Staff Rostering for all clinical areas

Trust Policy and Procedure Document Ref. No: PP(15)281 Staff Rostering for all clinical areas For use in: For use by: For use for: Document owner: Status: Contents All clinical areas of the Trust All clinical area managers/delegated individuals producing staff rosters Effective utilisation of staffing Directorate of Nursing and Governance Approved Page Scope - 2 - Aims - 2 - Introduction - 2 - Responsibilities - 3 - Definitions - 3 - Policy - 4 - Production of roster - 5 - Validation and approval - 5 - Skill mix and staffing levels - 6 - Staff requests - 8 - Unavailability - 8 - Changes to published rosters - 9 - Booking temporary staff - 10 - Monitoring Rosters via Healthroster Reports - 10 - Escalation - 10 - SafeCare Data Entry & Analysis - 10 - Action in case of system failure - 11 - Monitoring the effectiveness of the policy - 12 - Source: Workforce Status: Approved Page 1 of 24

Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Healthroster Information Guide to producing a roster & flow chart, standard abbreviations Annual leave calculation formulae Pre-registration Nursing Students Protocol for Requesting Shifts with West Suffolk Professionals Monitoring and Reporting against Key Performance Indicators SafeCare Information Legislative framework for this policy Data Protection Act 1998 Freedom of Information Act 2000 Management of Health & Safety at Work 1974 Human Rights Act 1998 Race Relations Amendment Act 2000 Equality Act 2006 & associated Equal Opportunities legislations European Working Time Directive Agenda for Change Staff Rostering for all clinical areas 1. Scope Trust wide. 2. Aims To minimise clinical risk associated with the level and skill mix of staffing levels To ensure that the correct levels of nursing care are provided against patient acuity using SafeCare as a tool for reference. To ensure safe/appropriate staffing for all clinical areas using fair and consistent roster To ensure that the required number of in-patient beds are safely staffed to meet elective and emergency demand To provide effective management of clinical area establishments, thereby driving efficiencies in the workforce across clinical areas To improve planning of clinical and non-clinical unavailability working days Improve the utilisation of existing staff and reduce bank and agency spend by giving Clinical Area 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 3. Introduction This policy has been developed to supersede the guideline produced from the Effective Utilisation of Staff in Clinical Areas Project in 2007, which was designed to develop and support consistent good practice in cost effective rostering of clinical teams across all areas; and introduced to support the use of Healthroster system. (Appendix 1) Source: Workforce Status: Approved Page 2 of 24

4. Responsibilities 1. Clinical area managers are responsible for ensuring that rosters are developed in line with agreed budgets, skill mix and establishments. Responsibility for updating of establishments with authorisation of Senior Managers, as identified on Healthroster, and the safe staffing of each clinical area lies with the clinical area manager, even if they do not undertake the task of producing the roster. 2. Roster Creators are responsible for the creation of all rosters within their designated area. In their absence the designated deputy is responsible for roster creation 3. Service Managers, Midwifery Managers (hereafter referred to as senior managers) will undertake monitoring and approval of the clinical area roster on completion. Analysis KPI reports, and approve all shifts where temporary staff are requested as part of the planned roster 5. Definitions Clinical Area = Ward/Unit/Department/Team Clinical Area Manager = Ward Manager, Unit Manager, Department Manager, Team Leader Senior Managers = Matrons, Service Managers, Midwifery Managers, Deputy Chief Nurse Unavailability Working Days = days that staff are not available for the roster e.g. leave, study days, clinical management days, sickness etc. Clinical Management Days = office days Long days = (circa 12 hours) are two shifts, combined E + L shifts recorded as LD Permanent = staff who have permanent contracted hours Temporary = WSP bank or agency staff Variations in shifts = differing start and finish times to regular shifts Headroom = relates to the 20% of unavailability working days that are included in an establishment which is split as follows. 14% Annual Leave, 3% Study Leave and 3% Sickness. Personal Pattern = every week a person works the same shift on the same day WTE = whole time equivalent Planned Roster = the initial roster produced 6 weeks prior to start date Establishment = The agreed budgeted skill mix for a ward or department broken down into staff groups, banding and whole time equivalent (WTE). KPIs = Key Performance Indicators which are agreed measures to monitor a system or process. Source: Workforce Status: Approved Page 3 of 24

