POLICY DOCUMENT CONTROL SHEET
Reference Number POL/NQ/0055
Title Temporary Staffing Policy
Version Number 1.0
Document Type Policy
Original Policy Date October 2015
Review & Approval Senior Nursing, Midwifery and Therapies Leadership group
Committee Quality and Healthcare Governance Committee
Approval Date December 2015
Next Review Date December 2018
Originating Directorate Directorate & Care group where applicable
Matrons
Document Owner ALTC
Lead Director or Associate Executive Director of Nursing
Director
Scope Trust-wide, In-patient wards
Equality Impact Assessment December 2015
(EIA) Completed on
Status Approved
Confidentiality Unrestricted
Keywords Bank, Agency, Temporary Staff
Ratification
Signature of Chairman of Ratifying Body
Name / Job Title of Chairman of Ratifying Chris Gray Executive Medical Director
Body:
Date Ratified December 15, 2015
Signed Paper Copy Held at: Corporate Records Office, DMH
POL/NQ/0055
Temporary Staffing Policy
VERSION CONTROL TABLE
Date of Issue
Version Number
Status
Oct 2015
1.0
Draft
Dec2015
1.0
Approved
TABLE OF REVISIONS
Date
Section
Revision
Author
POL/NQ/0055
Temporary Staffing Policy
CONTENTS
Policy Document Control Sheet .................................................................................. i
Version Control Table ................................................................................................. ii
Table of Revisions ....................................................................................................... ii
Contents...................................................................................................................... iii
1
Introduction ........................................................................................................ 5
2
Purpose ............................................................................................................... 5
2.1 Policy Objectives .................................................................................................. 5
3
Scope .................................................................................................................. 5
4
Duties .................................................................................................................. 5
4.1 Chief Executive .................................................................................................... 5
4.2 Director of Nursing ............................................................................................... 6
4.3 Director of Workforce and OD .............................................................................. 6
4.4 Staff Bank & Agency Service ................................................................................ 6
4.5 Associate Director of Operations/Nursing ............................................................. 6
4.6 Heads of Service .................................................................................................. 6
4.7 Matrons ................................................................................................................ 6
4.8 Ward and Deprtment Managers ........................................................................... 6
4.9 All Staff ................................................................................................................. 6
5
Policy .................................................................................................................. 7
5.1 General Principles ................................................................................................ 7
5.2 Summary of Service Provision – Staff Bank & Agency Service............................. 7
5.3 Considerations prior to ordering temporary staff ................................................... 7
5.4 Acceptable reasons for using temporary staff ....................................................... 8
5.5 Who is authorised to order temporary staff ........................................................... 9
5.6 How to make a request ........................................................................................ 9
5.7 If a request is no longer required .......................................................................... 9
5.8 Who is authorised to instruct that a request is to go out to agencies .................... 9
5.9 Expected standards of temporary workers ........................................................... 9
5.10 Temporary worker performance management .................................................... 10
5.11 Temporary worker capability management ......................................................... 10
5.12 Sickness management of temporary staff ........................................................... 10
5.13 Agency Induction ................................................................................................ 11
5.14 Agency invoice clearance ................................................................................... 11
5.15 Bank database management .............................................................................. 11
6
Definitions ........................................................................................................ 11
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6.1 Glossary of Terms Used ..................................................................................... 11
7
Dissemination Arrangements .......................................................................... 12
8
Monitoring......................................................................................................... 13
8.1 Key Performance Indicators ............................................................................... 13
8.2 Compliance and Effectiveness Monitoring .......................................................... 13
9
References ........................................................................................................ 13
10
Associated Documentation ............................................................................. 14
11
Appendices ....................................................................................................... 14
11.1 Appendix 1: Guidance on bank/agency authorisation booking process .............. 15
11.2 Appendix 2: Process for seeking approval to book bank staff (in hours) ............ 16
11.3 Appendix 3 : Process for seeking approval to book bank staff (out of hours) ...... 17
11.4 Appendix 4: Escalation pathway for booking Bank & Agency ............................. 18
11.5 Appendix 5: Equality impact assessement tool .................................................. 19
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1 INTRODUCTION
County Durham & Darlington NHS Foundation Trust recognises that from time to time
operational services may experience staffing difficulties and in order to maintain service
provision and ensure the safety of patients and staff there will be a need to secure temporary
staffing arrangements.
