Workforce and Development. E-Rostering Policy and Procedure. Document Control Summary. Replacement - H/BLU/gh/03 V2.0 V1.0 Date: August 2017

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1 Workforce and Development E-Rostering Policy and Procedure Document Control Summary Status: Version: Author/Owner: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement - H/BLU/gh/03 V2.0 V1.0 Date: August 2017 Suzanne Godwin E-Rostering and Supplementary Staffing Nurse Lead /Alyson Sargeant Head of Recruitment and Resourcing Policy and Procedures Committee Date: 21 September 2017 Trust Board Date: 28 September 2017 To support effective Electronic Rostering and workforce planning. Deliver regulatory, financial, performance and quality standards October 2017 October 2020 Shifts Roster Roster Creator Finalising Annual leave Skill Mix Flexible Working Safe Staffing Headroom Agenda for Change Terms and Conditions of Employment which includes guidance for annual leave. Managing Attendance Policy and Procedure. Maternity, Paternity and Adoption Leave Policy. Preceptorship guidelines. E-Rostering documentation. Performance and Development Review Policy. Flexible Working Policy. Study Leave Policy Disciplinary Procedure Staff Performance Management Policy Any other relevant department documents. 1

2 Contents 1. Introduction Purpose Scope Rostering 24/7 Services Process For Monitoring Compliance And Effectiveness Appendix 1 Summary of the Maps Healthroster process Appendix 2 E-Rostering Key Performance Indicator Threshold Table Appendix 3 Healthroster Reports Appendix 4 Roster Calendar Link Appendix 5 Quick Guide to Producing Rosters Appendix 6 Checklist for Validating and Approving Rosters Appendix 7 Annual Leave Algorithm Change Control Amendment History Version Dates Amendments 2

3 1. Introduction The purpose of this policy is to ensure the effective utilisation of the workforce through efficient rostering. Electronic Rostering (also known as HealthRoster but referred to as E-Rostering throughout the rest of this document) has been adopted by SSSFT to allow management and planning of the workforce in an efficient and effective manner. It has been implemented across a number of Trusts with clear benefits to both staff and organisation. SSSFT recognises the value of its workforce and is committed to supporting staff to provide high quality 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 respond to changing service requirements. A flexible, efficient and robust rostering system is key to achieving this objective. The rostering policy will be used in conjunction with E-Rostering as and when this system has been rolled out to individual Units. E-Rostering is a computerised system specifically designed for use by individual staff, Unit Managers and Senior Managers. It rosters staff to agreed staffing requirements, manages staff availability and contracts and allows clear visibility of unit demand levels. It will also track and produce reports for avoidable costs, absence, leave, additional duties, overtime and bank/agency usage and booking arrangements. Electronic Staff Record (ESR) will remain the master Human Resource and Payroll system. The secure interface between ESR and E-Rostering will be used to transfer data between systems keeping both up to date. 2. Purpose The purpose of this policy is to ensure the effective utilisation of the clinical workforce through efficient rostering by:- Ensuring that rosters are fair, consistent and fit for purpose, with the appropriate skill mix, in order to ensure safe, high quality standards of care Improving the utilisation of existing staff and reducing bank and agency spend by giving Department Managers clear visibility of staff contracted hours Providing accurate management information regarding the establishment thereby driving efficiencies in the workforce across 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 unavailability working days e.g. annual leave and study leave Enabling the legal requirements of the European Working Time Directive to be met Providing a mechanism for reporting against set Trust Key Performance Indicators Facilitating the payment of staff through data being entered at source 3

4 Ensure that staff feel valued as a resource by establishing a fair and equitable system to manage working time 3. Scope This policy is for use by all Units/Wards/24 hour services using E-Rostering, and by the staff that work within these Units/Wards/Teams (from this point to be called Departments) including Bank, Agency and contracted staff. It will assist with the production of fair rosters based on an agreed funded establishment and the development of safe staffing practices. This policy is for use by all areas using E-Rostering. 4. Rostering 24/7 Services All Departments will hold formal documentation relating to: Optimum staffing levels (number of staff) by shift and by day, which must be reviewed appropriately in conjunction with Service Leads and Finance in regards to changes to demand, commissioning intentions or the clinical/workforce strategies. The number of staff that can be on leave at any one time (follow annual leave algorithm (Appendix 7). Optimum skill mix (band/experience of staff required) by shift and by day, which must be reviewed appropriately in conjunction with changes to demand, commissioning intentions or the clinical/workforce strategies. The optimum staffing levels must be reflected in the Roster; it is the responsibility of the Department Manager to ensure their vacant duties accurately represent the agreed establishment. All flexible working arrangements or personal patterns should be agreed as per the Flexible Working Policy and reflected on personnel files accordingly. Each agreement should be reviewed in line with the Flexible Working Policy. 4.1 Definitions A number of terms are defined below to assist understanding: Unavailability working days One request Permanent: Temporary Substantive Variations in shifts Personal patterns Relates to days that staff members are not available for the roster i.e. annual leave, study days, management days, sickness, paternity leave, maternity and carers leave, etc. Closely tied to the 25% Departments Headroom. One request made by staff for a particular shift (Early/Late/Night) or day off. Staff who have permanent contracted hours. Bank and other temporary staff e.g. agency staff. Staff who have a permanent or fixed term contract. Not bank or agency staff. Differing start and finish times to regular shifts. Every week the person works the same shift on the same day; formally 4

