A health visiting service implemented supervision sessions to support health visitors dealing with complex cases and to improve its staff recruitment and retention rates
Sandwell Health Visiting Service identified difficulties in recruiting and retaining health visiting staff and fully meeting the needs of vulnerable families. Following the Laming report, the decision was made to introduce health visiting supervision leads. This resulted in improvements in record keeping and care planning and in better protection and support for vulnerable families.
Citation: Sagoo M et al (2013) Using supervision to protect vulnerable families. Nursing Times; 109: 44, 28-29.
Authors: Mandy Sagoo is a professional lead for health visiting; Jane O’Reilly and Monique Rawlings are both supervision leads for health visiting, all at Sandwell and West Birmingham Hospitals Trust.
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In 2009, Sandwell Health Visiting Service was facing pressures of vacant caseloads and difficulties recruiting and retaining health visiting staff. The high percentage of families with a child protection plan was among the reasons for the low retention rate, and many families under the health visiting caseload did not meet the criteria for children’s services but were still deemed vulnerable and with complex needs, which placed a greater demand on the health visiting service.
New paper records were introduced at the same time as an electronic database, causing standards of record keeping to drop and work to often be duplicated. In addition, care plans did not always reflect the most recent episode of care.
The Laming report (2009) states that regular, high-quality supervision is critical. In 2010, we introduced health visiting supervision leads to support health visitors (HVs) when dealing with vulnerable families - namely those identified as needing additional intervention or support from the service and a high level of skill and cognitive effort from the HV. Under the new family offer, as outlined in the Health Visitor Implementation Plan (Department of Health, 2011), these families fit into the “universal plus” category, meaning they will receive a rapid response from their health visiting team when specific expert help - such as support for postnatal depression - is needed.
The supervision lead’s key role is to support HVs in identifying and managing complex cases that require a high level of intervention, and to work with them to form an appropriate plan of action in line with the principles outlined in safeguarding children processes. It was decided supervision would be delivered on a quarterly basis to provide regular support.
Working Together to Safeguard Children (Department for Children, Schools and Families, 2013) acknowledges that ensuring children are protected from harm requires sound professional decisions to be made at the frontline. Feedback from frontline staff shows this process can be challenging so it is important for practitioners to have access to timely advice and support. The overall vision is for practitioners to understand the value of Universal Plus supervision, and for it to be embedded in the health visiting service and ethos.
The health visiting supervision leads were introduced to:
- Focus on the needs of the child and family;
- Promote good practice within the health visiting service and improve service delivery;
- Ensure issues highlighted in care plans are followed through;
- Ensure practice is consistent with policy and best-practice standards;
- Introduce a quality audit tool for vulnerable children and families;
- Ensure principles of good record keeping are consistent with Nursing and Midwifery Council standards;
- Facilitate supervision and support for supervisors.
The National Society for the Prevention of Cruelty to Children delivered a five-day training package to supervisors to equip them with the knowledge and skills needed to deliver and sustain an effective supervisory framework that places the child at the centre of safeguarding activities.
Universal Plus supervision process
We agreed that to support HVs working with vulnerable families, the following process needs to be followed:
- Supervision is offered to all HVs every 12 weeks;
- HVs must submit a list of all current vulnerable families for discussion;
- HVs select the families for discussion (usually those presenting with the most challenging issues);
- Families selected are those that have not reached the threshold for a child protection plan;
- Children who are in the looked-after system are not included in the process;
- Each HV is given a named supervisor;
- Supervisors must contact their allocated HV to arrange supervision sessions.
Universal Plus supervision uses Kolb’s (1984) reflective cycle as a framework. This enables the HV to discuss complex cases and reflect on their early intervention, enabling the theory of “conceptualisation”. Kolb describes this as being able to analyse and understand the situation; the HV is supported in drawing conclusions about their own practice and intervention.
