Sample policy · Reg 18

Supervision, Appraisal and Staff Support Policy

Statutory anchor: Regulation 18 (staffing), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 17 (good governance). · primary source

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Verivius pack version v1.1, 2026-07-19

1. What the regulation says

Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. (Reg 18(1): the headline duty)

receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. (Reg 18(2)(a): support, training, supervision and appraisal)

Regulation 17 adds the governance duty that this policy operationalises:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Reg 17(1): the umbrella duty)

assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services) ... assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity. (Reg 17(2)(a) and (b): quality and risk)

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/18 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/17. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You have to deploy enough suitably qualified, competent, skilled and experienced staff to meet Part 3. Staff have to receive appropriate support, training, professional development, supervision and appraisal. Where staff are health or social-care registered professionals, they have to be enabled to give their regulator evidence of meeting professional standards. Effective supervision and appraisal systems, recorded and acted on, are how a service shows it knows its staff are competent, supported and safe to practise, and they form part of the good-governance duty in Regulation 17.

3. Purpose

The purpose of this policy is to make sure that staff receive appropriate support, supervision, appraisal and development so they can carry out their roles safely, competently and in line with the values and requirements of the service.

Supervision is not only a welfare conversation. It is a governance process. It helps the service check whether staff understand their role, remain competent, follow policies, raise concerns, learn from incidents and provide safe, person-centred care.

This policy supports Regulation 18 staffing, Regulation 17 good governance, Regulation 12 safe care and treatment, safeguarding duties and professional standards.

4. Policy warning

Staff must not be left unsupported in roles where they are making decisions that affect people's safety, rights, dignity or care.

Missed supervision, weak appraisal, repeated informal management without records, or failure to act on competence concerns may create evidence of poor governance.

Where a staff member's conduct, health, competence, behaviour or practice creates risk, the manager must act promptly. Support must not be used as a reason to delay protective action where people may be at risk.

5. Scope

This policy applies to:

5.1 Local arrangements before adoption

Before adoption, the provider records:

The local procedure must include the Registered Manager's own supervision and provider oversight. A calendar entry without a meaningful record and followed-up actions is not evidence that Regulation 18 support and supervision are operating effectively.

6. Principles

The service will make sure that supervision and appraisal are:

Supervision should support good staff, challenge poor practice and protect people using the service.

7. Responsibilities

The Registered Manager is responsible for ensuring that supervision and appraisal systems are in place, followed and audited.

Line managers are responsible for completing supervision and appraisal, recording outcomes and escalating concerns.

Staff are responsible for attending supervision, preparing honestly, raising concerns and acting on agreed actions.

The provider or Nominated Individual is responsible for ensuring that the Registered Manager receives appropriate support and oversight.

8. Operational supervision and appraisal workflow

Managers follow this sequence for each staff member:

  1. Plan: assign a suitable supervisor, set the risk-based cadence and schedule probation, routine supervision, clinical or professional supervision and annual appraisal as applicable.
  2. Prepare: review previous actions, training and competency records, incidents, complaints, safeguarding matters, audit findings, feedback, attendance and any agreed adjustments that are relevant and lawful to discuss.
  3. Meet: provide private, protected time, invite the staff member's agenda, discuss wellbeing and practice honestly, and distinguish supportive reflection from any formal investigation or HR process.
  4. Assess and decide: identify strengths, learning needs, workload or culture risks, competence concerns and any immediate restriction, escalation or referral required.
  5. Record: document the date, participants, themes, decisions, agreed actions, owners, deadlines, evidence and next session. Keep sensitive detail only in the record authorised for it.
  6. Transfer actions: update the training matrix, competency record, risk register, incident or safeguarding record and improvement-action plan where the issue belongs in those systems.
  7. Follow up: check actions by the due date, increase supervision while risk or support needs remain, and record whether the intervention worked.
  8. Appraise and govern: use the year's evidence for appraisal and development planning. Review overdue sessions, recurring themes and unresolved concerns through provider governance without exposing unnecessary personal information.

8.1 Frequency

The service will set supervision frequency according to role, risk and experience.

As a minimum:

The Registered Manager may increase supervision frequency where risk, performance, conduct or wellbeing requires it.

9. Induction and probation supervision

During induction and probation, supervision must review:

A person must not be confirmed in post unless the manager is satisfied that they are suitable and competent for the role.

