Document name:
Supervision of the clinical workforce
policy
Document type:
Policy
What does this policy
replace?
Update and alignment of previous
SWYT and NHS Barnsley supervision
policies.
Staff group to whom it
applies:
Distribution:
All staff employed by the Trust who
have direct clinical contact with
service users or provide supervision
to those staff, including doctors in
training.
The whole of the Trust
How to access:
Intranet
Issue date:
October 2012
Next review:
July 2015.
Extension to May 2016 agreed by
EMT 14 January 2016
Approved by:
Executive Management Team
Developed by:
Alison Hill,
Lead Nurse Community Mental
Health/ Facilitator of Clinical
Supervisor Training
Barnsley BDU
Director of Nursing, Clinical
Governance and Safety
Director leads:
Contact for advice:
Professional/Clinical Leads
1
CONTENTS
1
2
3
4
5
6
7
8
9
10
11
12
Introduction .................................................................................................... 4
Purpose .......................................................................................................... 4
Definitions ...................................................................................................... 5
3.1 Management Supervision ........................................................................ 5
3.2 Clinical Supervision ................................................................................. 5
3.3 Safeguarding children supervision .......................................................... 5
3.4 Preceptorship .......................................................................................... 6
Duties .............................................................................................................. 6
4.1 Executive Management Team ................................................................. 6
4.2 Clinical Governance and Clinical Safety Committee ................................ 6
4.3 The District Director ................................................................................. 6
4.4 General Managers, Associate Medical Directors, Service Managers,
Clinical Leads, Consultants, Medical Tutors and Team Managers ........... 6
4.5 Supervisors ............................................................................................. 6
4.6 All Clinical Staff ....................................................................................... 7
Equality Impact Assessment ........................................................................ 7
Dissemination and Implementation Arrangements .................................... 7
Supervision Standards for Practice ............................................................. 7
7.1 Management Supervision ........................................................................ 7
7.2 Clinical Supervision ................................................................................. 8
7.3 Safeguarding Children Supervision ......................................................... 9
Training ........................................................................................................... 9
8.1 Management Supervision ........................................................................ 9
8.2 Clinical Supervision ................................................................................. 10
8.3 Safeguarding Children Supervision ......................................................... 10
Process for providing evidence of compliance with the policy .................. 10
Process for providing evidence of assurance ............................................ 11
Process for review and revision ................................................................... 11
References ..................................................................................................... 12
Appendix A
Equality Impact Assessment Tool ............................................................................ 13
Appendix B1
Supervision Requirements of the Yorkshire Deanery ................................................ 15
Appendix B2
Supervision Form for Doctors ................................................................................... 31
Appendix C
Sample Document Supervision Standards for Practice ............................................ 32
Appendix D
Clinical Supervision Proforma .................................................................................. 53
Appendix D2
Clinical Supervision Contract ................................................................................... 54
Appendix D3
Supervision Record 1:1 ............................................................................................. 56
2
Appendix D4
Supervision Record Group ....................................................................................... 57
Appendix E
Safeguarding Children Supervision .......................................................................... 58
Appendix E1
Contract for Safeguarding Children Supervision ...................................................... 58
Appendix E2
1:1 Safeguarding Children Supervision Record and Action Plan ............................. 59
Appendix E3
Safeguarding Supervision Contact Sheet/Record of Supervision ............................ 61
Appendix F
Minimum Learning Outcomes for Clinical Supervision Training ............................... 63
Appendix G
Checklist for the Review and Approval of Procedural Document ............................. 64
Appendix H
Version Control Sheet .............................................................................................. 66
3
Supervision of the clinical workforce policy
1.
Introduction
South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) recognises the
important role that the appropriate supervision of clinical staff plays both in contributing
to high quality clinical and professional practice leading to improved outcomes for the
people using our services and also in maintaining the well-being of our workforce.
Supervision supports the implementation of the workforce development strategy and
sits with the clinical governance framework.
This policy describes the different types of supervision endorsed within SWYPFT and
sets minimum standards for the supervision of all clinical staff. Some clinical areas or
professionals may have further requirements that are over and above these minimum
standards.
This policy provides a framework for practice for all clinical staff within the Trust,
including local authority staff working in integrated teams.
The format of the policy was designed to meet standards 6.1 of the National Health
Service Litigation Authority (NHSLA) standards (2012-13), Care Quality Standards
(outcomes 7, 14 and 16) and complies with the Trust policy for the development,
approval and dissemination of policy and procedural documents. It should be read in
conjunction with:
Nursing Preceptorship Programme
Policy and Procedures on the Protection, Safeguarding and Promoting the Welfare of
Children
Appraisal Policy
Medical Appraisal Policy/Appraisal for consultants and Appraisal for non-consultants
Dealing with poor performance at work policy/procedure
2.
Purpose
The purpose of this policy is to provide a formalised framework for the facilitation and
monitoring of supervision of all staff employed by SWYPFT who have direct clinical
contact with service users* and those who provide supervision to those staff. The term
‘clinical staff ‘is used to describe all of those staff, whether or not they have a
professional health care qualification. *The term ‘service user’ is used within this
document to refer to any person in receipt of SWYPFT clinical services including
carers.
Supervision is a practice focused, professional relationship involving a clinician
reflecting on practice guided by a skilled supervisor. No single model of supervision
can be adopted across the Trust as services must use the model that enables best
practice delivery, therefore one of the responsibilities of service managers is to ensure
that the model in use within their service is fit for purpose, provide evidence of this and
that supervision activity is taking place.
4
3.
Definitions
The Trust is committed to the notion of effective supervision and recognises that
different types of supervision are required to provide an efficient and effective modern
health service. There are four types of supervision formally recognised and supported
by the Trust:
3.1 Management supervision – This is the setting and monitoring of management
objectives with an individual and is guided by organisation, business unit and
team/service business plans. All staff employed by the Trust have an identified line
manager who has a responsibility to ensure that their members of staff undertake
induction, comply with the Trust’s appraisal process and Knowledge and skills
Framework (KSF) review and identify any training and development requirements. For
staff providing direct clinical care this will also include some form of caseload review
where focus will include promoting safety, quality, defensible practice and identifying
safeguarding issues.
All medical staff have an annual job plan review, where this is considered inappropriate
for staff grade/speciality doctors they must complete a record of regular supervision
(Appendix B2).
3.2 Clinical supervision – ‘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. The supervisee reflects on the part s/he plays as an
individual in the complexities of the events and the quality of practice.’ (Bond & Holland
2010:15). Clinical supervisors will have undertaken specific training to carry out this
role. Clinical staff depending on profession and role will have differing clinical
supervision requirements; this policy seeks to establish the expectation of a minimum
level of clinical supervision. Focus in the sessions is based on the needs/issues
identified by the supervisee/s.
3.3 Safeguarding children supervision – ‘is a formal, accountable process involving
one or more practitioners with a suitably experienced supervisor. It affords professional
support and learning which enables practitioners to develop knowledge, skills and
competence, assume responsibility for their practice and enhance safety and protection
of children in complex situations.’ (SWYPFT Safeguarding Children Supervision
guidance, 2012). Sessions are facilitated by supervisors who are trained in child
protection supervision and are based around a safeguarding children supervision
record and action plan. Safeguarding children supervision is specifically targeted at
clinical staff working routinely with children and young people or those working with a
parent whose child is subject to Child Protection/ In Need or Common Assessment
Framework (CAF) plan or where there are emerging safeguarding concerns identified.
5
3.4 Preceptorship - It is acknowledged as good practice that health care practitioners
at point of entry to the profession, following five years or more away from the profession
and when undertaking new roles, should engage in a period of preceptorship.
The purpose of which is to provide staff with a supportive, nurturing relationship which
assists their development and minimises the risk of inexperienced practitioners being
given responsibilities which are beyond their scope of practice and therefore provides a
safer environment for the novice, their colleagues and the service user.
This type of supervision will not be described in any further detail within this policy as it
is has its own guidance as stated within the Nursing Preceptorship Programme.
4.
Duties
The following duties apply to this policy:
4.1 Executive Management Team - The Director of Nursing, Clinical Governance
and Safety is the lead director for supervision within the Trust, supported by the
Medical Director. The lead director will be responsible for engaging relevant
stakeholders in the development of the policy and ensuring appropriate arrangements
are in place for managing any resource implications, including dissemination and
training and for ensuring that the most current version is in use and obsolete versions
have been withdrawn from circulation. The Director of Nursing, Clinical Governance
and Safety will also link with the District Directors and the Director of Human Resources
to identify any problems with the implementation or monitoring of this policy.
4.2 Clinical Governance and Clinical Safety Committee - The Clinical Governance
and Clinical Safety Committee is responsible for scrutinising the implementation and
effectiveness of this policy and providing assurance to the Trust Board.
4.3 The District Director - The District Director is responsible for monitoring the uptake of supervision as part of their monitoring of performance indicators. They will draw
the relevant managers attention to any performance issues on an exception reporting
basis.
4.4. General Managers, Associate Medical Directors, Service managers, Clinical
Leads, Consultants, Medical Tutors and Team Managers - General Managers,
Associate Medical directors, Service managers, Clinical Leads, Consultants, Medical
Tutors and Team Managers are responsible for ensuring that there are sufficient
supervisors and resources, including staff release within their services to provide
supervision in line with this policy. They are also responsible for provision of evidence
that the supervision models in use are fit for purpose and the minimum level of
supervision provided meets service need.
4.5 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.
6
4.6 All clinical staff - All clinical staff have a duty to ensure that they seek out and
participate in supervision in line with this policy.
5
Equality Impact Assessment
This policy has no differential impact on equality, as identified by the equality impact
assessment tool, completed in line with the SWYPFT policy for the development ,
approval and dissemination of policy and procedural documents, see appendix A.
6.
Dissemination and Implementation Arrangements
Once approved, the integrated governance manager will be responsible for ensuring
the up-dated version is added to the document store on the intranet and is included in
the staff brief.
7.
Supervision Standards for Practice
It is the responsibility of the line manager to ensure that management, clinical and
safeguarding supervision is available to all clinical staff within their service. It is the
responsibility of clinical staff to undertake supervision in line with organisational and
professional requirements and to draw any shortfalls to their line manager’s attention.
Staff with professional leadership responsibilities will provide advice to managers and
staff to support this process.
7.1 Management Supervision - Management supervision will be delivered through
the Trust’s current appraisal system and is line-management led, with the exception of
doctors in core training (including those who are not directly employed by the Trust)
who will follow the supervision requirements of the Deanery, for guidelines see
appendix B1. Supervision provision for junior grade doctors should follow the
guidelines for core trainees as far as possible and as amended by the associate
medical director for education and training.
During induction in the first 4 weeks of employment, staff will be allocated a line
manager who will provide their management supervision. Management supervision is
carried out by the person/role indicated on the job description. It is hierarchical in
nature and the agenda is dictated by the supervisory manager. It is compulsory as part
of terms and conditions of employment.
Access to management supervision is arranged at the discretion of the supervising
manager. Management supervision includes an annual staff appraisal and additional
