DOCUMENT CONTROL: Version: 3.1 Ratified by: Corporate Policy Approval Group Date ratified: 26 July 2021 Name of originator/author: Human Resources Department Name of responsible committee/individual:

Corporate Policy Panel

Date issued: 26 July 2021 Review date: November 2021 Target Audience All Trust employees who utilise health roster or

e-Bank. All staff who accrue time off in lieu (TOIL)

Rostering Policy and Procedure

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CONTENTS

SECTION PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 3 4.1 Care Group Directors and Corporate Directors 3 4.2 Service Managers, Matrons and Senior Clinicians and Managers 4 4.3 Ward Managers/Department Managers 4 4.4 Human Resources 5 4.5 Employees 5 4.6 Nurse Bank Team 5 5. PROCEDURE/IMPLEMENTATION 6 5.1 Rostering Principles 6 5.2 Roster Approvals 9 5.3 Shift Allocation 9 5.4 Skill Mix and Staffing 10 5.5. Swapping Shifts 10 5.6 Personal Patterns 10 5.7 Staff Development 11 5.8 Attendance 11 5.9 Agency/Bank Staff 11 5.10 Changes to Shifts 11 5.11 Staff Redeployment 12 5.12 Annual Leave 12 5.13 Headroom Allocation 13 5.14 Time Owing/Lieu Time Management/Time Owed 14 5.15 Calculating overtime/additional hours worked 14 5.16 Working Time Directive/Regulations 14 6. TRAINING IMPLICATIONS 15 7. MONITORING ARRANGEMENTS 15 8. EQUALITY IMPACT ASSESMENT SCREENING 15 8.1 Privacy, Dignity and Respect 16 8.2 Mental Capacity Act 16 9. LINKS TO ANY ASSOCIATED DOCUMENTS 16 10. REFERENCES 16 11. APPENDICES 16

Appendix One – Roster Periods and Schedule 17 Appendix Two – Time Owing Protocol 18 Appendix Three – Time off in Lieu Recording Form 20 Appendix Four – Rostering Checklist/Audit 21 Appendix Five – Key Performance Indicators (KPI) Guidance 23

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1. INTRODUCTION Rotherham Doncaster and South Humber NHS Foundation Trust has a duty to ensure that the services they provide are safe, effective and efficient. Staff rostering is fundamental to providing services that are safe and effective whilst at the same time enabling resources to be deployed in the most efficient way, to ensure the best use of public money in the delivery of NHS services. The Trust is therefore, committed to ensuring all staff rosters are based on service needs and providing the best level of care and support within agreed resources.

2. PURPOSE The purpose of this policy is to support managers in deploying staff in a way which recognises the importance of developing staff rosters fairly, transparently, in a timely manner and reflects the need to both appropriately plan care and as far as reasonably possible, support staff to achieve a positive work life balance. Duty rosters should be produced to an agreed, consistent set of standards Trust-wide, and based on agreed funded establishments. The policy also aims to provide a balance between the clinical risks associated with supporting and caring for service users/patients and the health, safety and wellbeing of staff. The safety and wellbeing of service users, carers, staff and visitors will at all times remain a priority for the Trust.

3. SCOPE This policy applies to all Trust employees who utilise Health Roster or the eBank system. All employees will be treated in a fair and equitable manner, recognising any special needs of individuals where adjustments need to be made. No employee should suffer any form of discrimination, inequality, victimisation, harassment or bullying as a result of implementing this policy. Any perception of discrimination will be dealt with using the appropriate policy. The policy is also applicable to staff (who do not utilise Health Roster or eBank) who accrue time off in lieu for additional hours which are worked and not paid. All relevant staff are required to comply with this policy, failure to do so may result in disciplinary action being taken.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Care Group Directors/Corporate Directors

• The Care Group Directors are responsible for the implementation of the policy.

4.2 Service Managers, Modern Matrons, Senior Clinicians and Managers

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• Senior Managers are responsible for informing all staff of the policy and that they are aware of the content.

