1. Supervision in Adult Social Work and Social Care settings where practitioners work together: a systems approach to providing evidence to improve outcomes
Tish Marrable and Sharon Lambley
Department of Social Work and Social Care
University of Sussex

2. The presentation content
Research focus
Literature review: key findings
Methodology
Systems theory
Research design
Key Findings
Conclusions

3. The research
Social Care Institute for Excellence (SCIE) looking to add to their ‘good practice guidance’ series
‘Supervision in a variety of adult care settings where there are health and social care practitioners working together’
The brief:
To capture what is being practised in a minimum of three settings where there are both health and social care practitioners working: e.g. a community mental health team; a team supporting older people and a residential or nursing establishment for older people.
To ask about areas of practice in supervision that seem to deliver positive outcomes.

4. Research aims:
To develop an understanding of how supervision is delivered in a range of joint and integrated adult team settings
To develop an understanding of how identified types of supervision practice affect stakeholders
To develop an understanding of the perceptions of supervision and its impact for people who use services
To identify areas of good practice and of innovation in joint and integrated health and social care supervision
To identify the costs perceived to be associated with supervision in different models of practice

5. Literature Review: key findings
Supervision takes place whilst welfare systems in England and Northern Ireland are transforming e.g. personalisation, restructuring, new services, finite funding, new workers and practices. Service users and carers are co-producers, customers, reluctant/passive recipients or they may give their voice to a proxy (Simmons, 2009). ‘Professional’ know-how is being challenged
Despite an extensive body of literature, the evidence base for supporting good supervision is ‘limited’ and ‘foundational’ (Bogo and McKnight, 2006, Milne et al, 2008, Carpenter et al, 2012, O’Donaghue and Tsui, 2013)

6. Literature Review: key findings
Employee and student supervision is different, despite sharing generic practices (Bogo and McKnight, 2006). Supervision treated as an international activity but there is only one 2 country study on supervision, and it was not comparative (O’Donaghue and Tsui, 2013). The SCIE study (Lambley and Marrable, 2013) is the ONLY study to have directly included service users in research on supervision although this has been suggested since the late 1980’s.

7. Literature Review: key findings
Carpenter et al (2012:1) found that good supervision in social work and social care was associated with many positive benefits (but causal links were not established in Mor Barak et al 2009 meta analysis), and the impact and outcomes for service users and carers ‘has rarely been investigated’ As an area of study supervision is poorly conceptualised i.e., implicit theorising, inconsequential or ambiguous hypothesis and conceptual and methodological flaws which result ‘in the capacity to test theory in nearly every study being compromised’ (Milne et al 2008:171)

8. Methodology Systems theory as a way to frame the research
Looking not just at what happens, but why it happens (Reder, Duncan & Gray 1993; Fish, Munro & Bairstow 2008)
Going beyond good practice within the supervision relationship to look at the effect of the (boundaried) environment on services users, workers (and vice versa).
A system of feedback should help to keep systems developing and innovating??
Influences from external environment informed practice, but was not the focus of the research

9. A [semi-open] system approach
Broader social systems (LA, commissioning bodies)
[environment]
Feedback
Resources and Organisational Structures
[Input]
Processes and practices within supervision
[Throughput]
Outcomes from supervision
[Output]
Feedback
Feedback

10. Systems approach – research participation
Workers from social care, social work, and health fields
Some professionally qualified, some not
Managers
some professionally qualified, some not
Service users
Two existing groups
Adults with learning disabilities
Mental Health service users
Local Authority Adult Services Commissioner
Ethical Approval: University of Sussex (and Social Care Research Ethics Committee – SCREC)
Governance: Association of Directors of Adult Social Services (ADASS) plus NHS

11. Research design: three phase approach (data collection)
Phase 1: Mixed methods online survey – processes, practices, experience, feelings and outcomes of supervision.
136 respondents across 28 practice sites – all receiving supervision, 50% (n=68) also acting as supervisors
Accessed through a call via SCIE newsletter and through the online Choice Forum (including some snowballing to other organisations via both calls)
Sites from England and Northern Ireland included:
Community mental health teams, care homes, palliative care hospice, local authority adult social services, community learning disability, domiciliary care service, substance misuse team.
Providers from the independent sector, social enterprise, local authority, National Health Service, charity and third sector, health and social care trust, direct support.