5 Shared patterns Personal preference Contingent workforce Unit: Management days / Working days WTE Planned roster Headroom Allowance Key Performance Indicator Monitoring Unfilled Duties Additional Duties by the Department Manager via the flexible working policy and subject to bi annual reviews. Patterns agreed to meet service need, for example ECT roster. It is for the benefit of the Trust Individual preferences relating to days/shifts worked or not worked, approved formally by the Department Manager and subject to bi annual reviews 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. Ward, department or team Office / administration days for nursing staff, usually department managers and deputies Whole time equivalent The initial roster produced and Approved within a specified time frame (see section 4) Relates to the percentage of unavailability working days that are included in each establishment Relates to the management of effective and efficient rosters through Roster Analysis, ensuring Key Performance Indicators are being considered before approval. Duties within the agreed staffing requirement that have not been filled by Trust employees Any duties allocated that are above the agreed staffing requirements for the Department 4.2 Responsibilities 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. Working their share of all shifts. Notifying the Department Manager of changes to a planned or worked shift, giving sufficient notice in advance of the planned shift. Requesting shifts using Employee On Line. Ensuring that correct personal details are displayed on Employee on Line. Any inaccurate information should be immediately updated by the individual using ESR s Employee Self Service (ESS). Raising any queries in relation to payment of their Unsociable hours/on Call and Call out payments with their managers in the first instance Roster Creators are responsible for: 5

6 The creation of all rosters as described at Section 4 of this document and in line with timeframes and Key Performance Indicators (Appendix 2). In their absence the designated deputy is responsible for roster creation Level 1 Approvers/Department Managers are responsible for: Identifying a Roster Creator and a Deputy and ensuring that these staff members are appropriately trained. Ensuring that all staff are aware of the local guidelines and Trust wide policies for rostering. Considering all roster requests from staff, ensuring fairness and equity in working patterns. Ensuring that a quality roster is produced, maintained and finalised in line with Section 4 of this document and in line with Key Performance Indicators (Appendix 2). As Level 1 approver, Department Managers are confirming that the proposed rota is to their knowledge and ability the best use of Trust resources to meet Service need. 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 fair and equitable allocation of annual leave and study leave. Ensuring that their expenditure does not exceed the allocated budget. Ensuring any Additional Duties are absolutely necessary and informing the Level 2 Approver if the use of an Additional Duty results in increased Bank/Agency use. The safe staffing of the Department even if they do not directly undertake the task of producing the duty roster. Notifying the relevant Directorate Accountant of any additional hours agreed above the required staffing resource such as specialing or emergencies. 4.3 Finalising Rosters Rosters should be finalised as a minimum on a weekly basis. By the 3rd working day of each month, as a minimum, managers must undertake a final review of the previous month s roster, ensuring that all shifts are finalised as this will ensure accurate staff payment. Failure to finalise a roster will result in incorrect staff pay and lost Trust opportunity to achieve efficiencies and benefits identified as deliverable through use of the E-Rostering system. This may result in the Performance Management and/or disciplinarily procedures being invoked. Managers are responsible in the first instance for responding to staff pay queries relating to Unsociable hours/on Call and Call out payments and for liaising with Payroll if E-Roster data is incorrect. NB: Under no circumstances should rosters be finalised if inaccuracies are apparent. If rosters are knowingly finalised with inaccurate information, this will be treated as negligence and invoke Performance Management or disciplinary procedures. Dependent on the circumstances, finalising rosters with inaccurate information will be seen as gross misconduct which may be subject to action under the disciplinary policy and could result in dismissal. In addition, the NHS Counter Fraud Service may be notified. 6

