year on year. Flexible working policy This policy has been developed to provide an operational framework through which managers will respond to requests from employees seeking to change their working arrangements. All reasonable efforts should be made to facilitate and accommodate flexible working requests where such arrangements are practicable and workable. Special Leave Policy This policy has been developed to provide an operational framework through which managers will respond to requests from employees requiring Special Leave. All reasonable efforts should be made to facilitate and accommodate such requests where such arrangements are practicable and workable. Managing Attendance Policy The aim of this policy is to provide a supportive framework in which sickness absence is managed ensuring adherence with relevant legislation. Version 1.0 October

13 7.0 Roles and Responsibilities for this Policy Title Role Key Responsibilities All Staff Adherence - Attend work in accordance with their duty roster - Adhere to the requirements set out in this policy - Ensure they are reasonable, flexible and considerate to colleagues within the rules set out by the Trust - Formally notify their Manager of any changes to personal details. E.g. address, telephone numbers etc. The Manager will then complete the necessary paperwork, thus allowing ESR and healthroster systems to be updated Managers Implementation - Ensure effective optimisation of staffing resources which is vital to ensure rosters are able to safely meet patient and service needs, and are efficient, and cost effective. This is required as Staff costs account for approximately 70% of total Trust spend - Ensure that their expenditure does not exceed the approved budget in all wards/unit - Ensure that the staffing/shift requirements indicated on the rota or electronic template are agreed within this budgeted establishment - Ensure all staffs individual rosters meet the best practice guidance referred to in this policy - Responsibility and accountability for the updating of establishments as identified in Healthroster and the safe staffing of each department lies with the manager, even if she/he does not undertake the task of producing the duty roster - Ensure the roster is approved by both the manager and the service manager/ matron responsible for the designated area Workforce Development Group Director of Workforce & Organisational Development - Approve all temporary staffing requests in line with this policy Responsible - Oversee the implementation of a systematic and consistent approach - Approve all policies and procedures that relate to their subject matter or area of practice - Provide exception and progress reports to the Quality and Safety Steering Group Executive Lead - Lead responsibility for the implementation of this policy - Allocation of resources to support the implementation of this policy - Ensure any serious concerns regarding the implementation of this policy are brought to the attention of the Board of Directors Version 1.0 October 2016

14 8.0 Training What aspect(s) of this policy will require staff training? Roster Management Which staff groups require this training? New Managers responsible for rostering Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? No, staff will receive specific training in relation to this policy where it is identified in their individual training needs analysis as part of their development for their particular role and responsibilities If no, how will the training be delivered? Internally face to face Who will deliver the training? Bank and Rostering Team How often will staff require training As and when required Who will ensure and monitor that staff have this training? Workforce Committee 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext or EqualityImpact.assessment@bcpft.nhs.uk 10.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. Version 1.0 October 2016

15 11.0 Monitoring this Policy is Working in Practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Each Manager is responsible for ensuring patient quality and safe staffing levels in line with this policy. All areas will be expected to efficiently manage the deployment of their workforce in line with Trust Performance Indicators. 4.0 Process Monitoring and approval of all rosters on completion by the roster creator and approve all shifts where additional staff are requested. Roster performance will be measured in line with the following categories: Safety Budget Effectiveness Unavailability Fairness Health and Wellbeing Service Managers Monthly Executive Team Managers and Service Managers will be accountable for the management of performance against KPI s. Minutes of meetings/ action plans signed off/ copies of performance reports Where the above categories are not achieved, an analysis of the reasons for this will be provided by the Manager and an appropriate action plan developed to ensure compliance is achieved within an agreed timescale. A performance report relating to each service area in respect of performance against KPI s will be produced The HealthRoster system provides a suite of reports that the Manager and the Service Manager may access to aid roster production, operational management and performance management. Responsibility for accessing this information on a regular basis should be agreed within management teams. Version 1.0 October 2016

