CSR, iESR and ESR guidance

Who carries out the CSR?

The Clinical Supervisor is responsible for writing the report, although it is appropriate and usual for the CS to discuss the CSR with colleagues to inform the final report.
In addition to gathering information from colleagues, it is expected that the CS will have carried out at least one of the mandatory Workplace Based Assessments personally (CbD/MiniCEX/COT) before each CSR.

Where there are concerns about a GP registrar’s progress and there is more than one experienced CS working in the department or practice, it is appropriate, and good practice, for more than one CSR to be written for a single period of training.

Anyone assessing a Workplace Based Assessment is required to sign in to the Trainee Portfolio. Assessors will need to create a free-of-charge FourteenFish account if they do not already have one.
The GP registrar is responsible for arranging a meeting with the CS to ensure that the report is completed before the end of the placement and in time for the ESR meeting.

If a Clinical Supervisor has significant concerns about a GP registrar’s performance, they should not wait until the end of the post to highlight these. They should contact the local GP Training Programme Director or Associate Dean and share their concerns. The GP registrar may be asked to summarise the concerns in writing, potentially through an early CSR.

What is the reference point?

The CSR is used in both primary care and non-primary care/hospital posts. It is therefore important that the reference point is recognised in both settings.

There has been a recent change to the reference point for CSRs completed in ST1/2 primary care posts so that these mirror those completed in non-primary care/hospital posts.

In ST1/2 posts, the Clinical Supervisor is asked to compare the GP registrar’s performance with the expected performance of a GP registrar at that level of experience in that post. The assessment form asks the CS to make a judgement, after recording comments, of whether the GP registrar is:

• Significantly Below Expectations
• Below Expectations
• Meets Expectations
• Above Expectations

Within any of these ratings, the GP registrar will still be considered to be "needing further development" in relation to the ST1/2 stage of training.

In a final primary care post in ST3, the Clinical Supervisor is asked to compare the GP registrar’s performance with the standard expected of a registrar at the end of ST3: a newly qualified independent GP. The grades match those in the ESR and the form asks the CS to make a judgement of whether the GP registrar is:

• Needing Further Development - Below Expectations
• Needing Further Development - Meeting Expectations
• Competent
• Excellent

It may be useful to refer to the GP Capabilities and progression point descriptors when undertaking a CSR.

What does the form review?

Each of the seven questions covers a particular area of practice, for example Professionalism. There follows a description of how this is likely to be observed in the working environment.

Professionalism, for example, includes being respectful, diligent and self-directed in the approach to patients, colleagues and learning needs, developing resilience, and making appropriate ethical decisions.

Each question will automatically be linked to specific Capabilities in the Portfolio, for example Performance, Learning and Teaching; An Ethical Approach; and Fitness to Practise.

Capability descriptors have been written to support the grading and feedback for each question. These are available for ST1/2 primary care and non-primary care posts, and for ST3 primary care posts.

The CS is also asked to assess the level of supervision required compared with the expected level of performance for a GP registrar at this stage. There are four levels of supervision. If more supervision than would be expected is required, or the GP registrar cannot be left without supervision, an additional comment box will appear asking for further details.

Finally, in line with other specialties, there is a question about whether the GP registrar has been involved in conduct, capability or Significant Events and what the outcome has been.

Short Posts (for example 3 months or less)

It is particularly important that a CSR is completed for a short post so that there is an assessment of engagement and learning in the post. It would also be expected that there should be pro rata assessments (CbD/MiniCEX/COT) for these posts.

If a post is not completed due to absence or any other reason, the ARCP panel will need to determine whether a short post can count towards the GP registrar’s overall training time.

Being both ES and CS

There are occasions when the same person will be both the Clinical Supervisor and Educational Supervisor.

The CSR is a summary of the supervisor’s observations of the GP registrar’s performance under the various Capability headings. It is an opinion based on observation, debriefing, tutorials and other relevant interactions.

