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Non-Medical Staff Rostering Policy
Approved By: Policy and Guideline Committee
Date of Original 31 May 2013
Approval:
Trust Reference: B5/2013
Version: V4
Supersedes: Nursing or Ward / Unit Staff Rostering Policy
Trust Lead: Maria McAuley- Assistant Chief Nurse
Board Director
Julie Smith – Chief Nurse
Lead:
Date of Latest Extended date of October 2020 agreed by PGC on
Approval 21.2.20
Next Review Date: October 2020
CONTENTS
Section Page
1 Introduction and Overview 3
2 Policy Scope – Who the Policy applies to and any specific exemptions 3
3 Definitions and Abbreviations 3
4 Roles- Who Does What 6
5 Policy Implementation and Associated Documents-What needs to be 9
done.
6 Education and Training 19
7 Process for Monitoring Compliance 20
8 Equality Impact Assessment 20
9 Supporting References, Evidence Base and Related Policies 20
10 Process for Version Control, Document Archiving and Review 21
Appendices Page
1 Nursing and Midwifery Addendum 22
2 Theatre Areas Addendum 24
3 Annual Leave Algorithmn 26
4 Electronic Rostering Calendar 27
5 Recommended Autoroster Process 28
6 Checklist for validating and approving rosters 29
7 Working Time Directive Rules 30
8 Rostering Key Performance Indicators 31
9 RosterPerform management process 33
10 Electronic Payroll process 34
REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW
V4 – September 2015 – Review of V3
Main updates to the policy are within sections 5.9, 6.7,6.10, 6.11, 6.13 and 7.4 with
additional clarification and examples given where applicable.
New addendum two, updates to addendum one
New appendices: one, two, five, six, seven, eight. Updates to appendix 3
V3 - April 2014 , V2 - July 2013 , V1 – March 2013
KEY WORDS
Electronic Rostering
BankStaff Employee On-line Workforce
Annual leave Hours Rosters
SafeCare ESRGo
Policy for Non Medical Staff Rostering Page 2 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents1 INTRODUCTION AND OVERVIEW
1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trusts
(hereafter referred to as UHL) Policy and Procedures for the introduction and
implementation of an Electronic Rostering system. The purpose of this policy is
to ensure that the Trust provides clear, consistent information and procedures for
the production of staff rosters
1.2 UHL NHS Trust recognises the value of its workforce and is committed to
supporting staff to provide high quality patient care. Whilst acknowledging the
need to balance the effective provision of service with supporting staff to achieve
an appropriate work life balance, it is recognised that the Trust needs to be able
to respond to changing service requirements. A flexible, efficient and robust
rostering system is required to achieve this objective.
1.3 Electronic Rostering is a computerised system that has been specifically
designed to roster staff to an agreed duty requirement.
2 POLICY SCOPE
2.1 This policy has been developed to be used in conjunction with Manual Rostering
and the Electronic Rostering system and is for use by all areas and non medical
staff groups across all three sites within UHL who are utilising the Electronic
Rostering system.
2.2 As the project is rolled out to all staff groups this policy will have specific
addendums inserted to reflect the demand within these groups with agreement
from Staff Side.
2.3 This policy is to be used in conjunction with a number of Human Resource
policies/procedures, listed in section 11
3 DEFINITIONS AND ABBREVIATIONS
Electronic Rostering
A suite of computerised software programmes that will produce staffing rosters, reports,
manage temporary staffing requirements, pay staff and allow all staff access to their
work patterns electronically.
Electronic Rostering System
Electronic Rostering System is a web based system to support the effective allocation
and management of staff, based on one view of all staff groups and all staff types,
whether substantive, bank or agency.
Employee Online (EOL)
A web based system to allow staff to request Annual leave and work requests from
anywhere with access to the internet. Staff can view their own rosters / timesheets and
if appropriate book into bank shifts.
Shift
A period of contracted work that contributes to an indivduals contracted hours.
Electronic Rostering Reporting Software
Page 3 of 34
Policy for Non Medical Staff Rostering
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: July 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsAn electronic reporting system that takes the information from Electronic Rostering
System to enable the Trust to review, report and manage staffing behaviour through a
series of management dashboards and reports.
BankStaff
The Staff Bank supplies temporary staffing to areas within the Trust. The BankStaff
product links with Electronic Rostering System and Employee Online to support an
efficient and safe process to monitor and fill vacant shifts within the organisation.
Clinical Activity Management (CAM) Electronic Rostering System Medics
A web based system that enables the managing and maintenance of medical staff
schedules.
SafeCare
A system that allows nursing staff to capture actual patient numbers by acuity and
dependency and to see if their staffing levels match this demand.
Electronic Rostering Team (Electronic Rostering Team)
The Electronic Rostering Team within the UHL Trust to support software usage and
assist end users in understanding the system to improve roster performance and staff
utilisation across the Trust.
Electronic Staff Record (ESR)
The Electronic Staff Record or ESR is an Oracle-based human resources and payroll
database system currently used by the National Health Service (NHS) in England and
Wales to manage the payroll for millions of NHS staff members. The Electronic Staff
Record application is managed by McKesson Corporation for the NHS and is the Master
Database for staff records. Not to be confused with Electronic Rostering.
Roster
A printed or electronic four week schedule identifying when and the times of work
patterns for staff in order to provide a safe and efficient service
Roster Calendar
A set schedule of deadlines for when Rosters should be opened and closed to requests
and for when approved rosters will be available for view in Employee Online – Appendix
2
KPI (Key Performance Indicators)
A variety of measures within the Electronic Rostering systems to assist managers in
reviewing the performance of their rosters in regards to safety, efficiency, budget,
availability and fairness
Demand Template
The roster setup that comprises of the number of shifts by type/times/skills/staff grade
that is required to deliver the service within the department.
Roster Period
A time frame of normally 4 weeks that is rostered.
