Introduction

Clinical supervision is a formal process of professional support, reflection and learning, that supports and guides clinical decision-making, and contributes to individual development.

Safeguarding supervision has been well established in both nursing and in social care practice for several decades; this has been one of the primary drivers of quality improvement in safeguarding frontline practice. The NHS England 2022 Safeguarding Accountability and Assurance Framework requires all healthcare providers to ensure “effective safeguarding supervision arrangements for staff, commensurate to their role and function (including for named professionals).” (p14)

Working Together to Safeguard Children (2023) states that “supervision can play a critical role in ensuring a clear focus on a child’s welfare. Supervision should support professionals to reflect critically on the impact of their decisions on the child and their family.” (p59)

Most NHS organisations now have a safeguarding supervision policy, which requires regular supervision for all clinical staff. Some organisations have policies just for nursing and social work staff. Almost all doctors both give and receive clinical supervision informally as part of their roles; for most paediatricians, this will include safeguarding cases; however, much of this is undocumented, and in many services, would be difficult to evidence outside the department.

Recognising and responding to safeguarding concerns is a vital part of every paediatrician’s work. Safeguarding supervision is a key component of maintaining safeguarding skills and providing high quality safe care. Evidence of participation should be presented at appraisal and revalidation for all paediatricians.

This guidance is for all paediatricians, whether or not they are undertaking planned or unplanned child protection medical assessments. It also provides additional guidance for those with specific named and designated doctor roles for vulnerable children (including child safeguarding, child death overview and looked after children).

Purpose of safeguarding supervision

• To promote a positive outcome for children and young people by aiding the supervisee in forming an evidence-based opinion and/or management plan through case-based discussion with a supervisor who is a source of advice, guidance and expertise.
• To provide a proactive culture of learning, professional development and support, education and training, service improvement and improvement of multiagency processes.
• To allow individual paediatricians to take responsibility for their own practice by providing an environment for reflection, promoting critical thinking skills, and identifying gaps in knowledge or skills.
• To ensure practice is uniform and professional judgement is sound, which provides service-level assurance that case findings are objective, opinions are evidence-based and reports meet professional standards.
• To provide pastoral support and recognition of triggers that are barriers to sustaining resilience when faced with challenging or distressing work, decrease professional isolation, promote the sharing of best practice and understanding of the complexities of safeguarding situations.
• To contribute to the evidence collected by a clinician for the purposes of annual appraisal and revalidation, and by organisations for competent accountable performance.

Functions of safeguarding supervision

• Educational (formative): to address the professional development needs of the supervisee
• Management (normative): to provide accountability to the organisation through the monitoring of professional and organisational standards
• Supportive (restorative): to recognise the emotional impact of safeguarding work. This provides support for practitioners and explores strategies for coping and self-care
• Engagement: to engage the individual with the organisation.

Good quality safeguarding support and supervision can help to:

• keep a focus on the individual case; avoid drift
• maintain a degree of objectivity and challenge fixed views
• look at the evidence base for decisions made
• address the emotional impact of this work
• create a safe climate for practitioners to look at their work and its impact on them personally
• provide appropriate feedback, recognition and praise.

Definitions

There is no universally agreed definition of supervision. For the purposes of this document, the following definitions are used:

Clinical supervision is a form of reflective practice which involves both reflection by the supervisee, and guidance or direction by the supervisor. An experienced supervisor may guide a supervisee towards an orthodox interpretation, action or evidence-base, or encourage them to consider wider possibilities. It usually involves an experienced (senior or peer) supervisor providing a structured format for reviewing a case or situation, in a one-to-one or group setting. In supervision, the supervisee’s opinion and action plan may be formed. By contrast, in peer review, the examining doctor’s existing opinion is compared to and tested by others of equivalent experience.

Supervision may occur in a formal planned way or may be sought by the clinician in response to uncertainty about the interpretation of findings or course of action in a particular case.

Among paediatricians, safeguarding supervision is primarily a form of clinical supervision on safeguarding and child protection cases, although there may also be elements of management, professional or educational supervision, depending on the roles, grade and experience of the supervisor and supervisee (s).