meetings can be arranged in response to staff and service need. The environment
chosen for management supervision must be conducive to facilitating confidentiality
during the session. However, material from these sessions can be shared with the
wider organisation where this is appropriate e.g. higher management, Learning and
Development Department; in these situations it is good practice to inform the
supervisee of the intention to share information however their consent is not required.
Where a staff member fails to reach required standards managers should deal with the
minor performance problems of their staff as they arise. Where these are on-going or
significant the ‘dealing with poor performance at work’ policy/procedure should be
followed and the staff member informed of the same.
7
Documentation of management supervision sessions must be maintained in line with
standards for clinical record keeping, remaining the property of SWYPFT and should be
filed within the staff member’s personal file.
7.2 Clinical Supervision - Without exception all clinical services should strive to
embed a clinical supervision culture within their services. It is recognised within the
organisation that services have varying levels of clinical supervision culture and that
some services particularly those outside of mental health services may have been
working to a lower minimum requirement which does not comply with the
recommended minimum supervision of 12 hours per year (pro rata for part time staff)
as directed in the previous SWYPFT supervision policy. There is a paucity of evidence
within the nursing research literature to determine what could be a ‘gold standard’ for
the amount of recommended time spent in supervision except in mental health where
monthly supervision was considered most effective (Edwards et al 2005). All mental
health services across the Trust should work to the 12 hours per year minimum
requirement.
Where services outside of mental health currently do not meet the 12 hours per year
requirement and where the service can justify a lower level of clinical supervision for
example where there is a low level of complexity and clinical risk associated with the
work being undertaken, a minimum of 6 hours clinical supervision must be undertaken
per year – this decision must be reviewed on a yearly basis by service managers to
determine that this lower minimum level of supervision supports the development and
improvement/maintenance of high quality, innovative and defensible clinical and
professional practice. It is considered good practice that services formally produce
standards for supervision, where supervision expectations for all staff within their
service are made explicit, see appendix C for an example.
Across all services staff providing clinical supervision must undertake their own clinical
supervision at the higher recommended minimum of 12 hours per year, as research
has showed a detrimental effect on supervisor well-being where effective supervision is
not accessed (White et al 1998). Supervision of supervisors also serves as a quality
control and meets the necessary governance requirements.
Undertaking safeguarding children supervision and specialist clinical supervision as
part of an academic course may be counted towards minimum clinical supervision
requirements, unless this is not permitted professionally. Management supervision
should not be included as part of the minimum hours.
Clinical supervision may be facilitated within a group setting or on a one to one basis. It
can be received from outside of the Trust with the agreement of the line manager and
the understanding of the supervisee that they have a responsibility to check that
organisational policy and procedure allows them to follow guidance/advice from
external supervisors.
Clinical supervision must be provided by practitioners with competencies in the relevant
area of clinical practice. This will usually be from a member of the same profession
however where professionally there is no requirement for this, clinical supervision may
be delivered by practitioners outside of the supervisee’s profession providing their
guidance reflects any differences in professional code of conduct/practice. Staff may
choose their supervisor from the clinical supervisor list held by the Learning and
Development Department or from lists held locally.
8
Clinical supervision is facilitated around an agreement or contract between the
supervisor and supervisee that details the responsibilities of both parties and the
boundaries of the sessions (see appendix D2 for template). All clinical supervision
agreements/contracts must include details of the boundaries of confidentiality and
should be reviewed annually.
Documentation of clinical supervision sessions must be maintained in line with
standards for clinical record keeping (see appendix D for pro forma). It is recognised
that the confidentiality of these records is paramount in order to facilitate disclosure
within the sessions and make the best use of clinical supervision. Clinical supervision
agreements/contracts must always stipulate where 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 practitioner’s code of conduct or the law. Supervisors
may negotiate additional breach conditions as part of the agreement. Outside of the
breach conditions detailed on the agreement/contract consent to share information
should be obtained from the supervisee. Breaching of confidentiality without good
cause could result in disciplinary action. Documentation should be stored securely to
maintain confidentiality.
7.3 Safeguarding children supervision - Line managers should make new clinical
staff aware of the safeguarding children supervision process and paperwork, including
how to arrange supervision, as part of induction. All staff identified as requiring
safeguarding children supervision because of the nature of their caseload or the nature
of a particular case will have an allocated safeguarding children supervisor.
Safeguarding children supervision will be based on a written contract which should be
reviewed annually (see appendix E1). See the SWYPFT Policy and Procedure on the
Protection, Safeguarding Promoting the Welfare of Children which incorporates the
Safeguarding Children Supervision Guidance for further details on the practice and
processes involved in safeguarding children supervision.
At every session a Safeguarding Children supervision record will be produced which
will include any actions identified in order to safeguard children (see appendix E2 & 3).
Documentation relating to safeguarding children supervision is the property of the
organisation and 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 children supervision and any
actions arising from this.
8.
Training
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
annual training needs analysis programme, reflecting the training needs identified in
supervision and through the KSF and medical appraisal process.
8.1 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. Managers should be
confident in their knowledge of the appraisal and KSF process prior to carrying out staff
appraisal, it is acknowledged that many of the skills required for supervision are
transferable from other areas of competence.
9
8.2 Clinical Supervision - The quality of supervision is paramount to good practice
and therefore all practitioners who express an interest in becoming a clinical supervisor
should be assessed by their clinical/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.
All practitioners who meet the above criteria and are supported by their
clinical/professional lead must be supported by their line manager in order to access
Clinical Supervisor training; this can either be accessed in-house or through accredited
training depending on professional requirements. People who have attained clinical
supervisor qualifications in other employ and who are supported by their team manager
and clinical/professional lead 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 SWYPFT, see appendix G. Whereupon if deemed satisfactory their
name and contact details will be added to the clinical supervisor database. 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.
Supervisors who are subject to poor performance objectives should be advised by their
manager that they must not carry out their clinical supervisor role during this period.
Re-instatement to this role should be considered on the recommendation of both the
team manager and clinical/professional lead.
It is the responsibility of clinical/professional leads within the Business Delivery Units
(BDUs) to monitor the number of clinical supervisors that are available in their clinical
area and determine on a yearly basis the number of new supervisors required both to
meet workforce demand and counteract staff turnover bringing this information to the
attention of operational management.
8.3 Safeguarding Children Supervision - Safeguarding children supervisors must
have attended the appropriate child protection supervision training to be able to
facilitate supervision. Practitioners interested in becoming safeguarding children
supervisors who have the support of their line manager and clinical/professional lead to
pursue this role, should contact the Child Safeguarding Unit for information.
Safeguarding children 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.
9.
Process for providing evidence of compliance with the policy
To provide assurance that staff undertake the appropriate levels of supervision outlined
in this policy, monitoring will be facilitated via the management supervision/appraisal
process. For trainee doctors this will be facilitated via the Yorkshire Deanery.
Staff are expected to provide evidence that they have met the minimum clinical
supervision attendance requirement by producing their annual record of supervision
record (appendix D1) as part of their annual appraisal.
10
The staff appraisal pro forma prompts managers to consider that staff have met their
minimum supervision requirements, where this expectation has not been met it is the
responsibility of managers to include future compliance with supervision requirements
as part of the staff members objectives. Where compliance continues to be problematic
‘dealing with poor performance at work’ policy/procedure should be followed and the
staff member informed of the same.
Doctors in training will complete a monthly supervision form as required by the
Yorkshire Deanery (appendix B2). These will be monitored by their tutor. The Senior
Tutor in the Trust will advise the Medical Director of any concerns regarding the
supervision of doctors in training, or raised by the Yorkshire Deanery.
Trust doctors will record supervision in their portfolio, which forms the basis of their
annual appraisal by their line manager or Medical Director.
10. Process for providing evidence of assurance
Trust Board assurance will be through the Clinical governance and Clinical Safety
Committee and through the performance monitoring process at Board level, as part of
key performance indicators around staff appraisal (compliance with all supervision
requirements will be monitored by line managers at staff appraisal).
The Director of Nursing, Clinical Governance and Safety will provide exception
reporting to the Trust Board and the Clinical Governance and Clinical Safety
Committee where deemed appropriate.
The Medical Director will provide assurance to the Trust Board and/or the Clinical
Governance and Clinical Safety Committee that the supervision requirements of the
Yorkshire Deanery are being met, and that the requirements of the supervision policy
are being met by Trust doctors.
11. Process for review and revision
The policy will be reviewed by the agreed review date, in line with the Trust’s Policy for
the development, approval and dissemination of policy and procedural documents. This
may be brought forward if earlier review is required, for example because of an
identified risk or change in national policy.
The Integrated Governance Manager will notify the lead director three months before
the policy is due for review.
The lead director will check the policy. If no amendment is required, this should be
reported to the Executive Management Team for ratification by the review date and the
policy will be reissued.
If the policy requires minor amendments, the revised policy will be presented to the
EMT.
If significant amendment is required, the process described in the Trust’s Policy for the
development, approval and dissemination of policy and procedure documents should
be followed.
11
12. References
Bond M. and Holland S. (2010) Skills of Clinical Supervision for Nurses 2nd Edition.
Maidenhead: Open University Press
Butterworth T. et al (2008) Wicked spell or magic bullet? A review of clinical supervision
literature 2001-2007. Nurse Education Today 28 (3): 264-272
Edwards D et al (2005) Factors influencing the effectiveness of clinical supervision.
Journal of Psychiatric and Mental Health Nursing 12 (4): 405-414
DoH (2006) From values to action: the Chief Nursing Officer’s review of mental health
nursing. London: COI
DoH (2000) Framework for the Assessment of Children in Need and their Families
London: the Stationery Office
HM Government (2011) No health without mental health: a cross-government mental
health outcomes strategy for people of all ages.
HM Government (2010) Working together to Safeguard Children London: DCSF
HMSO (2004) The Children’s Act London: HMSO
NHSLA (2012) NHSLA Risk Management Standards (standard 6.1 clinical supervision)
Slone Graham (2006) Clinical supervision in Mental Health Nursing Chichester: Wiley
SWYPFT (2012) Policy and Procedures on the Protection, Safeguarding and
Promoting the Welfare of Children (incorporating the Safeguarding Children guidance
and Guidance of Child Visiting) Intranet Document store
SWYPFT (2012) Nursing Preceptorship Programme Intranet Document store
SWYPFT (2011) Policy for the development, approval and dissemination of policy and
procedure documents Intranet Document store
Turner J and Hill A (2011) Implementing clinical supervision (part 1): a review of the
literature. Mental Health Nursing 31 (3): 8-12
12
Appendix A - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management
Team for consideration and approval.
Equality Impact
Assessment Questions:
Evidence based Answers & Actions:
1
Name of the policy that you are
Equality Impact Assessing
Supervision of the clinical workforce
2
Describe the overall aim of your
policy and context?
The overall aim of the policy is to define and describe
the Trust’s approach to supervision.
Who will benefit from this policy?
All clinical staff
3
Who is the overall lead for this
assessment?
Director of Nursing, Clinical Governance and Safety
4
Who else was involved in
conducting this assessment?
Lead Nurse for Community Mental Health
Barnsley BDU
5
Have you involved and consulted
service users, carers, and staff in
developing this policy?
See appendix H for the consultation process for this
policy.
What did you find out and how
have you used this information?
To refine the document.
6
What equality data have you
used to inform this equality
impact assessment?
N/A
7
What does this data say?
N/A
8
Taking into account the
information gathered.
Does this policy affect one
group less or more favourably
than another on the basis of:
Where Negative impact has been identified please
explain what action you will take to remove or mitigate
this impact.
If no action is to be taken please explain your
reasoning.
YES
NO
Race
N
Disability
N
Gender
N
Age
N
Sexual Orientation
N
Religion or Belief
N
Transgender
N
Carers
N
13
9
10
What monitoring arrangements
are you implementing or already
have in place to ensure that this
policy:

promotes
equality
of
opportunity who share
the
above
protected
characteristics

eliminates discrimination,
harassment and bullying
for people who share the
above
protected
characteristics

promotes good relations
between different equality
groups,
Have you developed an Action
Plan arising from this
assessment?
This policy aims to align the previous SWYPFT
supervision policy and the NHS Barnsley clinical
/professional supervision policy and meet the
requirements of the CQC and NHSLA.
N/A
11
Who will approve this
Executive Management Team
assessment and when will you October 2012
publish this assessment.
12
Once approved, please forward a
copy of this assessment to the
Equality & Inclusion Team:
inclusion@swyt.nhs.uk
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the
action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate
Development or Head of Involvement and Inclusion.
14
Appendix B1 – Supervision Requirements of the Yorkshire Deanery
Yorkshire School of Psychiatry Learning Agreement
August 2011 to February 2012
GMC
Number:
Name of Trainee:
Training Scheme:
Employing Trust:
Contract type:
Year of training:
Training
Period
ST
CT
LAT
SHO
SpR
GP
1
2
3
4
5
6
From:
Locality:
To:
Specialty:
At the first meeting the trainee and Educational Supervisor should read and sign a
learning agreement.
The trainee will:
 Take an active part in the appraisal process including setting educational
objectives and developing a personal development plan
 Endeavouring to achieve the learning objectives by
 Utilising the opportunities for learning provided in everyday practise
 Attending formal teaching sessions
 Undertaking personal study
 Utilising locally provided educational resources
 Using designated study leave funds appropriately
 Acting on the principles of adult learning through:
 Reflecting and building on his/her own learning experiences
 Identifying his/her learning needs
 Being involved in planning his/her education and training
 Evaluating the effectiveness of his/her learning experiences
The educational/clinical supervisor will:
 Be available for, and take an active part in, the appraisal process
including setting educational objectives
 Ensure that the objectives are realistic, achievable and within the scope of
available learning opportunities
 Ensure that help and advice is available
 Ensure that there is a climate for learning
 Ensure that an individual doctor’s timetable allows attendance at formal
teaching sessions, is appropriate for his/her training needs and that there
is a correct balance between training and service in the placement
15
Signature:
Trainee
Educational Supervisor
Signature:
Name
(print):
Name
(print):
Date:
Date:
What do you need to learn?
You should base your personal development plan on the College curriculum. The
curriculum can be found on the College website along with portfolios that will allow you
to record your learning. Rather than listing all the curriculum objectives as learning
objectives in your personal development plan, you should refer to the curriculum and
portfolio in a statement about attaining the appropriate objectives for your year of
training. As your training progresses you may be better able to specify particular
objectives which you might list in your personal development plan. Different
placements can offer different opportunities to gain curriculum competences. As you
consider the opportunities available to you in each placement, you should plan how you
intend to make the most of them. You can use feedback to develop your PDP to focus
on the areas of improvement highlighted in the assessments.
Developing your PDP
As you progress, self evaluation, reflective practice, multi-source feedback and direct
assessment will all provide different perspectives on your performance and
development.
It is important to be aware of what information you are using when setting your learning
needs and that you are not missing important feedback that may be available to you.
For example, if all your learning needs originate from one feedback source it may be
worth re-examining what other information is available to you.
How will these needs be addressed and by when?
Your plan should identify what you intend to do during the year and in each placement,
how you will develop your learning and, most importantly, how and when you will be
assessed. While reflective practice is extremely important, one of the key goals of the
program is to demonstrate through your portfolio, a series of assessments that show
development against the Curriculum, and progression towards competence. Setting
yourself a target is always a good way to ensure progress. Discuss and agree realistic
and achievable targets for demonstrating progress with your educational/clinical
supervisor and record them here.
16
PERSONAL DEVELOPMENT PLAN
Record here development needs identified with the educational supervisor arising from discussions about the learning agreement
at the beginning of each year. This PDP is one component of the learning agreement.
It should be updated whenever there has been a change - either when a goal is achieved or modified or where a new need is
identified.
Date
The date on
which the
development
need is recorded
What
development
needs have I?
How will I
address them?
Explain the
need.
Explain how
you will take
action, and
what resources
you will need?
Date by which I
Outcome
plan to achieve the
development goal How will your
practice change as
The date agreed
a result of the
with your appraiser
development
for achieving the
activity?
development goal.
Completed
Agreement from your appraiser
that the development need has
been met (signature of
appraiser/supervisor and date)
1.
2.
3.
4
5.
17
Date
The date on
which the
development
need is recorded
What
development
needs have I?
Explain the
need.
Date by which I
How will I
plan to achieve the
address them?
development goal
Explain how
The date agreed
you will take
with your appraiser
action, and
for achieving the
what resources
development goal.
you will need?
Outcome
Completed
How will your
practice change as
a result of the
development
activity?
Agreement from your appraiser
that the development need has
been met (date and signature
of appraiser/supervisor)
6.
7.
8.
9
10.
18
Postgraduate Deanery
Yorkshire and the Humber School of Psychiatry Placement Report
February 2012 - August 2012
Please complete this form electronically then print off and sign
The purpose of this report is to inform the regular reviews that are conducted of a
Psychiatry specialty registrar’s progress through structured training. The report
should reflect your experience of the trainee’s performance during their clinical
placement and should be discussed with the trainee before submitting.
The report relates to two main areas:
The Trainee


Knowledge (relevant to the placement)
Professional competencies
Full name
GMC Number
Date of Birth
National training number(higher trainees
only)
The Post or Placement
Name of
consultant
supervisor
Specialty/sub-specialty
GMC number of
supervisor
Hospital
/Institution
Months
From
To
……day…..month……year
……day…..month……year
19


