29 Mar 2021

Supervisor resource 5 - Learning from reviews of practice

Supervisor resource 5 - Learning from reviews of practice

Learning from reviews across practice settings

In the aftermath of the Victoria Climbié tragedy a serious case review was conducted by Lord Laming (2009) who focused on social worker wellbeing, emotional costs of the work as well as supervision practices.

“There is concern that the tradition of deliberate, reflective social work practice is being put in danger because of an overemphasis on process and targets, resulting in a loss of confidence amongst social workers.”

Laming (2009)

The Care Inspectorate (2019) regularly consider aggregated learning from case reviews. This highlights that sufficient support for workers is needed to be confident and competent. This includes “robust and regular supervision that enables constructive challenge and time to reflect on practice and develop skills.”

The most comprehensive reviews occur when there have been extremely serious harms to vulnerable children or adults. In the case of social work these have often identified a break down in procedures (including appropriate supervision), meaning opportunities for intervention to prevent serious harms were missed.

In the overview for supervisors on this website, there was a reference to the Victoria Climbie enquiry which had significant findings for supervision in social work settings. Scottish case and learning reviews have also had findings around supervision adequacy.

Organisational and strategic leadership for learning and supervision

The National Child Protection Leadership Group provide strategic oversight and mechanisms for improvement regarding child protection across Scotland and have addressed reoccurring issues. These include organisational support and compliance with good quality supervision and support that addresses the scope of professional discretion and identifies training and development needs of practitioners. 

Indirectly related to social work but useful for reflecting on professional development issues was the prolonged and serious failure of care at Mid Staffordshire NHS Trust. The UK government review had findings for supervision for allied health professions saying: “Regulation is no substitute for a culture of compassion, safe delegation and effective supervision.

Putting people on a centrally held register does not guarantee public protection. Rather it is about employers, commissioners and providers ensuring they have the right processes in place to ensure they have the right staff with the right skills to deliver the right care in the right way”. (Department of Health 2013, s5.22). 

Another example is the case of Sharon Greenop, who lived with physical disabilities and was tragically killed by her sister. The South Ayrshire review had findings around the provision of supervision, accessibility of senior staff and extreme workload pressures contributing to critical errors in recognising adult protection issues.

Culture change

A number of reviews have commented that social work needs to maintain core values and practices which may have been diluted through reorganisation of services as the public sector has tried to do more with less in recent decades.

An example of such culture change was observed when students on a UK social work leadership course exhibited resistance to engaging in an experiential module focusing on reflective practice. This was felt to be connected to a stronger identification with wider public sector management approaches rather than core social work reflective supervision practices, (Ruch, 2012).

Useful ideas

  • Identify your own examples, where good supervision supported positive outcomes for people who use services and where something went wrong or opportunities for improvement was missed.
  • Consider which supervision factors impacted this.

Go to supervisor resource 6 – Professional knowledge in supervision

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