E-ROSTERING POLICY OCTOBER 2016 This policy supersedes all previous policies for e-rostering
Policy title e-rostering Policy Policy HR40 reference Policy category Human Resources Relevant to All Staff in HealthRoster Date published October 2016 Implementation October 2016 date Date last October 2016 reviewed Next review October 2018 date Policy lead Craig Stewart HR Systems and Programme Manager Contact details Email: craig.stewart@candi.nhs.uk Telephone: 020 3317 7174 Accountable director Approved by Approved by (Committee): Document history Membership of the policy development/ review team Consultation Claire Johnston, Director of Nursing and Performance Policy Review Group September 2016 Workforce Committee October 2016 Date Version Summary of amendments Oct 2016 4 Policy Update August 2014 3 Complete revision April 2012 2 Complete revision April 2008 1 New policy HR Systems and Programme Manager HR Staff NHSP Operational Meeting, Safe Staffing Group, Ward Managers, Team Managers, Policy Review Group, Occupational Health, Nursing Directorate, Human Resources, e-rostering Team. DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. I E-ROSTERING POLICY_HR40_OCTOBER 2016
Table of Contents 1.Summary... 1 2.Introduction... 1 2.1 Purpose... 1 2.2. Scope of the Policy... 2 2.3. Local documentation on safe staffing, skill mix & flexible working... 2 2.4. Definitions... 3 2.5. Roles and Responsibilities... 4 2.6 Communication... 7 2.7 Headroom Allowance... 7 3.Key Performance Indicators... 7 4.Producing Rosters... 8 4.1 Producing Rosters... 8 4.2 Rostering Rules and Restrictions... 9 4.3 Roster approval (Rostered Staff Only)... 11 4.4 Changes to published/finalised rosters... 12 4.5 New Staff... 12 5.Skill Mix and Shift Staffing... 13 5.1 Skill mix... 13 5.2 Flexible Working... 14 5.3. Staff Requests... 14 5.4. Shift patterns... 15 5.5 Working Time Regulations... 16 5.6 Students... 20 5.7 Staff redeployment... 20 6. Periods of staff unavailability... 20 6.1 Annual Leave... 20 6.2 Study Days and Study Leave... 22 6.3 Sickness Absence... 22 6.4 Special Leave (Paid & Unpaid)... 23 6.5 Maternity, Paternity and Adoption Leave... 23 6.6. Time Balances (TOIL)... 23 7. New Staff, Leavers and Contractual Changes... 24 8. Temporary Staffing (NHSP)... 24 9. Monitoring and Audits... 25 10. System failure... 26 11.Dissemination and Implementation Arrangements... 26 12.Training Requirements... 26 13.Appendices... 27 13.1 Appendix 1 Equality Impact Assessment Tool... 27 13.2 Appendix 2 E-Rostering Summary... 28 13.3 Appendix 3 E-Rostering Timeline... 29 13.4 Appendix 4 Quick Guide to Producing Rosters narrative responsibilities... 30 13.5 Appendix 5 Annual Leave Formula... 31 13.6 Appendix 6 NHSP Booking Process... 32 13.7 Appendix 7 Working Time Regulations Opt Out Form... 33 13.8 Appendix 8 Night Worker Health Questionnaire... 34 II E-ROSTERING POLICY_HR40_OCTOBER 2016
1. Summary HealthRoster is a computerised system that has been specifically designed to be used by staff, ward/team managers and senior managers. With HealthRoster members of staff have the opportunity to self-roster their shifts, ward/team managers can use it to produce effective and fair rosters and senior managers can monitor expenditure and trends. HealthRoster can also be used by non-clinical units for recording time and attendance, maintaining staff records and submitting monthly data to payroll. The HealthRoster system is capable of storing personnel data about an individual s contracted hours as well as information on annual leave, study leave and sickness absence which are essential to management. HealthRoster will also store ward/team/service area profile data such as establishment, vacancy, skill mix, Working Time Directive information and staffing levels so that management can access this information rapidly for effective planning and monitoring. This policy offers guidance that must be used in conjunction with HealthRoster applications and related training material. ESR (Electronic Staff Record) is the master system for HR and Payroll and Agresso is the master system for Finance. It remains that data quality in HealthRoster is of paramount importance as HealthRoster is the official Trust record of staff time and attendance. 2. Introduction 2.1 Purpose The purpose of this policy is to ensure the effective utilisation of the 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 NHSP 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 non-effective 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. Ensure staff feels valued as a resource by establishing a fair and equitable system to manage working time. 1 E-ROSTERING POLICY_HR40_OCTOBER 2016
The policy sets out Camden and Islington NHS Foundation Trust s standards for the use of HealthRoster and its related products in support of existing policies, which includes: Agenda for Change Terms and Conditions of Employment Annual Leave Policy E-Rostering Documentation Study Leave Policy Staff Handbook Flexible Working Policy Special Leave Policy Managing Attendance and Absence Policy Maternity, Paternity & Adoption Leave Policy NHSP Booking Protocols Any other relevant department documents 2.2. Scope of the Policy This policy is for use by all areas using erostering. 2.3. Local documentation on safe staffing, skill mix & flexible working All Departments will hold formal documentation relating to Agreed funded establishment as set in the Trusts annual budget. The associated staffing levels (number of staff) by shift and by day funded by the establishment. This must be reviewed appropriately in conjunction with service leads and directorate managers 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 formula Appendix 5) Funded 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 funded staffing levels must be reflected in HealthRoster; it is the responsibility of the ward/team 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. 2 E-ROSTERING POLICY_HR40_OCTOBER 2016
