Rostering. Policy and Procedural Rules

Rostering Policy and Procedural Rules Name of Policy Author &Title: Name of Review/Development Body: Ratification Body: Nicola Rose E-Rostering Manager Matrons Meeting Professional Nursing & Midwifery Steering Group Date of Ratification/effective from: November 2016 Review Date: November 2019 Reviewing Officer: Louise Stead, Director of Nursing & Patient Experience If this document is required in an alternative language or format, such as Braille, CD, audio please contact the PALS Office Date of Ratification: November 2016

Date Jan 2014 Review Type (please tick Minor amendment Version n No. Author of Review 1 Full Review 2.0 Nicola Rose Title of Author Interim E-Rostering Manager July 2016 3.0 Nicola Rose E-Rostering Manager Date Ratified TBC 2013 Ratification Body Page Numbers (where amended) Line Numbers (where amended) Details of change Inserted Delete d TBC N/A N/A N/A N/A Date of Ratification: October 2016 2

Contents Section Page Executive Summary 5 1 Introduction 5 2 Purpose 5 3 Scope 5 4 Duties and Responsibilities 6-9 4.1 Chief Executive Officer and Trust Board 6 4.2 Associate Director of Human Resources 6 4.3 Portfolio Heads of Nursing/Head of Midwifery/Deputy Directors of Operations 6 4.4 Matrons 6-7 4.5 Ward Managers/Senior Sisters/Senior Midwives 7-8 4.6 Clinical Site Manager 8 4.7 Site Nurse Practitioner 8 4.8 Staff Member 8 4.9 Roster Creators 8 4.10 Nurse in Charge 9 4.11 Temporary Resourcing Office 9 4.12 HR Business Partners 9 4.13 E-Rostering Manager/Roster Administrator 9 5 Rostering Rules 10-18 5.1 Trust Rules 10 5.2 Skill Mix and Shift Staffing 10-11 5.3 Staff Requests 11-12 5.4 Personal Patterns 12 5.5 Leave Entitlements 12-14 5.6 Study Leave 14 5.7 Sickness 14-15 5.8 Booking of Temporary Staff 15 5.9 Unsocial hours / Time Off In Lieu 15 5.10 Flexible Working 15 5.11 Roster creation, validation and approval 15-16 5.12 Unfilled Duties and Bank 16 5.13 Changes to Published Rosters 16-17 5.14 Roster approval parameters 17 5.15 Reporting 17 5.17 Key Performance Indicators 17 5.17 Process 18 6 Training 18 7 Implementation 18 Date of Ratification: October 2016 3

8 Monitoring compliance with & effectiveness of this policy 18 9 Process for Reviewing & Archiving 18 10 Dissemination and Publication 18-19 11 Equality Impact Assessment 19 12 Associated Documents 19 13 References and Further Reading 19 14 Appendices 20-26 Appendix 1 What is E-Rostering 20 Appendix 2 Link to Roster Timetable 21 Appendix 3 Shift times, patterns and the European Working Time Directive 22-23 Appendix 4 Annual Leave Calculations 24 Appendix 5 Matron s Approval Checklist 25 Appendix 6 Key Performance Indicators 26 Date of Ratification: October 2016 4

EXECUTIVE SUMMARY This policy sets out roles and responsibilities for all those involved in rostering within the Royal Surrey County Hospital NHS Foundation Trust (RSCH). It sets out responsibilities for all levels of staff within the Trust from Chief Executive Officer to members of ward staff. It also sets out Trust rules related to rostering including the creation and approval of rosters, the management of skill mix and staffing levels as well as managing changes to published rosters. 1. INTRODUCTION The RSCH recognises the value of its workforce and is committed to supporting staff to provide high quality patient care. Whilst acknowledging the need to balance the effective provision of service with supporting staff to achieve an appropriate work life balance, it is recognised that the Trust needs to be able respond to changing service requirements. A flexible, efficient and robust rostering system is key to achieving this objective. 2. 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 bank and agency spend by giving Ward / Unit Managers clear visibility of staff contracted hours Providing accurate management information regarding the establishment thereby driving efficiencies in the workforce across wards/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 requirements of the European Working Time Directive to be balanced with the needs of service delivery Providing a mechanism for reporting against set Trust Key Performance metrics Facilitating the payment of staff through data being entered at source. Reduce / eliminate need for timesheets, i.e. G85s 3. SCOPE This policy applies to all staff and departments using Electronic Rostering (Appendix 1) and/or BankStaff. It will also apply to clinical and non-clinical areas producing rosters even if not currently using E-Rostering to do this. Managers of departments that start to use Electronic Rostering will ensure that their staff are aware of the policy and how it applies to them. Date of Ratification: October 2016 5

