Quality Assurance Matrix V 1 4 12 Feb 09

Quality Assurance
Matrix
Royal College Psychiatrists
Quality Assurance Committee
February 2009
Royal College Psychiatrists Quality Assurance Matrix based upon PMETB Generic Standards for Training December 2008
The Quality Assurance Matrix was designed by members of the College Quality Assurance Committee. The document should
be read alongside PMETB’s Generic Standards for Training (2008) upon which it is based and it represents an interpretation of
how the standards might be applied in psychiatric training.
For each of the standards there are suggested activities that will assist in achieving the requirements and there is an indication of
who might take responsibility within the Schools of Psychiatry and Local Education Providers.
The matrix also lists potential indicators of success and potential sources of evidence for quality management purposes.
It is expected that the standards for training as published by PMETB will change, and therefore the matrix will need to evolve
both in line with these changes and any other significant changes in the provision of psychiatric training. This version of the
matrix has incorporated the most recent changes from PMETB. The matrix therefore, will be updated from time to time by the
Quality Assurance Committee. Any suggestions for change can be sent to Claire Drummond on cdrummond@rcpsych.ac.uk
We are particularly keen to learn about how schools of psychiatry are identifying success indicators.
This version is in PDF format. An Excel version will also made available shortly.
The main contributors to the matrix were Dr Chris Murphy, Dr Floriana Coccia, Dr Nick Brown and Dr Harry Allen.
Dr Chris Murphy
Member Quality Assurance Committee.
December 2008
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1.1 Trainees must make the needs of patients their first concern.
In psychiatry there is a need to have special regard for the rights and needs of vulnerable and frequently disempowered groups and
individuals.
Level of Responsibility Activities to achieve Sources of evidence Success indicators
Head of School/Board Training for trainers including 1. Records of relevant training Results of National Patient Survey
induction and supervision, both both content and attendance. are positive
clinical and educational, to ensure
patients are trainees first concern
Liaison with Trusts about

matching of education and clinical 2. Induction Programmes; content
Governance systems. & attendance
Programme Directors/ Year Leads Trainee Induction.
Teaching programme.
Local Tutors Trainee Induction/Teaching
programme.
3. ARCP outcomes and
Educational Supervisors 1.Trainee Induction into Post Workplace Based Assessments
2. Provision of educational assess trainees’ attitude towards
supervision according to patients.
contemporary guidance and
ensuring clinical supervision. 4. National Patients Survey
Trainees Clinical supervision. 5. Trust Clinical Governance

Educational supervision. systems and their published
evidence.
Chief Executive / Medical 1. Ensure systems for clinical
Directors / Directors of Medical supervision including development 6. Trainees log of educational
Education of supervisors and timetabled supervision
arrangements within job planning.
2. Involvement of trainees in 7. Content of and attendance at
Clinical Governance including training programme for trainers
complaints and serious incident
reviews.
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1.2 Trainees must be appropriately supervised according to their experience and competence.
In psychiatry the standard is one hour per week individual educational supervision with the identified educational supervisor (see also
6.3) in addition to clinical supervision.

Ensure Training for trainers 1. National Trainee survey 1. National trainee survey
Head of School/Board includes trainee induction and indicates regular and appropriate
supervision both clinical and (to level of need) clinical
educational. 2. Content of training supervision is occurring in all
programmes for trainers posts
Dialogue with Trusts to ensure
awareness of standard 3. Content of induction 2. All trainees are demonstrated to
programmes for trainees receive timetabled weekly
Programme Directors/ Year Leads Ensure supervision arrangements educational supervision.
are included in induction 4 Evaluation of training posts
programmes for trainers and
trainees
Local Tutors Ensure supervision arrangements
are included in induction
programmes for trainers and
trainees
Educational Supervisors 1. Ensure that their trainees are
receiving appropriate clinical
supervision at all times and
trainees know who to gain Clinical
supervision from when trainer is
not available.
2. To ensure educational
supervisors provide one hour per
week one to one educational
supervision.
Trainees 1. Seek out supervision
appropriate to their level of
experience.
2. report supervision difficulties to
school or trust
Chief executive/ Chief Executive / 1. Include supervision
Medical Directors / Directors of arrangements in job plans and in
Medical Education annual appraisal.
2. Ensure trainees know who to
contact if they have supervision
problems
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1.3 Those supervising the clinical care provided by trainees must be clearly identified, competent to do so, accessible and approachable by day
and by night, with time for these responsibilities clearly identified within their job plan.
In psychiatry the complexity of service delivery requires that the lines of clinical responsibility and supervision must be explicit at all
times.
Head of school/Board Dialogue with trusts to ensure that 1. Content of training programs for National Trainee survey indicates
for all trainee placements there trainers that clinical supervision is
are clear lines of clinical satisfactory at all times including
supervision 2. Evaluation of posts out of hours
Induction and training for trainers 3. Description of posts includes National trainer survey indicates
must include clinical supervision of clinical supervision arrangements. that all trainers have time
trainees identified in job plan to provide
4. Duty and on-call rotas clinical supervision
Programme Directors/ Year Leads Evaluate posts to ensure trainees
are receiving satisfactory level of 5. National trainee survey
clinical supervision
Local Tutors Evaluate posts to ensure trainees 6. National trainer survey
are receiving satisfactory level of
supervision
Educational Supervisors Ensure trainees are receiving
regular and adequate clinical
supervision
Trainees Must report any difficulties in
obtaining clinical supervision to
the trust or school
Participate in evaluation of posts

Chief Executive / Medical 1. Ensure that there are systems
Directors / Directors of Medical including rotas that clearly identify
Education who is responsible to supervise all
clinical activities involving
trainees.
2 Review in annual Appraisal
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1.4 Trainees must be expected to obtain consent only for procedures which they are competent to perform.
In psychiatry particular attention must be paid to procedures involving mental health and capacity legislation.
Head of school/Board Dialogue with Trusts to ensure 1. Induction programmes and MHA commission reports indicate
there are standards for obtaining training for trainees good practice.
consent
2. Content of induction and
Programme Directors/ Year Leads Include consent issues in programmes of Training for
induction programmes and in trainers.
ongoing training for trainers
3. Local policies for obtaining
Ensure that trainees develop consent
competence in obtaining consent
as part of the training programme 4. Training programme content
Local Tutors Include consent issues in includes obtaining consent.
induction programmes and in
ongoing training for trainers 5 Trainers maintain section12
Educational Supervisors Induction into post must include approval
awareness of obtaining consent.
Ensure supervision includes

consent issues
Trainees Must maintain awareness of
consent policies and seek
supervision when obtaining
consent
Chief Executive / Medical Ensure that policies are in place

Directors / Directors of Medical concerning obtaining consent,
Education including the role of trainees
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1.5 Shift and on-call rota patterns must be designed so as to minimise the adverse effects of sleep deprivation.
Accountable Officer
Head of school/Board Dialogue with Trusts to ensure all 1. National Trainee Survey National trainee survey indicates
posts are EWTD compliant trainee satisfaction with on-call
2. EWTD monitoring rota patterns
Programme Directors/ Year Leads Evaluation of posts should inquire
about on-call rota patterns. 3. Evaluation of posts Regional EWTD monitoring
Local Tutors illustrates compliance
Educational Supervisors Monitor trainees on call

experience in supervision
Trainees Report any difficulties arising to
trust or school
Participate in the evaluation of

posts
Chief Executive / Medical Ensure that rotas and on call
Directors / Directors of Medical patterns are not adversely
Education affecting sleep patterns
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1.6 Trainees in hospital posts must have well-organised handover arrangements ensuring continuity of patient care at the start and end of periods
of day or night duties.
In psychiatry it must be recognized that handover requirements are not confined to hospitals. For example, they must include crisis
resolution teams, community units, etc.
Head of school/Board Dialogue with Trusts to ensure 1. National Trainee Survey National Trainee Survey
that awareness of this standards
Programme Directors/ Year Leads Include in Trainer induction 2. Induction programmes content Trainees’ timetables show time is
allocated for the handover.
Local Tutors Include handover arrangements in 3. Local policies and monitoring of
local induction handover arrangements
Educational Supervisors Ensure trainees are using
handover arrangements 4. Evaluation of posts
Trainees Maintain an awareness of the
policies 5. Trainees timetables
Chief Executive / Medical Ensure that there are policies for
Directors / Directors of Medical adequate handover arrangements
Education and that these are monitored
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2.1 Programmes, posts, associated management, and data collection concerning trainees and local faculty must comply with the European
Working Time Directive, Data Protection Act and Freedom of Information Act.