2.4. Definitions A number of terms are defined below to assist understanding. Please also see appendix 2 and 4 for further definitions Non-effective working days One request Permanent: Temporary Substantive Variations in shifts Personal patterns Shared patterns Personal preference Contingent workforce Unit: Management days / Working days WTE Planned roster Headroom Allowance Key Performance Indicator Monitoring Unfilled Duties Additional Duties Relates to days that staff 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 21% Departments Headroom. One request made by staff for a particular shift (Early/Late/Night) or day off. Staff who have permanent contracted hours. NHSP and other temporary staff e.g. agency staff. Staff who have a permanent or fixed term contract. Not NHSP or agency staff. Differing start and finish times to regular shifts. Every week the person works the same shift on the same day; approved formally by the ward/team manager and subject to biannual reviews. It is for the benefit of the individual. 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 ward/team 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 ward/team 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 non-effective 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 3 E-ROSTERING POLICY_HR40_OCTOBER 2016
2.5. Roles and Responsibilities 2.5.1 Employees 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 ward/team 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 the appropriate HR change form i.e. Personal Details Change Form Raising any queries in relation to payment of their Unsociable hours/on Call and Call out payments with their managers in the first instance. 2.5.2 Roster Creators are responsible for: - Producing rosters in line with the Roster Production Trust Timetable and roster KPIs as described in this document. Completing a roster to the best of their ability aided by the roster functionalities such as the auto rostering function and the roster analyser. Ensuring that the roster is fully completed without any days being left empty on the roster grid for any staff. Seeking help and guidance in a timely manner should they experience any problems using HealthRoster. 2.5.3 Level 1 Approvers: Ward/Team Managers are responsible for:- Identifying a Roster Creator and a Deputy and ensuring that they 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 the Trusts e-rostering policy and in line with Key Performance Indicators (Section 3). 4 E-ROSTERING POLICY_HR40_OCTOBER 2016
As Level 1 approver, ward/team 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 NHSP/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. Ensuring process for monitoring and auditing rosters is followed as per section 9 in this document. Finalising Rosters Rosters should be finalised as a minimum on a weekly basis. By the 4th 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 mean that staff do not receive the correct pay. This may result in the Performance Management and/or disciplinarily procedures being invoked. 2.5.4 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 3) and Key Performance Indicators (Section 3). Reviewing analysis reports and Key Performance Indicators on staffing, expenditure and quality in their area of responsibility and action change. Monitoring and questioning the use of Additional Duties; ensuring Level 1 Approver is informing of Additional Duty use that increases NHSP/Agency use. Secondary Authorisation: reviewing all shifts where temporary staff have been 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 ward/team manager or deputy in the creation of duty rosters, using the Key Performance Indicators as a reference. 5 E-ROSTERING POLICY_HR40_OCTOBER 2016
Ensuring process for monitoring and auditing rosters is followed as per section 9 in this document. N.B Level 1 and Level 2 approval roles will be defined and agreed by the ward/team manager/matron/service manager/divisional manager 2.5.5 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 (Section 3). Using Key Performance Indicators to form an understanding of rostering patterns to ensure that the clinical resource is managed efficiently. Report to appropriate senior managers including Executives. Ensuring process for monitoring and auditing rosters is followed as per section 9 in this document. 2.5.6 The Director of Nursing and People is Responsible for:- Overseeing the continued implementation and use of e-rostering across the Trust. Monitoring and reporting against Key Performance Indicators, with the support of the Finance and Human Resources Teams and reporting through Divisional performance mechanisms to the Trust Board via the Foundation Trust Executive Team. Ensuring that the roster approval and finalisation process is adhered to especially in regard to timelines. 2.5.7 The HealthRoster Group 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 proactive 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 RosterPerform) and ensuring the development and implementation of appropriate action plans. 2.5.8 E-Rostering Team is Responsible for:- Monitoring compliance with Trust Mandatory Roster Publication Timetable providing operational managers with compliance information and notifications via RosterPerform. 6 E-ROSTERING POLICY_HR40_OCTOBER 2016