12. Phase 2: Case studies at four sites of ‘good’ provision, drawn from online survey participants – 19 semi-structured interviews.
Sites were chosen
because supervision was perceived to be strong and/or innovative in some aspect of its approach and/or outcomes
To provide a spread across adult services where social care and health were both working
Participants – managers, professionals from health and social work, social care practitioners, other service staff
A local authority led integrated health team
A large social enterprise providing services for adults with disability or frailty in the community – residence and at home
A care home – dementia and mental health care
A primary care trust community mental health team

13. Phase 3: Consultation with service users, advisory group and commissioner
Two separate pre-existing service user forums
Mental health discussion group
11 participants, receiving community based services.
Experience of services provided by health and social care professionals, management and care staff, housing and voluntary organisations
Learning disability strategic consultation group –
5 participants. This group was providing guidance to service providers about including service users in staff recruitment and development.
Experience of social workers, general practitioners, nurses, psychiatrists, as well as support workers, care workers, key workers, senior care workers, deputy and care managers
SCIE advisory group input – social workers, service managers, service users, advisory organisations.
Local Authority Service Commissioner

14. The system Conditions for supervision practice Supervision practice
Organisational ‘conditions’, i.e., policies, procedures, spaces, culture, worker and supervisor expectations, power, decision making, values, standards, leadership, discretion
Supervision practice
Proforma's to guide the process or checklists, recording/agreements, relationships, emotional containment , communication skills, expertise, protected time, flexibility, expectations
The effect and impact of supervision
Improved experiences for service users, improved direct practice, improved worker wellbeing, improved decision making, access to development opportunities, service innovations and improvements

15. Conditions for supervision practice
The key findings (1)
Conditions for supervision practice
Leadership that supports supervision
Supervision is embedded and monitored
Supervision policies
Training and expertise which is fit for purpose
Time built into workloads
Space made available
Dynamic links to other organisational systems e.g., HR, quality, performance, career advancement, innovation
“Expectation that everyone receives monthly supervision and this is regularly audited.” Manager, Residential Home

16. The key findings (2)
‘But the whole thing interweaves the whole time, so from the supervision I’m discussing my needs; I’m also discussing the needs of the service user and what I need to support him and how you can support me and how I can support you and the whole thing works that way.’ (Senior support worker)
Supervision contract with agreed/negotiated expectations
Formal and informal supervision (1-1 most common, but also linked to group, peer, ad-hoc consultation)
Supportive (i.e., a focus on the relationship with the individual as well as the task)
Supervisor is a leader (expert leader as well as able to manage upwards and across agencies)
Supervision supports worker development, career progression, practice and service innovation
Is focused on the service user, staff and the organisation (but framed differently in the 4 sites)
Supervision Practice

17. The supervision context
LA integrated ALD
Social Enterprise
Care Home
PCT and CMHT
Purpose
Focus on ‘helping’ service users and HR
Delivery of care plans, HR
Assessment, delivery of care plans, HR
Focus on ‘dynamic’ work with clients and HR
Type
1-1, peer, ad-hoc
1-1 team, group, use of external advisor, ad-hoc
1-1, peer, ad-hoc, consultation
Use of self
limited expectation
not expected
expected
Critical reflection
Yes
Limited

18. Knowledge Supervision
Clinical supervision – focused on understanding the SU ‘condition/experience’ by applying theory, research and practice knowledge. Reflecting on how professional is working with SU. Identifying achievements, progression and gaps. Evidencing outcomes
Professional supervision focused on making sense of clients world through the application of theory, research and practice knowledge. Supervision explores what the workers knows and what is expected. Progress and achievements are reviewed. Evidencing outcomes
Management Supervision focuses on the management of staff and is concerned with delivering care plans/targets. Management and care knowledge informs ‘practice’ and is informed by practice. Supervision is linked to quality, service innovation and staff development and progress
Service User perspectives
(1) Co-producers was to share knowledge from experience, and co-develop services, make decisions together, and want supervision to be led by employer guidance as supervision part of overall service experience
(2) Customers have a right to a good service and want to use best ways to provide feedback/complaints about a service. Want to influence decision making about themselves.

