Supervision policy

1 Introduction

Rotherham Doncaster and South Humber NHS Foundation Trust (the trust) is committed to providing the framework and resource for effective supervision to enhance and inform practice and provide support and development for colleagues. Different types of supervision are required to provide efficient and effective care and service delivery. The types used may overlap.

2 Purpose

The purpose of this policy is to provide a formalised, structured framework for the facilitation and monitoring of supervision of all colleagues employed by the trust and for those who provide supervision to those colleagues.

All colleagues, depending on profession and role, will have differing supervision requirements. No single model of supervision can be adopted across the trust as services must use the model that enables best practice delivery.

This policy seeks to establish the expectation of a minimum level of all types of supervision. Focus within the sessions is based on the needs or issues identified by the supervisor and supervisee(s) and is consistent with their training and development needs.

3 Scope

This policy applies to all trust employees including executives and volunteers and covers the supervisory needs of the workforce, based on their job role. All colleagues have an annual personal development review (PDR), which will take into account the annual business plan and the priorities of the care group as well as meeting the needs of the service.

Learners in practice currently receive structured supervision sessions throughout their placement. These are determined and based upon their scope of practice.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

On behalf of the executive team, the director of people and organisational development will provide assurance to the board that supervision is carried out in accordance with this policy. The board of directors is responsible for providing assurance to the board that:

the implementation of all policies and procedures are in place to maintain the safety of service users, colleagues, and the public
there is provision, monitoring and ensuring the resourcing of supervision for all employees
provide assurance that attendance at clinical or professional and management supervision sessions is monitored
the quality of clinical records, risk assessments or care and treatment plans and coproduction is evident through scrutiny of records in supervision

4.2 Care Group Senior Management team and corporate directorates

The Care Group Senior Management team, corporate directorates and psychological professional leads, have the responsibility to set the culture that supports the requirement for all colleagues to participate in supervision and to ensure that colleagues are given the time to fulfil their supervision responsibilities and that the quality of clinical records, risk assessments or care and treatment plans and coproduction is evident through scrutiny of records in supervision.

4.3 Managers

Managers are responsible for:

ensuring that colleagues are given the time and resources to take part in supervision provision
monitoring of the supervision for colleagues within their areas of responsibility
creating an environment where supervision is valued as an essential activity which supports the delivery of high quality, safe and effective care
actively promoting an understanding of the aims of supervision amongst their colleagues and teams on an ongoing basis
making effective use of their operational management structure so that supervisory responsibilities are shared amongst colleagues according to the care model identified for the service
ensuring that management, clinical and safeguarding supervision is available to all colleagues within their service
allowing Supervisors time to complete supervision for supervisors within contracted hours
ensuring arrangements are made to provide a suitable alternative supervisor for when supervisors are absent for long periods of time which would have a significant impact on being able to meet the trust’s minimum requirements of engaging in supervision at a minimum of every six to eight weeks
ensuring that the supervision is recorded. Where group supervision has taken place, such as for ancillary colleagues, meeting notes may be the record of their supervision
ensuring that the supervision is recorded on the staff portal RDaSH portal (staff access only) (opens in new window) or on the electronic service record (ESR) once supervision is moved to this method of reporting

Managers are also responsible for:

ensuring that where appropriate clinical records, risk assessments or care and treatment plans are in place of good quality and coproduction is evident through scrutiny of records in supervision, it is recommended that a minimum of 3 random records ought to be checked as part of each supervision session
ensuring that where appropriate case load complexity and caseload management issues are discussed and considered. Ensuring that caseloads are reviewed including discussions about complexity and case load management
ensuring that samples of the clinical records are reviewed within supervision including, care and treatment plans, risk assessments, and other elements of clinical records. It is recommended that a minimum of 3 random records ought to be checked as part of each supervision session

It is the responsibility of clinical or professional leads, modern matrons and service managers within the care groups to monitor the number of clinical supervisors that are available in their clinical area and to determine the number of new supervisors required on a yearly basis.

These requirements will be to meet workforce demand and counteract staff turnover; this information will be brought to the attention of operational management. It is also their responsibility to ensure that arrangements are made to cover long term absences of clinical supervisors.

4.4 Supervisors

All supervisors are responsible for:

ensuring that they have received relevant training and are competent to provide whichever form of supervision they are facilitating
accessing supervision for supervisors training within the trust in line with MAST requirements
ensuring that if the supervisor is new to role, then developmental needs are addressed with their line manager to facilitate additional support
ensuring that the supervision is recorded. Where group supervision has taken place, such as for ancillary colleagues, meeting notes may be the record of their supervision
inputting supervision activity into the staff portal (staff access only) (opens in new window)

For clinical supervision, supervisors are also responsible for:

ensuring that preceptorship and the care certificate are reviewed within clinical supervision if applicable
ensuring that annual supervision contracts are completed

4.5 All colleagues

All colleagues should be instrumental in setting the agenda for their own supervision which ensures relevant support is received
All colleagues have a duty to ensure that they seek out and participate in supervision in line with organisational and professional requirements and draw any shortfalls to the line managers attention

5 Procedure or implementation

This policy should be read alongside relevant professional guidance.
For example:

The NG225 self-harm, assessment management and preventing recurrence (NICE guidance) makes specific recommendation around staff supervision:

All colleagues who work with people of any age who self-harm should have the opportunity for regular, high-quality formal supervision from senior colleagues with relevant skills, training, and experience. Supervision should:

take into account the emotional impact of self-harm on colleagues and how best to support them
promote the delivery of compassionate care
focus on ongoing skill development
include reflective practice
promote confidence and competence in colleagues working with people who have self-harmed

All colleagues working with people who self-harm have easily accessible ongoing support from senior colleagues with relevant skills, training, and experience. Support should include:

clear lines of responsibility around decision-making, particularly for situations where there are challenges around the balance between autonomy and safety for a person who has self-harmed
emotional support or signposting to emotional support services, as preferred by the member of staff

Colleagues should refer to the safeguarding adults manual for further guidance.

