Nursing and Midwifery Rostering Policy
Reference Number: 156
Jan Lynn Lead Nurse Workforce Development and Author & Title: Education Ana Gleghorn Head of Nursing for Surgery Helen Blanchard Responsible Director: Director of Nursing and Midwifery
Review Date: 07 September 2020
Ratified by: Strategic Workforce Committee
Date Ratified: 07 September 2017
Version: 2.0
Maternity, Paternity, Adoption, Parental and Related Policies and Shared Parental Leave Policy Guidelines Appraisal Policy Managing Temporary Staffing Policy Working Life Policy and Procedure Supporting Attendance Policy Secondary Employment Policy Fixed Term Contract Policy
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 1 of 26
Index:
1. Policy Summary ______4 2. Policy Statements ______5 3. Definition of Terms Used ______5 4. Duties and Responsibilities ______6 4.1 Employees ______6 4.2 Roster Managers ______7 4.3 Department Manager (Budget Holder) ______8 4.4 Staffing Solutions ______8 4.5 Matrons ______9 4.6 Heads of Nursing & Midwifery ______9 4.7 E-Rostering System Administrator ______9 5. Procedure ______10 5.1 Rostering Rules ______10 5.2 The Production of Roster ______14 5.3 Poor Rostering ______15 6. Monitoring Compliance ______16 6.1 Key performance indicators ______16 7. Review ______17 8. References ______17 Appendix 1: Roster Process – Quick Guide ______18 Appendix 2: 12 Golden Rules for Good Roster Management ______19 Appendix 3: Timetable for Roster Completion and Sign off 2017/2018 ______20 Appendix 4: Shift Times Consultation Agreed Times ______21 Document Control Information ______24 Ratification Assurance Statement ______24 Consultation Schedule ______25 Equality Impact: (A) Assessment Screening ______26
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 2 of 26
Amendment History
Issue Status Date Reason for Change Authorised 1.0 Final Oct 2013 New Policy Director of HR 2.0 Final Sept 2017 Review and update Strategic Workforce Committee
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 3 of 26
1. Policy Summary
The Trust is committed to delivering safe, quality patient care by demonstrably effectively managing its resources, including its workforce.
The purpose of this policy is to outline the parameters for effective rostering in conjunction with the Trust’s electronic rostering system, RosterPro Central (RPC), to ensure that the Trust’s patients are consistently cared for by staff who have been effectively and equitably deployed in line with service need, agreed staffing levels and, wherever possible, to reflect the requests of individual employee’s with regards to the off duty, to ensure a work life balance.
This policy also outlines those occasions when use of the Trust’s flexible workforce may be considered, by clearly identifying where shortages in the workforce may adversely impact on the maintenance of appropriate staffing levels.
This policy is designed to enable maximum utilisation of the RosterPro Central system to ensure that the Trust is able to adequately report upon the utilisation of its workforce to demonstrate its effective use of public monies in its delivery of patient care and compliance with the standards outlined by the Care Quality Commission (CQC), including Outcome 21: Records – Essential Standards of Quality and Safety.
The Policy also supports the staffing efficiencies as recommended by Lord Carter within his report Operational productivity and performance in English NHS acute hospitals: Unwarranted variations (2016) where he recommended good rostering practice guidelines. These guidelines are incorporated within this Policy. The purpose of this Policy is :
To ensure safe/appropriate staffing for all departments using fair and consistent off duties that comply with the agreed standardised shift patterns (appx 4 ) . To minimise clinical risk associated with the level and skill mix of nursing and midwifery staffing levels. To give all staff the opportunity to self-roster in line with Improving Working Lives. 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. To improve planning of clinical and non-clinical “non-effective” working days (e.g. annual leave, sickness and study leave). To provide effective management of inpatient (hereafter referred to as nursing establishments), thereby driving efficiencies in the nursing and midwifery workforce across wards and departments. To describe the process of monitoring roster completion against the timetable and escalation process if required Improve the utilisation of existing staff and reduce bank and agency spend by giving Managers and Senior Managers clear visibility of staff contracted hours.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 4 of 26
To improve monitoring of sickness and absence by department and/or individual, generating comparisons, identifying trends and priorities for action. To provide guidelines for the effective use of (RPC) when linking to Electronic Staff Records (ESR) for the purpose of paying staff.
2. Policy Statements
All new employees will be made aware of this Policy through the Induction Process and supported by Managers and Supervisors, through the management communication process.