19. Key Findings (3)
“After supervision I tend to deal with the service user with more confidence, feeling like I've got an action plan in place to help them and get them the services they need. Supervision certainly has a positive effect on how I deal with people and what kind of services they receive.” (Assistant manager, older people’s service, local authority)
Conditions for supervision practice
Supervision practice
The effect and impact of supervision
Direct and indirect effects and impacts
Staff: benefits transcended work to improve relationships and sense of self in a general sense
Linked to career progression as improvements recorded or used for professional re-registration
Improved practice as staff feel valued, informed and are better able to cope with practice challenges
Supervisors: Supervision provides an opportunity to focus on the work of an individual staff member which includes checking of work has been completed and if there are any difficulties. It can be linked to appraisal so can inform career advancement as well as capability processes.
Service users: key decision making meeting which excludes service user directly. Worker can be a gatekeeper and this can be a problem

20. Impacts of supervision from employee perspectives
Conditions for supervision practice
Supervision practice
The effect and impact of supervision
Having experienced frequent migraine attacks, a professionally qualified staff member learnt from service users that they wanted continuity of service, and therefore she might need to see service users less often, but should commit to, and attend, arranged appointments. Supervision helped the staff member to slow down and manage her health problems so that she could be reliable and available to service users when they needed her.
A community nurse said that she used supervision to bring up a concern that she had about a service user, which was taken up to be discussed by the senior management team as there were funding issues and something needed to happen at a more senior level.

21. Direct impacts of supervision for service users (from employee perspectives)
Conditions for supervision practice
Supervision practice
The effect and impact of supervision
A supervisor and member of staff discussed the possibility of changing a resident’s room when a room was being redecorated. The worker consulted the key worker who talked to the service user, who was happy to move to the bigger room. The member of staff said that “all conversations we have, whether they’re in supervision direct or not, we have an outcome for people.” (Care worker)
A worker in a residential home described how supervision had helped when a new resident arrived with habits that contradicted the care of another resident. Sensitivity was needed to come up with a solution that suited both residents, “because we don’t want to upset any of them and they still have the choice of what they want.”
An administrator noticed that a lady used to ring the office regularly and would cry, so the administrator brought this up in an ad-hoc supervision and asked for something to be done. The administrator felt that supervision had benefitted the service user as her behaviour had been brought to the attention of the staff team who could act on this information

22. Satisfaction questionnaires
Impacts of supervision from service user perspectives; group 1 (ALD customers)
Conditions for supervision practice
Supervision practice
The effect and impact of supervision
The group expected to be treated as ‘customer(s) with a right to a good service’. However they provided positive and poor examples of their experiences of the services, and suggested that they would like to be able to feed these experiences into supervision because they were not always convinced that the feedback methods currently used by service providers led to any real change 
Group members were unaware that health and social care staff were supervised
They had no personal experience of being involved in, or providing feedback, for supervision, although they were active in shaping other parts of services. 
They identified how service users
and carers provided feedback;
Satisfaction questionnaires
Complaint post cards (this was being piloted by one local authority customer services)
Telling ‘trusted staff’ what they felt about a service they had received or a problem they were experiencing. 

23. Impacts of supervision from service user perspectives; group 2 (MH)
The group members were confused about different worker roles (e.g., what’s the difference between a social worker and a care manager?), and they were unclear why a service user couldn’t be a supervisor. 
They wondered why supervisors didn’t know about poor services, and why they didn’t improve services, when they did know. 
Conditions for supervision practice
Supervision practice
The effect and impact of supervision
The group said that they knew that not all workers got supervision (e.g., personal assistants didn't get supervision) and that some workers had too many service users on their caseloads, and they questioned whether it was possible to supervise workers properly with a high caseload. 
The group were unclear about what actually happens in supervision, and in particular how a worker might make sure that a service user’s thoughts, feelings or wants, were conveyed in supervision
Supervision was considered a ‘good thing’ if it helped service users to get what they needed but a threat if it did not. 2 members of the group gave examples of both