• Monitor and action final approval (second approver) of the duty roster for

the associated wards/departments in line with the approval periods, escalating concerns where necessary, ensuring that cover is arranged for periods of leave

• Conduct KPI audits within the associated wards/departments and ensure

the development and implementation of appropriate action plans. • Responsible for finalising shifts for the relevant Ward Managers/Managers

during lockdown

4.3 Ward/Department Managers

• Ensuring that the demand template on Health Roster remains aligned to the agreed minimum safe staffing levels.

• Ensuring that their expenditure does not exceed the allocated budget in all

wards, units and departments (hereafter referred to as departments). • Creating and approving the roster (first approver), in line with the approval

periods and the defined parameters of eRostering. • Ensuring the roster is an accurate and maintained record of the shifts

worked. • Finalising rosters on a weekly basis in readiness for submission to payroll

and is aware of the impact of failing to do so. • The safe staffing of the ward even if they do not directly undertake the task

of producing the duty roster. • Nominating a deputy Roster Creator and ensuring that these staff are

appropriately trained. • Ensuring that there are sufficient employees in the right place at the right

time, based on the agreed and funded skill mix, with the required competencies, to meet the needs of the service.

• Fair and equitable allocation of annual leave and study leave.

• Considering all roster requests from staff, ensuring fairness and equity in

working patterns

• Monitoring the quality of care provided through clinical governance mechanisms e.g. audit, complaints, clinical benchmarking and addressing any issues.

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• Investigating any reports of short staffing and taking steps to prevent recurrence.

• Monitoring factors which impact on staffing levels, e.g. sickness, occupancy

rates and responding to these appropriately. • Before appointing to a vacancy, considering the best way in which to meet

the current service delivery need in accordance with the Appointment of Staff Policy.

• Discuss the use of additional duties and hours with the Modern

Matron/Service Lead/Manager 4.4 Human Resources

• The Human Resources Team will provide appropriate technical advice and support on Health Roster and the application in accordance with the associated Trust Employment Policies and Procedures associated with Health Roster.

4.5 Employees

• Attending work as per their duty roster. • Adhering to the requirements set out within the Duty Rostering policy. • Being reasonable and flexible with their roster requests and being

considerate to their colleagues within the rules set out by the Trust. • Notifying the Ward Manager/Department manager of changes to a planned

or worked shift. • Notifying the Ward Manager/Department Manager of changes to personal

details, e.g. address, telephone number, etc. • Requesting shifts and annual leave using Employee Online, ensuring that

personal details are kept up to date. • Using the Flexible Working Policy and Procedure to request changes to

working patterns. 4.6 Nurse Bank Team

• The Nurse Bank Team will provide appropriate technical advice and support

on the eBank system and the application of it in accordance with the Trusts Employment Policies and Procedures.

5. PROCEDURE/IMPLEMENTATION

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5.1 Rostering Principles

• All duty rosters must commence on the same day of the week and be published 6 weeks in advance in accordance with the Trust’s Roster Calendar.

• Systems for staff to requests shifts should be available for a minimum of 8

weeks in advance to ensure fairness for all staff. • The production of rosters is the responsibility of the Service

Manager/Modern Matron/Senior Clinician. • In the first instance, permanent staff (fixed term contracts/secondments

included in the establishment) should be used to cover the required shifts. Any gaps in the roster should then be filled using the hours which are available where an employee hasn’t worked their contracted hours over the four week roster period.

• The roster must reflect the agreed skills, grade mix and staff numbers

required and should not include staff who are a grade mix above this unless approved by the Service Manager/Modern Matron/Senior Clinician.

• Annual leave must be booked or cancelled before a roster is finalised. • Shifts given a higher priority must be filled first, i.e. nights and weekends. It

should not be routine to use overtime, bank or agency staff permanently on any shifts.

• Any staff working a non-standard start or finish time must be entered on the

roster to ensure that the correct hours are worked and paid. • Management days should be distributed across all shift patterns, usually

Monday to Friday, to ensure that senior staff are not all working the same patterns.

• Only where it is impossible to cover all the required shifts through the

allocation of available staff and using time owing and/or time off in lieu, should consideration be given to the use of bank staff. The deployment of bank staff should be in keeping with the agreed skill, grade mix and required staff numbers. When using bank staff, managers must not compromise the safety of /patients and other staff and must ensure they have the required induction and training to work in that clinical area.