5.1 Health and wellbeing support

Health and wellbeing conversations are required as part of supervision discussions. Supervision is to be used as a forum to collectively recognise presence of any trauma symptoms and the impact of these within a safe and supportive environment. We have a wide range of support available on our health and wellbeing pages which are on our intranet and website.

You can find all the information on our intranet COVID-19 news (staff access only) (opens in new window).

5.2 Types of supervision

Employees need to access the form(s) of supervision they require to meet the purpose and function of their role, profession, and any specific therapeutic function they are developing or delivering.

5.2.1 Clinical supervision

Clinical supervision is facilitated around an agreement or contract between the supervisor and supervisee(s) that details the responsibilities of the parties involved and sets the boundaries of the sessions. All clinical supervision agreements or contracts must include details of the boundaries of confidentiality and should be reviewed annually.

These agreements or contracts must always stipulate where a confidentiality breach would occur, in all cases harm to self or others either real or perceived would result in a breach and where behaviour contravenes the supervisee(s) professional code of conduct or the law. Supervisors may negotiate additional breach conditions as part of the agreement. Outside the breach conditions detailed on the agreement or contract, consent to share information should be obtained from the supervisee. Breaching of confidentiality without good cause could result in a disciplinary investigation or action in accordance with the disciplinary policy.

Clinical supervision must be provided by practitioners with experience and competencies in the relevant area of clinical practice. This does not necessarily have to be from a member of the same profession. Many nurses within our trust currently receive clinical supervision from either a medic or a psychologist, which is good practice. In some instances, clinical supervision may be delivered by practitioners outside the supervisee’s profession, providing they have the required skills and experience, and their guidance reflects any differences in professional code of conduct or practice. For example, a clinical nurse specialist in older people’s mental health could provide some elements of clinical supervision to an occupational therapist in the same specialty.

Considerations should be given to the effectiveness, scope and limitations of supervision and arrangements made to fulfil any gaps arising from profession or specific elements.

The quality of supervision is paramount to good practice and therefore all registered practitioners who express an interest in becoming a clinical supervisor should be assessed by their clinical or professional lead as having:

credible clinical practice
evidence of continuous professional development
qualities consistent with good quality supervision provision such as warmth, honesty, integrity, empathy, respect, and the ability to be reflective
ability to role model attitudes and behaviours that reflect the trust values (appendix B)

Clinical supervision is a structured process to:

reflect on and review practice
discuss individual cases in depth
change or modify practice and identify training and continuing development needs
scrutinise the quality of record keeping, risk assessments, care and treatment planning and co-production

When reviewing the quality of clinical records, this may include:

comprehensive and contemporaneous record keeping
comprehensive risk assessments and management plans
adhering to information governance principles
good quality care and treatment plans that are up-to-date, patient centred and relevant

Supervisor or supervisee must participate in scrutinising the clinical record to review quality of record keeping. Samples will need to be available within supervision to form part of the discussion.

There are various barriers to good quality record keeping and these should be considered or discussed within supervision to ensure that elements of the patient record are fully completed to appropriate standards. Supervisors may address behaviours associated with non-compliance within supervision sessions.

It is the responsibility of the supervisee to input into the relevant healthcare record where discussion of the case has occurred in clinical supervision with any actions arising from this.

Supervision can be delivered in a variety of ways and does not always need to be a formal 1 to 1 session. It may be facilitated within a group setting, via the phone, via video conferencing or in ward or team reviews of cases. It can be received from outside the trust with the agreement of the line manager or budget holder and the understanding of the supervisee that they have a responsibility to check that organisational policy and procedure allows them to follow guidance or advice from external supervisors. This arrangement would need to be formalised during the management supervision session.

To maintain high quality supervision, the supervisor may take anonymised issues they feel appropriate from the session forward for their own supervision. The supervisee will be informed of this, and the information shared will be kept to the minimum necessary, unless the above applies.

Clinical supervisor training can either be accessed in-house or through accredited training depending on professional requirements. Access to this training will need to be supported by the line manager. People who have attained clinical supervisor qualifications in other employment and who are supported by their team manager to take on the clinical supervisor role should provide details of their past training and experience to the learning and development department, to determine that their training meets the minimum learning outcomes recognised by the trust. Clinical supervisor training is a one-off event however, there is an expectation that clinical supervisors will use their own clinical supervision to embed and further develop their skills.

The nursing and midwifery council exists to protect the public. They do this by making sure that only those who meet their requirements are allowed to practise as a nurse or midwife in the UK, or a nursing associate in England. Although some nurses may not be in a role that is front facing and in direct contact with patients, if nurses are revalidating and they have a live registration, their work does impact on patients and aspects of care and the content of supervision sessions should reflect this. Through revalidation, nurses, midwives, and nursing associates provide evidence of their continued ability to practise safely and effectively. The Code is central to the revalidation process as a focus for professional reflection. Further information can be found on the NMC website (opens in new window).

5.2.2 Restorative supervision

The professional nurse advocate (PNA) programme delivers training and restorative supervision for nurses across England, using the A-EQUIP model. Restorative supervision contains elements of emotional and psychological support and through polite and professional challenge the supervisees develop further their ability or capacity to cope, especially in managing difficult situations. When faced with complex workloads and decision-making, professionals need to process feelings of anxiety, fear, and stress to liberate their minds, so they can focus on learning and development needs and move towards a more creative, solution focused approach.

Restorative supervision addresses the emotional needs of colleagues whilst providing ‘thinking space’, which reduces stress and burnout and in turn improves staff retention. Restorative supervision is open to nurses, student nurses and providers of nursing services.

Restorative supervision is in addition to clinical supervision, which focuses on colleague’s clinical workload and complex cases. Restorative supervision aims to provide psychological support and develop holistic resilience regarding emotional wellbeing.