24. Costing and Commissioning
Costing: “We do not cost supervision as it is part of what we do. If we wanted to we may just do that simple calculation of the two people’s hourly rate multiplied. However it might not be very sophisticated as you may be taking people away from direct support but productivity should increase”
Commissioning: it would not be usual for supervision to be identified in a contract: inputs are not the focus of attention.  As long as the service user is getting the service that has been commissioned, and this meets their needs then the commissioner (and even monitoring team) wouldn't become involved in details such as supervision

25. Conclusion: Policy developments require a paradigm shift at practice level. Using systems theory and mixed methods, the following picture emerged
Feedback
Structural changes, and a focus on outcomes for service users
Processes and practices within supervision diverse but little or no input from SU
Impact and outcomes from supervision –research is under-developed
Feedback
Feedback

26. Good supervision was defined as…..
Conditions
Clear purpose. Professional leadership, policies, procedures linked to wider organisational frameworks, time and space to supervise (and be supervised), training, expertise and multiple types of supervision to reflect differing purpose and conditions
Practice
Well planned, focused on the needs of the worker and SU, delivered with respect and is dominated by relationship not performance . Informative, challenging and supervisor has relevant expertise
Effect and Impact
Beneficial to the worker, the service user, the organisation (reflecting different expectations and needs). Transparency and different levels of engagement needs to be designed into current models.

27. Some research limitations…
The limited resources available for the practice enquiry meant that it was impossible to scope all models of supervision in social work and social care.
The ‘cost and benefits’ of supervision was an area that was not calculated within any of the study sites in a sophisticated way so the data we gathered had very limited use.
The scope of the practice enquiry did not allow for any in depth work looking at the supervision of personal assistants and home-based care provided through direct payments. This is an area which requires further study.
A separate study is called for, looking to identify any causal links between good supervision practices which include the voices of service users on staff retention and turnover. While the practice enquiry was able to provide some limited associations in this area, it would benefit from a closer and more specific focus.

28. Further research is needed to:
Develop, pilot and evaluate methods for collecting data on the impact and outcomes from supervision
Engage service users in developing our understanding of how supervision practice can further support practice and service improvements
Identify any causal links between good supervision practices, which include the voices of service users, on staff retention and turnover.
Develop a costings methodology (including retention) to help employers to understand the cost/benefits of use of different types of supervision models.

29. References
Bogo,M. and McKnight, K. (2006) ‘Clinical supervision in Social Work: a review of the research literature.’ The Clinical Supervisor, 24(1−2), 49−67.
Carpenter, J., Webb, C., Bostock, L. and Coomber, C. (2012) Effective supervision in social work and social care. London: SCIE.
Carpenter, J. Webb, C. and Bostock L (2013) ‘The surprisingly weak evidence base for supervision: Findings from a systematic review of research in child welfare practice ( )’, Children and Youth Services Review. Available online 5 September 2013, ISSN ,
Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing an inter-agency systems approach for case reviews, London: SCIE.
Lambley, S. and Marrable, T. (2013) Practice enquiry into supervision in a variety of adult care settings where there are health and social care practitioners working together. London: SCIE.
Milne, D. Aylott, H., Fitzpatrick, H., and Ellis, M.V. (2008) ‘How does clinical supervision work? Using a best evidence synthesis approach to construct a basic model of supervision’. The Clinical Supervisor, 27(2),
Mor Barak, M.E., Travis, D.H., Pyun, H., and Xie, B (2009) ‘The impact of supervision on worker outcomes: a meta analysis.’ Social Sciences review, 83 (1) pp 55-65
O’Donaghue, K., and Tsui, M (2013) ‘Social Work Supervision research (1970 – 2010): The way we were and the way ahead’, The British Journal of Social Work, 3-8
Reder, P., Duncan, S., Gray, M. (1993) Beyond Blame: child abuse tragedies revisited. London: Routledge.
Simmons, R (2009) Understanding the ‘differentiated consumer’ in public services. in Simmons, R., Powell, M., and Greener, I., (eds) The consumer in public services choice, values and difference. Bristol; Policy Press