This policy is to be used in conjunction with the following Trust policies Annual Leave Policy PP (09) 165 Annualised hours Policy PP (10) 103 Flexible Working Policy PP (09) 127 Improving Employee Attendance PP (09) 036 Overtime Policy PP (11) 168 Special Leave (Domestic, Personal & Family Reasons) Policy PP (08) 066 Study Leave Policy PP (09) 067 Term Time Working policy PP (10) 091 6. Policy Clinical areas may develop and publish written guidance on local staffing but this should not invalidate any aspect of the Staff Rostering for all clinical areas Policy. Local guidance may include: Optimum staffing levels and skill mix (number of staff and experience level required) by shift and by day. This must be reviewed annually in conjunction with Trust budget setting process Roster requirements for the period incorporating 20 December to 3 January Working patterns Where possible the Trust supports work/life balance (see Flexible Working Statutory Right to Request PP(14) 127, 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. In the planning of rosters Clinical Managers will seriously consider requests for flexible working, but may decline them if this pattern cannot be accommodated into the service needs. Clinical Managers have a responsibility to ensure that staffing numbers and skill mix provide a safe environment for patients and staff. Staff may be required to move between clinical work areas (usually within the directorate) if service needs require them to in order to ensure adequate staffing numbers and skill mix across all areas of the Trust. Guidance re maximum number of shifts relates to all staff, both substantive and temporary. Any decisions to work in excess of this needs to be taken in accordance with European Working Time Directives (EWTD) and authorised by the Clinical Manager. If substantive staff undertake temporary staff shifts, the WSP office, using Healthroster will view all shifts both worked and planned to ensure that these meet EWTD. Decisions to allocate temporary shifts will be taken in line with EWTD. Any future changes to the EWTD will be incorporated into this policy. Shift patterns abide by Agenda for Change Terms and Conditions. Source: Workforce Status: Approved Page 4 of 24

7. Production of Rosters using Healthroster A table and flow chart of the process can be located in appendix 2 of this policy The publication of the roster will take place as scheduled across all clinical areas in the Trust using Healthroster (timetable available on intranet) All rosters must commence on a Sunday Ideally rosters should be completed 6 weeks in advance and must be completed at least 4 weeks in advance of the start date (see Appendix 2). This will enable staff to better manage their personal arrangements and to afford the WSP bank office sufficient time to fill vacant shifts Required WSP bank requests from the approved roster will be sent to the WSP bank office within 2 days of the roster being published All rosters should be created to adequately cover the designated area s operational hours utilising permanent staff proportionally across all shifts Shifts given a high priority on Healthroster must be filled first, i.e. nights, weekends, and public holidays. It must not be routine to use temporary staff/overtime to staff night shifts If any staff work non-standard shifts such as late starts this should be entered to avoid misinterpretation Substantive administrative staff should also be entered as appropriate Please see appendix 4 for guidance in respect of Pre-registration Nursing students. All new starter details should be sent to the Healthroster Team as soon as possible to ensure they appear on the roster in advance of their start date. 8. Validation/Approval The Clinical Area Manager reviews the roster analyser within timeframes specificed on the intranet information and if this meets defined parameters, approves roster and informs the Senior Manager ready for their review The review must include: o Currently potential unsafe shifts o Shifts for which temporary staff are planned. Ward Manager and Senior Nurses to discuss option of using staff from within the directorate, rather than temporary staff, to cover gaps. o Any of the agreed parameters and KPI s that have been exceeded o Any issues identified must be reviewed with senior manager All changes made, after the roster has been approved, are clearly marked for audit purposes and if this has an impact on the booking of temporary staff, immediately communicated to the WSP bank office Key performance indicators and parameters will be set and monitored, using Healthroster analysis reports, by the Senior Managers. To optimally manage the rosters the following key metrics should be within the parameters identified below: Unavailability working days staff unavailability during the 4 week roster period, broken down in to the following categories. The total percentage of these should equate to the 20 % headroom that is built in to each establishment. % of annual leave (14%, parameters set to 12 16% (Appendix 3)) % of sickness (3% target) % of study days (3% target) Source: Workforce Status: Approved Page 5 of 24

Working Day i.e. clinical management day, other non-clinical day, Band 6 (Management role) 15 hours per 4 week roster (pro-rata for part-time staff) Net hours - hours accumulated over time, whether owed to the Trust or Staff Additional duties used (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) Unfilled shifts in hours (duties within the agreed demand that have not been filled by permanent staff, broken down by number of shifts, hours and approximate cost based on WSP bank pay rates) Bank and Agency Hours Approval Compliance Targets for the above are available on the Key Performance Indicators Report All rosters must be reviewed and scrutinized for approval/rejection by Senior Management. If not approved it will be returned to the roster creator to re-do. If it is approved, permission will be given to publish. KPIs will also be reviewed by the Workforce Information Project Board. 9. Skill Mix and Staffing Levels for Wards and Clinical Departments Each clinical area should have a total number of staff and skill mix per shift agreed with the clinical area manager and senior manager concerned. Agreed numbers and skill mix must be achievable within the clinical area budget Each clinical area should have a level of staff with specific competencies on each shift, i.e. the ability to take charge, IV designated staff, as agreed with the Clinical Area Manager concerned In areas where the workload is known to vary according to the day of the week staff numbers and skill mix should reflect this Staff will be required to work a variety of shifts and shift patterns as agreed by their Clinical Area Manager Staff may work long shifts, short shifts or a combination of both in order to meet the clinical requirements and meet the agreement within the service area. Variations to these shifts may be worked but must be agreed with the Clinical Area Manager and a written record kept (see Agenda for Change Part 4 section 27) The early and late shift should have a 30 minute unpaid break included in the shift time e.g. 07.00 to 15.00 7.5 hours paid and 0.5 hours unpaid break o A long day has 1 hour unpaid lunch break which can be split into 2 0.5 hours unpaid break included in the shift e.g. 08.00 to 20.00 11 hours paid and 1 hours unpaid breaks o Coffee and tea breaks (paid) are at the discretion of the manager and should be a maximum of 15 minutes o The night shift has an hour unpaid break and a refreshment break (paid) that should be no longer than 15 minutes, preferably with a gap of two hours minimum between. This enables staff to have two rest periods Source: Workforce Status: Approved Page 6 of 24

