ROSTERING POLICY FOR ALL CLINICAL STAFF (Excluding …

Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 of 41

ROSTERING POLICY FOR ALL CLINICAL STAFF (Excluding Doctors, Dentists And Ambulance)

Policy Type Non Clinical

Directorate

Clinical

Policy Owner

Chief Nurse including Midwifery and Allied Health Professionals

Policy Author

Deputy Director of Nursing

Next Author Review Date

1st July 2022

Approving Body

Policy Management Sub-Committee 9th October 2018

Version No.

3.0

Policy Valid from date

1st December 2018

Policy Valid to date:

31st December 2022

‘During the COVID19 crisis, please read the policies in conjunction with any updates

provided by National Guidance, which we are actively seeking to incorporate into policies through the Clinical Ethics Advisory Group and where necessary other

relevant Oversight Groups’


DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue

Version No.

Date Approve

d

Director Responsible for Change

Nature of Change Ratification / Approval

08 Jul 14 0.1 Executive Director of Nursing and Workforce

Review by HR

04 Sep 14 0.1 Executive Director of Nursing and Workforce

Out for Consultation

16 Sep 14 0.2 Executive Director of Nursing and Workforce

Ratified at Senior Nursing Team

15 Oct 14 0.2 Executive Director of Nursing and Workforce

Ratified at Risk Management Committee

21 Oct 14 0.2 Executive Director of Nursing and Workforce

Ratified at Policy Management Group

10 Nov 14 1.0 10 Nov 14

Executive Director of Nursing and Workforce

Approval Approved at Rust Executive Committee

14 Dec 15 1.1 Executive Director of Nursing

To approve Appendix

Trust Executive Committee

27 May 16 1.1 Executive Director of Nursing

Voting to approve addition of Appendix to policy

Policy Management Group

2 Jun 16 2.0 2 Jun 16 Executive Director of Nursing

Change to Appendix E approved

Policy Management Group

August 2018

2.1 Director of Nursing Policy reviewed

09 Oct 2018

3.0 9 Oct 2018

Director of Nursing Approved subject to final agreement with Partnership Forum

Policy Management Sub- Committee

14 Dec 2018

3.0 14 Dec 2018

Director of Nursing Policy agreed Partnership Forum

29 Jan 2021

3.0 14 Dec 2018


12 month blanket policy extension due to covid 19 applied with author review date set 180 days prior to Valid to Date.

Quality & Performance Committee

20 May 2021

3.0 14 Dec 2018


Extended policy uploaded and linked back with new cover sheet

Corporate Governance

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust


Contents Page

1. Executive Summary…………………………………………...... 4

2. Introduction……………………………………………………….. 5

3. Definitions………………………………………………………… 5

4. Scope……………………………………………………………… 6

5. Purpose…………………………………………………………… 6

6. Roles & Responsibilities………………………………………… 7

7. Policy Detail / Course of Action………………………………… 10

8. Consultation……………………………………………………… 19

9. Training…………………………………………………………... 19

10. Monitoring Compliance and Effectiveness…………………… 20

11. Links to other Organisational Documents…………………… 20

12. References……………………………………………………… 21

13. Appendices……………………………………………………... 21


1 Executive Summary

The Rostering policy is a key document to support effective staffing resulting in safe

care for all areas. The policy sets out the expectation of Nursing staff and Nursing

Managers alongside requirements for rostering management at Isle of Wight NHS

Trust.

The policy aims to enable Ward/Department Managers to manage their staffing

requirements on behalf of the Isle of Wight NHS Trust. Collaborative working is

anticipated and working between wards and departments is sometimes required.

Staff must work together to maintain staff health and wellbeing and patient safety.

The purpose of this policy is to ensure the effective utilisation of the workforce

through efficient and effective rostering. The key elements are:

All duty rosters will be published for staff viewing a minimum of eight weeks in

advance.

Production of the rosters is the responsibility of the Ward Manager or Team

Lead.

There is a three stage process for creating and approving rosters:

Stage 1: Level 1 Partial Approver

Stage 2: Level 2 Full Approver

Stage 3: Escalated to Head of Nursing and Quality (HONQ) to review when a

roster is approved that does not achieve the rostering principles

specified in Healthroster and is therefore RAG rated Red.

The rostering system (Employee Online) will be used by all staff to make

requests for all types of duty or unavailability.

2 Introduction

The Isle of Wight NHS Trust recognises the value of its workforce and is committed

to supporting staff to provide high quality and safe patient care. Whilst

acknowledging the need to balance the effective provision of service with supporting


staff to achieve an appropriate work life balance, it is recognised that the Isle of

Wight NHS Trust needs to be able respond to changing service requirements. A

flexible, efficient and robust rostering system is key to achieving this objective and

will provide consistency and transparency for all staff.

3 Definitions

A number of terms are defined below to assist understanding:

For the purpose of this document the Ward Sister/Charge Nurse will be

referred to as Ward Manager. Department Leader or Team Leader are all

referred to as Team Leader.

Nursing and Midwifery: for the purpose of this document staff employed in all

clinical areas throughout the acute trust and community with the exception of

ambulance this will include but is not exclusive of Nurse, Midwife, Operating

Department Practitioner, Health Care Assistant or all ward based staff on the

ward or departmental roster.

Substantive: Staff who have permanent contracts and are employees of the

Trust.

Temporary: Bank and other temporary staff, eg. Agency.

Variations in shifts: differing start and finish times to regular shifts.

WTE: Whole time equivalent.

ESR: Employee Staff Record.

Working restrictions: restrictions around the days or times that staff can work.

Planned roster: the initial roster produced eight weeks prior to start date.

Headroom Allowance: the % built into budgets to cover absence.

EOL: Employee Online.

KPIs: Key Performance Indicators.