7 Level 2 Approvers: Senior Clinicians / Snr Managers are responsible for: Monitoring and Level 2 approval of each roster within their remit in line with Trust time frames (Appendix 4) and Key Performance Indicators (Appendix2). Reviewing analysis reports on staffing, expenditure and quality in their area of responsibility using HealthRoster analysis and action change. Monitoring and questioning the use of Additional Duties; ensuring Level 1 Approver is informing of Additional Duty use that increases Bank/Agency use. Secondary Authorisation: reviewing all shifts where temporary staff members are requested. If necessary, approving the request only after options to redeploy staff from other shifts/departments have been considered as required by organisational good duty rota management. Providing guidance and support to the Department s Manager or designated other in the creation of duty rosters, using the Key Performance Indicators as a reference. Directorate Managers are responsible for: The implementation of this Policy. Performance reviews bi-annually and implementing change to maintain the Trust within Key Performance Indicators (Appendix 2) Monitoring performance and effectiveness through HealthRoster analysis and championing action. Report to appropriate senior managers including Executives The Director of Nursing Services is Responsible for: Monitoring and reporting against Key Performance Indicators, in conjunction with the Finance and Human Resources Teams and reporting through Divisional performance mechanisms to the Trust Board via the Trust Management Team. Ensuring that the roster approval and finalisation process is adhered to especially in regard to timelines. Trust Management Team is responsible for: Monitoring reports in staff demand profile and temporary staffing usage against departments. Monitoring staff absence and ensuring that the divisional management teams are pro- active in managing sickness absence and achieve the Trust s absence target. The implementation of an early intervention and recovery plan for departments failing to meet Key Performance Indicators. Reviewing Key Performance Indicators audits (through HealthRoster analysis) and ensuring the development and implementation of appropriate action plans. 7

8 E-Rostering Lead is responsible for: Monitoring compliance with Trust Mandatory Roster Publication Timetable providing operational managers with compliance information and notifications via HealthRoster analysis. Reviewing rosters on completion and reporting against Key Performance Indicators, ensuring the provision of reports to the appropriate managers where better rostering could improve the utilisation of the clinical workforce. Summarising data for presentation at Trust Management Team and Directorate Management Teams on a monthly basis. Ensuring the E-Rostering system remains appropriately configured. Providing support and ongoing training to the E-Rostering users. Liaising with the E-Rostering IT Support Team to resolve system issues as required. Directorate Management Accountant is responsible for: Annually, to agree and sign off the staffing resources for each Department with the appropriate manager and Directorate Lead. Reviewing the Key Performance Indicators (through HealthRoster analysis) that affect the use of resources with the Directorate Manager/Senior Clinician to ensure that the clinical resource is managed efficiently. Review SafeCare analysis with clinical managers to inform establishment review Updating the E-Rostering Advisor of changes to establishment figures for staffing and budget at least monthly. 4.4 Communication Both the Trust wide Rostering Policy and any unit based local documentation relating to E- Rostering should be displayed and be readily available to all staff. Staff should be encouraged to access this information via the intranet or through copies on shared drives. Local Induction materials for new staff should include links to this information. 4.5 Associated Documents This policy must be read in conjunction with the following documents:- Agenda for Change Terms and Conditions of Employment which includes guidance for annual leave. Managing Attendance Policy and Procedure. Maternity, Paternity and Adoption Leave Policy. Preceptorship guidelines. E-Rostering documentation. Bullying and Harassment Policy and Procedure. Staff Handbook. Performance and Development Review Policy. Operational Policy for Discharge, Bed and Clinical Site Management. 8

9 Flexible Working Policy. Study Leave Policy Disciplinary Procedure Staff Performance Management Policy Any other relevant department documents. 4.6 Headroom Allowance Within each Department Headroom Allowance should be included in the unit budget to cover expected absence. The percentage of the staffing budget is 25% as follows: Annual Leave and Bank Holidays % Sickness/Maternity/Paternity Leave and other Special Leave 3.85 % Working Day i.e. Management day 2.00 % Study Days 3.38 % 4.7 Equality and Diversity This document complies with the SSSFT Equality and Diversity statement. SSSFT is committed to the principles of Equality and Diversity. No 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, and disability or Trade Union membership. 4.8 Key Performance Indicator Monitoring Performance Reports A number of reports can be produced by E-Rostering to assist in business planning and review and to support performance management. These are shown at Appendix 3. These reports should be generated on a monthly basis by the E-Rostering Advisor for distribution on a monthly basis and review at relevant Divisional Meetings. Other ad-hoc reports will be generated and circulated by the E-Rostering team as required, i.e. to respond to an audit committee request. Key Performance Indicators All Departments will be expected to efficiently manage the deployment of their workforce in line with Trust Key Performance Indicators set at Appendix 2. Level 1 and 2 approvers will be accountable for the management of their performance against the Key Performance Indicator s. 9