Roster Bar
The purple roster bar in Electronic Rostering System indicates a loaded demand
template that covers a roster period.
Partial Approval
Policy for Non Medical Staff Rostering Page 4 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsThe first level of approval usually completed by the ward/department manager once the
roster creation process is completed. This indicates that the ward/department manager
is saying the roster is fit to work.
Full Approval
The second level approval usually completed by the Matron/Service Manager upon
notification that the first level approval has been completed. This indicates that the
Matron/Service Manager agrees that the roster is fit to be worked.
Finalisation
This is the process of locking down shifts for submission to payroll; a finalised duty has
a padlock on it.
Working Time Directive (WTD)
The Working Time Regulations (1998) aim to protect all workers from the risks of
working long hours, without appropriate rest periods, which could affect their health and
safety.
Rules
A set of principles guiding the process of allocating duties and unavailability’s on a
particular area’s roster.
Personal Patterns
Were members of staff work the same set shift/day off pattern throughout the working
week/s, as part of a formal agreement.
Restrictions
Limit and control the hours and days that a member of staff is available to work, as part
of a formal agreement.
Requests
Staff asking for specific shifts/duties and/or days off on the roster
AutoRoster
The process by which Electronic Rostering System automatically assigns shifts to staff
on a roster.
Formal Flexible Work Agreement (FWA)
This is an agreement to allow an employee to work in a way that suits their needs, the
agreement should be reviewed annually.
Management of Change (MOC)
The process of bringing change to a department, with regards to their staffing, shifts and
practices.
Unavailability
This is anything that is not your normal working day, e.g. annual leave, study and
sickness
Temporary Staffing
An employment situation where the working arrangement is limited to a certain period of
time based on the service demand of the employer, e.g those without a contract of
employment – bank staff, agency staff.
Vacant Duties
Policy for Non Medical Staff Rostering Page 5 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsThe red shifts that are in the demand section of the roster and are yet to be assigned to
staff and/or send to bank
Acuity
Refers to how ill the patient is, their increased risk of clinical deterioration and how
complex their care needs are and the corresponding nursing workload required to
explain staffing decisions, and to aid in long-range projection of staffing and budget.
Establishment
The number of staffing by grade funded to work in a particular ward, department or
hospital to deliver the service. This includes all staff in post, as well as unfilled
vacancies or vacancies being covered by temporary staff. Staffing establishments are
usually expressed in number of whole time equivalents.
Headroom
The number of staff needed to cover the all shifts to include an extra allowance to cover
absence of all kinds including leave / absence / study. The UHL Trust headroom is 23%.
ESR Go
An electronic system that links Electronic Rostering System with ESR to enable staff
changes to sync across automatically into Electronic Rostering System when made in
ESR.
WTE (Whole Time Equivalent)
It is a measure of staffing numbers, taking into account full and part-time working.
These measures are not the same as headcount or the actual number of people
employed.
4 ROLES
4.1 Executive Lead – Chief Nurse is accountable to the Trust Board for ensuring
Trust wide compliance with the policy. Monitoring and actions of compliance are
reviewed by the Workforce Board and reported to the Executive Lead.
4.2 Electronic Rostering Lead is responsible for the day to day management of the
Electronic Rostering system. Ensuring users can access and use the system.
Monitoring and review of staff utilisation and dissemination of workforce
information across the organisation.
4.3 Electronic Rostering Team
The Electronic Rostering Team are responsible for the implementation of
Electronic Rostering and ensuring that Electronic Rostering can be sustained
once implementation is complete and are committed to:
Deliver training to each budget holder to enable a roster to be created and
maintained through follow up support for 2 rosters post training.
Monitoring and reporting of all live rosters to budget holders, finance, HR, CMG
Leads and Exec Team.
Collaborative working with CMG budget holders to meet the project aims.
Provision and maintenance of personal Employee on Line accounts for all UHL
staff.
Support desk provision for all staff 5 days a week.
Implementation and management of Temporary Staffing Software.
Policy for Non Medical Staff Rostering Page 6 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsElectronic Rostering System Medics and Live payroll interface.
4.4 Workforce and Organisational Development Team and HR Generalist Team
4.4.1 To support the implementation of Electronic Rostering by reviewing the impact of
the system on roles and responsibilities of staff, to ensure all changes are
managed and consulted with staff and Staff Side. Trust policies, procedures and
job descriptions are updated to reflect those changes.
4.4.2 Provision of ESR master data to agreed timescales to be imported into the
system ensuring the data is current and most relevant.
4.4.3 The management of electronic payroll files from Electronic Rostering System to
the pay provider.
4.4.4 Provision of Electronic Rostering data as and when requested by Staff Side
colleagues in relation to active investigations.
4.5 Finance Team
To work with budget holders and finance leads to check and use the data within
the Electronic Rostering reporting software to improve workforce utilisation,
temporary staffing and budget management.
4.6 Exec Team/CMG Head of Operations /Heads of Nursing/ CMG Directors
4.6.1 Responsible for ensuring policy implementation and compliance in each Clinical
Management Group to ensure the workforce is utilised appropriately.
4.6.2 Any additions to templates regarding the increase of budgets and WTE must be
approved by Head of Nursing / Head of Operations.
4.6.3 To confirm expectations and standards through the utilisation of Electronic
Rostering Reporting Software in relation to using the data produced from the
system to inform and manage workforce planning.
4.7 Heads of Nursing/Head of Operations
4.7.1 Responsible for ensuring policy implementation and compliance in each Clinical
Management Group to achieve the identified Key Performance Indicators by
reviewing the data from Electronic Rostering Reporting Software and data
provided in CMG packs by the Electronic Rostering team, to celebrate areas of
success and challenge areas where improvement is required.
