Executive Director of Nursing and Operations Jackie King Clinical Nurse Manager Flexible Staffing

Transcription

1 Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Rostering Policy NTW(O)59 Executive Director of Nursing and Operations Jackie King Clinical Nurse Manager Flexible Staffing Business Delivery Group Date ratified August 2014 Implementation Date September 2014 Date of full implementation September 2015 Review Date Mar 2018 Version number V03.2 Review and Amendment Log Version Type of Change Date V03 Review Sept 14 V03.1 update May2015 Description of change All Sections updated and new Standard Appendices A, B, C completed Reference to appendix 3 removed appendix no longer part of policy V03.2 Ext Rev Sept 17 Extension to review to Mar 18 This policy supersedes the following which must now be destroyed: Reference Number Title NTW(O)59 - V03.1 Rostering Policy

2 Rostering Policy Section Contents Page No: 1 Introduction 1 2 Purpose 1 3 Policy Principles 2 4. Scope 2 5. Communicating the Policy to Staff 2 6 Definitions 2 7 Duties and Responsibilities 3 8 Local Procedures 4 9 Flexible Working 4 10 Working Time Regulations /opt out 5 11 Skill mix and Shift Staffing 5 12 Long Days 7 13 Principles for the Production of the Roster 7 14 Changes to Roster 8 15 Non Effective Periods 9 16 Unsocial Hours /Time Owing Overtime (agenda for change Terms and Conditions) Booking of Temporary Staff In Work Breaks Study Leave Sickness PART 2 e-rostering principles Changes to Roster Workload Variation Identification of Stakeholders Training Equality and Diversity Assessment Implementation Monitoring Compliance Standards/Key Performance Indicators Fair Blame Fraud, Bribery and Corruption Associated Documentation 17

3 Standard Appendices attached to policy A Equality Analysis Screening Tool 18 B Communication and Training Checklist/Needs Analysis 20 C Audit and Monitoring Tool 22 D Policy Notification Record Sheet 24 Appendices listed separate to policy Appendix No: Description Issue No: Issue Date Review Date Appendix 1 Declaration Form 1 Sept 17 Mar 18

4 1 Introduction 1.1 Staff rosters are one of the fundamental systems used to deliver care to our clients. It is therefore essential that they are drawn up in a timely and appropriate manner, maximising the benefits for our patients and without incurring any unnecessary expenditure. For staff to be able to achieve a work life balance in line with Improving Working Lives (IWL), rosters must be drawn up giving maximum notice and taking reasonable account of the needs and wishes of individual members of staff. 1.2 (the Trust/NTW committed to ensuring that the rostering process is fair and transparent as possible without prejudice to either staff or the patients whose care we strive not to compromise in any way. 1.3 Good, fair and equitable rostering is necessary to contribute to the achievement of 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 the right people with the right skills in the right place at the right time. This must be based on the needs of the people using our services. 2 Purpose 2.1 The purpose of this policy is to provide the principles upon which all working patterns must be based. 2.2 The Trust has adopted the SMART, bound computerised system to ensure rosters are compliant with the Working Time Regulations. However, it is expected that while this electronic system is rolled out all other aspects of this policy apply to existing rostering processes:- Specific Measurable Agreed Realistic Time 2.3 This policy also covers compliance with Section 27 of the Agenda for Change Handbook which covers the Working Time Regulations (WTR). This policy 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. 2.4 The Trust s NTW(HR)11 - Flexible Working Policy must be read in conjunction with this policy to support staff that may have particular requirements in their working patterns. 1