The training was full-time
Please
delete as appropriate
The training was part-time and the ratio of part-time to full-time
was…………….
1. Knowledge-base relevant to the placement
Insufficient
Evidence
Needs Further
Development
Competent
Excellent
Anything particularly good?
Areas for development
2. Professional Competencies
If you are viewing this document electronically, the footnote will appear
when you hover your mouse pointer above the relevant footnote number
Insufficient
Evidence
Needs further
development
Competent Excellent
1. Providing a good
standard of practice
and care
2. Decisions about
access to carei
3. Treatment in
emergenciesii
4. Maintaining good
medical practiceiii
5. Maintaining
performanceiv
20
6 Teaching and
training, appraising and
assessing.v
7. Relationships with
patients vi
8. Dealing with
problems in
professional practice vii
9. Working with
colleaguesviii
10. Maintaining
probityix
11. Ensuring that
health problems do not
put patients at risk x
Anything particularly good?
Areas for development
Endorsement
Endorsement by Supervisor
I confirm that the above is based on my own observations and the results of
workplace-based assessments and has been discussed with the trainee
concerned
21
Name
Signed
Date
1
This competency is about the clinical assessment of patients with mental health problems. It
includes history-taking, mental state examination, physical examination, patient evaluation,
formulation and record keeping. It also includes the assessment and management of patients with
severe and enduring mental health problems. Evidence to consider will include WPBA’s, particularly
the ACE, mini-ACE, CbD and multi-source feedback
2 This competency is about the application of scientific knowledge to patient management including
access to appropriate care, and treatment. Evidence to consider will include WPBA’s, particularly the
ACE, mini-ACE, CbD and multi-source feedback
3 This competency is about the assessment and management of psychiatric emergencies. Evidence
to consider will include WPBA’s, particularly the ACE, mini-ACE, CbD and multi-source feedback
4This competency is about the maintenance and use of systems to update knowledge and its
application to professional practice. This will include legislation concerning patient care, the rights of
patients and carers, research and keeping up to date with clinical advances. Evidence to consider will
include WPBA, reflective notes in the trainee’s portfolio, the trainee’s Individual Learning Plan and any
record of educational supervision that they have kept
5 This competency is about the routine practice of critical self-awareness, working with colleagues to
monitor and maintain quality of care and active participation in a programme of clinical governance.
Evidence to consider will include multi-source feedback, records of audit and research projects
undertaken and the trainee’s reflective notes on these projects.
6 This competency is about the planning, delivery and evaluation of learning and teaching; appraising
and evaluating learning and learners; supervising and mentoring learners and providing references.
Evidence to consider will include multi-source feedback, completed Assessment of Teaching forms
and any quality data kept by the relevant teaching faculty or programme
7 This competency is about the conduct of professional patient relationships, including good
communication, obtaining consent, respecting confidentiality, maintaining trust and ending
professional relationships with patients. Evidence to consider will include WPBA’s, particularly the
ACE, mini-ACE, CbD and multi-source feedback
8 This competency is about handling situations where there are concerns regarding the conduct or
performance of colleagues, handling complaints and formal inquiries, holding indemnity insurance and
providing assistance at inquiries and inquests. Evidence to consider will include CbD, multi-source
feedback and reflective notes, including critical incident reports
9 This competency is about treating colleagues fairly, by working to promote value-based nonprejudicial practice; about working effectively as a member and a leader of multidisciplinary teams;
arranging clinical cover; taking up appointments; sharing information with colleagues and appropriate
delegation and referral. Evidence to consider will include CbD and multi-source feedback
10
This competency is about maintaining appropriate ethical standards of professional conduct
which may include the following: providing information about your services; writing reports,
giving evidence and signing documents; carrying out and supervising research; properly
managing financial and commercial dealings; avoiding and managing conflicts of interest and
advising others on preventing and dealing with them and appropriately managing financial
interests that may have a relevance to professional work. Evidence to consider will include
CbD and multi-source feedback and your review of reports written by the trainee.
11This competency is about the doctor’s awareness of when his/her own performance,
conduct or health, or that of others might put patients at risk and the action taken to protect
patients. Behaviours you may wish to consider: observing the accepted codes of professional
practice, allowing scrutiny and justifying professional behaviour to colleagues, achieving a
healthy balance between professional and personal demands, seeking advice and engaging in
remedial action where personal performance is an issue.
22
Postgraduate Deanery
Yorkshire and the Humber School of Psychiatry
Annual Structured Report
2011 – 2012
Please complete this electronically, print off and sign.
This report is to be submitted to the Annual Review of Competence Progression
panel by the trainee’s current educational supervisor, summarising the trainee’s
learning Portfolio since the previous assessment. This report should be discussed
with the trainee before submitting it.
Section 1: Basic information
Trainee’s name:
GMC number:
Training number (if applicable):
Core Training Scheme (delete as appropriate):
Leeds & Wakefield / Bradford & Airedale / Calderdale & Kirklees / Hull & East Riding
/North Yorkshire
Higher Training Scheme (delete as appropriate):
General Adult Psychiatry / Psychotherapy /Child / Old Age /Learning Disability /
Forensic
Year of training as Core or Higher trainee (delete as appropriate)i.e. first year Higher
Trainees leave One
One/two/three/four/five/six/seven
Name of Educational Supervisor submitting report:
Position:
GMC number:
Placements from August 2011 – August 2012:
Placement 1
Educational supervisor:
23
Dates of placement:
Number of sessions if trainee flexible
Placement 2
Educational supervisor
Dates of placement:
Number of sessions if trainee flexible
24
Section 2: EVIDENCE SUMMARY
Workplace based assessments (WPBAs) in current placement/s
Assessment Date
assessment
took place
ACE (1)
Outcome –numerical score for
performance at this stage of training
should be entered here
(2)
(3)
Mini-ACE (1)
(2)
(3)
(4)
DOPs (1)
(2)
CbD (1)
(2)
Mini-PAT (1)
(2)
PSQ (1)
(2)
CP (1)
(2)
JCP (1)
(2)
AoT (1)
(2)
Other
(please
describe)
25
Experiential outcomes (evidenced by portfolio review)
Activity
Date/s
Comments
Psychotherapy
Please record
training as
evidenced in
portfolio. Also record
any restraints in
receiving training.
Audits
Please record title of
one audit as
evidenced in
portfolio
Research projects
Publications
Teaching
Management
development
Presentations
Examination progress (must review RCPsych exam feedback)
Exam
Date(s) taken Passed or
failed
Notes/action points
Date(s) taken Passed
Notes/action points
MRCPsych 
Paper 1
Paper 2
Paper 3
CASC
Other exams
26
Trainee has evidence that they have completed PMETB feedback form
Yes/No
Other outcomes
Delete as appropriate
Date
Notes
Reported adverse
incidents
Complaints
Record if justified or unjustified
in view of person who
investigated complaint
Sick leave
Other leave (maternity,
paternity, carers,
compassionate)
On calls completed (record
number only)
For trainees not on out of
hours rota record number of
assessments of individuals
with a range of diagnosed
conditions and with first line
management plans conceived
and implemented.
27
Section 3: Overall Summary
3. Professional Competencies
In assessing these domains you should rate the trainee against your
expectations for the current stage of training. When this report is
completed in the final placement of a stage of training, you should assess
against the standard expected for the completion of the stage. If you are
viewing this document electronically, the footnote will appear when you
hover your mouse pointer above the relevant footnote number
Insufficient
Evidence
Needs further
development
Competent
Excellent
1. Providing a good
standard of practice and
carexi
2. Decisions about
access to carexii
3. Treatment in
emergenciesxiii
4. Maintaining good
medical practicexiv
5. Maintaining
performancexv
6 Teaching and training,
appraising and
assessing.xvi
7. Relationships with
patients xvii
8. Dealing with
problems in
professional practice xviii
9. Working with
colleaguesxix
10. Maintaining probityxx
11. Ensuring that health
problems do not put
patients at risk xxi
28
2. Professionalism
Anything especially good?
Areas for development
Concerns identified*
Health
I confirm/do not confirm that there are no health
concerns that impact on this trainees fitness to
practice
Total days sick since last review – xxxx
Probity
I confirm/do not confirm that there are no concerns in
relation to probity for this trainee
Complaints/adverse
incidents (or none)
* Where cause for concern is documented the basis for this must be clear and explicit
 Please delete as necessary
Section 4: TRAINER DECLARATION
I confirm that (tick as appropriate):
 I understand that I have a professional duty to document any concerns identified
AND
 I have reviewed the evidence required to demonstrate fitness to progress for the
relevant year of training and consider the trainee fit to progress and suitable for a
career in psychiatry OR
 I have concerns about this trainee which have been documented in the report
Print Name ________________________ Signed _________________________
Date _______________
Section 5: TRAINEE DECLARATION
I confirm that:
The evidence provided to inform my annual review is a complete, accurate record of
the evidence collected and assessments undertaken during the relevant training
period
Print Name ________________________ Signed _________________________
Date _______________
29
Section 6: COLLEGE TUTOR DECLARATION
The college tutor should verify this review.
I confirm that:
I have checked this review and can confirm that to the best of my knowledge it
represents a complete and accurate review of the trainee’s evidence
Print Name ________________________ Signed _________________________
Date _______________
30
Appendix B2 – Supervision Form for doctors
SUPERVISON RECORD
NAME:
DATE OF SESSION:
SUPERVISION KEY DISCUSSION POINTS:
AGREED ACTIONS:
SIGNED:
SUPERVISOR’S NAME:
SUPERVISOR’S SIGNATURE:
Please complete after your supervision session and bring to the next session
for sign off by your supervisor.
Ensure this record is kept for appraisal / revalidation purposes.
31
Appendix C
Sample document supervision standards for practice
SAMPLE
DOCUMENT
SUPERVISION STANDARDS for
CLINICAL STAFF WORKING WITHIN
COMMUNITY MENTAL HEALTH SERVICES
BARNSLEY BDU
Authors: Alison Hill, Lead Nurse, Sandra Keen, Deputy Manager Community
Mental Health, Jude Mitchell, Lead OT, Lisa Tattershall, Senior Social worker
and Lisa Winter, Consultant Psychologist, Julie Warren-Sykes, Designated
Nurse for Safeguarding (Mental Health)
Acknowledgements to Clinical Leads: Joanna Burton, Rachel Butterworth,
Eamonn Lynott and Mark Stoud for their help in shaping this document.
32
CONTENTS
Page
1.
Introduction.
3
2.
Purpose.
5
3.
Roles and Responsibilities.
6
4.
Standards for Practice
4.1
Management Supervision
8
4.2
Clinical Supervision
10
4.3
Safeguarding Children Supervision
17
5.
Auditing the standards
18
6.
References.
19
7.
Review of the standards for supervision.
20
8.
Appendix