This function of the A-EQUIP model addresses the need for nurses to be familiar with and contribute to quality improvement, to help improve patient care. Direct contribution to quality improvement and quality assurance systems, as well as ensuring the safety of those receiving nursing care, are fundamental aspects of a nurse’s role. This function ensures that the improvement of quality care becomes part of everyone’s role, every day, across the organisation and the wider NHS.

5.2.2.1 Professional nurse advocate structure within the trust

RDaSH has a nominated PNA lead and deputy lead who are the link between the trust and regional PNA leads. This is hosted by the nursing, safety and quality team and overseen by the director of nursing.

Within each care group there is a nominated PNA ambassador who provides group supervision and support to the professional nurse advocates within their services.

The PNA council (including the PNA lead and the organisations PNA workforce) meet on a bi-monthly basis and set the trust agenda and plan the direction of travel to fulfil the trusts’ commitment to the A-EQUIP model.

Each ward or department across the organisation should have a minimum of one identified PNA. PNA sessions will be recorded on the internal supervision portal and the data will be visible at care group level.

All PNAs will be encouraged to join local and regional ‘communities of practice’ events.

5.2.2.2 Oversight and assurance

The PNA lead will have oversight of the live register for the organisation.

The PNA ambassadors will collect the data for each care group and forward on to the workforce systems manager for RDASH who will complete and submit the provider workforce return (PWR) for the trust.

Any concerns raised during or following restorative supervision will be escalated to the PNA ambassadors or PNA council and appropriate action taken by them.

Information from the trust PNA council will be escalated to board through the matrons meeting, patients’ safety operational group and via bi annual report to quality committee.

Further information on the PNA role can be found on the NHS England website (opens in new window).

5.2.3 Non-medical prescribing (NMP) supervision

NMPs are active throughout the various care groups within the trust and have a wide range of roles and responsibilities. They are responsible and accountable for all aspects of their prescribing decisions, and to their employers and regulatory bodies for their actions or omissions. They should only prescribe those medicines they know are safe and effective for the patient and condition being treated within their sphere of competence and remain up to date with knowledge and skills to enable competent and safe prescribing.

As part of their practice, they must maintain and update a competency framework and receive a minimum of quarterly supervision from their supervising practitioner. An annual declaration must also be completed and submitted.

5.2.4 Safeguarding supervision

At every supervision session safeguarding should be discussed, however safeguarding supervision is mandatory for those colleagues working at level 3 and above as outlined in the intercollegiate document for children or the intercollegiate document for adults. It should be held a minimum of 3 monthly with a trained safeguarding supervisor and recorded on the staff portal. Documentation will be held securely by the safeguarding supervisor and a copy provided to the supervisee. It is the responsibility of the supervisee to record within the healthcare record that they have accessed safeguarding supervision and any actions arising from this.

Further guidelines for safeguarding supervision can be found in appendix C.

Safeguarding supervision sessions will count towards the trusts’ minimum frequency supervision requirements.

5.2.5 Management supervision

Management supervision is carried out by the supervisee’s line manager or delegated other (through a supervision hierarchy approach) and it should be collaborative in nature. It is compulsory as part of terms and conditions of employment.

Management supervision includes opportunities to reflect on performance and personal development review. Additional meetings can be arranged in response to staff and service need. All medical colleagues have an annual job plan review, which will take into account the annual business plan and the priorities of the care group as well as meeting the needs of the service.

The environment chosen for management supervision must be conducive to facilitating confidentiality during the session. However, material from these sessions can be shared on an anonymous basis with the wider organisation where this is appropriate, for example, with senior management and the learning and development department. It is good practice to inform the supervisee of the intention to share information, but their consent is not required.

Where colleagues are carrying out clinical work and they are registered health care professionals, the manager will routinely give feedback on performance against compliance with record keeping standards (risk assessments or care planning) and the quality of clinical record keeping. There is a tool in place for use within clinical skills (technical or non-technical) (staff access only) (opens in new window) and Benners’ tool (staff access only) (opens in new window) to assess competence, appendix K details contemporaneous records quality definitions and what makes a good quality record.

5.2.6 Medical supervision

5.2.6.1 Doctors in training

Doctors in training work within RDaSH but are not employed by RDaSH.  They have specific nationally prescribed supervision requirements, needing a minimum of an hour formal direct supervision each week, this is reflected upon within their e-portfolio.

Doctors in training that pass through RDaSH therefore sit outside our clinical supervision processes.

5.2.6.2 Consultants

The clinical supervision of consultants is modest. As expert practitioners obligated by the general medical council and Royal College of Psychiatrists to undertake self-directed learning and peer review, demonstrated through annual appraisal, there is no expectation of frequent clinical supervision for consultants.

It would be problematic to expect or require frequent supervision of consultants, because due to the context just described above, there is no requirement for regular clinical supervision, so it is explicit in consultants’ contracts of employment that they do not have regular clinical supervision.

However, the trust reflected upon how the national guidance from the Royal College of Psychiatrists (in the Occasional Paper OP98 “Continuing professional development, guidance for psychiatrists” published March 2015), Royal College of Psychiatrists, continuing professional develop (opens in new window). There is an expectation that consultants will meet formally with a peer group, with minutes, throughout the year. There is mostly a role of oversight in this forum, ensuring proposed and undertaken CPD is appropriate to that consultant’s role and area of practice.  The Royal College allows five hours per year per consultant to be clinical, within this forum.  The Royal College, general medical council and trust require two case-based discussions to be presented within this area to be appraised and critiqued by peers with formal written outcomes of this to be uploaded for annual appraisal and medical revalidation with the GMC.  This amounts to two hours of summative assessment each year.  This leaves three hours (of the five hours that the Royal College will allow) for broader clinical supervision.

This is in keeping with trust expectations, requiring that consultants attend three peer groups per year.  The Royal College of Psychiatrists also stipulates that there should be peer group reflection at the beginning, middle, and end of the year.

The proposal is that consultants therefore are expected to evidence three clinical supervision sessions per year within the RDaSH clinical supervision reporting.  For a doctor working less than full time this would be proportionately reduced.