o An adult worker is entitled to a main break of 20 minutes if their working time is more than 6 hours. The adult worker is entitled to take the rest break away from the workstation if they have one (European Working Time Directive). This does not have to be paid and should not be at the end of the shift. The clinical area manager or shift coordinator is responsible for ensuring breaks are facilitated, if breaks are unable to be taken at an agreed time (due to clinical need), they should be taken as soon after this point as possible Weekend shifts are defined as Friday night, Saturday day or night, Sunday day or night and Bank Holidays. Enhanced unsocial hours start at 8pm Staff should have at least a minimum of one weekend off per 4-week roster, ideally two in normal circumstances (unless they have agreed work patterns). Additional weekends off can be rostered if the clinical area requirements allow. Staff may work more weekends if they specifically request to do so The maximum number of consecutive standard 7.5/8.5 hour day shifts recommended for staff to work is 7. (Consideration can be given to an increase in this in exceptional circumstances) It is recommended in the European Working Time Directive that there should be 11 hours break between shifts. However, if staff opt to work long shifts the maximum number of consecutive shifts recommended for staff to work is 3. (Consideration can be given to an increase in this in exceptional circumstances) The maximum number of consecutive night shifts recommended for substantive staff is 4. 9.1. Flexible Rostering Guidelines Areas using flexible rostering will have local management agreement that this approach is appropriate to the delivery of service in that area. Suitable areas will usually provide a specialist service with predictable or fluctuating workloads that can be managed through flexible working to maximise use of staffing resource. The roster will be completed in line with this document. Flexible rostering Allows for the management of employee contracted hours where the standard working shift(s) of the clinical area is not a multiple of 150 (or the 4 week total of contracted working hours) An employee may be rostered for an agreed variable number of shifts within each 4 week roster generating a positive or negative balance. This should be agreed between the roster creator and the member of staff and where possible should not exceed + or a standard shift duration e.g. 12.5 hours This will facilitate the use of an on-call system, which will be administered at short notice to meet the needs of the clinical area. Where a current workload is predicted to need fewer than the core establishment levels to deliver the service, an employee may revert from their rostered shift to an on-call shift Source: Workforce Status: Approved Page 7 of 24

Rules The opportunity to revert from rostered shift to on-call can be requested, however there is no guarantee of agreement to this by the senior nurse on for that shift. Retrospective annual leave can be granted to clear any time owing, provided the individual has not used their full entitlement to date Management of the on-call system must consider cancellation of bank shifts before moving substantive staff to an on-call status Where an employee owes hours to the Trust the roster creator will use those hours on the subsequent roster before requesting any bank hours Clear, accurate, and auditable records must be maintained of flexible working and accrued hour balances 10. Staff Requests There will be a maximum of 4 requests shifts/days off per 4-week roster pro-rata - this equates to 20%. This can be reviewed and determined by the Clinical Area Manager Staff must not assume that the roster will be written to accommodate these requests as service needs will take priority Each clinical area will use Employee On Line for staff to make requests for all types of leave and requests. These requests will be considered in the light of service needs Requests for specific shifts or days off can be made. These are known as personal patterns. Service requirements and equity for other staff members must be taken into account when applying these. They must be agreed and reviewed 6 monthly by the Clinical Area Manager. Personal patterns are not to be considered as requests 11. Unavailability Periods 11.1 Annual Leave (Refer to Annual Leave Policy) Annual leave must be booked or cancelled before the roster is rostered. Annual leave requested after this can only be given if staffing levels permit, near to the day All leave should be booked at the earliest possible opportunity (at least 8 weeks in advance, except in case of domestic emergencies, and authorised by the Clinical Area Manager) to enable effective roster creation. The period incorporating 24 December to 2 January; this period will be treated as all other weeks in terms of leave. Each Clinical Area will determine how the usual level of leave will be allocated, and write this in the local policy; i.e. more staff may get a small number of leave hours as opposed to a small number of staff having one week blocks of leave. This will depend on the adequacy of staffing at the time. All requests for this will be in writing to the Clinical Area Manager or Roster Creator, stating exact dates required Source: Workforce Status: Approved Page 8 of 24