Unavailability/Unavailability’s: relates to days that staff are not available for a

normal working day i.e. Leave, Study days, Management days, Sickness.

Personal pattern: every week, two weeks or four weeks the person works the

same shift on the same day.


Red flags are those occurrences stipulated by NICE (July 2014) which maybe

an indicator that the quality of care has declined and patients are being made

vulnerable. It could be necessary to increase staffing levels on the basis of

these events.

4 Scope

This policy is for use by all clinical staff (excluding doctors, dentists and ambulance)

employed by the Isle of Wight NHS Trust and applies to the production of rosters

using the eRostering system.

5 Purpose

The purpose of this policy is to ensure the effective utilisation of the Isle of Wight

NHS Trust Nursing and Midwifery workforce through efficient eRostering by:

Ensuring that rosters are fair, consistent and fit for purpose, with the

appropriate skill mix, in order to ensure safe, high quality standards of care.

Improving the utilisation of existing staff and reduce the use of temporary

staffing.

To enable a balance of the needs of service delivery with legislation including

the European Working Time Directive.

Improving the planning of staff working days and unavailability.

Improving the monitoring and management of sickness absence and

identifying trends and priorities for action, in accordance with the Attendance

Management Policy.

Providing accurate management information regarding the establishment

thereby driving efficiencies in the workforce across wards and departments.

Providing a mechanism for reporting against set Trust Key Performance

Indicators (KPIs).

Facilitating the payment of substantive and temporary staff through data being

entered at source and ultimately locked down for payment as set in the

rostering timetable.


6 Roles and Responsibilities

6.1 Trust Board is responsible for

The Isle of Wight NHS Trust Board take assurance from a monthly report on

staffing and a six monthly safe staffing report that covers all nursing and

midwifery services within the Trust.

6.2 Director of Nursing is responsible for

Monitoring Trust wide staff demand profile and temporary staffing usage

against safer staffing approved establishments.

Monitoring Trust wide staff absence and ensuring that the directorate

management teams are pro-active in managing sickness absence and

achieve Trust’s absence target.

Monitoring and reporting of KPIs.

6.3 Associate Director of Nursing Midwifery and AHPs is responsible for

Agreeing and signing off the agreed staffing resource for each ward,

department with the Director of Nursing, Heads of Nursing and Quality,

Matron and Ward Manager.

Reviewing the KPIs that affect the use of resources within the service to

ensure that the nursing resource is managed effectively and efficiently in line

with best available evidence and the Nursing and Midwifery rostering policy.

6.4 Heads of Nursing and Quality is responsible for

Agreeing and signing off the agreed staffing resource for each ward,

department with the Director of Nursing, Associate Director of Nursing, Matron

and Ward Manager.

Reviewing KPI audits and ensuring the development and implementation of

appropriate action plans.

Reviewing the KPIs that effect the use of resources within the service.

6.5 Matrons are responsible for

Ensuring that the Ward Manager/Team Leader expenditure does not exceed

the allocated budget in all wards, units, departments.


Ensuring that there are enough nurses in the right place at the right time,

based on the agreed and funded skill mix, with the required competencies, to

meet the needs of the service.

Producing analysis reports on staffing, expenditure and quality in their area of

responsibility

Approving shifts where temporary staff are requested.

Ensuring all staff redeployed from one area to another are captured on

HealthRoster. The responsibility of tracking daily redeployment is the

donating ward. The responsibility for prolonged redeployment is with the

incoming ward and requires a change form to be sent to Finance and HR.

Providing guidance and support to the Ward Manager/Team Leader or

designated other in the creation of duty rosters, using the KPIs as a reference.

Ensuring Level 2 approval 8 weeks prior to working.

Analysing with the Ward Manager or Team Leader the forward looking

Rosters to review safety, effectiveness, fairness and budget control.

Notifying the Head of Nursing and Quality of any additional hours prior to

approving above the required staffing resource.

Escalating to the Head of Nursing and Quality when the roster has identified

Red Flags prior to level Level 2 approval.

6.6 Ward Manager/ Team Leader are Responsible for:

Ensuring that a quality roster is produced, approved, maintained and finalised

in line with timetabled deadlines and Trust KPIs.

Refer to Safe Staffing Escalation. (Appendix A)

Producing analysis reports using the management reporting facility on

Healthroster.

The fair and equitable allocation of annual leave and study leave.

Considering all roster requests from staff, ensuring fairness and equality in

working patterns.

Ensuring that all staff are aware of the Isle of Wight NHS Trust procedure for

rostering.

Ensuring Level 1 approval 10 weeks prior to working.


Audits should be undertaken every three months as a minimum for each ward

and at the discretion of the Matron. (Appendix B)

6.7 Nursing and Midwifery Staff are responsible for:

Attending work as per their duty roster.

Adhering to the requirements set out by the roster procedure.

Being reasonable and flexible with their roster requests and being considerate

to their colleagues within the rules set out by the trust.

Working their shifts as per contract.

Negotiating with their Manager any changes they request to an approved shift

in advance of the shift being worked.

Notifying their Manager of changes to personal details, e.g. address,

telephone number, etc.

Requesting shifts and unavailability in accordance with timetable via

Employee Online.

6.8 The rostering team are responsible for

Producing the Trustwide Rostering Timetable.

Monitoring rosters on completion and reporting against KPIs, feeding back to

the appropriate managers where improved rostering could maximise the

utilisation of the workforce.

Ensuring the Healthroster system remains appropriately configured.

Providing support and on-going training to healthroster users.

Reviewing roster set up and rules on a regular basis.

Liaising with the Supplier Support team to resolve system issues as required.

6.9 The Care Group/ Divisions Management Accountant is responsible for

Agreeing and signing off the agreed staffing resource for each area with the

Head of Nursing and Quality, Matron and Ward Manager or Team Lead.