10. Regular supervision content

Supervision should include, where relevant:

Supervision must not be reduced to a tick-box form. The record must show meaningful discussion and any action agreed.

11. Reflective supervision

Reflective supervision should be offered after:

Reflective supervision should support learning, emotional processing and safe future practice. It must not replace investigation, safeguarding referral or disciplinary action where those are required.

12. Clinical and professional supervision

Where staff are registered professionals or carry out clinical, specialist or high-risk tasks, the service must consider whether clinical or professional supervision is required.

This may include:

The service must not prevent staff from meeting professional-regulator requirements.

13. Appraisal

Each staff member must receive an annual appraisal.

The appraisal must review:

The appraisal must produce a development plan where needed.

14. Actions from supervision and appraisal

Actions agreed in supervision or appraisal must be recorded.

Actions must include:

Where an action affects safety, competence or staffing risk, it must be added to the service action plan or risk register.

15. Concerns identified through supervision

Where supervision identifies a concern about conduct, competence, health, fitness or safety, the manager must decide what action is needed.

This may include:

The decision and rationale must be recorded.

16. Staff wellbeing and retention

Supervision must include space for staff to discuss wellbeing, workload, stress, bullying, harassment, discrimination, fatigue, moral distress or other pressures affecting their work.

The service will use supervision themes to identify retention risks, staffing risks and culture concerns.

Repeated concerns about workload, burnout, poor culture or staffing pressure must be escalated as governance risks.

17. Confidentiality

Supervision records are confidential staff records, but confidentiality is not absolute.

Information from supervision may need to be shared where there is a safeguarding concern, risk to people using the service, conduct concern, professional-regulatory issue, criminal matter, legal duty or serious governance concern.

Staff must be told where information needs to be escalated, unless doing so would increase risk or compromise an investigation.

18. Records

The service must keep records of:

Records must be stored securely and access restricted to authorised people.

19. Missed supervision

Missed supervision must be rearranged promptly.

Repeated missed supervision must be escalated to the Registered Manager.

Managers must not allow supervision records to fall behind without explanation, especially for staff in direct care, clinical, high-risk or lone-working roles.

20. Audit

The Registered Manager must audit supervision and appraisal records at least quarterly.

The audit must check:

Audit findings must be reviewed through the governance process.

21. Related policies

This policy should be read with:

22. Review

This policy will be reviewed annually, or sooner following a CQC finding, serious incident, safeguarding concern, supervision audit failure, repeated staff turnover, professional-regulator concern or change in legal or regulatory expectations.

23. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

24. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

25. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Added local supervision architecture and an end-to-end planning, meeting, action, follow-up and appraisal workflow.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Supervision is how a service finds out that a capable member of staff has quietly stopped being capable, and it is the first thing to disappear when the rota is tight. In smaller services the manager works alongside the team every day, so concerns get raised in the corridor, settled informally and never written down, and the service loses any ability to see that a pattern was building before it reached someone's care. The people who carry that cost are usually the least able to report it: someone who cannot say that personal care is being rushed, or a patient with no way of knowing that the clinician in front of them is working beyond their scope. A written trail also protects the staff member, because a concern raised early with support and a development plan is a fairer outcome than a capability process assembled later from months of unrecorded frustration. Regulation 18 of the 2014 Regulations makes appropriate support, supervision and appraisal a duty, and Regulation 17 makes the written record the only way to show that duty is genuinely operating.

  1. Supervision and appraisal actually happen at the set cadence and leave a record, not just a diary slot. Direct-care, clinical and high-risk staff have supervision at the stated frequency and each session has a written record behind it, not a booking that was missed or a calendar entry with nothing attached.

    Strong evidence: The supervision register and overdue report showing dates, attendance and the risk-based cadence set for each role (sections 8.1 and 18), with new starters covered during induction and probation; a calendar entry without a meaningful record and followed-up actions is not evidence that Regulation 18 support and supervision are operating effectively (section 5.1).

    Weak evidence: The register has a "planned" column filled in and a "completed" column that has been blank for months, or a run of sessions all dated in the same week because someone caught up before an audit. Bank and agency staff who work in the service regularly appear nowhere on the register, and new starters show only "induction completed" with no session record behind it. Nothing counts how far behind the service actually is, so overdue supervision for direct-care, clinical and lone-working staff is invisible until someone asks.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 18(2)(a)

  2. The record shows a real conversation, not a completed tick-box form. It captures meaningful discussion, decisions and agreed actions, not a signed pro-forma with no substance.