Requests for the period incorporating 24 December to 2 January annual leave should be made by a date agreed locally and staff should be notified if their request has been approved. No temporary staff should be routinely booked on planned rosters for the period incorporating 24 December to 2 January, to meet standard unit requirements Staff must put in requested dates for annual leave entitlement as soon as possible and wherever possible, 25% of annual leave should be taken each quarter, to ensure an equal spread of leave allowance throughout the year. Please refer to Special Leave for Domestic, Personal and Family Reasons - Policy PP(08)066 for details and information on Special Leave 11.2 Study Leave (Refer to Trust Policy) Study leave should be granted and managed in line with the Trust Study Leave Policy PP (14)067, acknowledging variations in individual days and course requirements. A study day is usually the equivalent of a 7.5 hour shift and where an individual s usual shift is longer than this the remaining hours will need to be allocated on the roster Ensure that mandatory training is balanced throughout the year and assigned per rota 11.3 Sickness Leave (Refer to Trust Policy) Improving employee Attendance Policy PP (14)036 Sickness absence must be reported by telephone to the Clinical Area Manager or deputy with maximum notice possible, but no later than one hour after the shift commences. Informing the manager of the nature of illness and expected length of absence. If unable to identify length of absence then the individual must ensure they keep in regular contact to report on progress (e.g. day 1, day 3, day 7 & subsequently in line with expiry of sick certification). If off-duty days follow on from sick days, and the member of staff has not advised that they are available to work, then off-duty days will be reclassified as sick leave Where there are concerns about an employee s health or if members of staff are often or regularly sick, the manager will use the Bradford score to trigger a review with the HR and Communications Directorate and possible referral to Occupational Health. In accordance with the policy PP (14) 036. 12. Changes to Published Rosters It will be the responsibility of the Clinical Area Manager or designated staff to amend rosters with unavailability shifts i.e. sickness, no shows, and additional duties 8 hours to ensure the system maintains accurate reporting facilities. It is the clinical area manager s responsibility to ensure appropriate staff have access and are trained to make these changes. Staff are responsible for negotiating changes to the shifts booked in their permanent post once the roster is completed, but must not change previously booked bank work without further discussion with the WSP bank office. Any changes must be approved by the Clinical Area Manger or designated deputy in his/her absence together with bank office as appropriate Source: Workforce Status: Approved Page 9 of 24

All changes should be negotiated by the individual with an equal band and approved by the clinical area manager (or senior practitioner in her absence). Overall skill mix, student mentoring arrangements need to be considered Any changes to staffing must go through the normal channels. e.g. new recruits must have undergone all pre-recruitment checks and undertaken induction prior to commencing on the roster, any internal staff (including bank staff) movement must be authorised by all relevant parties and a Vacancy Approval Form (VAF) to HR. If this is not reflected on the roster the online Healthroster request form should be completed to ensure the update is available for the next roster being produced. 13. Booking temporary staff 13.1 Booking Arrangements (please see protocol in appendix 5). 14. Monitoring Rosters via Healthroster Reports A range of reports can be produced on Health Roster and generated on a monthly basis by the Clinical Area Manager or Senior Manager (Appendix 6). The Workforce Team produce reports on Approval compliance, Prospective Key Performance Indicators (KPIs) and Retrospective KPIs which are published on a regular basis. 15. Escalation (Refer to Trust Patient Flow and Hospital at Night Operational Policy PP (08) 182 (formerly Bed Management and Escalation Policy) Escalation will be undertaken when; either a directorate or WSP bank draws attention to a major problem with staffing and will be discussed with the bleep holders/smoc/patient Flow Team These include: Emergency bed pressures High levels of sickness and vacancies of nursing staff or high level of unfilled WSP bank staff, as defined by site coordinator and SMOC 16. SafeCare Data Entry and Analysis 16.1 Maintain Acuity Data Patient acuity data is entered onto SafeCare which is a module of Healthroster Manager, it is the responsibility of the Nurse in Charge / Co-ordinator to ensure that it is entered for each Census Period as per the agreed time frames in Appendix 7. The data can be entered by any individual who has the appropriate access to the system. The patient data should be entered between 90 minutes prior to the start of the Census Period and 30 minutes after the start of the Census Period. All data entered prior to the 2 hour window will be considered as predictive. Data entry is monitored by Ward Managers and Matrons to ensure that all data is entered, and where relevant challenge the levels of a patient s acuity. 16.2 Maintaining Rosters Out of Hours 20:00 to 08:00 sickness will be reported by the staff member who is off sick to bleep 888. Bleep 888 holders will be responsible for updating SafeCare of any staff that do not show for work, for reasons such as sickness. During hours the ward should be contacted directly. Source: Workforce Status: Approved Page 10 of 24