The ESR, in contrast, is a summary of information from different sources about the GP registrar’s performance, recorded in the Portfolio. It is appropriate for the ES to quote the assessment made by the CS as evidence, along with other evidence, even if the ES also completed the CSR.

If the CS is also the ES in a primary care post, the CSR does not need to be completed unless the evidence within the Portfolio does not give a full enough picture and information in a CSR would provide this missing information, or the GP registrar and supervisor feel it is appropriate. In these situations, the CSR should be completed irrespective of whether the CS and ES are the same person.

Communication between the CS and ES

The CSR is one of several sources of evidence used by the ES to reach a judgement about the GP registrar’s progress. While it has been designed to provide useful structured information, it is no substitute for dialogue between the Clinical and Educational Supervisor.

If there are known concerns about the GP registrar’s performance before the start of a post, it is appropriate for the ES and/or Training Programme Director to ensure that the CS is aware of the concerns and for the ES to remain available for advice. It is good practice for the GP registrar also to be aware of these conversations and their overall content.

Resources

Blank CSR Forms

• CSR - Template - CSR for ST1 and ST2 (PDF file, 129 KB)
• CSR - Template -  ST3 (PDF file, 154 KB)

Example CSRs
The following resources have been provided as 'exemplar' CSRs. Clinical Supervisors can use these as guidance on how to structure and write a CSR. Examples have been provided for GP registrars who do not require more supervision in their next post, and for GP registrars who do require more supervision in their next post.

• CSR - Example in  ST1 or ST2 (PDF file, 165 KB)
• CSR - Example in  ST1 or ST2 More Supervision (PDF file, 169 KB)
• CSR - Example in ST3 More Supervision (PDF file, 191 KB)
• CSR - Example in ST3 (PDF file, 192 KB)

Capability progression in ESR 

For the six-monthly reviews, you’ll first conduct a self-assessment of your progress on the 13 capabilities. You will then be assessed by the educational supervisor. Quality of evidence is more important than quantity. In the early stages of training, it’s unlikely that you’ll be able to provide evidence of readiness to practise. But the review will form the basis of a learning plan, highlighting where you’re doing well and where more support is needed. 

By the end of ST3, the educational supervisor will be looking to establish fitness to practise and readiness for completion of training through several sets of evidence in each capability area, collected from a range of settings and through different tools. Each portfolio will look slightly different, but it should provide a rich picture built up over three years. 

• Workplace Based Assessment (WPBA) capability framework 

Clinical experience groups coverage in the ESR 

While it’s not the main focus of ESR, you’ll have opportunities to consider breadth of clinical experience groups coverage as well as progress in the capabilities. When reviewing your Trainee Portfolio, you and your educational supervisor can monitor how far you’re covering the range of knowledge described in the curriculum, in preparation for the Applied Knowledge Test (AKT) and clinical practice. 

Completing trainee self-rating and educational supervisor capability grading for ESR

Capability areas 

For each Capability the list of linked evidence should be reviewed. These can be opened and reviewed by clicking on them in your Portfolio. You are required to pick up to three pieces of evidence from the range available for each Capability. 

Trainees in ST3 in full time placements are advised to include a minimum of 3 pieces of evidence per review to ensure there is an adequate amount of evidence to support their capability rating. Similarly, this is encouraged in ST1 and ST2 but it is recognised that some capabilities in non-primary care placements are harder to achieve and this may not be possible. Trainees in less than full time rotations need to include evidence which reflects the pro rata number of assessments and log entries for their percentage of training. 

The evidence chosen needs to demonstrate your current performance within that Capability area. 

It is preferable that a range of types of evidence from the learning log and workplace-based assessments is selected, though often logs alone may be used if these demonstrate a range of the descriptors. 

Using the capability descriptors, the trainee states what these pieces of evidence show them doing and how they support the grade they have given. They should only comment on evidence within the portfolio not their opinion of anything that is not recorded. 