4.7.2 To ensure Managers that have not met the Key Performance Indicators after
receiving support and guidance from their Matron / General Managers and the
Electronic Rostering team to improve (Refer to Appendix 7 – Electronic Rostering
Reporting Software Management Process) are formally invited to a Confirm and
Challenge meeting in order to discuss. At the discretion of Clinical Management
Group further investigation may lead to the instigation of the Improving
Performance (Capability) Procedure or the Disciplinary Policy and Procedure.
4.7.3 Responsibility for reviewing and updating of establishments and the safe staffing
of each ward/department lies with Heads of Nursing/Head of
Operations/Matrons. The Electronic Rostering team must be notified of any
changes to budget / establishment, so these changes can be reflected in
Electronic Rostering System.
4.8 Matrons / General Managers
Policy for Non Medical Staff Rostering Page 7 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents4.8.1 Responsible for ensuring policy implementation and compliance in their area of
responsibility within their Clinical Management Group to achieve the identified
Key Performance Indicators.
4.8.2 To check each planned four week roster in conjunction with the Rostering
calendar using the Roster Analyser feature within Electronic Rostering System.
To ensure safe and effective utilisation of staff within budget, quality and safety
limits before final approval of planned rosters.
4.8.3 To ensure Managers in their area of responsibility that have not met the Key
Performance Indicators are provided with support and guidance in producing an
action plan to enable them to improve. Additional support and guidance is
available from the Electronic Rostering team on request. The performance of all
rostered areas is monitored by the Clinical Management Groups and the
Executive Board, continued underutilisation of staff in any area and failure to
meet quality and safety standards may lead to further investigation through a
formal confirm and challenge meeting by the Clinical Management Group and
ultimately may lead to the instigation of the Improving Performance (Capability)
Procedure or the Disciplinary Policy and Procedure. (Refer to Appendix 7 –
Electronic Rostering Reporting Software Management Process).
4.8.4 To review worked roster statistics in Electronic Rostering Reporting Software to
celebrate areas of success and challenge areas where improvement is required
to ensure continuous monitoring of safe and effective utilisation of staff.
4.9 Team Leaders/Line Managers/Managers
4.9.1 Responsible to their Matrons/General Manager for implementing the policy at
local level and for ensuring compliance.
4.9.2 The ward/department manager is accountable for either completing the roster or
appointing a responsible individual to create the ward / department roster within
the constraints of the Staff Rostering Policy and to accurately record staff
utilisation using the system. This may be delegated to a responsible deputy but
overall responsibility will always lie with the ward / department manager.
4.9.3 To check each planned four week roster in conjunction with the Rostering
calendar using the Roster Analyser feature within Electronic Rostering System.
To ensure safe and effective utilisation of staff within budget, quality and safety
limits before partial approval of planned rosters.
4.9.4 The Matron/General Manager will monitor the utilisation of staff in the area.
Failure to meet budget, quality and safety standards will be reviewed by them to
implement an agreed action plan, enabling services to meet the Key
Performance Indicators. Support from the Electronic Rostering team is available
if required. The performance of all Rostered areas is monitored by the Clinical
Management Groups and the Executive Board, continued underutilisation of staff
in any area and failure to meet quality and safety standards will lead to confirm
and challenge by the Clinical Management Group and ultimately may lead to the
instigation of the Improving Performance (Capability) Procedure or The
Disciplinary policy. (Refer to Appendix 7 – Electronic Rostering Reporting
Software Management Process).
4.9.5 While the CMG Head of Operations has ultimate accountability for expenditure,
the ward/department manager is responsible for ensuring that their expenditure
does not exceed the allocated staffing budget in all wards/departments unless
otherwise agreed.
Policy for Non Medical Staff Rostering Page 8 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents4.9.6 Ensuring that a quality roster is produced and all vacant shifts are sent to Bank 6
weeks in advance dependant on the utilisation of UHL temporary staffing.
Accurately maintaining and finalising in line with payroll timescale requirements
(Appendix 9) and the Key Performance Indicators [KPIs] – Appendix 6 .
4.9.7 Report any changes of personal details received from staff to ESR using the
appropriate HR form. A scanned copy should be sent to the Electronic Rostering
team for immediate amendments to be made on the ER System.
4.9.8 Responsibility for updating and maintaining individual’s skills information within
the Health Roster system
4.9.9 Utilise the skills information to capture temporary changes over 6 months.
Occupational Health / Maternity adjustments etc. can be assigned as a skill with
a review date and notes attached to ensure it doesn’t drop off the radar.
Temporary changes under 6 months in length would have to be manually
adjusted on the roster due to the timeframes of compiling rosters 8 weeks in
advance.
4.10 All Staff
4.10.1 All staff working within UHL are responsible for complying with the policy and
system usage guidelines.
4.10.2 Ensuring any changes to personal details are given to Line managers as soon as
they occur to ensure ESR is correct and in turn salary is unaffected.
4.10.3 Responsibility for maintaining skills in line with statutory and mandatory training
requirements for their role.
5. POLICY IMPLEMENTATION AND ASSOCIATED DOCUMENTS
5.1 Staffing Levels/Skill Mix
5.1.1 Following establishment reviews each area must have agreed safe minimum
number of staffing per shift/day to ensure business continuity, as agreed between
the manager and matron/head of department and signed off by the CMG. Agreed
numbers and skill mix must be achievable within the budget. It is acknowledged
that occasionally numbers may drop below this number in which case specific
workload/dependency issues must be considered.
5.1.2 Each ward/department must have a level of staff with specific competencies on
each shift, as agreed between the ward/department manager and matron/head of
department and signed off by the CMG. When someone with a particular
competency is off sick, other staff with that required competency may be
requested to swap shifts, with mutual consent.
5.1.3 There must be a highlighted, designated substantive person in charge for the
areas for each shift who has been identified as having the required skills and
competencies for a leadership and co-ordinating role where required.