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 for the Safe Staffing Group and Directorate Management Teams on a monthly basis. Ensuring the e-rostering system remains appropriately configured. Setting up new users with log in details and passwords. Providing support and on-going training to the e-rostering users. Liaising with the e-rostering IT Support Team to resolve system issues as required. 2.5.9 Directorate Management Accountant is Responsible for:- Supporting departments with their annual review of staffing resources by undertaking the annual budget setting exercise in conjunction with the appropriate manager and Directorate Lead. To validate any changes to establishment figures for staffing and budget in a timely fashion. 2.6 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. 2.7 Headroom Allowance The Department Headroom allowance should be included in the unit budget and is used to cover expected absence. The Headroom Allowance is 21% of a unit s budgeted establishment and is as follows: - Annual Leave and Bank Holidays 15% Sickness 3% Maternity/Paternity Leave, Special Leave and Study Leave 3% 3. Key Performance Indicators All units will be expected to efficiently manage the deployment of their workforce in line with any agreed Trust Key Performance Indicators. Level 1 and 2 approvers will be accountable for the management of their performance against the Key Performance Indicator s. To ensure proactive management of the rostering process, all senior managers and clinician s and any other identified staff (HR, Finance, and Clinical Governance) can have access to RosterPerform (the e-rostering management information system). The Divisional Performance Group will also receive a regular report relating to each Directorate in respect of performance against the Key Performance Indicators. 7 E-ROSTERING POLICY_HR40_OCTOBER 2016
Some examples of the Key Performance Metrics that will be managed and reported upon from HealthRoster are as follows: Non-patient care working days: Staff s unavailability during the 4 week roster period is broken down in to the below categories. The total percentage of these should not exceed the 21% overhead that is built in to each establishment. o o o o o o Annual Leave Sickness Study Leave Other Leave Parenting Working Day (Duties out of the Numbers i.e. Management Day, Housekeeper) Roster Approval Lead Times: The number of days in advance of the first shift, a roster is produced and signed off. Lost Contracted Hours not used per month: The total number of contractual hours not worked by staff on a roster. Additional Duties and reasons for booking: Any duties allocated that are above the agreed staffing requirements for the department. NHSP and Agency Usage %: The amount of the hours that is assigned to NHSP or agency staff. NHSP Fill Rate %: The percentage of NHSP requested shifts that have been filled.. NHSP and Agency Usage % on weekend and night duties: The percentage of NHSP requested shifts that have been filled by NHSP that fall on a weekend or at night. Staff with Working Restrictions %: The amount of contracted staff that are not fully flexible. Auto-Roster %: The % of the roster created using auto-roster. Thresholds will be set based on overall Trust or departmental/divisional performance targets. It is recommended that thresholds are reviewed and if required amended to ensure they reflect any on-going service improvement initiatives. 4. Producing Rosters 4.1 Producing Rosters The Roster Production Trust Timetable must be adhered to in order to ensure accuracy of scheduling and pay. There will be 13 rosters per annum, with each roster covering a 4 week period. All rosters must commence on a Monday and if required must be ready for Level 2 approval at least seven weeks in advance of the roster start date. Level 2 approvers will normally be a matron, senior clinician or senior manager. If a roster is rejected by a Level 2 approver, any amendments must be made and approved no less than six weeks in advance of the roster start date. This will allow for the roster to be 8 E-ROSTERING POLICY_HR40_OCTOBER 2016
published and made available to staff in accordance to the Roster Timetable. This will enable staff to better manage their personal lives whilst giving Level 2 approvers time to consider requests and alternative staffing options to fill any vacant duties. All rosters should be composed to adequately cover the agreed set hours i.e. 24 and should utilize substantive staff proportionally across all shifts/departments. Shifts designated as high priority by the unit must be filled first i.e. weekends, nights. The use of temporary staff to cover high priority shifts should be avoided where possible. All staff time and attendance, sickness and absence must be accurately captured on the roster to ensure accuracy of hours. A quick guide to producing rosters is shown in appendix 4 and should be used in conjunction with the e-rostering Timeline (appendix 3) 4.1.1 Students & their inclusion in Rosters All student 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 numbers. 4.2 Rostering Rules and Restrictions System rules and restrictions are used by e-rostering to promote: - Fairness Flexible Working Patient Safety Consistent application of local and national policy across all areas. Workforce efficiency and productivity. There are two main rule types used by e-rostering. These are: - Duty Rules These determine the ward/team working and rostering rules, specifically related to how different types and combinations of shifts should/should not be worked and by whom, and any limitation for example requests and people on shift. Unavailability Rules - These determine the ward/team working and rostering rules around unavailability, for example limits on the allocation of leave or rules that generate warnings that assist with sickness/absence management. Ward/Team managers are able to define rules at a local level to aid in the creation of their rosters and use of auto-fill functionality. Normally these rules would be unit specific i.e. the 9 E-ROSTERING POLICY_HR40_OCTOBER 2016
