ROSTERING AND WORKING TIME REGULATIONS POLICY AND
PROCEDURE
REF NO SABP/WORKFORCE/0030
NAME OF POLICY, PROCEDURE
OR GUIDELINE
Rostering and Working Time
Regulations Policy
REASON FOR POLICY OR
PROCEDURE
To provide guidance on procedures for
producing
staff
rosters,
either
electronically or manually, that are
compliant with the Working Time
Regulations.
WHAT THE POLICY WILL
ACHIEVE?
Legally
compliant
and
efficient
deployment of staff and resources by
effectively rostering staff.
WHO NEEDS TO KNOW ABOUT IT
All staff
DATE APPROVED
January 2014
VERSION NUMBER
3.0
APPROVING COMMITTEE
Executive Board
DATE OF IMPLEMENTATION
January 2014
DATE OF FORMAL REVIEW
An extension for this policy has been
granted until July 2017 to enable a full
comprehensive review to be completed.
Responsible Directorate
Quality
Distribution
All Staff
AUTHOR
Director of Human Resources
1
Rostering Policy
1. Introduction
1.1
Staff rosters are one of the fundamental systems used to deliver care to people who use
our services by ensuring safe staffing levels at all times. It is therefore essential that they
are drawn up in a timely and appropriate manner, maximising the benefits to people who
use our services and without incurring any unnecessary expenditure. For staff to be able
to achieve a work life balance in line with our Health and Well Being Strategy, rosters
must be drawn up giving maximum notice and taking reasonable account of the needs
and wishes of individual members of staff.
1.2 Good, fair and equitable rostering is necessary to achieve the Trust’s Vision and Values. All
people using our services, as well as staff, have a right to expect the best support from
the Trust. To do this we must ensure that work is distributed appropriately and fairly with
our staff having had appropriate rest to deliver a safe, high quality service. This must be
based on the needs of the people using our services.
2. Purpose
2.1 The purpose of this policy is to provide the principles upon which all rosters for staff
must be based. It applies to all staff working patterns, not just those working a variable
shift pattern. The only exception to this is the application of the Working Time
Regulations to some junior medical staff which is covered in a separate policy Implementation of Working Time Directive for Doctors in Training. All other aspects of
this policy apply.
2.2
This policy also covers compliance with Section 27 of the Agenda for Change Handbook
which covers the Working Time Regulations (WTR). Section 27 should be read in
conjunction with this policy where full details of the restrictions on working time necessary
to comply with the Working Time Regulations can be found.
2.3 The Trust has adopted the Healthcare Roster computerised system to ensure rosters are
compliant with the Working Time Regulations though guidance is given for manual rosters
too where this system is not in operation.
2.4 The Flexible Working Policy must be read in conjunction with this policy to support staff that
may have particular requirements in their working patterns.
3. Scope
3.1
This policy and procedure applies to all staff except Directors and staff with Medical and
Dental Terms and Conditions of Service.
2
4. Policy Principles
4.1. To ensure that the services are safely staffed.
4.2. To ensure safe and appropriate staffing for all departments using fair and consistent
rotas.
4.3. To improve the utilisation of staff and reduce temporary workforce expenditure by providing
managers with clear visibility of staff’s contracted hours.
4.4. To minimise clinical risk associated with the level and skill mix of clinical and non-clinical
staffing levels.
4.5. To improve monitoring of sickness and absence by department and individual, generating
comparisons, and identifying trends and priorities for action.
4.6. To improve planning of study days, annual leave and other non-clinical care working
days.
4.7 Any employee’s flexible working arrangement agreed by the service manager should be
reviewed regularly and be published so that all staff working a particular roster understand
the local arrangements, where they exist, for all staff on that roster.
4. References
5.1
This procedure is to be read in conjunction with the following:







Flexible Working Policy
Leave (Paid and Unpaid) Policy
Grievance Policy and Procedure
Absence Management Policy
Agenda for Change Handbook
Implementation of Working Time Directive for Doctors in Training
Health and Safety at Work Policies
3
ROSTERING AND WORKING TIME REGULATIONS PROCEDURE
REF NO SABP/WORKFORCE/0030
NAME OF POLICY, PROCEDURE
OR GUIDELINE
Rostering
and
Working
Regulations Procedure
REASON FOR POLICY OR
PROCEDURE
To provide guidance on procedures
for
producing staff
rosters,
either
electronically or manually, that are
compliant with the Working Time
Regulations.
Legally compliant
and
efficient
deployment of staff and resources by
effectively rostering staff.
WHAT THE POLICY WILL
ACHIEVE?
Time
WHO NEEDS TO KNOW ABOUT IT
All staff
DATE APPROVED
January 2014
VERSION NUMBER
3.0
APPROVING COMMITTEE
Executive Board
DATE OF IMPLEMENTATION
DATE OF FORMAL REVIEW
January 2014
An extension for this policy has been
granted until July 2017 to enable a full
comprehensive
review
to
be
completed.
Responsible Directorate
Quality
Distribution
All Staff
AUTHOR
Director of Human Resources
4
Summary of Changes since Version 3
Page /Paragraph/
Appendix Number
(select the
appropriate action)
Original / New / Amendment / Deleted – Statement (select the
appropriate action)
Amendment
Policy and Procedure combined into one document and Title
Changed to remove E-Rostering
Insert “Reviewed by the Rostering Manager and their line manager”
where the former policy was non-specific before
Added a requirement to ensure the rostering manager takes account
of forthcoming staff changes when developing their roster
Throughout the document, the word ‘Ward’ is replaced with ‘Service’
1.1 Amendment
1.1 New
1.1 Amendment
5.1 Amended
Added a requirement to review previous year’s allocation in
determining who may have annual leave when there are multiple
requests
Flexible working arrangements review period extended to 6 months in
light of discussions at Staff Survey Forum discussions
The words ‘each day’ have been added for clarification
5.1 Amendment
‘except where necessary’ has been removed
5.1 bullet point 14
Bullet point replaced with ‘In addition to clinical staff, all staff that
support the service should be entered onto the roster’
6.5 Removal
Point deleted
7.8 Amendment
20 hours’ time owing reduced to 12 hours.
7.10 Amendment
Requirement to take time owing within three months and the right to
overtime removed.
Wording adjusted for clarification following comments by our
employees “Although the legislation allows staff to opt out” is added.
3.2 Amendment
4.3 Amendment
9.3
Deletion
Section 9 on Overtime
10.4 Deletion
The opt out to work more than 48 hours in the Trust is removed in line
with the Trust’s Quality of Service agenda
5
13.1 Amendment
Removed ‘as far as practicable’.
17. Deleted
Duplication of earlier detailed steps in the policy
General
Throughout the policy, duplication has been removed wherever
possible
ROSTERING PROCEDURE
1.
PRINCIPLES FOR PRODUCTION OF THE ROSTER
1.1 Managers should produce a duty roster at least 6 weeks in advance of the period to which
the roster relates, using Healthroster where implemented, and should ensure that the
roster reflects the following requirements:
2.