5.1.4 A risk assessment by the ward/department manager must be completed as soon
as the minimum number is not achieved. Actions should be taken to utilise staff
from across the Trust or proceed within the guidelines of the Temporary Staffing
Policy. Movement of staff would be within CMG first and in extreme
circumstances across the Trust following a completed risk assessment.
Policy for Non Medical Staff Rostering Page 9 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents5.1.5 The skill mix and establishment must be reviewed bi-annually, as part of the
budget setting and workforce planning process. Skill mix and establishment
reviews may happen more frequently if a need / risk is identified.
5.1.6 Changes to the roster template in relation to increases or reductions to staffing
levels must be approved and authorised by the budget holder before the
Electronic Rostering team will amend the system
5.2 New Starters / Inductions / Students
5.2.1 New substantive staff (permanent and fixed term) should have a
supernumerary/induction period and will be assessed on an individual basis,
taking into consideration the requirements of the area the maximum
supernumerary period for an area will be 12 weeks. New staff should work
primarily where possible with their mentors or other nominated member of staff
for support during the supernumerary period, to ensure that their induction is
completed and objectives are planned. After this they should plan to work with
their mentor as agreed to complete objectives and competencies. These shifts
must be recorded as supernumerary unavailability on the system to ensure these
staff are not counted into the work numbers.
5.2.2 New staff may have annual leave booked. This should be honoured if it has been
discussed at interview or agreed upon commencement in a new post.
5.2.3 Pre-registration students must be classified as supernumerary to the established
staffing levels per shift. Pre-registration students must be rostered to participate
in the same shifts – or part of shifts – as their mentor, or nominated other, for at
least 15 hours per week.
5.2.4 Whilst giving direct care/working in a practice setting at least 40% of the student's
time must be spent being supervised by a mentor/practice teacher. When in a
final placement this 40% is in addition to the protected time (one hour per week)
that is to be spent with a sign-off mentor. This is inclusive of National
Qualifications that are being supported by the Trust.
5.3 Breaks
5.3.1 Shift patterns for areas to be rostered must be standardised to minimal variances
in order to meet the service demand, before transfer to the Electronic Rostering
system.
5.3.2 Handover periods must be efficient and timely and allow adequate and safe
handover of clinical/managerial department functions and relevant information.
5.3.3 The Working Time Regulation stipulates that a minimum of a 20 minute break is
required for shifts of more than six hours, therefore UHL applies the following
break periods to assist in employee safety, employee well-being and patient
safety.
6 hour shift or less no break entitlement
Shifts longer than 6 hours, 30 min unpaid break
up to and including 9 hours
Shifts longer than 9 hours 1 hour unpaid break (can
be taken in 2 x 30 mins or
as 1 x 60 mins)
Policy for Non Medical Staff Rostering Page 10 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsIf these break periods have a detrimental impact on the delivery of your service
please seek further guidance from your CMG HR Lead as you will need to submit
a business case with robust rationale for any variance.
5.3.4 Under Agenda for Change Terms and Conditions there is no requirement to
provide a paid break, however there is the provision of a 15 minute paid
discretionary break. Staff on shifts of 10 hours or more may take a discretionary
15 minute break per shift, as agreed with management and subject to service
needs which must take priority.
5.3.5 The ward/department manager, the person in charge and the individual are
responsible for ensuring that breaks are taken. If breaks are unable to be taken
at an agreed time due to service needs, they must be taken as soon as possible
after this point.
5.3.6 Breaks must not be taken at the end or the beginning of a shift, as their purpose
is to provide rest time during the shift.
5.3.7 If a break has not been taken this must be recorded on the roster to reflect the
actual hours worked to ensure employees are paid appropriately and safety /
quality standards can be monitored to ensure this does not become regular
practice.
5.4 Hours
5.4.1 Standard Hours as per Agenda for Change Terms and Conditions
Handbook Section 10: Hours of the working week
10.1 The standard hours of all full-time NHS staff covered by this pay system will
be 37½ hours, excluding meal breaks. Working time will be calculated exclusive
of meal breaks, except where individuals are required to work during meal
breaks, in which case such time should be counted as working time.
10.2 The standard hours may be worked over any reference period, e.g. 150
hours over four weeks or annualised hours, with due regard for compliance with
employment legislation, such as the Working Time Regulations.
5.4.2 Additional Hours
All time worked by staff over and above their contracted hours must be agreed by
the manager prior to being worked or by the person in charge on the day of
working and recorded on the roster. This time should be rounded up or down to
the nearest 5 minute interval e.g. finishing at 17.37 would be rounded to 17.35 or
finishing at 17.38 would be rounded up to 17.40. The additional hours agreed to
be worked can be taken as lieu time or if agreed with the manager paid as
overtime in line with Agenda for Change terms and conditions (Section 3
Overtime Payments)
5.4.3 Staff who for operational reasons are unable to take time off in lieu within three
months must be paid in accordance with Agenda for Change Terms and
Conditions.
5.4.4 Staff must not accrue more than 10% of their normal contractual hours as time in
lieu.
Policy for Non Medical Staff Rostering Page 11 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review:Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents5.4.5 Lieu time taken back as a full shift must be recorded on the roster by the
ward/department manager/deputy as Flexi time with zero hours worked, adding
on the notes section that it is time taken back. Any lieu time taken back as part of
a working day can be reflected by amending the start / finish times of the shift
and adding a note
5.5 Shift Allocation
5.5.1 Within areas that have weekend / night / on call shifts, staff are expected to cover
an agreed number of weekend/night/on call shifts during a set period unless a
flexible working entitlement has been granted and agreed by the respective CMG
or as part of a reasonable adjustment due to health. Linked to the principles
outlined in Section 1.2 of this policy.
5.5.2 Health and Safety Executive Guidelines recommend that two full night’s sleep
should be allowed when switching from a night shift to a day shift.