This guidance has been developed to reflect the Department of Health and National Audit
Office guidelines on the best practice for the use of temporary staff.
It is designed for the users of temporary staff within County Durham & Darlington NHS
Foundation Trust, to assist in ensuring best practice is followed.
2 PURPOSE
The purpose of this policy is to ensure that all wards and departments within the Trust who
use temporary staff are aware of the correct process to book temporary staff and that
temporary staffing is managed appropriately and effectively.
2.1 Policy Objectives
This policy will:
Outline to all Managers the need for seeking internal alternatives to staffing issues.
Provide standards and guidance under which temporary staffing placements may
occur to cover shortfalls within the Trust.
Ensure that temporary staffing placements are standardised, coordinated, appropriate
and managed within budget, without detriment to service.
Provide procedures and guidelines for the management of temporary staff.
3 SCOPE
This policy applies to all users of temporary staff working within the Trust.
4 DUTIES
All staff have a responsibility for ensuring that the principles outlined within this document are
universally applied.
Key organisational duties are identified as follows:
4.1 Chief Executive
The Chief Executive has overarching responsibility for the Trust’s Temporary Staffing Policy.
Operational responsibility has been delegated to the Director of Nursing.
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4.2 Director of Nursing
The Director of Nursing is responsible for safe levels of nurse staffing across the Trust and
has overall responsibility for ensuring that policies and procedures are in place for the use of
temporary staff.
4.3 Director of Workforce and OD
The Director of Workforce and OD has responsibility to ensure that the Staff Bank & Agency
Service meets its objectives and complies with legislative requirements.
4.4 Staff Bank & Agency Service
The Staff Bank & Agency Service is responsible for the administration of temporary staff
bookings and to ensure that all controls and procedures are in place for this department.
4.5 Associate Director of Operations/Nursing
The Associate Director of Operations/Nursing is responsible for ensuring compliance within
their Care Group, i.e. that controls in place are adhered to at all times regarding the
authorisation of temporary staff and recruitment of temporary staff is within the total staffing
budget allocated.
4.6 Heads of Service
Heads of Service are responsible for ensuring this policy is implemented across their wards
and departments and that this is monitored on a monthly basis.
4.7 Matrons
Matrons are responsible for overseeing the implementation and monitoring compliance with
this policy within their clinical areas.
4.8 Ward and Deprtment Managers
Ward and Department Managers are responsible for ensuring that this policy is implemented
for their area. Band 7 staff, or nominate deputy, are identified in advance that can authorize
bank for their area. They are also responsible for the management of temporary staff in their
area whilst on duty.
4.9 All Staff
All staff groups are responsible for complying with this policy
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5 POLICY
5.1 General Principles
1. Managers are responsible for ensuring that staffing arrangements for the service they
are responsible for delivering are planned in advance.
2. Managers are responsible for ensuring that all spend on staffing (both on substantive
posts and for any use of temporary staff) is within their agreed budget.
3. Requesting a temporary member of staff for any post should only take place after the
manager has reviewed all other options, including reviewing existing staff rotas and
moving any existing staff.
4. Request to cover staffing with a temporary member of staff should be at the lowest
possible grade and for the minimum number of hours to still provide a safe and
effective service.
5. In the event that a temporary staffing request is deemed to be necessary it is
essential that the correct booking process is followed (see below) and that wherever
possible, for cost-effectiveness and to reduce risk, that this is covered by a bank staff
member (as opposed to agency)
6. Substantive staff can only work temporary shifts in CDDFT through the bank, and are
not permitted to work back at the Trust if they leave their substantive post in the form
of agency staffing for a period of 12 months from their last day of work. They will also
need to complete a re-registration to the bank if they wish to continue to work at the
Trust.
7. Substantive staff who have been off work with sickness should not work future bank
shifts within an agreed period with their line manager, dependent on the nature of the
original sickness.
8. Substantive staff who wish to work through the bank must ensure they are not in
breach of the 48 hour working week as per the European Working Time Directive
1998, unless they have signed an opt out agreement.