As an ST1/2 it would be expected that they would be meeting the Needs Further Development NFD descriptors but may also have some showing competent. 
For the pre ARCP ESR evidence from any time in that year, even if it does not appear in this review, can be cited. 

The ES or CS may have stated, in the learning log comments or assessments feedback, why they were linking the log to set capabilities or grading the assessment as they did and if they have done this, quoting the capability descriptors. Their comments can be selected to be moved into the trainee self rating. Trainees should make it clear in their log which of the capabilities they feel they are addressing, so the ES can make appropriate comments. 

In order to have a good range of evidence to use it is important that all of the capabilities have at least one log linked to it in the review period. More logs allow for more of the capability descriptors to be evidenced and a higher grade awarded. It is important to demonstrate the capabilities across the range of Clinical Experience Groups but not all have to be demonstrated in each one. How many is possible will depend on the post under review. 

Ratings 

ST1, ST2 and ST3 who are not due to CCT 

The ESR outcome options for ST1, ST2 and ST3 who are not due to CCT in this review period will be as follows: 

• Making progress above the expected rate 
• Making progress at the expected rate 
• Making progress below the expected rate 
• Making progress significantly below the expected rate 

ST3 trainees who are at their currently due CCT date 

The ESR outcome options for ST3 trainees who are at their currently due CCT date will be as follows: 

• Competent/Excellent in WPBA requirements as evidenced by this ESR 
• Progress below the expected rate in WPBA requirements as evidenced by this ESR 
• These outcomes were introduced in November 2021. 

Word descriptors for ESR outcomes 

ESR "Grading"

ST1, ST2 and pre-final ST3

Making progress above the expected rate

• CSR areas rated as above expectations
• Assessments have been graded as working above the level of a GP trainee working in the current clinical post.
• All mandatory WPBA have been completed.
• Many capabilities are graded as Needing Further Development – Above expectations.
• LEA/SEA, QIA, 36 Clinical Case reviews, Placement Planning Meeting (relevant to requirements for training year)
• Regular engagement with the Portfolio and proactively engages with the supervisor, arranging and being well prepared for meetings.
• Progress demonstrated in at least one PDP in the training year
• In-date evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• All safeguarding requirements met: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.

Making progress at the expected rate

• CSR areas graded as meeting expectations
• Assessments are graded as at the level of a GP trainee working in the current clinical post.
• Capability areas are graded as: Needing further development – Meeting Expectations. (Depending on the capability, if a capability is harder to achieve in non-primary care placements and has been rated as below expectations, this may be acceptable in this context).
• All mandatory WPBAs are completed or a plan on providing those outstanding, up to a maximum of two
• Trainee has engaged with the Portfolio and engages with the supervisor in an appropriate time frame.
• LEA/SEA, QIA, 36 Clinical Case reviews, Placement Planning Meeting (relevant to requirements for training year)
• Progress demonstrated in at least one PDP in the training year
• In-date evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• All safeguarding requirements met: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.

Making progress below the expected rate

Engagement concerns

• Incomplete number of assessments/ CSRs – maximum of 2 areas missing
• Repeated late entry/sharing of log entries
• Missing mandatory evidence – LEA/SEA, QIA, 36 Clinical Case reviews, Placement Planning Meeting (relevant to requirements for training year)
• Educator notes relating to lack of engagement
• No PDP progressed in the training year
• Missing or incomplete evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• Missing one or more pieces of safeguarding evidence: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.

Performance concerns

• CSR highlights requires more supervision than would be expected.
• WPBA areas graded in some but not all assessments as below the expectation for a trainee working in the current post.
• Needing further development – Below expectations in up to two capability areas
• Concerns around knowledge gaps highlighted in assessments/reports/educator notes, but insufficient to impact on patient safety.

Professional concerns

• Evidence of concerns within the trainee’s professional behaviour as evidenced in assessments, log entries, CSRs, ESRs and educator notes, for example honesty and integrity, time keeping, evidence of difficulty in accepting feedback.

