POLICY REFERENCE NUMBER SABP/WORKFORCE/0030 POLICY NAME ROSTERING AND WORKING TIME REGULATIONS POLICY

Transcription

1 POLICY REFERENCE NUMBER SABP/WORKFORCE/0030 POLICY NAME ROSTERING AND WORKING TIME REGULATIONS POLICY BRIEF OUTLINE OF THIS POLICY This policy provides guidance on procedures for producing staff rosters, either electronically or manually, that are compliant with the Working Time Regulations. Version Number 4.0 Approving Committee Policy Category Executive Lead Name of Author Executive Board Workforce Director of Workforce Employment Services Manager Date Approved 02 nd November 2017 Date Issued 5 th July 2018 Review Date 02 nd November 2020 Target Audience All Staff KEY PRINCIPLES ABOUT THIS POLICY 1. To ensure that services are safety staffed using fair and consistent rotas 2. To improve the utilisation of staff and reduce temporary workforce expenditure by providing clear visibility of contracted hours 3. To improve monitoring of sickness absence and planning of annual leave and other types of leave N/A This policy has been reviewed and is compliant with the most up to date Code of Practice and NICE Guidelines Title of Code of Practice NICE Reference Number(s)

2 VERSION CONTROL LIST Version Date Author Status Comment 3.0 January November 2017 Director of Human Resources Liz Case- Green Approved Approved Summary of Changes since Version 3.0 Numbers (Select the appropriate action) Page Paragraph Appendix Original/New/Amendment/Deleted Statement (select the appropriate action) This policy has received a full review and it has been transferred over onto the new SABP policy template. X 1.1 New - Proposals for changes to existing rosters or new units to be set up and have access to rostering will require pre-consultation with the rostering department as early as possible, to discuss timelines for roll out and ensure the needs of the service can be met and the outlay of roster is acceptable to the Manager. X 3.1 New - Annual Leave applications are separate to Shift Requests but must also be made prior to 8 weeks in advance of the rota planned start date. Consideration will be given to late requests in line with requirements of the unit and staffing levels at Page 2 of 46

3 the time and should not incur any expenditure in respect of booking NHSP to cover the absence. New - Manager to advise employees not to make and pay for holiday bookings until annual leave has been approved. New - Managers must use the Roster Analyser to view the percentage of staff on leave prior to approval of leave and production of the roster. New - We will review how much notice staff should give if they wish to book more than one week off. New - Staff who do not submit any annual leave requests will be allocated annual leave by the Unit Manager. New - Pre-arranged annual leave for new starters must be determined at interview and factored into the roster prior to the start of employment. X 5.3 New - Managers must ensure that normal hours do not exceed an average of 60 hours over a 17 week reference (changed from 48). X 6.6 New - Shifts missed from rosters with enhancements will not be paid if more than 3 months old. X 6.7 New - Managers to update and finalise rosters on a daily/weekly basis. X 7.9 New - Net hours of 12 or more must be reduced on production of new roster X 7.11 New - Any net hours owed on transfer to an internal unit to be managed prior to transfer. If not able to manage prior to transfer then incoming Manager to confirm they are happy to have the hours transferred to their unit and these net hours to be managed within 28 days of transfer. X 7.13 New - When Staff hand in their notice of termination of employment then manager should Page 3 of 46

4 process My Staff Hours report to calculate staff net hours. Any hours owed to the Trust that cannot be managed prior to leaving date will be deducted from final pay. X 7.14 New - Net hours should be managed prior to leaving date. X 7.15 New - Net hours where time owed (TOIL) to staff is shown will not be paid in salary on resignation from the Trust X 9.3 and 9.4 New - Working Time Directive opt out changed from 48 hours per week to 60 hours per week X 15.6 New - Staff must have received training before permissions are granted to view and administer rosters. X 15.7 New - Requests for staff to receive training must originate from their Manager and sent by to the Rostering Department. X 15.8 New - Managers to nominate another Manager to carry out the approval/finalisation of their rosters if they are to going to absent at the time of roster calendar deadlines and to inform rostering who the nominated staff are. X New - Roster Unit Manager: Ward Manager, Deputy Ward Manager and approved Senior Admin will be responsible for creating and updating the roster, and partial approval of the roster. Roster Service Manager: Service Manager, Matron and nominated Ward Manager will be responsible for partial and full approval of roster and finalisation of duties in preparation for payroll. Roster Administrator: Administration staff do not have to be on a roster in order to have access responsible for managing unavailabilities and editing of staff personal details. Page 4 of 46

5 Roster View Only Access: Corporate staff such as HR and Directors Can view rosters, unavailabilites and personal details with read only access and produce reports X New - Requests for days off are counted as Requests and will be deducted from the 4 shift requests in 28 days X New - Shift Requests are separate to applications for Annual Leave X 18.9 New - Any rosters not finalised within deadlines as set out in the Roster Calendar will not be finalised by rostering and consideration will be given to withdraweal from the payroll batch. Failure to finalise on time will result in overtime/ enhancements not being paid to staff. Enhancements etc will not be paid until the following month. Advances will not be issued for non-payment of enhancements etc. due to unfinalised rosters. X New - All duties on rosters will be finalised by Service Managers/Matrons. Unit Managers will therefore inform their Service Manager/Matron that the rosters are ready to be finalised in accordance with dates set out in the roster calendar Page 5 of 46