Minimum staffing levels (number of staff) and skill mix (experience of staff required
and gender) by shift and by day. This must be reviewed by the rostering manager
and their line manager regularly in the light of any significant change to the ward
function but at a minimum on an annual basis.

Rules relating to all types of leave, most importantly the Annual Leave, Study
Leave and Working Time Regulations

Rules relating to self rostering where appropriate.

Christmas off duty requirements in line with local procedures

Service requirements.

The maximum number of requests that can be considered for days off on any
single date.

The maximum number of requests a member of staff may make in any one rota
period

The maximum time ahead that requests can be entered, in order to ensure that
new employees who join the team have a fair chance of adding their requests.

The date by when requests have to be made for consideration within the roster

Staff changes such as retirements, resignations and the recruitment to
vacant posts
LOCAL PROCEDURES
2.1. This policy requires each department to produce local procedures or review any existing
procedures in consultation with the staff group. Local procedures must comply
7
with the principles and guidance set out in this policy and procedure. Where consensus
cannot be reached, the Trust Grievance Procedure should be followed.
2.2
Local procedures must be agreed with the manager or director, who must sign a copy.
The manager must then ensure that all staff are aware of these procedures,
understand and follow them. Copies must be available to local staff and included in
local induction.
2.3. All local procedures must be reviewed at least annually.
3.
ANNUAL LEAVE
3.1
All managers must draw up or review local procedures following consultation with their
staff team for the agreement to, and allocation of, annual leave in line with the Trust’s
leave policy.
The following minimum standards must be attained:







The maximum number of staff and/or staff groups that can be offered annual
leave at any one time, which must be based on skill mix and needs.
Fifty per cent of annual leave including time allowed for bank holiday should
normally be booked by the 31st May and the remainder by the 31st October.
Exceptions may be allowed in local procedures but they must not cause the
department to incur extra expenditure.
A maximum of 5 days may remain unallocated.
Both manager and staff member must ensure that all annual leave is taken within
the financial year
Annual leave must not be booked over the Christmas and New Year period until
the Manager is satisfied it is not going to require cover with temporary staff.
A minimum of 20 days annual leave must be taken as leave without the member
of staff working for this Trust or elsewhere.
3.2 The local procedure must state how annual leave is to be allocated when there is more
than one request for the same period. The manager should make their objective decision
following discussions with the staff concerned, taking all factors into account. A review of
the previous year’s allocation may be helpful to ensure a fair approach. The precise
factors should be agreed with the local staff team as part of the local procedure.
4. FLEXIBLE WORKING
4.1 The Trust fully supports flexible working and family friendly working but needs to ensure
safe levels of staffing and skill mix and therefore reserves the right to decline such
requests.
8
4.2 Staff who have an existing Flexible Working arrangement should discuss this with their
manager. Where they are not currently in writing, they should be agreed and recorded
using the Flexible Working form.
4.3 Flexible working arrangements must be managed and reviewed at 6 monthly intervals to
maximise the quality of patient care and reduce clinical and non-clinical risk.
4.4 In the event that agreement cannot be reached the member of staff is entitled to pursue
the matter by use of the Trust’s Grievance Procedure.
4.5 Where staff have a special arrangement to work they cannot work on the bank or for any
other employer at times covered by the arrangement, without first offering to work those
shifts as part of their normal working week, in their normal place of work.
4.6 Staff that have informed the ward that they cannot work specific dates or times should not
be working these on the bank. Managers should keep these flexible arrangements under
regular review with staff members at supervision and seek confirmation from the individual
that they are not working bank at the relevant times.
5.
PRODUCTION OF STAFF ROSTER
5.1 There must be a local procedure for allocating staff to the roster, which will be introduced
following consultation with staff. The following principles must be included:

All ward/department duties must commence on a Sunday.

Each area should work to an agreed funded establishment which is reviewed
annually or in line with reconfiguration.

Permanent staff’s contracted hours must be used to cover as many different shifts
as possible each day. This will help to ensure that bank and agency staff are
working with regular staff when used.

The roster must reflect the skill mix and number required and should not include
staff or skills over the required level where this may cause shortfalls on other
shifts or the need for temporary staff.

Senior staff should not be on duty together. Service Managers must generally
work weekdays 9am – 5pm but may occasionally work differently to support the
service, e.g. for the ad hoc support of permanent night staff.