Making progress significantly below the expected rate

• Global failure to engage with the Portfolio
• Incomplete number of logs- less than half the required number
• Incomplete number of assessments /CSRs – less than half the required number
• No PDP progressed in the year
• Multiple educator notes on lack of engagement
• Missing or incomplete evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• Missing one or more pieces of safeguarding evidence: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.

Performance concerns

• CSR highlights concerns over being unable to be left without direct supervision
• WPBAs consistently graded below the expectation of a trainee working in the current post
• Needing Further Development - Below expectations in 3 or more capability areas
• MSF scores of 60% or below compared to peers for either clinical or professional behaviour and/or significantly concerning individual comments
• Significant concerns around knowledge impacting on patient safety are highlighted in assessments/reports/educator notes despite guidance and educational input.

Professional concerns

• Evidence of significant concerns within the trainee’s professional behaviour as evidenced in assessments, log entries, CSRs, ESRs and educator notes, for example honesty and integrity, time keeping, evidence of difficulty in accepting feedback.

ST3 "Final"

Competent/Excellent in WPBA requirements as evidenced by this ESR

• All mandatory WPBA completed
• Assessments completed towards the end of training are graded as competent for licencing
• All capabilities graded as ‘Competent for licensing’ or ‘Excellent’
• Progress must be demonstrated in at least one PDP in the training year and a post CCT pre-appraisal PDP created
• No concerns raised in the CSR (if completed)
• In-date evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• All safeguarding requirements met: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.
• Assessed as a safe and reflective GP prescriber as evidenced by the prescribing assessment or subsequent evidence within the portfolio

Progress below the expected rate in WPBA requirements as evidenced by this ESR

Engagement concerns

• below the minimum number of mandatory WPBA assessments
• No PDP progressed in the training year
• Missing or incomplete evidence of CPR and AED that demonstrates competence in these areas for both children and adults.
• Missing one or more pieces of safeguarding evidence: An in-date Level 3 Certificate covering both adults and children. An adult safeguarding knowledge update every 12 months. A child safeguarding knowledge update every 12 months. A Clinical Case Review every training year showing the application of adult safeguarding knowledge. A Clinical Case Review every training year showing the application of child safeguarding knowledge.

Performance concerns

• Number of WPBA overall graded as below the level of a GP working in the current clinical post
• CSR (if done) grading as needing further development or requiring more supervision than expected in the clinical role
• Any capability areas graded as needing further development

Professional concerns

Evidence of concerns within the trainee’s professional behaviour as evidenced in assessments, log entries, CSRs, ESRs and educator notes, for example honesty and integrity, time keeping, evidence of difficulty in accepting feedback.

Action plans 

After completing the capability grading the trainee will be asked to pick up to 3 capabilities that they feel they need to focus most on developing in the next review period. 

For each of these they need to write what they aim to achieve, ideally relating to the capability descriptors. 

The ES may add a further two of these if the trainee has not selected a capability that they feel is important for the trainee to address.
 
This is required even for final review ST3/4s as they need to plan further development in their post CCT pre-appraisal period. 

What should the Educational Supervisor do? 

The educational supervisor should read the trainee self-rating and review the evidence they have linked and decide if they feel that this does support the grade given. They also need to decide if this is a true representation of the trainee’s current level of performance as demonstrated within the portfolio. To do this they need to be aware of or review all the linked evidence. If the trainee has clearly stated what the evidence shows and how, using the capability descriptors, and they are able to justify the grade and the evidence linked supports this, the ES can simply agree, stating that they have confirmed this to be correct. If, however there is evidence that they feel supports a lower grade they need to link this evidence and state why this supports a lower grade. Similarly, if they feel that the trainee performance level is higher than they have graded themselves they justify this different grade using linked evidence and stating how this supports this revised grade. They are able to link up to an additional 3 pieces of evidence. 