This Policy recognises the importance of engaging staff in designing an effective roster for the delivery of safe patient care and the maintenance of a work life balance.
This Policy reflects the requirements of both the Working Time Regulations (1998) and the Trust’s Work Life Balance Policy, which provides detailed guidance on flexible working options within the Trust.
In addition, the utilisation of RosterPro Central recognises the need for impartial and equitable rostering to take place within the Trust, with time clearly allocated for essential professional development (Study Leave) and rest periods (Annual Leave) to ensure that the workforce is supported to have an appropriate work life balance and in line with service needs.
3. Definition of Terms Used
Actual: The activity that took place during the shift, e.g. employee was sick when rostered to work & should be retrospectively recorded as such.
Electronic Staff record (ESR): The NHS Staff record system used by Payroll.
Fixed Pattern: Set working pattern replicated each week without exception.
Headroom: Additional allowance within a budget equal to 20% to fund cover for the absence of substantive members of staff due to planned Study Leave, Annual Leave etc.
Non-Effective Working Days: Days that staff are not available for the roster i.e. Leave, Study days, sickness.
One Request: one day of duties/shift (e.g. Early / Late or a Long Day where appropriate).
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 5 of 26
Permanent: Employees who hold a substantive contract of employment with the Trust which has no end date and which has a set number of hours per week / year.
Temporary: Employees who hold a fixed term contract with the Trust or workers employed through the Bank or an Agency to undertake work on behalf of the Trust.
RReporter: The reporting element of RosterPro Central.
RosterPro Central (RPC): The Trust’s E-Rostering software system.
Rroster: The self-service interface which allows staff to electronically submit a self- roster for approval.
R-Link: The software that links RosterPro Central and ESR to enable payments to be made against information entered into RosterPro Central.
Variations in shifts: differing start and finish times to regular shifts.
Weekend Shifts: Friday Night, Saturday day or night, Sunday day or night and Bank Holidays.
Whole Time Equivalent (WTE): Full Time Work, 37.5 hours per week for Agenda for Change Staff; 40 hours per week (10 Programmed Activities) for Medical & Dental Staff.
.
4. Duties and Responsibilities
4.1 Employees Employees are expected to make all reasonable efforts to support effective rostering by requesting those shifts which would support them to have an appropriate work life balance. Employees should use the (RPC) for off duty requests via RRoster. These requests will be considered in the light of service needs. Whilst the Department Manager will be flexible in trying to accommodate as many requests as possible, service requirements and equity for other staff members must be taken into account first before applying these. Fixed shift patterns are not considered as requests but may be part of an agreed flexible working pattern for review on a 6 monthly basis.
Employees are responsible for ensuring that they appropriately plan their annual leave and study leave to ensure that they maintain their skills and receive sufficient rest throughout the year.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 6 of 26
However, employees are reminded that requests for annual leave and study leave are requests until they have been approved and no bookings or arrangements should be made until or unless their request is formally approved.
Employee requests should not exceed 4 shifts or days off pro-rata (roster period)
4 requests for 37.5hrs/pw contract 3 requests for 30hrs/pw contract 2 requests for 24hrs/pw contract 1 requests for 18hrs/pw contract
Employee’s must work within the roster timetable (Appendix 3) when making any working or non-working request. Employee’s may carry no more than one week’s (pro rata) annual leave into the next annual leave year. This must be with agreement from their line manager and must be taken within the first month of the new annual leave year. Employees should have taken 75% of their allocated leave by the end of quarter 3 of their annual leave period. Employee’s rostered for a shift wishing to change their off duty post publication, may do so by a fair swap which should be made with another member of staff of the same grade and holds the same skills set. This swap must then be approved by the department manager or their deputy.
Inappropriate shift requests, not in line with the Working Time Regulations (WTR) will not be considered by the Department Manager. The Working Time Regulations require: maximum working hours 48 hours per week averaged over 17 weeks a rest period of 11 hours in each 24 hour period unless compensatory rest is provided as soon as is practicable uninterrupted rest period of 35 hours (including the 11 hours daily rest) in a 7 day period or averaged over 2 weeks
Employees are required to undertake any shift which is not contrary to their contractual status as it appears on the published roster; this includes long shift, short shifts, nights and weekends as per the agreed standardised shift pattern arrangements for the department as agreed as part of the Trust shift consultation process (Appendix 4).