10 To ensure proactive management of the rostering process, all Senior Managers and Clinicians and identified Finance staff will have access to HealthRoster analysis (the E-Rostering management information system). The Trust Management Team will also receive a monthly performance report relating to each Directorate in respect of performance against the Key Performance Indicators. The table in Appendix 2 provides some examples of Key Performance Indicator thresholds. It is recommended that the Trust reviews and at times resets thresholds appropriate for the Trust with performance targets for Department Managers to work towards. Level 1 & 2 approvers are responsible for regularly checking and cross referencing Key Performance Indicators on the E-Rostering intranet page. 10

11 4.9 Producing Rosters The Roster Calendar (Appendix 4) must be adhered to in order to ensure accuracy of scheduling and pay. There will be 13 rosters per year with each roster being a four week period. All rosters must commence on a Sunday and must be ready for Level 2 approval eight weeks in advance. If a roster is rejected by the Level 2 approver, any changes needing to be made must be completed and approved by no less than six weeks in advance of the roster being worked. This will allow for the roster to be published and available to the Departments staff in accordance with the Trust Roster Calendar. This will enable staff to better manage their personal arrangements and to afford Level 2 approvers to consider requests and alternative options in terms of filling vacant shifts. All rosters should be composed to adequately cover 24 hours (or agreed set hours) utilising permanent staff proportionally across all shifts and Departments. Shifts given a high priority on E-Rostering must be filled first, i.e. nights and weekends. The use of bank and agency for nights and weekends should be avoided wherever possible. If staff members 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 is shown in Appendix 5 and should be used in conjunction with the Roster Calendar in Appendix 4. Students & their inclusion in Rosters All student and trainee shifts must be included, with their cohort identification and start and finish times. Pre-registration Nurses should, where possible, be rostered with their mentors (for a minimum of 40% of their shifts). Allied Health Professional and all other students should be rostered with their mentor in accordance with course guidelines. All shifts are supernumerary and students should not be counted in the establishment. Roster Validation and Approval A completed roster must be reviewed and approved by both a Level 1 and Level 2 prior to being published. The Department Manager undertakes the Level 1 validation and approval using the roster analysis information at least eight weeks in advance and must inform the Level 2 approver of its completion within the timeframe. The relevant Senior Clinician/Matron/ Senior Manager completes the Level 2 approval process and will approve the roster if it meets the defined parameters; any changes deemed necessary by the Level 2 approver must be completed to allow 11

12 the roster to be published at least six weeks in advance. Both Level 1 and Level 2 Managers are responsible to the Director of Nursing to maintain this timeline. The approval of rosters must take into account the roster analysis information and Key Performance Indicators. If a roster is rejected the Level 2 approver must ensure the Level 1 approver is aware of the rejection and indicating why it was rejected, adding a note to the roster bar for reference. At this point a date must be set for next approval review that accounts for the publish date. Quick reference guides for validating and approving rosters are available on the internet at: Changes to published rosters Whilst it is acknowledged that this task may be delegated, it is the responsibility of the Department Manager to ensure that rosters are amended and kept up to date with additional shifts and unavailabilities i.e. sickness, no shows, study leave, additional requests etc. Shift changes should be kept to a minimum. Staff members are responsible for negotiating their own changes once the roster is completed. These changes must be approved by the Department Manager. 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 the Level 2 Approver. All changes should be made with an equal grade and consideration for the overall skill mix of all shifts being changed. The skill mix and patient dependency factors must be taken into consideration. If an equivalent pay band is not available then the shift change must be agreed with the Level 2 Approver prior to its approval. Where staff are allocated to a student, shift changes should not occur without ensuring the student either changes with the staff member or is allocated to another suitable member of staff, that the student is aware of the change and that this change is recorded on the roster. Students should not be included as part of Establishment. All updates to the roster must be made within the period of the shift that the change occurred; if this is not possible then as soon as practically possible after the occurrence. This includes changes to shifts, times of attendance, late finishes, sickness and holiday. The actual worked roster must be verified and finalised by the Department Manager by midday every Monday for the previous week. It is the Department Manager s responsibility to ensure appropriate staff have access and are trained to make these changes. The above action will ensure accurate records and staff pay. Details of shifts worked will be lifted from E-Rostering and transferred through an interface into ESR to make staff payment. 12