All aspects of child protection/safeguarding cases may be subject to supervision including the advice given, clinical input into multiagency processes, the findings, interpretation of findings, documentation, case management, and report or witness statement. Safeguarding supervision will typically involve a ‘deep dive’ into the case, reviewing aspects in a greater degree of detail (for example guiding the supervisee to reflect on the clarity of their child protection report and/or role in the multiagency response) than at peer review (which may focus on the images and conclusion alone).

It is good practice for paediatricians, at all grades, to have regular planned safeguarding supervision. This is a scheduled regular protected meeting, of which a formal record is made.

Where a paediatrician is uncertain about the findings, or of the interpretation of the findings, or the best course of action in any clinical case, then ad-hoc safeguarding supervision is appropriate. This must be available in a timely way, so that safe decision-making and information-sharing is not delayed. This should be recorded in the child’s clinical record. The supervisor’s details should be recorded (unlike peer review attendance), and the supervisor’s contribution should be clear. A supervisor may for example prompt reflection with focused questions, signpost to an evidence-base or comparison cases, or provide their own experienced opinion of findings (second opinion); if a second opinion is provided, they should be aware they may be required to give a statement in the event of court proceedings.

It is also good practice to keep an auditable central or individual record of ad hoc supervisions occurring within a department.

Safeguarding supervision is a form of clinical governance. Along with peer review, participation in safeguarding supervision contributes to service-level assurance.

Difference between safeguarding supervision and peer review

Safeguarding supervision is distinct from child protection peer review, although both are forms of reflective practice, and both provide service-level quality assurance:

• Peer review provides group comparison and friendly-challenge of an established clinical opinion, ensuring the robustness and evidence-based foundation of that opinion.
• Safeguarding supervision is formative, allowing the supervisee to bring uncertainty, dilemma or difficulties of a case, and to developing their professional opinion or plan, through guided reflection and signposting by the supervisor.

This document is the sister guidance to the RCPCH Peer Review Guidance.

Principles and scope

The type of safeguarding supervision required will depend upon the roles and responsibilities within the department. Whatever the model adopted to deliver supervision, the process for supervision should include the following elements:

• facilitating staff to remain child/family focused
• use of reflection in a safe and supportive manner to promote best practice
• issues and boundaries of confidentiality are clearly communicated and understood
• consideration of what and where the outcome of the supervision, support or advice is recorded
• the accountability of the individual practitioner
• identified training needs are appropriately managed
• where issues of concern arises with respect to an individual’s practice, values or attitude, this must be addressed in line with the organisations reporting systems.

Who should participate in supervision?

All paediatricians are involved in safeguarding and child protection, whether they are receiving referrals for planned child protection assessment or the concerns arise during clinical duties.

All paediatricians with a community or general workload (including ambulatory and urgent care settings) should engage in regular formal and informal safeguarding supervision.

It is essential for all paediatricians, whether generalists or subspecialists, to maintain their safeguarding skills; it is therefore best practice for all paediatricians, including those without direct responsibilities for child protection medical assessment, to participate in regular formal and informal supervision. This group of paediatricians may not be accessing regular peer review, making supervision with a colleague experienced in safeguarding, such as a named doctor (or equivalent) particularly important.

Other clinical staff such as specialist nurses or physician’s associates who are involved in child protection work should also participate in supervision.

Paediatric residents (trainees) should always practice under senior supervision; safeguarding supervision for residents should be in addition to clinical and educational supervision, although a these may be delivered by the same supervisor and/or within the same discussion.

Frequency of supervision meetings and participation

Paediatricians with general or community workloads should attend a minimum of four safeguarding supervisions per year (aiming for quarterly on average). This may differ from allied health professionals, where at least 6 monthly is recommended. This will be a mix of formal and informal supervision (ad hoc, prompted by challenging cases). This number can be more frequent depending on need, case mix and experience.

Supervision is equally important for clinicians who see child protection cases infrequently. It is an important part of maintaining professional competencies. If a service has insufficient referrals/child protection cases/staffing to enable regular supervision, the service should consider combined meetings with other units regionally.

Scope

Any aspect of practice can be discussed in supervision, including the medical examination, findings, case notes, opinion, photo-documentation, report/court statements, investigations and case management. Any cases can be discussed in supervision.

In contrast to peer review (where cases should not be self-selected for presentation), the cases or situations discussed in supervision should be led by the supervisee, to meet their need for support, guidance, and assurance.

