Therapeutic Practice and Clinical Governance

1. Purpose

Therapy is at the centre of what we are commissioned to provide. Every learner is entitled to at least one hour of individual therapy a week, delivered by an accredited counsellor who is matched to them. This policy makes sure that therapy is:

• delivered every week, by properly qualified and checked counsellors;

• ethical, with consent, confidentiality and its limits handled correctly;

• safe, so that risk is never held by one person and always reaches the DSL;

• governed, through clinical supervision, records and audit that the commissioning local authority can inspect.

It also sets out the trauma-informed practice expected of every member of staff, because therapy only works when the rest of the day supports it.

2. Scope

This policy applies to every learner in Care Cove Alternative Provision, whoever commissions the place; to counsellors supplied by our partner My Solution Wellbeing; and to all Care Cove staff, agency staff and volunteers, who need to know what counsellors share and what they do not.

3. Law and guidance

• Commissioning local authority specifications. At least one hour of individual therapy per child per week, plus family or group therapy according to need, by a counsellor accredited by BACP or UKCP with experience of young people; evidence of qualifications and registration kept; a clear clinical supervision model and risk escalation pathway.

• BACP Ethical Framework for the Counselling Professions and UKCP Code of Ethics, which counsellors follow according to their registering body.

• Keeping Children Safe in Education 2026, under which self-harm and suicidal ideation are safeguarding concerns in their own right, and Working Together to Safeguard Children 2023.

• Gillick competence (for under-16s) and the Mental Capacity Act 2005 (for 16 and 17 year olds) on consent.

• UK GDPR and the Data Protection Act 2018, as amended by the Data (Use and Access) Act 2025. Therapy records contain special category health data.

• DfE guidance on gender questioning children where it applies.

4. Roles and responsibilities

• The Director owns this policy and manages the partnership with My Solution Wellbeing, including the written partner agreement, verification of counsellor registration, therapy capacity against roll, and clinical governance reporting. The partner arrangement needs the written consent of any commissioning local authority whose contract requires it. Care Cove keeps full accountability to the commissioning local authority for the therapy delivered.

• The DSL receives every disclosure and risk concern from counsellors, decides on action within the hour, and reviews every escalation weekly.

• The Clinical Advisor (Registered Nurse) makes same-day clinical decisions on urgent clinical risk, advises on health, medication and self-harm, and joins the weekly multidisciplinary case meeting as required. The Clinical Advisor is not a counsellor and does not provide clinical supervision to counsellors.

• The Head of AP timetables therapy so it never displaces core teaching, provides rooms, and makes sure staff use the strategies counsellors share.

• Counsellors deliver therapy under their professional code, tell the DSL about risk within the session, keep clinical records, attend clinical supervision and contribute agreed themes to the child plan.

• My Solution Wellbeing's clinical supervisor provides monthly clinical supervision from outside Care Cove's operational line.

• Key mentors and all staff support the learner's therapy, never ask learners what they talk about in therapy, and report any concern to the DSL.

• The Social Work Management Committee (SWMC) audits escalations and clinical governance each term and reviews this policy.

5. The therapy offer

5.1 The weekly entitlement

• Every learner receives at least one hour of individual therapy every week they attend, from their first session (within 2 weeks of starting) until discharge. If a learner declines, section 5.3 applies.

• Family therapy and group work are added according to assessed need, agreed at the weekly multidisciplinary meeting and recorded in the child plan.

• Sessions take place in the sound-attenuated therapy rooms on the second floor, which have a glazed panel with a screen so there is privacy without isolation. Another member of staff is always on the floor, and the counsellor has an agreed way to call for help.

• Therapy is normally timetabled from 13:00 to 14:00, and where more sessions are needed, from 14:00 to 15:00. It is never timetabled during a core block.

• Connect records every session (date, duration, type and whether it took place) and shows a live weekly check of every learner against the one-hour minimum. A shortfall is visible the same week.

• The entitlement is never reduced to fit counsellor availability. The Director reviews counsellor capacity against roll and forecast referrals every month, and My Solution Wellbeing holds an associate bench of counsellors to cover absence and growth.

5.2 Matching within 2 weeks

Each learner is matched to a counsellor within 2 weeks of starting, and the first session takes place within that time. Counsellors are matched to the individual, never allocated by rota. The Head of AP and My Solution Wellbeing consider:

• the learner's needs, history and any trauma or bereavement;

• the learner's preferences, for example the gender, culture or language of the counsellor;

• the counsellor's experience with young people and with the issues involved;

• the days the learner attends;

• any known conflict of interest (for example a counsellor who knows the family).

The match is reviewed with the learner after the first few sessions. A learner can ask for a different counsellor at any time without giving a reason.