5 3 Policy Principles To minimise clinical risk associated with the level and skill mix of nurse staffing levels To ensure safe/appropriate staffing for all departments using fair and consistent off duties Improve the utilisation of existing staff and reduce nurse bank and agency spend by giving Ward Managers and Senior Managers clear visibility of staff contracted hours To improve monitoring of sickness and absence by department and/ or individual, generating comparisons, identifying trends and priorities for action To improve planning of clinical and non-clinical non-effective working days (e.g. annual leave, sickness and study leave) To provide effective management of inpatient staff (hereafter referred to as nursing establishments 4 Scope 4.1 This policy is for use by all clinical areas and will assist with the production of duty rosters based on funded establishments as agreed in budget setting. It should be used by Service Managers/Community Clinical/Clinical Nurse Managers in the development of local policies/protocols on safe staffing. This policy and procedure applies to all rostered staff across the Trust and not just those working a variable shift pattern. 5 Communicating the Policy to Staff 5.1 Both the Trust wide policy and group/directorate based local guidelines on nurse/team staffing must be made readily available to all staff. The Trust wide policy will be available on the Trust intranet with a hard copy accessible on the ward/department. 6 Definitions 6.1 The following definitions are provided to assist staff: Word(s) Trust Ward Roster Non-Effective working days Trust Employee Permanent Temporary Staff Personal Pattern Calendar Week Meaning Unit/Department/Team Rota of staff scheduled to work for set periods of duty Relates to days that staff are not available for the roster i.e. annual leave, study days, management days, sickness Staff who are part of the funded establishment Nurse Bank / Nurse Agency Staff Every week the person works the same shift on the same days or a pattern only they work Monday to Sunday 2

6 6.2 Ward Managers is a generic term used within the policy on the understanding that the role title may differ within the Trust. 7 Duties and Responsibilities 7.1 Executive Director of Nursing and Operations: Accountable to the Trust Board for ensuring Trust wide compliance with this policy 7.2 Group Directors/Deputy Director of Clinical Governance: Responsible to Executive Director of Nursing and Operations to ensure this policy is implemented within each Directorate across the Trust for nursing and other rostered staff. 7.3 Directorate Managers/Service Managers/ Community Clinical/Clinical Nurse Managers Responsible for ensuring compliance with the policy in their areas and for reviewing minimum staffing establishments and skill mix as outlined in the policy. 7.4 Ward / Department Managers Responsible for implementing the policy at local level and for: Producing the duty roster and for ensuring that their expenditure does not exceed the allocated budget in their team, ward, unit and departments (hereafter referred to as wards) Responsibility for authorising any changes even if she/he does not undertake the task of producing the off duty roster Responsibility to maintain and amend rosters with non-effective shifts e.g. sickness, absences etc Responsibility for the safe staffing of each ward lies with the Ward/Team Manager, even if she/he does not undertake the task of producing the off duty roster Abiding by the Trusts Roster Publication Timetable and thus producing the off duty at least 6 weeks in advance using SMART where implemented (See appendix 2 for guidance) Ensuring staff sign any paper enhancement forms and for the Staff who are on the TAeR system they sign a yearly declaration which managers will keep either in a paper format or scanned and kept electronically To follow and refer to the TAeR to be processed 3

7 Completing a manual payroll file or an electronic pay roll file. When managers are completing this they will abide by the following declaration I understand that if I knowingly authorise false information within the TAeR system this may result in disciplinary action and I may be liable for prosecution and civil recovery proceedings. I consent to disclosure of information within the TAeR system to and by the Trust and NHS Protect for the purpose of verification and for investigation, prevention, detection and prosecution of fraud. Monitoring and checking monthly for any regular exceptions which fall in the grace period 7.5 Individual staff members Responsible for adhering to the principles as outlined in this policy Checking and ensuring that the enhancements they are claiming or that are in the TAeR system are correct and raise any issues that are not correct to their manger Signing all enhanced payment forms each month and on a yearly basis revisit and sign the following declaration: I understand that if I knowingly provide false information within the TAeR system this may result in disciplinary action and I may be liable for prosecution and civil recovery proceedings. I consent to disclosure of information within the TAeR system to and by the Trust and NHS Protect for the purpose of verification and for investigation, prevention, detection and prosecution of fraud. 8 Local Procedures 8.1 This policy requires each service to produce local procedures or review any existing procedures in discussion with the staff group. These procedures must comply with the principles and guidance set out in this policy and procedure. 9 Flexible Working 9.1 The Trust supports the principles embedded in Improving Working Lives (IWL) regarding work life balance and flexible working. However, this should be set against the need to ensure safe levels of staffing to maximise the quality of patient care and reduce clinical and non-clinical risk. Achieving adequate staffing numbers and appropriate skill mix is the main priority as is having the right people, in the right place at the right time delivering high quality care. All other factors are secondary to this, including requests, preferences and study leave. The Trust s NTW(HR)11 - Flexible Working Policy should be followed for any flexible working application. 9.2 Under the Part Time Workers Regulations, part time workers will not be treated less favourably than comparable full time employees. 4