5.5.3 Ward / department managers are responsible for ensuring the roster record is
updated in the event of changes after the roster has been approved and is
available for staff to view:
a) It is the responsibility of the Ward / Line manager to ensure that rosters are
amended and kept up to date.
b) All changes made after the roster has been approved should have notes
detailing the change reason for audit purposes.
c) Where relevant staff mentoring a student must ensure that the student is
aware of any changes to the roster and that the student mutually agrees to move
their shift to work with their mentor or is allocated to another suitable member of
staff. This change must be recorded on the roster.
d) All updates to the roster must be made as soon as possible after the
occurrence; taking into consideration payroll deadlines.
5.5.4 In line with the Trust’s Flexible Working Policy all staff will have an annual review
of flexible working arrangements with their ward/department manager (this is
separate to the review that takes place with Term Time Only agreements). The
annual review date will be added into the Electronic Rostering System by the
Manager as a skill attached to the person with a 12 month expiry date and the
details of the agreement in the notes section. Expiring agreements will appear on
the Unit Summary on the Electronic Rostering System which will show Managers
of the need for a review 28 days prior to the current flexible working agreement
expiring. If a review is required, a new application needs to be submitted and
reviewed against current service demand as dictated in the Flexible Working
Policy. The Electronic Rostering team need to be notified of any amendments
that need making to the Roster template by e- mail from the approver of the
flexible working agreement.
5.5.5 The Trust recognises that in exceptional circumstances we may require staff with
mutual agreement to swap shifts or vice versa. Where the system is used
prospectively an unforeseen change payment of £15 will be available. This will
be used where it is necessary for employers to ask staff to change their shift
within 24 hours of the scheduled work period. The payment is not applicable to
shifts that staff agree to work as overtime, or that they swap with other staff
members. It is not available, in any circumstances, in the retrospective system.
Swapping of shifts at the request of staff is governed by the following and is
recognised that in exceptional circumstances to avoid unforeseen problems with
changes in skill mix and continuity of cover:
Policy for Non Medical Staff Rostering Page 12 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documentsa) Staff who need to change their roster post publication are able to make a
fair and ‘like for like’ swap with another member of staff with the same
grade and skills, providing that doing so continues to meet the needs of
the service.
b) The swap needs to be approved by the Unit Manager or their designated
deputy and recorded on the system.
c) Using social networking sites to arrange swaps is strictly prohibited
5.5.6 The shift leader/team leader/coordinator takes responsibility for any shortages in
staffing to ensure adequate cover is recorded in the system or reported to
appropriate line managers
Creating an additional duty outside of the agreed establishment solely for the
purpose of using up excess staff hours is not allowed at the point of creating the
roster.
For example: 10 staff are available to work a shift that only requires 8 staff. Due
to no annual leave or study leave being taken, this has resulted in having 10 staff
on the shift thus being over their establishment = 2 excess staff.
The Electronic Rostering System will only have 8 shifts available so extra shifts
should not be created to accommodate the extra 2. These should be utilised
elsewhere in the organisation to reduce temporary staffing costs under mutual
agreement with the staff member if within a different CMG or location.
5.5.7 Excess staff hours can be utilised at the point of creating the roster by:
1) Allocating staff to cover unfilled duties on other wards/areas within the
CMG thereby reducing the need for temporary staffing in the CMG.
2) Offering out unutilised annual leave to the team.
3) Held on the roster, extra hours can be used to cover sickness/carer leave,
increased demand during the working period of the roster any unutilised
hours will then carry forward to the next roster period.
4) Allocating staff study/training hours to complete statutory/mandatory or
other training.
5.5.8 Over contracted/unused hours – under normal circumstances the manager would
endeavour for there to be no over contracted / unused hours in any roster period.
In the exception that there are over contracted / unused hours in any roster, no
more than the equivalent of one shift over/under worked shall be carried forward
to the next roster period. All over contracted/unused hours shall be agreed with
the manager and either worked, taken back in lieu at a mutually agreed time and
within 2 working rosters or will be paid in line with Agenda for Change terms and
conditions (Section 3 Overtime Payments)
5.5.9 When managers are altering staff rosters they must ensure that the requirements
of the governing professional bodies’ learning requirements are adhered to, for
example specified Continual Professional Training / Continual Professional
Development.
5.6 Requests for shifts to be worked and for days off
5.6.1 Requests cannot always be guaranteed. The granting of requests will remain at
the discretion of the ward/department manager and will be reviewed fairly.
Policy for Non Medical Staff Rostering Page 13 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents5.6.2 All requests must be made using the Employee on Line (EOL) service, verbal or
written requests will not be accepted. A maximum of six requests per person per
four week off duty are allowed, this is however, at the discretion of the ward
manager dependant on service needs in individual areas.
These requests are over and above any flexible working agreement that has
been agreed.
They are pro rata for part time staff which the system calculates to whole figures
– see table below:
Contracted hours range Maximum Number of Requests allowed
per 4 week Roster Period at the
discretion of the Manager
37.5 to 34.5 hours 6 requests
34 to 28.5 hours 5 requests
28 to 22 hours 4 requests
21.5 to 16 hours 3 requests
15.5 to 9.5 hours 2 requests
9 to 1 hours 1 request
When making requests for shifts to be worked and for days off, 1 request is used
per shift.
For Example:
If a weekend is requested this constitutes 2 shifts so 2 requests are needed.
If a singular shift is requested then 1 request is used.
5.6.3 Three months’ worth of rosters will be visible at any one time for staff to make
requests to allow for fair accessibility for all staff. The wards/departments shall
manage the opening and closing of rosters. Rosters will close to requests 8
weeks prior to the start date of the roster.
5.6.4 Consideration of requests is at the discretion of the ward / department manager.
to ensure service delivery will be prioritised in a fair and equitable way.