13 New Staff New substantive staff (permanent and fixed term) may have a supernumerary period. This may be for a minimum of 2 weeks and will be assessed on an individual basis, taking into consideration the requirements of the department/directorate. Periods of supernumerary working should be entered onto the roster New staff should work with their preceptor during the supernumerary period, to ensure that their induction is completed and objectives are planned. After this they should plan to work with their preceptor twice a week to complete objectives and competencies. Skill Mix An agreed and funded staffing baseline is essential to delivering high quality care. Each Department must have an agreed total number of staff and skill mix for each shift, approved by the budget holder in conjunction with the relevant Directorate Accountant, which is accurately reflected in E-Rostering vacant duties. Utilising SafeCare data, the skill mix and establishment must 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. In areas where the workload is known to vary, according to the day of the week, staff numbers and skill mix should reflect this. Each department should have an agreed level of staff with specific competencies on each shift, to enable appropriate cover e.g.:- Giving medication. Taking charge of the shift. Ability to perform assessments and observations in line with Trust Policy Ensure a safe environment including the ability to de-escalate potential and actual violence There must be designated person in charge for each shift who has been identified as having the required skills and competencies for a coordinating role. To achieve a balance of skills across all shifts senior staff should work opposite shifts. Department Managers should routinely work Monday to Friday dependent on the needs of the department. The Department Manager should only work nights where there is a identified need and prior approval from the Senior Clinician/Matron/Senior Manager. It must be recognised that a Senior Nurse is always available as the Hospital Coordinator. 13

14 The off duty for senior staff should be compatible with their commitment to the Hospital coordinator roster. Where Allied Health Professional staff members are rostered, there should be sufficient staff to complete initial or urgent referrals on each shift. Pre-Registration nurses and Allied Health Professionals must be rostered to work with their mentor for a minimum of 40% of their shift time. If their mentor/buddy is unavailable, an associate mentor should be allocated. This may vary with all other students who should be rostered with their mentor in accordance with course guidelines. Flexible Working Requests The Trust is committed to flexible working (refer to Trust Flexible Working Policy). The department manager will consider requests for flexible working, as per the Flexible Working Policy 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. Any personal patterns or personal preferences that are agreed between a member of staff and a Department manager will be documented as per the Flexible Working Policy. Staff contracts will be updated via a variation to contract form to reflect the agreed pattern and a Change Form submitted via payroll giving details of the agreement. The review is undertaken to establish if the patterns or preferences are still required by the member of staff and to ensure that the service can still support the request for these patterns or preferences Any changes to the above patterns must to recorded and submitted on the Trust Change Form. Personal patterns are not considered as requests. All staff will use the Employee on Line system to make requests. Department Managers are responsible for training their staff in the use of Employee on Line and ensuring they are using it for communicating requests. Department Managers are responsible for ensuring staff members have open rosters to enter their requests into. A maximum number of 4 requests will be allowed per staff member during every 4 week roster period for staff to utilise via Employee on Line. However, each Department Manager has discretion to allow more than 4 requests per staff member if other staff members do not make full use of their entitlement. Additional requests should be made direct to the appropriate Manager (Level 1 approver) or Deputy; all requested shifts that are changed (including shift swaps or any other reason that benefits the individual) after publication must be recorded as a request on the electronic roster No requests may be granted if this results in additional Bank/Agency use without the Level 2 approver consent. The total number of requests (including additional requests) per person is recorded by the system in a Staff League table to review equity and fairness. It should be recognised that 4 requests equate to 14