5.3 When a learner does not want to attend

Therapy cannot be forced. If a learner declines a session, the counsellor still makes contact where possible, explores what is getting in the way and offers other formats, such as a shorter session, a walk and talk, or creative and activity-based work. Every declined or missed session is recorded on Connect and discussed at the weekly multidisciplinary meeting. Where possible, a missed session is rearranged in the same week. Repeated refusal is discussed with the learner and family and reviewed in the child plan. Missing the weekly hour twice in a half term is escalated to the Director.

6. Counsellor standards and checks

No counsellor works with a learner until all of these are complete and recorded on the Single Central Record:

7. Consent and capacity

• At admission, we explain the therapy offer to the learner and parents, including the limits of confidentiality, and ask for parental consent. Parents are encouraged to take part in family work where it would help.

• At the first session, the counsellor asks for the learner's own agreement.

• For a learner under 16, the counsellor considers whether they are Gillick competent: whether they understand what therapy involves, its benefits and risks, and what will be shared. A competent learner can consent to their own therapy and has a say over what their parents are told.

• Learners aged 16 and 17 are presumed to have capacity to consent under the Mental Capacity Act 2005 unless assessed otherwise.

• If a parent refuses consent but a competent learner wants therapy, the counsellor discusses it with their clinical supervisor and the DSL, records the decision and the reasons, and keeps working to involve the parent.

• Family therapy requires the agreement of each person taking part.

• Any decision about a learner's social transition at Care Cove is made with parents, in line with DfE guidance on gender questioning children, which puts parental involvement first except in the rare circumstances where this would put the child at significant risk. This is not a decision a counsellor makes alone. Exploring feelings in therapy stays confidential within the usual limits.

8. Confidentiality

8.1 Explaining the limits

At the first session, the counsellor explains in plain language, and checks the learner understands, that:

• what they say in therapy stays private between them and their counsellor;

• the counsellor will tell the DSL straight away if the learner or someone else is at risk of serious harm, if the learner tells them about abuse, self-harm or thoughts of suicide, or if the law requires it;

• wherever possible, the counsellor will tell the learner first what they are sharing and why;

• staff will know whether sessions happen, and the themes and strategies the learner agrees can be shared.

The limits are explained to parents at admission, and the counsellor confirms them with the parent at or before the first session. The counsellor records on Connect that both explanations were given.

8.2 What is shared and what is not

Staff never ask a learner what they talked about in therapy. If a learner chooses to tell a member of staff, the staff member listens and reports any concern to the DSL in the usual way.

8.3 Clinical records

• Clinical notes are kept separately from the learner record, in a restricted clinical record that only the counsellor and their clinical supervisor can open. The partner agreement states where this record is held, how it is secured and who is the data controller for it.

• Clinical notes are never placed in, or visible through, the Family portal, the Partner portal, the Student app, school reports, reintegration guidance or any other family-facing or school-facing record.

• Safeguarding information from a session is recorded by the counsellor on Connect as a safeguarding concern, so it becomes part of the learner's append-only safeguarding chronology held by the DSL.

• Requests to see clinical notes, including subject access requests and court orders, go to the Director and are handled under Data Protection, Retention and Information Sharing, with advice from My Solution Wellbeing.

9. Risk escalation pathway

A counsellor never holds risk alone. Self-harm and suicidal ideation are always reported to the DSL.

9.1 What the counsellor does

1. Stay with the learner. Tell them you need to share this, and why, unless doing so would increase the risk.

2. Contact the DSL (or the Deputy DSL if the DSL is unavailable) within the session, using the agreed call or message route. For a Level 3 risk, ask a colleague to fetch the DSL so that you do not leave the learner.

3. Record the facts on Connect as a safeguarding concern the same day, in the learner's own words where possible.

4. Agree with the DSL what happens next, including who stays with the learner and how the learner gets home safely.

If the Clinical Advisor cannot be reached in a Level 3 situation, the DSL does not wait: they use NHS 111, option 2 (24-hour mental health crisis line) or 999. A trained DSL (Lead or Deputy) is on site in every operating hour and contactable outside them, on a cover rota known to all staff and counsellors.

9.2 Review of escalations

Every escalation at Level 2 or above is logged, reviewed at the weekly multidisciplinary meeting and by the DSL, and audited each term by the SWMC. Themes and volumes are reported to the commissioning local authority at half-termly monitoring meetings.

10. Clinical supervision and the Clinical Advisor

• Every counsellor receives clinical supervision of at least 1.5 hours a month from a qualified supervisor within My Solution Wellbeing, outside Care Cove's operational line. This keeps the professional line independent while making sure risk is shared.

• Supervision dates and durations are logged on Connect. The content stays between counsellor and supervisor.

• The Director checks each month that every counsellor has received their supervision. A missed month is raised with My Solution Wellbeing the same week, and the counsellor's caseload is reviewed if it is not put right within the next month.

• A counsellor representative attends the weekly multidisciplinary case meeting with teachers, mentors and, as required, the Clinical Advisor, sharing agreed themes, never session content.