9. All requests must be made through the agreed bookings channel / system and any
that are to start in less than 24 hours must also be flagged separately to the Staff
Bank & Agency Service team via a phone call.
10. Overtime will be decided at local department level.
11. No Trust staff are to directly contact any agencies for temporary cover. All agencies
must be contacted by the Senior Nurse Patient Flow (out of hours) in accordance with
the protocols agreed with the Trust
5.2 Summary of Service Provision – Staff Bank & Agency Service
The Staff Bank & Agency Service operates five days a week between 8am and 5pm. Outside
of these hours management of bookings is via the Senior Nurse Patient Flow.
5.3 Considerations prior to ordering temporary staff
Planned Absence
If a unit is considering using a member of temporary staff, the following should be considered
prior to making a request:
-
That requests should not be made unless the costs can be accommodated within the
budget
-
That annual leave and a level of sickness are included in establishment figures
therefore if the establishment does not have any vacancies, temporary staff should
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not be used to cover either of these. The only exception may be for an
unprecedented level of permanent staff sickness.
Unplanned Absence
If there is a potential requirement for temporary staff cover for an unplanned absence,
managers should consider the following:
-
Can the rota be altered and the shift covered without needing a bank or agency staff
member?
-
Can the rota of another unit within the Care Group / Trust be altered and the
requirement covered without needing a bank or agency staff member?
-
Are there any part time staff willing to do extra hours to cover the shift?
If the manager is confident that the requirement is still necessary then they should proceed to
making a request for a temporary member of staff.
5.4 Acceptable reasons for using temporary staff
There should be a justifiable reason for requesting a temporary member of staff which
includes:
When there is a vacant post with funding available and the work cannot be covered
from within the existing workforce
When the service will be at risk, including patient safety, or targets for delivery are
compromised
An unexpected increase in the volume of work (i.e. due to a flu crisis or heat-wave)
When there are adverse effects on the health and safety of staff
The following reasons are considered acceptable for using temporary staff:
Trust initiative/waiting list (use in Theatres, OPD service, etc.)
Maternity or Paternity Leave cover (preferably this should be covered with short term
contracts unless turnover allows for substantive recruitment without financial risk)
Unplanned leave/Special Needs Leave – compassionate, etc.
Unprecedented Levels of Staff Sickness
Increased Workload/Increased Dependency
Vacancy
Winter pressures/Seasonal Pressures & Additional Capacity
Specialing 1-1 Supervision/Enhanced Observation/Cohorting
Influenza Pandemic Staffing to support the Trust Contingency (not staff sickness)
Note: temporary staff should not be booked to cover planned annual leave, long-
term sick leave or study leave. This leave should be managed to ensure adequate
cover from existing staff.
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5.5 Who is authorised to order temporary staff
Trust staff at Band 7 or above or anyone nominated by the ward manager to perform this
task may at some point need to make a decision as to the use of a temporary member of
staff are authorized to make a request.
5.6 How to make a request
To minimise the risk to the Trust, the procedure detailed in Appendix 1 should be adhered to
at all times.
Instructions or training are available from the Staff Bank & Agency Service.
5.7 If a request is no longer required
If a request is no longer required and no temporary cover has yet been identified, the
manager may cancel the request if there is no person booked into the shift.
If the request is no longer required and temporary cover has already been identified, the
manager must contact the Staff Bank & Agency Service at the earliest opportunity to notify
them so they can seek to redeploy an individual elsewhere (if they are bank staff) or notify
the agency of the cancellation.
If the request is cancelled at two hours or less before the duty is due to start and the bank or
agency worker cannot be redeployed elsewhere, a two hour fee to cover time and expenses
is applicable, charged back to the relevant department.
5.8 Who is authorised to instruct that a request is to go out to agencies
Other than when there is a fixed agreement already in place, authorisation to approach an
agency with a temporary requirement can only be received from a Matron, Care Group
Associate Director of Nursing or Senior Nurse Patient Flow. Notification will be recorded in
writing for an audit trail. The process is outlined at Appendices 2, 3 and 4.