Reviewing the KPIs that affect the use of resources with the Operational

Lead, Head of Clinical Services, Matron and Ward Manager or Team Leader

to ensure that the nursing resource is managed efficiently.


Ensuring completion of Staff Controls form and presentation to Exceptional

Pay Panel for any change of establishment.

7 Policy detail/Course of Action

7.1 Producing Rosters

7.1.1 Roster requirements

Rosters must be level 1 approved 14 weeks in advance, to enable level 2

approval at 12 weeks as outline in the rostering timetable.

The ward must have eight weeks of approved roster’s available at all

times

All rosters should be composed to adequately cover 24 hours (or agreed set

hours) utilising substantive staff proportionally across all shifts.

Night, Weekend, Bank Holidays and all high priority shifts must be filled first.

The use of bank staff for nights and weekend should only be used following

approval at staff control panel.

Staff with a Bradford Score of over 128 points would have any additional dties

reviewed by their manager to ensure sickness does not further inpact on the

department or staff member.

All student and trainee shifts should be included. Students should be rostered

with a mentor for a minimum of 40% of their time on the roster.

Christmas and other and other public holiday rostering requirements must be

agreed by the Head of Nursing and Quality and Matron.

Following the formal flexible working procedure any flexible working

arrangements should be openly acknowledged and published, i.e. the number

of part time posts/hours a ward can permit before this becomes operationally

unsafe, the number of fixed days ( personal patterns) that staff work, which

can be safely accommodated as agreed by the Head of Nursing and Quality

and Matron.

7.1.2 New Staff

New substantive staff may have a supernumery period. This should be for a

maximum of two weeks and will be assessed on an individual basis, taking

into consideration the requirement for the department.


Following an agreed supernumery period staff should plan to work with their

mentor twice a week to complete objectives and competencies, this must be

no more than three months.

7.1.3 Roster Requests

Requests will be calculated according to an individual’s hours of work of

employment, as set out in table 1 below.

All staff will use Employee Online (EOL) to make duty requests.

All requests will be considered in light of service needs and the Ward

Manager or Team Leader will endeavour, as far as possible, to meet

individual requests however service needs will take priority.

Contractual arrangements do not need to be requested.

Table 1: Request Entitlement -

1 request = Early/ Late/ Night/ Day off/ Long Day

Minimum Staff Hours

per week

Total Number of requests per

four week roster

Please note:

The granting of

requests cannot

be guaranteed.

37.5 hours 6 requests


25 hours 4 requests



6.25 hours 1 request

Staff will be required to work flexibly across a variety of shifts and shift

patterns.

Staff at Band 7 and above will not be rostered to work nights, weekends or

bank holidays with the exception of Emergency Department and the maternity

Service. There may times when seasonal adjustments to this are required to

meet service demands.

Staff should work a minimum of one weekend per four week roster, (unless

they specifically request not to have weekends off).

Inappropriate shift requests, not in line with the Working Time Regulations

(WTR), will not be considered by the Department Manager.


7.1.4 Managing Non-effective working time

Non- effective working days – staff’s unavailability during the two week roster

period, broken down in to the following categories.

Annual Leave

Sickness

Special Leave

Working Day i.e. Management Day, non-clinical day

Study Days

Other

The total percentage of these should equate to the 22% headroom that is built

in to each establishment.

7.1.5 Key Performance Indicators (KPIs) for Nurse Staffing

Carter metrics

Rostering Indicators

Headroom and usage of Non-Effective working days e.g. annual leave and

study leave

6 week roster approval rates

Lost contracted hours (unused hours) - contracted hours not used over a four

week roster period.

Additional duties – any duties allocated that are above the agreed staffing

requirements for the department and reasons for booking

Auto-roster percentage enabled

Number of bank requests to total bank hours worked.

Number of bank requests on weekend and night duties

Safe Nursing Indicators (NICE guidance)

If a nursing red flag event occurs, it should be recorded on healthroster by the

nurse in charge of the shift. Prompting an immediate escalation response by the

registered nurse in charge.

These are: - Unplanned omission in providing patient medications.


- Delay of more than 30 minutes in providing pain relief.

- Patient vital signs not assessed or recorded as outlined in the care

plan. Regular checks on patients to ensure that their fundamental care

needs are met as outlined in the care plan. This is often referred to as

'intentional rounding' and involves checks on aspects of care such as

the following:

- Pain: asking patients to describe their level of pain level using the local

pain assessment tool.

- Personal needs: such as scheduling patient visits to the toilet or

bathroom to avoid risk of falls and providing hydration.

- Placement: making sure that the items a patient needs are within easy

reach.

- Positioning: making sure that the patient is comfortable and the risk of

pressure ulcers is assessed and minimised.

- Less than 2 registered nurses present on a ward during any shift

- A shortfall of more than 8 hours or 25% (whichever is reached first) of

registered nurse time available compared with the actual requirement

for the shift. For example, if a shift requires 40 hours of registered

nurse time, a red flag event would occur if less than 32 hours of

registered nurse time is available for that shift. If a shift requires 15

hours of registered nurse time, a red flag event would occur if 11 hours

or less of registered nurse time is available for that shift (which is the

loss of more than 25% of the required registered nurse time).

If a nursing red flag is identified and managed or the event occurs , complete and submit Datix form.

7.2 Validation and Approval

7.2.1 Approval Levels

Level 1 approval

The Ward Manager or Team Leader validates and approves the roster,

checking the roster analysis information. An unsafe roster must NOT be

approved without escalation to the Matron/Head of Clinical Service.

The Ward Manager or Team Leader Level 1 approves the roster and informs

the Matron that it is ready for their review.


Level 2 approval

The Matron or Head of Nursing completes the validation and where required

approves shifts for temporary staffing.