Record of clinical supervision one to one. (D3)
Annual record of clinical supervision session. (D1)
Record of Group clinical supervisor session.(D4)
Contract form – supervisor/supervisee.(D2)
Clinical Supervision Audit pro forma REMOVED
Safeguarding Children Supervisee record (E6)
Safeguarding Children Supervision contract (E1)
Safeguarding children personal development plan (E4/E5)
Management supervision pro forma (3)
33
1
INTRODUCTION
1.1 Community Mental Health Services recognises the importance of
supervision in contributing to the development of practitioners and
improving the quality of service delivery.
1.2 This document provides standards of practice for all staff within the
Community Mental Health Business Unit in relation to the supervision of
their work and includes managerial supervision, clinical supervision and
safeguarding children supervision. It should be read in conjunction with
SWYPFT Policy Supervision of the Clinical Workforce, Barnsley
Metropolitan Council (BMBC) Adult Social Services Directorate
Supervision Procedure and SWYPFT Policy and Procedures on the
Protection, Safeguarding and Promoting the Welfare of Children.
1.3 Managerial supervision provides a framework of accountability for the
service and facilitates the escalation of clinical and non-clinical issues to
the point within the organisation that has the authority to deal with them.
It also formally facilitates staff development via staff development reviews
(SDR) and monitors staff performance. The primary focus of managerial
supervision is effective service delivery and patient welfare.
1.4 The functions of management supervision can be described as the
bringing together of people and resources to achieve the goal of providing
good quality care and treatment for people with mental health needs. This
will include the effective organisation of work/workload and delegation of
responsibilities, monitoring of activity and performance, identification of
development needs and contributing to safe working practice.
1.5 Clinical supervision supports the implementation of the organisational
development strategy and sits within the clinical governance framework, it
is not a management tool, but rather a support for the development and
improvement or maintenance of high quality clinical and professional
practice in the delivery of patient care. The primary focus of clinical
supervision is staff development/welfare and the delivery of high quality
care.
1.6 The functions of clinical supervision have been described by Proctor
(1986) as:



Formative – the educative process of developing skills
Restorative – supportive help for professionals working constantly
with stress and distress and;
Normative – concerned with developing competent practice, the
internalisation of professional ethics, standards, self management and
monitoring.
34
Within the knowledge and skills framework (DOH 2004) staff are required
to provide evidence of their professional development, clinical supervision
is one means of achieving this.
1.7 Safeguarding children supervision is a formal process of professional
support and learning which aims to ensure that clinical practice
safeguards children and promotes their welfare.
1.8 Safeguarding children supervision is achieved by facilitating reflective
discussion, assessment, planning and review, thereby supporting the
development of good quality, innovative practice provided by safe,
knowledgeable and accountable practitioners. Sessions are facilitated by
supervisors who are trained in child protection supervision and are based
around a Safeguarding Children developmental plan.
1.9 The Community Mental Health Service is committed to the notion of
effective supervision and recognises that different types of supervision are
required to provide an efficient and effective modern mental health service
whilst at the same time ensuring staff are supported and encouraged to
reach their professional potential.
2.
PURPOSE
2.1 The purpose of this document is to provide standards of supervision;
managerial, safeguarding children and clinical for all clinical staff working
with the Community Mental Health Business Unit. Different types of
supervision particularly management supervision and clinical supervision
are often different to define and distinguish one from the other (Yegditch,
1999), this document attempts to provide a working framework to assist
staff in the implementation of managerial, safeguarding children and
clinical supervision.
2.2 The aims of managerial supervision are:
To assist in the delivery of the service to those people with mental
health needs as described in the operation policy of the specific
team/service. This includes, contributing to improving quality, timely
service delivery and cost effectiveness (which includes staff
performance and use of resources).
35



As part of the above duty the manager will be required to assess
the performance of the individual staff member through Staff
Development Review and identify any training requirements they
have. The manger will jointly with the staff member identify and
agree individual objectives that will add to the improvement of
service delivery.
To monitor that staff are working within the policy and procedures
set down by SWYPFT and to take action where this is found not to
be so.
To escalate and issues that increase clinical/organisational risk
through the management structure to the point where there is the
appropriate authority to deal with them.
2.3 The aims of clinical supervision are:









To facilitate staff to critically reflect on their practice through the
medium of reflective practice.
To safeguard standards by facilitating the internalisation of
professional standards/conduct, ethics and self-management
To develop professional expertise, clinical skills and promote the use
of evidence based practice.
To encourage a culture of continuous quality improvement
To share and utilise knowledge
To explore beliefs and values around the concept of recovery from
mental illness.
To acknowledge the staff member as a sentient being and facilitate
the expression of emotions.
To provide an enabling process that allows staff to achieve, sustain
and develop creatively a high quality of practice through means of
focused support and development.
To provide a life-long learning experience that should continue
throughout their employment at SWYPFT and beyond.
2.4 The aims of safeguarding children supervision are:



3.
To enable and empower practitioners to develop knowledge and
competence
To provide a safe and structured environment for practitioners to
reflect on, plan, review and account for their safeguarding children
work.
To provide support and recognition of the stress and uncertainties
which safeguarding work may involve.
ROLES AND RESPONSIBILITIES
3.1
Managerial Supervision
36
3.1.1 Responsibility of Line Managers (Supervisory Managers)
 The line manager will be responsible for monitoring that all types of
supervision are taking place appropriately, in accordance with the
standards in this document.
3.1.2 Responsibility of staff (Management supervision)
 Staff will ensure that they comply with attendance and use of
managerial supervision sessions in accordance with the standards
within this document.
3.2
Clinical Supervision
3.2.1 Responsibility of Managers
 Should ensure staff have dedicated time available to attend clinical
supervision in line with this framework, as stated in para. 4.2.9.
 Should ensure staff comply with attendance at clinical supervision,
monitoring attendance via staff performance review
3.2.2 Responsibility of Clinical supervisors
It is the responsibility of the clinical supervisor: to initiate and lead development of the clinical supervision agreement.
 to be available to the supervisee during the sessions and be
accountable for any advice they offer.
3.2.3 Responsibilities of the Supervisee
It is the responsibility of the supervisee: to protect time and space for clinical supervision, by keeping agreed
appointments and time boundaries.
 to prepare for the supervision in advance
 to bring material to the session and consider priorities
 to be honest, open and engage in reflective practice
 to be open to change and development
3.3
Safeguarding Children Supervision
3.3.1 Responsibility of Managers
 Should ensure that the safeguarding children dept are aware of new
staff joining the service who will require safeguarding children
supervision.
37
 Should arrange with the new staff and the safeguarding children dept
an induction within the first month of employment.
 Should ensure that staff have dedicated time available to attend
safeguarding children supervision in accordance with this framework.
3.3.2 Responsibility of Supervisors
 Ensure that within the first month following appointment staff receive
an induction with their safeguarding children supervisor, and are
made aware of the supervision process and paperwork, including how
to arrange supervision. At this induction the safeguarding children
supervision contract will be completed and signed (Appendix E )
 Provide information about the philosophy, aims and structure of
supervision
 Be available to staff for supervision and share responsibility for
arranging sessions
 Review the records for the families discussed, signing them to confirm
supervision has taken place, and discussing how recording can be
enhanced
 Agree and sign the supervision record for each family discussed
 Complete / update the supervisee development plan at each session
 Bring any factors which prevent or hinder staff from accessing
supervision to the attention of service managers
3.3.3 Responsibility of staff (supervisee)
 Share responsibility for arranging supervision sessions
 Ensure dedicated time is set aside free from interruptions for the
duration of the session
 Prepare for the session by completing the supervision record for each
family to be discussed (Appendix E )
 Agree and sign both the supervision record for each family and the
Development Plan (Appendix E )
 Bring any factors which result in the staff member being unable to
attend supervision sessions to the attention of their service managers
4
STANDARDS FOR PRACTICE
4.1
Management supervision
4.1.1 Standard MS1 – During induction in the first 4 weeks, staff will be
allocated a line manager who will provide their management
supervision.
Management supervision is carried out by the person/role indicated on
the job description. It is hierarchical in nature and the agenda is dictated
by the supervisory manager. It is compulsory as part of terms and
conditions of employment.
38
4.1.2 Standard MS2 – Line Managers for management supervision
purposes will be at band 6 and above or Senior Social Workers.
It is within management supervision that any concerns or issues around
work load and capacity, relationships within the team, development
needs and attendance at mandatory or other training events, sickness
and absence or a person’s performance at work may be addressed.
A band 5 Nurse may undertake management supervision of junior staff
where this is identified as development in terms of their CPD within the
SDR process. They will carry out this work under the supervision of a
band 6 Nurse.
NB. Some professions, e.g. social workers, combine both
management and clinical supervision within one supervision
session (This hybrid-type of supervision is not recommended
practice as it leads to confusion with regards to the focus of the
session, dominance of the supervisors agenda and a lack of clarity
with regards of ownership of any documentation that is produced
within the session ultimately impacting on the quality of clinical
supervision received).
4.1.3 Access to Management Supervision
Standard MS3 – All clinical staff should receive management
supervision to the frequency described in this framework.
Standard MS4 – Management supervision is arranged at the
discretion of the supervising manager.
 Management supervision should be undertaken as a minimum for
one hour four times per year, in addition to the staff members SDR.
Where there are additional needs meetings may be held more
frequently at the discretion of the manager.
 Staff can access their manager on a needs basis in-between their set
meetings.
4.1.4 Standard MS5 – Documentation of management supervision
sessions must be maintained in line with The Trust’s Standards for
Record-Keeping.
Standard MS6 – Documentation of management supervision
sessions remain the property of SWYPFT.
Documentation/Record Keeping in Management Supervision
 A record of management supervision must be kept by the supervisory
manager.
39
 Records of issues raised in management supervision sessions and
any actions arising from these, should be detailed by the supervisory
manager – it is considered good practice to request counter
signature of the record with these records remaining the property of
SWYPFT. These records, where appropriate, should meet the Trust’s
record keeping standards, e.g. be legible, in black ink, and be held
securely to maintain confidentiality; note, they may be called upon as
management evidence during disciplinary proceedings. A copy of the
record may be offered to the person under supervision at the
discretion of the supervisory manager.
 In line with the finding in the Norris Report (2010) line managers
should consider whether information collected as part of management
supervision should be entered into the particular staff members
personal file, advice from Personnel Dept should be sought with
regards to this.
 Supervisory managers may choose to keep their records in varied
formats – however, an example can be found at appendix 3.
 Supervisory management records should be retained for the period
that the staff member is employed by NHS Barnsley CSD and held
securely by the supervisory manager. Where staff members leave
our service, advice should be sought from Personnel Dept with
regards to approval to destroy these records. Records should be
destroyed via the destruction of confidential material process.
4.1.5 Standard MS7 – The environment chosen for management
supervision must be conducive to facilitating an appropriate level
of confidentiality during the session.
 Choice of venue is at the discretion of the line manager.
Consideration must be given to the level of confidentiality the venue
can provide, particularly in terms of sensitive information being overheard by third parties.
4.2
Clinical Supervision
4.2.1 Standard CS1 – Staff will choose their own clinical supervisor
unless there are the exceptions detailed with this guidance.
Clinical supervision is carried out by the staff member’s supervisor of
choice. Clinical supervisors should not be selected for staff by line
managers – except as a recommendation following a disciplinary
hearing.
40
4.2.2 Standard CS2 – Staff members who carry out clinical supervision
will undertake the Trust’s Clinical Supervisor Training or
equivalent.
Clinical supervisors must undertake clinical supervisor training to
prepare them for the role, in order to be supported to undertake the
training they must be seen as credible clinicians by their peers to ensure
that clinical supervision is a meaningful positive process. Clinical
supervisors who are external to SWYPFT should within their supervision
agreement acknowledge the boundaries of their knowledge of SWYPFT
policies and procedures and how this is to be managed
4.2.3 Standard CS3 – All clinical supervisors must undertake their own
clinical supervision.
Clinical supervisors must have their own regular clinical supervision
where they can take their own clinical/developmental issues and any
clinical/developmental issues arising from their supervision practice.
4.2.4 Standard CS4 – Staff will be able to choose the mode of
supervision that meets their professional needs.
A mixed economy of modes of clinical supervision will be available, one
to one, group, peer and expert within the Community Mental Health
Business Unit and practitioners should choose the mode that best suits
their professional needs.
4.2.5 Standard CS5 – The function of clinical supervision will follow
Proctor’s Tripartite Model.
It is recommended in the Trust’s clinical supervision training that the
process of clinical supervision will be delivered through Proctor’s
Tripartite model which asserts that formative, restorative and normative
functions should receive equal consideration within sessions with no one
function dominating the session.
4.2.6 Standard CS6 – Recovery values will be integrated into clinical
supervision.
Clinical supervision within the Community Mental Health Business Unit
will facilitate the sharing of recovery values as described in the NHS
Barnsley CSD ‘Policy for the implementation of the recovery model
incorporating physical well-being’.
41
4.2.7 Standard CS7 – Evidence based practice will inform guidance
delivered as part of clinical supervision.
Clinical supervision will provide an opportunity to address the theorypractice gap (Rolfe 1996) by the sharing of evidence-based practice in
relation to the clinical issues raised.
4.2.8 Standard CS8 – The underpinning theory used within the delivery of
clinical supervision will reflect the underpinning theory
recommended for the clinical work of the supervisee.
The underpinning philosophy used during clinical supervision will vary
dependent on the clinical work being undertaken, for example, for
practitioners utilising CBT within their practice a CBT framework should
be used, for practitioners utilising a PSI approach a stress-vulnerability
(Zubin and Spring 1977) within the emerging best practice framework
(NIMHE 2004) should be used.
4.2.9 Access to Clinical Supervision
This table serves to identify the minimum standard of frequency
and duration of supervision for the roles identified – where staff are
working with high risk and complexity, supervision arrangements
should be adjusted to meet their increased need.
Job Role
Clinical
supervision
frequency and
duration
Delivery
Counsellor
60-90 minutes monthly
By accredited clinical supervisor
of their choice
Nurse
One hour - 12 times By trained clinical supervisor of
per year
their choice
Nurse in Preceptorship
year
One hour – Monthly
By named preceptor
Non-medical prescriber
90 hours during
training – negotiated
needs thereafter
By designated psychiatrist
Occupational Therapist
(OT)
One hour - 12 times By trained clinical supervisor of
per year
their choice
OT in Preceptorship year
One hour - Monthly
Physiotherapist
One hour - 12 times By trained clinical supervisor of
per year
their choice
By named preceptor
42
Job Role
Clinical
supervision
frequency and
duration
Delivery
Physiotherapist in
Preceptorship year
One hour – Monthly
By named preceptor
Psychologist
Assistant/trainee
90 minutes - weekly
By qualified Clinical Psychologist
(Trainees may be supervised by
course approved alternate)
Psychologist
Highly Specialised
One hour - weekly
By qualified psychology
professional trained in clinical
supervision
Psychologist
Principal
One hour –
fortnightly
By qualified psychology
professional trained in clinical
supervision
Psychologist
/Psychotherapist
Consultant
60-90 minutes
monthly
By senior psychology
professional trained in clinical
supervision
Psychological Well-being
Practitioner
One hour weekly
By qualified psychology
professional
Psychotherapy
Trainee
One hour per six
hours client contact
By qualified psychotherapist in
same model
CB Psychotherapist
Trainee
One hour weekly
By qualified/accredited CB
Psychotherapist (CBP)
CBT Psychotherapist
(IAPT)
1-2 hours monthly
By Senior CBP
Psychotherapist
Senior
One hour - monthly
By qualified Psychotherapist
accredited / experienced in
supervision
Social worker
One hour - Monthly
Combined management and
clinical supervision carried out by
named senior social
worker/professional support
manager
43
Job Role
Clinical
supervision
frequency and
duration
Delivery
Social Worker in
preceptorship year
1.5 hour -2 weekly
at for first 3 months,
then one hour –
monthly
Combined management and
clinical supervision carried out by
registered social worker.
Support worker
One hour - 12 hours
per year
By trained clinical supervisor of
their choice
Students
Refer to specific
requirements for
placement.
Refer to specific requirements
for placement
4.2.10 Standard CS10 – All clinical supervision relationships will have a
clinical supervision agreement drawn up jointly with the
supervisor and supervisee.
Clinical Supervision Agreement
All clinical supervision relationships will have a written agreement with
a review date of not more than one year, which details boundaries in
terms of:
Confidentiality
Availability of supervisor
Frequency/duration of sessions
Resources available
Documentation
Although the agreement is a joint responsibility, the responsibility for
initiating and ensuring that an agreement is developed rests with the
clinical supervisor.
4.2.11 Standard CS11 – The boundaries of confidentiality will be made
explicit within the clinical supervision agreement.
Confidentiality

Boundaries around confidentiality should be made explicit as part
of the agreement and both parties should be aware of the
circumstances in which a breach of confidentiality will occur (where
the supervisee is receiving clinical supervision following
recommendations from a disciplinary hearing special attention
needs to be given to this).
44

The maintenance of confidentiality within clinical supervision is
fundamental to a high quality experience; therefore breaches of
confidentiality must be based on protection from harm and where
behaviour contravenes the practitioner’s code of conduct or the
law.