5.6.5 Any issues relating to an individual’s specific request remain confidential to the
individuals concerned and will be documented and discussed.
5.7 Roster Responsibility/Production of Roster
5.7.1 The ward/department manager is accountable for either completing the roster or
appointing a responsible individual to create the ward / department roster within
the constraints of the Staff Rostering Policy. Responsibility for the roster lies with
the ward/department manager (refer to Appendix 5 for Roster checklist). Any
issues relating to over/under rostering need to be raised with the Roster
Approver or equivalent line manager before full approval.
5.7.2 Publication of rosters will take place as scheduled across all wards/departments
in the Trust using Electronic Rostering. All rosters will commence on the same
Monday in accordance with the published Roster Calendar (Appendix 3).
5.7.3 Best practice for the recording of changes to start and finish times, breaks and
absence would be completed by roster maintainers, for transparency and
integrity we do not recommend individuals record or make amendments to their
own records. In some instances this may be unavoidable and it is the
Policy for Non Medical Staff Rostering Page 14 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documentsresponsibility of the line manager to agree and monitor adjustments to working
records.
5.7.4 All rosters should be composed to adequately cover 24 hours (or agreed set
hours) utilising permanent staff to fill enhanced rate shifts as a priority following
the recommended autoroster process provided by the Electronic Rostering team.
Rosters should be composed to ensure the Working Time Legislation is observed
and met, refer to the Working Time Regulations Policy. Compliance with these
regulations is monitored by the system and employees and managers will be
challenged if regular non-compliance is identified within an area to ensure staff
and patient safety.
5.7.5 Ward/Department Administration/Clerical staff should be entered as appropriate,
with individuals not making changes / amendments to their own working records.
5.7.6 The ward / department manager has a responsibility to assess and liaise with the
Electronic Rostering team to assign the appropriate level of access for staff to
view and manage rosters for that area.
5.7.7 The roster is available to view by staff 6 weeks in advance of being worked, if a
member of staff has concerns about their shifts / shift patterns this needs to be
raised with the roster creator or line manager to address their concerns at the
earliest opportunity and at least 4 weeks before it is due to be worked.
5.8 Self Rostering
It is expected that Electronic Rostering will replace localised self rostering
systems.
5.9 Validation/Approval of Rosters
5.9.1 The ward/department manager undertakes the validation and approval by
checking the roster analysis information. The ward/department manager partially
approves the roster and informs the Matron (or equivalent line manager) that it is
ready for their review and to fully approve.
5.9.2 The Matron or equivalent line manager will hold responsibility for approving the
roster and become the designated ‘second approver’. The CMG must implement
a process to ensure rosters are finalised on time and fit for purpose.
5.9.3 Ward /department managers should be involved in an audit every 6 months of
the rosters to monitor the effectiveness of the roster to meet service need and
maintain fairness and equality to all staff.
5.10 Leave Management
5.10.1 Staff Utilisation
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V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsNon-working days are days when staff are being paid but are not working, broken
down in to the following categories. The total percentage of these should equate
to the 23% (approx.) headroom that is built in to each wards establishment
Annual Leave 15%
Sickness 3%
Parenting (Maternity/ Paternity/Adoption) 3%
Study Days 2%
Total less than or equal to 23%
5.10.2 Annual leave must be allocated according to Agenda for Change Terms and
Conditions.
The weekly annual leave granted should be maintained between 11-17% of the
WTE in the ward/department. The Ward/Department managers have a
responsibility to ensure that this is allocated according to skill mix within the
team.
5.10.3 As a governing principle, the number of hours taken as paid annual leave will
equal the number of hours the employee would otherwise have worked. Where
employees work varied shift patterns at least a quarter of their annual leave
entitlement must be booked on their longer working weeks to ensure equality,
fairness and service requirements are met as per Annual leave policy.
5.10.4When requesting Annual Leave through Employee on Line the exact dates of
leave are used. If a member of staff requires the day before as an unavailability
then this must be requested by them as a day off or the Annual leave extended.
For example : Staff member requests 1 week AL, this shows them as unavailable
for work only during these days, it does not automatically show them as
unavailable for the shifts before or after it.
Sat Sun Mon Tues Wed Thu Fri Sat Sun
AL AL AL AL AL
If the staff member requires the surrounding days off from work they would need
to request these through Employee On Line as a shift request day off.
Sat Sun Mon Tues Wed Thu Fri Sat Sun
R - off R- off AL AL AL AL AL R - off R - off
5.10.5Fair, personal and equal allocation of annual leave requests should be available
to all staff 12 months of the year including highly sought after periods, such as
school holidays, Easter and the observation of other religious holidays as
outlined in the Annual Leave Policy.
5.10.6 Quarterly reviews of outstanding annual leave for each member of staff must be
made by the ward manager/department manager to avoid accumulation of
untaken leave.
5.10.7 Approval of Annual Leave requests of more than 10 working days is at the
discretion of the manager and must be requested at least 12 weeks in advance
providing information on the circumstances to be considered. The requests will
Policy for Non Medical Staff Rostering Page 16 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documentsbe reviewed against the ward/department existing limits for annual leave. In
relation to approval and/or refusal of Annual leave requested notes should be
recorded in the notes section on the system to evidence the
decision/consideration process.
5.10.8 Staff have a responsibility to ensure that they request and take their entitlement
of leave within the annual leave year, there is not a consequence of losing leave
however it must be taken as specified in the Trusts Annual leave policy. Only in
exceptional circumstances can a maximum of one week’s Annual Leave be
carried over with agreement from their line manager and it must consequently be
planned to be taken within the first month of the new holiday year as specified in
the Annual leave Policy.
5.10.9 Carryover of leave must be approved by the Matron/Service Manager, following
the Annual Leave Policy guidance and the number of hours to be added to the
entitlement forwarded to the Electronic Rostering team by the 7th April to allow
the Electronic rostering Team to input into the system.