8 10 Working Time Regulations (WTR)/Opt Out 10.1 It is the responsibility of all employees to ensure compliance with WTR. Further information regarding WTR can be found in section 27 (Part 4) Employee Relations of Agenda for Change (AfC) for Working Time Regulation requirements. However the key requirements are highlighted below Every shift exceeding 6 hours must include at least 20 minutes unpaid break Breaks cannot be taken at the beginning or end of the shift as their purpose is to ensure staff rest time during the shift Staff should not work more than 48 hours per week over a 17 week average in total. This total includes hours worked in all employment including bank, overtime and agency, whether for the Trust or any other employer All members of staff who wish to exercise their right to opt out of the 48 hour limit must do so in writing using the Trust form Under the WTR night staff cannot opt out of the 48hr 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 Working Time Directive states a minimum daily rest period of 11 hours between shifts and a rest period of 24 hours in each 7 day period. 11 Skill mix and Shift Staffing Each area has an agreed funded establishment. Base line staffing levels (number of staff) and skill mix (experience of staff required and gender) by shift and by day must be agreed and reviewed in the light of any significant change to the ward function but at a minimum on an annual basis Each area should have an agreed base line of staff with specific competencies on each shift, e.g. the ability to take charge, respond to emergency situations or act as point of contact, as agreed with the Ward Manager. Agreed number and skill mix must be achievable within the ward budget Each area should display in a public area of the ward their base line staffing levels planned and actual each shift both registered and unregistered updated on a daily bases In areas where the workload is known to vary according to the time of day, day of the week or number of patients, staff numbers and skill mix should reflect this The roster of senior staff must be compatible with their commitment to Trust requirements There should be a designated nurse in charge who has been identified as having the required skills and competencies for a coordinating role 5

9 Senior ward staff should work opposite shifts (e.g. Band 6 staff) Ward Managers must generally work 4-5 weekday shifts per week and be flexible to meet the needs of the service outside of normal business hours Ward Managers should not be rostered on night shift. Student nurses should be rostered with their mentor where possible and 50% of the working week as a minimum. If their mentor is unavailable, an associate mentor should be allocated Shift patterns should maximise staff rest time whenever possible e.g. nurses should have 2 consecutive days off Consideration should be given to flexible working; however, this needs to be fair and equitable to all staff and balance with service need Under AFC terms and conditions staff that are employed to work in a service that provides a 24 hour service will be required to work a variety of shifts to meet need Staff may work long shifts, short shifts or a combination of both in order to meet clinical or health requirements (to be decided in conjunction with the Trust NTW(HR)10 - Attendance Management / Sickness Absence Management Policy. Variations to these shifts may be worked but must be agreed with the Ward Manager. A written record of the shift agreement will be kept for all variations in shifts, and will be reviewed by the Ward Manager on a three monthly basis Weekend shifts are defined as Friday night, Saturday day or night, Sunday day or night and Bank Holidays Staff may have a minimum of two weekends off per 8 week roster in normal circumstances. Additional weekends off can be rostered if the ward requirements allow The maximum number of consecutive standard day shifts recommended for staff to work is 6. Staff should work no more than this unless by special arrangement (to a maximum of 8) The maximum number of consecutive long days recommended for staff to work is 2 To be rostered for only nights or days each calendar week Sunday night is in the previous week Night shifts should be kept together where 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 being rostered for a night shift 6

