Supervision policy and guidance for

Clinical and professionally registered staff

POLICY DOCUMENT – VERSION CONTROL CERTIFICATE
TITLE / Title: Supervision policy and guidance for
Clinical and professionally registered staff
SUPERSEDES / Supersedes: None
Description of Amendments: Reference to College of Social work at 1.3 removed
ORIGINATOR / Originator/Author: Mr. Michel Le Straad
Designation: Designated Nurse for Safeguarding & Vulnerable People,
Clinical lead and advisor for PREVENT, Mental Capacity and the Deprivation of Liberty Safeguards
EXECUTIVE APPROVAL / Approved by: Chief Operating Officer
Date Approved :Discussed but not approved July 2014
EQUALITY ANALYSIS / Date Completed: January 2014
Link to website: [to be completed once form is uploaded onto the CCG website]
CIRCULATION / Issue Date:
Circulated by:
Issued To: (as per Circulation List)
REVIEW / Review Date: August, 2016
Responsibility of: Mrs Catherine Randall
Designation: Chief Nurse
CIRCULATION LIST
Prior to Approval, this Policy Document was circulated to the following for consultation:
Chief Clinical Officer
Chief Operating Officer
Designated Nurse for Safeguarding Children and Young People
Following Approval this Policy Document will be circulated to:
All CCG employees
CONTENTS
Section / Page
1 / Introduction / 4
2 / Purpose / 5
3 / Roles & Responsibilities / 5
4 / Clinical and professional supervision / 7
5 / Procedure / 8
6 / Guidance for Supervision Meetings / 9
7 / Evaluation / 10
8 / Training / 11
Appendices
Appendix 1 / Supervision Contract / 12
Appendix 2 / Supervision Plan & Decision Making Record / 14
Appendix A / Checklist for the Review and Approval of Procedural Document / 16
Appendix B / Equality Impact Assessment Checklist / 19

Supervision Policy and guidance for clinical and professionally registered staff

1. Introduction

1.1Supervision has been defined as a regular protected time for facilitated, in depth reflection on professional and 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. (Bond and Holland 1998)

1.2Supervision is a structured, formal process through which staff can continually improve their professional and clinical practice, develop skills, maintain and safeguard standards of practice.

1.3The Nursing and Midwifery Council (NMC) supports the establishment of clinical supervision as an important part of clinical governance and in the interests of maintaining and improving standards of patient and client care. (NMC 2002). As part of a Nurse or Midwifes Revalidation programme on a 3 yearly basis registrants will be required to evidence that they have undergone a minimum number of clinical supervision sessions, these can also count towards the required trajectory for reflective practice discussions. As part of the CCG’s commitment to ensuring all its Nurses successfully revalidate, the provision for clinical supervision will be both supported and encouraged.

1.4The Health, Care & Professions Council Standard of Proficiency recognises the importance of professional supervision alongside other forms of Continuing Professional Development (CPD) as do other Allied Health Profession specific bodies in highlighting the importance of supervision in the quality and safety of services and the value of reflection on practice. (HCPC 2013)

1.5This policy underpins the values of NHS Trafford CCG (hereafter known as the CCG). It supportsand embeds professional/clinical supervision processes across all registered professional groups thus providing a safe environment that enhances quality commissioning and service delivery. The process also contributes to annual appraisals and personal development plans through the delivery of continuous support.

1.6The term ‘supervision’ describes a range of interventions. Clinical/professional supervision is mandatory for all registered practitioners.

2.0Purpose of this policy

2.1This policy outlines the mandatory requirement for all clinical and professionally registered staff to undertake supervision on a regular basis. It describes the procedure and provides procedural guidance for managers, supervisors and supervisees. It provides copies of the mandatory documentation required for the recording of all supervision.

2.2The procedure outlines to supervisors the process for all clinical and professionally registered staff employed by the CCG. It is based on the organisation’s commitment that all clinical and professionally registered staff members undertake continued professional development and have an opportunity to reflect on their clinical and non-clinical work to ensure safeguarding, safe practice, ongoing service improvement, the identification of learning and development needs on a regular basis.