4.2 Roster Managers Roster Managers are individuals identified as the designated employee responsible for the development of a roster in line with this policy and within the timescales outlined in their relevant departmental protocol.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 7 of 26
4.3 Department Manager (Budget Holder) The department manager is responsible for ensuring that their expenditure does not exceed the allocated budget each month and year for their specified area(s).
The department manager is responsible for undertaking the monitoring and pre- approval of the off duty on completion whether or not it is them who produce's the roster. This approval should be completed in line with the pre-defined Roster timetable.
The department manager is responsible for the first line approval/rejection of all shifts where temporary staff are requested prior to those requests being escalated as per the Temporary Staffing Policy.
The department manager is accountable for the effective maintenance and management of the RosterPro Central system within their department, including the inputting of up to date information – including actuals - and reporting from the system to demonstrate effective use of resources.
The department manager is responsible for informing the System Administrator of any new starter’s /leavers /changes of staff’s terms and conditions as soon as possible. This information must be inputted on to (RPC) in advance of the change date by the System Administrator.
The department manager is responsible for ensuring shifts are verified for payment within the Payroll deadlines in line with counter fraud guidelines.
The department manager is responsible for ensuring that breaks are facilitated.
The department manager is responsible for ensuring that shifts worked are within the agreed standardised shift pattern arrangements for that area.
4.4 Staffing Solutions Staffing solutions are responsible for the administration and maintenance of RPC for both Temporary staff bookings and E-Rostering.
Where a temporary staffing solution cannot be identified, Staffing Solutions are responsible for flagging this in a timely way to the relevant manager.
Staffing solutions are responsible for populating and updating (RPC) with all relevant staff information.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 8 of 26
4.5 Matrons The relevant Matron or nominated Deputy will, within the agreed roster sign off timetable (Appendix 3) undertake the monitoring and approval of the Departments roster on completion. The Matron or nominated Deputy will sign off the off duty only as and when it complies with agreed parameters for example:
Annual leave % allocation Staffing levels per shift, including hard to fill shifts e.g. late and night shifts Nurse/Midwife in Charge and other skilled staff Study leave and Administration allocation Supervisory shifts
The Matron/Midwife will approve shifts where agency staff are requested and when requests for bank staff exceed the agreed set parameters as per Temporary Staffing Policy.
4.6 Heads of Nursing & Midwifery The respective HoN will monitor the rosters in line with the Carter recommendations ensuring the following:
The roster is safe and effective Short falls in the roster are managed appropriately Roster completion timetable is adhered to.
4.7 E-Rostering System Administrator The E-Rostering System Administrator is responsible for the training of all employees and roster managers in the use of (RPC).
4.7.1 Rostered staff training: All rostered staff must be trained as part of their local induction to use the self- service interface (RRoster). Staff must be shown how to make requests electronically for working shifts and planned absence in their permanent role. All RRoster users must be aware of:
The priority weighting of requests The request notification period The request confirmation process
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 9 of 26
4.7.2 Roster Manager’s training: Roster Managers must be as a minimum trained to undertake:
The development of a planned roster The confirmation of RRoster requests The notification of shortages The entry of actuals (what actually happened within the roster i.e. sickness). The accurate Verification of actuals to ensure accurate payment of staff via the ESR interface The use of RReporter, an electronic tool that can report on information entered onto (RPC) such as annual leave and sickness Work within the timeframes outlined in the roster completion timetable (Appendix 3)
5. Procedure
5.1 Rostering Rules
5.1.1 General
All rosters must start on a Monday and should be produced at least 6 weeks in advance and follow the roster timetable (appendix 3 ). There is an assumption within the Trust that under Agenda for Change (AfC) the annual leave percentage in any Ward Nursing and Midwifery roster period will not exceed 14.2%. Statutory/mandatory training and sickness is set at 5.8% This equates to a headroom percentage of 20% for ward nursing budgets .This must be taken into account when producing a roster along with the less predictable non-effective working days such as maternity/paternity leave. If this is not considered, rosters may not be produced within budget.
5.1.2 Study Leave Study leave will be assigned in line with Trust Access to Study Leave policy. All requests and authorisation of study leave should be recorded on the Learning agreement form in the Access to Study Leave policy.
The Department Manager should: Utilise the available number of study leave days in each roster. Prioritise mandatory training requirements for staff which may include induction, updates etc.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 10 of 26
5.1.3 Sick leave
All sickness absences should be managed as per the trust Supporting Attendance policy If off-duty days follow on from sick days, the Department Manager or deputy must be kept informed of recovery and unless notified, off-duty days will be re-classified as sick leave and must be entered as sick days with in (RPC). If a member of staff has taken sick leave, it is good practice to work 2 week or 75 hours pro rata of rostered shifts before agreeing to work any additional hours, in order to allow time to recover.