3.1. Definitions Term Off Duty Ward Manager Roster Creator Roster Publication Timetable Special Additional Duty Employee Online (EOL) Description / explanation Roster Senior Sister/Midwife/Charge Nurse or person responsible for daily management of the unit The person creating the first draft roster and partially approving it Dates of Trust wide deadlines for requests and roster publications Additional staff requirement above the agreed staffing level, i.e. one to one care due to high risk of falls A Duty that is in addition to the agreed and funded staffing establishment Web application available to all staff to make requests and view rosters 4. DUTIES AND RESPONSIBILITIES 4.1 The Chief Executive and Trust Board are responsible for: The overall responsibility for ensuring that an adequate and effective process for providing efficient rostering is delivered throughout the Trust. 4.2 The Associate Director of Human Resources is accountable for: Ensuring that HR Business Partner support is available to challenge performance and staff working restrictions. 4.3 Portfolio Heads of Nursing/Head of Midwifery/Deputy Directors of Operations are accountable for: Agreeing and signing off the agreed staffing resource and clinical skill mix for all nursing staff. Reviewing the performance indicators to ensure that the nursing resource is managed efficiently across nursing. Providing advice on staff demand profile and temporary staffing usage against ward establishments. Overseeing staff absence and ensuring that the directorate management teams are pro-active in managing sickness absence and achieve the Trust s absence target. Managing performance for department managers who do not approve their rosters within the deadline. 4.4 Matrons are accountable for: Ensuring that the wards adhere to the deadlines in the Roster Publication Timetable (Appendix 2), in particular with regard to sending shifts to bank. Full approval of the roster using Roster Analyser prior to its publication i.e. a minimum of 6 weeks in advance. Areas without a Matron will have a delegated manager who will be responsible for full approval of the roster. If a Matron is not available to approve the roster the escalation process should be followed. Date of Ratification: October 2016 6

Adding any Additional Duties to the roster once they have approved a request. Approving or rejecting all Agency requests following a rigorous process to assess the need. Approving or rejecting all requests for Specials following a rigorous process to assess the need as in the Specials Policy. Monitoring staff absence and being pro-active in managing sickness trends across wards to achieve the Trust s absence target. Monitoring the Key Performance Indicators and acting on any poor staffing practices, such as planning to have shifts without charge cover when the roster is partially approved. Providing guidance and support to the Ward Manager in the creation of duty rosters, using the Key Performance Indicators as a reference. Ward and SBU scorecard reporting in conjunction with Finance and Human Resources. Agreeing and signing off the agreed staffing resource and clinical skill mix for the wards within their remit. Reviewing the performance indicators which affect the use of resources to ensure that the nursing resource is managed efficiently across the wards within their remit. 4.5 Ward Managers/Senior Sisters/Senior Midwives are accountable for: The safe staffing of the ward even if they do not directly undertake the task of producing the duty roster. Ensuring that there are enough nurses 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. Considering all roster requests from staff, ensuring fairness and equity in working patterns. Ensuring that a roster is produced, maintained and finalised in line with the Key Performance Indicators. Ensuring that the ward adheres to the deadlines in the Roster Publication Timetable (Appendix 2), in particular with regard to sending shifts to bank. Ensuring that their expenditure does not exceed the allocated budget in all wards, units and departments (hereafter referred to as department). Ensuring that all absence (sickness, study / annual leave) is entered correctly onto E-Rostering and is entered in a timely manner, ideally at the time the change occurs and as a minimum on a weekly basis. Monitoring staff absence and being pro-active in managing sickness trends. Approving or rejecting all study and annual leave requests. Ensuring that all shifts requested for Bank (requested by the Roster. Creator, Nurse in Charge or Bleep Holder) are approved or rejected. Ensure that the majority of Bank requests are made with minimum of 4 weeks lead time. Requesting Bank shifts being converted to Agency and seeking Matron s approval. Requesting Specials and seeking Matron s approval. Requesting Additional Duties and seeking Matron s approval. Managing staff hours by using the net hours column and ensuring they are as near to zero as possible. Nominating a Roster Creator and deputy and ensuring that these staff are appropriately trained. Ensuring that all staff are aware of the local and Trust wide policies for rostering. Date of Ratification: October 2016 7

Ensuring that skills are assigned and maintained in E Rostering for all staff particularly those of NMC/HCPC registrations, Take Charge and IV Trained as applicable. 4.6 Clinical Site Managers are accountable for: Following a rigorous process to assess the need for agency staff and approving or rejecting all Agency requests, in the absence of the Matron. Following a rigorous process to assess the need, approving or rejecting all requests for Specials, in the absence of the Matron. 4.7 Site Nurse Practitioners: Following a discussion with the Manager/Matron On- Call, Site Nurse Practitioners are accountable for: Assisting Nurse in Charge and Bleep Holder with out of hours Bank requests. Approving or rejecting all Agency requests, only in the absence of Matron and Clinical Site Manager. Approving or rejecting all requests for Specials, only in the absence of Matron and Clinical Site Manager. 4.8 Staff Every member of staff is accountable for: Attending work as per their duty roster. This includes ensuring they are ready for work upon returning from annual leave. Regularly checking their Employee Online (EOL) account for any shift changes/updates. 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 less desirable shifts e.g. nights and weekend shifts. Notifying the Ward Manager as soon as possible of wish to change a planned shift. Ensuring that personal details are kept up to date on EOL / Notifying the ward / unit manager of changes to personal details, e.g. address, telephone number, etc. Requesting shifts and annual leave using EOL, in line with the Trust Roster Publication Timetable. Those wishing to do Bank shifts on their own ward should write their name on the list of unfilled duties published by the Ward Manager. 4.9 Roster Creators are accountable for: Ensuring they receive appropriate training in the creation of rosters prior to commencing their production. The creation of all rosters. Roster creators may be a Band 6 or 7. Create rosters with the aim of assigning 100% of the shifts to the ward s substantive staff. Inputting all Study leave requests onto E-Rostering. The partial approval of each roster they produce. In line with the Roster Publication Timetable this should be a minimum of 8 weeks prior to the roster start date. In the absence of the Nurse/Midwife in Charge, is accountable for inputting sickness on E-Rostering and sending any vacant shifts (as a result of sickness) to Bank. Identify the need for a Special. Date of Ratification: October 2016 8