2.3This policy and procedure supports the CCG’s commitment to having in place clear processes to ensure the safeguarding of vulnerable adults and children.

2.4Discussion of safeguarding of vulnerable client groups is mandatory in all supervision meetings for clinical staff.

3. Roles & Responsibilities

3.1The Chief Operating Officer has overall responsibility and accountability for ensuring there are robust clinical supervision arrangements in place for relevant clinical staff and professionally registered staff and that these are implemented within the commissioning organisation. The Chief Operating Officer has delegated the management of Clinical Supervision to the Designated Nurse for Safeguarding & Vulnerable Adults.

3.2The Designated Nurse for Safeguarding & Vulnerable Adults will ensure that a model of clinical and professional supervision is available to clinical and professionally registered staff within the CCG.

3.2.1The Designated Nurse will provide a quarterly exception report to the Quality, Finance and Performance Committee regarding the implementation of this policy across the commissioning organisationand include cases where appropriate audit and monitoring has not been undertaken, or where relevant staff do not have a named supervisor responsible for their clinical or professional supervision or are not completing regular supervision sessions. The Designated Nurse will also report on the actions taken to rectify such instances.

3.3Heads of Service will ensure that all relevant staff members have access and time to participate in regular clinical or professional supervision. CCG heads of service will provide the Designated Nurse with a quarterly exception report, following consultation with line managers. The exception report will indicate cases where appropriate audit and monitoring has not been undertaken, or whererelevant staff do not have a named supervisor responsible for their clinical or professional supervision or are not completingor participating in regular supervision sessions. Head of Service will also include in the exception report the actions taken to rectify any such instances.

3.4CCG line managersof clinical and professionally registered staff are required to be aware of, and implement, this policy.CCG line managers have a responsibility for ensuring clinical and professionally registered staff in their teams have access to and participate in clinical supervision and that there is evidence of protected time and documentation of attendance.

3.4.1CCG line managers will, through quarterly audit and monitoring, ensure all staff members have a named supervisor responsible for their clinical supervision and completion of regular supervision sessions.

3.4.2CCG line managers will provide their head of service with a quarterly exception report, following consultation with employees. The exception report will indicate cases where relevant staff do not have a named supervisor responsible for their clinical or professional supervision or are not completing or participating in regular supervision sessions. Line managers will also include in the exception report the rationale for any such instances and actions taken to rectify these.

3.5CCG employed clinical and professionally registered employeesare required to be aware of,and implement, the requirements of this policy.

3.5.1CCG employees to whom this policy applies will identify a named supervisor responsible for their clinical or professional supervision.CCG employees may, should they choose, select a clinical or professional supervisor external to the CCG.

3.5.2CCG employees to whom this policy applies must inform their line manager where they experience difficulty in identifying an appropriate clinical or professional supervisor or where the clinical or professional supervisor is unable to continue to offer this support.

3.5.3Clinical and professionally registered employees must ensure they schedule regular supervision sessions to which the actively contribute and engage.

3.5.4Clinical and professionally registered employees who deliver care or participate in the review of commissioned care, must, in advance of any supervision session discuss and agree with their line manager appropriate time away from the workplace to undertake their clinical or professional supervision.

3.6Clinical and professional supervisors are skilled, experienced professionals who assist clinical or professionally registered employees in the development of their skills, knowledge and professional values.

3.6.1All supervisors are required to have attended training and be responsible for keeping up to date on supervisory issues/responsibilities.

3.6.2All supervisors are required to recognise issues of accountability and where boundaries of supervision sit as opposed to individual responsibilities and ethical practice. Any issues arising in clinical or professional supervision around competence, safeguarding or personal conduct which conflicts with the employee’s code of professional conduct should be evidenced in the recording and reported back to line managers. The supervisee will be informed that this is to happen and a clear rationale given for why.