• In situations where it is not possible to cover all the required shifts by the

time owing, time off in lieu or bank, then the use of overtime or agency must be approved by the Service Manager/Modern Matron/Senior Clinician or senior on-call manager, when out of hours. The designated manager must clearly state and record the reason for the request for overtime or agency staff. The use of agency staff should only be considered as a last resort.

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For inpatient areas only, there must be a designated person in charge for each shift and this must be clearly identified on the published roster.

• Once rosters are approved, staff wishing to make changes should, in the

first instance, attempt to exchange shifts with other appropriate team members. Any changes are made within equal grade bands and with consideration to the overall skill mix of all the shifts not being changed. Changes to rosters should be at no additional cost (see section 5.5).

• All changes are authorised by either the Ward/Department Manager or

designated deputy as soon as possible or at least before the start of the shift. Changes must not result in overtime expenditure or the use of nurse bank or agency staff. Only in exceptional circumstances can changes be made and retrospectively approved by the manager or deputy.

• All requests will be given full consideration and no reasonable request will

be refused. However, in certain circumstances the needs of the organisation may not allow for the request to be granted. If a request is denied, a full and detailed reason for the refusal will be given through the system.

• Except in instances of operational necessity, at least 24, and ideally 48

hours’ notice will be required to request a change to a set roster. However, in consultation and agreement with a member of staff, the manager may require a change of roster with less notice e.g. an urgent clinical situation. When there are unforeseen circumstances, i.e. a member of staff leaving duty due to sickness at short notice or additional hours are needed, then the most cost-effective method available must be used, usually in the following priority order;

1. Use ‘time owed’ from individuals on the roster if available. 2. Offering employees to use time off in lieu from individuals on other

rosters, providing the individual has the correct competencies if available.

3. Use additional part-time staff hours (up to 37.5 hours) 4. Use of bank staff, if available. 5. Only in exceptional circumstances after the above options have been

fully explored should overtime or agency be used and this must be approved by the relevant manager.

• The Employee Online system will be used by all staff to make requests for;

days off, preferred shifts or other variations in work rosters. Requests will be calculated according to individual hours of work, as set out below and will be considered in light of service needs. The granting of requests cannot be guaranteed.

• Requests will close 8 weeks before the roster being worked as per the

Trust’s Roster Calendar.

Staff Hours Per Week Total number of requests per 4 week period

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Up to 37.5 hours 4 requests Up to 28.125 hours 3 requests Up to 18.75 hours 2 requests Up to 9.375 hours 1 request

• With reference to the above table, those staff who have agreed flexible

working/personal patterns are not eligible to make requests • Staff will be required to work a variety of shifts and shift patterns to fit the

needs of the service. • Staff should have a minimum of one weekend off per 4 week roster, (unless

they specifically request not to have weekends off). Additional weekends off can be rostered if the departmental requirements allow.

• The number of consecutive standard day shifts recommended for staff to

work is 5 in a 7 day period. • The number of consecutive long day shifts recommended for staff to work

is 2. Staff may work up to a maximum of 3 if they specifically request this. • Night Duty should not exceed a maximum of 4 consecutive shifts followed

by a sleep day and a day off on the ward where they have worked the shift. • In law, all staff should have 11 hours rest before their next shift. Where short

shifts are the norm, a late to early shift pattern should be avoided if the pattern breaches the 11 hours rest rule in the provisions of the Working Time (Amendment) Regulations 2002. It is however recognised that this provision is not always achieved and in this context, the compensatory rest provision will apply.

• All staff must have a consecutive 24 hours rest in every 7 days or 48 hours

rest in every 14 days, either one consecutive period of 48 hours or two separate periods of 24 hours.

• Staff should not work more than an average of 48 hours per week over a 26

week reference period. • All shifts of 6 hours or more (up to less than 12 hours) must include a

minimum of 20 minutes unpaid break and a 40 minute unpaid break for shifts of 12 hours or more in accordance with Agenda for Change and the European Working Time Directive (see section 5.16 for further detail). Night shifts must include a 30 minute unpaid break.