4.10 The Nurse/Midwife in Charge is accountable for: Inputting sickness on E-Rostering and send any vacant shifts (as a result of sickness) to Bank. Identify the need for a Special. 4.11 Bleep Holders are accountable for: If the Ward Manager is unavailable, input sickness on E-Rostering and send any vacant shifts (as a result of sickness) to Bank. In the absence of the Ward Manager, create a shift for a Special and send to Bank/ Agency, once approved by the Matron. 4.12 The Temporary Resourcing Office is accountable for: Sending shifts to Bank if the Nurse in Charge, Roster Creator or Bleep Holder is not available. Sending Bank shifts to Agency once approved by the Matron or the Clinical Site Manager (in their absence). Assist the Ward Manager in creating a Special and sending to Bank/Agency once approved by the Matron or the Clinical Site Manager (in their absence). Monitoring the Bank request lead times and escalate when majority of the shifts are requested with less than 4 weeks lead time. 4.13 HR Business Partners are accountable for: Monitoring workforce metrics to support Matrons and Ward Managers with interventions to improve attendance and productivity. Supporting Ward and Department Managers in reviewing staff with working restrictions at least every six months to ensure that staff are as flexible with their working hours as possible. 4.14 The E-Rostering Manager/Roster Administrator are accountable for: Producing the Trust wide Roster Publication Timetable. Monitoring rosters on completion and reporting against metrics, feeding back to the appropriate managers where better rostering could improve the utilisation of the nursing workforce. Ensuring the E-Rostering system remains appropriately configured. This will include adding new starters, closing leavers, moving staff to different departments, amending contracted hours. Providing support and ongoing training to the E-Rostering users. Liaising with the Allocate Software Support Team to resolve system issues as required. Updating E-Rostering with members of staff s information including Contact, DBS & NMC details. Providing regular and ad hoc reports based on data within the electronic rostering system based on the Trust KPI s. These will include (but are not exclusively) roster approval performance, the use of staff hours annual leave, other leave, additional duties. Date of Ratification: October 2016 9

5. ROSTERING RULES 5.1 Trust Rules These rules apply to all areas in the Trust that use rosters even if a department is not currently using E- Rostering to produce its rosters. All ward/department rosters must commence on a Sunday. Rosters must be completed partially approved a minimum of 8 weeks prior to the roster start date and fully approved at least 6 weeks in advance of the start date. This will enable staff to better manage their personal arrangements and give the Temporary Resourcing Office more time to fill any vacant shifts. All duty rosters should be composed to adequately cover 24 hours utilising permanent staff proportionately across all shifts. Ward Managers/Senior Sisters should be aware of their harder to fill shifts and should prioritise these shifts to cover with substantive staff wherever possible. If any of the staff are working non standard shifts such as late starts, this should be entered to avoid misinterpretation. Ward Manager/Senior Sister administration staff hours should also be entered as appropriate. Each Ward Manager should be aware of minimum staffing levels (number of staff) and skill mix (experience of staff required) by shift and by day and this must be reviewed on an annual basis in conjunction with the Trust budget setting process. Each ward or department manager will be aware of which shifts are considered to be hardest to fill and should, wherever possible, cover these shifts first. Trust rules about all types of leave, most importantly the Trust Annual Leave Policy and Study Leave Policy, must be adhered to. Each Ward Manager should know the maximum number of requests that can be considered for days off on any single day. The maximum number of non-worked weekends in a 4 week period will be one. Each department manager will be aware of the funded Headroom that they have as part of their budget and will roster and manage their absences accordingly. Headroom includes cover for annual leave, sick leave, study leave and other leave. Maternity Leave may be included in the Headroom or centrally funded depending on how a Portfolio decides to manage it. 5.2 Skill Mix and Shift Staffing Each area has an agreed funded establishment which is reviewed annually or in line with service reconfiguration. Each area will have an agreed pattern and number of shifts to cover the required template. All shifts must comply with The European Working Time Regulations and may be a combination of 6, 7.5 and 11.5 hour shifts. Start and finish times of shifts may vary depending on the area and clinical requirements. Full information about shifts and shift patterns can be found at Appendix 3 Each area should have an agreed level of staff with specific skills on each shift, i.e. the ability to take charge, IV designated staff, as agreed with the Ward Manager and Matron. In areas where the workload is known to vary according to the day of the week staff numbers and skill mix should reflect this. The off duty of senior staff must be compatible with their commitment to Business Unit requirements. Senior ward staff (Nurse in Charge) must be rostered to provide senior cover across the 24 hour period. Date of Ratification: October 2016 10