The Roster must show who is in charge on each shift and who is providing
medication cover. These individuals must have the designated skills and
competencies to lead the service.
9

All shifts should be equitably allocated to all staff in accordance with their
contract of employment and the Trust’s policy on Flexible Working to ensure all
staff receive a fair allocation and variety of shifts. Managers must ensure that
normal hours do not exceed an average of 48 hours over a 17 week reference
period.

Any new requests for flexible working should be processed in accordance with the
Flexible Working Policy and the outcome recorded using the form provided within
this Policy.

Only once all permanent staff shifts have been allocated, should other shifts be
made available for bank coverage. The bank and agency protocol should then be
followed to fill any gaps in the roster.

Staff should not make more than 4 requests within a 28 day period pro rata for
part time unless there are exceptional circumstances. Managers should
endeavour to comply with all reasonable requests; however, this should not
require the use of agency staff. All staff must have equal access to requests for
particular shifts/time off.

Requests for popular periods (Bank Holidays and School Holidays) should be
considered equitably and a review of last year’s allocation undertaken where
necessary to ensure fairness.

Managers should be mindful of the need to assist staff with leave wherever
possible, whose religious festivals occur at different times of the year from the
eight national holidays.

All off duties should be composed to adequately cover requirements utilising
permanent staff proportionately across all shifts

Shifts given a high priority on Healthroster must be filled first, i.e. nights and
weekends. It should not be routine to use bank/agency permanently on night
shifts.

The relevant Service Managers will undertake the monitoring and approval of each
unit’s off duty upon completion, produce analysis reports, and approve all shifts
where temporary staff are requested.

If any of the staff are working non–standard shifts such as late starts, this should
be entered to avoid misinterpretation.

In addition to clinical staff, all staff that support the service should be entered onto
the roster.

In areas where the workload is known to vary over the week staff numbers and
skill mix should reflect this.
10
6.

Senior staff time will be distributed across different shifts.

Responsibility for the updating of establishments, as identified on Healthroster,
and the safe staffing of each ward lies with the Service Manager, even if she/he
does not undertake the task of producing the off duty roster.