3.6.3All supervisors will ensure supervisees have completed and understood the preparatory workbook prior to the commencement of supervision

3.6.4All supervisors will ensure a record of each supervision session is kept, they will also record the number of supervision sessions providedto individual employees. This policy extends to those supervisors who are external to the organization. Supervisors by recording the number of supervision sessions undertaken and through the provision of documentary evidence will support monitoring and audit of this policy by line managers.

3.6.5Where supervisors who are external to the organization are unwilling or unable to agree and adhere to the requirements of this policy they must inform the employee in writing and decline to accept the responsibility for supervising the employee.

4. Clinical and professional supervision

4.1The Department of Health definition is: - A formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety in clinical situations.

The right for clinical and professional supervision extends to all staff of all national agenda for change pay bands and those employed on local CCG pay bands.

5. Procedure

5.1Delivery of and participation in clinical or professional supervision is mandatory for all professionally registered employees as determined by their role. However a “common sense” discretionary approach to frequency and duration of clinical or professional supervision meetings should be implemented within teams. The rationale for determining frequency of supervision meetings must take account of, and provide evidence for, an individual’s needs and circumstances, for example individual roles and responsibilities or area of work.

5.2All clinical/professional staff who conduct supervision must attend supervisory skills training.

5.3An introduction to clinical and professional supervision processes must be covered by the line managers during local staff induction/orientation for new staff.

5.4For clinical and professional supervision a supervision contract must be agreed and signed by both parties.

5.5All clinical and professionally registered staff are mandated to participate in supervision sessions which ideally will be someone from within the local service area. A choice of supervisor may be made available to the supervisee, where this is able to be facilitated. CCG employees may, should they choose, select a clinical or professional supervisor external to the CCG.

5.6For Clinical Supervision, Group supervision is one of the recommended models of clinical supervision within the CCG. (Group supervision does not exclude use of individual supervision where teams do not exist or where an individual format has been discussed and is felt to be appropriate).

5.7The aim of clinical and professional supervision is to ensure the safeguarding and welfare of service users by supporting and developing staff so that they are able to deliver the highest quality of clinical care.

5.8Clinical and professional supervision is a process that provides uninterrupted, quality time to allow professionally registered employees to undertake reflection and self-assessment with an experienced practitioner(s) to maintain and develop their quality of practice. There are a number of formats for clinical and professional supervision, which can be multidisciplinary, including, one to one, peer and group supervision.

5.9Frequent changes of supervisor, or having several different supervisors over a short period of time, should be avoided except in exceptional circumstances.

5.10The uptake of supervision will be monitored locally within the CCG and may be audited at anytime but as a minimum quarterly. Responsibility for the quarterly audit of clinical and professional supervision will rest with line managers. Accountability rests with the Designated Nurse for Safeguarding and Vulnerable Adults and Chief Operating Officer.

6.Guidance for Supervision Meetings

Guidance / Clinical Supervision
Confidentiality / Confidentiality should be discussed and clarified when negotiating the supervision agreement.
Confidentiality will be maintained except in cases where safeguarding, professional competence or capability issues are identified which must be dealt with in accordance with the organizations policies and procedures
The venue should provide an environment where confidentiality can be maintained.
Purpose / Clinical and professional supervision provides a formal structured relationship, offering support and guidance for professionals to develop through reflection and promotion of research based best practice
Frequency / 4 – 12 weeks
Actual frequency will be determined based on the needs, role and responsibilities of the individual post holder
Duration / 1-2 hour (approximate)
Schedule / Dedicated uninterrupted time allocated
Meetings booked 6 – 12 months in advance
Cancellations, lateness and/or rescheduling to be avoided.
Where this occurs it must be discussed and documented at the next meeting
Record Keeping / Supervision Contract/Agreement contract to be signed by supervisor and supervisee before supervision commences (Pro forma)
1) Supervision Plan and Decision Making Record to be signed by supervisor and supervisee (Pro forma)
2) All records to be kept on supervisors file with copy for supervisee’s own records

7. Evaluation

Local compliance will be monitored within individual teams and the CCG Quality, Performance and Finance Committee will further monitor compliance and effectiveness through audit, survey and feedback.

