Standards › Standard 2E › Policies
Policy · WRK-POL-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.9
At a glance
- Maximum working hours and minimum rest are set in writing for every role.
- Rotas are checked against these limits before they are published.
- Any excess is reported the same week and reviewed.
- Staff are never asked to work beyond safe limits to cover a gap without a recorded decision.
- Stop and get help straight away if: a staff member is working beyond the maximum hours with no recorded decision.
1. Purpose
To set working hours and rest so that staff can work safely, and to make excess visible and reviewed [EC].
2. Scope
| Applies to | All workforce members, including locums and bank staff |
| Locations | All services |
| When | Always; limits checked for every rota |
| Does not apply to | Voluntary extra shifts within the limits |
3. Definitions
| Term | Meaning |
|---|---|
| Maximum hours | The longest working time allowed in a set period, as set in the policy |
| Minimum rest | The rest period required between shifts, as set in the policy |
| Excess | Hours or rest beyond or below the set limits |
4. Background
Fatigue increases error and harm to patients and to staff. Written limits and checked rotas are the basic protection.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Approves the limits | Executive |
| Rota managers | Build rotas within the limits and check them before publishing | Management |
| Staff member | Reports fatigue and excess hours | Own role |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Rota and working hours log (WRK-REG-004) | Current | Updated each week |
7. Safety
- A staff member who is too tired to work safely must not start or continue a shift. This is never a disciplinary matter.
8. Before you start
- Confirm the maximum hours and minimum rest for each role are set and approved.
9. Procedure
Step 1. Set the limits.
- Set maximum hours and minimum rest for each role.
- Publish them to all staff in writing.
Key point: A limit that is not written cannot be checked.
Step 2. Build and check the rota.
- Check each rota against the limits before publishing.
- Record the check in WRK-REG-004.
Key point: Check before, not after.
Step 3. Record and report any excess.
- Record each excess with the reason, the person and the time.
- Report it to the rota manager the same week.
Key point: Excess is recorded whether or not it is agreed.
Step 4. Review.
- Review each excess at the monthly meeting.
- Change the rota or the staffing where a pattern is found.
Key point: A pattern means the staffing is wrong, not the people.
10. Decision points
- Where cover cannot be found within the limits, the clinical director decides and records the decision, the hours and the review date.
11. Special situations
| Situation | Action |
|---|---|
| Emergency | Extra hours are allowed for a set time, with a recorded decision and a rest period afterwards. |
12. Escalation
- Any shift beyond the maximum without a recorded decision is reported to the chief executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Rotas checked before publishing | 100% | Weekly | Rota managers | Escalate to clinical director |
| Excess recorded with reason | 100% | Monthly | Rota managers | Escalate to chief executive |
| Rest periods respected | At least 70% | Monthly | Rota managers | Review rota |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WRK-REG-004 Rota and working hours log | Rota office | 3 years |
15. Training
- Rota managers are trained in the limits and in recording excess at appointment.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-REG-004 | Rota and working hours log | Record used in step 2 |
| WRK-POL-003 | Occupational health, safety and wellbeing policy | Health and safety policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Limits set by the ASF Expert Committee by the Committee and by national law. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)