Ward Managers will normally work short shifts, 80% of which should be worked between Monday and Friday. Ward Managers may work one weekend per roster period, although this can be split days, and nights only for a specific reason e.g. ad hoc supporting of permanent night staff. Consideration should be given to flexible working, however, this needs to be fair and equitable to all staff (refer to Trust Flexible Working Policy). Staff will be required to work a variety of shifts and shift patterns as agreed by their Ward Manager. All staff will be expected to work a proportion of night shifts, unless an alternative pattern of working has been agreed. It is not permitted for a member of staff to work nights only unless specifically stated in their contract of employment or as a temporary arrangement for a specific personal circumstance. This will be by prior arrangement and will be reviewed at least annually It is not permitted for a member of staff to work weekends only unless specifically stated in their contract of employment or as a temporary arrangement for a specific personal circumstance. This will be by prior arrangement and will be reviewed at least annually. Ward managers must ensure that normal hours do not exceed an average of 56 hours over a 17 week period. Nights should be rostered together where possible. No more than 4 nights in a row should be allocated to a staff member. Following night shifts staff should have same number of rostered days off as the number of nights they have just worked unless otherwise requested. All shifts must include a minimum 20 minute unpaid break if > 6 hours and two 30 minute unpaid breaks for 12.5 hour shifts. The Ward Manager/ Nurse in Charge is responsible for ensuring that breaks are facilitated. Breaks must not be taken at the end of a shift, as their purpose is to provide rest time during the shift. Weekend shifts are defined as Friday night, Saturday day or night, Sunday day or night and Bank Holidays. Staff may normally have a minimum of one weekend off per 4 week off duty, in normal circumstances. Additional weekends off can be rostered if the ward requirements allow. The maximum number of consecutive short day shifts recommended for staff to work is 5. The recommended number of consecutive long day shifts for staff to work is 2. In exceptional circumstances the Ward Manager having risk assessed the impact of working longer shift patterns may exercise discretion in authorising a variation in these recommendations. 5.3 Staff Requests Staff are allowed a number of personal requests (not professional requests), such as a Day Off or to work a specific shift. To ensure equity, all staff should be allowed a maximum of 4 requests per 4 week roster period; e-rostering will calculate pro rata request numbers as follows: 29 to 37.5 hours per week = 4 requests per 4 week period 19 to 28.9 hours per week = 3 requests per 4 week period 10 to 18.9 hours per week = 2 requests per 4 week period 0 to 9.9 hours per week = 1 request per 4 week period Date of Ratification: October 2016 11

Each four week roster period will automatically close to requests 56 days prior to the start of the roster. Ward Managers may close the roster to requests earlier than this if they need to compile the roster sooner than the timetable requires. It cannot be assumed by staff that the off duty will be written to accommodate them which includes essential requests. Service needs will take priority over requests. Staff should use Employee Online for making requests. Staff must be considerate of their colleagues, and the requirement that they are fulfilling their share of weekend and night shifts. Requests from staff, who typically make few requests, should be given higher priority than requests from staff that make higher numbers of requests. The request deadline must be adhered to and no further requests accepted after this date (Appendix 2). If staff rostered wish to change their off duty post publication, a fair swap should be made with another member of staff of the same grade. Swaps are only allowed once the Ward Manager has approved them. In exceptional circumstances the Ward Manager has the ability to agree requests at their discretion, only if: The request doesn t exceed their maximum requests in that 4 week period The request does not impact on the unit s ability to meet service requirements 5.4 Supernumerary Staff/Student Nurses All new starters must attend the Trust s Corporate Induction programme as soon as possible after their start date. All HCA s must undertake the HCA training programme which includes supernumerary time Registered nurses will receive a minimum of two weeks supernumerary time which may be as much as four weeks depending on ward/department worked in. Any extension to the supernumerary time must only be made after a discussion between the Portfolio Head of Nursing and the Deputy Director of Nursing Services. Student nurses should have their duties written on the paper copy of the roster and be assigned a mentor for the duration of their placement. NMC requirements state that they should work with their mentor for at least 40% of the time. They are expected to work a variety of shift patterns in order to experience the 24 hour cycle of care 5.5 Personal Patterns Personal patterns are agreed rolling patterns of shifts. Service requirements and equity for other staff members will be taken into account when considering requests for personal patterns. People with agreed Personal Patterns therefore are not entitled to any requests Personal Patterns are a local agreement that have to be reviewed every six months. Personal Patterns are not permanent arrangements unless they have been applied for and approved under the terms of the trusts flexible working policy 5.6 Leave Entitlement Annual leave is allocated in hours for all members of staff. Ward and department managers should be aware of permitted annual leave levels each week based on funded establishment and in post numbers. The Roster Date of Ratification: October 2016 12