10 12 Long Days 12.1 Whilst the Trust does not condone Long Days, if clinical or staff needs require these to be worked then 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 Failure to attend a long day shift results in the loss of cover of two shifts and therefore the rostering of long days will need to be regularly reviewed by the Ward Manager The maximum number of consecutive long days recommended for staff to work is The maximum number of long days rostered each calendar week should not exceed two unless this has been agreed as an exemption at Group level. 13 Principles for Production of the Roster 13.1 There must be a local procedure for allocating staff to the roster, which will be introduced following discussion with staff. The following principles must be included: Production of a duty roster at least 6 weeks in advance using SMART where implemented All ward/department duties must commence on a Monday Trust employees should be allocated to provide cover for as many different shifts as possible. This will help to reduce the use of bank and agency staff to provide consistency for the patients and staff 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 except where necessary The roster must show who is in charge on each shift All shifts should be equitably allocated to all staff in accordance with their contract of employment and the Trust s NTW(HR)11 - Flexible Working Policy Any new requests for flexible working should be processed in accordance with the Trust s NTW(HR)11 - Flexible Working Policy Only once all trust employees shifts have been allocated, should other staffing be requested to cover for the unfilled shifts overtime and bank arrangements should always be considered ahead of agency which should be a last resort Requests for popular periods (Bank Holidays and School Holidays) should be considered equitably 7

11 Rules relating to all types of leave, most importantly the Annual Leave, Study Leave and Working Time Regulations should be adhered to as set out in this policy All rosters should be composed to adequately cover service requirements utilising Trust staff proportionately across all shifts Shifts given a high priority must be filled first, i.e. nights and weekends. It should not be routine to use nurse bank/agency permanently on night shifts The relevant Service Managers will undertake the monitoring of each wards roster upon completion, produce analysis reports, and approve all shifts where temporary staff are requested If any of the staff are working non standard start or finish times this should be entered to avoid misinterpretation Senior staff time will be distributed across different shifts 14 Changes to Roster NTW(O) 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 in the staffing and skill mix section and be authorised by either the manager or designated deputy before the start of the shift and should not result in overtime expenditure or use of nurse bank or agency staff. Only in exceptional circumstances can changes be made and 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. The manager should not seek to enforce a change if this would cause disruption to care commitments, booked annual leave or prepaid arrangements made by the member of staff involved 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. In these circumstances overtime should be paid in line with Agenda for Change Terms and Conditions. i.e. part time staff receive additional basic hours until they have worked 37.5 hours The Service Manager must authorise any additional hours that are granted as overtime. Only in exceptional circumstances can overtime be agreed and retrospectively approved by the Service Manager If staff are allocated to a student they should not change their shift without ensuring the student either changes with them or is allocated to another suitable member of staff, and that this is written on the roster. 8

12 15 Non-effective Periods 15.1 Annual Leave All Service/Ward Managers must draw up or review local procedures following discussion with their staff team for the agreement (time off in lieu) toil, and allocation of, annual leave in line with this policy. Annual leave is to be used within the context of the Agenda for Change Terms and Conditions of Service The following minimum standards must be attained: No holiday bookings should be made until the Ward Manager has sanctioned the annual leave requested. Annual leave should be allocated in hours for all members of staff Trust employees should take approximately 40% of their annual leave entitlement by 31 st August each year with approx 35% being used between September and December leaving 25% to be taken between January and March of the annual leave year except: By prior arrangement with the line manager Due to the needs of the service As a result of ill health/maternity leave Annual leave must be booked or cancelled before a roster is produced If a member of staff needs to delay or amend an annual leave booking this will be considered taking into account local service needs, provided it does not incur extra expenditure Ward 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% and should also reflect staffing and skill mix. Each Ward Manager is responsible for calculating the number of qualified/unqualified staff who must be given annual leave in any one week. An agreed number should be explicit and adhered to. Staff should be made aware of the need to maintain this number throughout the year in order to effectively manage the workforce to meet patient need. Should this number not be met by way of requests, the Ward Manager will allocate leave following discussions with the staff concerned 9