Head of school/Board Dialogue with trusts to ensure 1. Local Survey data concerning Board members are all aware of
awareness of need to meet the board/ administration staff responsibilities in relation to above
standard. knowledge and application of legislation.
above legislation
Board members receive training in
above legislation
2. content of Induction
Ensure that above legislation is programmes for board members
part of a QA programme of and trainers
monitoring
Programme Directors/ Year Leads Train trainers in above legislation

Include in induction
Local Tutors Include in induction
Educational Supervisors Trainers maintain awareness of

the above legislation
Trainees
Chief Executive / Medical Ensure monitoring of posts for

Directors / Directors of Medical adherence to above legislation
Education
-9-
2.2 Deaneries must show that they are developing their capacity for quality control, review and evaluation to meet PMETB’s standards.
Accountable Officer
Head of school/Board Ensure that there is a QA lead School / Board minutes Those with responsibility for
with clear responsibilities who Quality Assurance have clear lines
reports to the Board Programme Handbook of responsibility and reporting,
Programme Directors/ Year Leads with dedicated admin support
Local Tutors
Educational Supervisors
Trainees
Trust
Chief Executive / Medical

Directors / Directors of Medical
Education
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2.3 Deaneries, working with others as appropriate, must have processes for local quality management, and through local education providers, for
quality control of all postgraduate posts and programmes designed to ensure that the requirements of PMETB’s standards for training,
assessment and curricula are met.
In psychiatry there are additional standards set out by the College and its Faculties that must be met.
Head of school/Board 1. Ensure that PMETB standards 1. Board minutes Annual QA reporting of posts and
are central to the running of the programmes is able to indicate
School 2. Content of training and strengths and weaknesses in
2. Encourage board members and induction for supervisors. curriculum delivery.
supervisors to attend national
training and other activities to 3. Trainee induction programme
maintain awareness of PMETB
standards
3. QA lead needs to ensure that
appropriate information is being
gathered and reported to board
with suggested action plans
Programme Directors/ Year Leads Ensure Trainer awareness of
PMETB standards through
induction programmes
Local Tutors Ensure trainer and trainee
awareness of PMETB standards
through induction programmes
Trainees
Chief Executive / Medical Ensure that PMETB standards are

Directors / Directors of Medical central to the management of
Education training locally
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3.1 At all stages training programmes must comply with employment law, the Disability Discrimination Act, Race Relations (Amendment) Act, Sex
Discrimination Act, Equal Pay Acts, the Human Rights Act and other equal opportunity legislation that may be enacted in the future, and be
working towards best practice. This will include compliance with any public duties to promote equality.

Head of school/Board 1 Ensure that the above legislation 1. Board minutes Training programmes achieve
is central to the running of the best practice in the daily
school 2. Post evaluation data application of the above legislation
2. Ensure Induction and ongoing
training for Board Members in the 3. local surveys of facilities
above legislation
3. Ensure that advice on above 4. local policies and practice
legislation is available.
4.
Programme Directors/ Year Leads Evaluation of posts for evidence of
bullying /discrimination
Local Tutors
Trainees
Chief Executive / Medical Ensure that the above legislation

Directors / Directors of Medical is followed at all times
Education
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3.2 Information about training programmes, their content and purpose must be publicly accessible either on or via links on Deanery and PMETB
websites.

Head of school/Board Provide information to deanery to 1. Deanery Website review Up to date information can be
include on website found with ease.
2. PMETB website review
Ensure that there is a designated
individual with responsibility for 3. training programme handbooks
maintaining up to date and
accessible information
Programme Directors/ Year Leads Each programme must have a

comprehensive handbook with
details of training posts, training
programme and policies relating to
both training activity and
implementation of college
curriculum
Local Tutors
Trainees
Chief Executive / Medical Ensure that individual with

Directors / Directors of Medical responsibility for training are
Education identified and contact details are
available
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3.3 Deaneries must take all reasonable steps to ensure that programmes can be adjusted for trainees with well-founded individual reasons for
being unable to work full time to work flexibly within the requirements of PMETB Standards and rules. Deaneries must take appropriate action to
encourage trusts and other training providers to accept their fair share of doctors training flexibly.
Head of school/Board 1. Board should include a member 1. National trainee survey All those with good reasons to
with responsibility to support Less work less than full time are able to
than Fulltime Working. (LTFTW) 2. Board minutes do so.
2. Dialogue with trusts to develop 3. Trainee induction programme LTFT trainees have equal access
an understanding of how these to training and learning
posts can be supported and 4. Evaluation of posts and opportunities
financed. programmes
Programme Directors/ Year Leads 1. Must facilitate less than full time
working placements where a need
has been identified.
2. Ensure trainers are aware of
less than full time working issues
3. Trainer induction must include
awareness of LTFTW
Local Tutors Trainee induction must include
awareness of LTFTW
Trainees
Chief Executive / Medical Must support the LTFTW

Directors / Directors of Medical placements where a need has
Education been identified
- 14 -
3.4 Appropriate reasonable adjustment must be made for trainees with disabilities, special educational or other needs.
Head of school/Board 1. Ensure that the supporting of 1. Board minutes All trainees with disabilities and
trainees with special needs is one special needs are able to
of the central components of the 2. Induction and training complete a full programme of
running of the programme. programme for Board members training.
2. Dialogue with trusts to ensure
that such trainees are given and 3.Trainee Survey All trainees with disabilities and
supported in appropriate special needs have equal access
placements 4. Tutor and Trainer Induction to training and learning
3. Ensure Induction and ongoing Programme opportunities
training for Board Members in the
above. 5. Trainee Induction Programme
Programme Directors/ Year Leads 1. Must facilitate such placements
where a need has been identified. 6 Post evaluation
relevant issues
3. Ensure trainees are aware of
how to obtain support with special
training needs
Local Tutors 1. Must facilitate such placements

where a need has been identified.
relevant issues
3. Ensure trainees are aware of
how to obtain support with special
training needs
Educational Supervisors Assist in the identification of

training needs
Trainees
Chief Executive / Medical Must be proactive in the

Directors / Directors of Medical identification of special needs and
Education support appropriate adjustments
- 15 -
3.5 Trainees should have access to appropriate evidence on trainee recruitment, appointment, and satisfaction, (and on ARCP panel) with the
results analysed by ethnicity, place of qualification, disability, gender and part time training/working.
Head of school/Board The Board through Quality Annual QA reports These reports are readily available
Assurance leads must collect and to trainees and prospective
disseminate data appropriate trainees.
Programme Directors/ Year Leads Assist in the collection and
dissemination of data
Local Tutors Assist in the collection and
dissemination of data
Trainees
Trust

Education
- 16 -
4.1 Candidates will be eligible for consideration for entry into a specialist training programme if they:
a. are a fully registered medical practitioner or hold limited registration with the General Medical Council or are eligible for any such registration;
b. are fit to practise.
Head of school/Board Ensure that adequate processes 1. Review of long / short-listing Short listing considers the
are in place to identify eligible procedures applications of all eligible
candidates for entry into the candidates.
programmes of training 2.content of and register of
Programme Directors/ Year Leads attendance at training for those
involved in the recruitment
Local Tutors processes
Educational Supervisors 3. Annual reports to the board on

recruitment
Trainees

Education
- 17 -
4.2 To be eligible for consideration for entry onto a specialist training programme, candidates must be able to demonstrate the
competencies required to complete Foundation Training, candidates who apply before completion and those who have not undertaken
Foundation Training, but can demonstrate the competences in another way)

Head of school/Board Ensure that adequate processes Annual report to the board on All candidates considered for
are in place to identify that Recruitment, selection and Specialty Training Programmes
candidates have the appointment indicating have the required competencies
competencies required to methodology used. for completion of foundation
complete Foundation Training training.
Programme Directors/ Year Leads
Local Tutors
Trainees
Chief Executive / Medical Identify and release of staff for

Directors / Directors of Medical training.
Education Include review of selection training
at annual appraisal and job
planning for those involved in
specialty training
- 18 -
4.3 The selection process (which may be conducted by interview or by other process) must
• ensure that information about places on training programmes, eligibility and selection criteria and the application process is made widely
available in sufficient time to doctors who may be eligible to apply;
• use criteria and processes which treat eligible candidates fairly;
• select candidates on the basis of open competition;
• have an appeals system against non-selection on the grounds that the criteria were not applied correctly, or were unfairly discriminatory;
• seek from candidates only such information (apart from information sought for equalities monitoring purposes) as is relevant to the published
criteria and which potential candidates have been told will be required.