The authorisation of requirements to go to agencies will be reviewed on an on-going basis
5.9 Expected standards of temporary workers
Managers should expect temporary staff from either the bank or the agency to adhere to the
following behaviours. This list is not exhaustive:
1. Shifts / assignments should only be accepted if the individual can be confident they
can honour the booking.
2. Short notice cancellations (less than 48 hours) are not acceptable other than in
exceptional circumstances and restrictions may be applied to those who fail to
follow this instruction.
3. No bank or agency staff should breach the European Working Time Directive
regulation regarding the 48 hour working week.
4. Any bank or agency worker requested to make a reasonable move to another unit in
order to maintain safe levels of staffing is expected to cooperate with this request.
5. All bank and agency staff should comply with Trust requirements relating to
uniforms and dress codes.
6. All agency staff should submit to ID and registration checks at time of their first
assignment on any ward, unless a framework agreement with certain agencies
capture this information through contracting. The Staff Bank and Agency service will
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advise (see section on Agency Induction - Agency Worker Notification Process
below).
7. All bank and agency staff should ensure that they complete and submit their
timesheets in a timely manner
8. All payroll queries should be directed to the bank or the agency as appropriate.
9. Mobile phones are not permitted to be used during working hours. In the event of
needing to receive an urgent phone call, bank or agency staff should seek
permission from the senior nurse in charge of the area.
10. Bank and agency staff are expected to arrive in good time for their shift and to
return promptly from breaks
11. Bank and agency staff are not permitted to sleep while on paid duty under any
circumstances
12. If a bank or agency worker wishes to raise a complaint, concern or incident relating
to temporary working at County Durham and Darlington NHS Foundation Trust they
should do so through a senior member of the bank team or through the Trust’s
whistle blowing policy, or in the case of agency staff, through their agency and their
agency’s whistle blowing policy.
5.10 Temporary worker performance management
Bank staff may be subject to disciplinary action in the event of any of the following:
- Repeated short notice cancellations
- Non-attendance for booked shifts
- Any reported conduct issues
Agency workers are subject to the performance management processes of their agency.
If there are concerns about bank or agency workers the Staff Bank and Agency Service
should to be informed immediately.
5.11 Temporary worker capability management
Any concerns regarding a bank or agency worker’s capability for the role they have been
placed in to should be immediately reported to the Staff Bank and Agency team so that this
can be monitored centrally. The Staff Bank and Agency team will escalate any problems to
the agencies where necessary.
Concerns will be reviewed on a case by case basis.
Agency workers are subject to the capability management processes of their agency.
5.12 Sickness management of temporary staff
1. Bank staff who hold a substantive post with CDDFT– if a substantive member of staff
cancels a bank shift due to the sickness the bank team will inform the relevant
department to ensure this is recorded and to take advice on any restriction to be
applied to future bank working. The bank will then endeavour to cover the shift that
has had to be cancelled. For those areas who are not paperless the ward area needs
to inform the bank about the temporary workers sickness absence. For those areas
who manage a paperless system this will be addressed immediately by the staff bank
and agency team.
2. Bank only staff – if a non-substantive bank member of staff cancels a bank shift due
to sickness then subsequent shifts may also be cancelled dependent on the nature of
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the condition and a record will be held of the number of episodes of sickness. The
bank will then endeavour to cover the shift that has had to be cancelled
3. Agency staff – if an agency member of staff cancels a shift due to sickness then it will
be the responsibility of the agency to advise whether future shifts need to be
cancelled.
In the event of an outbreak in a clinical area of norovirus or other infection control incident
the Staff Bank and Agency team need to be informed at the earliest opportunity so they can
inform all staff that have worked a temporary shift there in the previous period to ensure they
do not work
elsewhere and that they are given instruction regarding showing any symptoms.
Any staff who have had symptoms will be expected to be symptom free for a minimum of 48
hours before undertaking any work at the Trust.
5.13 Agency Induction
Ward and Department staff are responsible for checking agency worker ID and completing
local induction when the agency worker presents for duty. This is outlined in the Agency
Worker Notification guidance which is available via the trust intranet. Agency workers who
work continuously for a period of 6 weeks should complete trust induction.