minimum number of females required on each shift or the minimum number of staff on each shift with a specific skill. Some rules will be set at a Trust level and are therefore applicable to all areas. These rules are used to determine whether rosters are being produced in line with local and national policy i.e. the minimum number of free weekends each employee should receive or the maximum number of hours staff are permitted to work as per Working Time Regulations. 4.2.1 Rule Breakages When an employee s assigned off duty triggers a warning, this will be clearly highlighted on the roster (normally in red or bright yellow). Ward/Team managers are expected to investigate any rule breakages and where relevant take the appropriate action to resolve or prevent any further occurrences In some cases a rule may be set to trigger a violation. If this is the case the system will prevent you from assigning off duty i.e. a day shift should not be rostered immediately after a night shift. If a local rule is no longer required the Ward/Team manager should notify the e-rostering Team at the earliest opportunity so that it can be removed from the system. The % of duties with warnings attached is monitored and should be reviewed by both the 1 st and 2 nd Level Approvers during roster sign off. 4.2.1.1 Rule Breakages and NHSP Shifts Workers who are booked by the unit or self book using StaffBank to shifts originating in HealthRoster are subject to the same rules and associated warnings and violations. Workers will be unable to request bookings if any of the following rules are broken: - If the total hours worked, including NHSP exceeds 60 hours in any 7 day reference period. This is measured from Monday to Sunday. If the total weekly average worked exceeds 48 hours, this is measured over a rolling 17 week reference period. Staff wishing to opt out of this rule should refer to section 5.5.5 in this document. Invalid shift patterns such as: - o Day shift the same day as a Night Shift o Day shift after Night Shift o Night shift followed by Study Leave/Training Day Working any shift for up to 7 days following sickness Conflict Shifts Where NHSP shift overlaps a rostered duty. 10 E-ROSTERING POLICY_HR40_OCTOBER 2016
Employees are reminded to check their rostered duties using Employee Online before requesting any NHSP. Roster Managers should ensure any changes to off duty agreed verbally or on paper are entered into the system within 24hours. 4.3 Roster approval (Rostered Staff Only) A completed roster must be reviewed and approved at Level 1 and Level 2 prior to publication. Typically the team/ward manager will undertake the Level 1 validation and approval using the Roster Analyser Tool. This should be done at least seven weeks in advance and they should inform the Level 2 approver once this has been completed. The level 2 approver, who will normally be the senior clinician/matron/senior manager will check to confirm the roster meets the defined parameters and if needed recommend any changes before allowing the roster to be published at least six weeks in advance. Both Level 1 and Level 2 approvers are accountable for maintaining this timeline. When approving the roster, the following should be taken into account: - The total cost of the roster and whether it is within budget The no. of unfilled duties and whether this matches current vacancy levels That annual leave is planned between 11-17% That all staff hours have been assigned That there are no additional duties without prior agreement That there is evidence of staff duty requests That the no. of duties with warnings is within tolerance If rosters are rejected by the Level 2 approver, they must ensure this is communicated to Level 1 including the reasons why and the date which any changes must made by. 4.3.1 Late Rosters Where a roster will be published with less than six weeks notice it will be considered late. Every effort will be made to establish whether there are any extenuating circumstances preventing sign off and in situations where none can be found the following escalation process will be applied: - 1 14 days late: Rostering Team will notify the Level 1 and Level 2 Approvers that roster is overdue and that immediate action is required. 15-28 days late: Rostering Team will notify the relevant Divisional Director that roster is overdue and that immediate action is required. 29 days late or more: Rostering Team will notify the Chief Operating Officer that the roster is overdue and that immediate action is required 11 E-ROSTERING POLICY_HR40_OCTOBER 2016