Any roster that falls outside of the parameters must be reviewed and

scrutinised for approval/rejection. If not approved it will be returned to the

Ward Sister or Team Leader to re-do. If it is Level 2 approved publishing will

be automatic.

7.2.2 Changes to Approved rotas

Approved rosters may be liable to short notice change with agreement of the

staff member to accommodate needs of the service and instances of short

notice absence. In line with Agenda for Change annex 2.25 a payment will be

made made for short notice of 24 hours or less.

It is the responsibility of the Ward Manager or Team Leader to ensure that

rosters are amended and kept up to date on a daily basis i.e. unavailability,

study leave etc.

Shift changes should be kept to a minimum and must be approved by the

Ward Manager or Team Leader.

Where staff are allocated to a student, shift changes should not occur without

ensuring the student either changes shift with the staff member or is allocated

to another suitable member of staff.

All updates to the roster must be made immediately as above; this includes,

allocation of agency nurses, changes to shift times, times of attendance, and

unavailability etc.

Staff moved from area to area must be redeployed on Healthroster. This is

the responsibility of the donating ward.

7.2.3 Finalising/ Locking Down Rotas

The roster must be verified and locked down by the Ward Manager or Team

Leader every Monday for the previous week to ensure weekly payment to

bank staff.


In accordance with the rostering timetable all rosters must be locked down on

the 2nd business day of the month to ensure staff payment and accuracy of

information transferred to ESR.

7.3 Skill Mix and Staffing

7.3.1 Skill Mix

Each area should have an agreed level of staff with specific competencies on

each shift to enable appropriate cover e.g.

-Giving medication

-IV administration

-Taking charge of the shift

-Ability to perform assessments and observations

The roster for senior staff must be compatible with their commitment to any

bleep holding/ weekend working roster.

There must be one designated person in charge for each shift and this must

be clearly identified on the roster and whiteboards. It is a Ward Manager or

Team Leader’s responsibility to ensure the Nurse in Charge is clearly marked.

Is expected that there will be a minimum of one Band 7 on every shift in the

Emergency Department and Maternity Service to provide safe oversight of the

department.

Senior staff should work opposite shifts to achieve a balance of senior cover

across all shifts.

Ward Managers or Team Leaders should routinely work Monday to Friday and

not weekends unless specifically requested or required.

The Ward Manager or Team Leader should not work nights without prior

approval from Matron.

7.4 Shift Patterns and Working Time Directive

7.4.1 Shift Patterns

Staff will be required to work a variety of shifts and shift patterns as agreed by

their Ward Manager or Team Leader or as specified in their contract of

employment.


Staff may work long shifts or a combination of both in order to meet the

service requirements.

It is not expected any member of staff will have “fixed” patterns of working.

Those staff who work predominately nights will be expected to roster to day

shifts at least one week per calendar month.

Standard shift start and finish times will be agreed and applied on a consistent

basis across the Trust. Additional shifts or shift start and finish times may be

approved only by the Head of Nursing and Quality and Matron.

Staff should work a minimum of one weekend per four week roster (unless

they specifically request not to have weekends off). Additional weekends off

can be rostered if department requirements allow.

The number of consecutive 12.5 hour shifts for staff to work should be no

more than 4.

All staff must have 11 hours rest before their next shift

All staff must have 24 hours rest in every 7 days OR 48 hours rest in every 14

days

Staff must not work more than an average of 48hours per week unless they

signed Working Time Directive (WTD) opt out.

Staff who have opted out of the WTD 48 max working rule must not work

more than an average of 60 hours per week over any 26 week period.

7.4.2 Unpaid Breaks

The Ward Manager or Team Leader or person in charge, and the individual

are responsible for ensuring that breaks are taken.

Staff may rest in designated rooms within their break period, but must return

to the clinical area to work at the set time.

7.4.3 Annual Leave

The general principles that detail annual leave management within the

Directorate procedure or protocol must include the following:

Annual leave must be booked at least 8 weeks in advance

Annual leave must be booked or cancelled before a roster is finalised

Staff should take 25% of their annual leave each quarter throughout the leave

year as follows:-


- 25% quarter 1 (April, May, June)

- 25% quarter 2 ( July, Aug, Sept)

- 25% quarter 3 (Oct, Nov, Dec)

- 25% quarter 4 (Jan, Feb, March)

-

Each department should calculate how many registered and unregistered staff

must be given annual leave in any one week, with a defined limit for each

Band. Annual leave requests that exceed the documented acceptable level

for the department should not be approved.

Clinical Area xx has 21WTE Band 5 nurse and 7WTE HCA

The agreed percentage of staff on annual leave at any one time is 14%

Calculation:

21 x 0.14 = 2.94 round up to 3WTE

21 x 0.14 = 0.98 round up to 1WTE

You would need to try and allocate approximately 3 Band 5 registered nurses

and 1 HCA per week on annual leave to achieve balance over the year.

Please note: This number is based on WTE in post: therefore as staff join

and/or leave you will need to recalculate the above.

A maximum of 14 consecutive calendar days of annual leave can be

requested (ten working days and four days off)

Staff requesting more than 2 weeks leave at a time must have it approved in

writing. Unpaid leave may be given at the managers discretion depending on

service demands and service delivery.

If a staff member does not arrive for duty following annual leave it will be

unpaid as it was not planned leave.

Only in exceptional circumstances can leave of no more than 5 days be

carried forward into the next year and this must be authorised by the Head of

Nursing and Quality or Associate Director, with the relevant formal

notifications made to the Directorate Finance Manager. This carried over

leave must be taken in Month 1 of the new financial year.


It is recognised there will be a disproportionate amount of leave allocated in

Q1 in response to this carry forward position. This will need to be assessed

by the Ward Manager.