5.2.6.3 SAS doctors

For doctors employed within RDaSH who are not in consultant posts, expectations of clinical supervision is identical to expectations to senior nurses in clinical posts.

5.2.7 The IAPT programme

The IAPT programme has its own competence framework, which is supported by the IAPT supervision guidance document. This guidance highlights the different types of supervision that should be present within an IAPT service.

The IAPT programme is outcome focussed and to facilitate this there should be within each IAPT service a clinician who is responsible for overseeing and ensuring effective supervision is delivered to all colleagues who are offering psychological intervention to patients. Without exception, individuals providing supervision should have completed a specific supervisor training course.

The amount of supervision that a supervisee receives should be proportionate to their role and whole time equivalent. There is a greater emphasis on supervision for trainees, as with qualified staff, all trainees are to be supervised by an experienced, qualified supervisor who can offer modality appropriate supervision.

Leading to effective outcomes, the IAPT supervision guidance states that supervision should be delivered by an IAPT colleague, be individual and take place weekly, for one hour and that every two to four weeks all ongoing clinical cases should be reviewed, this process is called case management supervision. Group supervision can also be considered but must be proportionate in time. Live and recorded observation are encouraged considering the fidelity to models and competency checks, this would be agreed supervisee to supervisor. Additionally psychological wellbeing practitioners are to receive one hour per week, individual case management supervision and clinical skills supervision, our hour every two weeks as minimum.

Outside the trust, trainees within IAPT service will also receive supervision, provided by the University they are associated with.

5.2.8 Talent or career management supervision, the career conversation

In our inclusive culture talent management is for everyone. The career conversation is the start of the talent management process, career stable and career active colleagues. The aim is to understand individuals, their career intentions, levels of job satisfaction and future aspirations and identify how individuals can be supported to maximise their job satisfaction and achieve their career aspirations.

The career conversation provides a structure for individuals and their reviewer to have regular conversations based upon the following principles:

its focus is individualised, humanistic and based on the person, their role and their career
it happens frequently, at least once a year and is complimented through regular one to ones
it assumes the person’ life, career, motivations, and performance are subject to change
it demonstrates how every individual’s contribution is valued and supports the development and retention of all our colleagues

It is not:

a way of categorising people or putting them in a box
a judgemental process that makes rigid assumptions about people’s future
a way of dealing with performance issues or having difficult conversations

The outcomes of career conversations should be recorded on ESR in the supervision or scope for growth area.

Career conversations summaries will be collated centrally to enable trust wide support for individuals where appropriate and to consider any succession planning opportunities identified.

A template to record the outcomes of career conversations is provided at appendix M and high-level information should be logged on ESR, supervision and scope for growth.

5.3 Frequency of supervision

Supervisees should have as much supervision as they need to fulfil their role. This may depend on experience and the type of role and should be negotiated accordingly. Research has shown a detrimental effect on supervisor wellbeing where effective supervision is not accessed (White et al.,1998). The frequency of supervision may be increased or decreased depending on changes in the work environment or the supervisee’s home life. As a minimum requirement to support a colleague within the workplace, supervision must take place every 6 to 8 weeks and should be of a high quality. The frequency of supervision should be adjusted pro rata for colleagues working part-time hours. This minimum requirement is applicable for clinical and management supervision and not related to talent or career management supervision. Supervision must be documented on the appropriate pro forma. Informal supervision, ad hoc discussions, may also take place.

5.4 Documentation of supervision

The templates provided in the appendices are designed to guide supervisors and supervisees to effectively document discussion points raised in supervision including the recording of safeguarding and management supervision. These templates are provided as an aid and are based around good practice standards, as the agenda will be focused on what the supervisee wishes to discuss.

The documentation will form part of and support the employee’s annual performance or personal development review (personal development review (PDR) policy, RDaSH NHS Foundation Trust) and where applicable preceptorship or care certificate.

The clinical supervision contract (appendix D) should be completed once the supervisor has been agreed.

The following templates are available to document discussion:

appendix E, supervision record (generic)
appendix F, values based supervision record(generic)
appendix M, career conversation feedback summary

There is an option of appendix E or appendix F to be used as documentation for any type of supervision. This should be determined by the person’s job role. Appendix F may be suitable to document a more detailed discussion to reflect on the trust values and how they positively influence actions.

Appendix G is a prompt sheet that has been designed as a way of supporting and structuring your clinical or safeguarding supervision discussion, please use this if you feel this would be helpful to you.

Appendix H provides information about the health passport which has been designed for individuals working in the trust with a long-term health condition, mental health condition, neurodiversity, or disability and learning disability to help them access the support they may need in the workplace. It allows individuals to easily record information about their condition, any reasonable adjustments they may have in place and any difficulties they face.

Appendix I is a safeguarding supervision contract and appendix J is a group safeguarding supervision record.

Documentation of supervision sessions must be maintained in line with standards for clinical record keeping, remaining the property of the trust, and should be filed or electronically stored within the colleague’s personal file. It is recognised that the confidentiality of these records is paramount to facilitate disclosure within the sessions and make the best use of supervision. No third party personal identifiable information should be recorded in these records, for example, full names or NHS or SystmOne numbers. Documentation should be stored securely to maintain confidentiality; supervisors and supervisees are advised where possible to scan their records to an electronic format.

All information disclosed in the supervision session will be kept confidential with the following exceptions:

where harm (real or perceived) to self or others is disclosed or potential for harm is recognised by the supervisor
where unsafe, unethical, or illegal practice is disclosed that the supervisee has failed to recognise or is unwilling to go through appropriate procedures or channels to address

When a colleague fails to reach required standards, managers should deal with the minor performance problems of their colleagues as they arise and document them in the supervision record. If these problems are ongoing or significant, the performance and, or conduct should be discussed immediately with a member of Human Resources (HR) to explore options available. Please refer to the following policy for further details and information performance (capability) management policy and procedure, RDaSH NHS Foundation Trust.