13 Requests for Christmas, Ramadan, Chinese New Year, New Year and other religious or cultural festivals should be agreed within each directorate. Staff should be notified if their request has been approved two months in advance. Ward Managers must be sensitive to the cultural needs of staff. However, staff need to be aware that requests may not always be granted. If annual leave is granted on a weekly basis over busy holiday periods then bookings must be considered taking into account local service needs, staffing and skill mix and authorised only if it does not incur extra expenditure Quarterly reviews of outstanding leave for each member of staff should be made by the Ward Manager to avoid accumulation of untaken leave A maximum of two weeks continuous leave can be booked together unless an application to the Ward Manager has been made under special circumstances Staff who, unless with prior agreement, do not book their leave in conjunction with the policy will be informed by the Ward Manager that it will be automatically allocated as available to avoid a high percentage of annual leave outstanding at the end of the year It may not be presumed that all annual leave for new starters will be honoured. This will need to be negotiated to ensure clinical requirements are met The total amount of leave should not be increased because of the difficulties and cost of obtaining temporary staff. Discussions between those requesting school holidays off are encouraged so that each member of staff has an equal chance of being granted leave Local procedures must state how annual leave is to be allocated when there is more than one request for the same period. The Ward Manager should make their objective decision following discussions with the staff concerned, taking all factors into account Staff are not permitted to work overtime on annual leave; if they are required to work then the annual leave will need to be cancelled and rearranged Weekly reports are produced to show planned and actual staffing levels measured against the baseline staffing numbers should there be any time when the baseline levels are over or under a rational must be given 10

14 16 Unsocial Hours / Time Owing 16.1 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 Ward Manager and recorded Any time claimed back, must be recorded and authorised by the manager Local procedures should be in place for the process of authorising time owing which should be taken by joint agreement and should reflect principles outlined in this policy 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 service need. In either case the reasons must be recorded and signed by both the Ward Manager and the staff member concerned Managers must ensure that no more than 20 hours time owing either way is allowed. In the event of accumulating time owing in excess of 20 hours, this must be authorised by the Service Manager during office hours or the on-call manager out of hours Hours agreed above 20 must be taken within 3 months and any difficulties in achieving this must be brought to the attention of the Service 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 Staff who for operational reasons are unable to take time off in lieu within three months must be paid at the overtime rate in line with the Agenda for Change Terms and Conditions Booking of time-owing should follow the same principles as for annual leave in that it should not incur unnecessary expenditure. 17 Overtime (Agenda for Change Terms and Conditions) 17.1 All staff in pay bands 1 to 7 will be eligible for overtime payments Overtime payments will be based on the hourly rate provided by basic pay plus any long-term recruitment and retention premia Part-time employees will receive payments for the additional hours at plain-time rates until their hours exceed standard hours of 37.5 hours a week The overtime rate will apply whenever excess hours are worked over full-time hours unless working on the nurse bank or time off in lieu is taken, provided the employee s line manager has agreed with the employee to this work being performed outside the standard hours at this rate 11

15 17.5 Trust support workers who are seconded to undertake the Diploma in Nursing Studies Registered Nurse Programme will not be entitled to any additional overtime or leads for any additional working hours Enhance payments are only paid for hours worked and annual leave/facilities time and for no other absences are enhancements paid 18 Booking of Temporary Staff 18.1 Temporary staff should only be booked by strict following of the Trust s nurse bank protocols. On completion of a roster following review and agreement by the Service Manager, requests for temporary staffing should be requested via the SMART nurse bank system at the earliest opportunity to the nurse bank preferably on the day the roster is produced i.e. 6 weeks in advance 18.2 All staff must be made aware they may at times be requested to move temporarily within the Trust to cover unfilled shifts or sickness absence No replacement staff should be booked without assessing the need for them, the grade required and the time they need to start and finish. Temporary staff shifts may only be authorised by the Ward Manager if requests meet the following criteria: within budget within existing vacancies to cover unpaid maternity leave 18.4 It is not acceptable to use temporary staff to cover annual leave requests that exceed the documented acceptable level for each ward All areas will have base line staffing levels should a unit fall below those levels ward managers should raise this with their clinical nurse manager and out of hours it should be raised with the POC 18.6 Temporary staff required outside these parameters must be authorised by the Service Manager or on-call manager out of hours Temporary staff should not 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 Staff who have been off sick in the previous 7 days must not undertake bank or overtime work for a period of 5 working days 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 unless in exceptional circumstances and with the prior agreement of the Service Manager. 12