• The Clinical Advisor gives health input to therapeutic planning: medication, self-harm care, physical health, substance misuse health checks and advice before any dietary approach for a learner with a suspected eating disorder. With consent, the Clinical Advisor liaises with GPs and CAMHS so that our therapy does not conflict with other treatment.

11. Trauma-informed practice across the whole staff team

Therapy happens for one hour a week. Trauma-informed practice happens all day. Every member of staff:

• completes Thrive trauma-informed relational practice training before learner contact and Nurture UK's three-day Theory and Practice of Nurture Groups;

• if they administer the Boxall Profile, completes Boxall training (by 14 December 2026);

• keeps routines predictable and explains changes in advance;

• treats behaviour as communication and uses repair rather than punishment, with no public correction;

• uses the regulation spaces and the strategies counsellors share;

• listens and reassures if a learner talks about past harm, but does not probe for detail, and reports to the DSL.

We aim to be recognised as a Thrive organisation during the 2026 to 2027 academic year.

12. Staff wellbeing and reflective practice

Working with trauma affects the people who do it. We provide:

• monthly group reflective practice for mentors and support staff, led by a social worker from the SWMC;

• fortnightly one-to-one supervision for mentors, half-termly reviews for teachers and monthly management supervision for the Head of AP;

• a same-day debrief after any incident;

• access to the counselling partnership for staff wellbeing. Where possible, staff are seen by a counsellor who does not work with Care Cove learners, and what they discuss is confidential within the usual limits.

13. Outcome measures

Results inform the child plan, the weekly multidisciplinary meeting and the commissioning local authority's monitoring reports. Scores are explained to learners and parents in context and are never used to label a young person. A poor score on its own never ends therapy.

14. Ending therapy and handover

• Endings are planned. Where possible, the counsellor and learner agree the ending at least two sessions in advance and use the final sessions to review progress and what helps.

• Before reintegration, and with the learner's agreement, the counsellor contributes a short summary of strategies that help (never session content) to the written guidance for the receiving school.

• If a learner needs therapy to continue, the counsellor and DSL agree an onward referral with the learner and family before discharge, for example to the receiving school's counselling service, CAMHS or the GP.

• During the 6 weeks of outreach after reintegration, the key mentor checks on the learner's wellbeing and tells the DSL of any concern.

• If a placement ends suddenly, the counsellor offers a closing session where possible and makes sure any open risk is handed to the DSL.

15. Complaints and concerns about therapy

• A learner or parent can raise a concern with the counsellor, the key mentor or the Head of AP, or use our Complaints policy. A learner can change counsellor at any time without giving a reason.

• The Director handles complaints about therapy with My Solution Wellbeing. Care Cove remains accountable to the family and to the commissioning local authority.

• A concern about a counsellor's professional conduct can also be raised with BACP or UKCP.

• Any concern that a counsellor may have harmed a child is handled under Managing Allegations Against Staff and Low-Level Concerns.

16. Record retention

• Session records and outcome measures on Connect are kept in line with the retention schedule in Data Protection, Retention and Information Sharing.

• Clinical notes are kept until the learner's 25th birthday (or 26th if they were 17 when therapy ended), the default in Data Protection, Retention and Information Sharing, unless the partner agreement sets a longer period. They are not destroyed while a safeguarding enquiry, complaint or legal claim is open.

• Before any child data is deleted, safeguarding records are transferred properly, as the law and our contracts require.

17. Monitoring and review

• Weekly: the Director reviews the therapy hour KPI on Connect; the DSL reviews every escalation.

• Monthly: counsellor capacity against roll; supervision log; counsellor registration and insurance expiry alerts.

• Termly: the SWMC audits escalations, a sample of therapy session records (not clinical notes) and supervision logs.

• Half-termly: therapy delivery, outcome measures and escalation themes reported to the commissioning local authority.

• This policy is ratified by the SWMC and reviewed every year, or sooner after an incident, a change in law or statutory guidance, or a contract change. It is available to the commissioning local authority at any time.

18. Related policies

• 01 Safeguarding and Child Protection
• 02 Safer Recruitment
• 03 Managing Allegations Against Staff and Low-Level Concerns
• 12 Special Educational Needs and Disabilities (SEND)
• 13 Curriculum, Teaching and Assessment
• 17 Data Protection, Retention and Information Sharing
• 19 Complaints
• 21 Staff Code of Conduct
• 24 Supporting Medical Needs and Administering Medicines
• 30 Referrals, Admissions and Ending Placements
• 33 Staff Supervision, Appraisal and Training

Appendix A: Who's who and key contacts

Document control and ratification

This policy is signed off by the Designated Safeguarding Lead and the Head of Alternative Provision, and ratified by the Social Work Management Committee. It is reviewed every year, or sooner after an incident or a change in law, statutory guidance or contract requirements, and it is available to any commissioning local authority on request.