Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-008 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.26
At a glance
- Supervisory visits are made on-site, in person, on a set schedule that matches the level of care (HC-FRM-010).
- For personal care only, the supervisor observes the caregiver giving care (29.27).
- Visits are counted by calendar interval, not by caregiver visits.
- A visit is not replaced by a phone call.
- Stop and get help straight away if: a client’s care plan is never visited by a supervisor in a year.
1. Purpose
To make sure supervision happens in person, on schedule and by observation (29.26, 29.27).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A supervisor who never enters the home cannot see how care is given. Supervisory visits on site, on a schedule, are the only way to check the care that is delivered.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Home care service lead | Owns the supervision schedule | Clinician or manager |
| Supervisor | Makes the visits and observes care | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Schedule.
- Set the supervisory visit interval for each client by level of care.
Key point: Scheduled.
Step 2. Observe.
- Observe the caregiver giving personal care, with the caregiver present.
Key point: Observed.
Step 3. Record.
- Record each visit on HC-FRM-010.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Clients with a supervisory visit on schedule | 95% | Monthly | Home care service lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HC-FRM-010 | Supervisory visit record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)