5.1.4 Skill mix Each area must have an agreed total number of staff and skill mix for each duty. A joint decision on this must be reached with the Heads of Nursing/Midwifery Matrons/Midwives and Department Managers. Agreed numbers and skill mix must be achievable within the department budgeted establishment. Each area must have an agreed basic level of staff with specific competencies on each duty. 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 any bleep holders’/manager’s rota. Consideration should be given to flexible working, however, this needs to be fair and equitable to all staff ,adhering to standardised shifts , and should be regularly reviewed (refer to Trust Flexible Working Policy). Staff may be required to work a variety of shifts and shift patterns as agreed with their Department Manager. All staff if required to do so should work nights, unless by prior agreement with their Department Manager and a valid reason recorded in their staff personnel records. If there is a valid reason this must be reviewed on an annual basis and documented as above. Staff may work long shifts, short shifts, or a combination of both in order to meet the department and clinical requirements. Variations to these shifts may be worked within the rules but must be agreed with the Department Manager All shifts of six hours or longer must include a 30 minute unpaid break. Breaks must not be taken at the beginning or end of a shift, as their purpose is to provide rest time during the shift. This is a legal requirement in line with Working Time Regulations. There must be a designated nurse/midwife in charge for each shift who has been identified as having the required skills and competencies for a co- coordinating role or for delegation of those duties whilst maintaining accountability.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 11 of 26
Senior staff should work opposite shifts. The maximum number of consecutive standard 7.5hrs shifts recommended for staff to work is 5. Staff may work more than this by local agreement but department managers should ensure that staff have at least one whole day off every week, or two days a fortnight. The maximum number of consecutive 12 hour day shifts is 3. The maximum number of consecutive 12 hour night shifts is 4. Where staff work 12 hour shifts, no more than 7x12hour shifts should be worked in a 14 day period. Any regular / fixed patterns outside of the maximum shift recommendations must be agreed with the matron and HoN.
Working or rest day requests should not exceed 4 shifts or days off pro-rata (roster period)
o 4 requests for 37.5hrs/pw contract o 3 requests for 30hrs/pw contract o 2 requests for 24hrs/pw contract o 1 requests for 18hrs/pw contract
Staff may have a minimum of one weekend off per 4 week roster, in normal circumstances. Additional weekends off can be rostered if the ward requirements allow and in line with the request allocation. Nights should be consecutive where possible. There should be a minimum of 23 hours off after being rostered a night shift. Senior Sister/Charge Nurse/Midwife should generally work 4 - 5 week-day shifts per week dependent on the specific needs of their department. Senior Sister/Charge Nurse/Midwife should not generally work weekends or bank holidays except as part of a bleep/site rota or with the agreement of the Matron. Senior Sister/Charge Nurse/Midwife should not generally work nights except when specifically required to do so and with the approval of the Matron Pre-registration student nurses and midwives should have supernumerary status and can expect to be able to work with mentors to meet the NMC Nursing and Midwifery Educational Standards. All students must be supervised at all times, either directly or indirectly over a range of shift patterns. Supernumerary period, including Trust induction to be determined at local level and to take into account individual staff member’s previous experience. Supernumerary period for part time staff should be equivalent in hours to that of full time staff.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 12 of 26
If more than 2 week supernumerary period is required – this needs to be approved by the Matron and HoN’s. Annual leave must be allocated in hours for all members of staff. The Department Manager, or designated deputy, must approve or decline all annual Leave within one month of the request being made. Each Department should calculate the range of maximum and minimum numbers of staff e.g. registered and non-registered nurses that must be given annual leave in any one week. An agreed number needs to be set and adhered to giving consideration to current department vacancies. Only in exceptional circumstances can annual leave be given over these agreed levels. Staff should be made aware of the need to maintain this number constantly throughout the year. Should this range not be met, by way of requests, the Department Manager will allocate leave following discussion with the staff concerned. In principle, 75% of leave should have been taken by staff by the end of quarter 3 of their annual leave year. It is expected that staff should only have 25% of their leave outstanding at the commencement of the final 3 months of the annual leave year except: o By prior arrangement with the Line Manager; o Due to the needs of the service; o As a result of ill health/maternity leave. o Staff must work within the roster timetable (Appendix 3) when making any working or non-working request. Annual leave must be booked or cancelled before a roster is published. Annual leave requested after this can only be given if staffing levels permit near to the day. Staff should not commit themselves to any holiday plans until they have received approval from their line manager, to avoid disruptions to the service and to avoid any potential disagreements. All staff are encouraged to book their annual leave in advance, maximum advanced notice is 12 months from the date of the request. Staff are responsible for ensuring all their annual leave is used before the end of their annual leave year. Otherwise the manager will be entitled to allocate leave at their discretion Requests for leave during school holidays may present additional pressures. The set amount of leave whether annual or study leave etc. should not be increased during these weeks. 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 must be shared equitably.