Redeployment of staff (commonly known as blue boxing ) between departments will be maintained by the Clinical Lead of Contracted Pool or at ward level. 16.3 Redeployment Plan & Decision Bleep 888 and the Clinical Lead of Contracted Pool to review staffing levels and create a plan of action to redeploy staff where appropriate. This plan will be reviewed a discussed with Service Managers or the Nurse in Charge to confirm viability. 16.4 Analysis & Decision based on Trend data Data will be reviewed by Deputy Chief Nurse to analyse possible trends to assist in the Establishment Review Data entry compliance and required nursing v actual nursing rostered will be reviewed monthly at the Workforce Information Project Board. This same data will be made available to all departments that are recorded on SafeCare so that they are able to monitor their own compliance and analyse the data to ensure that they are using staff effectively. 17. Action in case of Healthroster system failure Print out roster as required after each update, use this print out at front desk for all staff, remove and dispose of previous print out copies. If system fails, use this print out with hand written corrections until system available; at earliest opportunity update from this print out. If system fails during roster writing period, contact your system administrator to find out when system available; work done since last backup (hourly) will be lost. Rosters are triple backed up x2 internal backups, x1 external. There may be a delay in Healthroster if backup required. Clinical area managers and senior managers will be informed of this via e-mail as soon as possible Source: Workforce Status: Approved Page 11 of 24

Power Failure Known system down time Unexpected system failure, requiring rollback to previous uncorrupted files Maintain paper roster until power returns Update roster with changes Contact Roster team if you have problems updating once power returns E-mail alert to all users will be sent to advise logging out of Healthroster Maintain paper roster E-mail alert will be sent to advise system available for use. Contact Roster team if problems occur E-mail update of situation will be sent ASAP after event Make note of changes made to live system in previous hour, and make them on paper roster. Maintain paper roster for ongoing changes E-mail updates will be sent, including the time and date of system restore file View roster, make changes requires Contact roster team if support required 18. Monitoring the effectiveness of the Policy (Do we need this bit? Does it happen? Include: The key standards/practices that require monitoring KPI s in Roster Policy Frequency of monitoring roster central analysis across the Trust per month and annual review There will be an annual review of rosters against the policy The results will be reported to the Rostering Steering Group Source: Workforce Status: Approved Page 12 of 24

Disclaimer It is your responsibility to check that this is the most recent issue of this document Author(s): Other contributors: Approvals and endorsements: Consultation: Issue no: File name: Supercedes: Equality Assessed Implementation Monitoring: (give brief details how this will be done) Other relevant policies/documents & references: Additional Information: Leonard Rowland Workforce Information Manager Rebecca Rutterford Rostering & Training Improvement Manager Lorraine Weaver-Smith Healthroster Co-ordinator Denise Needle Deputy Director (Workforce) Jane Croker NVQ Care Coordinator Claire Scott WSP Manager and representatives from Trust Council Workforce Information Project Board Trade Union and Staff Two Staff Roster Policy for Clinical Areas PP(15).doc Staff Roster Policy for Clinical Areas PP(11).doc Yes This document will be available to all wards and departments electronically on the Intranet. This document will be reviewed every 3 years as per review date. Annual Leave Policy PP (14) 165 Annualised hours Policy PP (14) 103 Flexible Working Policy PP (14) 127 Improving Employee Attendance PP (14) 036 Overtime Policy PP (13) 168 Special Leave (Domestic, Personal & Family Reasons) Policy PP (13) 066 Study Leave Policy PP (14) 067 Term Time Working policy PP (14) 091 Source: Workforce Status: Approved Page 13 of 24

APPENDIX 1 Healthroster Information Healthroster is a computerised system specifically designed for use by Clinical area Managers, and Senior Managers. It rosters staff to an agreed duty requirement, manage staff availability and contracts and allows clear visibility of ward manning levels. It will also track and produce reports for absence, leave, additional duties and temporary staff usage (WSP bank, agency, overtime) Healthroster can be summarised as follows: Manage Rosters Details the processes for creating and updating rosters and deleting rosters where they are not required Assign Duties Describes the overall parent process for assigning roster duties. The process describes the steps involved in filling the roster and references sub processes that explain how the Ward Manager assigns duties using the Auto Roster and manually. The process also shows how the Senior Manager reviews the Ward Manager approved roster, and approves the roster for publishing Auto Assign Duties The detailed process steps for assigning duties using the Auto Roster feature. This process describes how the Ward Manager chooses an Auto Roster favourite (Strict or Moderate), sorts the list of duties for assignment, and runs the Auto Roster. This process does not describe the internal functional operation of the Auto Roster. This is detailed in another document: Auto Roster Guidelines Assign Duties Manually Describes the process for assigning duties manually, including the processes for swapping and combining duties, after the Auto Roster has completed. This process describes how Healthroster indicates whether a duty assignment is a perfect fit, is assigned but with warnings, or whether the duty assignment has been rejected due to a rule violation Assign Duties to Staff from Other Wards After the Ward Manager has approved their roster it is ready for review by the Senior Manager (Second approver). The Senior Manager should review the wards within their remit and try to fill any outstanding vacant duties with suitable staff that are available from other wards Administer Rosters Once the roster has been published, the Ward Manager must manage the ongoing changes made to the roster. Examples of changes made to the roster include the recording of No Shows (e.g. sickness/ last minute annual leave / carers leave), cancelling duties, and the creation of additional duties. This process describes how the Ward Manager accomplishes these tasks Source: Workforce Status: Approved Page 14 of 24