7.1 Audit Standards

  • All staff undertaking clinical or professional supervision are trained in clinical and managerial supervisory skills within 6 months of appointment
  • All clinical and professionally registered staff have access to clinical supervision
  • All clinical and professional supervision is recorded and records retained by both parties
  • Copies of supervision records that identify concerns should be provided to the line manager
  • All clinical and professionally registered staff have a current clinical supervision agreement that is reviewed at least annually
  • Supervision records may be used by the supervisee to inform annual performance reviews/appraisals

8. Training

8.1Initial and refresher training will be provided by Greater Manchester CSU and detailed in the Greater Manchester CSU training schedule accessed via the Human Resources Business Partner.

Supervision Contract

Clinical Supervision Proforma
Name of Supervisee
Name of Supervisor
Frequency of meetings Agreed:
Duration of meetings agreed:
Venue for meeting to be held:
Supervisor responsibiltiies
To maintain confidentiality (unless there are professional reasons why this cannot be upheld).
To lead on the structure of the meeting
To maintain and develop own supervision knowledge and skills
To offer advice, support and challenge to enable supervisee reflection on practice issues
To share information, experience and skills appropriately
Supervisee responsibilities
Identify issues to discuss
Be open to advice, support and challenge as part of reflective practice
Implement agreed actions
Maintain own records
Shared responsibilities of supervisor and supervisee
To abide by the agreed terms laid down in this contract
To prepare for the supervision session to maximise effective use of time
To contribute proactively to the session
To complete supervision records
To prepare for and maintain privacy and confidentiality (within professional parameters)
Disclaimer
All information that is disclosed during clinical supervision will be treated with strict confidentiality and will not be discussed outside of the session EXCEPT where disclosures:
  • relate to criminal offences
  • are an actual or potential breach of the supervisees code of conduct,
  • or would impact on the health, safety and/or well-being of others.

Supervisor / Supervisee
Name
Signature
Date contract signed
Date of Contract review: / Name
Signature
Date contract signed

Supervision Plan &

Decision Making Record

Supervision Plan & Decision Making Record
This written record must be completed as part of the supervision meeting. The record must accurately reflect the discussion and agreed actions and be signed by BOTH the supervisor and the supervisee at the end of each meeting or the beginning of the next.
Name of supervior
Name of supervisee
Date and time of supervision session:
Duration of supervision session:
Plan and decision making
Topic / Discussion / Actions
By whom / By when
Safeguarding Children and/or Adults
Agreement
We the undersigned agree this as a true and accurate record of the supervision session recorded on this document.
Supervisor / Supervisee
Name:
Signature:
Date signed: / Name
Signature
Date signed:

Appendix A: Checklist for the Review and Approval of Procedural Document

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed: / Yes/No/
Unsure / Comments
1. / Title
Is the title clear and unambiguous? / YES
Is it clear whether the document is a guideline, policy, protocol or standard? / YES
2. / Rationale
Are reasons for development of the document stated? / YES / The CCG is required to have a supervision policy for clinical and professionally registered employees
3. / Development Process
Are people involved in the development identified? / YES
Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? / YES
Is there evidence of consultation with stakeholders and users? / YES
4. / Content
Is the objective of the document clear?
Is the target population clear and unambiguous?
Are the intended outcomes described?
Are the statements clear and unambiguous?
5. / Evidence Base
Is the type of evidence to support the document identified explicitly?
Are key references cited?
Are supporting documents referenced?
6. / Approval
Does the document identify which committee/group will approve it?
If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?
7. / Dissemination and Implementation
Is there an outline/plan to identify how this will be done?
Does the plan include the necessary training/support to ensure compliance?
8. / Document Control
Does the document identify where it will be held?
Have archiving arrangements for superseded documents been addressed?
9. / Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?
Is there a plan to review or audit compliance with the document?
10. / Review Date
Is the review date identified?
Is the frequency of review identified? If so is it acceptable?
11. / Overall Responsibility for the Document
Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation?
Individual Approval
If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.
Name / Date
Signature
Committee Approval
If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.
Name / Date
Signature

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