16 18.11 Staff that have informed the ward that they can not work specific dates or requested times should not be working these on the nurse bank or for overtime. 19 In Work Breaks 19.1 Working Time Directives state that all staff should have 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 their workstation should they wish to do so. Where the member of staff is recalled to the workplace, (should circumstances demand), this will be a paid break and the finish time of the shift will not be extended by the length of the break In exceptional cases where an unpaid break cannot be taken, a record must be made indicating the circumstances why this was not possible and this should be regularly reviewed by the Service Manager The Ward Manager/Nurse in Charge of a shift is responsible for ensuring that breaks are facilitated Unpaid breaks are taken outside working hours 37.5hrs per week. 20 Study Leave 20.1 Study leave will be assigned in line with the Trust s NTW(HR)23 - Study Leave Policy Ward Managers should ensure that mandatory training is balanced throughout the year giving consideration to staffing and skill mix Study leave should be assigned as part of contracted hours and all study leave must be clearly recorded within rosters Enhanced payments are not made for study leave 21 Sickness 21.1 Sickness should be managed in accordance with the Trust s policy NTW(HR)10 Attendance Management / Sickness Absence Management Policy 21.2 Electronic Staff Record (ESR) remains the master system for recording all staff data therefore SMART should be kept up to date at all times in view of the reports that it generates. 13

17 PART 2 22 PART 2 E-rostering Principles 22.1 This section details procedures for use of the SMART computerised system designed for rostering staff to an agreed staffing profile for a ward/department SMART provides the facility for staff to be rostered to an agreed duty requirement, managing staff availability and contracts 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 SMART to request shifts and leave It is for use by the appropriate persons for creating and authorising rosters, recording absences and is linked into the Electronic Staff Record computerised payroll system The system has the facility to track and produce reports for absence, leave, additional duties and temporary staff usage The e-rostering system will be accessible to Human Resource and Finance staff as appropriate. 23 Changes to Roster 23.1 Shift swaps are to be approved by the Ward Manager. If staff wish to change their rostered shift a fair swap should be made with another member of staff of the same grade that meets the Ward Manager s approval Once the roster has been approved by the Ward Manager, it should be printed and made available for viewing by all applicable staff at least 6 weeks prior to its effective date The actual worked roster must be updated on SMART by 12:00 every day. 24 Workload Variation 24.1 SMART can produce exceptions for any additional time worked which can then be authorised by the Ward Manager as overtime or time in lieu as applicable. 25 Identification of Stakeholders 25.1 This is an existing policy which has been reviewed in line with the Trust s, NTW(O)01 Development and Management of Procedural Documents Policy and has been circulated for a four week Trust wide consultation to the following: Senior Management Team Local Negotiating Committee Consultant Psychiatrists Planned Care Group 14

18 Specialist Care Group Urgent Care Group Psychological Services Clinical Governance and Medical Directorate Safeguarding Trust Allied Health Profession Services Finance, IM&T, Estates and Performance Staff-side Trust Pharmacy Workforce Communications 26 Training (See Appendix B) 26.1 Service Managers and Community Clinical/Clinical Nurse Managers: for each directorate will be responsible for addressing the implementation of the policy with the ward / department with Ward Managers in each clinical area. Awareness and understanding of the policy will be embedded through a series of workshops Each ward / department will receive training and induction of the SMART system as per matrix (see appendix B) when they commence roll out of e-rostering. 27 Equality and Diversity Assessment (See Appendix C) 27.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 28 Implementation 28.1 Taking into consideration all the implications associated with this policy, it is considered that a target date of one year from issue date is achievable for the contents to be embedded within the organisation. 29 Monitoring compliance 29.1 The Service Manager should periodically review the rosters for each area within their directorate to ensure the policy protocol and guidelines are being met, and the production of an effective roster is meeting the service need Ward / department managers should quarterly audit the rosters (see audit tool, Appendix C), to monitor the effectiveness of the roster to meet service need and maintain fairness and equality to all staff. 15