Staff on rotational programmes should take annual leave proportionate to

each placement.

7.4.4 Christmas and New Year

The Christmas and New Year period will be treated as all other weeks in

terms of the maximum amount of leave by Band that can be allocated.

Each ward or department will determine how the usual level of leave will be

allocated i.e. a few staff get some leave as opposed to a small number of staff

having blocks of leave.

All requests for Christmas and New Year annual leave should be made by 1st

October and agreed locally. Staff should be notified if their leave has been

approved by the end of October.

Temporary Staff should not be routinely booked on planned rosters for

Christmas and New Year Periods.

7.4.5 Staff Development

Study leave should be allocated in line with mandatory training policy and

statutory requirements

The Ward Manager and Team Leader should:

Utilise the available number of study leave days in each roster.

Prioritise mandatory training requirements for staff which may include

induction, updates, etc.

Produce rosters ensuring staff have the required mandatory training.

7.4.6 Sickness and absence

Sickness Absence will be managed in accordance with the Trust’s Attendance

Management Policy.

The Trust’s sickness absence target for nursing and midwifery is 3%.

If days on duty follow on from sick days, the Ward Manager or Team Leader

must be kept informed of recovery – the staff member should notify their line

manager and advise when they are fit to return.


Staff with a Bradford Score of over 128 points would have any additional

duties reviewed by their manager to ensure sickness does not further inpact

on the department or staff member.

7.4.7 Unused Hours

Any hours worked over contracted hours should be agreed by the Ward

Manager or Team Leader and recorded on the roster.

All hours worked over contracted hours must be claimed back within 4 weeks

if due to service demand time owing can not be taken back this will be paid.

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

Ward Manager or Team Leader. These hours should be recorded as Time

Owing unavailability within Healthroster.

8 Consultation 8.1 Consultation on this document during planning has included:

Interim Deputy Director of Nursing

Human Resources Rostering Team

Heads of Nursing

Matrons

Ward Managers and Team Leaders

9 Training

9.1 How will staff be made aware of the policy?

Following approval, the policy will be circulated as follows:

Directors and Associate Directors – communication directly by e- mail and

discussion at Trust Executive Committee (TEC)

General Managers/Service Leads - communication directly by e-mail and

discussion at Executive Brief

Heads of Nursing and Quality– communication directly by e-mail and to be

notified by Directors through line management briefing


Matrons and Ward & Department leaders – the policy will be disseminated

through the Nursing and Midwifery Development Days and the Nursing and

Midwifery Back to the Floor Days to Matrons and ward team leaders

All Nursing and Midwifery staff – The policy will be posted on the nursing

and midwifery intranet site. Trust communications channels will be employed

including “eBulletin”. Staff will be notified of the policy by Matrons or

Department heads in line management team briefings.

9.2 Training Provision

This Nursing and Midwifery Policy does not have a mandatory training

requirement. General training relating to management of the eRostering system is

available from the eRostering team.

10 Monitoring Compliance and Effectiveness

Compliance will be monitored by Clinical Rostering Lead during weekly check and

challenge meetings with Ward Sisters and Matrons.

Effective use of the policy will be monitored via the KPIs.

Monitoring is the responsibility of the Ward Manager and Matron and is to be

reviewed by the Heads of Nursing and Quality.

Audit results will be reviewed at the local Care Group meetings, Quality

Meeting and Board Meeting as part of the statutory staffing reports they

receive

Audits will be undertaken every three months as a minimum for each ward

and at the discretion of the Matron. (Appendix B)

Where failings have been identified, the Matron will be required to draw up an

action plan and ensure roster management is brought back in line with

requirements.

11 Links to other Organisational Documents

Agenda for Change Terms and Conditions of Employment

Local held - Annual Leave Guidance/Protocols

Attendance Management policy


Flexible Working policy

Special Leave policies - policies and procedures (Maternity Leave, Paternity

Leave, Adoption Leave, Carers Leave, Career Break and other Special

Leave)

Staff Redeployment policy

Control of temporary staff guidelines

NHS Constitution

Capability Policy and Procedure

Maternity- Staffing on Labour ward

12 References

Good Practice Guide: Rostering (June 2016)

Safer staffing for nursing in adult inpatient wards in acute hospitals ( July

2014)

Safe midwifery staffing for maternity settings (February 2015)

How to ensure the right people, with the right skills, are in the right place at

the right time. A guide to nursing midwifery and care staffing capacity and

capability (National Quality Board 2013)

Francis report on Mid Staffordshire (Francis 2013)

13 Appendices

Appendix A: Safe Staffing Escalation Appendix B: Rostering Audit Tool Appendix C: Nursing Temporary Staffing Standard Operational Procedure Appendix D: Accountable and Responsive Framework for Nursing and Midwifery

Staffing ‘Ward to Board’ Appendix E: Staff Cost Controls Form

Appendix F: Financial and Resourcing Impact Assessment on Policy Implementation

Appendix G: Equality Impact Assessment (EIA) Screening Tool


Appendix A

No

Yes

Safe Staffing Escalation

Complete eRoster with staff in post ensuring adequate cover days, nights and

weekends. Allow for peaks and troughs in planned activity, e.g. theatre lists,

winter pressures. Ensure roster is 1st and 2nd approved 8 weeks in advance

by Ward Manager and Matron

Do you have the right staff, right skills to staff your clinical area safely?

Yes No -

Unplanned No - Planned

Gaps in the roster?