    Strong evidence: A supervision sample showing date, participants, themes, decisions, agreed actions with owners and deadlines, and the next session date (section 8 step 5, section 10).

    Weak evidence: Every form says "no concerns, doing well", in near-identical wording across different staff members, with the actions box empty and only a signature to show for the meeting. The pre-printed agenda is ticked down the page with no free text, so nothing in the record could only have come from a conversation with that particular person. Incidents, complaints or feedback involving that staff member are not mentioned anywhere on the form even though the service holds them.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  3. Actions agreed in supervision land in the systems that own them and get followed up, not left on the form. A competence or safety action is transferred to the training matrix, competency record, risk register or improvement plan and checked by its due date.

    Strong evidence: An action log cross-referenced to the training matrix, competency record, risk register and any incident or safeguarding record (section 8 steps 6 and 7, section 14).

    Weak evidence: A training need identified in supervision never reaches the training matrix, and a competence concern is written on the form while the competency record, the improvement action plan and the risk register stay untouched, so nothing outside the supervision folder changes. Actions read "discuss with the team" or "keep an eye on it", with no owner, no due date and no evidence expected, and the same line reappears unchanged in the next two sessions with no note of whether it was ever done.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. Competence, conduct, health or fitness concerns surfaced in supervision trigger a recorded decision, not a quiet note. The concern leads to a decision and rationale on restriction, escalation or referral, not an informal word that went nowhere.

    Strong evidence: The recorded decision and rationale for the concern (section 15) covering restriction of duties, occupational-health referral, capability or disciplinary process, safeguarding referral, Disclosure and Barring Service referral consideration, professional-regulator referral consideration or CQC notification consideration, with any restriction note and linked human resources or safeguarding record.

    Weak evidence: The trail stops at a note saying "had a word" or "will monitor", with no recorded decision and no rationale, and nothing to show whether restriction of duties, an occupational-health referral, a capability process or a disciplinary process were considered. The external routes are collapsed into a single internal outcome: a safeguarding referral to the local authority, a referral to the Disclosure and Barring Service, a referral to the staff member's professional regulator and a notification to CQC are four separate decisions, and the file shows none of them considered and ruled out on its own terms. The only account of what was decided is the manager's memory, and the concern surfaces again months later as if it were new.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 19(3)

  5. The Registered Manager audits supervision and appraisal and the audit drives change, rather than always coming back clean. A quarterly audit finds overdue sessions and unfollowed actions and shows them escalated through governance.

    Strong evidence: The quarterly supervision and appraisal audit (section 20) checking frequency, completion, overdue supervision and appraisal, actions followed up, training needs transferred to the training matrix and competence concerns acted on, reviewed through the governance process.

    Weak evidence: The audit sheet is a column of ticks against "compliant", with no count of overdue supervision, no count of overdue appraisal, no named actions and no owner. The wording is copied from the previous quarter, the audit counts sessions without opening one to read its quality, and there is no minute anywhere in governance showing that the findings were discussed or that anything changed as a result.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  6. Registered professionals can meet their regulator's requirements and managers are themselves supervised, not just front-line staff. Registered staff have access to professional or clinical supervision for revalidation and continuing professional development, and the Registered Manager receives their own supervision and provider oversight.

    Strong evidence: The clinical or professional supervision plan (section 12) and the record of the Registered Manager's own supervision and provider or Nominated Individual oversight (sections 5.1 and 7).

    Weak evidence: Registered nurses, doctors or allied professionals have no named clinical or professional supervision route, and the service cannot say what its registered staff need for revalidation or continuing professional development, let alone show that it enabled them to obtain it. Requests for supervision time, case discussion or a scope-of-practice review are declined or left unanswered with nothing recorded either way. The Registered Manager's own supervision file is empty or last dated before the current provider arrangements began, and provider or Nominated Individual oversight is evidenced only by email threads about rotas and staffing numbers.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

Related

Last verified 20 July 2026

Audit this policy

Supervision, appraisal and staff support procedure checklist

A policy is the intent; the evidence is what a CQC inspector actually asks to see. This matching checklist turns the policy above into the records to keep, the audit to run, and the places small services most often fall short.

Open the Supervision, appraisal and staff support procedure checklist

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Last reviewed 19 July 2026