6 Contents Page Section Page POLICY SECTION Version Control List 2 Summary of Changes Policy Purpose Policy Statement Related Policies Policy Principles References 10 PROCEDURE SECTION 6.0 Roles and Responsibilities Procedure Flow Chart Procedure Statement Annual Leave Flexible Working Production of Staff Roster Changes to Roster Unsocial Hours/Time Owing Uneven Working Patterns Working Time Regulations (WTR) /Opt Out In Work Breaks Weekly Rest Period Shift Patterns Long Days 24 Page 6 of 46

7 PROCEDURE SECTION (A procedure is the series of steps to follow to accomplish an end result) 20.0 Sleep-Ins Additional E-Rostering Principles Staff Requests Production of off Duty Rosters Roster Validation and Approval Key Performance Indicators Booking of Temporary Staff Changes to Published Rosters Annual Leave Study Leave Sickness Electronic Staff Records (ESR) Monitoring Table 35 Equality Analysis 36 Appendices 43 Appendix 1 Guidance for Producing a Roster Appendix 2 Schedule Information 44 Appendix 3 Roster Report Details 45 Page 7 of 46

8 POLICY SECTION 1.0 Purpose The purpose of this policy is to provide the principles upon which all rosters for staff must be based. It applies to all staff working patterns, not just those working a variable shift pattern. The only exception to this is the application of the Working Time Regulations to some junior medical staff which is covered in a separate policy - Implementation of Working Time Directive for Doctors in Training. All other aspects of this policy apply. This policy also covers compliance with Section 27 of the Agenda for Change Handbook which covers the Working Time Regulations (WTR). Section 27 should be read in conjunction with this policy where full details of the restrictions on working time necessary to comply with the Working Time Regulations can be found. The Trust has adopted the Healthcare Roster computerised system to ensure rosters are compliant with the Working Time Regulations though guidance is given for manual rosters too where this system is not in operation. The Flexible Working Policy must be read in conjunction with this policy to support staff that may have particular requirements in their working patterns. 2.0 Policy Statement This policy and procedure applies to all staff except Directors and staff with Medical and Dental Terms and Conditions of Service. Staff rosters are one of the fundamental systems used to deliver care to people who use our services by ensuring safe staffing levels at all times. It is therefore essential that they are drawn up in a timely and appropriate manner, maximising the benefits to people who use our services and without incurring any unnecessary expenditure. For staff to be able to achieve a work life balance in line with our Health and Well Being Strategy, rosters must be drawn up giving Page 8 of 46

9 sufficient notice and taking reasonable account of the needs and wishes of individual members of staff. Good, fair and equitable rostering is necessary to achieve the Trust s Vision and Values. All people using our services, as well as staff, have a right to expect the best support from the Trust. To do this we must ensure that work is distributed appropriately and fairly with our staff having had appropriate rest to deliver a safe, high quality service. This must be based on the needs of the people using our services. 3.0 Related SABP Policies This procedure is to be read in conjunction with the following: Flexible Working Policy and Procedure Leave (Paid and Unpaid) Policy and Procedure Grievance Policy and Procedure Absence Management Policy and Procedure Agenda for Change (AFC) Handbook Implementation of Working Time Directive for Doctors in Training Health and Safety at Work Policies 4.0 Policy Principles To ensure that the services are safely staffed. To ensure safe and appropriate staffing for all departments using fair and consistent rotas. To improve the utilisation of staff and reduce temporary workforce expenditure by providing managers with clear visibility of staff s contracted hours. To minimise clinical risk associated with the level and skill mix of clinical and nonclinical staffing levels. To improve monitoring of sickness and absence by department and individual, generating comparisons, and identifying trends and priorities for action. Page 9 of 46

10 To improve planning of study days, annual leave and other non-clinical care working days. Any employee s flexible working arrangement agreed by the service manager should be reviewed regularly and be published so that all staff working a particular roster understands the local arrangements, where they exist, for all staff on that roster. 5.0 References This procedure is to be read in conjunction with the following: Flexible Working Policy and Procedure Leave (Paid and Unpaid) Policy and Procedure Grievance Policy and Procedure Absence Management Policy and Procedure Agenda for Change (AFC) Handbook Implementation of Working Time Directive for Doctors in Training Health and Safety at Work Policies Page 10 of 46