All agency staff should be booked via a framework agency and eventually will be through a
neutral vendor. For those agency staff who are not booked through the aforementioned the
agency staff PIN number needs to be check on the NMC web site to ensure it is active with
no restrictions.
For further guidance please see The Agency Worker Notification Process at:
http://intranet/communities/FormsMgt/Guidance%20and%20Assistance/Agency%20Worker
%20Notification%20Guidance.doc
5.14 Agency invoice clearance
It is the responsibility of the departmental lead to check and authorise and agency invoices.
5.15 Bank database management
Bank only staff who do not work for a period of 12 months will have their bank assignment
disabled. They may re-join the bank at any time if they wish to undertake bank work.
6 DEFINITIONS
6.1 Glossary of Terms Used
Agency staff – temporary or interim staff provided through an external organisation for an
agreed rate where the contract of employment lies with the providing company rather than
the end user.
Bank staff – staff registered to provide work on an ad hoc basis, with no obligation for
regular work. Administered by the Trust, these staff are workers not employees.
Substantive staff – staff employed by the organisation on an ongoing contract of
employment, usually referred to as permanent staff.
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Temporary staff – staff employed by the Trust on a fixed term contract of employment for an
event or period that is of limited duration. Their employment is on NHS terms and conditions
of employment and their service can be counted for continuity of employment.
Government Procurement Service – formally known as Buying Solutions. Government
Procurement Service is an executive agency of the Cabinet Office. Their overall priority is to
provide procurement savings for the UK public sector as a whole and specifically to deliver
centralised procurement for central government departments.
7 DISSEMINATION ARRANGEMENTS
This policy will be available to staff via the Trust’s intranet. Notification will be sent to staff via
the All User Bulletin.
Please note that the intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as ‘uncontrolled’ and as such, may not
necessarily contain the latest updates and amendments. When superseded by another
version, it will be archived for evidence in the electronic document library.
Copies of this guidance should not be printed unless absolutely necessary as this could pose
a risk of out of date copies in circulation within the Trust.
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8 MONITORING
8.1 Key Performance Indicators
The Staff Bank & Agency Service will aim to achieve the following performance indicators:
85% bank fill rate for planned requests and unplanned requests which are submitted.
Provide monthly fill figures for registered nurses and health care assistance.
The Staff Bank & Agency Service will provide on an ad hoc basis figures as
requested by wards and departments in the areas who have a paperless system.
8.2 Compliance and Effectiveness Monitoring
Monitoring Criterion
Who will perform the monitoring?
Staff Bank & Agency Service Manager will monitor
fill rates.
What are you monitoring?
The effectiveness of this policy to provide assurance
to the Trust that the Staff Bank & Agency Service is
following legislation and applies best practice
guidelines in the use of temporary staff.
When will the monitoring be Monthly trend analysis.
performed?
Annual audit.
How are you going to monitor?
Monthly trend analysis:
Bank & agency spend and fill rate report
Tracking of performance against agreed KPIs
Annual audit will measure compliance against the
following areas:
Booking process
Authorisation process
Completion of induction forms
Timesheet authorisation
What will happen if any shortfalls An action plan for improvement will be developed
are identified?
Where will the results of the The monthly/quarterly tracking of performance
monitoring be reported?
against agreed KPIs will be shared at the Nurse
Recruitment Campaign group/workforce planning
group.
Quarterly board reports.
9 REFERENCES
List any relevant legislation, and other sources referred to.
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10 ASSOCIATED DOCUMENTATION
This Temporary Staffing Policy refers to the following CDDFT Trust policies and procedures:
PROC/PD/0003 - Recruitment & Selection Procedure
PROC/PD/0025 - Employment Checks Procedure
POL/PD/0019 - Working Time Regulations Policy
POL/PD/0051 - Staff Induction Policy
PROC/PD/0006 - Capability Procedure
POL/PD/0039 - Raising Concerns Policy
This policy refers to the following guidance, including national and international standards:
<list all external (to this Trust) policies, national and international standards>
11 APPENDICES
Appendix 1 – Guidance on bank/agency authorisation booking process
Appendix 2 – Process for seeking approval to book bank staff (in hours)
Appendix 3 – Process for seeking approval to book bank staff (out of hours)
Appendix 4 - Escalation pathway for booking Bank & Agency
Appendix 5 – Equality Impact Assessment Tool
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11.1 Appendix 1: Guidance on bank/agency authorisation booking process
In 2013/14 pay budgets received an uplift increase to 21% to cover annual leave, training
and sickness. Increasing pay costs have resulted in closer scrutiny of bank and agency
use.