19 30 Standard/Key performance indicators 30.1 The following key performance indicators and parameters will be set and monitored. Operational Management groups will monitor the indicators. % 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 due to: annual leave, sickness, special leave, study leave, other Requests - numbers of requested shifts compared with Trust policy Number of nurse bank requests to total nurse bank hours worked. Number of vacancies Number of bank requests on weekend and night shifts 30.2 The Key Metrics are: Non-Effective working days staff s unavailability during the 4 week roster period, broken down in to the following categories. The total percentage of these should equate to the 21-23% time out that is built in to each budgeted establishment Annual Leave - should be 14%, parameters set to % based on average annual leave entitlements plus statutory bank holidays Sickness - should be below 5% Study Days including mandatory training less than or equal to 2% 30.3 Additional duties any duties allocated that are above the agreed staffing requirements for the ward will be automatically flagged as this will be above the agreed establishment/budget 31 Fair Blame 31.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 16

20 32 Fraud, Bribery and Corruption 32.1 In accordance with the Trust s policy NTW(O)23 Fraud, Bribery and Corruption, Any timesheet or Time Attendance and erostering entry that staff or managers suspect of being fraudulent must be reported immediately to the Local Counter Fraud Specialist on or to the Executive Director of Finance. Alternatively, concerns may be reported via the fraud and corruption reporting line on or via All reports are treated in strictest confidence and can be reported anonymously if required. 33 Associated Documentation NTW(HR)10 Attendance Management Policy NTW(HR)11 Flexible working Policy NTW(HR)23 Study Leave NTW(O)01 Development and Management of Procedural Documents 17

21 Appendix A Equality Analysis Screening Toolkit Names of Individuals involved in Review Robin Green, Elizabeth Moody and Jackie King Policy to be analysed Date of Initial Screening Review Date V03 - March 2014 March 2017 Trust wide Is this policy new or existing? Service Area / Directorate NTW(O)59 - Rostering Policy V03 Existing What are the intended outcomes of this work? Include outline of objectives and function aims Summary of Policy The Trust supports the principles embedded in Improving Working Lives (IWL) regarding work life balance and flexible working. However this should be set against the need to ensure safe levels of staffing to maximise the quality of patient care and reduce clinical and non-clinical risk. Achieving adequate staffing numbers and appropriate skill mix is the main priority as is having the right people, in the right place at the right time delivering high quality care. All other factors are secondary to this, including requests, preferences, and study leave. The flexible working policy should be followed for any flexible working application. The Trust is committed to ensuring that the rostering process is as fair and transparent as possible without prejudice to either staff or the service user whose care we strive not to compromise in any way Who will be affected? e.g. staff, service users, carers, wider public etc This policy relates more to specific practice for managers and does not specifically mention groups within the community For service users - Ensuring that there are appropriate staffing levels at all times ensuring a safe and smooth running of services Protected Characteristics under the Equality Act The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race If everyone s needs are not acknowledged it could lead to staff being treated disproportionately. However the policy guides managers to take into account the need for flexible working and the principles of Improving Working Lives Age Gender reassignment (including transgender) Sexual orientation Religion or belief The Policy makes reference to cultural and religious festivals and holidays. Certain groups of staff may feel the need to ask for specific times off at certain times of the year. Whilst this cannot always be guaranteed managers should consider requests taking into account 18