Guidance can be found at Appendix 1
CHANGES TO ROSTER
6.1. Staff wishing to alter their roster should, in the first instance, attempt to exchange shifts
with other appropriate team members. Changes should be made within equal band and
with consideration to the overall skill mix of all shifts being changed.
6.2 All changes must follow the principles outlined above, be authorised by either the
manager or designated deputy, and should not result in overtime expenditure or use of
agency staff. Only in unforeseen circumstances can changes be made and
retrospectively approved by the manager or deputy.
6.3. No member of staff should be required to change their rota with less than 24 hours
notice. Any such change to the rota can only be made following discussion and
agreement with the member of staff involved. The manager should not seek to enforce
a change if this would cause disruption to prior commitments made by the member of
staff involved.
6.4 When there are unforeseen circumstances, i.e. a member of staff going off sick at short
notice, the manager may request a member of staff to agree to stay on and work
additional hours. See Section 7.
1.
UNSOCIAL HOURS / TIME OWING
7.1 Unsocial hours should be distributed evenly and fairly, in accordance with agreed
contractual restrictions.
7.2 Any time over/above shift times should be authorised by the relevant Matron and recorded
on Healthroster.
7.3 Any time claimed back, must be recorded and signed by the manager.
7.4 Every 8 weeks the Ward Manager must run a report using the ‘My staff hours’ report
available to ensure any staff hours that do not balance over a 4 week period are balanced
over an 8 week period.
7.5 Local procedures should be in place for the process of authorising time owing.
7.6 All time-owing/time in lieu must be agreed in advance where possible. Any accrued or
taken hours must be appropriately recorded.
11
7.7 Retrospective agreement will only be given where there was a clear and urgent need. In
either case the reasons must be recorded and signed by both the line manager and the
staff member concerned.
7.8 Managers must ensure that no more than 12 hours’ time owing either way is
accumulated. In the event of accumulating time owing in excess of 12 hours, this must
be authorised by the /operational manager during office hours or the first line on-call
manager out of hours and the additional hours taken back the following week.
7.9 Accumulated time-owing hours above 12 must be taken within 28 days of working the
additional hours and any difficulties in achieving this must be brought to the attention of
the Manager. Managers may not unreasonably refuse to allow time off in respect of time
owing. However, where this is unavoidable it will not result in any loss of hours. Managers
must confirm in writing the reasons for any decision made relating to this.
7.10. Booking of time-owing should follow the same principles as for annual leave in that it
should not incur unnecessary expenditure.
8.
UNEVEN WORKING PATTERNS
8.1. As stated in Sections 10.1 and 10.2 of the Agenda for Change Handbook, the standard or
contracted hours may be worked over any reference period, e.g. 150 hours over 4 weeks
or annualised hours, with due regard for compliance with employment legislation such as
the Working Time Regulations.
8.2. A record should be kept to ensure that this principle is correctly adhered to.
2.
WORKING TIME REGULATIONS/OPT OUT
9.1. See section 27 (Part 4) Employee Relations of AfC for Working Time Regulation
requirements. These should be complied with in addition to the requirements below.
9.2. It is the responsibility of ALL employees to ensure compliance with Working Time
Regulations.
9.3 Although the legislation allows staff to opt out, our Trust’s local arrangement requires
staff to abide by the 48 hour working week limit.
9.4 By local agreement, no member of staff shall work more than 48 hours in any 7-day
period. This total includes hours worked in all employment including bank, NHS
Professionals and agency, whether for the Trust or any other employer.
9.5 This requirement will also be placed upon all agencies providing staff to the Trust.
12
9.6 Under the WTR night staff cannot opt out of the 48hr 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.
10. IN WORK BREAKS
10.1 The Trust requires all staff to take a minimum of twenty minutes unpaid break during any
period of work in excess of 6 hours. During that break period they should be free to leave
the premises should they wish to do so.
10.2 Breaks must not be taken at the end of a shift, as their purpose is to provide rest time
during the shift.
10.3 In exceptional circumstances, following a risk assessment, if the member of staff is
required to remain available for immediate recall to work, this will be a paid break and the
finish time of the shift will not be extended by the length of the break.
10.4 In all cases where there is a paid break, a risk assessment must be included in the local
procedures. Where there is no risk assessment it will be assumed that staff are free to
leave the premises during their work break.
3.
WEEKLY REST PERIOD
11.1 As far as possible staff should be rostered so that their rest days are taken
consecutively. A rest day must be a minimum of 24 hours plus 11hours break between
shifts making a total of 35 hours. A 2 day rest must be 48 hours plus 11hrs making a
total of 59 hours.
11.2 Unless by special arrangement, no one should be rostered to work more than 6
consecutive days.
4.
SHIFT PATTERNS
12.1 11 hours must be allowed between shifts as far. This means that staff should not be
required
to
work
an
opposing
pattern
of
shifts.
For
example:
Late/Early/Late/Early/Late/Early. However, it is permissible to have one break that is less
than 11 hours in a run of shifts.
12.2 Night shifts should be kept together wherever possible. No more than 4 nights in a row
should be allocated to a staff member. There should be a minimum of 2 days off after a
period of night working.
12.3 All shifts longer than 6 hours must include a minimum 20 minute unpaid break. Shifts of 12
hours or more should include 60 minutes of unpaid breaks.
12.4 The Manager/Nurse in Charge has responsibility for ensuring that breaks are taken.
12.5 Staff should not work more than three consecutive weekends. Additional weekends off
can be rostered where ward requirements allow.
13
12.6 Weekend shifts are defined as Friday night, Saturday day or night, Sunday day or night.
12.7 Staff should work no more than a maximum of 5 consecutive standard day shifts. Staff
may specifically request to work more than this to a maximum of 6 days
13. LONG DAYS
13.1 Staff must not be rostered to work for any period longer than 13 hours.
13.2 Within the 13 hours there must be appropriate breaks of not less than 40 minutes.
13.3 The preferable number of consecutive 12-hour shifts (days or nights) recommended for
staff to work is 3. In exceptional circumstances, staff may work a maximum of 4.
5.
SLEEP-INS
14.1 Sleep-ins are subject to a separate agreement but should not breach the requirements of
the Working Time Regulations. Best practice would preclude a sleep-in being placed
between a late shift and an early or preceding an early shift.
6.
ADDITIONAL E-ROSTERING PRINCIPLES
15.1 This section details specific principles only available within the electronic rostering
system.
15.2 Healthroster provides the facility for staff to be rostered to an agreed duty requirement,
managing staff availability and allowing clear visibility of ward (staffing) levels.
15.3 It provides a facility for recording annual leave and sickness absence. Staff are also
provided with access to Healthroster by the associated Employee On Line facility to
request shifts and leave.
15.4 It is for use by the appropriate persons for creating and authorising rosters and recording
absences. The system has the facility to track and produce reports for absence, leave and
additional duties.
15.5 The E-rostering system will be accessible to Human Resource and Finance staff as
appropriate.
15.6 A Healthroster authorised user will be able to :
 Manage Rosters – creating and updating rosters and deleting rosters where they are
not required.
14
 Auto Assign Duties – When creating a new roster users must use Auto Roster
feature to assign duties to a roster. Auto Roster will automatically assign shiftsrespecting the rules, personal patterns and skill mix - to the available staff. Auto
roster will first assign Nights and weekends and after day shifts.
 Assign Duties Manually – Users must assign duties manually, including the
processes for swapping and combining duties, after the Auto Roster has
completed.
 Administer Rosters – once the roster has been published, the user must manage
the ongoing changes made to the roster. Examples of changes made to the roster
include the recording of “No Shows” (e.g. sickness/ last minute annual leave / carers
leave), cancelling duties, and the creation of additional duties.
15.7
Authorised users:
Roster Administrator - Ward Manager or Service Manager or Deputy Ward Manager or
admin and will be responsible for creating and updating the roster.
Roster Manager - Ward Manager or Service Manager and will be responsible for
reporting, partially approving and partially finalising the roster.
Roster Approver - Service Manager or Modern Matron or Associate Director and will be
responsible for reporting, fully approving and fully finalising the roster.
16.
STAFF REQUESTS
16.1
Staff will have access to the Employee on Line facility to make requests for shifts and
annual leave.
16.2
These requests will be considered in the light of requirements to a maximum of 4
requests per person within a 28 day period.
16.3
Leave arrangements are set out in the Leave (Paid and Unpaid) Policy and requests
for flexible working patterns will be considered in accordance with the Flexible Working
Policy.
16.4
Requests will be considered in the light of need. Staff should indicate if their request
is essential or desirable.
16.5 Application can be made for regular specific shifts or days off. These are known as
personal patterns. They must be agreed and reviewed quarterly by the Manager who
must take into account requirements and equity for other staff members before
agreeing to the request.
16.6
If annual leave is being taken during this time, off-duty requests should be pro rata.
16.7
Personal patterns are not to be considered as requests.
16.8
It cannot be assumed by staff that their requests will be accommodated. This includes
essential requests. The needs of the service must take priority. Staff should be
15
considerate of their colleagues and the requirement that they are fulfilling their share of
weekend and night shifts.
16.9
Requests from staff who typically make few requests, will be given higher priority by
Health Roster than requests from staff making numerous requests.
16.10 Where request forms are being used staff should be informed of the closing date and no
further requests will be accepted after this date. It is suggested this is 7 weeks prior to
the roster being worked.
16.11 If staff wish to change their rostered shift post publication a fair swap should be made
with another member of staff of the same grade that meets the Ward Manager’s
approval.
17.
PRODUCTION OF OFF DUTY ROSTERS
17.1
A table and flow chart of the process is attached at Appendix 3.
17.2
The publication of working rosters will take place according to the Roster Calendar
shown at Appendix 4.
1.
18.1
ROSTER VALIDATION AND APPROVAL
The following processes apply:

Rosters to be published 6 weeks before off duty commences;

Shifts to have an agreed total number of staff and skill mix as shown by the
establishment templates;

Creation of the off duty should be within budget for the ward;

All staff to have at least one weekend off in a 4 week period;

The number of unfilled shifts that occur on nights and weekends is 0%;

Only 5 standard shifts days/nights should be worked consecutively and no more
than a maximum of 7, if specifically requested;

Use ‘Approve and Analyse’ when checking the Roster Effectiveness Indicators.
There should be no hours carried forward.
Check the Roster Analyser Summary Tab for the following:
Roster Effectiveness Indicators
 Roster unfilled – this should be no more than 20%
 Over Contracted Hours - this should be as near to 0 as possible
 Lost Contracted Hours – this should be as near to 0 as possible
 Additional Shifts – why have they been used
 Wrong grade type – why have they been used
16
Fairness and Safety Indicators

Requests – no more than 4 agreed within the policy according to hours worked.

Shifts with Warnings

Check that the policy rules are not being broken by viewing my Roster Stats and
reviewing the Rule/Violation column

If rules are being broken, contact the Rostering Administrator for further details

Shifts without Charge Cover – this should be 0, all shifts must have an identified
team leader

Annual Leave is evenly distributed and is consistent with the % calculated for the
ward

Mandatory Unfilled Shifts, Sunday/Bank Holiday should be lowest figures
Check Effectiveness Tab for:

Requirements v Availability

Staff Unavailability – there should be 0 warnings

Filled Shifts – there should be 0 Optional and Additional Shifts unless agreed prior
to the creation of the roster

Check that Personal Patterns are still valid by reviewing flexible working
arrangements every 3 months.
18.2 If a roster is rejected an email should be sent to the Roster Manager indicating why it was
rejected.
18.3 A completed roster must be reviewed by the Roster Approver responsible manager and
approved prior to being published.
18.4 The purpose of the review is to identify potentially unsafe shifts, shifts for which temporary
staff cover is planned and other possible options discussed and any agreed parameters
that have been exceeded.
18.5 Once the roster is reviewed it should be fully approved – Approved by the Roster Manager
and by the Roster Approver. Fully Approved rosters are automatically published and
therefore available to Staff via Employee on-line.
18.6 Once the roster has been fully approved it should be printed and made available for
viewing by all applicable staff at least 3 weeks prior to its effective date.
18.7 Any changes made after the roster has been approved must be clearly marked for audit
purposes. Staff will be asked to sign a copy of the agreed roster in advance and will be
asked to make notification in writing of any eventual changes to working patterns.
17
19. KEY PERFORMANCE INDICATORS
19.1 The following Key Performance Indicators will be monitored by Associate Directors and
Roster Approver at Business Meetings, using Analysis Reports (Appendix 5):







% of lost contracted hours
% of over contracted hours
% of additional duties
% of unfilled duties
% of non-effective working days,
Details of vacant shifts by temporary staff cost category
Non effective working days - Staff’s unavailability during the 4 week roster
period is broken down in to the following categories. The total percentage of
these should equate to the overhead that is built in to each establishment.
For example the headroom, currently set for 24/7 services at 23%,
comprises:
Annual Leave
16%
Study Days
2%
Leave (Sickness, Maternity, other) 5%





Requests - numbers of requested shifts compared with Trust policy
Contracted staff by WTE
Number of bank requests to total bank hours worked.
Number of vacancies
Number of bank requests on weekend and night shifts
19.2 Rosters that fall outside set parameters may be rejected.
20. BOOKING OF TEMPORARY STAFF
20.1 Temporary staff shifts will only be approved if requests meet the following criteria:

within budget

within existing vacancies

to cover either band 5 or band 2 roles

to cover unpaid maternity leave
20.2 Temporary staff required outside these parameters must be authorised by the Matron,
Associate Director or on call manager.
18
20.3 Temporary staff cannot be used to take charge of departments unless they are known to
the department, have been assessed as competent to do so, and are willing to take
charge. This must be approved by the Matron, Associate Director or on call manager.
20.4 Staff who have been off sick in the previous 7 days must not undertake bank work for a
period of 5 working days from their date of return after sick leave.
20.5 Night and weekend shifts must be covered by substantive staff whenever possible, without
imposing unreasonable strain on substantive staff.
20.6 Study leave should not be covered by temporary staff.
21. CHANGES TO PUBLISHED ROSTERS
21.1 The following processes apply:

Unit managers will amend rosters to reflect actual shifts worked i.e. changes due
to sickness, no shows and additional shifts.

The actual worked roster must be updated on Health Roster by 12:00 every day.

Shift changes should be kept to a minimum.

In the first instance, staff wishing to alter their roster should attempt to exchange
shifts with appropriate team members. Changes should be made with an equal
grade, and with consideration for the overall skill mix of all shifts being changed.

All changes must follow the procedure, be authorised by either the manager or
designated deputy and should not result in overtime expenditure or use of
temporary workers. Changes to the roster sheets should only be made by the
manager or their deputy except in urgent, unforeseen circumstances and these
must be retrospectively approved by the manager or deputy.