Analyser will show the percentage of staff on leave based on WTE in post. Guidelines for calculating how many staff can be on leave each week can be found at Appendix 4 together with the link to find an electronic version of the Annual Leave calculator on the E-Rostering Intranet site. Staff that do not work standard 7.5 hour shifts must have their bank holiday entitlement added into the annual leave entitlement. All part time staff must have their bank holiday and annual leave entitlements added together. All requests for annual leave should be made using EOL. Requests for annual leave can be made online not less than 56 days prior to the start of the roster. The Ward Manager approves all annual leave. Ward and department managers should calculate how many qualified and unqualified nurses must be given annual leave in any one week. An agreed number needs to be set and adhered to. Staff should be made aware of the need to maintain this number constantly throughout the year. Should this number not be met by way of requests, the Ward Manager will allocate leave following discussions with the staff concerned. No holiday bookings or travel arrangements should be made until the Ward Manager has sanctioned the annual leave requested. It must not be assumed that all annual leave for new starters will be honoured and leave dates should be agreed at interview and must be documented in recruitment documentation. This may need to be negotiated to ensure ward requirements are met. Half term weeks and school holidays present additional challenges. The total amount of leave whether annual or study leave etc. should not be increased because of the well-recorded difficulties in obtaining bank and agency staff. Discussions should be encouraged between those requesting half terms off so that each member of staff has an equal chance of being granted annual leave. Annual leave requests for school holidays will be shared equally amongst those requesting. It is the staff member s responsibility to ensure their Annual Leave is used before 31st March. Unless there are exceptional circumstances there will be no carryover of annual leave into the following annual leave year. Exceptional circumstances will include Maternity Leave, long term sickness absence, exclusion from work. Annual leave must be booked or cancelled before an off duty is planned. Annual leave requested after this can only be given if staffing levels permit, near to the day. Annual leave must be booked at least 8 weeks in advance, except in case of domestic emergencies, and authorised by the Ward Manager. All requests for annual leave longer than 2 weeks must be made in writing with at least 3 months notice. Requests for annual leave in excess of 2 weeks will only be granted in exceptional circumstances and on a non-recurring basis. The Ward Manager or Matron has the ability to agree such requests, only if: The request doesn t exceed their maximum requests in that 4 week period The request does not impact on the unit s ability to meet service requirements The requested leave does not exceed 14% of the unit s total annual leave, for that 4 week period The requested leave does not exceed 14% of the employee team s total annual leave, for that 4 week period (e.g. for a HCA, their leave does not exceed 14% of the total HCA team s leave) Requests for Christmas/New Year/other faith holidays should be made by 1st September each year or as agreed locally. No temporary staff will be booked in Date of Ratification: October 2016 13

advance to cover absence of substantive staff on Christmas/New Year. At the discretion of the senior nursing team up to ⅓ of the normal leave allocation for a ward/department may be allocated in the two week period that includes Christmas and New Year. Staff on rotational programmes should take annual leave proportionate to each placement. In principle 40% of leave should have been taken by staff by the end of September, 75% the end of December. It is expected that staff should only have 25% of their leave outstanding at the commencement of the final three months of the annual leave year except: By prior arrangement with the ward manager To support the needs of the service As a result of ill health/maternity leave Staff can view how much leave they have taken or have booked across the whole year and for each quarter of the year by logging onto EOL and looking at the Annual Leave Tab which shows the entitlement taken each quarter. Please refer to Special Leave policy for further details and information on Special Leave. Please refer to the Maternity Leave Policy further details and information on maternity leave. Every effort should be made to allocate days off surrounding leave unless other requests are made by the staff member. Staff should ensure that upon returning from annual leave they are fit and ready for work and have recovered from any ill effects of travelling. 5.7 Study Leave Study leave will be assigned in line with the Trust Study Leave Policy. Statutory and Mandatory training must be balanced throughout the year and assigned per rota. 5.8 Sickness Sickness occurrences must comply with the Trust Sickness Absence Policy. Sickness must be communicated to the nurse in charge or Ward Manager with as much notice as possible; wherever possible at least 4 hours prior to the beginning of the shift, prior to the shift commencing. At this point, a time and date will be agreed for the staff member to ring back and report on progress. All days off due to sickness must be recorded onto the E-Rostering system. All continuous periods of sickness must be entered as one episode (not several) and extended if the sickness absence episode continues. When a member of staff reports in sick, they must declare when they are fit for duty, even if this falls on a rostered day off. If the staff member fails to report in fit for duty they will be recorded as sick up until their return to work. If a nurse has taken sick leave they will not be permitted to work any additional bank shifts either in their own department or in another in the hospital for 1 week after they return from sick leave. This will apply whether the sickness absence is one day or longer. If an employee has had an episode of long term sickness they will not be permitted to work any bank shifts during their phased return to work. If a pattern of sickness emerges that causes concern the Trust reserves the right to withhold the offer of bank shifts to the individual. Where there are concerns about an employee s health they should be referred to Occupational Health and should be encouraged to evenly space out their annual leave. Date of Ratification: October 2016 14