6 Training implications

6.1 All clinical and management supervisors

How often should this be undertaken: One off.
Length of training: 3 hours and 30 minutes.
Delivery method: Face to face (there is currently a blended approach to training because of the current restrictions and government guidance relating to COVID-19. This is under constant review in accordance with the latest advice).
Training delivered by whom: RDaSH learning and development.
Where are the records of attendance held: Electronic staff record.

6.2 Safeguarding supervisors

How often should this be undertaken: One off.
Length of training: 3 hours.
Delivery method: Face to face (there is currently a blended approach to training because of the current restrictions and government guidance relating to COVID-19. This is under constant review in accordance with the latest advice).
Training delivered by whom: RDaSH learning and development.
Where are the records of attendance held: Electronic staff record.

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings and supervision
continuous professional development sessions
posters
daily email (sent Monday to Friday)
practice development days
group supervision
special meetings
intranet
team meetings
local induction

Supervisors will be trained to carry out the various types of supervision that conform to professional requirements. The demands for training will be identified through the performance or personal development review.

Colleagues with professional leadership responsibilities will provide advice to managers and colleagues to support this process.

Undertaking safeguarding supervision and specialist clinical supervision as part of an academic course can be counted towards minimum clinical supervision requirements unless this is not permitted professionally.

6.3 Management supervision

Management supervisor training needs can be met through a variety of leadership and development opportunities which include mentoring, coaching and experiential learning as well as accredited and in-house formal training, therefore development is considered an ongoing process. It is acknowledged that many of the skills required for supervision are transferable from other areas of competence. Those new to line management responsibilities or fulfilling the role of management supervisor can access additional support from the Human Resources (HR) team.

The training needs analysis (TNA) for this policy can be found in the training needs analysis document which is part of the trust’s mandatory risk management training policy located under policy section of the trust website.

7 Monitoring arrangements

7.1 Compliance of supervision

How: Data grab from RePortal.
Who by: Head of workforce information and transactional services.
Reported to: Care group peoples’ meetings.
Frequency: Monthly.

7.2 Compliance of supervision

How: Full supervision report, colleagues names visible on multiple tabs.
Who by: Head of workforce information and transactional services.
Reported to: All managers.
Frequency: Monthly.

7.3 Effectiveness and compliance with the policy including the monitoring of clinical records (record keeping, risks assessments or care and treatment planning) with evidence of co-production

How: Data from P and I and L and D.
Who by: Associate nurse directors.
Reported to: People and organisational development committee.
Frequency: Annual.

7.4 Staff training

How: Training records.
Who by: Learning and development.
Reported to: Nurse directors.
Frequency: Annually.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the principles of the Mental Capacity Act (2005).

9 Links to any other associated documents

This policy should be read with reference to the following:

Supporting effective clinical supervision CQC supporting information and guidance (2013)
Performance (Capability) management policy and procedure RDaSH NHS Foundation Trust
Personal development review (PDR) policy RDaSH NHS Foundation Trust
Health passport guidance and health passport form (staff access only) (opens in new window)
CCAST Assessment Tool (staff access only) (opens in new window)
Benners’ tool to assess competence (staff access only) (opens in new window)

10 References

BABCP, (2023). Supervision Guidance (opens in new window).
Bond, M. (2010). Skills Of clinical supervision For nurses: A practical guide For supervisees, clinical supervisors and managers (supervision in Context). Open University Press.
Department of Health, (1993). A vision for the future: The nursing, midwifery and health visiting contribution to health and health care. NHS Management Executive, Stationery Office, London.
HM Government, (2015). Working together to safeguard children (opens in new window).
Morrison, T. (2005). Staff supervision in social care. Brighton: Pavilion.
NHS England, (2021). Nursing, midwifery and care staff delivering the NHS Long Term Plan, Professional Nurse Advocate. (opens in new window).
NHS England, (2021). The Improving Access to Psychological Therapies Manual (opens in new window).
NICE Guidance, (2021). Self-harm: assessment, management and preventing recurrence (opens in new window).
NMC NMP Standards, (2023). Standards for prescribers (opens in new window).
Nursing and Midwifery Council, (2015). NMC Code (opens in new window).
Safeguarding adults manual.
Royal College of Psychiatrists, (2015) Continuing professional development, Guidance for psychiatrists (opens in new window).
White, E, Butterworth, T, Bishop, V, Carson, J, Jeacock, J, and Clements, A. (1998). ‘Clinical supervision: insider reports of a private world’, Journal of Advanced Nursing.