KPI s relating to Roster Approval Lead Times will be reported on at the Divisional Monthly Performance Meeting. 4.4 Changes to published/finalised rosters It will be the responsibility of the ward/team manager or designated nurse in charge for each shift to amend off duties with non-effective shifts i.e. sickness, special leave, and additional duties. Where possible shift changes should be kept to a minimum. Staff are responsible for negotiating their own shift swaps. NHSP should not be used to accommodate staff shift changes unless the change is required to meet service needs. If a roster has been approved and published, all changes made will be clearly marked in the system for audit and reporting purposes. When making changes, roster managers must ensure they consider the following patient safety factors:- Grade Skill mix Patient dependency If an equivalent band/skill mix is not available, a risk assessment should be carried out before authorising any change. 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. All updates to the roster must be made before the roster is finalised and within the same period in which the change occurred. In the event that a genuine mistake has been made which has been finalised and submitted to payroll in error, managers are to contact the e- Rostering Team to initiate a manual payroll amendment. As the correction of finalised recordings involves a manual process requiring time and resources, the utmost effort should be made in ensuring that recordings are correct before being finalised. 4.5 New Staff New substantive staff (permanent and fixed term) may have a supernumerary period. This is normally around 2 weeks but should be assessed on an individual basis, taking into consideration the requirements of the department/directorate. Newly registered nurses should be rostered in accordance with the Preceptorship Handbook for Nurses. This will include being rostered as unregistered whilst awaiting professional registration, working with their Preceptor for at least 1 shift per week as well as regular supervision meetings. As a minimum staff must receive monthly supervision however best practice recommends this takes place weekly. Nurses within the Preceptorship Programme will not be allowed to Take Charge, unless supervised. 12 E-ROSTERING POLICY_HR40_OCTOBER 2016
5. Skill Mix and Shift Staffing 5.1 Skill mix A staffing baseline which has been agreed and funded is essential to delivering high quality care. Each unit must have an agreed total number of staff and skill mix required for each shift, approved by the budget holder in conjunction with Finance, which is accurately reflected in vacant duties. The skill mix and establishment must be reviewed every 6 months, with the budget setting and workforce planning process. Skill mix and establishment reviews may happen more frequently if a need/risk is identified. From June 2014 all NHS Trusts have been required to publish information about the number of actual qualified nurses and unqualified support workers per inpatient ward shift, together with the percentage of shifts meeting safe staffing guidelines. This initiative is part of the response to the Francis Report, and is in the spirit of openness, public accountability and candour. Information on ward staffing is displayed for patients and visitors in all wards. This shows the planned and actual staffing available at the start of every shift. Information about staff fill rates is published on our website and our Board of Directors receives a monthly report including information about those wards where actual staffing numbers do not meet planned levels. The nurse staffing establishment is reviewed by the trust board every six months, in accordance with expectations from NHS England. 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.:- Control and Restraint Administer 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 co-ordinating role. To achieve a balance of skills across all shifts senior staff should work opposite shifts. Ward or team managers should routinely work Monday to Friday dependent on the needs of the service. The ward or team Manager should only work nights or weekends where there is an identified need and have prior approval from the senior clinician/matron/senior manager. It must be recognised that in some areas of the Trust a senior nurse should always be available as the site co-ordinator. The off duty of senior staff must be compatible with their commitment to any bleep holder s rota. Pre-registration nurses must be rostered to work with their mentor for a minimum of 40% of their shift time. If their mentor 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. 13 E-ROSTERING POLICY_HR40_OCTOBER 2016
Newly registered nurses must be rostered to work with their preceptor a minimum of 1 shift per week, as well as meeting for supervision for at least 1 hour each month. 5.2 Flexible Working The Trust is committed to supporting all employees to balance work and other life needs to promote the use of flexible working patterns where possible. (Please refer to flexible working policy) Any flexible working patterns that are agreed between a member of staff and a ward/team manager, including the date next review, should be communicated to the e-rostering team so that they can be recorded in the system. 