Except in instances of operational necessity, managers should provide at least
24 hours notice of a change of roster. However in discussion and agreement with
a member of staff the manager may request a change of rota with less notice
e.g. to cover for a member of staff going off sick.
22. ANNUAL LEAVE
22.1 The following processes apply:
• Annual leave must be booked within the context of the Trust’s Leave Policy.

The Manager or designated deputy is responsible for approving all annual leave
and for ensuring that annual leave is taken in accordance with this policy.

Managers should ensure that staff are aware of local procedures for the
allocation and agreement of annual leave.
19
 If a member of staff needs to delay or amend an annual leave booking this will be
considered taking into account local needs, provided it does not incur extra
expenditure.
 Managers are responsible for calculating the number of qualified and unqualified
nurses who must take annual leave in any one week. This number must be made
explicit and adhered to in order that the workforce is appropriately used to cover
needs.
 Annual leave parameters are expressed as percentages in the Healthroster
reporting system and managers are responsible for ensuring that the total
amount of leave taken by staff each week falls within the band of a minimum
of 11% to a maximum of 17%. Should this number not be met, by way of
requests, the Manager will allocate leave following discussions with the staff
concerned. This is a key performance indicator for assessing effective use of
the workforce and will be monitored regularly by Associate Directors and senior
management.
 The Employee Online system tool is available to enable staff to book annual
leave and should be used to enable effective collation of annual leave
information. Managers may refer to e-rostering annual leave records when
signing annual leave forms to ratify leave taken which are in the Leave Policy.
 Roster Managers must liaise with the Rostering Team when there are staff
under term time contract working at the unit in order to set special parameters
for them.
23.
STUDY LEAVE
23.1 The following processes apply:
 Study leave will be assigned in line with the Leave Policy.
 Managers should ensure that mandatory training is balanced throughout the year
and assigned per rota.
24.
SICKNESS
Please see Absence Management Policy and Procedure (SABP/Workforce/0033)
1.
ELECTRONIC STAFF RECORD (ESR)
ESR remains the master system for recording of all staff data.
20
21
Appendix 1
Guidance for Producing a Roster
Process
Use the Trust standard roster dates
Close the roster to requests and input / approve requests and add /
approve any non-effective periods.
Run the autoroster (this will try to fill in the expensive / difficult to fill
shifts (e.g. nights / weekends) first and create a balance).
Ensure that there is a nurse in charge for each shift, manually move
shifts as necessary.
Fill remaining staff hours with vacant shifts, adjusting duty times
where necessary.
Review roster analysis data, ensure good balance of staff across 4
week period, all staff hours are used, charge cover allocated and
there is an even balance of popular and unpopular shifts amongst
substantive staff. Staff unavailability should be within the
specified parameters, if it is not the roster should be reviewed
and amendments made before reviewing the analysis data.
Approve the roster and inform Roster Approver (Matron/Service
Manager/AD) that the roster is ready to be fully approved.
Roster Approver review analysis data, if there are gaps in the roster
try to cover them by moving nurses or responsibilities between teams
/ wards.
Once approved by Roster Approver the roster is automatically
publish in Employee On-line. It should also be printed, including the
agreed vacant shifts to be filled by Momentum.
If there are still gaps in the roster, plan to fill them with temporary
staff or by using supernumerary staff e.g. prioritise workload or
consider moving less urgent tasks to another shift and/or make best
use of supernumerary staff available.
If temporary staff are necessary, ensure you are rostering them for
the cheapest possible shift, length of time and grade.
Inform Momentum of likely temporary staff requirements as soon as
possible.
Responsibility
Roster Administrator
Roster Administrator
Roster Administrator
Roster Administrator
Roster Administrator
Roster Manager
Roster Approver
/
Roster Manager
Roster Approver
Roster Administrator
Roster Manager
Roster Manager
Roster Approver
Roster Manager
Roster Approver
/
/
22
Appendix 2
Analyse, approve and
publish roster
Analyse roster to assess
effectiveness, make relevant
changes to ensure within
defined parameters e.g.
unavailability and approve.
Pass roster approved by
Roster Manager to Roster
Approver for 2nd level
analysis and approval.
Manage roster Enter
changes on to
Healthroster as occur
e.g. shift swaps,
sickness, leave, and
time owing.
Produce request
sheet
Request sheet
available for staff to
complete, with a
stated closing date
Week 3
Week 1
Week 4
Week 4
Produce
roster
Close requests, produce
roster, using all available
hours and filling most
expensive shifts first.
Week 4-12
Fill shortfalls
Send vacant shifts to be filled to bank
Make amendments to roster e.g. shift
swaps, leave etc.
23
Appendix 3
Electronic Rostering Calendar
Rostering units using the MAPS software will work to a timetable. The time table will consist of
series of 4 and 5 week rosters timed to coincide with payroll deadlines. Each roster cycle will
have a schedule based on Trust policy.
Schedule
Schedule is shown based on roster start date, so that for example, second level approval and
publish to staff happen at week -6 and finalise roster for payroll happens at week +5 or +6
depending on length of roster.
Schedule Responsibility
Activity
Example
Action
Week
Start creating
-9
Roster Administrator 24/08/2008
roster
Close for
-8
Roster Administrator 31/08/2008
requests
Roster
-7
Roster Manager
07/09/2008
Manager
approval
Roster
-6
Roster Approver
14/09/2008
Approver
approval
Publish to
-6
Roster
14/09/2008 Six weeks
before start
Manager/Roster
staff
Approver
date
Roster start
0
26/10/2008
date
Roster end
29/11/2008
+4/5
date
Update for
Roster Administrator
Maintain
absences
roster
and changes
03/11/2008
Finalise
+5/6
Roster
Manager/Roster
roster
Administrator
email reports
Roster