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Staff may carry no more than one week’s (pro rata) annual leave into the next annual leave year. This must be with agreement from their line manager and must be taken within the first month of the new annual leave year. Where an employee works more than their contracted hours with the agreement of their Manager and consequently accrues Time off in Lieu (TOIL) this must be taken within three months and should be recorded as TOIL on RosterPro Central by the Roster Manager. TOIL must not be taken as pro rata whole days off. Contracted hours not used over a 4 week roster period should not exceed 12hrs and must be worked within 3 months and should be used to cover shortfall in the roster before making a request for bank and agency staffing where ever possible
5.2 The Production of Roster Staff should refer to (Appendix 1) - Roster Process Quick Guide and Appendix 3 roster sign off dates
The following steps should create a roster that is safe and cost effective and should be followed in conjunction with the 12 golden rules for rostering (Appendix 2).
Assemble all necessary information. Assess the establishment for the department and review the process for recruitment. Assess and review all current “custom & practice” agreements Know and understand the local policies and best practice for planning rosters. Roster Manager must check the self-roster requests on the RRoster. Roster Manager approves or declines the requests in line with the local process for the approval of working and Non-working requests. Roster Manager enters fixed shift patterns before the production of the main off duty. Create the roster on (RPC), if this is not done by the Department Manager, it must go to them prior to completion. All off duties should be composed to adequately cover 24 hours if required utilising permanent staff proportionately across all shifts. Shifts with a high priority on (RPC) must be filled first, i.e. nights and weekends or locally recognised high priority shifts e.g. Theatre days. The Department Manager must check the roster does not exceed budgeted establishment. The Roster Manager must make any changes in consultation with staff members. The Department Manager checks the proposed off duty for skill mix and cover. The Department manager reviews the roster and highlights:
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 14 of 26
Potentially unsafe shifts 1. Vacant shifts which have no cover; i.e. Shifts for which temporary staff appear to be needed 2. Any of the agreed parameters that have been exceeded, such as staffing levels or skill levels. The Department Manager and Matron/Midwife and /Head of Nursing/Midwifery discuss options of using appropriate staff from within the division /local area, rather than temporary staff, to cover gaps. Where there is more staff than available shifts for a roster period, the Department Manager will offer any extra staff to another unit within their area who may be short of staff. If this is happening regularly, then the skill mix should be reviewed. The Matron authorises ‘signs off’ the roster by completing it on the Eroster in line with the roster completion timeframe (Appendix 3). Unfilled duties which may require temporary staff will be reviewed by the Department Manager to ascertain how many vacant shifts are in fact essential for the safe running of the department/service. The Roster Manager Identifies Shortages and notifies authorised planned bank shifts electronically to Staffing Solutions office. A single copy of the roster is printed for all staff to view at least - 6 weeks prior to the roster start date. This will enable staff to better manage their personal arrangements. The Roster Manager reviews and adapts the roster in a timely manner whilst it is in use notifying new additional authorised bank shifts electronically to Staffing Solutions. The Roster Manager enters ‘actual’ information live and no later than one week following the roster being worked.
5.3 Poor Rostering Electronic rosters to be reviewed periodically e.g. post seasonal holiday periods (planned versus actual) by the Nursing and Midwifery Workforce Planning Group.
Where a Roster Manager or Budget holder repeatedly generate and / or approve rosters which are over budget or outside the agreed parameters with regards to skill mix, these rosters will be reviewed by the Matron and department Manager who will complete a full departmental review including skill mix; current vacancies, clinical need/workload, following which recommendations may be made with regards to further training or a revised approach to rostering with a view to recouping the previous excess expenditure.
The HoN, Matrons and department manager will collectively monitor the step changes and the impact of this on the roster safety and efficiency.