Head of school/Board 1. Develop and follow policies on 1. recruitment procedures Adherence to best contemporary
Recruitment, selection and recorded in board minutes practice can be demonstrated
appointment that incorporate the
above principles, ensuring that all 2. Induction and ongoing training
Involved in selection have had the programme of Board members.
necessary training
3. programme handbooks and
2. Include above in Programme websites
Handbooks and on deanery
Website
3. induction and training for school

board members to include equal
opportunity training
4. Work in collaboration with trusts

to ensure that selection process is
fair.
Local Tutors
Trainees
Chief Executive / Medical Trusts need to be actively involved

Directors / Directors of Medical in the release of human resources
Education staff to support the development
of the selection process. This is
properly the role of the Lead
Employer in areas where such a
system exists
- 19 -
4.4 Selection panels must consist of persons who have been trained in selection principles and processes.
Head of school/Board Ensure Board members and those 1. Annual report to the board on All those involved in the selection
involved in selection have Recruitment, selection and process have received the
received Selection and Equal ops appointment. relevant training.
training
Programme Directors/ Year Leads 2. Induction and ongoing training
programme of Board members.
Local Tutors
3. Attendance registers for
Educational Supervisors selector training events.
Trainees
Chief Executive / Medical Identify and release of staff for

Directors / Directors of Medical training.
Education
include review of selection training
at annual appraisal and job
planning for those involved in
specialty training
- 20 -
4.5 Selection panels must include a lay person.

Head of school/Board Identify and train lay persons Annual report to the board on All selection panels include a lay
Recruitment, selection and person.
Programme Directors/ Year Leads appointment.
Local Tutors
Trainees
Chief Executive / Medical Trusts need to actively support the

Directors / Directors of Medical identification of appropriate lay
Education people and the release of staff to
take part in the selection process.
- 21 -
5.1 Sufficient practical experience must be available within the programme to support acquisition of competence as set out in the approved
curriculum.
In Psychiatry
1. Trusts must ensure that training occurs in an assured safe environment, e.g., safe interview rooms, availability of panic alarms.
2. Within individual posts the position of the trainee as a full working member of the team must be ensured according to their
competency level.
3. The acquisition of certain competencies can only be achieved in certain specific clinical placements. This means that training must
be planned to ensure that individual trainees are not denied essential opportunities.
4. Particular attention must be paid to the acquisition of skills in emergency psychiatry including out of hours (see table for details).
Head of school/Board 1. The Head of School must have 1.Report to board concerning the 1. At all times trainees in
dialogue with trust to ensure that safety of trainees psychiatry will interview patients in
safety standards are met. an environment meeting
Programme Directors/ Year Leads 1. Those with responsibility for the 2. Policies for rotational planning standards for safety as set out by
organisation of programmes must Royal College of Psychiatrists.
ensure that trainees are placed to 3. Handbook demonstrates a
ensure that they receive sufficient variety of placements covering the 2. At annual review all trainees will
and relevant experience. core skills have achieved the competencies
2. There must be forward and other educational objectives
planning of rotational placements 4. ARCP results set out in their agreed programme
where possible. of training.
3. There needs to be some 5. Health and safety review
flexibility within programmes to
allow trainees to develop 6. National Trainee survey
subspecialty skills in addition
to the core skills.
4. Selection of trainers to the
programme must reflect the
needs of trainees to obtain the
necessary competencies.
5. ARCP panels must assess that
the appropriate range of
competencies have been
acquired
Local Tutors Ensure that trainees are getting
sufficient exposure to emergency
psychiatry.
Educational Supervisors 1. Ensure that trainees receive
regular formative assessment to
ensure that they are developing
the appropriate skills.
Trainees
Chief Executive / Medical Directors 1. Ensuring trainees are part of
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/ Directors of Medical Education the Crisis Resolution Teams.
2. Ensure a safe working
environment for mental health
practitioners with particular
attention to the provision of
alarms, appropriate interview
rooms and security support.
- 23 -
5.2 Each programme must show how the posts within it, taken together, will meet the requirements of the approved curriculum and what must be
delivered within each post
In psychiatry special attention must be paid to the trainees’ requirements for psychotherapy and other experiential training.
Psychotherapy training may require a trainee to continue working with a service user for a period of time greater that the duration of
one post, requiring them to be released from subsequent placements to continue this work and attendance at psychotherapy
supervision.
Head of school/Board 1. Ensure that each programme 1. Annual reports to the board on 1. Trainees will each have a
can demonstrate how it meets the meeting the curriculum. programme which addresses
demands of the curriculum. a) how their training will enable
2 Dialogue with trusts to ensure 2. Trainees survey. them to meet the requirements of
that there is a shared goal to the curriculum and
ensure that the requirements of 3. Trainers survey. b) the need to develop
the curriculum are met. psychotherapy skills in line with
Programme Directors/ Year Leads 1. Ensure that programme is 4. ARCP Outcomes the recommendations of the Royal
proactively addressing the need to College of Psychiatrists
meet the curriculum, e.g. through 5. Minutes and reports from
curriculum subcommittees programme subcommittee
2. Ensure that there is induction meetings
and ongoing training for trainers
on the curriculum for their year/ 6. Induction and programmes of
specialty training the trainers
Local Tutors Must have a good knowledge of
the curriculum as a whole and be
able to identify strengths and
weaknesses in the local curricular
training.
Educational Supervisors Must have a good knowledge of
the curriculum as a whole and
particular awareness of the
training they are to deliver to
enable their trainees to obtain
specific competencies.
Trainees
Chief Executive / Medical Must support the need for the

Directors / Directors of Medical work of trainees to be focussed
Education upon the develop competencies
and adjusted where necessary to
the development of psychotherapy
skills
- 24 -
5.3 Trainees must be reminded about the need to have due regard to, and to keep up to date with the principles of Good Medical
Practice

Head of school/Board Induction programmes
Trainee surveys
Local Tutors Ensure that this referred to in the

induction course
Educational Supervisors Should have a good knowledge of
GMP and take opportunities to
refer to it in supervision
Trainees Must be familiar with GMP

Education
- 25 -
5.4 Trainees must be able to access and be free to attend training days, courses and other material that forms an intrinsic part of the
training programme

Head of school/Board Dialogue with trusts to ensure that Trainees survey There will be a minimum of 70%
there is a shared goal to ensure Content and attendance at attendance by trainees at the core
that trainees are attending the programmes for training the training events set out on an
appropriate training. trainers annual by the Programme Director
Programme Directors/ Year Leads Ensure that the core training and Content of trainee Induction / Year Leads. There will be
other courses that trainees are programmes satisfactorily explanations for any
expected to attend are clearly Attendance registers for training absences.
identified and disseminated to events
trainers and trainees ARCP results
Maintain registers of attendance at Trainees timetables
training events Duty rotas
Make clear at Trainer and Trainee Bleep/contacting doctor policies
induction the expected attendance
at training events
Encourage the use of learning
agreements
Develop system to allow trainees
to report problems attending
training events
Local Tutors
Educational Supervisors Maintain registers of attendance at

training events
Develop and maintain a culture
that training must be attended.
Trainees Maintain learning portfolio
Ensure that where ever possible
clinical work is kept up-to-date to
minimise impact of any absence
from the clinical setting
Chief Executive / Medical Ensure that there is appropriate
Directors / Directors of Medical medical cover to allow the release
Education of trainees to attend training
events
Ensure bleep / contacting Doctors
policies support undisturbed
attendance at training
- 26 -
5.5 The overall purpose of the assessment system must be documented and in the public domain and must be implemented.
The Royal College of psychiatrists has developed a range of workplace based assessment tools.
Head of school/Board Ensure that training in College 1. Trainees survey Trainees and trainers will be using
Work placed based assessments the workplace based assessment
is available for Trainers and 2. Trainer survey tools as set out by the RCPsych
trainees and approved by PMETB.
Programme Directors/ Year Leads Induction for trainers and trainees 3. Attendance register at training
must include details and training in events
the use of college workplace
based assessment tools and how 4. Induction programme for
they relate to specific trainees
competencies within the
curriculum 5. Induction and programme of
Local Tutors Must maintain a knowledge of the training for trainers
workplace based assessment
tools and support trainees in using 6. ARCP outcomes
them scratch that in their use.
Educational Supervisors 1. Must ensure that they are
aware of the workplace based
assessment tools.
2. Must use the workplace based
assessment tools regularly with
their trainees
3 Should support trainees other
than their own current trainee by
being available to undertake work
placed based assessments.
4. Should be registered to record
online
Trainees Maintain a learning portfolio which
includes work placed based
assessments
Chief Executive / Medical Through job planning, support
Directors / Directors of Medical trainers using work place based
Education assessments for trainees other
than those that they are directly
supervising
- 27 -
5.6 The purposes of each and all components of the approved assessment system must be specified and available to the trainees,
trainers, professional bodies including the regulatory bodies, and the public

Head of school/Board Ensure that training in College
Work placed based assessments
is available for Trainers and
trainees
Programme Directors/ Year Leads Induction for trainers and trainees
must include details and training in
the use of college workplace
based assessment tools and how
they relate to specific
competencies within the
curriculum
Local Tutors Must maintain a knowledge of the
tools and support trainees in their
use, including examinations
Trainees

Education
- 28 -
5.7 The sequence of approved assessments must match the progression through the career pathway

Head of school/Board
Programme Directors/ Year Leads Must ensure that educational

supervisors are familiar with and
use appropriate assessment
methods as trainees progress.
Local Tutors
Educational Supervisors Must be familiar with the range of

approved assessment methods
and use them
Trainees

Education
- 29 -
5.8 Individual approved assessment within the system should add unique information and build on previous assessments

Local Tutors Ensure the trainees are familiar

with the full range of WPBAs as
appropriate during their
placements
Educational Supervisors Must be familiar with the range of
approved assessment methods
and use them
Trainees

Education
- 30 -
5.9 Trainees must have regular feedback on their performance within each post.