11 PROCEDURE SECTION 6.0 Roles and Responsibilities Chief Executive The Chief Executive has overall responsibility for ensuring the Trust has suitable and effective rostering arrangements in place to plan safe, fair and effective rostering and that staff working hours are within legal frameworks. Director of Workforce The Director of Workforce has board level responsibility for ensuring the Trust meets its statutory duties under the Working Time Regulations. The Director of Workforce reports to the Chief Executive and Executive Team any significant issues arising from the implementation of this policy including evidence of non-compliance or lack of effectiveness arising from the monitoring process so that remedial action can be taken. All Directors All directors are responsible for ensuring that suitable and effective arrangements are in place for rostering. Directors are also responsible for ensuring that we comply with Safter Staffing requirements and the health and safety of their staff. Modern Matron/Service Manager Modern Matrons/Service Managers are responsible for checking and approving duty rosters at least 6 weeks in advance of the period to which the roster relates, using Healthroster where implemented, and should ensure that the roster reflects the following requirements: Minimum staffing levels (number of staff) and skill mix (experience of staff required and gender) by shift and by day. This must be reviewed by the rostering manager and their line manager regularly in the light of any significant change to the ward function but at a minimum on an annual basis. Page 11 of 46

12 Rules relating to all types of leave, most importantly the Annual Leave, Study Leave and Working Time Regulations Rules relating to self-rostering where appropriate. Christmas off duty requirements in line with local procedures Service requirements. The maximum number of requests that can be considered for days off on any single date. The maximum number of requests a member of staff may make in any one rota period The maximum time ahead that requests can be entered, in order to ensure that new employees who join the team have a fair chance of adding their requests. The date by when requests have to be made for consideration within the roster Staff changes such as retirements, resignations and the recruitment to vacant posts Proposals for changes to existing rosters or new units to be set up and have access to rostering will require pre-consultation with the rostering department to set out a project plan 12 weeks prior to the roster becoming effective, to discuss timelines for roll out and ensure the needs of the service can be met and the outlay of roster is acceptable to the Manager. Managers Principles for Production of the Roster Managers should produce a duty roster at least 6 weeks in advance of the period to which the roster relates, using Healthroster where implemented, and should ensure that the roster reflects the following requirements: Minimum staffing levels (number of staff) and skill mix (experience of staff required and gender) by shift and by day. This must be reviewed by the rostering manager and their line manager regularly in the light of any significant change to the ward function but at a minimum on an annual basis. Page 12 of 46

13 Rules relating to all types of leave, most importantly the Annual Leave, Study Leave and Working Time Regulations Rules relating to self-rostering where appropriate. Christmas off duty requirements in line with local procedures Service requirements. The maximum number of requests that can be considered for days off on any single date. The maximum number of requests a member of staff may make in any one rota period The maximum time ahead that requests can be entered, in order to ensure that new employees who join the team have a fair chance of adding their requests. The date by when requests have to be made for consideration within the roster Staff changes such as retirements, resignations and the recruitment to vacant posts Proposals for changes to existing rosters or new units to be set up and have access to rostering will require pre-consultation with the rostering department to set out a project plan 12 weeks prior to the roster becoming effective, to discuss timelines for roll out and ensure the needs of the service can be met and the outlay of roster is acceptable to the Manager. Staff Staff are responsible for using Employee On-line (EOL) to view their shifts, request their annual leave in line with the requirements in the procedure and if they wish to change or request different shifts. Staff should ensure that they do not breach the Working Time Regulations. Page 13 of 46

14 7.0 Procedure Flow Chart 8.0 Procedure Statement 8.1 This policy requires each department to produce local procedures or review any existing procedures in consultation with the staff group. Local procedures must comply with the principles and guidance set out in this policy and procedure. Where consensus cannot be reached, the Trust Grievance Procedure should be followed. 8.2 Local procedures must be agreed with the manager or director, who must sign a copy. Page 14 of 46

15 The manager must then ensure that all staff are aware of these procedures, understand and follow them. Copies must be available to local staff and included in local induction. 8.3 All local procedures must be reviewed at least annually. 9.0 Annual Leave 9.1 All managers must draw up or review local procedures following consultation with their staff team for the agreement to, and allocation of, annual leave in line with the Trust s leave policy. The following minimum standards must be attained: The maximum number of staff and/or staff groups that can be offered annual leave at any one time, which must be based on skill mix and needs. Fifty per cent of annual leave including time allowed for bank holiday should normally be booked by the 31st May and the remainder by the 31st October. Exceptions may be allowed in local procedures but they must not cause the department to incur extra expenditure. Both manager and staff member must ensure that all annual leave is taken within the financial year Annual leave must not be booked over the Christmas and New Year period until the Manager is satisfied it is not going to require cover with temporary staff. A minimum of 20 days annual leave must be taken as leave without the member of staff working for this Trust or elsewhere. Annual Leave applications are separate to Shift Requests but must also be made prior to 8 weeks in advance of the rota planned start date. Consideration will be given to late requests in line with requirements of the unit and staffing levels at the time and should not incur any expenditure in respect of booking NHSP to cover the absence. Manager to advise employees not to make and pay for holiday bookings until annual Page 15 of 46