Supervisors must enter in the clinical supervision agreement that
they may take some material from their supervision sessions to
their own clinical supervisor. Where this happens they should
reassure supervisees that they will not be identified by name and
that their clinical supervisor has a duty of confidentiality.
Supervisees must be informed that this is non-negotiable and is the
main mechanism that assists in the maintenance and promotion of
quality within clinical supervision.
4.2.12 Standard CS12 – Clinical supervision will be arranged around the
availability of the clinical supervisor.
Availability of supervisor

Clinical supervision sessions are arranged around the availability of
the clinical supervisor. The supervisee has no right to demand
additional supervision from that which is arranged but may discuss
any unforeseen supervision needs with their supervisor who will
then determine if they have the appropriate capacity to meet the
additional need.

Dependent on profession the number of supervisees a supervisor
engages varies, for example in nursing it is recommended that
clinical supervisors aim to take on three supervisees, in social work
it is recommended that supervisors aim to take six supervisees.
Any increase or reduction in the recommendations should be
negotiated with their line manager.
4.2.13 Standard CS9 – clinical staff will receive clinical supervision of the
frequency and duration specified within table 4.2.9 in line with
their professional background and job role.
Frequency/duration of sessions

The frequency and duration of sessions is to be agreed between
the clinical supervisor and supervisee. Staff are expected under
the SWYPFT supervision of the clinical workforce policy to access
clinical supervision regularly with a minimum of 12 hours per year.

When staff are negotiating the duration of sessions they should
bear in mind the nature of the work undertaken in clinical
supervision and ensure that adequate time is allowed to facilitate
this.
45

When staff are negotiating the frequency of sessions they should
bear in mind that there is some inter-relatedness between sessions
in terms of feedback and review and ensure that frequency is
planned to assist with this.
4.2.14 Standard CS13 – the environment for clinical supervision chosen
must be conducive to facilitating the work carried out in clinical
supervision.
Resources
 Resources such as a quiet environment that is conducive to
confidential and developmental work are a requirement in clinical
supervision. Who is responsible for arranging this should be
decided as part of the agreement.
 It is important that clinical supervision sessions are not interrupted
by routine telephone calls – however, it is acknowledged that
urgent calls by their nature would be allowed.
4.2.15 Standard CS14 – Documentation of clinical supervision must be
maintained and be kept in line with the Trust’s Standards for
Record-Keeping.
Record Keeping
 All clinical staff must keep their own records of attendance at
clinical supervision sessions as evidence that they are meeting
their minimum requirements under the policy. For the purpose of
evidencing clinical supervision sessions have taken place, when
asked during SDRs, a pro forma signed by the supervisor showing
the dates of attendance for clinical supervision can be found at
appendix D.
 For documentation of the session the SWYPFT pro forma can be
used – alternatively practitioners may have their own preferred pro
forma which can be used. All sessions must be recorded and the
SWYPFT record-keeping guidelines must be followed.
 Records of the sessions can be written by the supervisee or by
both/either parties, each party requires a copy of the record and has
a duty to keep these records in a secure place which affords them
the consideration given to any other confidential record.
 Records of clinical supervision sessions should be retained by each
party whilst they remain in clinical practice. Some consideration may
need to be given to the potential of supervision records being
subpoenaed from previous periods of employment i.e. that the
person has left this organisation may not be the point at which
records are destroyed.
46
 The records are the property of the supervisor/supervisee and
unless agreed differently in the clinical supervision agreement
cannot be disclosed to a third party unless both are in agreement or
where breaches of confidentiality are based on protection from harm
and where behaviour contravenes the practitioners code of conduct
or the law.
Standards relating to Identification and Training of Supervisors
4.2.16 Standard CS15 – Practitioners who wish to become clinical
supervisors must meet the selection criteria outlined in this
framework.
Standard CS16 – Clinical Supervisors must be able to show
evidence of up-dating their practice in line with the CPD
requirements of their profession.
Standard CS17 – Those who have undertaken clinical supervision
training will fulfil this role whilst working as a clinician with the
Community Mental Health Business Unit.
Standard CS18 – Clinical Supervisors who are subject to poor
performance objectives will cease to work as clinical supervisors
during this period and will be subsequently re-instated to the role
on the recommendation of their clinical lead and team manager.
Identification and training of clinical supervisors
It is essential to the delivery of high quality clinical supervision that
clinical supervisors have the knowledge, skills and qualities to carry out
this role.
All practitioners who express an interest in becoming a clinical
supervisor should be assessed by their clinical/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.
All practitioners who meet the above criteria and are supported by their
clinical/professional lead must be supported by their line manager in
order to access the Trust’s Clinical Supervisor training or equivalent.
Supervisors who are subject to performance review should be advised
by their manager that they must not carry out their clinical supervisor
47
role during this period. Re-instatement to this role should be
considered on the recommendation of both the team manager and
clinical lead
The community mental health business unit has made a commitment to
provide clinical supervisors with ongoing support in addition to their
own individual clinical supervision throughout the time they carry out a
clinical supervision role, by providing bi-monthly support and up-date
sessions for clinical supervisors and by developing a resource file
specifically for clinical supervisors.
4.3
Safeguarding Children Supervision
4.3.1
Standard SG1 Where any concerns are raised around child
protection within clinical or managerial supervision, the
supervisor must direct the practitioner to seek safeguarding
children supervision.
Safeguarding children supervision can be arranged by contacting the
Safeguarding Unit.
4.3.2
Standards SG2 Safeguarding children supervisors must have
attended the appropriate child protection supervision training
4.3.3
Standard SG3 Safeguarding children supervision will be
undertaken in a 1:1 confidential environment.
4.3.4
Standards SG4 A supervision contract will be formulated between
supervisor and supervisee at the induction session (or first
session when changing supervisor)
4.3.5
Standard SG5 The supervisee will be responsible for the
preparation of the issues to be discussed and complete relevant
paperwork prior to the session
.
Due to the session length, it is likely that a maximum of 3 cases can be
discussed at each session, supervisees with more cases that require
supervision will need to book a further session.
The supervisor, in collaboration with the supervisee will formulate a
Safeguarding Children development plan, which will be brought to all
sessions by the supervisee, and updated at each session.
48
4.3.6
Standard SG6 Boundaries of confidentiality will be respected and
reflected in the supervision agreement.
Supervision sessions are confidential to the supervisor and the
supervisee, and issues arising may only be disclosed outside the
session following discussion between the supervisor and supervisee.
However both supervisor and supervisee will work within the
professional code of conduct for their profession, and SWYPFT
Employment Policies. The professional codes of conduct and the
Employment Policies take precedence over the supervision
agreements. Anonymised supervision records will be made available to
the Designated Nurse safeguarding children for quality assurance
purposes.
Supervision will be undertaken within a framework of anti-oppressive
and non-discriminatory practice. Both supervisor and supervisee will be
expected to challenge practice that is outside of these frameworks.
Safeguarding children and child protection are recognised as being
stressful. Safeguarding children supervision will form a safe
environment for supervisees to discuss their feelings
4.3.7
Standard SG7 All documentation identified under the
responsibilities of supervisors and supervisees must be
completed appropriately.
This has been appendixed to this document at appendix E
5
AUDITING SUPERVISION STANDARDS
5.1
Audit of Management Supervision
A baseline e-mail audit of management supervision activity will be
undertaken – as part of this audit staff will be asked to identify their
supervisory manager and the frequency of their supervision meetings.
This will be repeated to measure compliance with the standards.
5.2
Audit of Clinical Supervision
The auditing of the clinical supervision standards will be based on an
audit programme rolling over three years:
 in year one the standards that are applicable to supervisees only will
be audited,
 year two standards that are applicable to supervisors only will be
audited
 in year three standards that are applicable to supervisees only will
be audited
49
A further telephone audit of clinical supervisor’s activity will be carried
out on a yearly basis to measure the extent of implementation of clinical
supervision with the community mental health business unit
5.3
Audit of Safeguarding Children Supervision
5.3.1
The quality and effectiveness of safeguarding children supervision will
be monitored as an ongoing exercise in the following ways:
Qualitative audits of supervisee experience of safeguarding children
supervision will be conducted within the first year following this
protocol, and every 2 years.
6
5.3.2
Regular evaluation of the safeguarding children supervision Record for
compliance and quality.
5.3.3
Safeguarding children supervision will be reported as part of the
quarterly report for the Director of professions
REFERENCES
Barnsley Metropolitan Borough Council (BMBC) Adult Social Services
Directorate (2009) Supervision Procedure
Children’s Workforce Development Council (2007) Providing Effective
Supervision Leeds. CWDC.
Department of Health (2006) From values to action: The Chief Nursing Officer’s
review of mental health nursing. London: COI
Department of Health (2000) Framework for the Assessment of Children in
Need and their Families London. The Stationery Office.
DFES (2004) National Framework for Children, Young People and Maternity
Services London. DFES
HM Government, (2010) Working Together to Safeguard Children London.
DCSF
HMSO (2004) The Children Act. London. HMSO
Lord Laming (2003) The Victoria Climbié Inquiry Report. London. The
Stationery Office
Lord Laming (2009) The Protection of Children in England London. The
Stationery Office
Morrison, Tony (2007) Staff Supervision in Social Care Brighton. Pavilion
50
NHS Barnsley Care Services Direct (CSD) (2009) Clinical/Professional
Supervision Policy
NHS Barnsley (2010) Safeguarding Children Supervision Policy.
Slone, Graham (2006) Clinical Supervision in Mental Health Nursing
Chichester: Wiley.
YEGDICH, Tania (1999) Clinical Supervision and managerial supervision:
some historical and conceptual considerations. Journal of Advanced Nursing 30
(5), 1195-1204.
7
8
REVIEW OF THIS DOCUMENT
7.1
The standards will be reviewed 3 years from the date of approval
7.2
Audit of supervision activity will contribute to the review.
APPENDIX
Examples of Record Keeping Paperwork :Appendix 1 Clinical supervision pro forma – see appendix D
Appendix 2 – Safeguarding children supervision pro forma – see
appendix E
51
Appendix 3
LINE MANAGEMENT SUPERVISION
Name of Supervisee:
Date:
Name of Supervisor:
Venue:
Matters Arising
Supervisee Personal Agenda
Caseload/Workload/Clinical Issues
Safeguarding/Risk Issues
Anti oppressive/Anti discriminatory Practice (Equality & Diversity)
Training (Mandatory/Non-mandatory)
Management Issues/Feedback/Development
Supervisee Signature:
Supervisor Signature:
Date and time of next session:
52
Appendix D – Clinical Supervision pro forma
RECORD OF SUPERVISION
Appendix D1
Name of Supervisee:
Name of Supervisor:
Date/Duration
Type (Group or 1:1)
Supervisor signature
53
Clinical Supervision Contract
Appendix D2
SUPERVISEE
NAME:
DESIGNATION/AREA OF WORK:
SUPERVISOR
NAME:
DESIGNATION/AREA OF WORK:
1. FREQUENCY OF CONTACT/MINIMUM HOURS REQUIREMENT
2. LENGTH OF SESSION
3. VENUE OR PERSON RESPONSIBLE FOR ARRANGING VENUE
4. RECORD KEEPING
A record of the session must be documented – in keeping with the standards
for healthcare records.
Documentation will held securely – describe process,
54
5. CONFIDENTIALITY
All information disclosed in the clinical supervision session will be kept
confidential with the following exceptions:



Where harm to self or others is disclosed.
Where unsafe, unethical or illegal practice is disclosed that the
supervisee is unwilling to go through appropriate procedures/channels
to address.
To maintain high quality clinical supervision the supervisee has to
agree to allow the supervisor to take any issues they feel appropriate
from the session forward to their own clinical supervision, however the
supervisor agrees to disclose the minimum of information necessary.
Where supervisees choose to integrate their supervision records within their
CDP portfolio, any record should avoid personal identification of service users
or third parties, as service users may be able to apply for access to such
records under the Data Protection Act.
6. REVIEW PROCESS
7. PROCEDURE FOR RESOLVING CONFLICT/ISSUE OF DIFFERENCE
8. CANCELLATION/RE-ARRANGEMENT PROCEDURE
SIGNATURES
DATE
55
REVIEW DATE:
SUPERVISION RECORD 1:1 Appendix D3
SUPERVISEE:
SUPERVISOR:
DATE:
KEY ISSUES BROUGHT:
COMMENTS/REFLECTIONS:
OUTCOMES/PLAN:
SIGNATURES:
DATE:
56
SUPERVISION RECORD: GROUP Appendix D4
SUPERVISOR NAME (PRINT):
DATE:
SIGNATURE:
SUPERVISEES NAMES (PRINT):
1.
2.
3.
4.
5.
6.
7.
8.
DURATION:
SUPERVISEE SIGNATURES:
KEY ISSUES BROUGHT:
COMMENTS/REFLECTION:
OUTCOMES/PLAN:
57
Appendix E – Safeguarding Children Supervision pro forma
Appendix E1
Contract for Safeguarding Children Supervision
Name of Supervisee –
Name of Supervisor –
Frequency / Duration of Supervision Sessions – Minimum of 3 monthly for
minimum of 1 hour.
The supervisor will:








Encourage the utilisation of reflection to facilitate the supervisee’s critical analysis
of practice.
Create a forum which facilitates the supervisee to explore values, assumptions
and attitudes in relation to practice.
Provide professional support.
Constructively challenge elements of practice where required.
Ensure that the supervisee remains focused on the child and where required
considers the needs of other children in the family.
Promote effective interagency working and information sharing.
Ensure that Local Safeguarding Children Board policies and procedures are
adhered to.
Agree any actions required and identify timescales for their implementation with
the supervisee.
The supervisee will:





Identify families of concern for discussion within the supervision framework.
Present case files for children and families discussed within supervision where
practically possible
Utilise reflection to facilitate professional development.
Maintain professional accountability and responsibility for their actions.
It is the responsibility of the supervisee to record within the clinical record that
they have accessed safeguarding children supervision and any actions arising
from this.
N.B. Personal issues discussed within the context of supervision will remain
confidential unless it becomes clear that withholding information may place a
child/young person/adult or family at risk.
Contract agreed
Supervisee ………………………………………..
Date ………………………….
Supervisor ………………………………………..
Date …………………………..
58
Appendix E2
1:1 Safeguarding Children Supervision Record and Action Plan
Action Plan
Date
Supervisee’s Name
Supervisor’s Name
Review of issues/actions discussed at last session (if applicable):
Issues/children discussed at today’s session:
59
Action agreed for each issue or child
Date of Next Meeting:
Signed (Supervisee)
Signed (Supervisor)
Cc
Supervisee
Supervision File
60
Appendix E3
Safeguarding Supervision
Contact Sheet/Record of Supervision
Name: ………………………………………………………………………………………
Date
Notes
Signature
61
Date
Notes
Signature
62
Appendix F
Minimum Learning outcomes for Clinical Supervision Training
On completion of the training the learner will:

have knowledge of the context within which supervision is provided and an
understanding of the inherent responsibility.

understand the importance of modelling the professional role.

have knowledge of developmental models of learning which may have an
impact on supervision.

have an awareness of a number of supervision frameworks.

will understand how the SWYPFT policy on clinical supervision impacts on
practice.

understand the importance of a safe environment in facilitating learning and
the factors that affect the development of a supervisory relationship.

have an awareness of contracting and negotiating with supervisees and the
importance of maintaining documentation..

have an understanding of the transferability of professional skills into
supervision.

have an understanding of constructive criticism and ongoing positive
feedback.

will understand the role of reflective practice in clinical supervision.

The learner will understand the need for undertaking ongoing clinical
supervision in their development as a clinical supervisor.
63
Appendix G - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Title of document being reviewed:
1.
2.
4.
5.
6.
Comments
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
YES
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
YES
Development Process
Is the method described in brief?
YES
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
Content
Is the objective of the document clear?
YES
Is the target population clear and
unambiguous?
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the
document identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Approval
Does the document identify which
committee/group will approve it?
YES
If appropriate have the joint Human
64
Title of document being reviewed:
Yes/No/
Unsure
Comments
Resources/staff side committee (or equivalent)
approved the document?
7.
8.
9.
10.
11.
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
YES
Does the plan include the necessary
training/support to ensure compliance?
YES
Document Control
Does the document identify where it will be
held?
YES
Have archiving arrangements for superseded
documents been addressed?
YES
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance
with the document?
YES
Review Date
Is the review date identified?
YES
Is the frequency of review identified? If so is it
acceptable?
YES
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
YES
65
Appendix H
Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
March
2009
May
2010
Marie Knott
Final
Final versions approved by SWYPFT and
NHS Barnsley Trust Boards
Supervision Policy
Group
Final
1
July
2012
Alison Hill
Lead Nurse
Community Mental
Health/ Clinical
Supervisor Training
Facilitator
Draft
SMYPFT Supervision policy for clinical
staff and NHS Barnsley
Clinical/professional supervision policy
aligned.
1
August
2012
Alison Hill
Lead Nurse
Community Mental
Health/ Clinical
Supervisor Training
Facilitator
Draft
First draft sent out for consultation:
Tim Breedon, Dr Adrian Berry, Anna
Basford, Ann Hargate, George Smith, Julie
Fleetwood, Karen Batty, Anne Hoyle,
Simon Plummer, Dr Nisreen Booya, Julie
Hickling, Sean McDaid, Richard Clibbens,
John Cordall, Caroline Rake, Tonia
Devenport, Sheila Lewis, Professor Nigel
Beail, Carol Bishop, Carol Circuit, Diane
Collinson, Di Dillon, Ruth Donnoghue, Sue
Dymock, Janet foster, Helen Dixon, Sarah
Hudson, Kyra Ayre, Anita McCrum,
Deborah McLeaod, Ann Meynell, Hiliary
Mosley, Janet Owen, Kathryn Padgett,
Sandra Montisci, Bob Senior, Simon
Robinson, Julie Smith, Andrew Stones, Jill
Thicket, Alison Thomas, Dawn Thomas,
Linda Wake, Helen Walker, Sean Rayner,
Sue Wing, Dave Ramsay, Andrea Wilson,
Jeremy Robbins, Dr Keith Sands, Dr
Suresh Chari, Clinical Supervisors Up-date
and Support Session (Barnsley Mental
Health)
Staff side: Paul Smith, David Pickersgill
HR: Hilary Bannister, Kate Redican, David
Batty, Marilyn Gill, Janet Hirst
2
Sept
2012
Alison Hill
Lead Nurse
Community Mental
Health/ Clinical
Supervisor Training
Facilitator
First draft reviewed and amended following
feedback from:
Prof. Nigel Beail, Ann Hargate, Sarah
Hudson, Sharon Kehoe, Julie WarrenSykes, Jeremy Robbins, Andrea Wilson,
Julie Smith, Anne Hoyle, Dawn Thomas,
David Ramsay, George Smith, Christine
Harrison, John Cordall, Dr Lisa Winter,
Simon Plummer, Dr Delyth James, Julie
Hickling
66
67