15 20% of the roster; if this figure is reached then meeting the needs of the Service over that of staff requests is extremely difficult to achieve. This Policy needs to be considered in conjunction with other Trust policies and papers All requests will be considered in the light of service needs and the Department Manager will endeavor, as far as possible, to meet individual requests, by referencing the appropriate request league tables to ensure fairness. 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 Department Manager is responsible for approving all requests and ensuring Level 2 approval has been gained where appropriate. Shift patterns Staff will be required to work a variety of shifts and shift patterns as agreed by their Department Manager or as specified in their contract of employment. Shift patterns must comply with agreed Trust guidelines; in response to special circumstances any shift pattern that does not comply must be recorded and reviewed bi-annually by the Level 2 Approver and a report on its validity for the provision of service sent to the Director of Nursing. Although the Trust will seriously consider special circumstances in staff shift patterns, the needs of the service will take priority. Shift times should not vary across units. Start and finish times for each shift are standardised to facilitate appropriate staff cover and skill mix. Staff will be expected to adhere to these times and will be expected to provide cover in other departments when appropriate Staff may have a minimum of one weekend off per 4 week roster, in normal circumstances (unless they specifically request not to have weekends off). Additional weekends off can be rostered if the departmental requirements allow. The maximum number of consecutive standard 8 hour day shifts recommended for staff to work is 5. Staff may work more than this (to a maximum of 7) if they specifically request to but must comply with European Working Time Directives. The maximum number of Long Day (LD) shifts per week is 3 and where LD s exceed 12 hours LD shifts should not be consecutive to comply with EWTD. When rostered consecutively for service need, the appropriate compensatory rest will be assigned. LD shifts which allow for the minimum 11 hour rest between shifts can be rostered consecutively to a maximum of 2 consecutive. Night Duty should not exceed a maximum of 4 consecutive shifts. Internal rotation is expected by the organisation and all staff will be required to work both days and nights, unless exempted for any reason by their Department Manager and this reason is documented and reviewed bi-annually. Any staff that work a majority of nights must comply with mandatory training requirements and other training to maintain core competencies and, if applicable, continuing professional development as required by their professional body. All staff must have 24 hours rest in every 7 days or 48 hours of continuous rest in every 14 days. Staff and students must not be rostered to work more than an average of 48 hours per week over a 17 week period, in line with European Working Time Directive. 15

16 Where staff opt out of the 48 hour limit to undertake bank shifts they can work a maximum of 56 hours per week averaged over a 17 week period. Shift patterns; exceptions There may be a need in order to meet Service demands for a shift pattern that does not comply wholly with the statements of 5.4 and 5.5 of this document. This may be due, for example, to a particularly large geographical area for Department staff to cover. In all circumstances the principles discussed in this document must remain of complying with European Working Time Directive, cross Department cover and working no more than 12.5 hours per day. Any shift pattern that does not fall within 5.4 and 5.5 of this document must have agreement at the Joint Staff Partnership. Breaks during shifts Students Shift systems should adopt a standardised shift pattern across the Trust consistent with a basic hour of work principle being a standard 8 hour shift with a 30 minute unpaid break and two consecutive days off per week, an 11 hour minimum break between shifts and no more than 7 consecutive shifts to be rostered at any one time. This will apply to all shifts with the exception of night shifts. Night shifts will not exceed 11 hours, excluding the break. Night shift breaks will be unpaid and must comply with European Working Time Directive. The Department Manager 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 owing to clinical need, they should be taken as soon after this point as possible. No break is to be forfeited without discussion with the Hospital Coordinator and/or adjacent departments to establish other options to cover staff breaks. The E-Rostering Advisor will complete a monthly report of European Working Time Directive breakages for Level 2 Approvers and other senior staff. Breaks should not be taken at the beginning or the end of a shift, as their purpose is to provide rest time during the shift. Sleep within clinical and public areas on Trust premises on any shift is not permitted. Staff may rest in designated rooms within their break period, but must return to the clinical area to work at the set time. Students must be recorded on the roster and should work a minimum of 2 shifts per week with their mentor. Pre-Registration nursing Students: Students should work 1 weekend in 3. Students are required to spend hours on nights over their clinical placement. Year 1 students do not do night duty. Year 3 students can do night duty either to make up night duty hours from year 2 or as part of their continued placement learning. 16

17 Designated sign off mentors for pre-registration nursing students must be allocated 1 hour per week with each year 3 final placement student. Allied Health Professionals/All other students These students should follow their professional/course guidelines for working night and weekend shifts. Staff Redeployment During staff shortages staff will be required to work in other clinical areas to provide a safe and efficient service. The Hospital Coordinator or other designated person for each area is responsible for the redeployment of staff both within the Directorate and to/from other Directorates to meet service requirements. Out of hours, this decision will be made by the Hospital Coordinator/On-call Manager. Redeployment of staff should be entered onto the roster or entered directly in SafeCare to ensure that Nurse Hours per Patient Day are adjusted correctly 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 E-Rostering system will be used to manage workforce redeployment in the event of a major incident or significant event. If staff members are required to move from their contracted base SSSFT will meet transport costs at the rates agreed within staff Terms & Conditions. Unavailability Annual Leave Annual leave is rolled up with Bank Holidays and allocated in hours for all members of staff as per Agenda for Change except for medical and dental staff. Each member of staff is responsible for booking their annual leave in accordance with the agreed Departmental guidelines. The Department Manager is responsible for approving all annual leave. 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 principles of not having high volume of staff on annual leave at the same time apply. Each department should calculate how many qualified and unqualified staff must be given annual leave in any one week, with a defined limit for each band (see Appendix 7 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 of requests. The Department Manager will allocate leave following discussions with the staff concerned. Annual leave must be booked at least 12 weeks in advance, and approved no less than 8 weeks in advance of the leave date by the 1st level approver, except in case of domestic emergencies. A maximum of 14 consecutive calendar days of annual leave can be requested. Any more than this will need special approval from the Level 2 Approver. 17