16 leave has been approved Managers must use the Roster Analyser to view the percentage of staff on leave prior to approval of leave and production of the roster We will review how much notice staff should give if they wish to book more than one week off Staff who do not submit any annual leave requests will be allocated annual leave by the Unit Manager Pre-arranged annual leave for new starters must be determined at interview and factored into the roster prior to the start of employment. 9.2 The local procedure must state how annual leave is to be allocated when there is more than one request for the same period. The manager should make their objective decision following discussions with the staff concerned, taking all factors into account. A review of the previous year s allocation may be helpful to ensure a fair approach. The precise factors should be agreed with the local staff team as part of the local procedure Flexible Working 10.1The Trust fully supports flexible working and family friendly working but needs to ensure safe levels of staffing and skill mix and therefore reserves the right to decline such requests Staff who have an existing Flexible Working arrangement should discuss this with their manager. Where they are not currently in writing, they should be agreed and recorded using the Flexible Working form Flexible working arrangements must be managed and reviewed at 6 monthly intervals to maximise the quality of patient care and reduce clinical and non-clinical risk In the event that agreement cannot be reached the member of staff is entitled to pursue the matter by use of the Trust s Grievance Procedure. Page 16 of 46

17 10.5 Where staff have a special arrangement to work they cannot work on the bank or for any other employer at times covered by the arrangement, without first offering to work those shifts as part of their normal working week, in their normal place of work Staff that have informed the ward that they cannot work specific dates or times should not be working these on the bank. Managers should keep these flexible arrangements under regular review with staff members at supervision and seek confirmation from the individual that they are not working bank at the relevant times Production of Staff Roster 11.1 There must be a local procedure for allocating staff to the roster, which will be introduced following consultation with staff. The following principles must be included: All ward/department duties must commence on a Sunday. Each area should work to an agreed funded establishment which is reviewed annually or in line with reconfiguration. Permanent staff s contracted hours must be used to cover as many different shifts as possible each day. This will help to ensure that bank and agency staff are working with regular staff when used. The roster must reflect the skill mix and number required and should not include staff or skills over the required level where this may cause shortfalls on other shifts or the need for temporary staff. Senior staff should not be on duty together. Service Managers must generally work weekdays 9am 5pm but may occasionally work differently to support the service, e.g. for the ad hoc support of permanent night staff. Page 17 of 46

18 11.2 The Roster must show who is in charge on each shift and who is providing medication cover. These individuals must have the designated skills and competencies to lead the service All shifts should be equitably allocated to all staff in accordance with their contract of employment and the Trust s policy on Flexible Working to ensure all staff receive a fair allocation and variety of shifts. Managers must ensure that normal hours do not exceed an average of 60 hours over a 17 week reference period. Any new requests for flexible working should be processed in accordance with the Flexible Working Policy and the outcome recorded using the form provided within this Policy. Only once all permanent staff shifts have been allocated, should other shifts be made available for bank coverage. The bank and agency protocol should then be followed to fill any gaps in the roster. Staff should not make more than 4 requests within a 28 day period pro rata for part time unless there are exceptional circumstances. Managers should endeavour to comply with all reasonable requests; however, this should not require the use of agency staff. All staff must have equal access to requests for particular shifts/time off. Requests for popular periods (Bank Holidays and School Holidays) should be considered equitably and a review of last year s allocation undertaken where necessary to ensure fairness. Managers should be mindful of the need to assist staff with leave wherever possible, whose religious festivals occur at different times of the year from the eight national holidays. All off duties should be composed to adequately cover requirements utilising permanent staff proportionately across all shifts Shifts given a high priority on Healthroster must be filled first, i.e. nights and weekends. It should not be routine to use bank/agency permanently on night shifts. The relevant Service Managers will undertake the monitoring and approval of each Page 18 of 46

19 unit s off duty upon completion, produce analysis reports, and approve all shifts where temporary staff are requested. If any of the staff are working non standard shifts such as late starts, this should be entered to avoid misinterpretation. In addition to clinical staff, all staff that support the service should be entered onto the roster. In areas where the workload is known to vary over the week staff numbers and skill mix should reflect this. Senior staff time will be distributed across different shifts. Responsibility for the updating of establishments, as identified on Healthroster, and the safe staffing of each ward lies with the Service Manager, even if she/he does not undertake the task of producing the off duty roster. Guidance can be found at Appendix Changes to Roster 12.1 Staff wishing to alter their roster should, in the first instance, attempt to exchange shifts with other appropriate team members. Changes should be made within equal band and with consideration to the overall skill mix of all shifts being changed All changes must follow the principles outlined above, be authorised by either the manager or designated deputy, and should not result in overtime expenditure or use of agency staff. Only in unforeseen circumstances can changes be made and retrospectively approved by the manager or deputy No member of staff should be required to change their rota with less than 24 hoursnotice. Any such change to the rota can only be made following discussion and agreement with the member of staff involved. The manager should not seek to enforce a change if this would cause disruption to prior commitments made by the member of staff involved. Page 19 of 46