• The Ward Manager/ Manager or person in charge and the individual are

responsible for ensuring that breaks are taken. 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.

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• Breaks should not be taken at the end of a shift, as their purpose is to provide rest time during the shift.

• Annual leave must be booked at least 8 weeks in advance, except in case

of domestic emergencies and authorised by the Ward Manager/Service Manager a maximum of 14 consecutive calendar days of annual leave can be requested. Any more than this will need approval from the Matron/Service Manager.

• The Net Hours Left/Hours Left Column within Health Roster should be

reviewed for each employee prior to full approval of the roster. • Rosters must be finalised before the payroll deadline (details are available

on the Trust Intranet). If on the deadline date, wards have not finalised by 5.00 pm, the remaining unfinalised shifts will be removed from the roster and the relevant pay in relation to unsociable hours, additional hours, overtime and bank will not be processed.

• Payments for shifts which have not been assigned or finalised on the roster

by the payroll deadline will not be paid until the following month unless exceptional circumstances apply and in agreement with the Pay Services Manager.

5.2 Roster Approvals

There is a 2 stage process for approving rosters as follows;

1. Ward/Department Manager 2. Service Manager/Modern Matron/Clinical Manager

The approval of rosters must take into account the roster analysis information and the KPIs as detailed in Appendix 4.

5.3 Shift Allocation

• All staff must be expected to work a fair and equal share of early/late and night shifts unless exceptions have been agreed e.g. following a period of sickness in line with the Trusts Policy Relating to the Management of Sickness Absence.

• All staff are expected to cover weekend and night shifts during a set roster

period unless flexible working entitlement has been granted in line with policy e.g. Flexible Working Policy and Procedure for which these shifts are exempt or on health grounds following advice from Occupational Health.

• A night duty roster can be used to allow staff to identify when they will be

expected to cover night shifts on the understanding that this may need to change due to service need.

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• In the event that a night roster is used, it will be on the understanding that sufficient cover must be available to ensure annual leave requests can be approved.

• The standard hours may be worked over any reference period, e.g. 150

hours over four weeks, however, hours should be as balanced as possible over the 4 weeks

• In the event that staff have existing night only or day only contracts there is

an expectation that staff will undertake an agreed number of alternative shift patterns to maintain their skills and competencies, identified during an annual Appraisal review.

5.4. Skill Mix and Staffing

Each area should have an agreed level of staff with specific competencies on each shift, to enable appropriate cover which should include (but not limited to):

• Giving medication • IV administration • Ability to perform assessments and observations • Managing a cardiac arrest • Specialist skills relevant to specific areas • The roster for senior staff must be compatible with their commitment to any

bleep holding roster. • Senior staff should work opposite shifts to achieve a balance of skills across

all shifts. • Senior Sister/Charge Nurse should routinely work Monday to Friday and not

weekends, unless on the Trust Site Cover roster. • The Senior Sister/Charge Nurse should not work nights without prior

approval from the Service Manager/Modern Matron/Senior Clinician. • Trust Bank Staff are members of the team for their given shift and their

individual skills must be utilised appropriately. • Staff supplied by the Nurse Bank should not be asked to take charge of a

shift unless previously agreed with the bank nurse.

5.5 Swapping shifts

One shift swap per week, per individual is considered to be sufficient. Any additional swaps must be authorised by the ward manager.

5.6 Personal Patterns

All personal patterns must be agreed as per the Trusts Flexible Working Policy including current arrangements for staff to work opposite shifts to partners. If there are current arrangements for staff to, as far as reasonably possible, work opposite shifts, then subject to it not compromising safety or incurring additional expense, the Trust will look to honour them: however, no guarantees for new arrangements will be given.

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5.7 Staff Development

Study leave should be prioritised in line with the current Trust Policy for the Management of Local and Corporate Induction. The Ward/Department Manager will:

• Calculate and utilise the available number of study leave days in each

roster. • Prioritise mandatory training requirements for staff which may include

induction, updates, etc. • Produce the roster ensuring staff have the required mandatory training.

5.8 Attendance

Sickness Absence will be managed in accordance with the Trust’s Policy Relating to the Management of Sickness Absence.