Identify need for specific shifts

Allocate any unused hours

Consider if any study days could be cancelled

Identify staff from other areas that may be able to help

Send shifts to Bank

Offer excess hours if employee is contracted <37.5hrs overtime if employee is contracted >37.5hrs

2 weeks prior to shift if not covered by bank send shifts to agency with completed staff controls form

24hrs prior to shift review needs and cancel bank /excess hours/ agency shifts if not required

High acuity and dependency Short term unavailability, sickness at work or within 4 hours of shift commencing

Identify any staff excess to ward requirement Allocate outstanding annual leave Offer support to other ward across the Trust

Safe

Staffing

Identify any non-rostered staff who may be able to help e.g. Matrons, clinical educators

Utilised unused hours

Offer excess hours if employee is contracted <37.5hrs overtime if employee is contracted >37.5hrs

Ask colleagues (Sisters/ Matrons/ Heads of Nursing) for help

Consider moving patients to provide better staff cover

Discuss bed closure with Matrons, Heads of Nursing and Director of Nursing

If Safe Staffing concerns are not addressed, complete and submit Datix form

If a situation arises where patient’s safety is compromised due to staffing, the Senior Manager On Call and Executive On Call must be notified.


Roster Audit Tool Appendix B

The audit tool should be used to monitor compliance of the rostering policy at least 6

monthly and should be completed by the Ward Manager/ Team Leader. An action

plan should be agreed for areas requiring improvement as recommended in the

Carter Review

Ward/Department:

Audit completed by:

Date completed:

Yes/ No Comment Action

Has the roster template been reviewed on a six monthly basis to ensure it is current, realistic and reflects the staffing required?

Are all the staff aware of the policy?

Do the shift and break times conform to European Working Time Directives?

Are the approved minimum numbers of staff rostered for each shift?

Is the skill mix maintained?

Have any staff been moved within the Trust to cover vacancies?

Is annual leave allocated as per policy?

Is study leave allocated fairly as per policy?

Are there any work/life balance procedures for any person in the ward/department


Yes/No Comment Action

Is the request system used as per policy?

Are there 8 weeks of completed roster available for staff to view?

Does the ward/department have adequate handover time?

Are break time guidelines being followed?

Is there evidence of annual review of existing work patterns?

Are 3 months of rosters available for requests?

Does Matron/ Head of Department approve rosters?

Is annual leave between 11-17%


Appendix C

Nursing Temporary Staffing Standard Operational Procedure

Version Review Date Written by

V1 26/07/2020 Sue Biggs

1 Introduction

1.1 Background

The Trust acknowledges that from time to time departments may experience staffing difficulties and that in order to maintain service provision may need to secure temporary staffing. Temporary staffing refers to the engagement of bank, agency staff through the HR Temporary Staffing Team, approved recruitment agencies or specialist recruitment agencies for any given period. Due consideration should be given to viable alternative options before temporary staff are engaged. It is essential that Managers minimise the cost of using temporary staff 1.2 Purpose

To provide all appropriate stakeholders with clear simple guidance in requesting Temporary

Staffing in line with good practice, the Isle of Wight NHS Trust Rostering and Temporary

Staffing policies

1.3 Scope

Inpatients wards

Ward/Units Sisters/Charges nurse and Deputies

Matrons

Heads of Nursing and Quality

Clinical Site Co-Ordinators

Human Resources Temporary staffing team

Human Resources e-Rostering Team

Senior Managers on Call

Executive Directors on Call

Executive Director of Nursing


Service Directors


• HR Temporary staffing commence filling vacant shifts with initially with Bank

staff.

• Once this process is complete and the following has been explored:

1 Any ward staff on the bank wish to cover.

2. Excess hours.

3. Overtime

and financial approval received in HR Temporary staffing, they will submit

agency request

• If Temporary staffing fill shift via the bank they will put on Healthroster

• If shift covered at ward/unit level it is their responsibility to put on Healthroster

• Agency staff rosters will be sent to appropriate ward/unit who are responsible

for putting on Healthroster

2. Requesting Temporary staffing process

• When a shift is cancelled by bank staff or agency via Temporary Staffing

it is their responsibility to inform ward/unit and source appropriate cover.

• When a shift is cancelled by bank staff on the ward/unit it is the

ward/units to cancel and send shift to temporary staffing and review

options

• If shift cancelled at ward/unit level it is the responsibility of the ward/unit

to inform staff member and/or temporary staffing if bank and temporary

staffing if agency prior to the shift

• These must be for unexpected short notice absence only within 12 hrs of

shift i.e. sickness, bereavement

• Vacant shift to be submitted via healthroster and supported by a phone call

to temporary staffing ext. 6000

• If out of hours and requires immediate attention then the nurse in charge

must make the appropriate alterations to Healthroster and contact the

Clinical site Co-coordinator, for risk assessment and internal cover where

possible.



3. Temporary Staff checks, Training and support

The following must be undertaken when Agency Nurse or Bank staffs arrive on ward/unit:

If new to ward or not known to staff on duty the following must take place:

Introductions

Show layout of ward ensuring they are aware of the location of: 1. Fire exits 2. Fire extinguishers 3. Defibrillators 4. Emergency call bell

And any other emergency, health and safety equipment within Ward/Unit

If Agency training and system access must be checked (JACS, E-care logic etc.), if

training not completed: In hours the appropriate department must be contacted these are IT, Pro4 and Pharmacy and staff member released to undertake to enable them to safely undertake all duties associated with role Out of hours the Nurse in Charge must contact the Clinical Site Co-ordinator on bleep 000 who will support to ensure staff member can safely undertake all duties associated with role.

When allocating work wherever possible Agency and Bank staff must work in partnership with a substantive member of staff and not with another Temporary staffing member.



4. Escalating Incident and Concerns

Agency and Bank staff must be held to account and treated in line with all Trust policies,

with this in mind when any incident occurs that raises concerns and may require

investigation we must follow the same process as we would for substantive staff, but with the

involvement of the Resourcing Manager or Deputy.

Please refer to flow flowchart (appendix B).