20 12.4 When there are unforeseen circumstances, i.e. a member of staff going off sick at short notice, the manager may request a member of staff to agree to stay on and work additional hours. See Section Shifts missed from rosters with enhancements will not be paid if more than 3 months old Mangers to update and finalise rosters on a weekly basis if Rostering is requested regularly to unlock a roster following finalisation and the payroll run Unsocial Hours / Time Owing 13.1 Unsocial hours should be distributed evenly and fairly, in accordance with agreed contractual restrictions Any time over/above shift times should be authorised by the relevant Matron and recorded on Healthroster Any time claimed back, must be recorded and signed by the manager Every 8 weeks the Ward Manager must run a report using the My staff hours report available to ensure any staff hours that do not balance over a 4 week period are balanced over an 8 week period Local procedures should be in place for the process of authorising time owing All time-owing/time in lieu must be agreed in advance where possible. Any accrued or taken hours must be appropriately recorded Retrospective agreement will only be given where there was a clear and urgent need. In either case the reasons must be recorded and signed by both the line manager and the staff member concerned. Page 20 of 46

21 13.8 Managers must ensure that no more than 12 hours time owing either way is accumulated. In the event of accumulating time owing in excess of 12 hours, this must be authorised by the /operational manager during office hours or the first line on-call manager out of hours and the additional hours taken back the following week Net hours of 12 or more must be reduced on production of new roster Accumulated time-owing hours above 12 must be taken within 28 days of working the additional hours and any difficulties in achieving this must be brought to the attention of the Manager. Managers may not unreasonably refuse to allow time off in respect of time owing. However, where this is unavoidable it will not result in any loss of hours. Managers must confirm in writing the reasons for any decision made relating to this Booking of time-owing should follow the same principles as for annual leave in that it should not incur unnecessary expenditure Any net hours owed on transfer to an internal unit to be managed prior to transfer. If not able to manage prior to transfer then incoming Manager to confirm they are happy to have the hours transferred to their unit and these net hours to be managed within 28 days of transfer When Staff hand in their notice of termination of employment then manager should process My Staff Hours report to calculate staff net hours. Any hours owed to the Trust that cannot be managed prior to leaving date will be deducted from final pay Net hours should be managed prior to leaving date Net hours where time owed (Toil) to staff is shown will not be paid in salary on resignation from the Trust. Page 21 of 46

22 14.0 Uneven Working Patterns 14.1 As stated in Sections 10.1 and 10.2 of the Agenda for Change Handbook, the standard or contracted hours may be worked over any reference period, e.g. 150 hours over 4 weeks or annualised hours, with due regard for compliance with employment legislation such as the Working Time Regulations A record should be kept to ensure that this principle is correctly adhered to Working Time Regulations (WTR) /Opt Out 15.1 See section 27 (Part 4) Employee Relations of AfC for Working Time Regulation requirements. These should be complied with in addition to the requirements below It is the responsibility of ALL employees to ensure compliance with Working Time Regulations Staff who wish to opt out of the 48 hour limit are able to do so. However, the Trust s local arrangement requires staff to abide by the 60 hour working week limit.. Members of staff who do not wish to opt-out will not suffer any discrimination By local agreement, no member of staff shall work more than 60 hours in any 7-day period. This total includes hours worked in all employment including bank, NHS Professionals and agency, whether for the Trust or any other employer This requirement will also be placed upon all agencies providing staff to the Trust Under the WTR night staff cannot opt out of the 48 hour maximum. Night staff are defined as staff who regularly work nights. For example this would include staff on rotating shift patterns who work one week in three on nights. Page 22 of 46

23 16.0 In Work Breaks 16.1 The Trust requires all staff to take a minimum of twenty minutes unpaid break during any period of work in excess of 6 hours. During that break period they should be free to leave the premises should they wish to do so Breaks must not be taken at the end of a shift, as their purpose is to provide rest time during the shift In exceptional circumstances, following a risk assessment, if the member of staff is required to remain available for immediate recall to work, this will be a paid break and the finish time of the shift will not be extended by the length of the break In all cases where there is a paid break, a risk assessment must be included in the local procedures. Where there is no risk assessment it will be assumed that staff are free to leave the premises during their work break Weekly Rest Period 17.1 As far as possible staff should be rostered so that their rest days are taken consecutively. A rest day must be a minimum of 24 hours plus 11 hours break between shifts making a total of 35 hours. A 2 day rest must be 48 hours plus 11 hours making a total of 59 hours Unless by special arrangement, no one should be rostered to work more than 6 consecutive days Shift Patterns hours must be allowed between shifts as far. This means that staff should not be required to work an opposing pattern of shifts. For example: Late/Early/Late/Early/Late/Early. However, it is permissible to have one break that is less than 11 hours in a run of shifts. Page 23 of 46