5.3. Staff Requests Personal Patterns are not considered as requests. All staff must use Employee Online to make requests. Roster Managers are responsible for training their staff in the use of Employee Online and for ensuring they are using it for submitting requests. Full time staff are permitted up to six duty requests per four week roster. This is on a pro rata basis and is subject to contracted hours (please see Table 1 below). In extenuating circumstances staff may exceed their request allocation verbally to their line manager. The total number of requests per person, including any additional requests, is recorded by the system and shown in a Staff League table to review equity and fairness. Staff should recognise that the number of requests they can submit will equate to 20% of the roster. Approval of a request is not guaranteed as the roster manager must consider them in light of service needs and what other staff have requested. The Roster Manager will endeavor to meet individual requests as far as possible and where appropriate reference the appropriate request league tables to ensure fairness. No requests should be granted if this results in additional NHSP use. If a member of staff regularly wishes to exceed their request allocation, they should consider whether a flexible working request should be submitted instead, as per the Trusts Flexible Working Policy. Personal/Flexible Working Patterns are not considered as requests. However if staff have had flexible working approved, no further duty requests will be permitted. 14 E-ROSTERING POLICY_HR40_OCTOBER 2016
Table 1 Staff Hours per Week Total number of requests per 4 week roster 28 Hours + 6 Requests 19 27 hours 4 Requests 10 18 hours 3 Requests 0 9 hours 2 Requests 5.4. Shift patterns Staff will be required to work a variety of shifts and shift patterns as agreed by their ward/team manager or as specified in their contract of employment. All shift times and patterns, including breaks must comply with agreed Trust guidelines and with the Working Time Regulations. In cases where a shift pattern does not comply, it 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 Workforce Group. Staff must have a minimum of one weekend off per 4 week roster unless they have specifically requested to work weekends. Further weekends off are permitted, providing service needs are met and that the allocation of weekend work is managed fairly. The maximum number of consecutive standard 8 hour day shifts recommended for staff is 5. Staff may work more than this (to a maximum of 7) if specifically requested but managers and staff must ensure compliance with The Working Time Regulations. The maximum number of consecutive standard 11.5 hour Long Day Shifts recommended for staff is 2 up to a maximum of 3 if specifically requested. Staff should not be rostered to work more than 4 Long Days per week. Where a Long Day exceeds 12 hours, they should not be rostered consecutively to comply with Working Time Regulations. If rostered consecutively for service needs, the appropriate compensatory rest will be assigned. The maximum number of consecutive Night Shifts recommended for staff is 4. Internal rotation is expected by the Trust and all staff should work a combination of both days and nights, unless exempted for any reason by their ward/team manager and this reason has been documented and is reviewed bi-annually. Staff are not permitted to work permanent nights. Staff who 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. For areas that operate Sleep In Shifts, it is recommended that these are not rostered consecutively in order to ensure compliance with Working Time Regulations. If rostered consecutively for service needs, staff should only work a maximum of 2 consecutive Sleep In Shifts and managers must ensure the appropriate compensatory rest is assigned 15 E-ROSTERING POLICY_HR40_OCTOBER 2016
5.5 Working Time Regulations The Trust is committed to the health and safety of its employees and acknowledges its obligations within the Working Time Regulations. The Working Time Regulations set down entitlements of employees to maximum working hours, rest periods, rest breaks whilst at work, annual leave and working arrangements for night workers. Under the health and safety at work legislation there is a responsibility on all employers for the health, welfare and safety of their employees, as far as practicable. Management and control on working hours should be regarded as an integral element of promoting and managing the health and welfare of employees 5.5.1 Line Manager s Responsibilities To ensure that the regulations outlined below are adhered to at all times and ensure their staffing off duty complies with the Regulations. To ensure employees are made aware of this policy and understand their responsibilities in relation to it. To ensure the working hours of their staff are monitored and that they are not in breach of the Regulations. To ensure that employees take their entitled rest period and breaks to reduce the risk of fatigue, loss of concentration and associated stress. 5.5.2 Employee Responsibilities To ensure they take appropriate rest breaks in agreement with their line manager and in line with the Regulations. To inform their line manager of any additional employment and the hours they work, including NHSP and agency work. To make their manager aware if they believe that their working pattern is in breach of the Regulations. Where an employee is uncertain as to the application of any aspect of the Regulations, they should contact Human Resources for further clarification. 5.5.3 Provisions of the Working Time Regulations In summary the core provisions of the Regulations are as follows: Average 48 hour working week over a 17 week reference period 11 hours rest per 24 hours Rest Breaks Average 8 hours working time for night workers over a 17 week reference period Health assessments for night workers Paid annual leave 16 E-ROSTERING POLICY_HR40_OCTOBER 2016