APPENDIX 2 Guide to producing a roster & flow chart Process Use the Trust standard roster dates Close to the roster to requests and approve requests and add / approve any unavailability periods as appropriate. Run the autoroster (this will try to fill in the expensive / difficult to fill shifts (e.g. nights / weekends) first and create a balance). Ensure that there is a nurse in charge for each shift, manually move shifts as necessary. Fill remaining staff hours with vacant shifts, adjusting duty times where necessary, ensuring all net hours are utilised first. Review roster analysis data, ensure good balance of staff across 4 week period, all staff hours are used, charge cover allocated and there is an even balance of popular and unpopular shifts amongst substantive staff. Staff unavailability should be within the specified parameters, if it is not the roster should be reviewed and amendments made before reviewing the analysis data. Approve the roster and inform Senior Manager ready for approval. Senior Manager reviews and analyses data, if there are gaps in the roster try to cover them by moving nurses or responsibilities between teams / wards. Once approved by Senior Manager publish roster Allocate any vacant shifts required by the service to be filled to WSP Bank, immediately after roster has been approved at second level. According to Bank Policies. Additional ad hoc requests can be made later according to Bank Policies If there are still gaps in the roster, plan to fill them with temporary staff or by reviewing unavailability shift allocations e.g. prioritise workload or consider moving less urgent tasks to another shift and/or make best use of supernumerary staff available. If temporary staff are necessary, ensure you are rostering them for the cheapest possible shift, length of time and grade. Inform WSP Bank office of likely temporary staff requirements as soon as possible. Responsibility Roster Creator Roster Creator Roster Creator Roster Creator Roster Creator Roster Creator / Clinical Area Manager Clinical Area Manager Clinical Area Manager /Senior Manager Roster Creator Clinical Area Manager Clinical Area Manager Clinical Area Manager Clinical Area Manager Source: Workforce Status: Approved Page 15 of 24

Flow chart for producing a roster Produce request sheet/healthroster request period Request period available for staff to complete, with a stated closing date Analyse, approve and publish roster Analyse roster to assess effectiveness, make relevant changes to ensure within defined parameters. Pass roster approved by clinical area manager to senior manager for 2 nd level analysis and approval Manage roster Enter changes onto Healthroster as they occur Week 3 Week 4 Week 8 Week 1 Week 4 Week 4-12 Produce roster Close requests, produce roster, using all available hours and filling the most expensive shifts first Fill shortfalls Forward vacant shifts to WSP bank Make amendments to roster Roster commences Enter any changes to keep roster updated Agreed standardised abbreviations to be used by all clinical areas: LD = Long day (12.5 hrs) L = Late E = Early N = Night NR = Non rostered/admin TW = Twilight AL = Annual Leave TO = Time Owing DO = Day Off SD = Study Day ML = Maternity Leave P = Paternity Leave BH = Bank Holiday CL = Compassionate Leave CA = Carers Leave S = Sick Leave FTR = Fit to Return UPL = Unpaid Leave 718/390 or designated bleep WC = Ward Clerk CC = Care Coordinator Recep = receptionist Coord = coordinator Source: Workforce Status: Approved Page 16 of 24

APPENDIX 3 Annual Leave Calculation Formulae Allocation Formulae Total Hours per rota for leave Example: Example: Bank holidays per year Total leave to be allocated per year Total leave to be allocated per off-duty 30 days average of annual leave multiplied by WTE s on clinical area equals the number of hours of annual leave required for the year. (8 x 7.5 hours) multiplied by WTE s on clinical area equals the number of hours of annual bank holiday allowance required for the year. Add the two totals (annual leave and bank holidays) together. Divide the annual hours required by the number of weeks per year 52.143 then multiply that number by four to give you the number of hours you are required to allocate per 4 week off-duty 30 (days) x 32 (WTE s) = 960 (days) Each day is equal to 7.5 hours 960 (days) x 7.5 (hours) = 7200 (hours) (8 x 7.5 hours) = 60 (hours) 60 (hours) x 32 = 1920 (hours) 7200 + 1920 = 9120 9120 / 52.143 x 4 = 699.6 (hours) Study Leave Calculations Allocation Formulae Total Hours per person Example: Example: Total leave to be allocated per roster 5 days average of study leave multiplied by WTE s on the clinical area equals the number of hours study leave required for the year. Divide the annual hours required by the number of weeks per year 52.143 (365/7). Then multiply by four to give you the number of hours you are required to allocate per 4 week off-duty 5 (days) x 28.5 (WTE s) = 142.5 days Each day is equal to 7.5 hours 142.5 (days) x 7.5 (hours) = 1068.75 (hours) 1068.75 / 52.143 x 4 = 81.96 (hours) Link to Annual Leave Calculator on Hospital Intranet Source: Workforce Status: Approved Page 17 of 24