For resident doctors, and paediatricians with less safeguarding/child protection experience, the cases which may be most helpful to discuss can include, but are not limited to, cases where there is uncertainty around the range of possible interpretations regarding the nature or mechanism of injury, the consistency of findings with explanation offered in the history, the wording of reports, thresholds in multiagency working, or wider safeguarding support processes.

For experienced paediatricians, the cases which may be most helpful to discuss can include, but are not limited to: cases where there is risk of drift such as where concerns have accumulated or been held over time; familial non-engagement with services; consequences for children in cases of domestic abuse or substance misuse or parental capacity; concerns around perplexing presentation or fabricated illness; concerns of gangs and extremism. In the event of a plethora of options, increased complexity or more nuanced or emotionally demanding cases should be selected.

Supervision should enable effective, focussed and safe decision making, facilitate learning and reflection and provide pastoral and personal support if required.

Child safeguarding work is emotionally demanding. It is acknowledged that the opportunity to discuss cases with peers undertaking similar work, and to receive assurance around case management, has a significant role in maintaining the wellbeing and perspective of clinicians involved. Supervision is a chance for the supervisee to receive emotional support as well as clinical guidance in formulating an opinion. It is appropriate to arrange supervision following involvement in particularly serious abuse cases, challenges with multiagency working. complaints, safeguarding practice review or critical incident. This allows the supervisee a space for structured supportive reflection on their role and the emotional impact of the case.

Restorative supervision is a specific type of supervision. Supervisors trained in restorative supervision may be well placed to offer support in vicarious trauma. Organisations should consider the availability of this for paediatricians involved in child protection.

Job planning

As supervision discusses specific cases and may influence the management of an individual case, it should be considered direct clinical care (DCC) for job planning purposes.

Employing organisations must ensure sufficient time is included in job plans to allow participation.

Aims and objectives

Aims of safeguarding supervision

• To discuss any aspect of safeguarding concerns or child protection cases, raised by the supervisee to support their practice, or by the supervisor for assurance or supervisee-development purposes. This may include review of history/chronology, photo-documentation, the medical report/witness statement, the evidence-base, and multiagency process/working/communication.
• To provide a proactive culture of learning, promote quality improvement, maintain high evidence-based clinical standards, provide training and support.
• To provide a supportive environment to discuss cases, in order to help reflective practice, prevent professional isolation and aid sharing of best practice.
• To provide a forum for the paediatrician to discuss the emotional impact on them of working within this challenging area of practice.
• Reduce the level of stress, burn-out and potential for dangerous professional practice that could put the child, the professional and the employing organisation at risk.

Objectives of safeguarding supervision

• To provide time for discussion of cases in a non-threatening atmosphere seeking to minimize time pressure at the meeting within the context of any concurrent clinical exigencies.
• To provide a space for the supervisee to reflect on cases, and to formulate appropriate evidence-based management and opinion, under the guidance of the supervisor.
• To provide support through the sharing of professional experiences of others.
• To help identify areas for additional training for the group and/or individuals concerned.

Conducting safeguarding supervision meetings

Organisation and structure

• Supervision can be conducted one on one or within a small group setting; it may be planned (regularly scheduled) or ad hoc (case-needs led). It is best practice to have a mix of these.
• Safeguarding supervision may take place in-person, or using secure remote platforms such as Microsoft Teams or Zoom, provided these are approved by the employing organisation.
• Informal/ad hoc supervision may be provided by any consultant or senior doctor with significant safeguarding experience, appropriate to the case. This is often delivered on a best-endeavours basis between senior colleagues, and local arrangements should be in place to ensure this is available in a timely manner.
• Resident paediatricians (trainees) should be supervised by the consultant clinically responsible for the case. They may also access planned supervision within the department (for example with the named doctor), group or individually.
• The frequency of planned/formal supervision meetings will depend on the nature of the service and caseload and role. It is good practice for supervisor and supervisee(s) should meet regularly
• It is good practice to have formal supervision agreements in place between supervisor and supervisee(s).
• Supervision arrangements for paediatric medical staff regularly engaged in child protection medical assessments are usually led by the named doctor for safeguarding children (or four-nation equivalent) within the employing organisation. Delivery of supervision (formal and ad hoc) may be shared between the consultants (or equivalent senior paediatrician with appropriate safeguarding experience) acting as supervisors for peers and for less experienced colleagues.
• It is essential that job plans adequately reflect any supervisory responsibilities.
• Employing organisations must ensure adequate equipment to facilitate the viewing of images, whether by digital projection, hard copy, or remote access. Similarly, supervision meetings will require facilities for access to notes and reports, and to ensure appropriate documentation of the meeting.
• Not all safeguarding/child protection cases need to be discussed at supervision cases should be brought to supervision when the clinician involved in the clinical care wishes to receive support, guidance or a ‘sense-check’ on any aspect of the case.
• Attendees should be fully informed of the aims and objectives of safeguarding supervision.