11 Appendices

11.1 Appendix A Definitions and explanation of terms used

Definitions
Term	Definition
Clinical supervision	This term is used to refer to the supervision for all colleagues who directly care for people who use services, including registered professionals, support workers and those colleagues that work on the bank contract. Clinical supervision maintains the professionalism of these staff groups. In some professions and occupations, alternative titles may be used, such as ‘peer supervision’, ‘developmental supervision’, ‘reflective supervision’ or just ‘supervision’, but generally clinical supervision is seen as complementary to, but separate from managerial supervision. This is regular, protected time for facilitated in-depth reflection on complex issues influencing clinical practice. It aims to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development
Safeguarding supervision	This is a formal, accountable process which affords professional support and learning. It involves one or more practitioners meeting with a trained safeguarding supervisor to develop skills and competence, assume responsibility for their practice and enhance safety and protection of those at risk in complex situations (DoH 1993, Morrison 2005, Skills for Care and CWDC 2007),’ (policy and procedures on the protection, safeguarding and promoting the welfare of children (incorporating the safeguarding children supervision guidance) 2016). Sessions are facilitated by supervisors who are trained in safeguarding supervision and are based on a safeguarding supervision record and action plan. Safeguarding supervision is specifically targeted at clinical colleagues working routinely with children and adults at risk and may present with a range of vulnerabilities
Professional supervision	This term is often interchangeable with clinical supervision. This term is sometimes used where supervision is carried out by another member of the same profession or group. This can provide colleagues with the opportunity to: review professional standards keep up-to-date with developments in their profession identify professional training and continuing development needs ensure that they are working within professional codes of conduct and boundaries There can be varying professional and role specific types of supervision.
Non-medical prescribing supervision	Non-medical prescribers (NMPs) must have in place arrangements for supervision which supports their prescribing practice. NMPs should meet regularly with their supervising practitioner (SP) to discuss prescribing practice. Supervision sessions will be documented and signed by both the NMP and SP as a true account of the discussion (see non-medical prescribing policy)
Medical staff supervision	Many of our practitioners also have professional supervision, particularly medics and psychologists which is different from clinical supervision and the supervisor is someone from the same professional group
Consultant psychiatrists clinical supervision	In the line with the requirements of the Royal College of Psychiatrists, consultant psychiatrists are expected to be a member of a peer-supervision group, which provides a supportive and reflective space to monitor healthy practice. It is the choice of the individual Consultant, with the agreement of their line-manager, which of these options they would like to take part in, the option to mix and match would provide flexibility and allow Consultants to partake in sessions most suitable for them. The frequency of supervision should reach the RDaSH specified requirement of a minimum of every 6 to 8 weeks. Below are the options for the supervision format: 1 to 1 clinical supervision session between supervisee and supervisor, to be arranged by supervisee structured group supervision, akin to a Balint group, to be arranged by those wishing to take part in such a group open group supervision (peer supervision), this type of supervision can be arranged monthly for any consultant to attend if they wish to. For these regular organised sessions, the proposal is that the dates, room bookings and attendance register can be undertaken by medical HR or education, similar to the current arrangements for the weekly education meetings on a Wednesday external group supervision, this option may be preferable to those working in a sub-speciality where there are limited or no peers of that sub-speciality within RDaSH or for those who may already be part of external clinical supervision groups. For those who wish to take up this option, attending out of area supervision sessions every 3 to 4 months may be a suitable solution. This would be arranged by those wishing to partake in this type of clinical supervision non face to face clinical supervision, through digitally facilitated case discussions and reflection, as arranged by supervisee or supervisor
Specialty doctors	Specialty doctors should similarly be a member of a peer group and, as such, will also receive 1 to 1 clinical supervision from the consultant supervisor in their clinical area
Training grade doctors	Training grade doctors have different mandatory requirements for clinical supervision depending on the nature of their scheme. The Royal College of Psychiatrists requires that core and higher psychiatric trainees have one hour of 1 to 1 supervision each week from their consultant supervisor and this should form part of the consultant job plan where relevant. At this trust this has been extended to all trainees of any type (foundation doctors and general practitioners (GPs) on the vocational training scheme) and (non-trainee) specialty doctors
Management supervision	This is the setting and monitoring of management objectives with an individual and is guided by the organisation, care groups, and team or service business plans. All colleagues employed by the trust will have an identified line manager who has a responsibility to ensure that their colleagues undertake induction, comply with the trust’s appraisal process, monitor performance, staff health and wellbeing and identify any training and development requirements. For all employees providing direct clinical care, this will also include some form of caseload review where focus will include promoting safety, quality, and defensible practice in record keeping and identifying safeguarding issues. Care and treatment plans will also be reviewed to ensure they are timely, up-to-date, good quality and patient centred. All medical colleagues have an annual job plan review, which will take into account the annual business plan and the priorities of the care group as well as meeting the needs of the service. To summarise, management supervision is a regularly scheduled mechanism between managers and colleagues to: review performance set priorities or objectives in line with the organisation’s objectives and service needs identify training and continuing development needs
Record keeping	Supervisees must complete their self-assessment of competence (AOC) and share with their supervisor during supervision and then jointly scrutinise record keeping entries to enable the completion of supervisor AOC. Refer to the 12 standards below and rate your entries on a scale between 0 and 4 where 0 equals not at all. 4 equals all the time: relevant objective Concise complete jargon free logical clear accurate respectful abbreviations free understandable timely

11.2 Appendix B Values and behaviour framework

11.2.1 Passionate

We work hard to deliver a quality service.
We are determined to do what’s right for people.
We are positive in all that we do.
We endeavour to be our best through personal development.
We do our best to make a positive difference to people.

11.2.2 Reliable

We follow through on what we say we will do.
We take responsibility for things we can do something about.
We take ownership to know and follow best practice.
We are accessible whenever possible.
We turn up on time and complete tasks in the time agreed.

11.2.3 Caring and safe

We promote equality, diversity and inclusion.
We take a person-centred approach.
We take time to listen with empathy and compassion.
We introduce ourselves.
We make sure we keep people safe and speak up when something is wrong.

11.2.4 Open

We include people in the decisions that affect them and keep them informed.
We give and receive purposeful feedback.
We acknowledge our own biases and learn from others perspectives.
We celebrate our successes and learn together from our mistakes.
We are honest and accountable taking responsibility for our actions.

11.2.5 Supportive

We encourage good physical and mental health including promoting a healthy work-life balance.
We appreciate and respect other people’s input and ideas.
We value our patients, their families, their carers and each other.
We work together as #onerdash team.
We help each other to do the best job we can.

11.2.6 Progressive

We work together for continuous improvement.
We seek out and share information, knowledge, and experiences.
We are adaptable and flexible, open to innovation and change.
We strive for excellence through identifying and testing new ways of working.
We take responsibility to share and learn from and about each other.

11.3 Appendix C Guidelines for safeguarding supervision children and adults

Safeguarding supervision is required for those colleagues working at level 3 and above as outlined in the intercollegiate document, safeguarding children and young people, roles and competencies for healthcare staff (opens in new window) for children or the intercollegiate document, adult safeguarding, roles and competencies for health care staff (opens in new window) for adults.