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Where issues persist after the third month, continuing overspends, will be reported to the Executive Management Team for consideration and review via the HoN. Any department highlighted by the Executive Management Team as consistently overspending on the staffing budget for 3 consecutive months will be notified to the RosterPro team. Any identified performance issues will be dealt with via the Trust Managing performance process.
At the point of escalation to the Executive Team, a process review will then be initiated by the RosterPro team. This will be a joint exercise between the Head of Nursing/Midwifery, Matron/Midwife and Department Manager / /Roster Manager/Divisional Accountant and the RosterPro team. The Department Manager will make available to the RosterPro team any existing flexible working arrangements already agreed and in place and information on when they were last reviewed. The RosterPro team will assess the last 4 rosters and discuss/assess with the Department Manager the criteria used for producing the roster. The next 4 weeks roster will be produced as a joint exercise and the performance reviewed.
If there is a consistent reduction in overspend over the 4 week period, the Department Manager /Roster Manager will produce the next 4 weeks using the same criteria and again the performance will be reviewed by the whole group.
If there is no improvement, the RosterPro team will then produce the roster for the following 4 weeks and again the rosters will be reviewed against budget.
If there is still no ability to produce a roster within budget, the RosterPro team will produce a report to go to Executive Management Team highlighting the issues and reasons for overspend. These may include things like poor skill mix; high level of vacancies; inappropriate budget setting.
6. Monitoring Compliance
Compliance with these guidelines will be monitored through the Nursing and Midwifery Workforce Planning Group.
6.1 Key performance indicators Key performance indicators (KPIs) and parameters will be set and monitored, using (RPC) system reports. Monthly reports will be generated by staffing solutions and disseminated to senior management teams in medical and surgical division. Roster completion and Matron/Midwife sign off against the Roster timetable. Roster completion will be used as a KPI for the Ward Accreditation Programme (Bronze level and above). Monthly reporting to Nursing and Midwifery Workforce planning group outlining performance ,issues and risks. Quarterly update to Strategic Workforce Committee as part of the workforce strategy update.
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7. Review
This policy will be subject to a planned review every three years as part of the Trust’s Policy Review Process. It is recognised however that there may be updates required in the interim arising from amendments or release of new regulations, Codes of Practice or statutory provisions or guidance from the Department of Health or professional bodies. These updates will be made as soon as practicable to reflect and inform the Trust’s revised policy and practise.
8. References
Operational Productivity and performance in English NHS acute hospitals: Unwarranted variations (2016) Flexible workforce: strategic planning to reduce costs and improve quality. NHS Employers, November 2010 Controlling the use of temporary staff through large scale workforce change NHS Employers, January 2007. Electronic Rostering: Helping to improve workforce productivity .A guide implementing electronic rostering in your Workplace. NHS Employers, October 2007 Improving working lives. Department of Health ,October 2000 Five high impact actions to effectively manage your temporary workforce. NHS Employers, April 2012 Standards for better health. Department of Health, July 2004 Working Time Regulations Agenda For Change
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Appendix 1: Roster Process – Quick Guide
All rotas to be generated on Roster system
Start
All staff set up on roster including fixed shift patterns
All Staff request shifts/Annual leave Via RRoster
6-8 Weeks before requirement Duty Roster inputted to roster system
Senior Sister/Department manager Review and approve Roster
Matron/Midwives complete ‘sign off’ roster
Identify Shortages and Notify electronically to bank
Entry of Actuals inputted by Roster Manager live or before the end of each current roster week
Entry of Actuals verified and signed off On completion of the rota period prior to payroll deadlines
Manpower information generated and forwarded to HR/Finance
Finish
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 18 of 26
Appendix 2: 12 Golden Rules for Good Roster Management
1. Off duty must be completed at least 6 weeks in advance of the start date.
2. Off duty must be available for staff to view 6 weeks in advance.
3. All off duties should be composed to adequately cover 24 hours utilising permanent staff proportionately across all shifts.
4. Shifts with a high priority on RosterPro Central must be filled first, i.e. nights and weekends or locally recognised high priority shifts.
5. All fixed pattern shifts should be entered before the production of the main off duty.
6. Off duty requests should be reviewed and agreed fairly whilst priority must always be given to service requirements rather than staff preferences.
7. The correct percentage of staff must be on annual leave for the period of the Roster – whether requested or not.
8. Ward administration staff hours should also be entered as appropriate (as should any other hours that have an impact of the staff cost budget).