Booking Bank Staff
Must be authorised at Matron level or equivalent. The use of agency staff will only be
approved in exceptional circumstances when a risk assessment dictates this. Agency staff
will only be sourced from framework agencies. The use of non-framework approved agency
staff will only be granted in the most exceptional circumstances and must be authorised by
an Executive Director
In Hours.
The process for bank/agency authorisation is via the Band 6 or above (or nominated deputy)
on MAPS, E-Mail or via the phone within the opening hours of (Mon – Fri 8am to 5pm). For
all areas utilising paperless rostering requests will only be accepted via MAPS.
Out of Hours
The responsibility for booking bank staff will be the responsibility of Senior Nurse Patient
Flow
The responsibility for booking agency staff out of hours will be the responsibility of the
Senior Nurse Patient Flow.
The booking of bank staff out of hours will normally only be for short term absences. It is
expected that all longer term absences such as vacancy will have been actioned using the in
hours process.
The use of agency staff will only be approved in exceptional circumstances when the clinical
risk dictates necessity. Agency staff will only be sourced from via framework agencies. Only
Associate Directors of Nursing and Gold command are empowered to overrule this directive.
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11.2 Appendix 2: Process for seeking approval to book bank staff (in hours)
For advice on any aspect of this process, please contact your department manager.
Step 1
Shift
requested
via
e-
The ward manager or authorised deputy
rostering (MAPS), E-Mail or authorises to need to raise the shift on e-
telephone the bank at short rostering.
notice.
The ward manager is responsible for
ensuring that:
· The off duty is reviewed to confirm that
‘bank’ is required.
· Can annual leave booked be cancelled or
moved?
· Can any non-essential training be
cancelled?
· Can staff be reallocated from future
shifts?
Step 2
The Staff Bank & Agency The Staff Bank & Agency Service on
Service
receipt
of
a
E-rostering
or
E-Mail
authorisation request is responsible for:
• Allocating staff if available
• Texting staff to obtain cover for the
request
If bank staff are not available to cover the
request The Staff Bank & Agency Service
will gain approval for agency stating the
reasons for not filling.
If Bank Staff are not available then the
process for booking Agency Staff should
be followed.
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11.3 Appendix 3 : Process for seeking approval to book bank staff (out of hours)
For advice on any aspect of this process, please contact your department manager.
Step 1
Ward/Department
The department manager or authorised
request bank staff
deputy contacts the Senior Nurse Patient
Flow and requests bank staff stating the shift
times and reason for request.
The department is responsible for ensuring
that:
The off duty is reviewed to confirm
that ‘bank’ is required.
Can annual leave booked be
cancelled or moved?
Can any non-essential training be
cancelled?
Can staff be reallocated from future
shifts?
Step 2
Senior Nurse Patient The Senior Nurse Patient Flow to decide
Flow
whether there is a requirement for bank staff.
If approval is not supported, the Senior Nurse
Patient Flow should discuss and explain the
reasons for refusal to the department.
The Senior Nurse Patient Flow is responsible
for ensuring that:
• Cross- cover cannot be provided.
• Ward is not able to cover internally and bed
state support the requirement for bank staff
• Text message showing shift site, area and
times is sent to appropriate level of staff.
If no bank staff are available and the cover is
required then the Senior Nurse Patient Flow
should contact the Manager on Call to
discuss framework agency booking.
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11.4 Appendix 4: Escalation pathway for booking Bank & Agency
•The additional staffing should be approved by the Associate Director of
Nursing or Service Manager and sought in the following order.