A summary of Annual leave entitlement with any additional leave - carry over,
additional years’ service or purchased (if known at that time) for each employee
must be supplied by ward / department manager for their area by the 28th
February, to ensure entitlements can be recorded on the system by the 1st April.
5.10.10 The Purchasing of Annual Leave remains as specified in the Flexible Working
Scheme on INsite can be purchased throughout the year at the Area/Ward
Managers discretion. Any additional leave that is authorised by the
Ward/Department Manager should be on an Additional Annual Leave Form, once
signed a copy of this should be sent to Electronic Staff Record team (add in the
email address) to ensure payment is calculated and also a copy to the Electronic
Rostering team in order for the increase of leave entitlement to be inputted into
Electronic Rostering System.
5.10.11Each year during the first week of September the Electronic Rostering Team will
send out a standard email to each LIVE unit with an attachment detailing unit
name, staff name, assignment number and the annual leave entitlement for that
year. This information will be pulled off of Electronic Rostering System by the
Electronic Rostering Team for staff that are recorded as working in an area on the
1st April of the coming year.
5.11 Special Leave/Study Leave
5.11.1 Special leave must be allocated in accordance with the Trust’s Special Leave
Policy (Trust reference A18/2002)
5.11.2 Ward/departments must ensure all staff are allocated study time to complete
statutory / mandatory and areas specific study. The responsibility for identifying
and requesting the appropriate study lies with the individual staff. This request
will then be reviewed and approved by the appropriate line manager. Fair and
equal allocation of study leave should be available to all staff and requested
following the Trust’s Study Leave Policy and Procedure. Study times should be
recorded accurately on the Roster to reflect the actual time spent studying,
breaks and travel time should also be recorded.
For example: Nurse A based at LGH travels to LRI to attend a Dementia
Awareness training session. Travel time is recorded as an unavailability from the
area from the LGH to LRI, the duration of the session is recorded as Study Leave
(with break periods shown if applicable), then return travel recorded as
unavailability as before.
Policy for Non Medical Staff Rostering Page 17 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsThis is to allow the organisation to monitor the total time requirements of study
across the organisation to be included in workforce planning, as well as keeping
travel time to a minimum.
5.12 Flexible Working
5.12.1 The Trust recognises that there may be occasions when staff are unable to work
the normal shift pattern used in their workplace, refer to the Flexible Working
Policy.
5.12.2 In exceptional circumstances if restricted working patterns are discussed at
recruitment, they must be compared to previously refused flexible working
requests for staff in post in that area. Thus ensuring all staff are treated fairly and
equitably. Please be aware in normal circumstances staff must be working within
UHL for a minimum of 26 weeks before they can apply for Flexible Working.
5.12.3 Flexible working agreements must be reviewed yearly for each individual to
ensure fairness and equality in Rostering is maintained. They will be recorded on
the Electronic Rostering System under each employee as a skill, with a 12 month
expiry date in order to ensure this annual review is completed.
5.13 Temporary Staffing
5.13.1 The Trust acknowledges that departments may experience staffing difficulties
and in order to maintain service provision, may need to secure temporary staffing
arrangements. Due consideration must be given to viable alternative options
before temporary staff are engaged to minimise the high cost of using temporary
staff. Furthermore, the Trust recognises that for enhanced service user
experience and continuity of care it is preferable to use current Trust employees,
who bring the added benefit of local knowledge and experience. Staff will be
moved within the scope of their professional practice, however in extreme
circumstances may be asked to function at a junior level. i.e. RN function as HCA
in a ward environment.
5.13.2 Each ward/department has an obligation in terms of workforce planning to take
into account planned absence such as annual leave, as well as a certain amount
of unexpected leave such as sickness or special leave. Temporary staff should
only be engaged as a last resort after considering other staffing alternatives.
Temporary staff must never be used as an on-going staffing solution; ‘temporary’
refers to a period of a few days or weeks and only in exceptional circumstances
should it be for a period of months.
5.13.3 The use of bank/agency staff must be booked according to the Temporary
Staffing Policy.
5.13.4 For all areas that utilise bank staff, once a shift has been approved it will be
visible on line to be booked by those of the appropriate grade and experience
with a bank contract. Areas also have the facility to direct book bank staff into the
approved shift or return the shift to the area for filling if a substantive member of
staff agrees to cover it.
5.13.5 Bank/agency must not be used to cover for planned annual leave.
5.13.6 All staff must be made aware they may at times be required to move temporarily
within the Trust to cover unfilled shifts or sickness absence within any
ward/department/CMG. Any moves will be discussed with the individual to
ensure that they have the right skill set to work safely in the area they are
Policy for Non Medical Staff Rostering Page 18 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documentsneeded. These redeployments of bank/substantive staff must be captured and
updated on the roster by the relevant manager making the decision. Any
redeployment of Agency staff must be notified to the Bank office so they can
make the correct amendments.
5.13.7 Text Message Alerts offering shifts, confirming shifts, confirming cancellation of
shifts and shift reminders are sent between 9am and 8pm, although there are
potential delays that can be caused by network errors in delivery of the alerts.
Staff can choose to opt out.
5.13.8 Paid time for statutory and mandatory training for temporary staff will be booked
and recorded on the system by the Bank office team. Specialist training required
for temporary staff to work in a specific area, will need to be booked, paid for and
recorded by that specific area on their own roster (refer to Electronic Rostering
website on Insite for the process).
5.13.9 The standards and timeframes for the recording and locking of shifts for
temporary staff must meet the same standards as substantive staff.
5.14 System Failure For Electronic Rostering
Action in the Event of System Failure
To enable business continuity in the event of system failure:
• Report to the Electronic Rostering helpdesk on 7238 or email
electronic.rostering@uhl-tr.nhs.uk
• Refer to the Electronic Rostering Continuity SOP
• Record changes to planned roster on hard copy and log book until the system is
available and can be updated.