Head of school/Board Ensure that educational processes 1.Programme Handbook All trainees will receive regular
including providing feedback to and timely feedback from
trainees are central to the 2. Trainee survey supervisors who have been
organisation and running of the trained for this purpose
school 3. Evaluation of posts.
Programme Directors/ Year Leads Induction programme for trainers
must include training on effective 4. Induction and programmes of
feedback and expectations as a training the trainers
trainer to provide feedback
regularly. 5. ARCP outcomes
Evaluation of training posts 6. Trainer survey

Local Tutors Obtain feedback from trainees
regarding the quality of feedback
received.
Educational Supervisors Regularly provide feedback to
trainees in a timely and
appropriate manner.
Trainees Must be ready to practice clinical
skills in front of the trainers in
order that they may receive
feedback
Chief Executive / Medical Ensure that educational
Directors / Directors of Medical supervisors have sufficient time in
Education their job plan to provide effective
clinical supervision and feedback
to trainees.
Ensure that there is an
educational ethos within the
organisation.
- 31 -
6.1 Every trainee starting a post or programme must attend a departmental induction to ensure they understand the curriculum, how
their post fits within the programme, their duties and reporting arrangements, to ensure they are told about departmental policies and to
meet key staff.
In psychiatry trainees must have induction at levels of the programme, the Trust, the site and the post respectively.
Head of school/Board Ensure that all programs provide 1. Content and records of All trainees will have been
adequate induction for trainees. attendance at trainees’ induction enabled to attend a
Programme Directors/ Year Leads Must develop and run induction programmes. comprehensive induction process
programs for all trainees entering introducing them to the curriculum
each year/speciality programme, 2. Trainee survey. and all levels of the training
setting out curricular objectives for programme.
the year and how the trainee will 3. Induction leaflets/booklets
be assessed setting out responsibilities
Local Tutors Must develop and run induction
programs introducing new trainees 4. education programmes
to hospital/locality, setting out
local responsibilities as well as the 5. Content and attendance at
educational program. induction and programmes of
Educational Supervisors Must ensure that the trainee has training for supervisors
an induction into the post, with a
clear description of their duties 6. duty rotas
and responsibilities, as well as
their role within the clinical team. 7. departmental policies
Trainees must be made aware of
local policies and procedures
designed to ensure personal
safety.
Trainees Must ensure that they attend
induction meetings
Chief Executive / Medical Ensure that there is no timetabled
Directors / Directors of Medical clinical activity that clashes with
Education the induction programme.
Ensure that there is medical cover
so that trainees are not disturbed
whilst attending induction
programmes
- 32 -
6.2 At the start of every post within a programme, the educational supervisor (or representative) must discuss with the trainee the
educational framework and support systems in the post and the respective responsibilities of trainee and trainer for learning. This
discussion should include the setting of aims and objectives for the trainee to achieve in the post.

Head of school/Board Ensure that educational 1. Induction and programmes of All trainees will have a
supervisors receive training in training for educational documented plan of training for
setting learning objectives supervisors each post including learning
Programme Directors/ Year Leads Ensure that educational objectives.
supervisors and trainees are 2.Trainee documentation
aware of their responsibility to set
educational objectives 3. Trainee survey
Local Tutors Ensure that educational 4. Trainee induction programme

supervisors and trainees are
aware of their responsibility to set 5. Trainer survey
educational objectives
Educational Supervisors 1. Must set aside time to discuss 6. ARCP outcomes
the framework of educational
activity in this post. This should
include responsibility for learning.
2. Specific aims and objectives to
achieve in this post should be
recorded and referred to in
supervision
3. A record of this discussion
should be made
Trainees 1. Must take responsibility for their
own learning
2. Must maintain an up-to-date list
of learning objectives, plans on
how to achieve them (including
methods of assessment) and
progress towards achieving them.
Chief Executive / Medical Ensure that it is written into job
Directors / Directors of Medical plans of educational supervisors
Education that they will support the above
activities
- 33 -
6.3 Trainees must have a designated educational supervisor.

Head of school/Board Rotation data and programme At all times there will be a
handbooks designated and Educational
Programme Directors/ Year Leads Ensure that all trainees have a Supervisor for each trainee.
designated approved educational
supervisor.
Local Tutors
Trainees

Education
- 34 -
6.4 Trainees must sign a training/learning agreement at the start of each post.

Head of school/Board Ensure monitoring of use of 1. Copies of documentation used. All trainees will have a signed
learning agreements learning agreement
Programme Directors/ Year Leads 1. Ensure that a model for 2. Results of monitoring of use of
educational agreements is learning agreements.
available and distributed to
educational supervisors. 3. Trainee survey
2. Must monitor that educational
agreements are being completed 4. Trainer survey
Local Tutors Must monitor that educational
agreements are being completed
Educational Supervisors Must ensure that a learning
agreement is completed and
signed at the start of each post,
and a copy retained
Trainees Must retain a copy of the learning
agreement in the portfolio
Chief Executive / Medical Must support the use learning
Directors / Directors of Medical agreements
Education
- 35 -
6.5 Trainees must have a logbook and/or a learning portfolio relevant to their current programme, which they discuss with their educational
supervisor (or representative)

Head of school/Board Ensure monitoring of use of 1. Trainee survey All trainees will have a training
portfolios portfolio, which supervisors and
Programme Directors/ Year Leads 1. Ensure that the relevant 2. copies of documentation used trainees have received training
portfolio is available for trainees and guidance in using.
and trainers to use, and that as 3. ARCP outcomes
the portfolio develops, updated
versions are disseminated. 4. Induction and programmes of
training for trainers
2. Ensure that trainers and
trainees receive guidance on the 5. content of Trainee induction
use of portfolios, both summative
and formative assessment.
Local Tutors
Educational Supervisors Ensure that portfolios are used

regularly in supervision
Trainees Maintain an up-to-date portfolio of
learning activity and learning
achievement.
Education
- 36 -
6.6 Trainees must have further meetings with their educational supervisor (or representative) at least three-monthly, to discuss their progress,
outstanding learning needs and how to meet them.
In psychiatry this role is currently carried out by the College Tutor, Training Programme Director, or other individuals who are able to
provide this over a period of time or phase of the curriculum.
Head of school/Board Ensure monitoring of midpoint / 1. ARCP outcomes All trainees will have within their
three monthly review learning portfolio documentation
Programme Directors/ Year Leads There must be timetabled 2. monitoring of midpoint review with agreed outcomes from their
midpoint or three monthly review three monthly meetings with the
to review the progress of trainees, 3. Trainee survey tutor or training programme
with the outcome recorded and director, or educational supervisor.
copies maintained in the learning 4. Trainer survey
portfolio
Local Tutors There must be timetabled
midpoint or three monthly review
to review the progress of trainees,
with the outcome recorded and
copies maintained in the learning
portfolio
Educational Supervisors Must ensure that any relevant
review documentation is
completed in time for progress
reviews
Trainees Must ensure that they prepare for
review meetings and complete
any relevant documentation on
time
Chief Executive / Medical Ensure that supervisors undertake
Directors / Directors of Medical regular reviews through job
Education planning and trainer appraisal
- 37 -
6.7 Trainees must have a means of feeding back in confidence their concerns and views about their training and education experience to an
appropriate member of local faculty.
In psychiatry this must include opportunity to express concerns about the safety of the working environment.
Head of school/Board 1. Ensure that there are easily 1. Programme handbook and All trainees will know how to use
accessible points of contact for website agreed policies to report concerns
trainees to feed back in and views about their training
confidence any concerns and 2. policies for trainees
views about their training both experiencing difficulties in post
within a particular programme and
if necessary direct to members of 3. Evaluation of posts
the board or deanery
2. Ensure that all trainers attend 4. Induction programme for
an induction and programme to trainees
develop their teaching skills
5. Induction and programme of
Programme Directors/ Year Leads Ensure that all posts are training the trainers
evaluated on a regular basis
Local Tutors Must be approachable and willing 6. Action points arising from
to listen to concerns of trainees evaluation of posts and reported
about their educational experience concerns
Educational Supervisors Must be approachable and willing
to listen to concerns of trainees
about their educational experience
Trainees In addition to feeling able to
feedback concerns about training,
trainees must inform
representatives of trusts or the
school of psychiatry of any
shortcomings that might leave
trainees or other members of staff
at risk.
Chief Executive / Medical Must ensure that there are local
Directors / Directors of Medical mechanisms for trainees to report
Education concerns about personal Safety.
- 38 -
6.8 There must be ready access to career advice