24 18.2 Night shifts should be kept together wherever possible. No more than 4 nights in a row should be allocated to a staff member. There should be a minimum of 2 days off after a period of night working All shifts longer than 6 hours must include a minimum 20 minute unpaid break. Shifts of 12 hours or more should include a 60 minute unpaid breaks The Manager/Nurse in Charge has responsibility for ensuring that breaks are taken Staff should not work more than three consecutive weekends. Additional weekends off can be rostered where ward requirements allow Weekend shifts are defined as Friday night, Saturday day or night, Sunday day or night Staff should work no more than a maximum of 5 consecutive standard day shifts. Staff may specifically request to work more than this to a maximum of 6 days 19.0 Long Days 19.1 Staff must not be rostered to work for any period longer than 13 hours Within the 13 hours there must be appropriate breaks of not less than 40 minutes The preferable number of consecutive 12-hour shifts (days or nights) recommended for staff to work is 3. In exceptional circumstances, staff may work a maximum of Sleep-Ins 20.1 Sleep-ins are subject to a separate agreement but should not breach the requirements of the Working Time Regulations. Best practice would preclude a sleep-in being placed between a late shift and an early or preceding an early shift. Page 24 of 46

25 21.0 Additional E-Rostering Principles 21.1 This section details specific principles only available within the electronic rostering system Healthroster provides the facility for staff to be rostered to an agreed duty requirement, managing staff availability and allowing clear visibility of ward (staffing) levels It provides a facility for recording annual leave and sickness absence. Staff are also provided with access to Healthroster by the associated Employee On Line facility to request shifts and leave It is for use by the appropriate persons for creating and authorising rosters and recording absences. The system has the facility to track and produce reports for absence, leave and additional duties The E-rostering system will be accessible to Human Resource and Finance staff as appropriate Staff must have received training before permissions are granted to view and administrate rosters Requests for staff to receive training must originate from their Manager and sent by to the Rostering Department Managers to nominate another Manager to carry out the approval/finalisation of their rosters if they are to going to absent at the time of roster calendar deadlines and to inform rostering who the nominated staff are A Healthroster authorised user will be able to : Manage Rosters creating and updating rosters and deleting rosters where they are Page 25 of 46

26 not required. Auto Assign Duties When creating a new roster users must use Auto Roster feature to assign duties to a roster. Auto Roster will automatically assign shiftsrespecting the rules, personal patterns and skill mix - to the available staff. Auto roster will first assign Nights and weekends and after day shifts. Assign Duties Manually Users must assign duties manually, including the processes for swapping and combining duties, after the Auto Roster has completed. Administer Rosters once the roster has been published, the user 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 Authorised users: Roster Unit Manager: Ward Manager, Deputy Ward Manager and approved Senior Admin will be responsible for creating and updating the roster, and partial approval of the roster Roster Service Manager: Service Manager, Matron and nominated Ward Manager will be responsible for partial and full approval of roster and finalisation of duties in preparation for payroll Roster Administrator: Administration staff do not have to be on a roster in order to have access responsible for managing unavailability s and editing of staff personnel details Roster View Only Access: Corporate staff such as HR and Directors Can view rosters, unavailability s and personnel details with read only access and produce reports Page 26 of 46

27 22.0 STAFF REQUESTS 22.1 Staff will have access to the Employee on Line facility to make requests for shifts and annual leave These requests will be considered in the light of requirements to a maximum of 4 requests per person within a 28 day period Leave arrangements are set out in the Leave (Paid and Unpaid) Policy and requests for flexible working patterns will be considered in accordance with the Flexible Working Policy Requests will be considered in the light of need. Staff should indicate if their request is essential or desirable Application can be made for regular specific shifts or days off. These are known as personal patterns. They must be agreed and reviewed quarterly by the Manager who must take into account requirements and equity for other staff members before agreeing to the request If annual leave is being taken during this time, off-duty requests should be pro rata Personal patterns are not to be considered as requests It cannot be assumed by staff that their requests will be accommodated. This includes essential requests. The needs of the service must take priority. Staff should be considerate of their colleagues and the requirement that they are fulfilling their share of weekend and night shifts Requests from staff who typically make few requests, will be given higher priority by Health Roster than requests from staff making numerous requests. Page 27 of 46

28 22.10 Where request forms are being used staff should be informed of the closing date and no further requests will be accepted after this date. It is suggested this is 7 weeks prior to the roster being worked If staff wish to change their rostered shift post publication a fair swap should be made with another member of staff of the same grade that meets the Ward Manager s approval Requests for days off are counted as Requests and will be deducted from the 4 shift requests in 28 days Shift Requests are separate to applications for Annual Leave 23.0 Production of off Duty Rosters 23.1 A table and flow chart of the process is attached at Appendix The publication of working rosters will take place according to the Roster Calendar shown at Appendix Roster Validation and Approval 24.1 The following processes apply: Rosters to be published 6 weeks before off duty commences; Shifts to have an agreed total number of staff and skill mix as shown by the establishment templates; Creation of the off duty should be within budget for the ward; All staff to have at least one weekend off in a 4 week period; The number of unfilled shifts that occur on nights and weekends is 0%; Only 5 standard shifts days/nights should be worked consecutively and no more than a maximum of 7, if specifically requested; Page 28 of 46