If a member of staff is sick on a recurring basis the manager should explore if they are working bank/agency shift and if this has contributed to their ill health. This should form part of the return to work interviews. 5.9 Booking of Temporary Staff All bookings of Temporary Staff must comply with the Trust s Temporary Staffing Policy No replacement staff should be booked without assessing the need for them (the grade that is required and the time that they are needed to start and finish) by the Ward Manager. The Roster Creator, Nurse in Charge, Ward Manager, Matron and SNPs have authority to book bank shifts which must be booked via the E Rostering system rather than via the Bank system. Agency staff may be booked by the Ward Manager, Matron, CSM, SNP or the Temporary Resourcing Office but only with authorisation from the Matron or CSM. There should be no use of bank and agency for bank holiday shifts unless approved by the Matron. Bank and agency staff cannot be used to take charge of wards unless they are known to the ward, and have been assessed as competent to do so, and are willing to take charge. This must be approved by the Matron. Staff who have informed the ward that they cannot work specific dates or times should not be working these on the bank. This includes staff with term time contracts. 5.10 Unsocial Hours / Time Off In Lieu Unsocial hours will be distributed evenly and fairly, in accordance with agreed contractual restrictions. Time Off In Lieu (TOIL) will only be authorised in exceptional circumstances and only after the Ward Manager has checked the net hours left column on the E Rostering system to verify that the member of staff has time owed to them. TOIL should be authorised by the relevant Matron and recorded on E- Rostering system ensuring that work time is removed from the TOIL thereby ensuring accuracy of net hours as per the Trust TOIL policy. 5.11 Flexible Working The Trust supports the principles embedded in the Trust Flexible Working Policy, regarding work life balance, flexible working and family friendly 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. The Trust will seriously consider requests for flexible working, but may decline them if this pattern cannot be accommodated into the service needs. Achieving adequate staffing numbers and skill mix is the main priority. All other factors are secondary to this, including requests, preferences, team coverage and study leave. 5.12 Roster creation, validation and approval The Trust deadlines for rosters can be found in the Roster Publication Timetable (Appendix 2 for link to timetable) The process for creating, validating and approving the roster is: Roster Creator closes the roster period for requests Roster Creator reviews all Annual Leave and Staff Requests in conjunction with Ward Manager Date of Ratification: October 2016 15

Roster Creator populates roster with the Vacant Duties Roster Creator checks analysis data Approve/Analyse Roster and if fits within defined parameters approves roster and informs Ward Manager that it s ready for their review. Matron reviews roster and highlights to Ward Manager or Roster Creator: Potential unsafe shifts Shifts for which temporary staff are planned for. Ward Manager and Matron to discuss option of using staff from within the directorate, rather than temporary staff, to cover gaps. Any of the agreed parameters that have been exceeded. Ward Manager partially approves the roster unless any issues have to be raised with the Head of Nursing. The Matron then reviews the roster and fully approves it if it fits agreed parameters. A single copy of the roster is printed on the ward for all nurses to view at least 6 weeks prior to roster beginning. All changes made, after the roster has been approved by Matron, will be clearly marked for audit purposes. Matron s Roster Approval Checklist can be found at Appendix 5 5.13 Unfilled Duties and Bank When the duty rota has been fully approved the remaining unfilled shifts must be sent to Bank and the process for this is: The printed roster will include a list of all unfilled duties, which the staff can sign up to. The Roster Creator or Ward Manager removes the list of unfilled duties 4 weeks prior to the start of the roster period. The Roster Creator or Ward Manager assigns bank shifts to the staff that signed the unfilled duties list. The remaining unfilled duties must be sent to Bank by the Roster Creator or Ward Manager 4 weeks prior to the start of the roster period. For rostered areas, all unfilled duties that require bank to fill them will be booked via E-Rostering not via the Bank system. Some bank shift bookings will generate a booking warning(s). Anyone booking bank shifts on the system must ensure they check what the warning is prior to overriding a warning. Violations usually due to a recent sickness episode cannot be overridden at ward level. 5.14 Changes to Published Rosters It is the responsibility of the Nurse in Charge to amend rosters with noneffective shifts i.e. sickness, no shows, and additional duties. In the absence of the Nurse in Charge, the Roster Creator and Bleep Holder should assist with input of sickness on E-Rostering and send any vacant shifts (as a result of sickness) to Bank The Ward Manager is accountable for ensuring that all roster changes are approved or rejected and input correctly into E-Rostering. Matrons should monitor any roster changes less than 4 weeks prior to the roster start, to minimise the use of Agency Short notice shift changes should be kept to a minimum. Staff are responsible for negotiating their own changes (swaps) once the off duty is completed. These changes must be approved by the Ward Manager or designated deputy in their absence and recorded on the E-Rostering system. Date of Ratification: October 2016 16

