An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
NHS Mental Health & Learning Disability Trust
An Organisation-wide Document for the Clinical and
Managerial Supervision of all Clinical Staff
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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March 2012
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 4
4.1
4.2
Duties within the Organisation ............................................................................................... 4
Committees and Groups with Overall Responsibilities........................................................... 5
5
Clinical Supervision .................................................................................................. 6
6
Managerial Supervision ........................................................................................... 6
7
Clinical Supervision Models ..................................................................................... 6
7.1
7.2
7.3
7.4
One to One Supervision .......................................................................................................... 6
Peer Group Supervision .......................................................................................................... 6
Multidisciplinary Group Supervision ....................................................................................... 6
Informal Supervision ............................................................................................................... 6
8
Frequency of Supervision ........................................................................................ 7
9
Contracts of Supervision .......................................................................................... 7
10
Recording .............................................................................................................. 7
11
Confidentiality ...................................................................................................... 7
12
Training ................................................................................................................. 7
13
Equality Impact Assessment ................................................................................. 7
14
Monitoring Compliance with the Document ....................................................... 8
14.1
14.2
15
15.1
16
Process for Monitoring Compliance ....................................................................................... 8
Standards/Key Performance Indicators .................................................................................. 8
References ............................................................................................................ 8
Guidance from Other Organisations ....................................................................................... 8
Associated Documentation .................................................................................. 9
Appendix A - Template Document for the Clinical and Managerial Supervision of all
Clinical Staff .................................................................................................................. 10
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.3
Annual review
Mar 2011
Update to section 15 ‘References’
V.3
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.4
Annual review
Mar 2012
Update to section 4 ‘Duties’
V.4
Amendment
Mar 2012
Change to format including automated
contents page
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-16, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
1
Introduction
This section should give an overview of the importance of supervision as an integral
component of staff support and professional development, which in turn raises the
standards of service delivery.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure that
supervision of clinical staff is managed in the most effective way.
This guidance seeks to inform the development of local strategies, models and procedures
for clinical and managerial supervision for all clinical staff.
3
Explanation of Terms
This section should provide the meaning of the terms used in the context of the document if
considered necessary. For example:

Clinical supervision
This is “a formal process of professional support and learning which enables
individual practitioners to develop knowledge and competence, assume responsibility
for their own practice and enhance consumer protection and safety of care in
complex clinical situations. It is central to the process of learning and to the scope of
the expansion of practice and should be seen as a means of encouraging selfassessment, analytical and reflective skills”. (Vision for the future, DH 1993)
The following list is a guide only and is not exhaustive:
a
4

Management supervision

Supervision models
Duties
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
4.1
Duties within the Organisation
Some example responsibilities have been identified below; however, these should
be considered within the context of the individual organisational structure.
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Senior Manager(s)
Roles and responsibilities of senior manager(s) and their involvement in clinical and
managerial supervision of all clinical staff should be documented.
Line Manager(s)
Roles and responsibilities of line manager(s) and their involvement in clinical and
managerial supervision of all clinical staff should be documented.
Risk Manager
Roles and responsibilities of the risk manager in relation to the clinical and
managerial supervision of all clinical staff should be documented.
Supervisor Responsibilities
This section should detail the need to ensure that the diverse needs of the person
being supervised are considered in relation to the process. The document should
identify that there is joint responsibility for drawing up a supervision contract
between the supervisor and the supervisee(s).
Supervisee Responsibilities
This section should detail the need to choose an appropriate model of supervision
and to seek an appropriate supervisor or group for the chosen model of supervision.
The document should identify that there is joint responsibility for drawing up a
supervision contract between the supervisee(s) and the supervisor.
4.2
Committees and Groups with Overall Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for the Clinical and
Managerial Supervision of all Clinical Staff there must be active support from the
most senior members of the organisation. Organisations should detail how the chief
executive and the nominated directors are to gain assurance that this document is
being implemented within the organisation. There must be effective cooperation at
all levels of the organisation in order for this process to be successful.
Committees/Groups
This section should identify the committee/group which will have overall
responsibility for the clinical and managerial supervision of all clinical staff. The
section should include:
V.4