29 Use Approve and Analyse when checking the Roster Effectiveness Indicators. There should be no hours carried forward. Check the Roster Analyser Summary Tab for the following: Roster Effectiveness Indicators: Roster unfilled this should be no more than 20% Over Contracted Hours - this should be as near to 0 as possible Lost Contracted Hours this should be as near to 0 as possible Additional Shifts why have they been used Wrong grade type why have they been used Fairness and Safety Indicators: Requests no more than 4 agreed within the policy according to hours worked. Shifts with Warnings Check that the policy rules are not being broken by viewing my Roster Stats and reviewing the Rule/Violation column If rules are being broken, contact the Rostering Administrator for further details Shifts without Charge Cover this should be 0, all shifts must have an identified team leader Annual Leave is evenly distributed and is consistent with the % calculated for the ward Mandatory Unfilled Shifts, Sunday/Bank Holiday should be lowest figures Check Effectiveness Tab for: Requirements v Availability Staff Unavailability there should be 0 warnings Filled Shifts there should be 0 Optional and Additional Shifts unless agreed prior to the creation of the roster Check that Personal Patterns are still valid by reviewing flexible working Page 29 of 46

30 arrangements every 3 months If a roster is rejected an should be sent to the Roster Manager indicating why it was rejected A completed roster must be reviewed by the Roster Approver responsible manager and approved prior to being published The purpose of the review is to identify potentially unsafe shifts, shifts for which temporary staff cover is planned and other possible options discussed and any agreed parameters that have been exceeded Once the roster is reviewed it should be fully approved Approved by the Roster Manager and by the Roster Approver. Fully Approved rosters are automatically published and therefore available to Staff via Employee on-line Once the roster has been fully approved it should be printed and made available for viewing by all applicable staff at least 3 weeks prior to its effective date Any changes made after the roster has been approved must be clearly marked for audit purposes. Staff will be asked to sign a copy of the agreed roster in advance and will be asked to make notification in writing of any eventual changes to working patterns All duties on rosters will be finalised by Service Managers/Matrons. Unit Managers will therefore inform their Service Manager/Matron that the rosters are ready to be finalised in accordance with dates set out in the roster calendar 24.9 Any rosters not finalised within deadlines as set out in the Roster Calendar will not be finalised by rostering and will be withdrawn from the payroll batch. Failure to finalise on time will result in overtime/enhancements not being paid to staff and any paper timesheets Page 30 of 46

31 submitted to the payroll department due to unfinalised rosters will have missed the payroll closedown. Enhancements etc will not be paid until the following month. Advances will not be issued for non-payment of enhancements etc. due to unfinalised rosters All duties on rosters will be finalised by Service Managers/Matrons. Unit Managers will therefore inform their Service Manager/Matron that the rosters are ready to be finalised in accordance with dates set out in the roster calendar 25.0 Key Performance Indicators 25.1 The following Key Performance Indicators will be monitored by Associate Directors and Roster Approver at Business Meetings, using Analysis Reports (Appendix 3): % of lost contracted hours % of over contracted hours % of additional duties % of unfilled duties % of non-effective working days, Details of vacant shifts by temporary staff cost category Non effective working days - Staff s unavailability during the 4 week roster period is broken down in to the following categories. The total percentage of these should equate to the overhead that is built in to each establishment. For example the headroom is currently set for 24/7 services at 20%. Total leave should not exceed 20% and should be within the tolerances set below : Annual Leave 7-17% Study Days 2% Leave (Sickness, Maternity, other) 5% Page 31 of 46

32 Requests - numbers of requested shifts compared with Trust policy Contracted staff by WTE Number of bank requests to total bank hours worked. Number of vacancies Number of bank requests on weekend and night shifts 25.2 Rosters that fall outside set parameters may be rejected Booking of Temporary Staff 26.1 Temporary staff shifts will only be approved if requests meet the following criteria: within budget within existing vacancies to cover either band 5 or band 2 roles to cover unpaid maternity leave 26.2 Temporary staff required outside these parameters must be authorised by the Matron, Associate Director or on call manager Temporary staff cannot be used to take charge of departments unless they are known to the department, have been assessed as competent to do so, and are willing to take charge. This must be approved by the Matron, Associate Director or on call manager Staff who have been off sick in the previous 7 days must not undertake bank work for a period of 5 working days from their date of return after sick leave Night and weekend shifts must be covered by substantive staff whenever possible, without imposing unreasonable strain on substantive staff Study leave should not be covered by temporary staff. Page 32 of 46