All changes should be made with an equal grade and maintain the overall skill mix of all shifts being changed. Mentor allocated to a student must not change their shift without ensuring the student also changes or is allocated to another suitable member of staff, and that this is written on the off duty. Any changes to staffing must go through the normal channels. E.g. new recruits must have undergone all pre-recruitment checks prior to commencing on the roster. Any internal staff movement must be authorised by all relevant parties and an appropriate EMF submitted to HR. 5.15 Finalisation of payroll periods for enhancements and absence Information is transferred from the E-Rostering system on a monthly basis to the Electronic Staff Record (ESR) system. When finalising E-Rostering you must ensure that the period shows a true reflection of work done and all absence entries are correct. All rosters must be finalised by the ward/department authorised signatory or nominated deputy (who must appear on the area s authorised signatory list) by the fifth of the following month. Any changes to this schedule will be communicated by the E-Rostering Manager. Failure to comply with actions to finalise by the cut-off date will result in no timesheet claims being submitted for any person on the unit concerned for that month. Any changes made after the extract date will not be sent across to ESR and must be communicated to the relevant Reward Officer so that ESR can be adjusted. 5.16 Roster approval parameters When validating a roster 4 parameters must be met to ensure the roster provides safe and cost effective patient care: Roster unfilled should be as close to 0% as possible Shifts without charge cover must be 0 Unused and over contracted hours should both be as near to zero as possible Annual leave should be between 12% and 16% Approval of the Roster should be made using the Matron s Approval Checklist (Appendix 5) which should be available for viewing by the Deputy Director or Director of Nursing as required. 5.17 Reporting Key Performance Indicators and reporting mechanism will be reviewed on a regular basis to ensure they meet Trust Board and NHS Improvement reporting requirements. 5.18 Key Performance Indicators Following a review of current reporting metrics and processes, the Matrons, Ward Managers and Senior Sisters have chosen a set of Key Performance Indicators to ensure the safe and cost effective staffing of the wards. The Key Performance Indicators will be monitored (using Roster Perform) by the Ward Manager, Matron, Heads of Nursing/Midwifery and Director of Nursing. The criteria for the Key Performance Indicators are laid out in Appendix 6. Date of Ratification: October 2016 17

5.19 PROCESS The Key Performance Indicators can be found in the web application Roster Perform. All Ward Managers, Matrons, Heads of Nursing/Midwifery and Director of Nursing, will have access to Roster Perform. The E-Rostering Manager will develop appropriate reports with Matrons and Portfolio Heads of Nursing / Midwifery, Director of Nursing according to required information which may change according to trust or NHS Improvement requirements. 6. TRAINING Training in the use of the E-Rostering system will include Roster Creators being made aware of the policy and its intended use is provided by the Roster Administrator or E- Rostering Manager. All new Roster Creators or Ward Managers will be required to make contact with the E- Rostering Manager who will assess their need for training prior to providing log in details for the system. 7. IMPLEMENTATION No action plan applicable as systems already in place. 8. MONITORING COMPLIANCE WITH & EFFECTIVENESS OF THIS POLICY Monitoring will take place with the use of three monthly audits of rosters by the Roster Administrator who will feed back results to Ward Managers, Matrons, Heads of Nursing/Midwifery and the Director of Nursing and Patient Experience as appropriate 9. PROCESS FOR REVIEWING AND ARCHIVING The policy will be reviewed every 3 years or earlier if national policy or guidance changes are required to be considered. The review will then be subject to approval and re ratification. The author or Central Policy Officer is responsible for ensuring that archive copies of superseded working documents are retained in accordance with the Records Management: NHS Code of Practice, 2009, refer to Policy Development and Management: including policies, procedures, protocols, guidelines, pathways and other procedural documents. Persons requiring access to an archived policy must contact the Central Policy Officer or the Company Secretary and provide them with the document title, name of author, ratification date and the version required. In addition, an electronic version of this is available on TrustNet under outdated policies. Date of Ratification: October 2016 18

10. DISSEMINATION AND PUBLICATION Dissemination of the final policy is the responsibility of the author. They must ensure the policy is uploaded to the Trust s Central Library (TrustNet) either via their Local Policy Officer or submitted directly to the Central Policy Officer. The Head of Marketing and Communication is responsible for the trust-wide notification of existence of the policy. DDO s, Clinical directors, Specialty Business Unit (SBU), or supporting services management teams, Ward Sisters/Charge Nurses and Heads of Department are responsible for distributing this policy and ensuring that all staff under their management (including bank, agency, contracted, locum and volunteers) are aware and understand the policy. 11. EQUALITY IMPACT ASSESSMENT The author of this policy has undertaken an Equality Analysis Initial Screening. No adverse impacts were identified. The Equality Analysis Initial Screening has been archived and is available via the Central Policy Officer. 12. ASSOCIATED DOCUMENTS This policy incorporates the Trust published values and behaviours and should be read in conjunction with the following policies and documents: Agenda for Change Terms and Conditions of Employment Sickness policy/procedure Annual Leave policy Flexible Working policy/procedure Special Leave policies/procedures (Maternity Leave, Paternity Leave, Adoption Leave, Carers Leave, Career Break and other Special Leave) Booking of temporary staff/bank and agency policy/procedures Dignity at work policy Nursing Staffing Policy Midwifery Staffing Policy Training and Development Policy TOIL Policy 13. REFERENCES AND FURTHER READING Electronic Rostering: helping to improve workforce productivity. A guide to implementing electronic rostering in your workplace. NHS Employers (2007) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. Department of Health (2016) Good Practice Guide: Rostering. NHS Improvement (2016) Date of Ratification: October 2016 19

14. APPENDICES Appendix 1 What is E-Rostering? E-Rostering is a computerized system specifically designed for use by nurses and other staff groups to produce work rosters, including the booking of all temporary staff It can be used to auto-assign or manually assign staff to an agreed duty requirement. It can also be used to manage staff availability and contracts and allows clear visibility of unit staffing levels. It will also track and produce reports for absence, leave, additional duties and temporary staff usage (bank and agency). All links for the Trust s e-rostering system are available via the Trust Intranet via the E- Rostering page http://trustnet2.royalsurrey.nhs.uk/sbus/corporate/hr/pages/e-rostering.aspx Date of Ratification: October 2016 20