PDP review 

Reviewing the PDP and helping the trainee write SMART entries is an important part of the ESR meeting and review. 

Before each placement/post, as well as during it, trainees should think about what their learning needs are, relevant to that post and how to address these. For ST1s this can be done before or at their initial meeting with their ES and subsequently when completing their self-assessment review for their ESR. Trainees should propose at least one PDP idea that covers a learning need and make a SMART plan for achieving this. At the ESR the supervisor can edit these and also help the trainee create other relevant ones if needed. 

PDPs are focusing on specific topic, skills or learning needs that the next post will require and help them achieve. They may well be about specific parts of the GP curriculum and are separate to the actions plans which focus on demonstrating progression in the capabilities. 

More information about the PDP can be found on the WPBA Assessments page. 

An Interim ESR should NOT be done when: 

• The last ARCP panel outcome was a 2 or 3 
• The panel asked for a full ESR at your last ARCP 
• The trainee has newly identified or previously declared Significant Events (GMC threshold of potential or actual serious harm to patients, complaints or other investigations which have not been resolved since their last ARCP i.e. any declaration made on the last Form R (or SOAR in Scotland) which is outstanding. 

The sign-off for the Interim ESR is slightly different to that of a full ESR. If the supervisor has any sufficient concerns and selects any outcome other than "satisfactory", the portfolio will prompt to switch to a full ESR, where the ES will then be required to grade and evidence each capability and give the full ESR grading at the end. 
Examples where concern may be raised include: 

• If concerns raised at a previous ESR have not been resolved 
• There are concerns over the ‘Level of Supervision’ needed, or your performance in the WPBA tools. 
• There have been concerns identified about your lack of engagement in the Portfolio 
• Concerns have been highlighted by the local education team or supervisors in the 'Educators notes’ section of your Portfolio.

Should an Interim ESR be completed in error or where the Deanery have subsequently requested a full ESR, the ES must request an interim ESR roll back and then switch to a full ESR and complete this as normal with the trainee.

When is it appropriate to complete an interim ESR? 

You need to have a review with your ES annually and at the midpoint of each year. 
If you are progressing satisfactorily then you can have an interim review at the midpoint of the year rather than the full review.

When is an interim ESR not appropriate and the full ESR required?

If at your last ARCP you were given an outcome 2 or 3, the previous ARCP panel asked for a full ESR. 
If you have been involved in a Significant Event which has not been resolved. 
If your ES has concerns about your progress.

What will be assessed at an interim ESR? 

It is important to assess whether you are producing satisfactory evidence across all the RCGP 13 Capabilities and Clinical Experience Groups as well as reviewing the overall quality of your Portfolio and checking that the required number of assessments have been completed. 

Which ESR should be completed if a trainee has not done half of the mandatory assessments by the midpoint of the training year? 

If you have shown a good level of engagement and done a little less than half of the year’s assessments by the midpoint, and there are no other factors which necessitate a full ESR then an interim ESR should be completed. If, however, you have done significantly less than half of the requirements this raises concerns about your engagement and progress. In this situation your ES will seek advice from the local education team and complete a full ESR. 

Does it make any difference to the review needed if I am less than full time? 

You need to have a full ESR each calendar year you are in training whether you are full or part time. All reviews in between these ESRs, can be interim ESRs as long as the stipulations detailed above are followed. 

Who can complete my interim ESR? 

Only your ES can complete an interim ESR: 

• If concerns raised at a previous ESR have not been resolved 
• There are concerns over the ‘Level of Supervision’ needed, or your performance in the WPBA tools. For example, more than the anticipated number of WPBA have been graded as you ‘needing further development – below expectations’ for this stage in your training 
• There have been concerns identified about you relating to a lack of engagement in the Portfolio 
• Concerns have been highlighted by the local education team or your supervisors in the 'Educator Notes' section of your Portfolio