• Try to secure staff on-duty in wards within the speciality/care group
1
• Try to secure cross cover from another care group/site
2
• Try to secure staff from within area with lost contracted hours or assigned
to additional duties/training
3
•Additional hours to be offered to staff contracted to work less than 37.5
hrs only to a max of 37.5hrs
4
•Ward areas roster to be completed 6-8 weeks in advance which will
advance vacant shifts to the staff bank in order to offer shifts to temp staff,
5
making it fair and equitable
•Bank staff fill vacant shifts in accordance with temporary staffing
operational policy
6
•Over time to substantive staff
7
•Agency staff in accordance with temporary staffing operational policy
(only through staff bank in hours and PFT out of hours).
•NB Senior management approval must be sought at each point of
8
escalation from 5pm onwards
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Ward Sister / Charge nurse approval required for Bank requests v approved roster.
Matron approval required for Agency (on framework within Monitor price caps)
requests v approved roster.
If CDDFT substantive staff have a flexible Working Agreement in place they cannot
work Bank, Agency, Additional or overtime shifts that convene their agreement.
Associate Director of Nursing approval required for off framework Agency requests.
Director of Nursing/Director of Performance and Operations, CEO approval required
for very High cost Agency e.g. Thornbury.
11.5 Appendix 5: Equality impact assessement tool
Equality Analysis / Impact
Assessment
EAIA Assessment Form
v3/2013
Division/Department:
Medical Director
Title of policy, procedure, decision,
Temporary Staffing Policy
project, function or service:
Lead person responsible:
Executive Director of Nursing
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People involved with completing
this:
Type of policy, procedure, decision, project, function or service:
Existing
New/proposed
x
Changed
Date Completed:
14/12/2015
Step 1 – Scoping your analysis
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What is the aim of your policy, procedure, project, decision, function or service and
how does it relate to equality?
This policy is for use by all clinical areas. It will assist with the production of rosters based on
funded establishments as agreed in budget setting. It should be used by Associate Directors
/ Matrons / Ward Managers in conjunction with local policies/protocols on safe staffing and
temporary staffing. This policy and procedure applies to all rostered clinical staff across the
trust and not just those working a variable shift pattern.
The purpose of this policy is to provide the principles upon which all working patterns must
be based.
Who is the policy, procedure, project, decision, function or service going to benefit
and how?
What barriers are there to achieving these outcomes?
How will you put your policy, procedure, project, decision, function or service into
practice?
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Does this policy link, align or conflict with any other policy, procedure, project,
decision, function or service?
Step 2 – Collecting your information
What existing information / data do you have?
Peer review
Who have you consulted with?
Ward managers
What are the gaps and how do you plan to collect what is missing?
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Step 3 – What is the impact?
Using the information from Step 2 explain if there is an impact or potential for impact
on staff or people in the community with characteristics protected under the Equality
Act 2010?
Ethnicity or Race
No
Sex/Gender
No
Age
No
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Disability
No
Religion or Belief
No
Sexual Orientation
No
Marriage and Civil Partnership (applies to workforce issues only)
Pregnancy and Maternity
No
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Gender Reassignment
No
Other socially excluded groups or communities e.g. rural community, socially
excluded, carers, areas of deprivation, low literacy skills etc.
No
Step 4 – What are the differences?
Are any groups affected in a different way to others as a result of the policy,
procedure, project, decision, function or service?
No
Does your policy, procedure, project, decision, function or service discriminate
against anyone with characteristics protected under the Equality Act 2010?
Yes
No
X
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Temporary Staffing Policy
If yes, explain the justification for this. If it cannot be justified, how are you going to
change it to remove or mitigate the affect?
Step 5 – Make a decision based on steps 2 - 4
If you are in a position to introduce the policy, procedure, project, decision, function
or service? Clearly show how this has been decided.
If you are in a position to introduce the policy, procedure, project, decision, function
or service, but still have information to collect, changes to make or actions to
complete to ensure all people affected have been covered please list:
How are you going to monitor this policy, procedure, project or service, how often and
who will be responsible?
POL/NQ/0055
Temporary Staffing Policy
Step 6 – Completion and central collation
Once completed this Equality Analysis form must be forwarded to Jillian Wilkins,
Equality and Diversity Lead. xxxxxxx.xxxxxxx@xxxxx.xxx.xx and must be attached to
any documentation to which it relates.
POL/NQ/0055