5.9 Agency/Bank Staff

• There should be no use of temporary staff without the ward manager having assessed the need, after reviewing substantive staff with unused hours, and to include review of the grade required and the start and finish time.

• There should be no use of temporary staff to cover annual leave requests

that exceed the documented acceptable level for the department. However in exceptional circumstances where high or unforeseen clinical demand creates a risk to patient safety, approval must be sought from the Head of Service/Modern Matron / Senior Clinician

• There should be no use of temporary staff for Bank Holiday cover. However

in exceptional circumstances where high or unforeseen clinical demand creates a risk to patient safety, approval must be sought from the Modern Matron / Head of service.

• Temporary Staffing requests should be made in accordance the Nurse Bank

Office agreed processes.

5.10 Changes to Shifts

• In the event that a member of staff wishes to change a shift their first responsibility is to explore alternatives with their own colleagues following the considerations re: skill mix, minimum staff numbers etc.

• All shift changes must be authorised by the ward manager/service manager

or their deputy and should not incur the use of temporary staffing or agency staff.

• Due to unforeseen circumstances it may be necessary for the ward

manager/ service lead to change the existing roster to maintain a safe and efficient service, after discussion with the affected employees and

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providing a reasonable amount of notice. • Managers will discuss any changes to the roster with the affected

employees. • Any time worked by nurses/staff over and above their contracted hours must

be sanctioned by the Ward Manager/Manager/Nominated Deputy and recorded on the roster.

• Any time claimed back, via time owing must be recorded and approved by

the Ward Manager/ Manager. These shifts should be allocated on the roster as ‘Time Owing’ and recorded as taken.

5.11 Staff Redeployment

During staff shortages/business continuity arrangements it is accepted that staff may be required to work in other clinical/corporate areas to provide a safe and efficient service, taking into account the relevant skills and mandatory and statutory training. The Matron/Service Manager/Manager or other designated person for each area is responsible for the redeployment of staff within the area to meet service requirements in accordance with the Trust Business Continuity Plans. Out of hours, this decision for staff redeployment will be made by the on call manager/Director. It is accepted that in the event of serious unanticipated pressures, e.g. a Major Incident, staff will be redeployed, taking into consideration their skills and competencies, to provide the best patient care. The Health roster system will be used to manage workforce redeployment in this event.

5.12 Annual Leave

It is important that annual leave is allocated fairly and in a cost effective way. The Trust allows for an additional circa 30% funding for staff cover for leave and sickness. The roster will be created to ensure minimum and maximum levels of leave are maintained. Rosters should take consideration of this allowance before considering using Bank/agency/overtime to cover absence. In order to facilitate the creation of workable duty rosters throughout the year all staff should comply with the Trust’s Annual Leave and General Public Holidays Policy and Procedure Fair, personal and equal allocation of annual leave requests should be available to all staff in highly sought after periods such as school holidays and summer months, and public holidays such as Easter and Christmas. The Staff Leagues functionality within Health Roster can be used to assist in the fair allocation of annual leave during public holidays. The allocation of leave during the school holidays should not be increased. Annual leave requests for school holidays will be shared equally amongst those requesting.

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Quarterly reviews of outstanding annual leave for each member of staff should be carried out by the ward manager/department manager to avoid accumulation of untaken leave. The authorised line manager must ensure that all annual leave requests are authorised/denied 6 weeks in advance of request period to enable the production of the roster. The Roster periods can be found in the eRostering section on the Trust Intranet: http://nww.intranet.rdash.nhs.uk/support-services/workforce-organisational-development/hr/e-rostering/ Each department will calculate how many qualified and unqualified staff may take annual leave (including Bank Holidays/General Public Holidays) in any one week, with a defined limit for each band which will then be factored into the ward rules for the production of the roster Holidays should not be booked until the annual leave request has been approved/declined by authorising manager. It remains the responsibility of each individual to monitor their own leave allocation and to ensure it is taken before 31st March. Staff should ensure that their leave is spread out across the annual leave year to ensure an effective work life balance and to meet the needs of the service. As a guide, staff should take approximately 40% of their annual leave entitlement by 31st August each year with approximately 35% being used between September and December leaving 25% to be taken between January and March of the annual leave year except:

1. By prior arrangement with their line manager 2. Due to the needs of the service 3. As a result of ill health/maternity leave

5.13 Headroom Allocation

The Trust currently, as part of the staffing establishments, allow for an additional circa 30% funding for staff cover for annual leave, sickness and training. The roster will be created to ensure minimum and maximum levels of leave are maintained and this should be taken into consideration before contemplating using Bank or agency workers. Annual leave – should be 15% (target range 11 % to 17%) Sickness absence/Special Leave – should be set at 4% or below Study leave 3% Management day, non-clinical day less than 2%

5.14 Time Owing/Lieu Time Management/Time Owed

Some Wards/Departments may operate a time owing or lieu time system for managing additional time worked. It is also recognised that there may be a need at times to carry hours forward into the next roster period. In these cases the following principles apply;

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• Lieu time can only be accrued for a genuine service reason and must be an

exception to normal practice. Staff are normally expected to fulfil their work commitments within the hours for which they are rostered.

• Time owed in lieu may be recorded for any additional period in excess of 15

minutes worked. • No more than 10 hours should be carried forward either as time owing or

time owed into the next roster period. • Additional time worked must be recorded in a time owing book/agreed

recording mechanism and agreed by the Ward/Department Manager or their nominated deputy.

• Any time claimed back, must be authorised and recorded on the roster by the Ward/Department Manager or Roster Coordinator.

• Time owing/time owed must be reconciled within 3 months of being accrued.

For employees who have accrued time owed and if for operational reasons they cannot take this, they must be paid at the overtime rate.

Further guidance is contained in Appendix Two.

5.15 Calculating overtime/additional hours worked

The Ward/Department Manager is responsible for ensuring that the correct payment is attached to the shift which has been worked as overtime or additional hours. Any hours up to and including 37.5 hours per week should be assigned as additional hours. Anything over and above this should be assigned as overtime.

5.16 Working Time Directive/Regulations

In constructing staff rosters, managers should take account of the EWTD as detailed below. Advice and support regarding the EWTD is available from the HR Department.

• Every shift exceeding 6 hours must include at least 20 minutes unpaid

break. • Breaks cannot be taken at the beginning or end of the shift as their purpose

is to ensure staff rest time during the shift. • Where an individual is working for another employer, these hours must be

declared to the ward manager. • Members of staff who do not wish to opt-out of the 48 hour working limit will

not suffer any discrimination.

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• Under the EWTD night staff cannot opt out of the 48 hour working maximum. Night staff are defined as staff who regularly work nights. For example this would include staff on rotating shift patterns who work one week in three, on nights.

• A night working risk assessment should be carried as per EWTD.

6. TRAINING IMPLICATIONS (Training Needs Analysis)

ROSTERING POLICY AND PROCEDURE

Staff groups requiring training

How often should this be undertaken

Length of training

Delivery method

Training delivered by whom

Where are the records of attendance held?

Managers

On revision of the policy or new appointment/promotion

NA

Trust communication channels

HR Advisors/ Line Managers

NA

Human Resources

On appointment or revision of the policy

NA On the job training/mentoring

HR Managers/Head of Workforce

NA

Staff Side

On revision of the policy and at Policy Forum

NA Awareness/Briefing sessions on the policy

Workforce and OD Directorate

NA

7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported to Frequency

Grievances against e-Rostering decisions

Monitoring sheets (HR Database)

HR Managers

Care Group Directorate Meetings

Annually

8. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this policy’s webpage on the Trust Policy website.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review

Indicate how this will be met

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of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9. LINKS TO ANY ASSOCIATED DOCUMENTS

Flexible Working Policy and Procedure Policy in Relation to Special Leave Policy Relating to the Management of Sickness Absence. Annual Leave and General Public Holidays Policy and Procedure

10. REFERENCES

Agenda for Change Terms and Conditions of Service Handbook Working Time Regulations 1998 Part Time Workers Regulations

11. APPENDICES

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Appendix 1 Roster Period and Schedule