We use a formal, structured process that allows for case discussion, care planning and the standard of record keeping to be assessed. The families discussed at supervision are the most vulnerable on HVs’ caseloads. This type of structured supervision aims to address practitioners’ anxieties that they may have missed something and, with gentle questioning, the supervisor encourages analytical thinking and develops skills of professional curiosity. The supervision process helps additional support needs to be identified so that an action plan can be developed.
The action plan focuses on:
- Support: difficult challenges in the HV’s work are discussed and explored and time constraints are addressed;
- Mediation: communication and engagement with the supervisee;
- Education: professional development and learning from practice, as well as feedback on performance;
- Management: overall performance in line with policy and best-practice standards.
A supervision pack was designed so all supervisors follow the same process and provide the same standard of supervision. This documents the process structure and has been a useful resource for supervisors.
The process has been supported by the organisation’s safeguarding team and senior management. Supervision has been rolled out service-wide; non-compliance is attributed to long-term sickness.
Several common themes have been identified from supervision sessions, including domestic abuse, maternal mental health factors, drug and alcohol misuse, housing problems and teenage mothers, children with a “child in need plan” in place, and developmental delay. Variations within the locality have also been identified: for example, some towns have a higher incidence of drug and alcohol misuse while others have higher rates of maternal mental health problems. Domestic abuse was a common theme across each clinical base.
By identifying these trends, we have been able to deliver specific training to the different localities and negotiate further training to be commissioned and delivered by the local children safeguarding board, for example in female genital mutilation.Identified training needs will also be included in the annual workforce plan and the training needs analysis so the most appropriate training can be commissioned.
Two supervision team members sit on the child death overview panel. It is vital we learn as much as possible from the panel’s findings to try to prevent future deaths and to support health professionals. Examples of good practice have been highlighted and shared; lessons learnt have influenced our current practice.
Compliance is monitored and an audit undertaken with supervisees annually to find out their views on the supervision process. The audit has shown yearly improvements in the quality of record keeping and care plan writing (Box 1). Assessments appear more robust and the supervision sessions allow for assurances that the supervisee is delivering a high standard of care and a quality visit has taken place. Where this appears not to be the case, an action plan is put in place.
Box 1. Audit results
- 94% of records audited had a completed care plan (5% increase)
- 85% of the care plans reflected the most up-to-date care delivered at the last contact (8% increase)
- 72% of the healthcare needs analysis on the child reference card tallied with the care plan (5% increase)
- 84% of the children had been seen in the previous six months (14% increase)
Effective supervision has proved important in promoting good standards of practice and supporting individual staff members; it may also help retain newly qualified HVs and those returning to practice. This has enhanced our health visiting service.
Early indications reveal the Universal Plus supervision model is embedded into the service and is being well received by experienced and newly qualified HVs. The protected time away from a busy office allows for reflective thinking and case discussion. Student HVs are introduced to this supervision model in their third semester.
The results show that HVs appreciate the support supervision provides. It enables them to continue to put early interventions in place and empower the most vulnerable families to safely parent their children. To maintain this standard of quality supervision, regular evaluation should be carried out. The Laming report (2009) recommends that supervision be open and supportive, focusing on decision quality and improving outcomes for children, rather than meeting targets.
- Regular, high-quality supervision is critical for professionals working with vulnerable families
- Vulnerable families with complex needs require a rapid response from health-visiting teams
- Protecting children from harm requires sound professional decisions to be made at the frontline
- Kolb’s reflective cycle helps professionals to analyse and understand situations
- By identifying which issues are more prevalent, health visitors can tailor training to each locality’s needs
Ofsted (2010) Learning Lessons from Serious Case Reviews: Interim Report 2009-10. Manchester: Ofsted.
Department for Children, Schools and Families (2013) Working Together to Safeguard Children: A Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children. Nottingham: DCSF.
Department of Health (2011) Health Visitor Implementation Plan 2011-15: A Call to Action. London: DH.
Kolb D (1984) Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall.
Laming (2009) The Protection of Children in England: A Progress Report. London: The Stationery Office.