Appendix 2 The Rostering Timetable can be found on the E-Rostering page of the TrustNet. http://trustnet2.royalsurrey.nhs.uk/sbus/corporate/hr/pages/e-rostering.aspx Date of Ratification: October 2016 21

Appendix 3 Shift times, patterns and The European Working Time Directive (EWTD) All shifts must be recorded on the roster. A code should be assigned to each shift and the codes are determined within the e-rostering system. All shifts that exceed 6 hours will have a 30 minute unpaid break. In order to conform to the EWTD, for all shifts this break must be taken during the shift and not at the beginning or end of the shift. All shifts that exceed 12 hours will have a 60 minute unpaid break which on negotiation will either be taken as one break of 60 minutes or two breaks each of 30 minutes. There must be a minimum of 11 hours rest time between shifts and shift patterns that fail to meet this will not be entered onto e-rostering. EARLY SHIFTS An early shift should be a maximum of 8 hours in length with a 30 minute unpaid break. Early shift start and end times will be determined by the ward or department. Example early shifts 07:00 15:00 7.5 hours paid 07:30 15:30 7.5 hours paid 07:00-13:00 6 hours paid LATE SHIFTS A late shift should be a maximum of 8 hours in length with a 30 minute unpaid break. Late shift start and end times will be determined by the ward or department. Example late shifts 11:30 19:30 7.5 hours paid 12:00 20:00 7.5 hours paid 14:00 20:00 6 hours paid LONG DAYS A long day will be a maximum of 12.5 hours in length with 60 minutes unpaid break. Long day start and finish times will be determined by the ward or department. They may be shorter than 12.5 hours but not as short as an early or late. Example long day shifts 07:00 19:30 11.5 hours paid 07:30 20:00 11.5 hours paid If the 12 hour shift pattern is chosen a full-time member of staff will be required to work 13 x 12.5 hour shifts across each four week period. NIGHT SHIFTS A night shift will be a maximum of 12.5 hours with 60 minutes unpaid break. Night shift start and end times will be determined by each ward or department. Example night shifts 19:00 07:30 11.5 hours paid 19:30 08:00 11.5 hours paid Date of Ratification: October 2016 22

TWLIGHT SHIFTS Some areas may wish to utilise a twilight shift which should be a maximum of 8 hours in length with a 30 minute unpaid break. Twilight shift start and end time will be determined by each ward or department. Example twilight shifts 16:00 00:00 7.5 hours paid 18:00 02:00 7.5 hours paid DAY SHIFT Departments such as theatres and outpatients are likely to use day shifts as their main shift requirement and these shift times will depend on service requirements. The principles of the EWTD and taking unpaid breaks will apply to these shifts. Example day shifts 08:00 18:00 9.5 hours paid 10:00 19:00 8.5 hours paid Date of Ratification: October 2016 23

Appendix 4 Annual Leave calculations To calculate annual leave you need to know how many hours for each grade type that your staff in post need to have each year to fit all of their leave in. You will also need to make some assumptions based on vacancies. For example if there are 3 WTE RN vacancies, work on the assumption that 1 will have <5 years service, 1 will have 5-10 years service and 1 >10 years service. For HCA s, if there are 3 vacancies work on 2 with < 5 years service and 1 with 5 10 years service. An example is shown below and the spreadsheet to aid your calculations can be found on the E-Rostering Intranet page using the following link http://trustnet2.royalsurrey.nhs.uk/sbus/corporate/hr/pages/e-rostering.aspx Unit A has 21 registered nurses (16.5 WTE) who have total annual leave entitlements of 4250 hours across the year. They have a vacancy factor of 2.5 WTE total RN establishment is 19.0 WTE. In this example, (1 with < 5 years, 1 with 5-10 years and 1 > 10 years) the vacancy annual leave allowance will require an additional 693.75 hours which makes a total of 4943.75 hours to allocate across the year. 4943.75 hours / 50 weeks in the year (no annual leave in Christmas or New Year weeks) 98.875 (99) hours per week (2.64 WTE) will need to be assigned to fit it all in across the year. This equates to the ward needing to have 13.89% of their RN s on leave each week across 50 weeks. You then need to do the same calculation for unregistered staff. At the discretion of the senior team up to 1/3 of the normal allocation of leave may be taken in the two weeks that include Christmas and New Year. If leave in this period is permitted this will need to be factored into the above calculations. Please remember that when looking at the HealthRoster Approve/Analyse Roster it will calculate annual leave percentages based on numbers of staff in post rather than total establishment. It also helps to check if leave requirements fit into the establishment. For a unit with 19 WTE in the establishment 15% is equal to 2.85 WTE so the above example would allow all of the leave to be fitted in without going above the 15% permitted leave figure provided it is assigned smoothly each week. Not all wards/departments will be able to fit 15% in each week so use the Roster Analyser to assess how much leave is assigned each week and then across the four week roster. Date of Ratification: October 2016 24