33 27.0 Changes to Published Rosters 27.1 The following processes apply: Unit managers will amend rosters to reflect actual shifts worked i.e. changes due to sickness, no shows and additional shifts. The actual worked roster must be updated on Health Roster by 12:00 every day. Shift changes should be kept to a minimum. In the first instance, staff wishing to alter their roster should attempt to exchange shifts with appropriate team members. Changes should be made with an equal grade, and with consideration for the overall skill mix of all shifts being changed. All changes must follow the procedure, be authorised by either the manager or designated deputy and should not result in overtime expenditure or use of temporary workers. Changes to the roster sheets should only be made by the manager or their deputy except in urgent, unforeseen circumstances and these must be retrospectively approved by the manager or deputy. Except in instances of operational necessity, managers should provide at least 24 hours notice of a change of roster. However in discussion and agreement with a member of staff the manager may request a change of rota with less notice e.g. to cover for a member of staff going off sick Annual Leave The following processes apply: Annual leave must be booked within the context of the Trust s Leave Policy. The Manager or designated deputy is responsible for approving all annual leave and for ensuring that annual leave is taken in accordance with this policy. Managers should ensure that staff are aware of local procedures for the allocation and agreement of annual leave. If a member of staff needs to delay or amend an annual leave booking this will be considered taking into account local needs, provided it does not incur extra expenditure. Page 33 of 46

34 Managers are responsible for calculating the number of qualified and unqualified nurses who must take annual leave in any one week. This number must be made explicit and adhered to in order that the workforce is appropriately used to cover needs. Annual leave parameters are expressed as percentages in the Healthroster reporting system and managers are responsible for ensuring that the total amount of leave taken by staff each week falls within the band of a minimum of 11% to a maximum of 17%. Should this number not be met, by way of requests, the Manager will allocate leave following discussions with the staff concerned. This is a key performance indicator for assessing effective use of the workforce and will be monitored regularly by Associate Directors and senior management. The Employee Online system tool is available to enable staff to book annual leave and should be used to enable effective collation of annual leave information. Managers may refer to e-rostering annual leave records when signing annual leave forms to ratify leave taken which are in the Leave Policy. Roster Managers must liaise with the Rostering Team when there are staff under term time contract working at the unit in order to set special parameters for them Study Leave 29.1 The following processes apply: Study leave will be assigned in line with the Leave Policy. Managers should ensure that mandatory training is balanced throughout the year and assigned per rota Sickness Please see the Absence Management Policy and Procedure (SABP/Workforce/0033) 31.0 Electronic Staff Records (ESR) ESR remains the master system for recording of all staff data. Page 34 of 46

35 32.0 Monitoring Table What will be monitored How/Method Frequency Lead Reportin g to Deficiencies / gaps recommendations and actions Compliance with the Report Annual Director of Quality Non-compliance will policy. Workforce Committee be reported to the Mandatory relevant Divisional Director Page 35 of 46

36 Equality Analysis The equality analysis guidance notes and template are provided to support you in meeting the requirements of the Public Sector Equality Duty which came into force on 5 April You should use this template to record evidence that equality analysis has been carried out before policy decisions take place. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. 1. About the policy/project/change Title of the policy / project / change: What are the intended outcomes / changes expected as a result of this policy / project / change: Are there links with other existing policies/projects: (if yes provide details) Rostering and Working Time Regulations Policy and Procedure To provide guidance on procedures for producing staff rosters, either electronically or manually, that are compliant with the Working Time Regulations. To ensure that effective rosters are legally compliant and provide efficient deployment of staff and resources Flexible Working Policy and Procedure Leave (Paid and Unpaid) Policy and Procedure Grievance Policy and Procedure Absence Management Policy and Procedure Agenda for Change (AFC) Handbook Implementation of Working Time Directive for Doctors in Training Health and Safety at Work Policies 2. Decide if the policy / project / change is equality relevant Does the policy/project involve, or have consequences for people using services, carers, employees or other people? If yes, please state the Yes Page 36 of 46

37 groups of people who are likely to be affected. If yes, then the policy/project is equality relevant. If no, you can skip to section 6. However the majority of Trust policies and projects are equality relevant because they affect people in some way. 3. Gathering evidence to inform the equality analysis What evidence have you gathered to help inform this analysis? This can include evidence from national research, surveys & reports, interviews and focus groups, policy monitoring and evaluations from pilot projects, etc. If there are gaps in the evidence available under any of the characteristics, please explain why this is the case and state what actions will be taken to close the gaps as part of the action plan. Please ensure you check Annex C of the guidance notes for sources of evidence. The Protected Characteristics & Evidence Using the relevant available evidence - what is known, understood or assumed about each of the equality groups / protected characteristics identified below that could be relevant to this policy / project / change. Record the sources of the evidence used for all the protected characteristics ESR hold staff protected characteristics but not carer information. We know from this data that our 24 7 services where most rosters have a higher percentage of staff from a BME background than in community services 4. Engagement and Involvement Record the names of the people and/or groups involved in gathering evidence and/or testing the evidence against the policy / project / change. Who and how were they involved? Who name of individual / group(s) represented HR Team How have these people been involved e.g. meeting Meeting Page 37 of 46