18 In exceptional circumstances staff may be requested to move annual leave for example in response to circumstances i.e. as identified in a Business Contingency Plan. Guide for Duty Roster Creators Where possible, all leave should be planned and booked in advance, at the start of the annual leave year (i.e. by 1st April for AfC contracts or as per Terms and Conditions for Medical and Dental staff). 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 It is an individual s responsibility to ensure annual leave entitlement is used before 31st March. A maximum of 37.5 hours annual leave may be carried forward into the next annual leave year at 31st March if authorised in advance by the Level 2 Approver. Any other leave not taken will be lost. The carryover of leave should only be considered in accordance with the Managing Attendance Policy. Annual leave must be booked or cancelled 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. Staff on rotational programs should take annual leave in accordance with contracted weekly hours. School Holidays and Bank Holidays The amount of annual leave taken during school and bank holidays should remain within the 11% - 17% ranges. Discussions should be encouraged between those requesting time off so that each member of staff has an equal chance of 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 (Appendix 7). 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 or not by the end of October. To ensure cost effectiveness and continuity of care, shifts over the Christmas/New Year periods should be filled by substantive 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 that are built-in to the E-Rostering system and overseen by the Level 1 Approver. 18

19 Study Leave Study leave will be assigned in line with Mandatory and Statutory requirements and the Trust s guidance on study leave. The Department Manager should: Utilise the available headroom in each roster. Prioritise mandatory training requirements for staff which may include induction, updates Produce roster ensuring staff have the required mandatory training. Sickness Absence Sickness Absence will be managed in accordance with the Trust s Managing Attendance Policy. Sickness must be communicated by telephone to the Department Manager or nominated deputy as agreed in the Trust s Managing Attendance Policy and in line with local reporting arrangements. Sickness details should be recorded in the roster as soon as possible by the appropriate manager who should select a sickness narrative that describes the employee s condition as accurately as possible. If off-duty days follow on from sick days, the Department Manager must be kept informed of recovery. Unless notified otherwise, off-duty days will be reclassified as sick leave. All Musculoskeletal or Stress, Anxiety or Depression conditions should be referred to the Occupation Heath and Well Being Service by the manager immediately, and E-Rostering updated to show the date of the referral. On return to work following sick leave Department Manager s must record the date of their staff members return to work discussion in MAPS E-Rostering. Time Off in Lieu It is recognised that staff may be requested to work extra time over their contracted hours to support service delivery objectives. Employees are expected to self-manage Time off in Lieu, to reduce excessive hours banked and to liaise with their Department Manager to claim back or return owed hours at reasonable intervals. Any time worked by staff over and above their contracted hours should be sanctioned by the Department Manager in advance and then recorded on the E-Roster. Department Managers must satisfy themselves before extending shifts in E-Roster that the time claimed has been worked and that the work was in response to a service delivery need. The time will accrue as Time Owing. Any time taken back against time owing must be agreed in advance by the manager and recorded in E-Rostering. Full shifts taken as Time Owing should be recorded with the specific TO shift; no time value is given to this shift. However it should be considered best practice for Time Owing to be both accrued and taken back in short periods to limit the impact on service delivery. Time Owing must only be given when service needs have been met. No Time Owing may be granted if this results in additional Bank/Agency use without the Level 2 approver consent. 19

20 Employees and Department Managers are responsible to ensure Time Owing does not accrue to excessive amounts. Agenda for Change Under Agenda for Change Terms and Condition (3.5) staff may request to take time off in lieu as an alternative to overtime payments. However staff who, for operational reasons, are unable to take back their lieu time within three months of it being accrued the time becomes payable at overtime. Overtime rates are time and a half with the exception of work on a Bank Holiday, which is paid at double time. Part-time staff receives overtime at plain rates until their hours exceed the standard 37.5 hours per week, when overtime rates become applicable. Senior staff in Agenda for Change bands 8 or 9 is not eligible for overtime payments. All time in lieu not taken within 3 months is eligible to be paid at plain rate times. It is considered extremely poor practice for an employee to claim overtime payments due to a mismanagement of time owing accrual rates and the time being taken back. Time owing figures in E- Rostering are continually changing and represent a considerable difference from a static figure written down. As such it is time consuming and problematic to establish the 3 month timeframe. Bank & Agency Bank and Agency staff will be managed through E-Rostering, with unfilled shifts sent through to Bank by the E-Rostering system once rosters have been approved. Level 1 and/or Level 2 approvers will consider alternative staffing options prior to approving a request for a Bank shift. 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 and that all previous versions removed. This will ensure that each department 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 E-Rostering 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 will be sent for E-Rostering/E-Pay team as soon as possible 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. 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 through their Department Manager 20