how this committee/group links with all the other relevant risk management
committees;

the role this committee/group has with ensuring continuous development of
this document;

the role the committee/group has in the analysis of the clinical and
managerial supervision of all clinical staff;
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff

how this committee/group communicates both up to board level, and down
to the local management levels; and

how the committee/group facilitates organisational learning and
improvement as a result of monitoring the provision of staff support
mechanisms.
It would be considered good practice if the organisation developed terms of
reference for this committee/group including: accountability, responsibility,
authority, membership (including identified co-opted members and deputies),
meeting schedule and quorum, etc. In addition the terms of reference should be
dated and signed.
b
c
d
5
Clinical Supervision
This section should include how the organisation provides clinical supervision, including how
the organisation makes sure that staff receive appropriate clinical supervision. It should also
be distinguished from preceptorship and mentoring.
6
Managerial Supervision
This section should include how the organisation’s expectations in relation to managerial
supervision. It should also include how the organisation makes sure that staff receive
managerial supervision.
7
Clinical Supervision Models
The organisation is encouraged to outline the supervision models in use which may include:
7.1
One to One Supervision
This type of clinical supervision usually takes place between two members of the
same staff group with the supervisor usually being senior to the supervisee.
7.2
Peer Group Supervision
Peer group supervision usually takes place within a small group setting of the same
staff group with equal experience and sharing supervision tasks equally.
7.3
Multidisciplinary Group Supervision
This model of clinical supervision is a non-hierarchical relationship and takes place
between a facilitator and a group. The facilitator does not have a line management
relationship with the supervisees and the supervisees will be from different
professional groups.
7.4
Informal Supervision
This can happen in a variety of settings and forms and may be called consultation.
All staff should have access to daily ad hoc supervision for urgent and routine work.
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
8
Frequency of Supervision
It is expected that each organisation will set the frequency with which both clinical and
managerial supervision are required to take place and include these timeframes within the
documentation.
9
Contracts of Supervision
This section should include a description of the negotiated and written agreements which
identify the terms of the supervision relationship and could include the following:

frequency, duration and venue for sessions;

records or notes to be kept regarding supervision sessions;

responsibilities of parties and expectations of each other;

ground rules for the relationship, including limits of confidentiality; and

arrangements for termination of the relationship.
The supervision contracts should be reviewed at least annually.
10
Recording
Supervisee(s) should keep a log of supervision, covering dates, times, duration and a record
of any cancelled sessions.
Record forms in use within the organisation should be appended to the document and may
be used by the organisation for audit purposes.
11
Confidentiality
Clinical supervision is a confidential process between the supervisor and the supervisee.
There are limits to the confidentiality, for example issues of grave concern regarding
possible malpractice, lack of competence or issues affecting the safety of others, which may
require reporting through appropriate channels by the supervisor.
e
12
Training
It is important that all staff are trained in supervision and appraisal processes, so they are
clear what is expected of them and can benefit fully from the process. The organisation’s
expectations in relation to both supervisor and supervisee training should be included in the
organisation’s training needs analysis and a link to this document should be clearly
identified.
13
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
f
14
Monitoring Compliance with the Document
14.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for the Clinical and Managerial Supervision of all
Clinical Staff. As a minimum it should include the review/monitoring of all the
minimum requirements within the NHSLA Risk Management Standards. The
following list is a guide to issues which could be considered within this section and
should be added to where appropriate:
14.2

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
15
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
V.4
15.1
Guidance from Other Organisations

The Department of Health website provides further information and resources:
www.dh.gov.uk

Vision for the future (1993)

The Ten Essential Shared Capabilities A Framework for the whole of the
mental health workforce (2004)

Guidance on New Ways of Working for Psychiatrists in a Multi-agency
Context (2004)

From values to action: The Chief Nursing Officer’s review of mental health
nursing (2006)
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
16