Roles and responsibilities

Supervision is a two way process involving rights and responsibilities on the part of both supervisors and those individuals that they supervise.

Role of supervisor

Supervisors should:

• be experienced in child protection and child safeguarding
• remain up to date with legislation and policy relevant to safeguarding
• receive their own regular supervision
• be accountable for the advice they give
• set and agree a contract with the supervisee
• facilitate a safe learning environment
• facilitate effective reflection through discussion of decision making
• if required, constructively challenge professional and personal areas of concern
• recognise when the supervisee may need to be re-directed to another supervisor if they do not have the required knowledge
• provide assurance that supervision has taken place in accordance with organisation policy.

Role of supervisees

Supervisees should:

• understand their responsibilities in relation to safeguarding include actively accessing supervision, advice and support when necessary
• prepare for the session by identifying issues/cases needing to be discussed. It is good practice to send case outlines of issues to be discussed where possible. It is essential to have all relevant detail available
• be responsible for ensuring that the plans formulated during supervision are adhered to and that targets set are achievable and realistic
• be prepared for constructive feedback and professional challenge
• be aware of any learning needs identified and take positive action to address these
• evidence they have developed practice as a result of supervision (e.g. reflective accounts)
• ensure changes to plans are carried out
• record supervision meeting in the child’s record.

Both the supervisor and supervisee are responsible for ensuring that:

• this is a two way process
• has a child safeguarding focus
• any arrangements are prioritised
• the sessions are used to promote effective practice to maintain the safety of children (and adults) at risk.

Both supervisors and supervisees must:

• maintain respect, confidentiality and professionalism
• come to an agreement on the process with each other at every meeting
• sign a safeguarding supervision contract prior to the meeting and retain a copy each
• also engage in the peer review process
• evidence participation in safeguarding supervision for appraisals.

Accountability

Resident doctors, and those new to an area of practice or service, may be practicing under the direct clinical supervision of a clinical supervisor. The clinical supervisor will hold full or joint responsibility for the case, including for any safeguarding elements. Separate safeguarding supervision may be sought but is not usually required.

Resident doctors undertaking child protection medical assessments should do so under the clinical supervision of a senior paediatrician (see RCPCH Child Protection Service Delivery Standards).

For all other cases, the supervisee, as the examining paediatrician, retains accountability and responsibility for the management of their case, and for the opinion provided in any child protection report or other communication with safeguarding partner agencies. This responsibility extends to any subsequent document changes such as addendum reports.

If as a result of the supervision, the examining doctor’s level of concern, interpretation of findings or management plan changes, the examining doctor (supervisee) is responsible for documenting the supervision, how it has influenced opinion, and any actions in the case. The examining doctor (supervisee) is responsible for actioning any issues arising, such as further tests, referral, follow up or further information gathering/sharing.

Process

There has previously been no definitive model of safeguarding supervision. Previously proposed models include Proctor (1987), Wallbank and Wonnacott (2015), and cycles of reflection such as those by Kolb (1984) and Gibbs (1988).

Whatever model used, the supervisee should be encouraged to reflect on the case, their decision making process and identify any learning needs.

There are a number of ways in which safeguarding supervision meetings can occur.

For most paediatricians, ad hoc supervision has long been part of regular practice, informally and proactively requesting a ‘sense-check’ on a challenging case from a trusted colleague. However, this was often not recorded or audible. This type of supervisee-initiated immediate supervision tends to become less frequent as paediatricians gain seniority,  and is less likely to involve longer-term concerns (which hold inherent risk of drift). The addition of regular planned supervision helps guard against silo working, ensures knowledge/best practice is current, and is able to include a broader range of cases/safeguarding issues. Accessing a mix of supervision types is recommended practice.