Head of school/Board 1. The board must identify a lead 1. Programme Handbook / All trainees will know how to
for careers advice, website access relevant careers advice
from a person who is trained to
2. Trainees must be made aware 2. Trainee survey provide this.
of how they can access careers
advice 3. Reports from careers advice
lead to the Board
Programme Directors/ Year Leads 1. Ensure that information on
obtaining careers advice is 4. Induction programme for
included in trainees’ induction. trainees
2. Ensure that trainers are aware 5. Induction and programme of

of the role of careers advice training the trainers
through induction and ongoing
training.
Local Tutors
Trainees

Education
- 39 -
6.9 Working patterns and intensity of work by day and by night must be appropriate for learning (neither too light nor too heavy).
At all stages of training there must be meaningful involvement in systems of care that enables the trainee to incrementally gain all the
required competencies.
Head of school/Board There must be dialogue with trusts 1. Trainees survey Evaluation of posts will show that
to ensure that appropriate working trainees have been able to
patterns are established for all 2. Post evaluation develop the required
posts. competencies as a consequence
Programme Directors/ Year Leads 1. The continued approval of all 3. Supervision log of their clinical activities and
posts is subject to a review of the without hindrance from
intensity of work and job plan on 4. ARCP outcomes inappropriate working patterns
at least an annual basis.
2. Regular Evaluation of posts
must include questions on the
intensity of work and work
patterns.
Local Tutors Must monitor through dialogue
with trainees that the work loads
are at an appropriate level
Educational Supervisors Trainers will need to adjust the
workload of trainees to ensure it is
neither too light nor too heavy
Trainees Trainees must discuss their
workload in supervision,
maintaining some form of log of
clinical activity for both regular and
on-call work
Chief Executive / Medical The job plans of Trainees will
Directors / Directors of Medical need to reflect the competencies
Education required for their stage of training.
- 40 -
6.10 Trainees must be enabled to learn new skills under supervision, for example during theatre sessions, ward rounds and outpatient clinics.
In psychiatry trainees must have access to patients and training in a wide range of clinical settings and sub-specialties.
Head of school/Board Ensure that all trainers have the 1. Trainees survey Evaluation of post will show that
skill to teach in a variety of clinical regular clinical supervision is
settings 2. Trainer survey contributing to trainees developing
Programme Directors/ Year Leads Introduction and ongoing training competencies.
of trainers should set out 3. ARCP outcomes
expectations with regards to
teaching and supervision of 4. Attendance and content of
trainees within posts. induction and programmes of
Local Tutors training for supervisors
Educational Supervisors 1. Clinical teaching must occur in

a variety of clinical settings. This
may include inpatient, outpatient
and community settings. There
must be direct observation of
trainees at work and appropriate
feedback given.
2. Educational supervisors must
ensure that trainees were given
the opportunity to learn skills set
out in learning objectives at the
start of the post.
Trainees Trainees must be prepared to
address learning objectives and
look for opportunities to learn new
skills, where possible under
supervision.
Chief Executive / Medical Ensure that clinical activity is
Directors / Directors of Medical supervised by a clinician with the
Education skills to facilitate learning
- 41 -
6.11 Trainees must not be subjected to, or subject others to, behaviour that undermines their professional confidence or self-esteem

Head of school/Board 1. The school must have clear 1. Programme Handbook / Evaluation of posts and
policies minimising the likelihood Website programmes demonstrate that
of trainees experiencing bullying trainees are not being subjected to
of any sort that are readily 2. Trainer induction and any form of bullying or other
available in the handbook. programme of training the trainers behaviour that they feel
2. Trainees must know how to undermines their confidence.
confidentially report any bullying 3. Trainee induction programme
that they have experienced. Induction programme
3. Dialogue with trust to ensure
that policies are in alignment with 4. Trust and School Policies
school/ deanery expectations.
Programme Directors/ Year Leads Anti bullying policies must be 5. trainee survey
included in the induction
programme for both trainers and
trainees.
Local Tutors Local anti bullying policy must be
included in the local induction
Educational Supervisors Trainers must attend workshops to
ensure their awareness of anti
bullying policy
Trainees Must report any bullying or similar
behaviour that they had
experienced or that they observe
using the trust/deanery policy
Chief Executive / Medical Must ensure that anti bullying
Directors / Directors of Medical policy is in place
Education
- 42 -
6.12 While trainees must be prepared to make the needs of the patient their first concern, routine activities of no educational value should not
present an obstacle to the acquisition of the skills required by the curriculum.
In psychiatry, trainees’ placements must be made with an emphasis on learning needs rather than the filling of service gaps with
consequent diluting of training.
Head of school/Board Ensure that there is dialogue with 1. Trainee survey Evaluation of posts will show that
trusts and agreements that non all trainees have had a timetable
educational activities should be 2. Post evaluation without inappropriate activities that
minimised is designed to enable them to
Programme Directors/ Year Leads Ensure that there is inquiry about 3. Trainers survey meet the competencies expected
non educational workload at the at their level of training.
midpoint and end of Post review.
Local Tutors Ensure that there is inquiry about

non educational workload at the
midpoint and end of Post review
Educational Supervisors Must represent to trust
management and the school any
concerns that trainees are being
diverted from educational
experiences in order to undertake
non-educational activities.
Trainees Should report to the educational
supervisor any concerns they
have about the nature of their
workload
Chief Executive / Medical Ensuring trainees are not routinely
Directors / Directors of Medical expected to perform tasks of no
Education educational value.
Ensure that there are
administrative, phlebotomy and
similar technical support services
available.
- 43 -
6.13 Trainees must regularly be involved in the clinical audit process, including personally participating in planning, data collection and analysis.

Head of school/Board Dialogue with trusts to ensure that 1. Trainee survey All trainees will present to their
all trainees are involved in audit educational supervisor or an audit
Programme Directors/ Year Leads 1. Expectations with regards to 2. ARCP committee at least one completed
involvement in clinical audit must audit for each post in their training
be included in induction for 3. induction of trainees and at least once every 6 months
trainees and their participation in
audit reviewed at the annual 4. Education programmes
review.
2. training in the principles of 5. Minutes of Audit meeting
clinical audit must be included in
the programme
Local Tutors Ensure that clinical audit is
included in the local in-house
educational programme.
Educational Supervisors Ensure that clinical audit is part of
the program activity of trainees,
and the learning objectives are set
accordingly. These should be of
increasing complexity during the
course of their training
Trainees Must regularly attend audit
meetings.
Complete and present a minimum
of one completed audit per year.
Chief Executive / Medical Identify lead clinician to support
Directors / Directors of Medical trainees in identifying and
Education presenting audit projects
- 44 -
6.14 Access to Occupational Health services for all trainees must be assured.

Head of school/Board Hold dialogue with trusts to ensure 1. Handbook All trainees will know how to
that occupational health services access Occupational Health
are available for all trainees and 2. Trainee survey Services.
appropriate information available
in the handbook 3. Trainer survey
Programme Directors/ Year Leads 1. Trainee induction must include
information on accessing 4. Trainee Induction programmes
occupational health services.
2. Trainer induction should make 5. Induction and training
trainers aware of when they programmes for training the
should encourage trainees to trainers.
access occupational health
services
Local Tutors Trainee induction must include
information on accessing
occupational health services
Educational Supervisors Must be able to identify when the
trainee leads to access
occupational health services
Trainees
Chief Executive / Medical Ensure that occupational health

Directors / Directors of Medical services are available for medical
Education personnel
- 45 -
6.15 Trainees must be able to attend relevant, timetabled, organized educational meetings or other events of educational value to the trainee, as
agreed with the educational supervisor, and have time protected for this activity.
In psychiatry the approval is given by the College Tutor and/or the local Deanery representative.
Head of school/Board 1. Hold a dialogue with trusts to 1. Trainee survey For each trainee there will be at
ensure that trainees are released least 70% attendance at the
to attend relevant training. 2. ARCP outcomes programmed training activities
2. ensure that there are study
leave guidelines for trainees 3. Register of attendance at
Programme Directors/ Year Leads 1. Ensure that there is a relevant training events
timetabled programme of
educational meetings that trainees 4. study leave guidelines
are expected to attend.
2. Ensure that trainers are aware
of the programme of training that
trainees are expected to attend.
3. Where trainees requests study
leave in addition to the organised
training programme, guidelines
should be available to assist
trainees and educational
supervisors decide upon the
appropriateness of that request.
Local Tutors
Educational Supervisors Must ensure that trainees are

released to attend the programme
of training
Trainees Must ensure that they attend the
relevant program
Chief Executive / Medical Must ensure that trainees are
Directors / Directors of Medical released to attend the programme
Education of training.
- 46 -
6.16 Trainees must be able to access training in generic professional skills at all stages in their development.