9. Following completion rosters must be reviewed by Department Manager to ensure:
. That the roster does not exceed budgeted establishment. . That vacant shifts which have no cover; i.e. Shifts for which temporary staff are currently planned, or appear to be needed are appropriate and there are no potentially unsafe shifts. . That options for using staff from within the local area /division has been looked at rather than temporary staff and overtime. . That any of the agreed parameters have not been exceeded, such as staffing levels or skill levels.
10. Vacant shifts authorised for temporary staff cover have been notified to the Staffing Solutions office 4 weeks in advance.
11. Enter ‘actual’ information and at the latest on the week following the roster being worked to effectively report on sickness and absences and adhere to payroll deadlines.
12. The Roster must be reviewed in a timely manner whilst it is in use and any change to the roster must be approved by the Department Manager/Deputy.
Document name: Nursing and Midwifery Rostering Policy Ref.: 156 Issue date: 27 September 2017 Status: Final Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 19 of 26
Appendix 3: Timetable for Roster Completion and Sign off 2017/2018
Rosters should be available a minimum of SIX weeks prior to their commencement. The dates below are the latest dates for completion
01 Jan Date Roster Commences 27 Mar 24 April 22 May 19 June 17 July 14 Aug 11 Sept 09 Oct 06 Nov 04 Dec 2018
Requests closed 23 Jan 20 Feb 20 Mar 17 April 15 May 12 June 10 Jul 7 Aug 4 Sept 2 Oct 30 Oct
Deadline for Roster 06 Feb 06 Mar 03 Apr 01 May 29 May 26 Jun 24 Jul 21 Aug 18 Sept 16 Oct 13 Nov Completion
Deadline for Matron Sign Off 12 Feb 12 Mar 09 Apr 07 May 04 Jun 02 Jul 30 Jul 27 Aug 24 Sept 22 Oct 19 Nov
Roster is released 13 Feb 13 Mar 10 Apr 08 May 05 June 17 03 Jul 31 Jul 28 Aug 25 Sept 23 Oct 20 Nov
Staffing Solutions will send a report on roster status to matrons and heads of nursing 2 days prior to matron sign off dates
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 20 of 26
Appendix 4: Shift Times Consultation Agreed Times Core shifts Maternity
Bath Birthing Centre and Mary ward
Early Breaks Actual hours paid
07.30-15.30 30 min unpaid break and one 15 min 7.5 discretionary break
Long Day
07.30 – 20.00 30 min unpaid break and two 15 min 12 discretionary breaks
Late
12.00-20.00 30 min unpaid break and one 15 min 7.5 discretionary break
Night
19.30 – 08.00 30 min unpaid break and two 15 min 12 discretionary breaks
On Call -19.30 – 08.00
Birthing Centre and Community Teams
Early Breaks Actual hours paid
08.00-16.00 30 min unpaid break and one 15 min 7.5 discretionary break
Short Early Shift prior to over-night on-call
8:00 – 14:00 one 15 min discretionary break 6
Late
12.30-20.30 30 min unpaid break and one 15 min 7.5 discretionary break
Long day
08:00 – 20:30 30 min unpaid break and two 15 min 12 discretionary break
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 21 of 26
Night shift
20:00 – 08.30 This will include a 30 min unpaid break and 12 two 15 min discretionary break
On call – 20:00 – 08.30
Core shifts Nursing
Early Breaks Actual hours paid
07.00-15.00 30 min unpaid break and one 15 min 7.5 discretionary break
07.30-15.30 30 min unpaid break and one 15 min 7.5 discretionary break
Long Day
07.30 – 20.00 30 min unpaid break and two 15 min 12 discretionary breaks
07.00 – 19.00 30 min unpaid break and two 15 min 12 discretionary breaks
Late
13.00-21.00( when the early 30 min unpaid break and one 15 min 7.5 shift starts at 07.00) discretionary break
13.30-21.30( when the early 30 min unpaid break and one 15 min 7.5 shift starts at 07.30 discretionary break
Night
19.30 – 08.00(when the long 30 min unpaid break and two 15 min 12 day is 07.30-20.00) discretionary breaks
19.00 – 073.0(when the long 30 min unpaid break and two 15 min 12 day is 07.00-19.30) discretionary breaks
Supplementary shifts Can be utilised to meet service needs when agreed by senior sister/Matron and Head of Nursing
Morning Twilight Breaks Actual hours paid
06.00-14.00 30 min unpaid break and one 15 min 7.5 discretionary break
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 22 of 26
Day shift
10.00-18.00 30 min unpaid break and one 15 min 7.5 discretionary break
Evening Twilight
15.15-23.15 30 min unpaid break and one 15 min 7.5 discretionary break
Exceptions
Emergency department
Early Breaks Actual hours paid
07.30-15.30 30 min unpaid break and one 15 min 7.5 discretionary break
Late
13.30-21.30 30 min unpaid break and one 15 min 7.5 discretionary break
Nights
21.15-07.45 30 min unpaid break and one 15 min 9.0 discretionary break
Staffing solutions – Nurse bank
In line with existing arrangements bank shifts will be adjusted to reflect shorter versions of each area shift times
Children’s Ward
Early Breaks Actual hours paid
07.30-15.30 30 min unpaid break and one 15 min 7.5 discretionary break
Late
12.00-20.00 30 min unpaid break and one 15 min 7.5 discretionary break
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 23 of 26
Document Control Information
Ratification Assurance Statement
Dear Strategic Workforce Committee
Please review the following information to support the ratification of the below named document.