16 Appendix 1 Additional Rules of Effective Rostering The following policy is for operational use during the roster preparation, production and management processes. This has been put in place to ensure consistency of approach and practice throughout the Trust to encourage effective and safe roster production. Skill Mix and Shift Allocation Blank rosters for requesting days off should be made available a maximum of three months in advance. This is to ensure that any template changes and service reconfigurations are able to be actioned in a timely fashion. Annual leave may still be requested in line with the Annual Leave Policy. Each unit has an approved staffing establishment which is reviewed annually and/or at the point of service reconfiguration. This must be agreed by the Service Manager / Bank & Rostering Manager in consultation with the Finance Manager and should be maintained within budget at all times. Each unit should have an agreed level of staff with specific competencies on each shift, i.e. the ability to take charge (which is mandatory) and MAPA training requirements. In areas where the workload is known to vary according to the day of the week staff numbers and skill mix on the roster template should reflect this. There MUST be an RMN on every shift in charge who has been identified as having the required skills and competencies for a supervisory / co-ordinating role. Band 6 s and above should work opposite shifts. Unit managers should not be rostered on unsociable hours / weekend shifts unless this is necessary to maintain the service and has been approved by the Service Manager. Ward Unit Managers should be supernumerary on rosters. All ward / unit staff must be included on the roster (excluding nursing students and others not on the Trusts payroll). For staff that are working supernumerary shifts i.e. (Return to work, Preceptorship) a non-effective should be recorded within health-roster with a note explaining the reason for this. Consideration should be given to formal requests for flexible working in line with the Trust s Flexible Working Policy. Managers must ensure that individual working hours do not exceed an average of 48 hours per week over a 26 week reference period unless they have formally opted out of the Working Time Regulations, using the appropriate process for doing so. Opt out forms must be signed off by the Service Manager of the Individuals substantive workplace area. The Bank & Rostering Manager must authorise any bank staff Version 1.0 October

17 working arrangements, taking into account other work contract and previous shifts worked. All rostered shifts must include a minimum 20 minute uninterrupted unpaid break for each shift where >/= 6 hours are worked, with a minimum 60 minute unpaid break on The Manager /identified individual in charge for each shift is responsible for ensuring that breaks are facilitated. Breaks must not be taken at the end or beginning of a shift or not taken at all, as their purpose is to provide rest time during the shift. In exceptional circumstances, where the service need requires that staff work through their break then this must be recorded by the Manager in order that compensatory rest may be taken at a later time in accordance with Agenda for Change. Week day shifts are defined as Monday to Friday (Between the hours of 8:00am to 8:00pm) Week night shifts are defined as Monday to Thursday (Between the hours of 8:00pm to 8:00am) Weekend shifts are defined as Friday night, Saturday day or night and Sunday day and night shifts. Night shifts will be followed by at least 2 days off before further shifts are worked. Days and night shifts should not be mixed with the same week. If contracted hours and standard shift times mean that the exact contracted hours cannot be worked each week, staff may be required to flex their work time each week. Time Owing / Time Owed should be reviewed and managers should be accountable for these hours. Overtime/Excess Hours must not be assigned to any staff unless they have worked their contracted hours for the roster period. Where staff accrue time owing this should be managed in line with Agenda for Change terms and conditions. Examples where Time Owing/Time Owed may occur Swapping shifts that are not like for like i.e. night to day shifts Non Effectives times i.e. Training/annual leave differing to standard shift times Too many non-effectives i.e. exceeding headroom levels of annual leave Taking on additional duties to cover deficits, then unable to recoup hours in future rosters It is the responsibility of the ward/unit manager when checking generated rosters that all hours have been worked or alternatively they are happy with the amount of under or over hours incurred by any ward individual before rosters are worked. Version 1.0 October

18 It will be the responsibility of the Roster Administrator to keep the rostered ward/unit managers informed of any updated time owing/time owed, which has resulted from changes being made on the ward after rosters have been worked. This information will be sent to ward managers before rosters are finalised for payment approval. Overall responsibility for time owing/time owed will be the responsibility of the ward/unit manager. However, the Centralised Rostering Team will need to be informed of decisions made in order to either offset the deficit or recoup hours when producing future rosters. The Centralised Rostering Team will continue to report on these changes, rolling on Time owing/time owed where applicable. The threshold for Time Owing/Time owed will be to a maximum of 8 hours either way. This offers a degree of flexibility for both staff and managers to cover shortfalls in shifts, and that these additional hours/under hours should be recouped (taken as TOIL or worked respectively) within a 3 month period. Trust Rules In order to maintain equity and consistency across the Trust and to comply with Working Time Regulations rules, a number of rostering rules need to be applied across the Trust: Where a sequence of night shifts has been worked, this must be followed by a minimum of two rest days, to facilitate adequate rest. The number of day off requests across the Trust will be set at four in a four week roster period and must be showed as requests on the roster. Where substantive employees have worked a night shift, they must not then go on to work a Bank day shift the following day. This breaks the Working Time Regulations and potentially leads to an unsafe working environment. No more than three long days must be worked consecutively. No more than four night shifts must be worked consecutively. No more than ten working days must be worked without days off. Ward / Unit Managers should be mindful of long days rolling over onto future rosters, to avoid breaking this rule Rosters will ensure individual staff at least 1 free weekend in three weeks No long days will be worked on Christmas Day, Boxing Day or New Year s Day. Consideration should also be given to staff working long days on other public holiday s, were applicable. Study days will reflect the number of hours worked on a day shift (e.g. 7 or 7.5 hrs). per session unless a longer or shorter period is indicated by the specific course length. Annual Leave hours for a single day will equate to the normal shift length (less the unpaid break) of an individual. Version 1.0 October

