Work Based Supervision (Improvement Plan)

• Care home

  Select

• Conducted on

  Date
• Location
  Address

Staff Details

• Name of Supervisee:

• Job Title:

  Select Carer Senior Carer Deputy Manager Matron Domestic Kitchen Staff

  • Carer
  • Senior Carer
  • Deputy Manager
  • Matron
  • Domestic
  • Kitchen Staff

• This form must be completed when there is a cause of concern.

Work Based Supervision

• Accurately describe the concern you have with the staff member.

• What is the impact of the concern.

  Low

  Medium

  High

  Severe

• Staff members response.

• What actions has the staff member put in place to prevent the above from happening?

• Does the staff member have any concerns or issues they wish to discuss? If YES, please describe.

Management

• Training organised?

  Yes

  No

  N/A

• Recommended training

  Select Fire Moving and Handling Safeguarding Management Policies and Procedures Other

  • Fire
  • Moving and Handling
  • Safeguarding
  • Management
  • Policies and Procedures
  • Other

Other Relevant Information

• Discuss areas for improvement for the staff member. i.e. Look at areas where the staff member can improve their work and stay motivated etc.

• Date for next supervision

  Date

• Location of next supervision

  Observed

  Office Based

• Supervisee Signature

  Sign

• Supervisor Signature

  Sign