Linked to:

Isle of Wight NHS Trust Nursing and Midwifery Rostering policy

Isle of Wight NHS Trust Temporary Staffing policy

NHS Improvement Good Practise – Rostering

Isle of Wight NHS Trust Disciplinary and Dismissal policy



Yes No

Incident occurs

Can incident be handled at ward level via a conversation

with staff member?

Ward/Unit Sister/Charge nurse or appropriate Deputy meet with staff member then

inform HR Temporary Staffing via email of incident

and outcome

In hours Out of hours

HR Temporary staffing to be informed

immediately via phone call and DATIX

completed

Meeting arranged with staff member , appropriate

Sister/Charge nurse or Deputy and Resourcing Manager or

Deputy

Nurse in Charge contacts Clinical Site Co-Ordinator and appropriate action

taken in line with Isle of Wight NHS Trust policies, DATIX completed and

Temporary staffing emailed with details of incident

Nurse in charge out of hours fully informs

Sister/Charge or Deputy to action

Action taken in line with the Isle of Wight NHS Trust Disciplinary and

Dismissal policy, Resourcing Manager or Deputy will liaise with the

appropriate Agency



Appendix D

Accountable and Responsive Framework for Nursing and Midwifery Staffing ‘Ward to Board’

A nursing workforce oversight meeting/process (to be put in place) will oversee the delivery of these key expectations and will report into the nursing and midwifery monthly meeting.

Report to the Board on nursing, midwifery and care staffing capacity and capability, highlighting concerns and making recommendations where necessary. Workforce data should be triangulated with data on quality of care.

Where staffing capacity and capability is insufficient to provide safe care to patients and cannot be restored, undertake a full risk assessment and consider the suspension of services and closure of wards in conjunction with the Directors of Operations, Chief Executive and Commissioners.

Foster a culture of openness and honesty amongst staff, supported by nursing and midwifery leaders, where staff feel able to raise concerns, and concerns are acted upon.

Chair and lead the nursing workforce oversight meeting, holding clinical leaders to account for core quality metrics related to nurse rostering and staffing.

Develop capability and capacity within the nursing and midwifery leadership teams to ensure that they understand the principles of workforce planning. Ensure that they can use evidence based tools informed by their professional judgement to develop workforce plans and make staffing decisions on a day to day basis.

Assure the Board that there are nursing and midwifery workforce plans are in place for all patient care areas/pathways

On a monthly and six monthly basis report workforce information to the Quality Committee and Trust Board on expected vs actual staff in post on a shift-to-shift basis together with information on key quality and outcome measures.

Ensure there is uplift in planned establishments to allow for planned and unplanned leave and ensure absence is managed effectively.

Trust Board

Director of Nursing

Ward

To

Board

and

Board to

Ward


Oversee the operational implementation of the nursing workforce strategy across the Trust.

Clinical Advisor/expert on nurse staffing.

Monitor compliance with staffing standards locally in conjunction with clinical business unit (CBU) leaders and put in place solutions where risk is identified via CBU leaders.

Develop responsive systems and local policy for the provision of safe nurse staffing across the Trust in conjunction with CBU leaders.

Implement Safe care across the Trust.

Review data provided by matrons/MAPS and monitor compliance with Rostering Policy, Lockdown and Approvals.

Hold Matron and Ward sisters to account for staffing capacity and capability across the CBU.

Support Matrons and Ward Sisters to work collaboratively with other CBU’s to manage staffing capacity and capability across the Trust.

Escalate concerns to the Director of Nursing where staffing is insufficient to sustain safe, effective care or positive patient experience.

Review and 2nd approve rosters submitted from wards/Departments.

Ensure all unused hours are utilized before the roster is 2nd approved.

Reallocate staff and authorise the use of temporary staffing solutions if necessary and where required.

Continuously review and monitor nursing, midwifery and care staffing capacity and capability across areas of responsibility.

Produce data / information and reports as required to inform the CBU, the quality committee, Trust Board, management of the organisation, and to inform workforce planning.


Head of Nursing

Matron

Ward to

Board

and

Board to

Ward


Hold Ward Sisters/Charge Nurses to account for having appropriate staffing capacity and capability on a shift to shift basis, and following escalation procedures where necessary.

Work as a leadership teams to undertake daily review of trust wide staffing to ensure parity and safety cross all wards.

Ensure efficient rosters are produced, managed and first approved in line with local policy.

Ensure all unused hours are utilized before the roster is 1st approved.

Ensure you ward/department is adequately covered in your absence and if not achieved this has been escalated to the matron and/or a plan left for local resolution to ensure safe staffing.

Measure quality of care and outcomes achieved for patients and the capacity and capability of staff on a ward-to-ward basis.

Take responsibility for recruitment and retention of the nursing workforce within their service.

Take responsibility for attendance management to ensure staff are fit and able to attend work

Ensure all staff are aware of your local escalation plan for staffing.

Respond in a timely manner to unplanned changes in staffing, changing patient acuity /dependency or numbers, including the request for and use of temporary staffing where nursing/midwifery shortages are identified.

Manage temporary staff covering your ward within local policy to ensure safe delivery of care.

Escalate concerns to line manager where staffing capacity and capability are inadequate to meet patient needs and complete a Datix risk form when indicated.

When a staffing incident occurs ensure the team know what action has been taken locally to correct it with 48 hours of the incident.

Attend bi annual staffing review meetings and staffing cafes as required.

Produce reports on your staffing when required.

Understand the evidence based methodology used to determine the nursing and/or midwifery staffing in your area of responsibility.

Ensure ward team comply with dependency and acuity data collection processes that will influence staffing levels three times daily.

Ward Sister/Charge

Nurse

Ward to

Board

and

Board to

Ward


Ensure you understand the safe staffing requirements of your ward/department area for each shift.

Ensure the roster policy is complied with.