Administrator/Roster
Manager
+6.5/7.5
Roster Manager
05/11/2008
Payroll
and/or Roster
deadline
Approver
24
Appendix 4
Report Master
Group
Roster Reports
Report name
Additional duties
Cancelled duties
Key Performance
Indicators
Roster Effectiveness by
grade type
Roster Efficiency
Annual report
Staff Unsocial hours
Unfilled duties
Unfilled duties projected
bank costs
Details of report
If duties have been
allocated over
agreed demand
Duties that have been
cancelled
High level report,
containing additional
duties, unfilled duties and
unavailability
% of lost/over contracted
hours, vacant shifts
Fairness and efficiency
graphs
Allocation of duties by
person, number of
unsocial shifts allocated
Number of vacant shifts
(also in hours)
Based on number of
vacant shifts and local
NHSP rates
Usage of report
Who should access
General usage
Roster Approver / Roster
Manager/ADO
General usage
Roster Approver / Roster
Manager / ADO
Balance Scorecard
Roster Approver / Roster
Manager/ADOr
General usage
Roster Approver / Roster
Manager /ADO
General usage
Roster Approver / Roster
Administrator / ADO
General usage
Roster Approver / Roster
Manager / ADO / HR
General usage
Finance
management
Roster Approver / Roster
Manager / ADO
Roster Approver / Roster
Manager /
ADO/Accountant
25
Report Master
Group
Sickness Reports
Report name
Details of report
Usage of report
Who should access
Sickness report by day
of week
Sickness report by day
of week and person
Sickness trends for wards
/ individuals
As above with further
detail
Overall % based on
registered / unregistered
grading
Attendance
management
Attendance
management
HR / ADO/ Roster
Manager/Roster Approver
HR / ADO /Roster
Manager/Roster Approver
Attendance
management
HR / ADO /Roster
Manager/Roster Approver
Attendance
management
Attendance
management
Attendance
management
Balance Scorecard
and Workforce
management
Workforce
management
Workforce
management
HR / ADO /Roster
Manager/Roster Approver
HR / ADO /Roster
Manager/Roster Approver
HR / ADO /Roster
Manager/Roster Approver
Sickness report by
grade type
Unavailability
reports
Sickness report by
person
Sickness report by
person and reason
Sickness report by
reason
Unavailability
breakdown by
Grade type
Unavailability
breakdown by Person
Unavailability
breakdown by Week
Sickness for each person
Sickness for each person
with reason (as on FINS)
Overall sickness by
reason
Details of total%
unavailability e.g.
sickness, maternity, leave
As above, by person
As above, by week
HR / ADO /Roster
Manager/Roster Approver
HR / ADO/Roster
Manager/Roster Approver
HR / ADO /Roster
Manager/Roster Approver
26
Equality Analysis (EA’s)
(Formally known as Equality Impact Assessments)
Introduction
The equality duty now makes it clear that public authorities are expected to consider the need to remove or
minimise disadvantage or to meet particular needs, such as through providing services for particular
groups. Public authorities are also required to think about how to encourage participation in public life. The
good relations duty now applies across all of the protected characteristics. In particular, public authorities
must have due regard to the need to tackle prejudice and promote understanding between people who
share a protected characteristic and those who do not.
Equality Analysis starts prior to policy/function development or at the early stages of a review. It is not
a one-off exercise, it is ongoing and cyclical and it enables equality considerations to be taken into
account before a decision is made.
Equality Analysis of proposed policies will involve considering their likely or possible effects in advance of
implementation. It will also involve monitoring what actually happens in practice. Waiting for information on
the actual effects will risk leaving it too late for your Equality Analysis to be able to inform decision-making.
Be wary of general conclusions – it is not acceptable to simply conclude that a policy will universally benefit
all and therefore the protected groups will automatically benefit, without having evidence to support that
conclusion.
When you decide that a policy is not relevant to equality, you will need to document this, along with the
reasons and the information that you used to make this decision. A simple statement of no relevance to
equality without any supporting information is not likely to be sufficient, nor is a statement that no
information is available. This is particularly important where you are not familiar with methods of equality
analysis or with equality concerns, as you could inadvertently overlook issues that could indicate relevance
to equality. This could leave you vulnerable to legal challenge.
This is a summary of the general duty and how they apply to each protected characteristic:
27
General equality duty 
Protected Characteristic 
Age
Disability
Sex
Race
Religion
Sexual orientation
Gender reassignment
To eliminate unlawful
discrimination,
harassment and
victimisation
To advance equality of
opportunity between
different groups
V
V
-V
-V
-V
-V
-V
V
V
-V
-V
-V
-V
-V
To foster good
relations between
different groups
V
V
-V
-V
-V
-V
-V
-
-
-
-
-
-
V
Marriage / civil partnership
-
Pregnancy / maternity
-
V
X
X
V
-
-
V
Please refer to Equality analysis and the Equality Duty: A guide for public authorities for more information.
Who should be present at the Screening of an Equality Analysis?
 A diverse group of people must be in attendance of the Screening; this must involve the policy author, Staff, people who use
services, Carers and other users of the Trust services if they are affected by the policy. For example, if the policy has a
potential affect on just the staff, some staff must be invited to provide their views on the possible impact.
 A Screening should be carried out BEFORE the policy is placed out for consultation. At this stage a Full Equality Analysis
could be identified. If a Full Equality Analysis is required, the outcomes should be carried over into the Action Plan.
 After the consultation deadline, all the data must be summarised and attached to the Screening and/or with Full Equality
Analysis as a form of evidence.
Equality Analysis (EA’s) Screening Tool
28
To be completed for all new proposals or reviews of existing policies, procedures, plans, services or functions. This screening should be undertaken at as