Mental Health: New Ways of Working for Everyone: A best practice
implementation guide (2007)

Capabilities for Inclusive Practice (2007)

New Horizons: A Shared Vision for Mental Health (2010)

‘The Mental Capacity Act Deprivation of Liberty Safeguards’ DH website list
of resources and links

Morgan, S. (2009) Clinical Risk Management: A Clinical Tool and Practitioner Manual

National Institute for Health and Clinical Excellence (NICE) CG16 Self-harm: The
short-term physical and psychological management and secondary prevention of
self-harm in primary and secondary care

Nursing and Midwifery Council (2008) Clinical supervision for registered nurses.

Patient Safety First ‘Deterioration’ Patient Safety First website page

Royal College of Psychiatrists (2010) Self-harm, suicide and risk: a summary Position
statement
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and not exhaustive:
V.4

Care Programme Approach (or other care planning processes dependent upon
configuration)

Induction

Mandatory training

Training needs analysis
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Appendix A - Template Document for the Clinical and Managerial Supervision of all
Clinical Staff
NHS Trust
An Organisation-wide Document for the Clinical and
Managerial Supervision of all Clinical Staff
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
V.4
March 2012
Page 10 of 14
An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Contents
1
Introduction ........................................................................................................... 13
2
Purpose .................................................................................................................. 13
3
Explanation of Terms ............................................................................................. 13
4
Duties ..................................................................................................................... 13
4.1
4.2
Duties within the Organisation ............................................................................................. 13
Committees and Groups with Overall Responsibilities......................................................... 13
5
Clinical Supervision ................................................................................................ 13
6
Managerial Supervision ......................................................................................... 13
7
Clinical Supervision Models ................................................................................... 13
7.1
7.2
7.3
7.4
One to One Supervision ........................................................................................................ 13
Peer Group Supervision ........................................................................................................ 13
Multidisciplinary Group Supervision ..................................................................................... 13
Informal Supervision ............................................................................................................. 13
8
Frequency of Supervision ...................................................................................... 13
9
Contracts of Supervision ........................................................................................ 13
10
Recording ............................................................................................................ 14
11
Confidentiality .................................................................................................... 14
12
Training ............................................................................................................... 14
13
Equality Impact Assessment ............................................................................... 14
14
Monitoring Compliance with the Document ..................................................... 14
14.1
14.2
15
15.1
16
Process for Monitoring Compliance ..................................................................................... 14
Standards/Key Performance Indicators ................................................................................ 14
References .......................................................................................................... 14
Guidance from Other Organisations ..................................................................................... 14
Associated Documentation ................................................................................ 14
Appendix A
Checklist for the Review and Approval of Procedural Documents ...... 14
Appendix B
Version Control Sheet ........................................................................... 14
Appendix C
Plan for Dissemination .......................................................................... 14
Appendix D
Equality Impact Assessment Tool ......................................................... 14
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
Review and Amendment Log
Version No
V.4
Type of Change
Date
March 2012
Description of change
Page 12 of 14
An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
4.1
Duties within the Organisation
4.2
Committees and Groups with Overall Responsibilities
5
Clinical Supervision
6
Managerial Supervision
7
Clinical Supervision Models
7.1
One to One Supervision
7.2
Peer Group Supervision
7.3
Multidisciplinary Group Supervision
7.4
Informal Supervision
8
Frequency of Supervision
9
Contracts of Supervision
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An Organisation-wide Document for the Clinical and Managerial Supervision of all Clinical Staff
10
Recording
11
Confidentiality
12
Training
13
Equality Impact Assessment
14
Monitoring Compliance with the Document
15
14.1
Process for Monitoring Compliance
14.2
Standards/Key Performance Indicators
References
15.1
16
V.4
Guidance from Other Organisations
Associated Documentation
Appendix A
Checklist for the Review and Approval of Procedural Documents
Appendix B
Version Control Sheet
Appendix C
Plan for Dissemination
Appendix D
Equality Impact Assessment Tool
March 2012
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