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:
- induction supervision
- probation reviews
- regular one-to-one supervision
- clinical or professional supervision where required
- reflective supervision after incidents or safeguarding concerns
- performance appraisal
- return-to-work support
- wellbeing support
- supervision linked to competence, conduct or capability
- supervision for agency or temporary staff where they work regularly in the service
6. Principles
The service will make sure that supervision and appraisal are:
- regular
- recorded
- proportionate to the person's role and risk
- supportive
- honest
- linked to competence and training
- linked to incidents, complaints, safeguarding and audit findings where relevant
- used to identify learning and development needs
- used to identify wellbeing or workload concerns
- followed by action where required
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. Frequency
The service will set supervision frequency according to role, risk and experience.
As a minimum:
- new staff must receive supervision during induction and probation
- staff in direct care, clinical, transport, support or regulated-activity roles should normally receive supervision at least every three months
- high-risk roles, new starters, staff under performance review or staff involved in serious incidents may require more frequent supervision
- all staff must receive an annual appraisal
- registered professionals must have access to professional or clinical supervision where required by their role or regulator
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:
- understanding of role
- completion of induction
- mandatory training
- competence for key duties
- safeguarding knowledge
- record keeping
- communication
- values and conduct
- punctuality and reliability
- confidence and support needs
- restrictions on unsupervised work
- feedback from people using the service, staff or managers
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:
- wellbeing and workload
- role performance
- competence and confidence
- training progress
- incidents, complaints or safeguarding involving the staff member
- record keeping
- communication with people using the service
- dignity, respect and person-centred care
- professional boundaries
- whistleblowing and raising concerns
- equality, diversity and inclusion
- health, safety and infection control
- medicines or clinical tasks where relevant
- lone working or personal safety
- feedback received
- actions from previous supervision
- development needs
- any change that may affect fitness to work
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:
- serious incidents
- safeguarding concerns
- distressing events
- complaints involving the staff member
- repeated errors
- conflict or poor team culture
- significant change in service-user needs
- bereavement or trauma
- whistleblowing or raising concerns
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:
- review of clinical decision-making
- review of scope of practice
- professional standards
- revalidation or CPD
- case discussion
- clinical-risk review
- medication or treatment practice
- audit findings
- professional-regulator requirements
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:
- performance over the year
- role expectations
- conduct and values
- training and competence
- supervision themes
- incidents, complaints or compliments
- safeguarding awareness
- professional development
- goals for the next year
- health, wellbeing and support needs
- career development where relevant
- any restrictions, adjustments or concerns
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:
- what will be done
- who is responsible
- due date
- evidence required
- review date
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:
- additional supervision
- training
- competency assessment
- restriction of duties
- occupational health referral
- reasonable adjustments
- capability process
- disciplinary process
- safeguarding referral
- DBS referral consideration
- professional-regulator referral consideration
- CQC notification consideration
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:
- supervision dates
- attendance
- discussion themes
- actions agreed
- training needs
- competence concerns
- wellbeing concerns
- escalation decisions
- appraisal outcomes
- development plans
- follow-up actions
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:
- frequency
- completion
- quality of records
- overdue supervision
- overdue appraisal
- actions followed up
- training needs transferred to the training matrix
- competence concerns acted on
- repeated staff themes
- escalation of risks
Audit findings must be reviewed through the governance process.
21. Related policies
This policy should be read with:
- Staffing Policy
- Training, Competency and Mandatory Training Policy
- Safe Recruitment Policy
- Staff Conduct and Disciplinary Policy
- Whistleblowing and Raising Concerns Policy
- Safeguarding Policy
- Incident Reporting, Investigation and Learning Policy
- Risk Management and Risk Register Policy
- Record Keeping Policy
- Equality and Diversity Policy
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.
- CQC Regulation 18: Staffing
- CQC Regulation 17: Good governance
- Professional regulator CPD and revalidation guidance (for example NMC, GMC, GDC, HCPC)
- ACAS performance and conduct guidance
- Learning disability and autism training requirements under the Health and Care Act 2022 and current Oliver McGowan / DHSC / CQC guidance
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/18)
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. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.