APPENDIX 4 Pre-registration Nursing Students All pre-registration nursing students will be documented on the student sheet in the roster, with their cohort (e.g. 09/08). All shifts are supernumerary and will be shown as such together with start and finish times. Student nurses will wherever possible be rostered with their mentors (the minimum requirement is 40% e.g. 15 hours per week) Student nurses should be rostered onto the area roster prior to commencement of their placement. They may then be allowed to negotiate changes to their roster ensuring that they continue to meet the minimum requirements for working alongside their mentors. The only set days when students cannot attend practice are college days. 1st year student nurses are not permitted to work long days or night shifts. 2nd and 3rd year students nurses may work long days if it follows the pattern of the area and only if they are on with their mentor, not at their convenience All student nurses are expected to work some weekends. Aim to ensure that there are only a maximum of 3 student nurses on any single shift, in order to maximise potential for learning opportunities. Source: Workforce Status: Approved Page 18 of 24

APPENDIX 5 Protocol for Requesting Shifts with West Suffolk Professionals All requests for the booking of bank and agency staff should be made through the WSP Bank office via the bank staff rostering system: o To comply with audit trail requirements o To ensure that all bank and agency staff supplied comply with requirements and are appropriately registered to maintain the optimum safety of patients o To ensure that the agencies used are appropriately licensed and comply with agency licensing legislation o The monitoring of working hours of all bank and agency staff at the point of booking to comply with the working time regulations Requests outside of the agreed establishment must be authorised by the senior manager. It will not be possible to book temporary staff to cover annual leave requests that exceed the documented level acceptable for the clinical area Bank and Agency staff cannot be used to take charge of clinical areas unless they have been assessed as competent to do so, and are willing to take charge. This must be approved by the senior manager No replacement staff should be booked without the Clinical Area Manager or deputy assessing: o The need for them o The grade that is required o The competencies required o The time that they are needed to start and finish Wards should indicate to the WSP Bank the names of those who have responsibility for communicating advance bookings (only these people will have permission within the system to request WSP Bank staff) and they should arrange to liaise with the WSP Bank each week regarding outstanding cover West Suffolk Professionals Shift Times Booking bank staff for weekend day shifts incorporates an additional cost of basic pay + unsocial payment as according to Agenda for Change. Therefore, rosters should be developed that cover these shifts with substantive staff in the first instance and any unfilled shifts should be balanced across week day shift in the rosters. It may be necessary to request temporary staff to allow substantive staff to cover special patients, it is not appropriate for WSP Staff to cover a full shift allocated as a special. In order to ensure that appropriate staff can be sourced to provide cover, these requests must be communicated in as much detail as possible to the WSP Bank office at the earliest opportunity Night shift times will remain unaltered unless advised by the West Suffolk Professionals team. Source: Workforce Status: Approved Page 19 of 24

When Authorised Personnel 1 are available The requirement for Bank shifts via West Suffolk Professionals should be reviewed by the Ward Manager/Sister and requested a minimum of twenty four hours prior to the commencement of the required vacant shift. Where short term/notice absence occurs, i.e. sickness, emergency leave, necessary changes to the area s Healthroster, they are to be made by the Ward Manager/Sister by creating the vacant duty and this must be sent to the West Suffolk Professionals office at this time. The requirement for additional staff, i.e. for extra beds, 1:1 nursing, must be authorised by the Service Manager/Matron/SMOC and the required additional duties created on the area s Healthroster, before the vacant duty is sent to the West Suffolk Professionals office. Should extended absence be recorded, i.e. long term sickness, extended emergency leave, the Ward Manager/Sister must take advice from their Service Manager/Matron. When Authorised Personnel 2 are not available during Week Days Within the hours of 07:00 16:30 Monday to Friday, the Senior Nurse on duty/bleep Holder must contact the Healthroster Team on Bleep 968. The information related should include the name of the staff member who is absent and the date and duties affected. The Healthroster Team will then add the unavailability activity and create the vacant duty which will then be sent to the West Suffolk Professionals office at this time as a bank shift request. When Authorised Personnel are not available - Saturday Mornings Where able, The West Suffolk Professionals Office is open between the hours of 08:30 12:30 on Saturdays. The nurse in charge of the clinical area will contact the Bleep Holder, who will then contact the West Suffolk Professional s Office and request the required duty. The West Suffolk Professionals staff on duty will accept verbal staffing requests from Bleep Holders without the requirement for the creation of a vacant duty on the area s Healthroster. West Suffolk Hospital Professionals will then, where possible, book the required staff to cover the shift. Ward Managers/Sisters will be responsible for updating their rosters when on duty next, adding the unavailability activity and retrospectively creating the vacant duty, which will then be sent to the West Suffolk Professionals office at this time. When Authorised Personnel are Not Available - outside West Suffolk Professionals/Healthroster Team Working Hours The nurse in charge on the clinical area/bleep Holder will cover the vacant duties where possible with available staff. Should available staff require payment via West Suffolk Professionals; the nurse in charge on the clinical area/bleep Holder will advise the Ward Manager/Sister/Rostercreator via email at the next available opportunity so the required vacant duty can be retrospectively created. (If 1 Authorised Personnel are senior staff who have the ability to access and amend rosters on the system. 2 Authorised Personnel are senior staff who have the ability to access and amend rosters on the system. Source: Workforce Status: Approved Page 20 of 24