5.5.4 Working Time Limits The regulations provide that a worker s average working time, including overtime and time on call at the workplace, must not exceed 48 hours per week. To calculate average working time, a reference period is used. The standard reference period is 17 weeks (over a rolling period). No employee is permitted to work in excess of 60 hours in any 7 day period. The reference period used to calculate the weekly limit will be from Monday to Sunday. 5.5.5 Agreeing to Work over the 48 Hour Average The Trust does not require any member of staff to work in excess of an average of 48 hours per week. However, there may be instances where an individual member of staff may wish to work more than this average, in which case they must agree in writing that the weekly limit does not apply. The Trust, through the relevant line manager, will need to be satisfied that the health and safety of the individual member of staff and the safe delivery of the service will not be adversely affected when making such individual agreements. If a worker wishes to opt out of the 48-hour weekly limit, they should complete the Opt Out form in Appendix 6 It is important that managers and staff do not presume that working beyond the average weekly limit of 48 hours is considered the norm. 5.5.6 Rest Periods All Trust employees are entitled to the following provisions: and Daily Rest (a break between working days) An uninterrupted rest period of at least 11 consecutive hours in each 24 hour period Weekly Rest (the 'weekend') An uninterrupted rest period (separate to the 11 hour break detailed above) of 24 hours in each 7-day period or alternatively a rest period of 48-hours in a 14-day period. 5.5.6.1 Exceptions and Compensatory Rest The Trust recognises that there will be occasions when the full entitlements to daily and weekly rest periods cannot practically be achieved, for instance: Where the staff member changes shifts (e.g. from a late shift to early shift) Where the staff member works split shifts (e.g. a morning shift and an evening shift) Where there is the need for continuity of care in areas where staff work in direct contact with patients in "round the clock services Where staff have undertaken work during an on-call period which is preceded and/ or followed by a period of duty Where staff are required to work due to emergency or unforeseeable circumstances In the case of such exceptions applying, the member of staff shall be allowed to take equivalent periods (i.e. the same number of hours lost) of compensatory rest, e.g. if there are only 8 hours daily rest one day, to be allowed the remaining 3 hours another day in 17 E-ROSTERING POLICY_HR40_OCTOBER 2016
addition to the 11 hours for that day. This should be taken within a reasonable period 2 weeks for daily rest and 1 month for weekly rest. Where this is not possible for objective reasons, then appropriate measures will be taken to safeguard the health and safety of the employee. 5.5.7 In Work Rest Breaks A member of staff shall be required to take an uninterrupted break of at least 20 minutes when working time is more than 6 hours. This is an unpaid break. This entitlement shall be modified where the exceptions detailed below apply. The Trust recognises that in exceptional circumstances there are some service areas and occasions when the entitlement to an in-work rest break cannot be achieved, for instance: Where there is a need for continuity of care in areas where staff work in direct contact with patients Where staff are required to work due to emergency or unforeseeable circumstances which would be a rare occasion and should not become custom and practice. In the case of such exceptions applying the member of staff shall be allowed to take equivalent periods of compensatory rest during another period of duty, as soon as reasonably practicable, usually within 2 weeks. This should not be taken, either at the start or the end of a period of working time. Where it is not practical for such compensatory rest to be allocated, the line manager must ensure that the staff member's health and safety is protected. A break of at least half an hour in a full day is to be encouraged and it is the Manager s responsibility to ensure that breaks are able to be taken. All Trust staff are entitled to: An uninterrupted rest break of 20 minutes in one block where daily working time exceeds 6 hours, which must not be taken at the start or end of the shift Rest breaks are normally unpaid and usually coincide with an individual s lunch break although departmental managers will determine appropriate break arrangements. Breaks should not be taken at the start or end of the day, or stored up and taken on a cumulative basis at a later date. Where an employee is unable to take a rest break, because their activities require the need for continuity of service, they will be entitled to take an equivalent period of compensatory rest, (i.e. same number of hours) as soon as possible. Managers should always plan for their staff to take appropriate rest breaks and if there is any difficulty in making adequate provision for these, they should seek advice from Human Resources. Where a department is repeatedly short-staffed and this impacting on the provision of rest breaks this should be reported using the Trust s Incident Report Form and the concern should also be escalated to senior management. 18 E-ROSTERING POLICY_HR40_OCTOBER 2016