21 5. MONITORING COMPLIANCE & REVIEW 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 Advisor, Department Managers and Modern Matrons on a three monthly basis and an action plan to be generated. E-Rostering Rule Breakages will also be monitored within the action plan on a three monthly basis to ensure all staff are treated fairly in the allocation of shifts and leave management. Data will also be available through HealthRoster analysis for Locality Managers and Directors as required (quarterly reviews recommended). Data reports will be escalated to Board Level as appropriate. 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 Staffing Party (JSP). 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 change 21

22 APPENDIX 1 The E-Rostering process can be summarised as follows:- Manage Rosters Assign Duties Auto Assign Duties Assign Duties Manually Assign Duties to Staff from Other Units Details the process for making rosters available for staff to place requests, closing requests, creating and updating rosters and deleting rosters where they are not required. Describes the overall process for assigning roster duties. The process describes the steps involved in filling the roster and incorporates other processes that explain how the Roster Creator assigns duties using the Auto Roster function, or manually. This process also includes how the Unit Manager reviews the completed roster and approves the roster for publishing. This process includes steps for assigning duties using the Auto Roster feature. It describes how the Roster Creator chooses an Auto Roster function, sorts the list of duties for assignment, and runs the Auto Roster. Describes the process for assigning duties manually, including the processes for swapping and combining duties after the Auto Roster has completed. This process describes how HealthRoster indicates whether a duty assignment has been rejected due to a rule violation. After the Roster Creator/Unit Manager has approved their roster (Level 1) it is ready for review by the Senior Clinician. They should review the Units within their remit and try to fill any outstanding vacant duties with suitable staff. Staff with lost contracted hours or assigned to additional duties should be identified to the Senior Manager for reallocation to units within their remit. They then approve the roster (level 2) Administer Rosters Once the roster has been published, the Roster Creator/Unit Manager must manage the ongoing changes made to the roster. Examples of changes made to the roster include the recording of No Shows (e.g. sickness/last minute annual leave/carers leave), cancelling duties and the creation of additional duties. This process describes how the Roster Creator/Unit Manager accomplishes these tasks. Finalise roster Final Review of Roster at Month End At the end of each week, all duties worked by all staff must be finalised. By the 3 rd working day of each month, managers must undertake a final review of the previous month s roster, ensuring that all shifts are finalised as this will ensure accurate staff payment. Failure to follow this process will result in your staff being under/overpaid. 22

23 Appendix 2 E-Rostering Key Performance Indicator Threshold Table Safety GROUP Fairness Effectiveness Unavailability Establishment RED THRESHOLD AMBER THRESHOLD 24 USE THRESHOLDS NAME DESCRIPTION Registered Skill Mix % Percentage False Percentage of all assigned hours filled by registered staff. Shifts without Charge Number of Shifts without the required Charge Count True Cover Cover skill. Unfilled Duty Hours % Percentage True % of the required demand that is left unfilled. Duties with Warnings % Percentage True Percentage of duties that have broken a warning rule. Roster requested % Percentage True Percentage of the roster that was requested by staff. Additional Duty Hours Hours True Hours of Additional Duties. Assigned duties where the duty s grade type is Duties assigned to Wrong Count True different to the person s (e.g. RN assigned an Grade Type HCA duty). Over Contracted Hours Amount that staff have worked over their Percentage True (4 week period) % contracted hours in a 4 week period. Unused Hours Amount that staff have not used their contracted Percentage True (4 week period) % hours in a 4 week period. % Time Worked Percentage True % of time from substantive staff that is rostered, rather than unavailable or unused. Staff of Sick Percentage True % of staff time marked as sick. Staff on Leave Percentage True % of staff time marked as leave. Staff on Parenting Percentage True % of staff time marked as parenting (e.g. maternity). Staff on Study Day Percentage True % of staff time marked as study day. Staff on Working Day Percentage True % of staff time marked as working day (i.e. performing non-clinical work). The amount of vacancies in the budgeted Post Vacancies WTE WTE True establishment the required posts WTE minus the staff in post. Redeployed People Hours Hours True Staff with Working Restriction Number of hours where unit staff are working in another unit. Count True Percentage of staff with Working Restrictions.