Head of school/Board Ensure that supervisors have the 1. Curriculum for each programme For each trainee there will be a
ability to teach generic plan to develop generic
professional skills. 2. Trainee survey professional skills, the attainment
Programme Directors/ Year Leads 1. Training in generic professional which will be reviewed annually at
skills must be part of the 3. Induction and programme of the ARCP.
programme of training. training the trainers.
2. Evaluation of training in generic
professional skills for each post 4. ARCP outcomes
Local Tutors
Educational Supervisors Educational supervisors will have

an important role to play in helping
trainees to identify such
educational goals and provide
appropriate training and
supervision
Trainees
Chief Executive / Medical Support local programmes of

Directors / Directors of Medical training in generic professional
Education skills
- 47 -
6.17 Trainees must have the opportunity to learn with other healthcare professionals.
In psychiatry it is also expected that trainees will learn with users, carers, families and other statutory and non-statutory agencies.
Head of school/Board Ensure that multi-professional 1. Trainee survey The programme of training will
learning is part of all training include timetabled
programmes 2. Education programmes multidisciplinary learning directed
Programme Directors/ Year Leads The programme of training must towards the gaining of specific
include multidisciplinary learning. 3. ARCP outcomes competencies.
Local Tutors Local training activity must include
multidisciplinary learning within
the programme, including training
from users and carers
Educational Supervisors Must guide trainees towards
multidisciplinary learning
opportunities
Trainees Must be willing to involve
themselves in multidisciplinary
learning
Chief Executive / Medical Ensure that trainees have access
Directors / Directors of Medical to attend local training with
Education members of other disciplines.
- 48 -
6.18 Access to confidential counselling services should be available to all trainees when needed.

Head of school/Board Ensure that there are policies 1. Handbooks All trainees will know how to
supporting the access to access confidential counselling
confidential counselling 2. Trainee Induction programmes and report any difficulties
Programme Directors/ Year Leads 1. Ensure trainees are informed of associated with such access.
how to obtain counselling in 3. Induction and training
induction programme for teaching the
2. Ensure that trainers are aware teachers
of counselling services and when
to advise trainees to access them
Local Tutors
Educational Supervisors Trainers should be aware of when

to advise trainees to seek and
obtain counselling
Trainees
Chief Executive / Medical Trusts must fund counselling

Directors / Directors of Medical services for junior doctors
Education
- 49 -
6.19 Trainees must be made aware how to apply for study leave and be guided as to what courses would be appropriate and what funding is
available.

Head of school/Board Policies for application to obtain 1. Programme handbooks. At the annual review there will
study leave must be available for evidence that the trainee has met
Trainees, taking into account that 2. Trainee survey their tutor/TPD and discussed and
within an individual deanery there received advice upon their use
may be several different trusts 3. Trainee induction programmes study leave.
with different local policies.
Programme Directors/ Year Leads 1. Induction programmes should 4. trust study leave policies
include advice on how to obtain
study leave
2. Each program must make clear
how much study leave is taken up
with the local programme of
training
Local Tutors
Educational Supervisors Educational supervisors should

discuss with trainees how they are
using their study leave and guide
them so that educational
objectives are achieved
Trainees
Chief Executive / Medical There must be clear local policy

Directors / Directors of Medical on how to obtain study leave and
Education guidance on funding
arrangements
- 50 -
6.20 Trainees must be able to take study leave up to the maximum permitted in their terms and conditions of service.

Head of school/Board There must be a dialogue with 1. programme handbooks Evaluation of posts will show that
trusts to ensure that they trainees were able to take study
understand the need to release 2 Trainee survey leave approved by their
trainees for study leave. tutor/programme director up to the
Programme Directors/ Year Leads Guidance on the use of study 3. Trainee Induction programme maximum permitted.
leave must be included in the
induction programme 4. Trust study leave policies
Local Tutors
Educational Supervisors Trainers must support trainees in

making use of their study leave to
meet educational objectives
Trainees
Chief Executive / Medical Trainees must be released in

Directors / Directors of Medical order to make maximum use of
Education their study leave if necessary up
to the maximum permitted in their
terms and conditions of service
- 51 -
6.21 The process for applying for study leave must be fair and transparent, and information about a deanery-level appeals process must be readily
available.

Head of school/Board 1. The process for applying the 1. Handbook All trainees will know how to apply
study leave must be agreed with for study leave and the associated
trainee representatives. 2. Induction Programmes for deanery level appeals procedures.
2. The programme handbook must trainees
include details about deanery level
appeals. 3. Trust policies
3. Dialogue with Trusts to ensure
that Trust and Deanery policies
are in harmony
Programme Directors/ Year Leads Induction for trainees must include
information on study leave policies
and appeals
Local Tutors Must guide trainees in the use of
study leave.
Trainees
Chief Executive / Medical Ensure that trust study leave

Directors / Directors of Medical policies are readily available
Education
- 52 -
6.22 Trainees should be exposed during their training to the academic opportunities available in their specialty

Head of school/Board Ensure the involvement of 1. Board minutes All trainees will know how to
academic staff on the school access the academic opportunities
board. 2. Training programme available to them.
Programme Directors/ Year Leads The programme of training must
include an academic component 3. Trainee survey
Local Tutors Ensure there is an academic

component to local training
programmes.
Trainees

Education
- 53 -
6.23 Trainees who recognise that their particular skills and aptitudes are well-suited to an academic career should be encouraged and guided in
that endeavour.

Head of school/Board 1. Develop within the programmes 1. Trainee survey Within the programme of training
pathways to allow trainees to there will be clearly identified
develop academic skills. 2. Training programme handbook individuals with responsibility to
2. Working with trusts and the provide support and advice to
deanery, develop or support those who are well suited to an
academic fellowship posts. academic career.
Programme Directors/ Year Leads Within each programs there must
be educational supervisors with
the skills and relevant experience
to support a trainee to develop an
academic career
Local Tutors
Trainees
Chief Executive / Medical Through appraisal and job

Directors / Directors of Medical planning, support the development
Education of local academic interest
- 54 -
6.24 Trainees who elect, and are competitively appointed to, follow an academic path must be sited in flexible programmes of academic training
that permit multiple entry and exit points throughout training (from standard training programmes).

Head of school/Board There will need to be procedures Handbook Academic programmes of training
to appoint trainees to an academic will demonstrate flexibility in their
program where such opportunities approach, allowing trainees to
exist. develop both the academic and
Programme Directors/ Year Leads Training programmes must non academic competencies
develop academic pathways required for them to complete
within the overall programme to their training
facilitate academic training
Local Tutors
Trainees

Education
- 55 -
6.25 Trainers must enable trainees to learn by taking responsibility for patient management within the context of clinical governance and patient
safety.
In psychiatry care must be taken to ensure that trainees working within and alongside multidisciplinary teams are given real
responsibility
Head of school/Board School must ensure that all Trainees' job descriptions. Positive feedback from surveys
programmes allow trainees to SUI reports. and evaluations.
incrementally gain competence in Trainers' induction.
patient management. Trainees' surveys.
Programme Directors/ Year Leads Trainees must have a programme Post evaluations by trainees.
of placements that expose them to Exit interviews for trainees.
increasing levels of responsibility.
Local Tutors Tutors must facilitate liaison with
other trainers both in their clinical
departments and within the
organisation to ensure a
consistent approach to education
and training and the sharing of
good practice across specialities
and professions.
Educational Supervisors Trainers must ensure that trainees
are given responsibility for patient
management which must be
appropriately supervised.
Trainees Trainees must expect to take
responsibility within a framework
of supervision, and report
wherever their competence is
exceeded.
Chief Executive / Medical Must ensure that training occurs
Directors / Directors of Medical while maintaining patient safety,
Education and involving trainees in reviews
of adverse events.
- 56 -
6.26 Trainers must understand and demonstrate ability in the use of the approved in-work assessment tools and be clear as to what is deemed
acceptable progress.
In psychiatry, those involved in training need a particular understanding of how the work place based assessment tools have been used
and developed by the RCPsych to assess the competencies set out in the curriculum.
Head of school/Board Must ensure that training in Training the trainers programmes ARCP outcomes
WPBAs is provided for trainers, and attendance registers;
and that trainers can use the tools programme handbooks;
to evaluate the trainee’s progress. Annual reporting;
Programme Directors/ Year Leads Must ensure that there are Exit interviews.
speciality meetings with trainers to
ensure consistency and that the
information on the expected usage
of the tools is set out in the
relevant training programme
handbook.
Local Tutors Tutors must facilitate liaison with
other trainers both in their clinical
departments and within the
organisation to ensure a
consistent approach to education
and training and the sharing of
good practice across specialities
and professions.
Educational Supervisors Attendance at regular updates
(every 3 years) on WPBAs
Trainees Must contribute to feedback
processes
Chief Executive / Medical Trusts must ensure that trainers
Directors / Directors of Medical are assessed in the use of
Education WPBAs.
- 57 -
6.27 Trainers must regularly review the trainee’s progress through the training programme, adopt a constructive approach to giving feedback on
performance, advise on career progression and understand the process for dealing with a trainee whose progress gives cause for concern
a) In psychiatry, regular appraisal needs to include information and assessments from a variety of sources including members of the
MDT as well as service users and carers, ensuring that both strengths and areas for development are identified.
b) There are many and varied career pathways in psychiatry and advice to trainees regarding these options should take the trainees
strengths and any weaknesses into account.
Head of school/Board Must ensure that there is a local Training the trainers programme;
process for assisting Trainees in Report from career's guidance/
Difficulty, including careers advice mentoring lead;
and that it is publicised in training Survey reports.
handbooks.
The School must require that its
trainers are able to apply the
assessment tools and give
accurate and constructive
feedback to trainees.
Programme Directors/ Year Leads Must ensure that trainees'
progression is reviewed regularly.
TPDs must be familiar with and
contribute to the process for
assisting Trainees in Difficulty as
necessary.
Local Tutors Tutors must review trainees
progress at intervals as above
(6.6) Must be familiar with local
processes for assisting Trainees
in Difficulty
Educational Supervisors Adherence to appraisal and
assessment procedure of trainees.
Regular training in supervision
skills every 5 years. Must be
familiar with processes for helping
Trainees in Difficulty
Trainees