Open – Roster opens for request on Employee Online (EOL)

Close - Roster close for requests on EOL and Roster creation begins

1st Approval – Ward Manager (partial approver)

2nd Approval – Modern Matron (full approval)

Roster Published

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Appendix 2 Time Owing Protocol

Time Owing Protocol and Guidance The Trust acknowledges that on occasion the demands of the service will require that employees will have to work extended hours of duty for which they may accrue time owing where authorised, as an alternative to overtime. The provision of this guidance offers a framework by which the accrual and redemption of time owing can be fairly and sensibly managed for the benefit of the staff and the service. It is the responsibility of the unit/area management team to ensure that time owing is kept to a minimum and that, wherever possible, staff are able to complete their span of duty at the correct time. It is recognised that it may not be practical to record periods of less than 15 minutes. Therefore the procedure for accruing and taking time owing for periods of less than 15 minutes will be determined at a unit/area level and need not be formally recorded. In the context of this guidance additional time worked must be in relation to the needs of the service and is not to be used as a method of building up hours to take off at another time. It is not intended that time owing is used as an alternative to emergency leave. Time owing will be accrued and taken as plain time. The ability to take time owing and/or carry forward time owing shall not be unreasonably withheld. No more than 10 hours should be carried forward either as time owing or time owed into the next roster period. Approval Approval should be sought from the person in charge or their deputy, before the time that the additional hours are worked. However, it is recognised that this is not always possible e.g. in emergencies etc. In these circumstances authorisation of the Time Owing must be obtained at the earliest opportunity. Time owing may not be redeemed at a time when the quality of care to clients would be affected or where it would result in the need to pay other staff enhanced rates to cover the hours. Bank, agency or overtime must not be used to facilitate an individual to take back time owing.

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Time owing should be taken back by a member of staff within three months of the additional time being worked. Managers should make every effort to assure any time owing is taken at the earliest possible opportunity. In the case of exceptional circumstances that any time owing is carried over the three month period this will be paid as per Agenda for Change Terms and Conditions of Service – 3.5 Requests to take back time owing must be made to the appropriate manager for authorisation. The time to be taken back must be identified on off duty/team.

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Appendix 3 Time off in Lieu Recording Form

Employee Name

Name of Line Manager

Business Division

Team

Location

Date Reason Time

Accrued/Taken Employee Initials

Duty or Line Manager Signature

Time Accrued

Time Taken

Balance in Hours and Minutes (Cumulative)

Balance Brought forward

Balance carried forward

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Appendix 4

Rostering Checklist/Audit

Rostering Audit

Ward/Department:

Completed:

Yes /No Comments Actions Do the shifts and break times conform to European Working Time Directives as set out in the policy?

Are the approved minimum number of staff rostered each shift? And skills mix maintained?

Is Annual Leave allocated as per policy?

Is Study Leave allocated as per policy?

Are the approval deadlines and roster schedules adhered to?

Is there evidence of the annual review of flexible working patterns?

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Yes /No Comments Actions Does the modern matron/service lead approve the roster?

Is there evidence of 6 monthly roster reviews?

Notes:

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Appendix 5 Rostering Key Performance Indicators (KPIs)

The KPI’s will be used to monitor the effectiveness of the rostering system itself through standard Trust operations management structures. This enables ward managers, matrons, senior staff and the Trust Board to review current levels of efficiency and quality.

1. Roster Approvals 6 week roster approval rates

2. Unavailability Headroom and usage of annual leave, study leave, sickness, maternity leave and other leave

3. Unfilled Duties Working restrictions. Auto roster percentage.

4. Hours Balance Lost contracted hours not used per month Utilisation of staff contracted hours, their time balance / time owing;

5. Temporary Staffing Number of bank requests to the total bank hours worked; and, Number of bank requests on weekend and night duties. Number of agency staff used per month

6. Additional Duties Additional shifts and reasons for booking

In order to monitor and review adherence to the policy and process for rostering a series of Key Performance Indicators (KPIs) should be reported 6 monthly. Where monitoring/auditing identifies deficiencies an action plan will be implemented and be monitored by the appropriate senior staff and the Trust Governance Structure.