11.3.1 The purpose, principles and components of supervision

Supervision is an interaction which should enable the service to:

maintain the quality and efficiency of services
ensure its commitment to the ongoing support, training, and development of colleagues
provide a supportive environment, sensitive to equal opportunities, which encourages the professional development of supervisors and supervisees

Supervision is guided by four principles:

sensitive to equal opportunities issues of the supervisee and supervisor
managed in a professional way
undertaken with mutual respect between the supervisor and the supervisee
regular assurance that it is fit for purpose

Supervision has four key components:

functional (normative), the promotion and maintenance of good standards of work, co-ordination of practice with policies of administration, and the assurance of an efficient and smooth-running service
reflective (formative), the facilitation of thoughtful and considered review of personal action in meeting organisational and professional objectives
educational (formative), the intellectual and emotional development of each individual colleague to enable them to reach their full potential
supportive (restorative), attention to the development and maintenance of emotional and intellectual capacity of the individual for personal well-being and good working relationships.

Safeguarding supervision is designed to:

ensure that the multi-agency practice is discussed and remains child focused or focused on making safeguarding personal
ensure that practice remains in line with legislation and procedures
ensure that practitioners fully understand their roles, responsibilities, and the scope of their professional discretion and authority
identify practice or management issues which could have an impact on safety and wellbeing of children, young people and adults at risk and discuss with managers as appropriate
explore the impact of any potential emotionally harmful environments on the child or adult at risk and agree the course of action
provide emotional support due to sensitivity of cases discussed
identify the training and development needs of practitioners, so that each has the skills to provide an effective service
review other areas of safeguarding management issues which could have an impact on professional workload and safe practice

Consideration also needs to be given to safeguarding issues and impact on children and adults at risk, particularly where:

parents, carers or member of the family living in the household have poor mental health
parents, carers are violent, abusive or highly resistant or hard to reach individuals
families are experiencing domestic abuse
parents or carers have a learning disability
parents or carers have a substance misuse issue

It is important to consider whether there is any impact on their ability or capacity to parent or care and assessments and analysis of risk should be discussed and an action plan agreed. It is also necessary to consider who is and, or should be involved in plans of support and appropriate information sharing.

Safeguarding supervision can be delivered via the following methods:

one to one supervision by an individual trained in delivering safeguarding supervision
multi agency supervision
group supervision facilitated by an individual trained in delivering safeguarding supervision

It is good practice in safeguarding supervision that both the supervisor and supervisee draw up a contract of supervision.

Responsibilities of supervisors include:

receiving regular supervision
facilitating and protecting the availability of time for supervision
recording supervision using the portal
ensuring that the diverse needs of the person being supervised are considered in relation to the process
adhering to the principles of this supervision policy
maintaining an environment conducive to achieving the aims of supervision
aiming to develop a supportive relationship to facilitate reflection and exploration
fulfilling responsibilities in relation to agreed action plans within the process of supervision
attempting to identify and resolve any areas of potential conflict that may arise within the process of supervision
seeking advice from a Safeguarding Named Nurse or lead professional, where conflicts remain unresolved

Responsibilities of supervisees include:

prioritising and attend supervision
discussing with and choosing an appropriate model of supervision
bringing issues of risk, health and safety to the attention of the manager
identifying learning and development and training needs that may be required
in partnership with the supervisor
actively identifying agenda items
maintaining personal portfolio

11.3.1.1 one to one supervision

Face to face, video conferencing or over the phone.

11.3.1.2 Multi agency supervision

Access to multi agency supervision is recommended in ‘What about the children’ (Ofsted March 2013). Colleagues requesting multi agency supervision will discuss this with their manager, safeguarding supervisor, named nurse, or lead professional, who will help to make arrangements with partner agency counterparts. Once completed, the manager is responsible for recording the colleague’s attendance at supervision on the staff portal.

11.3.1.3 Group supervision

This is a process where practitioners come together to reflect on their work by pooling their skills, experience, and knowledge. Group supervision can be case specific or based around a topic. It can be used to support a service team or include members of different teams who are working with the same family.

11.3.1.4 Safeguarding supervisors

Safeguarding supervisors must have attended safeguarding supervision training to be able to facilitate a safeguarding supervision session.

Safeguarding supervisors are practitioners who have received training to Level 3 or higher in safeguarding children or adults, who have also completed an additional full day safeguarding supervisors and practice leaders’ course. They act as a link between the Safeguarding Children and Adult team and their own clinical teams, offering day to day advice and support on safeguarding issues. They are also ideally placed to cascade safeguarding information to colleagues.

11.3.1.5 What safeguarding supervisors can expect from the Safeguarding team

Training in safeguarding supervision.
A support visit to their clinical area one month after the course.
Invitations to quarterly learning forums.
Invitations to supervisors group supervision sessions.
Receipt of any safeguarding information for their own use and to cascade to teams.
Day to day support with individual cases as requested.

11.3.1.6 What is expected of safeguarding supervisors?

Keep up-to-date with safeguarding training to level three.
Attendance at safeguarding supervisor training.
Attendance at quarterly supervisors’ supervision sessions and learning forums where appropriate.
Delivery of individual and group supervision within clinical their team.
Recording of supervision sessions using the portal.
Provision of day-to-day advice on safeguarding issues to clinical team.
Cascade safeguarding updates and information sent out by Safeguarding team to colleagues.

11.3.1.7 The safeguarding supervisors’ forum

Safeguarding supervisors’ forums take place on a regular basis in each of the geographical areas where RDaSH services are provided, co-terminus with the safeguarding children partnerships and safeguarding adult boards.

Forums are split into two halves, the first part of the session focusing upon dissemination and discussion of local safeguarding developments, national and local research, and guidance, and sharing good practice, listening to guest speakers. The second part of the session considers anonymised cases or scenarios provided reflective safeguarding supervision for those present. The named nurse or lead professional will record attendance on the portal.

In order to remain compliant with safeguarding supervision, safeguarding supervisors are expected to have supervision 3 monthly by a named nurse or lead professional or attend supervisors forums.