an early a stage as possible, in order to address any equality issues which are identified before consultation/approval.
Name of Initiative: Rostering and Working Time Regulations Policy and Procedure
Unit/Department:
Date: 3rd January 2013
Time: From: 11:00
To: 13:00
Briefly describe the purpose of the Policy/Function: To provide guidance on procedures for producing staff rosters, either
electronically or manually, that are compliant with the Working Time Regulations
Who is it intended to benefit from this Policy/Function? All Staff
What results are intended? Legally compliant and efficient deployment of staff and resources by effectively rostering staff
Why is it needed? See above
Considered all Consultation feedback if this Equality Analysis is carried out after the consultation. (Pre- Consultation)
What was the length of the Consultation Period:
(From:
To:
)
What was the consultation feedback and actions taken:
EA’s group: Identify a lead. Involve and consult stakeholders and people with expertise in the different equality areas –
get a balance of skills and experience including people who use services and community members.
Name
Henry Oblie
Chris Barker
Susannah Leyden
Colin Archer
Brian Palmer
Andy Erskine
Title
BME Lead
Staffside secretary
HRBP
AD
AD Specialist Services
Service Director LD
29
Helen Wood
Dennis Hockey
Please ensure all
the Trust website
Consider the potential
effects on protected
characteristics
(PC’s).
Age
Disability
Sex
AD WAA
HRBP
parties present are aware that this document will be published on
and is accessible to members of public.
‘Analysis of the effects on equality’ is intended to focus more attention on the quality of
the analysis and how it is used in decision-making, and less on the production of a
document. You need to analyse the effect on equality for all of the protected characteristics,
and all aims of the general equality duty as set out below.
E q u a l i t y A c t 2 0 1 0 G e n e r a l D u t y .
Advance equality of
Eliminate unlawful
Foster good relations between
opportunity between people
discrimination, Harassment
people who share a PC and
who share a PC and those
and Victimisation
those who do not.
who do not.
Equality is promoted by the
No evidence to believe that
The use of E-Rostering
use of E-Rostering as autoany group will be adversely
supplemented by appropriate
rostering
ensures
a
affected by the use of this
local procedures will promote
transparent and equitable
policy howevergood relationships between
allocation of shifts
Reference relevant H&S
people who share a PC and
policies regarding safe
do not.
working environment – Risk
Assessments
Equality is promoted by the
20.4 could have adverse
use of E-Rostering as autoimpact on staff with known
rostering ensures a
disability requiring time off for
transparent and equitable
treatment
allocation of shifts
This policy does not adversely Equality is promoted by the
affect either gender however
use of E-Rostering as autolocal procedures should
rostering ensures a
ensure gender mix
transparent and equitable
requirements are considered – allocation of shifts
with appropriate reference to
relevant policies e.g. Intimate
30
Race
Care .
No evidence to believe that
any group will be adversely
affected by the use of this
policy
Religion and Belief
References Christmas but not
other religious festivals.
Sexual Orientation
No evidence to believe that
any group will be adversely
affected by the use of this
policy
Pregnancy and
maternity
20.4 could have adverse
impact on pregnant staff
requiring time off for treatment
Gender
Reassignment
Marriage/ Civil
Partnership
Reference relevant H&S
policies regarding safe
working environment – Risk
Assessments
20.4 could have adverse
impact on staff requiring time
off for treatment.
No evidence to believe that
any group will be adversely
affected by the use of this
policy
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
N/A
N/A
31
Carers
Human Rights
implications if
relevant
Other equality
issues –please state
HR and workforce
issues/implications
if relevant
No evidence to believe that
any group will be adversely
affected by the use of this
policy
Equality is promoted by the
use of E-Rostering as autorostering ensures a
transparent and equitable
allocation of shifts
Develop a template to assist in the production of local procedures.
Explore the potential to develop link between e-rostering and NHSP
With reference to 20.4 There is a need for the manager to consult with HR to ensure that
reasonable adjustments are considered as necessary for individuals affected
Evidence used in the .
decision-making.
If the responses affect any of the protected characteristics then please complete the Action Plan to avoid or mitigate the
potential adverse effects on equality.
Decision to proceed (please circle yes or no):
Yes: We have decided to proceed to a full EA Action plan
No : We have decided that it is not necessary to carryout a full EA Action plan
If no, briefly summarise reasons and the evidence for this decision:
Signed by responsible Director or Associate Director: _ ______
Name:
Directorate:
Please send a copy of all completed screening and full EA’s/Action Plan to: Diversity & Inclusion Dept, Ramsay House, West
Park, Epsom, Surrey KT19 8PB. If you require any assistance, please call 01372 20 5871
32
Equality Analysis (EA’s)
Action plan
Issue/change sought
Evidence found in the
screening of any
issues that may have
an effect on Equality
for different PC’S
Action (SMART
targets)
E.g. Risk register/
policy Change/
training opportunities/
service plans
Expected Outcome
Milestones and key
deliverables. How
these will be
addressed?
By who
/Lead/Directorate
Who is responsible for
taking forward the
outcomes
Target dates
References Christmas
but not other religious
festivals – Make
statement broader to
encompass all bank
holidays/public
holidays other
religious festivals
Local procedures
should reflect this
Team Manager’s line
manager should
check
AD/Director
Change wording in
policy post
consultation
Potential for local
procedures that do not
pay sufficient regard to
PC’s when
undertaking rostering
in a particular service.
Develop a template to
assist in the
production of local
procedures.
33
The action plan should provide a focused set of priorities for improvement. It should only include the key activities that are likely
To increase the
In accordance with roll
out programme.
number of services
using E-Rostering
34