22 Marriage/Civil Partnership Pregnancy and maternity Carers Other identified groups - Staff cultural needs NTW(O)59 Positive Staff benefit from a fair process for rostering. Staff should be able to achieve a work life balance in line with Improving Working Lives (IWL), rosters will be drawn up giving maximum notice and taking reasonable account of the needs and wishes of individual members of staff on a fair and equitable basis. Negative If everyone s needs are not acknowledged it could lead to staff being treated disproportionately. Staff may request shifts but requests can not always be guaranteed as managers should always consider clinical needs as a priority. How have you engaged stakeholders in gathering evidence or testing the evidence available? Through standards policy process procedures How have you engaged stakeholders in testing the policy or programme proposals? Through standards policy process procedures For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Appropriate policy review author(s) Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. Improve the utilisation of existing staff and reduce bank and agency spend by giving Ward/Team Managers, Modern Matrons and Senior Managers clear visibility of staff contracted hours To ensure safe/appropriate staffing for all departments using fair and consistent off duties To minimise clinical risk associated with the level and skill mix of nurse staffing levels To improve monitoring of sickness and absence by department and/ or individual, generating comparisons, identifying trends and priorities for action To improve planning of clinical and non-clinical non-effective working days (e.g. annual leave, sickness and study leave) To provide effective management of inpatient staff thereby driving efficiencies in the nursing workforce Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation Advance equality of opportunity Promote good relations between groups What is the overall impact? Addressing the impact on equalities From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: R. Green/ E. Moody/J. King Date: March

23 Appendix B Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc. Please identify the risks if training does not occur. Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. Existing Awareness of the policy and related policies and guidance such as Improving Working Lives, Agenda for Change. Local induction training in SMART erostering as part of the programme of roll out. Yes, they are required to ensure adherence with Working Time Directives and ensure rostering is fair and equitable to maximise benefits to patients. Ensure all staff are aware of and adhere to policy requirements. All inpatient nursing staff and clinical community staff working to a roster. Policy awareness Understanding of SMART e-roster programme for roster producers. Understanding of SMART e-roster programme for staff team to request shifts etc Team brief Management cascade Trust Policy Bulletin Demonstration of system for e-rostering with practical support. Policy authors 20

24 Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training All inpatient areas Qualified Nursing Unqualified Nursing Other professional groups (excluding medical) working to a roster All community teams working a roster Qualified Nursing Unqualified nursing Other professional groups working to a roster Awareness and understanding of policy SMART induction as part of programme of implementation Awareness and understanding of policy SMART induction as part of programme of implementation 2 yearly Induction upon roll out 2 yearly Induction upon roll out Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact: (Option1) 21

25 Statement Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. NTW(O)59 - Rostering Policy - Monitoring Framework Auditable Standard/Key Performance Indicators 1 Is the skill mix maintained? Are the base line number of staff rostered for each shift? 2 Annual leave allocated as section 15 3 Time owing compliant with section 16 4 Use of grace periods by staff should be reviewed to ensure that staff do not consistently work less or more than their contracted hours due to grace periods Frequency/Method/Person Responsible Monthly Safer staffing team Exceptions reported to the group nurse director Quarterly Ward manager Exceptions reported to clinical nurse manger/service manager Monthly Ward manager Exceptions reported to clinical nurse manger/service manager Monthly Ward manager Exceptions reported to clinical nurse manger / service manager Where results and any Associate Action plan will be reported to implemented and monitored; (this will usually be via the relevant Governance Group). Directorate management group Directorate management group Directorate management group Directorate management group 22

26 NTW(O)59 - Rostering Policy - Monitoring Framework Auditable Standard/Key Performance Indicators 5 Exception reports from 2,3,4 to be viewed and assessed Frequency/Method/Person Responsible Quarterly Clinical nurse manager /service manager Outstanding exceptions to be reported to the directorate manager Where results and any Associate Action plan will be reported to implemented and monitored; (this will usually be via the relevant Governance Group). Directorate management group The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 23

27 Policy notification record sheet Appendix D Policy number NTW(O)59 Policy title Rostering Policy Date issued V03.3 Sept 17 Date of full implementation September 2015 Directorate/Service/Ward/Department Received by Date received Date placed in policy file I have read the above policy and understand its contents. Name (print) Signature Designation Service/Ward/Dept. Date This form is to be kept up to date at all times to act as a clear record that all relevant staff have received notification of the existence of the above policy, that they have read it and understood its contents. Form to be retained in the policy file in front of the policy specified. Policies and policy index lists are available via Trust Intranet. Index lists are continually updated and current lists should be retained in the front of policy files. 24