Name of document: Nursing and Midwifery Rostering Policy
Name of author: Jan Lynn and Ana Gleghorn Lead Nurse, Development Workforce & Education/Head of Job Title: Nursing
I, the above named author confirm that:
The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy; I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation; I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification; I will keep this Policy under review and ensure that it is reviewed prior to the review date.
Signature of Author: Jan Lynn/Ana Gleghorn Date: 07 Sept 2017 Name of Person Ratifying this policy: Claire Buchanan
Job Title: Director of HR
Signature: Date: 07 Sept 2017
To the person approving this policy:
Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, Apley House (E5), Royal United Hospital
The whole policy must be sent electronically to: [email protected]
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 24 of 26
Consultation Schedule
Name and Title of Individual Date Consulted Sharon Bonson - Matron March 2017 LIsa Cheek – Deputy Director of Nursing and Midwifery March 2017 Ana Gleghorn – Head of Nursing (Surgery) March 2017 Beatrice Buckley – Senior Sister SAU March 2017 Linda Chapman - March 2017 Amanda Gell - March2017 Helen Wickett - SSR March 2017 Melanie Griffin – SSR March 2017 Suzie Slade - SSR March 2017 Sarah Merritt – Head of Nursing (Women& Childrens) April 2017 Gav Hitchman April 2017 Jo Miller – Head of Nursing (Medicine) April 2017 Bev Boyd – Matron April 2017 Caroline Gileece - Matron April 2017 Anita West- Matron April 2017
The following people have submitted responses to the consultation process:
Name and Title of Individual Date Responded Sharon Bonson - Matron March 2017 LIsa Cheek – Deputy Director of Nursing and Midwifery March 2017 Ana Gleghorn – Head of Nursing (Surgery) March 2017 Beatrice Buckley – Senior Sister SAU March 2017 Linda Chapman - March 2017 Sarah Merritt – Head of Nursing (Women& Childrens) April 2017 Gav Hitchman April 2017 Jo Miller – Head of Nursing (Medicine) April 2017 Bev Boyd – Matron April 2017 Caroline Gileece – Matron April 2017
Name of Committee/s (if applicable) Date of Committee Safer Nursing and Midwifery Care Group April 2017
Document name: Nursing and Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: DRAFT Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 25 of 26
Equality Impact: (A) Assessment Screening
1. Title of document/service for assessment Nursing and Midwifery Rostering Policy 2. Date of assessment April 2017 3. Date for review September 2017 4. Directorate/Service HR 5. Approval Committee Safer Nursing and Midwifery Care Group 6. Does the document/service affect one group less or more favourably than another on the basis of: Protected characteristic: Yes/No Rationale Age No Disability No Gender reassignment No Pregnancy and maternity No Race No Religion and belief No Sex No Sexual orientation No Marriage and civil No partnership 7. If you have identified potential discrimination, are the exceptions valid, legal and/or justified?
8. If the answers to the above question is ‘no’ then adjust the element of the document / service to remove the disadvantage identified.
9. If neither of the above is possible, take no further action until you have contacted your EIA Divisional / Directorate link for review and support
Signature of person completing the Equality Impact Assessment Name Ana Gleghorn – Head of Nursing Surgery Time Date April 2017
Chair of decision making Board / Group / Committee approval and sign off Name Clare Buchanan – Director of HR Time Date April 2017
Document name: Nursing & Midwifery Rostering Policy Ref.: Issue date: 27 September 2017 Status: Author: Jan Lynn - Lead Nurse Workforce Development and Education Page 26 of 26