One-on-one safeguarding supervision

This is a clear negotiated process in place to discuss cases on a regular basis. A model of reflection may be used to ensure a clear and precise process allowing for description, analysis and evaluation of the experience.  The supervisor helps the supervisee to reflect on his/her own practice and to consider possible alternatives.

Agreed interventions are clearly recorded (Appendix 3) and a formal agreement is in place (Appendix 1).

This can be planned or requested as hoc.

It is the responsibility of the supervisee to arrange a mutually agreeable time and place. The supervisee will present a case/cases for discussion and the meeting should last up to 2 hours. The supervisee should take responsibility to act on any agreed action from the meeting.

Group safeguarding supervision

This is a negotiated process providing a proactive culture for learning and professional development.  Staff come together in an agreed format to reflect on their work by pooling skills, experience and knowledge.  The group supervision can be “topic” or “case” specific.  A formal agreement is in place/terms of reference should be in place.

This has the additional benefit of the team learning from an experience promoting consistency and cohesiveness amongst individuals with common caseloads. Number within the group should not exceed 6 and ideally the meeting should be face to face.

A member of the group should present a case and the supervisor should encourage reflection and discussion, encouraging all group members to contribute and support. If appropriate, the supervisor could deliver teaching on the theme for a short period of time during the meeting.

The individual whose case it is retain responsibility of actioned the agreed plan. Group members should be respectful of opinions and contributions, and challenge practice. If there is disagreement between group members, this should be resolved within the meeting context as far as is possible.

Ad hoc supervision

It is recognised that all staff need to be able to access supervision, advice and support in relation to safeguarding, outside of formal supervision sessions. Immediate supervision may be available from safeguarding professionals within the organisation by telephone.  However, the advice and guidance required by paediatricians, particularly in regard to the clinical aspects of child protection, may be most appropriately provided by senior paediatric colleagues within the organisation.

The appropriate person to ask for immediate supervision will depend on role, the nature of the case or aspect to be discussed, and availability.

For most paediatricians, the named doctor will provide much of the informal ad hoc supervision, although other consultant colleagues may also offer support.

This type of supervision, advice and support may involve giving emotional support, reassurance to staff involved with particularly stressful or complex cases, or assistance in procedural advice.  This type of supervision will not involve a formal agreement of supervision.

The actions from these discussions should be documented.  It should be made clear in the notes if such discussions are for advice or constitute a request for second opinion.

Post safeguarding incident debriefs

Debriefing is a model of supervision and support normally used when staff have been exposed to an acute or particularly traumatic incident. This model allows those directly involved with the incident to process the event and reflect on its impact on themselves and their colleagues.  It allows for review of processes, structures and procedures, promoting shared learning and professional development.

Supervision agreement

The purpose of a supervision agreement is to establish the basis for which the supervisor and supervisee will work together during their supervision sessions. The following should be considered and discussed when agreeing a supervision agreement:

• the purpose of supervision
• understanding of roles and responsibilities of supervisor and supervisee
• the frequency of supervision
• the venue
• the recording of the supervision
• the practical arrangements for setting dates/cancelling and rearranging sessions.

The completed supervision agreement should be signed by both the supervisor and the supervisee and a copy retained by both.

Training

It is recommended that safeguarding supervision should be provided by an appropriately experienced and qualified supervisor. There are a number of ways in which appropriate supervision training can be accessed. All supervisors should undertake a recognised safeguarding/clinical supervision training course.  This may be training accredited by relevant professional bodies or other in-house or externally provided, appropriate safeguarding supervision training.

Although it may not be possible to make a requirement for compulsory training for supervisees it should be noted that supervisees do require support and help in gaining understanding of the role of supervision in order to engage and fully benefit from the process.  This can be achieved via internal training sessions or supporting guidance.

Legal considerations

A minority of child protection medical assessments, particularly those involving serious injury or death, will form part of the evidence in a criminal investigation and prosecution. Supervision in such cases has implications in relation to the disclosure of unused material. Cases may also be within the family court arena/civil proceedings.

Unused material is material that is patient-identifiable, and which may be relevant to an investigation, which has been retained but does not form part of the case for the prosecution against the accused. Relevant material is anything that appears to have some bearing on any offence under investigation or any person being investigated or on the surrounding circumstances, unless it is incapable of having any impact on the case.

