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Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 1 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’
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 2 of 41
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
Chief Nurse including Midwifery and Allied Health Professionals
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
Chief Nurse including Midwifery and Allied Health Professionals
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
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 3 of 41
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
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 4 of 41
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
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 5 of 41
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.
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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.
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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.
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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.
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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.
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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.
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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
31.25 hours 5 requests
25 hours 4 requests
18.75 hours 3 requests
12.5 hours 2 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.
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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.
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 13 of 41
- 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.
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 14 of 41
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.
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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.
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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:-
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 17 of 41
- 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.
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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.
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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
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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
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 21 of 41
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
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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.
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 23 of 41
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
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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%
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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
Deputy Director of Nursing
Service Directors
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• 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.
Nursing Temporary Staffing Standard Operational Procedure
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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.
Nursing Temporary Staffing Standard Operational Procedure
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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
Nursing Temporary Staffing Standard Operational Procedure
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 29 of 41
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
Nursing Temporary Staffing Standard Operational Procedure
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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
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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.
Deputy Director of Nursing
Head of Nursing
Matron
Ward to
Board
and
Board to
Ward
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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
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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
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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
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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
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 36 of 41
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)
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 37 of 41
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 £
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 38 of 41
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:
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 39 of 41
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)
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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?
Rostering Policy for all Clinical Staff (excluding Doctors, Dentists and Ambulance) Version No. 3 Page 41 of 41
Scheduled for Full Impact Assessment Date: 02/10/18
Name of persons/group completing the full assessment.
Date Initial Screening completed