there are any problems with this the Healthroster team can in exceptional circumstances update the Roster, so please copy the email to the Healthroster team as well). The nurse working the shift also needs to be registered with West Suffolk Professionals to be paid, in this instance the ward manager should e-mail either the manager or team leader of West Suffolk Professionals to arrange registration. If West Suffolk Professionals are unable to provide the required grade of staff The West Suffolk Professionals team will endeavour to meet the Staff Grade Requirements of bank requests made via Healthroster. If the West Suffolk Professionals team are unable to provide the required grade of staff by no later than the commencement of the preceding shift, but are able to offer a member of staff at either a higher or lower grade, the West Suffolk Professionals team will contact the nurse in charge of the clinical area to gain verbal authorisation to down/upgrade the shift to the staff available. Agency Bookings All agencies currently used by the WSP Bank form part of the multi-regional agency framework As shifts are offered to bank staff in the first instance ward staff should not contact agencies or book agency nurses directly Agency Nurse bookings may only be made by the Trust s WSP Bank Office and SMOC out of hours Agencies will be approached on a day to day basis when required, and will not be advanced booked No substantive member of staff or non-contracted WSP bank staff can work through an agency at West Suffolk Hospital Links with Healthroster Finalisation All changes to Healthroster should be completed within forty eight hours and ensure the creation of bank requests as required. Ward Managers/Sisters will ensure that all required changes to their individual area s monthly rosters are completed by the 5th of each calendar month. This will allow an accurate payroll to be completed from the data, which generates all staff s unsocial payments claims. Please seek assistance from the Healthroster Team as required. Source: Workforce Status: Approved Page 21 of 24

APPENDIX 6 Monitoring and reporting against Key Performance Indicators for each clinical area (Overall report re KPI s to go to the project board on a monthly basis) Report Area Report Description Owner Reviewer (s) 1a Quality Contracted staff by whole time equivalent Ward Manager (WM) Rostering Creator (RC) Responsibility for reviewing and enacting changes Service Manager (SM) Frequency Bi-monthly 1b Numbers of vacancies WM RC SM Monthly 1c Unfilled shift distribution WM RC SM Monthly 1d Shifts without take charge cover WM RC SM Monthly 1e Nursing hours per patient day WM RC SM Bi-monthly 1f Number of shifts calculated at red due to staffing inadequacy WM RC SM Monthly 2 Fairness Requests WM RC SM Monthly 3 Down- time Management Staff unavailability during the 4 week roster period. - Annual leave - Sickness - Study leave/cpd - Mandatory training - Clinical skills training - Management time - Other WM RC SM Monthly Source: Workforce Status: Approved Page 22 of 24

4a Rostering Efficiency Lost contracted hours contracted hours not used over a 4 week period. 4b Over contracted hours hours used over those contracted to work WM RC SM Monthly WM RC SM Monthly Additional duties any duties allocated that are above the agreed staffing requirement for the ward WM SM SM Weekly 4c Overtime allocated WM RC SM Monthly 4d Bank/Agency allocated WM RC SM Monthly 4e Amendments to an approved roster after submission to ESR WM RC SM Monthly 5a Financial Efficiency Total cost of 4 week roster WM RC SM Monthly 5b Total temporary staff spend per 4 week roster WM RC SM Monthly 5c % temporary staffing per roster WM RC SM Monthly 5d Spend in comparison to allocated budget WM RC SM Monthly Source: Workforce Status: Approved Page 23 of 24

APPENDIX 1 SafeCare Information Census Period Name Census Period Time Census Period Entry Time Early 07:00 13:00 05:30 07:30 Late 13:00 20:30 11:30 13:30 Overnight 20:30 07:00 19:00 21:00 Source: Workforce Status: Approved Page 24 of 24