If the advice of the supervisor altered or significantly influenced the opinion of the supervisee (treating clinician), then the extent of the advice and/or the extent to which it altered the interpretation given may constitute relevant material.  The supervisor could be required to give evidence in the case. This would be unlikely where both supervisor and supervisee were of similar seniority (e.g. both consultants) and where the opinion of the supervisor and supervisee did not significantly differ, but may be more likely where the supervisee was a non-consultant grade and/or where the supervision given was more directive.

In most cases the supervisor prompts reflection and provides reassurance to the supervisee that their assessment is robust and judgement sound, or prompts the supervisee to further refection of possibilities. This would not constitute providing a second opinion, and it would be sufficient to document that the supervision occurred, and the supervisor agreed with the assessment and plan.

Where a case is subject of police investigation, the fact supervision (planned or ad hoc) has occurred, and what impact it had on the opinion given, must be revealed to the police and passed to the prosecution for consideration.

For this reason, it is good practice to include a standard statement within all child protection reports stating “any case may be subject to safeguarding supervision according to professional standards.” It is important to ensure that the supervision is documented in the patient’s clinical record, and that all child protection reports (and/or addendums) discuss the range possibilities considered by the examining doctor in reaching their conclusions; it is not necessary to specify which of those were discussed at supervision.

Receiving supervision in safeguarding leadership roles

Named doctors or equivalents

For regular planned supervision, a named doctor for safeguarding children should usually obtain their regular planned supervision from the designated doctor for safeguarding children (or 4-nation equivalent) or another named doctor. Other senior colleague may be appropriate, provided they have the skills and experience to fulfil the role.

Ad hoc supervision will depend on the nature and complexity of the case for which the named doctor is seeking advice and support or a ‘sense-check’. In many departments, an appropriate colleague is available informally.

Local or regional networks of named doctors are encouraged, although formal arrangements between organisations are encouraged.

Designated doctors or equivalents

Designated doctors for safeguarding children (or 4-nation equivalent) should receive supervision from paediatricians in similar roles: this may involve reciprocal (round robin) supervision arrangements with neighbouring designated doctors in region, and/or those in parallel roles (e.g. from the designated doctor for child death or children in care) of the same area.

In some localities the designated doctor has supervision with the chief nurse or designated nurse for the ICB. This fulfils many of the purposes of safeguarding supervision; however, most designated doctors maintain active clinical practice including involvement in child protection cases. The clinical complexity of this work means that peer supervision from fellow paediatricians in designated roles is good practice, in addition to ICB internal arrangements.

Process for safeguarding leadership supervision

It is good practice for paediatricians in these specific safeguarding leadership roles to receive supervision on their clinical safeguarding work and on their challenges and achievements in the leadership role itself.

An example model for named doctor supervision, for example, might involve:

• Three monthly scheduled group-supervision meeting for the named doctors from several neighbouring district general hospitals, the named doctor from the teaching hospital, and the named doctor from the community organisation in a region, with the designated doctor for the region.
• The first half of the meeting is scheduled for reflecting on role challenges, providing both guidance from the supervisor, and peer-support/problem solving from the group.
• The second half of the meeting is scheduled for clinical case supervision, and would typically involve complex cases such as FII, institutional abuse/position of trust concerns, multi-form abuse, or cases in the criminal justice system.

Documentation

Principles and considerations

There is a need for a central record that this auditable for service-level assurance and individual appraisal purposes. This simply needs to demonstrate that supervision is taking place at appropriate frequency, and that all individuals required are participating. Details of the cases discussed, particularly patient-identifiable details, are not required.

• Many organisations will have central electronic systems to record the fact that supervision has occurred.
• However, named doctors/clinical leads may also wish to keep a record of the type of issues arising to guide quality improvement and/or training at service-level and partnership-level.
• For formal planned supervision meetings, supervisors and supervisees may wish to agree to take brief minutes (usually taken by the supervisor). This demonstrates reflection and learning points and may be used for appraisal purposes by both parties.

Recording in patient clinical records

At the same time, since there are case-management (and potential forensic) implications there is a need for patient-specific entries in clinical notes of each case discussed.

An entry should also be made in the patient’s clinical notes, briefly documenting the themes of the discussion for that specific case.