6 EDUCATION AND TRAINING REQUIREMENTS
6.1 Training to use the Electronic Rostering System software will be delivered by the
Electronic Rostering Team following the Trust approved rollout plan for the
project. This training will be for all ward/Department managers and their line
managers, roster creators and those staff who will maintain the electronic roster
throughout the roster period.
6.2 On initial set up all appointed roster creators will receive training from the
Electronic Rostering project team on how to create a roster using the system.
Once in place it is the areas responsibility to deliver further training through
cascade training on the ward utilising the guides available on Insite.
6.3 All Roster approvers will receive training from the Electronic Rostering project
team on how to approve or reject rosters and formulate reports on the efficiency
of the roster
6.4 All staff will receive and can continually access training to use the Employee on
line system through the eUHL Employee Online tutorial videos and User guides
that are available to all Trust employees on InSite. Further support and guidance
is available from super users in the work area, first port of call would be the
management in that area followed by the Electronic Rostering Helpdesk.
7 PROCESS FOR MONITORING COMPLIANCE
7.1 Compliance with the Policy will be monitored by the utilisation of the information
from Electronic Rostering Reporting Software by all levels of management within
Policy for Non Medical Staff Rostering Page 19 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review:Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documentseach CMG to meet the agreed KPI’s. See Appendix 5 Checklist for Validating
and Approving Rosters and Appendix 7 Electronic Rostering Reporting Software
Management Process.
Key performance Workforce Electronic Monthly Dashboard sent out
Indicators Utilisation Rostering monthly to CMG
(Appendix 7) Lead Dashboard and Management Teams to
RosterPerform monitor and action to
improve or maintain
performance.
8 EQUALITY IMPACT ASSESSMENT
8.1 The Trust recognises the diversity of the local community it serves. Our aim
therefore is to provide a safe environment free from discrimination and treat all
individuals fairly with dignity and appropriately according to their needs.
8.2 As part of its development, this policy and its impact on equality have been
reviewed and no detriment was identified.
9 SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES
• UHL Special Leave Policy (A18/2002)
• Annual leave Policy (B22/2013)
• UHL Sickness Absence Management Policy (B29/2006)
• Working Time Guidelines (B19/2014)
• Flexible Working Policy (B7/2010)
• Allocation of Study Leave for AfC Staff (B32/2004)
• Improving Performance (Capability) Procedure (B12/2014)
• Disciplinary Policy (A6/2004)
• Staff Bank – Ward and departmental managers procedure guide (B37/2005)
• Perceptorship review policy for newly qualified Band 5 registered nurses
(B44/2007)
• Agenda for Change terms and conditions of service – Final agreement December
2004
• The Working Time Regulations 1998
• The Working Time (Amendment) Regulations 2003
• Healthcare Commission Report 2005
• National Audit Office Temporary Staffing Report 2006
• AUKUH Acuity/ Dependency tool 2007.
• Temporary Staffing Policy (B58/2011)
10 PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW
The policy will be reviewed by the Electronic Rostering Team at the times detailed on
the front page.
Policy for Non Medical Staff Rostering Page 20 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsThe updated version of the Policy will then be uploaded and available through INsite Documents
and the Trust’s externally-accessible Freedom of Information publication scheme. It will be
archived through the Trusts PAGL system.
Policy for Non Medical Staff Rostering Page 21 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsAppendix 1 – Nursing / Midwifery Areas Addendum
This is applicable to all staff working in Nursing and Midwifery areas on all
contract types, inclusive of permanent, fixed term, honorary, apprenticeships,
training and temporary - bank and agency.
5. POLICY IMPLEMENTATION AND ASSOCIATED DOCUMENTS
5.1 Staffing Levels/Skill Mix
5.1.7 Band 7 managers should not be routinely rostered for weekend, night or bank
holiday shifts unless as a requirement in specialist specific areas e.g. Emergency
Department, Theatres, ICU, Maternity, Radiology are bleep holding, working with
specific staff or to occasionally review service demand out of hours
5.1.8 Band 7 managers must be visible, accessible and have maximum presence in
their area. It is expected that full time ward managers will work 5 days per week,
between the core hours of 0700 and 20.00 and should incorporate 2 x 7.5 hours
supervisory shifts per week. (Pro rata if part time).
5.1.9 Band 6 staff should be rostered equally over the 24 hour period ensuring
consistent leadership/management of wards/departments. It is expected that
Band 6’s shall have 7.5 hours non clinical times per month. (Pro rata if part time).
5.3 Shift Duration and breaks
5.3.8 Standard paid long shifts must be 11.5 hours long.
5.5 Shift Allocation
5.5.10To support fair, safe and equitable rosters staff must not be rostered for:
• No more than 5 consecutive short shifts
• No more than 3 consecutive clinical Long Day shifts (11.5 hours in length,
this includes 11.5 hour twilight shifts)
• No more than 4 consecutive Night shifts
• No more than 6 consecutive combination of shifts
• All staff must have access to 8 weeks allocation of duties.
• Staff must adhere to the Trust ‘On Call Policy’ where applicable
• Staff must adhere to the Trust ‘Working Time Regulations Policy’
5.10 Leave Management
5.10.12 All Annual Leave requested for the 4 week roster spanning the
Christmas period will not be reviewed until the rosters for that period are
written, preventing Annual Leave being pre-booked for Inpatient wards. If you
already have pre-booked annual leave and this has been supported by your
manager, then this does not apply to you. Once the rosters are complete for this
period, very limited Annual Leave must be considered by the Ward managers, all
requests must be considered fairly
Policy for Non Medical Staff Rostering Page 22 of 34
V4 Extended date of October 2020 agreed by PGC on 21.2.20 Trust Ref: B5/2013 Next Review: Oct 2020
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite DocumentsYou can also read