19 Shifts given a high priority on ward template must be filled first, i.e. nights and weekends. It should not be routine to use bank permanently on night shifts. If any of the staff are working non standard shifts such as late starts, this should be entered into the roster/system to avoid misinterpretation. Teams can be included into rosters, but must adhere to local/trust rules (teams are defined as a set group of individuals within the rostered area), i.e. where wards are identified into teams Night shifts will be worked on a rotation basis unless specified in a formal flexible working arrangement, in line with Trust Terms and conditions. Night shift patterns will be fairly and evenly planned for all staff, each clinical area will work to either a 2 weeks or 4 weeks pattern, depending on the needs of the service Staff Requests Staff must be aware that service needs will take priority over requests and therefore all requests are subject to approval or being declined by the Manager as the roster is created. It cannot be assumed that the roster will be written to accommodate any or all requests. Staff must be considerate of their colleagues, and the requirement that they fulfil their share of unsociable hours shifts. Some individuals may wish to submit a formal request to work a personal pattern of set shifts over a 4 week roster period in accordance with the Flexible working Policy. Patient safety and service requirements and equity for other staff members must all be taken into account when considering these requests. As part of these agreements and reviews, the number of requests allowed may be reduced as a compromise for increased regular and specific input into roster restrictions. For specific shift requests, the roster analyser is available to support the decision making process when approving or denying a specific request. Rosters will have an opening and closing date for requests for each given roster period and no further requests will be accepted after this date, in order to enable the roster creator to efficiently prepare the roster. Opening and closing of rosters to requests is now an automated process. If staff wish to change their rostered shifts post publication, a like for like swap should be made with another member of staff of the same grade and skill set, that meets the service needs. All roster changes must be approved by the Ward / Unit Manager. Periods of Unavailability Annual leave is allocated in hours for all members of staff. The ward / unit manager must approve all annual leave requests. 15% of the ward / unit rostered staff should be on annual leave each week. If this % is not being met by way of requests, the Manager will discuss with staff and Version 1.0 October

20 encourage the possibility of individuals taking leave within the period. The manager should monitor leave throughout the year to ensure there are no peaks and troughs during the year. If appropriate levels of annual leave are not reached staff should be made aware that any staff assigned additional duties or with unused contracted hours will be identified to the Service Manager and may be re-allocated to another unit with vacant shifts unfilled. Any additional days off required need to be formally requested to be guaranteed. Annual leave should be requested from the first day of unavailability to the day prior to return to work. The total amount of leave sanctioned whether annual or study leave etc. will not be increased during school holidays. Discussions should be encouraged between those requesting school holidays as leave, so that each member of staff has an equal chance of leave being granted. Annual leave hours for school holidays will be allocated fairly and equitably. Annual Leave/Training and Study Leave (non-effectives) should be entered into the system before starting new rosters. Annual Leave should be entered in days taken, i.e. 5 days and 2 days off, or in the case of the Adult and OAP service, 4 Days and 3 Days off (Adult and OAP Annual Leave is currently in long days hours and short days 6.5, so this would need to be entered). If Leave is taken on a night shift, Annual Leave should be put in for the night period. One week s Annual Leave should equate to 37.5 hours unless part time working. Training should be entered for the hours training is taking place, for example if a training session is only for 2 hours then the duration needs to be changed and a shift needs to be put in also (adjusting the duty times). Any notes in reference to this training should also be entered. Sickness Reason should be entered where applicable, if reason is unknown then reason should be entered as Sickness Other. Study Leave Study leave will be assigned by the ward / unit manager in line with the Trust Study Leave Policy. The Manager will ensure that mandatory training is balanced throughout the year and assigned per roster as staffing levels. Training Leave should be 5% of rostered staff Sickness Sickness should be managed in line with Managing Attendance Policy, Sickness should be recorded as a non-effective within healthroster. All ongoing sickness period should be linked. Once an Off duty Roster has been created, only duties remaining in the vacant duties window, unfilled by contracted staff and still required for safe staffing of the area, may be requested as Bank shifts. The creation of additional duties outside of the budgeted template requirements should only be done with prior Senior Manager approval. Version 1.0 October