Education
- 58 -
6.28 Trainers must ensure that clinical care is valued for its learning opportunities; learning and teaching must be integrated into service provision
In psychiatry, every care must be taken to ensure that vulnerable patients are protected, and appropriate consent is gained.
Head of school/Board The School of psychiatry needs to Survey feedback.
make explicit that trainees must Patient feedback.
learn from their contact with Training the trainers programmes
service users in a variety of and attendance registers
clinical settings. Training the
trainers must include how to
facilitate such clinical learning
whilst respecting the needs and
rights of service users.
Local Tutors
Educational Supervisors Must ensure that training

opportunities are maximised within
the clinical setting.
Supervisors must demonstrate
that their trainees are learning
through clinical experience.
Trainees
Chief Executive / Medical Must ensure that training is

Directors / Directors of Medical integrated into service provision.
Education Community / Emergency
Psychiatry experience must be
available to trainees
- 59 -
6.29 Trainers must liaise as necessary with other trainers both in their clinical departments and within the organisation to ensure a consistent
approach to education and training and the sharing and good practice across specialties and professions.
In Psychiatry, much of the learning takes place in a multidisciplinary environment. Where ever individuals from other professions are
regularly involved in the training of doctors these individuals should be encouraged to share their experiences and learn from other
involved in training.
Head of school/Board The School must have methods to post evaluation;
share and disseminate good trainer and trainee surveys;
practice and this must include annual report from head of school
trainers from other professions.
Programme Directors/ Year Leads Must ensure that there are
speciality meetings with trainers to
ensure consistency.
Local Tutors Must ensure that there are local
meetings with trainers to ensure
consistency.
Educational Supervisors Supervisors must regularly attend
and participate any meetings set
up for the purpose of ensuring
consistency and sharing good
practice
Trainees Trainees must complete
evaluation of posts
Chief Executive / Medical Trusts must support and
Directors / Directors of Medical encourage trainers to attend
Education meetings of trainers.
The role of non-medical
professionals in the provision of
training must be recognised and
supported.
- 60 -
6.30 Organisations providing postgraduate medical education must ensure that trainers have adequate support and resources to undertake their
training role
In Psychiatry, some of those involved in postgraduate medical education will have responsibility for the assessment appraisal, teaching
and organisation of training for trainees within a programme that are based in different Trusts. Time and administrative support for
these extended responsibilities is essential for the coordinated running of these programmes. The distribution of non-consultant
medical support to teams should take into account that where training is taking place additional resource may be needed so that they
are not disadvantaged when compared with teams where training is not taking place.
Head of school/Board Dialogue with trusts to make clear National Trainer survey
what is expected of those involved Local Trainer survey
in post graduate training and the Trainee surveys
resources needed to fulfil these
roles
Programme Directors/ Year Leads Programme directors should
ensure that there are identified
individuals who can be
approached by trainers who
require advice and support on
educational matters.
Local Tutors Should be available to direct
trainers to where they can access
advice and support if it can not be
provided locally.
Educational Supervisors Need to bring to the attention of
the Trust and School where
resources and support are
inadequate to fulfil their role.
Trainees Complete post evaluation.
Chief Executive / Medical Must ensure that job plans

Directors / Directors of Medical adequately reflect the training role
Education of the doctors in the organisation,
and that resources in terms of
time, appropriate rooms and
administrative support are
available.
- 61 -
6.31 Deaneries must have structures and processes to support and develop trainers
In Psychiatry there is a need to support trainers who have an aptitude to teach psychotherapy skills.
Head of school/Board Must ensure that there are Annual reporting by head of
identified individuals with school and programme directors;
responsibility for a organising a Trainer surveys.
programme of training for trainers.
Those trainers wishing to develop
additional skills in training must be
able to do so.
Programme Directors/ Year Leads Ensure that all of the trainers are
involved in any training the
trainers events.
Local Tutors Tutors have an important role in
organising and supporting local
educational events for trainers.
Educational Supervisors Ensure that they have a plan for
the development of their training
skills
Trainees
Chief Executive / Medical Must ensure that training the

Directors / Directors of Medical trainers events are available to the
Education trainers. Those trainers wishing to
develop additional skills and
qualification in training must be
able to do so.
- 62 -
6.32 Trainers with additional educational roles must be selected and demonstrate ability as an effective trainer

Head of school/Board Ensure that there are policies for Annual report by the head of
the selection and appointment of school
individuals which require those
taking additional roles to
demonstrate their ability to
perform and that their
effectiveness is appraised on an
annual basis.
Local Tutors Ensure that tutors have a system

for identifying trainer’s strengths
and weaknesses.
Trainees
Chief Executive / Medical Appraisal of educational role of

Directors / Directors of Medical trainers, tutors and others with
Education training responsibilities must takes
place.
- 63 -
6.33 GP trainers must be trained and selected in accordance with PMETB requirements and the General and Specialist Medical Practice
(Education, Training and Qualifications) Order 2003.
Local Tutors
Trainees
Trust

Education
- 64 -
6.34 Trainers must have knowledge of, and comply with, the PMETB regulatory framework for medical training.

Head of school/Board Ensure that there is training for all Induction programmes for trainers.
trainers in the PMETB regulatory
framework
Programme Directors/ Year Leads induction of trainers
Local Tutors induction of trainers
Trainees

Education
- 65 -
6.35 Trainers must ensure that all involved in training and assessment of their designated trainee understand the requirements of the programme
In psychiatry training often occurs with multi-professional teams. It is important to keep members of these teams familiar with modern
medical education methods.
Head of school/Board Needs to ensure that the Reports from Programme A wide range of non-medical
requirements of the programme Directors assessors available, and
are disseminated to all parts of the consistent standards maintained
school. by them.
Induction of Board Members
Programme Directors/ Year Leads Induction of trainers
Local Tutors Induction of trainers
Educational Supervisors Must ensure that all those

involved in training or assessment
of their trainees are familiar with
WPBAs.
Trainees
Chief Executive / Medical Chief executives must impress on

Directors / Directors of Medical staff that non-medical staff can
Education contribute to medical teaching.
- 66 -
7.1 Training programmes must be supported by a management plan with a schedule of responsibilities and defined processes to ensure the
maintenance of PMETB standards in the arrangement and content of training programmes.

Head of school/Board 1. With reference to the PMETB 1. constitution of school board Each school will have a published
standards and the college schedule showing who is
curriculum, the school board will 2. job descriptions for school responsible for monitoring and
define the schedule of board members meeting the PMETB Standards for
responsibilities and management Training.
plans against which each of the 3. Reports by head of school
programmes will be required to
report progress and achievement 4. Reports by programme
2. Roles and Responsibilities for directors and year leads
committee members set out in
description of their posts. 5. job plans for those involved in
3. Appointment of training medical education include time
committee members will be allocated to this function
through open competition and
suitability for post
Programme Directors/ Year Leads Must report to the board on a

range of specific objectives set as
above.
Local Tutors
Trainees
Chief Executive / Medical Must ensure that trainers involved

Directors / Directors of Medical in the management of training are
Education supported in this important NHS
activity through job planning
- 67 -
7.2 The schedule must set out the responsibilities and accountabilities of the Postgraduate Dean, Royal Colleges/Faculty/specialty associations
,programme directors and other members of local faculty, the trainees, the employer, and the commissioners of health services and of educational
programmes.
In psychiatry attention must be paid to the settings and systems from which mental health services are delivered, e.g., decentralised
systems, joint Health and Social Care bodies, etc.
Head of school/Board Produce a schedule of Schedule is reported to the board The schedule will follow the
responsibilities (in line with annually PMETB template
PMETB and College expectations)
for board members, tutors
educational supervisors and
trainees to be approved by board
Local Tutors
Trainees

Education
- 68 -
7.3 There must be robust processes for identifying, supporting and managing trainees whose conduct, health, progress or performance is giving
rise to concern.