This should include:

• the date of supervision
• the name and role of the supervisor
• a brief summary of the discussion.
• the examining doctor’s final opinion
• any required actions by the examining clinician

Where supervision guides a change in level of concern, interpretation of findings, clinical management or any other aspect of the examining doctor’s opinion, this must be adequately recorded. This entry should record, for example, whether the supervisor simply prompted further reflection by asking questions, or took a more directive approach in the extent of any advice and guidance given. The latter may constitute a second opinion; this may be appropriate to the case and/or experience of the supervisee. In such cases the supervisor should accept they may be required to give evidence and/or provide a statement, in the event of court proceedings on the case.

Where the supervision provides assurance of the supervisee’s initial opinion, a simple statement such as “supervision received on [date] with [supervisor’s name & role]: plan and opinion affirmed” will suffice.

Safeguarding supervision meeting contract/agreement

For regular planned supervision, prior to the meeting taking place, the supervisor and supervisee should sign a contract detailing the expectations, understanding of roles and responsibilities, and details of the meeting. This document is separate to the record of agreed actions from individual cases and both supervisor and supervisee should retain a copy (Appendix 1).

Planned/formal supervision provides a regular ‘check-point’ for the supervisee; this continuity is facilitated by having an allocated or set supervisor, who can hold the an overview of whether the supervisee has engaged in supervision. However, some teams may prefer to have a more flexible approach with a departmental contract, and varying supervisors.

Issues and pitfalls

Addressing poor practice

If there are issues with poor practice including non-attendance, these should ideally be discussed within the supervision meeting and actions to address these agreed moving forward.

It is the responsibility of the supervisor to determine whether line managers will also need to be informed. If the supervisor judges the right thing to do is disclose, the supervisee should be informed of what action will be taken and why.

Pitfalls

If a supervisor is a close colleague, this may lead to a lack of challenge, and bias. Atmospheres in which supervisors feel reticent to challenge must be avoided.

Failure to regularly attend and failure to produce all evidence may indicate poor practice.

Supervision should not be used in place of peer review and vice versa.

Confidentiality and patient consent

Patient confidentiality and consent

Clinical governance is essential to the care of all patients and therefore supervision does not require specific consent.

Specific consent must be obtained for the use of images for teaching; while there is an educational element to supervision, it is primarily to support the professional judgement of the examining doctor (supervisee) and is not for the education of the supervisor. Therefore, consent to show images is not required. Patients should be informed that images may be used in supervision (and in peer review) prior to being taken.

Details of cases discussed at supervision will be given due confidentiality in accordance with General Medical Council (GMC) guidance.

Supervisee confidentiality

This should be set out in the supervision agreement. In general, both parties should reasonably be able to expect that standards of professionalism that issues discussed in supervision – whether individual or group – will remain confidential, provided this does not raise issues of professional competence, probity, or safeguarding/safety risk (including to adults).

Remote supervision

The use of video conferencing has become increasingly common as technology has advanced and remote working has become established. Concerns have been expressed regarding the security of discussing confidential information such as patient identifiable details and the sharing of sensitive images (e.g. intimate images and images of faces). However, remote supervision offers several benefits such as being time-efficient, and may facilitate networking across more than one geographical location.

There are some online platforms which, provided they have been confirmed as meeting the organisation’s or service’s information governance/data security requirements, should be suitable for use in supervision, including discussions of patient identifiable information and reviewing sensitive images provided that images are:

• shown only via screen sharing, from a secure location (e.g. restricted-access organisational central hard drive)
• not sent or uploaded via the platform e.g. Microsoft Teams, Zoom
• that element of supervision meeting where the images are shown, is not recorded on the platform.
• the clinicians must not save, copy, photograph, download or upload any of the images shared during supervision

Meetings should not proceed if a participant joins with an unidentified telephone number. It is good practice for the supervisor to remind supervisees of their information governance responsibilities at the start of the meeting. All participants must join the meeting from a location where they will not be overheard or disturbed, and images will not be accidentally viewed by person(s) not involved in the supervision meeting. Consideration should be given to showing line diagrams instead of particularly sensitive images, and to obscuring facial features, where this is possible.

All participants must agree to these principles. These may be established as a formal written agreement, or verbally agreed by being stated by the supervisor at the start of each meeting. Remote supervision has been conducted securely and successfully, but may require increased time for preparation and for the meeting itself than face-to-face meetings.