Named nurses or lead professionals have the following responsibilities in respect of the safeguarding supervisors forums:

offer supervision to safeguarding supervisors
coordinate and facilitate supervisors’ forums in each geographical area
record attendance of supervisors at supervision with named nurses and lead professionals or supervisors’ forums
retain a list of trained supervisors via the Safeguarding team administrators
communicate with supervisors who had not had supervision or have not attended a forum in a 3-month period to explore where they are getting their support

11.3.1.8 Named nurse or lead professional supervision

Named nurses and lead professionals receive regular supervision from the nurse consultant for safeguarding.

Supervision with a named nurse or lead professional is available on request. Supervisor and supervisees can contact the Safeguarding team to request one to one supervision which can be conducted face to face, via Skype or over the phone.

Where a named nurse or lead professional conducts a supervision session they will record it on the staff portal.

11.8 Appendix H What is a health passport?

The health passport has been designed for individuals working in the trust with a long-term health condition, mental health condition, neurodiversity, or disability or learning disability to help them access the support they may need in the workplace.

It aims to support colleagues to manage their health at work and remove obstacles in communicating their condition as they change role, department, or trust throughout their NHS career.

It allows individuals to easily record information about their condition, any reasonable adjustments they may have in place and any difficulties they face.

The passport helps to ensure there is a clear record and can be used with new line managers to explain what is needed in the workplace to help them carry out their role.

11.8.1 How should it be used?

For new colleagues, the passport can be discussed at their induction. It is important that the passport is used positively, and the individual understands that its purpose is to support them at work.

It can also be used as a tool to have ongoing conversations around an individual’s support needs in the workplace.

When scheduling a meeting with new or existing colleagues to discuss workplace support, you should:

assure the individual that the meeting and anything included in the passport will be held confidentially
make clear that the focus is on supporting the induvial to thrive at work
confirm that any actions you take as a manager are recorded and timeframes agreed
ask the individual if any adjustments have been agreed with occupational health and, if not, if they would like to be referred for an assessment
encourage the individual to share their thoughts throughout the meeting
ensure that any actions agreed with your colleague are reasonable for the trust, team, and department

The passport can also be used to help individual colleagues understand their needs, but it is crucial that they give their consent for the information to be shared wider than their immediate line manager

11.8.2 Suggestions for ways to open the conversation

“I would really like to use this time today to understand more about you and how I support you at work.”
“Can you explain what helps you to thrive at work?”
“I would like to discuss the information in your Health Passport so we can look at providing the right space and equipment for you to excel in your role.”

11.8.3 Where do you keep it?

Any information provided by any individual, either online or in paper form, is sensitive data and must be kept securely. It is the responsibility of the individual to look after their own copy of the passport.

11.8.4 When should it be updated?

The health passport is a live document and can be revisited as the conditions or needs of the individual change. Any changes should be recorded, signed, and dated by the individual and their line manager.

Further links to the health passport guidance and health passport form (staff access only) (opens in new window).

11.9 Appendix I Safeguarding supervision contract

Appendix I Safeguarding supervision contract (staff access only) (opens in new window)

11.10 Appendix J Group safeguarding supervision record

Appendix J Group safeguarding supervision record (staff access only) (opens in new window)

11.11 Appendix K Contemporaneous records quality definitions

11.11.1 What makes a good quality patient record?

Right login, are you logged in as yourself?
Right record, are you in the correct patient record? Double check before you start adding an entry.
Right module, are you in the right module?

Right place, are you in the correct template in the record for this piece of information?
Right time:
- are the entries or detail in the correct order chronologically where possible?
- have they been entered in a reasonable timeframe after contact with the patient? If not, have you explained why in the record?
Right detail included, for example:
- allergy status
- next of kin
- language
- documented fully that a letter has or has not been shared (check generic information tab)
- colleagues and other attendees documented, names and job roles in full
- actions and reasoning clear and relevant to the entry
Right wording used:
- wording appropriate, clear, and factual and relevant
- opinion, jargon, and speculation free
- free from abbreviations, or where used, to be written in full in first instance
- enough information to make the entry clear and to the point, avoid confusion (colleague or patient)
Right communication identified:
- nominated person to contact if not the patient themselves, carer or family member
- declined to share information with carer or family members
- ss this clear to other colleagues?
- have you checked the demographics? Address, contact numbers etc.
- alerts or flags
- correct format identified

Is the patient record individualised, reflecting person centred care which is:

appropriate and realistic
meets their individual needs
reflects the patients’ preferences

The record may also be accessed by other professionals who may be external to the organisation for the purposes of health and or social care delivery and they must be able to understand what is written.

11.12 Appendix L Supervision agreements

11.12.1 Where possible ‘in care group’ supervision arrangements should be made

If ‘in care group’ options are not possible (due to lack of specialism, lack of seniority or personal reasons) gain supervision from an appropriately qualified RDaSH supervisor in different care group, providing a reciprocal offer of supervision so not to disadvantage each other.

11.12.2 If “in trust” arrangements are not possible

If “in trust” provision is not possible due to lack of access to appropriate specialism, then an arrangement is to be sought with an ICS or NEY partner. The agreement for supervision should either be agreed with a reciprocal arrangement to make this cost neutral, or if no reciprocal arrangement can be agreed, a ‘reduced rate cost’ should be negotiated as part of multi-system working.

11.12.3 If integrated care system or North East and Yorkshire NHS service arrangement are not possible

If the above options have been exhausted, and the only option left is externally commissioned private supervision this should be gain as the most reasonable cost and reviewed at a minimum of a yearly to explore whether there has been any change in terms of internal or ICS or NEY.

11.13 Appendix M Career conversation feedback summary

Appendix M Career conversation feedback summary (staff access only) (opens in new window)

Document control

Version: 4.1.
Unique reference number: 506.
approved by: Corporate policy approval group.
Date approved: 25 January 2024.
Name of originator or author: Deputy manager and lead facilitator, learning and development.
Name of responsible individual: Director of people and organisational development.
Date issued: 26 January 2024.
Review date: 31 March 2026.
Target audience: All colleagues.

Page last reviewed: December 10, 2024
Next review due: December 10, 2025

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