21 No additional duties should be created without assessing the need for them; the grade required and the time they are needed to start and finish. Please consider the availability of staff from another area to fill the required shift. Should that prove unsuccessful then the following process must be followed in line with the authorisation table in 5.19 in the attached policy. Once approved, shifts in HealthRoster are sent electronically to the Bank & Rostering Team for the Bank Office to attempt to fill the required shift(s). It will not be possible to cover annual leave requests that exceed the documented acceptable level for the ward. There should be no request for bank and agency for bank holiday shifts unless approved by the Service Manager. For nursing areas, out of hours; the NIC needs to book bank/agency direct. All shifts must be entered onto your rosters, assigning the booked bank/agency direct into healthroster. Night and weekend shifts will be covered by substantive staff wherever possible. Staff on sick leave or a phased return will not be permitted to work bank shifts during that period or for 7 days after the initial sickness period. Staff must not agree or request to work a bank shift that breaks the working time regulations. E.g. an early or late shift following a night shift having been worked the night previously. Staff that have informed their substantive ward that they cannot work specific dates or times will not be permitted to work these shifts on the Bank or as Excess hours or Overtime (i.e. Flexible working arrangements). A completed roster must be reviewed and analysed by the ward/service manager prior to the rota being published Approval Process Finalisation Process Ward Managers complete daily changes of worked rosters in line with the roster management timetable, cancelling any changed duties (leaving audit trail) replacing roster with shifts worked. Each day shifts are finalised locked down when any changes have been made, ready for payroll. Version 1.0 October

22 Appendix 2 Roster Management Report - Key Performance Indicators Nursing Headroom Sickness 5% Roster % Month 1 Month 2 Month 3 Comments / Escalation Annual Leave 15% Training 5% Roster Effectiveness Over Contracted Hours Unused Contracted Hours Additional Duty Hours Budget Comparison Fairness Total Roster Cost Staffing Budget Requested Duties Duties with Warnings Timetable Date Produced Version 1.0 October

23 Appendix 3 Rostering Compliant Questionnaire Ward / Unit: Compliance Questionnaire completed by: Action / Compliance Yes / No 1. Are all Staff of aware of this policy? 2. Do the shift times and break time adhere to Working time regulations as set out in this policy? 3. Do you have the approved minimum staffing requirements for each shift? 4. Is your skill mix maintained? 5. Can other areas / units deploy staff to cover your shortfalls? 6. Is annual leave allocated as per this policy? 7. Is training allocated as per this policy? 8. Are you flexible working arrangements adhered to? Do you need to book a review with the Bank & Rostering Team / HR? 9. Are there 8 weeks of completed rosters out as per the roster management timetable? 10. Have all you non-effectives been built in, i.e. return to work / long term sickness etc...? 11. Are break guidelines being followed? 12. Are you within your staffing budget? 13. As you roster been approved by your area service manager? 14. Have you any rules breaks / non-compliance within your roster? 15. Do all you outstanding establishment shifts need to be covered with Bank / Agency? Date: Comments Actions Version 1.0 October

24 Appendix 4 Roster Management Timetable Generation of Rosters ROSTER MANAGEMENT PERIOD ROSTER COMPLETION DATE ROSTERS (ADVANCE) 11 th January th February th November Weeks 8 th February th March th December Weeks 7 th March rd April th January Weeks 4 th April st May th February Weeks 2 nd May th May th March Weeks 30 th May th June th April Weeks 27 th June th July nd May Weeks 25 th July st August th May Weeks 22 nd August th September th June Weeks 19 th September th October th July Weeks Version 1.0 October