5.5.7.1 Exceptions and In Work Rest Breaks The Trust recognises that there will be occasions when the full entitlements to rest breaks and the assigning of compensatory rest cannot practically be achieved, for instance: there are only two members of staff on a waking night-shift no other staff are able to cover it is not possible to provide a mid-way break and compensatory rest is not practical In the case of such exceptions applying local management will have scope to provide that the mid-way break is paid as an alternative to the break and compensatory rest. The need for such an arrangement will be identified and agreed in advance to avoid any issues about obtaining appropriate consent at the time. However, the need for the arrangement will be reviewed by local management on a regular basis (at least every 6 months) and the line manager must still ensure that the staff members health and safety is protected and undertake assessments of their health. Guidance should be sought from Occupational Health, as necessary. The application of this arrangement, the review of the arrangement and the assessment of staff members health will be recorded in writing by the line manager. They should be counter-signed by relevant Associate Divisional Director. 5.5.8 Night Workers Staff who regularly work at least 3 hours during the night period are night workers. The night period is 11pm until 6am. Normal hours for night workers should not exceed an average of 8 hours for each 24 hours over a 17 week reference period. Normal hours are the hours regularly worked and/or fixed by their contract of employment. Additional work via NHSP is not normal hours and is not included in this calculation. The Trust currently operates shift patterns where employees often work an 11.5 hour shift overnight. This will be compliant with these regulations so long as the average night hours do not exceed more than 8 hours within each 24-hour period. Night staff involved in work of a heavy physical or mental strain should not work for more than 8 hours per night. 5.5.8.1 Health Assessment for Night Workers The Trust will provide health assessments on appointment as part of the pre-employment checks to determine whether someone is fit to carry out the night work to which they are assigned. Managers must offer employees repeat assessments on an annual basis. Employees are not required to undertake an assessment however should they wish to take up the offer, they must complete a Night Worker Questionnaire Form (see Appendix 7). Managers should keep records of when questionnaires where last offered and/or completed. The completed questionnaire should be returned directly to Occupational Health who will then make a decision as to whether any further assessment is needed. If the Occupational Health advice is that a member of staff is suffering from health problems connected with the fact that they work during night-time, the Trust will, whenever reasonably practicable and subject to service delivery requirements, offer the option to transfer to suitable alternative day work, with pay and conditions applicable to day work. 19 E-ROSTERING POLICY_HR40_OCTOBER 2016
5.5.9 Annual Leave The Regulations specify that all workers are entitled to 5.6 week s paid leave (28 days if working a 5-day week). Part-time workers are entitled to the same amount of holiday prorata. This is inclusive of bank holiday entitlement. Employees should not undertake any extra work during this leave i.e. working NHSP shifts. For example, if an employee s leave entitlement is 40 days, they would be able to work NHSP whilst on leave up to a maximum of 12 days. Please refer to the Trusts Annual Leave policy for further information about NHS leave entitlements and appropriate processes to be followed regarding booking and taking leave. 5.6 Students Students must be recorded on the roster and should work a minimum of 2 shifts per week with their mentor. 5.6.1 Pre-Registration nursing students First year students should not be made to do night shifts unless they explicitly request them. Second and third year students are expected to do a range of different shift patterns over the 24/7 spectrum, which should include a few night shifts so they get to experience the whole 24 hour period before registration. All students should spend a minimum of 40% of their shifts with their allocated mentor. Final placement (sign off) students should spend a protected one hour a week with their mentor, in addition to a minimum of 40% of their shifts with their mentor. Designated sign off mentors for pre-registration nursing students must be allocated 1 hour per week with each year 3 final placement student. 5.5.2 All Other Students These students should follow their professional/course guidelines for working night and weekend shifts. 5.7 Staff redeployment At times staff may be required to be ad-hoc redeployed to other units as directed by their ward/team manager/matron/service co-coordinator/service director. Staff redeployment may also be necessary at times of emergency or main incidents, in such case the system will be used to manage any staff movements. 6. Periods of staff unavailability 6.1 Annual Leave Annual Leave is allocated in hours or days. For shift workers (i.e. 247) this will be inclusive of Bank Holidays for all staff (pro-rata for Part-timers) as per Agenda for Change. Each member of staff is responsible for booking their annual leave using HealthRoster in accordance with the agreed unit guidelines. The ward/team manager is responsible for approving all annual leave. 20 E-ROSTERING POLICY_HR40_OCTOBER 2016