Ensure the Health roster is kept live and up to date including the input of agency and bank staffing. .

Complete any required data returns that relate to staffing.

Ensure the ward is adequately covered when you leave your shift.

Escalate any staffing concerns to the ward sister /charge nurse/matron or clinical site manager for action and where unsafe staffing occurs report this via the Datix incident form reporting.

Participate in professional discussions about staffing requirements in your area when required.

Complete data returns where requested about the staffing in your workplace to inform workforce planning decisions.

Participate in discussions and decisions regarding staffing in your clinical area.

Look after your own health and welling to ensure you are fit for work.

Understand the agreed staffing capacity and capability is for your clinical area on a shift by shift basis.

Raise concerns regarding staffing and/or the quality of clinical care within your organisation when they arise via the line manager and completing a Datix Incident form.

Comply with dependency and acuity data collection processes that will influence staffing levels three times daily.

Ward Nurse

Ward to

Board

and

Board to

Ward

Nurse In Charge


Appendix E Staff Cost Controls form

SECTION A:

Care Group

Requesting Manager Name

Requesting Manager Job Title

SECTION B: Request Details

Job Title

Department

Cost Centre Subjective Code

Requirement Indicate with a Y or N

Existing Vacancy:

New Post:

Bank / Internal Locum:

Agency:

Change Request:

Band: WTE: Current worker:

Request Detail

Permanent: Fixed Term / Temporary:

Secondment: Secondment Period:

Start Date: End Date:

Apprentice: Recruitment Premia:

On Call: Clinical Excellence:

Date of last JD review:

Relocation Costs:

Reason for Request

Leavers Name

Leaving date

Summary of the alternative solutions considered

Justification (Include impact to patients / safety)

SECTION C: Costing & BI Report Summary


Section D: Financial Summary

Financial Impact

Impact to Forecast (£): Impact to Run Rate (£): Total value in excess of budget available (£) Plans to mitigate cost pressure

New Funding for post (if applicable)

Source of new funding

Confirmation of approval attached Y/N

Change of Establishment Form attached Y/N

Additional Financial Comments

Finance Approval

Finance Manager (print) Signature Date

SECTION E: Agreement

Impact to run rate £ Increase / (Decrease)

Total value in excess of budget available £

This request has been reviewed and is:

Supported

Not supported

Please ensure signatures are obtained by ADO, Executive Director and the Medical Director for

medical requests or the Director of Nursing for all nursing/AHP requests

Job Title Signature: Date approval given

Associate Director of Operations (ADO)

Executive Director

Medical Director (required for ALL medical


requests)

Director of Nursing

(required for ALL nursing and AHP requests)

SECTION F: Authorisation

Required for:

All Resourcing requests – permanent and temporary

Change forms that increase an individual’s hours or banding, and responsible allowance including recruitment and retention

The approval was given by the following Executive Directors to proceed with this staffing request. Two of CEO, CFO and DoHR required

Job Title Signature: Date approval given

Chief Executive Officer CEO

Chief Finance Officer (CFO)

Director of HR & OD (DoHR)


Appendix F

Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact.

Document title

Nursing and Midwifery Rostering Policy

Totals WTE Recurring £

Non Recurring £

Manpower Costs 0

Training Staff 0

Equipment & Provision of resources 0

Summary of Impact: Staff are aware of rostering requirements in an informal process. Staff are already trained to utilise the Healthroster system either by the e-Rostering team or via local induction for Ward Managers or Team Leaders. Additional training may be required to support staff as we go forward with improved management and this will be provided by the e-Rostering team. Risk Management Issues:

Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? YES Are there any reported equality issues? NO If “YES” please specify:

Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.

Manpower WTE Recurring £ Non-Recurring £

Operational running costs

N/A

Totals:

Staff Training Impact Recurring £ Non-Recurring £


Training implications for rosering team

Totals:

Equipment and Provision of Resources Recurring £ * Non-Recurring £ *

Accommodation / facilities needed N/A

Building alterations (extensions/new) N/A

IT Hardware / software / licences N/A

Medical equipment N/A

Stationery / publicity N/A

Travel costs N/A

Utilities e.g. telephones N/A

Process change N/A

Rolling replacement of equipment N/A

Equipment maintenance N/A

Marketing – booklets/posters/handouts, etc N/A

Totals:

Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:

Funding / costs have been agreed and are in place:

Signature of appropriate Executive or Associate Director:


Appendix G

Equality Impact Assessment (EIA) Screening Tool

1. To be completed and attached to all procedural/policy documents created within

individual services.

2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required.

Gender

Positive Impact Negative Impact Reasons

Men No

Women No

Race

Asian or Asian British People

No

Black or Black British People

No

Chinese people

No

People of Mixed Race

No

White people (including Irish people)

No

Document Title: Nursing and Midwifery Policy

Purpose of document To provide policy requirements for managing rosters for nurses and midwifes

Target Audience All Nursing and Midwifery Staff

Person or Committee undertaken the Equality Impact Assessment

Emily Mullan (Clinical Lead for eRostering and SafeCare)


People with Physical Disabilities, Learning Disabilities or Mental Health Issues

No

Sexual Orientation

Transgender No

Lesbian, Gay men and bisexual

No

Age

Children

No

Older People (60+)

No

Younger People (17 to 25 yrs)

No

Faith Group No

Pregnancy & Maternity No

Equal Opportunities and/or improved relations

No

Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact:

YES NO

Legal (it is not discriminatory under anti-discriminatory law)

Intended

If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below:

3.2 Could you improve the strategy, function or policy positive impact? Explain how below:

3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or improves relations – could it be adapted so it does? How? If not why not?


Scheduled for Full Impact Assessment Date: 02/10/18

Name of persons/group completing the full assessment.

Date Initial Screening completed

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