Head of school/Board 1. There will be a comprehensive 1. policy for supporting trainees in Evaluation of the process will
policy for trainees in difficulty difficulty show that where ever any
which will include objectives to concerns about a trainee’s
identify and support such trainees, 2. Training programme Handbook performance have been raised,
ensuring that patient safety is the policy has implemented and
paramount. 3. Trainer survey where possible concerns have
2. The policy will operate in been rectified using appropriate
conjunction with other policies 4. Trainee survey policies.
including access to occupational
health, less than full-time working, 5. Trainees induction programme
access to counselling, appraisal
and the assessment of trainees, 6. Trainers induction and
and will also need to work programme for teaching the
alongside policies within Trusts teachers
that address the performance of
clinicians. 7. trust policies
that policies are compatible
Programme Directors/ Year Leads 1. Information regarding the Policy
for trainees in difficulty will be
included in induction programmes
for trainers and trainees.
2. Programme directors will play a
key role in the management of
trainees in difficulty for their
speciality.
Local Tutors Local tutors will play a key role in
the management of trainees in
difficulty during the core training
years
Educational Supervisors Educational supervisors must be
aware of policies for trainees in
difficulty. They will be expected to
work in conjunction with
programme directors and local
tutors to resolve any training
issues connected with identified
difficulties
Trainees
- 69 -
Chief Executive / Medical Ensure that there are local trust
Directors / Directors of Medical policies to support trainees in
Education difficulty
- 70 -
7.4 It is highly desirable that all employing organisations as local providers of postgraduate medical education and training, have an executive or
non-executive director at Board level responsible for supporting training programmes, setting out responsibilities and accountabilities for training
and for producing processes to address underperformance in medical training.

Head of school/Board Dialogue with trusts to facilitate Report by head of school Trust boards will have an
the identification of board level identified individual with
director with responsibility for Constitution of school board responsibility and accountability
training and developing local for the delivery of post graduate
policy to address medical training.
underperformance in medical
training
Local Tutors
Trainees
Chief Executive / Medical Should identify a lead for medical

Directors / Directors of Medical education and training
Education
- 71 -
7.5 There must be clear accountability, a description of roles and responsibilities, and adequate resource available to those involved in
administering and managing training and education at institutional level, such as Directors of Medical Education and Board level directors with
executive responsibility, such as Medical Director, Finance Director, Director of Clinical Governance.

Head of school/Board Dialogue with trusts to facilitate Job plans for Directors of medical There will agreement between
the identification of directors of education Trusts and the School regarding
medical education. the designated roles of those with
Programme Directors/ Year Leads responsibility for managing and
providing post graduate medical
Local Tutors education, and the resources
required to deliver said training.
Trainees
Chief Executive / Medical Identify individuals who are

Directors / Directors of Medical responsible for and are ensured to
Education have capacity for the local
management and administration
of training
- 72 -
8.1 The overall educational capacity of the institution and any unit offering training posts within it must be adequate to accommodate the practical
experiences required by the curriculum, along with the educational requirements of all health care professionals in the same unit.

Head of school/Board Dialogue with trusts to ensure that 1. Trainee survey The handbook for the training
there are adequate resources to programme will identify for each
meet the requirements of the 2. Trainer survey post the resources required to
curriculum for specialty trainees achieve the learning objectives of
as well as the training needs for all 3. Handbooks will state the that post.
health care professionals capacity for training in each trust
Programme Directors/ Year Leads Ensure that no more trainees are
placed within any trust than it has 4. Man power planning reports
the capacity to provide training for.
Local Tutors Must raise concerns whenever it
appears that training capacity has
been exceeded
Educational Supervisors Must raise concerns where
training capacity appears to be
exceeded at the cost of quality of
training
Trainees Must participate in the evaluation
of posts
Chief Executive / Medical Must ensure that Man power
Directors / Directors of Medical planning takes into account the
Education training needs and the capacity to
deliver
- 73 -
8.2 There must be access to educational facilities (including a library), and resources (including access to the Internet in all workplaces) of a
standard to enable trainees to achieve the outcomes of the programme as specified in the curriculum.
In psychiatry there is a need to recognise the dispersed nature of services and the importance of adequate educational and information
resources.
Head of school/Board 1. Standards for educational Handbook For all trainees there will be
facilities and resources for all access to educational resources
providers of training must be Trainee survey of a standard set out in the Royal
agreed by the board and included College Psychiatrists Training
in the training Handbook Evaluation of posts Handbook.
that standards for educational
facilities are met
Programme Directors/ Year Leads Trainees must not be placed
within trusts where educational
facilities do not meet the required
standards
Local Tutors
Trainees

Education
- 74 -
8.3 There must be a suitable ratio of trainers to trainees. The educational capacity in the department or unit delivering training must take account
of the impact of the training needs of others (e.g. undergraduate medical students, undergraduate and postgraduate health care professionals and
non-training grade staff). With regard to trainers, including clinical supervisors, adequate time for training must be identified in their job plans (see
also 1.3).
In psychiatry, the maximum number of trainee that the consultant can supervise is two. Where there are more than two trainees this will
usually be a combination of one trainee at year ST 4-6 and the other at ST1-3 or FY1-2.
Head of school/Board Ensure that there are no more 1. Trainee survey No trainees will supervised by an
than two trainees for any educational Supervisor
educational supervisor 2. trainer survey responsible for more than two
Programme Directors/ Year Leads Must not place trainees where trainees.
there is an unsuitable ratio of 3. evaluation of posts
trainers to trainees
Local Tutors 4. Annual rotation data
Educational Supervisors 1. Must ensure that for every 5. Job plans for educational
trainee adequate time set aside supervisors
for clinical and educational
supervision.
2. Must ensure that there is
sufficient clinical activity to fully
occupy the training requirements
of trainees.
Trainees
Chief Executive / Medical Adequate time for training and

Directors / Directors of Medical supervision must be included in
Education job plans for medical staff
supporting trainees and non-
training grade doctors
- 75 -
8.4 Relevant specialty specific educational resources must be available and accessible where these are stipulated in PMETB-approved curricula
e.g. clinical skills centres, ‘wet labs’.
In psychiatry an example would be facilities and resources for developing communication skills including simulated patients and audio-
visual recording materials.
Head of school/Board Dialogue with trusts to ensure that 1. Trainee survey For all trainees there will be
facilities are available for the access to educational resources
provision of training to develop 2. Trainer survey of a standard set out in the Royal
communication and consultation College Psychiatrists Training
skills using audiovisual equipment. 3. ARCP outcomes Handbook.
Programme Directors/ Year Leads Trainees with specific educational
needs must be placed within trusts
where there are resources to
ensure these educational needs
can be met
Local Tutors
Trainees
Chief Executive / Medical Ensure that resources are

Directors / Directors of Medical available to support the teaching
Education of competencies in line with the
curriculum, in particular audio-
visual equipment.
- 76 -
8.5 Trainees must have access to meeting rooms and audio-visual aids.

Head of school/Board Dialogue with trusts to ensure that Trainee survey For all trainees there will be
there are adequate meeting rooms access to educational resources
Programme Directors/ Year Leads Trainer survey of a standard set out in the Royal
College Psychiatrists Training
Local Tutors Handbook.
Trainees
Chief Executive / Medical Ensure that there are adequate

Directors / Directors of Medical meeting rooms with audiovisual
Education aids for postgraduate medical
educational meetings.
- 77 -
9.1 Trainees must have access to analysis of outcomes of assessments, and exams for each programme and each location benchmarked against
other programmes. As part of the quality framework, PMETB will establish requirements for a minimum data set. This will be part of regular
reports as specified, from the post graduate deaneries.

Head of school/Board Quality assurance leads will Reports from quality assurance Annual reporting will include
develop processes to collect data leads for local performance. analysis of outcomes in
from all those involved in training RCPsych exam results accordance with a template
within the school and publish this published by RCPsych
information with reference to
PMETB standards.
Local Tutors
Trainees

Education
- 78 -

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Quality Assurance

Royal College Psychiatrists

Quality Assurance Committee

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Liaison with Trusts about

Trainees Clinical supervision. 5. Trust Clinical Governance

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Participate in evaluation of posts

Ensure supervision includes

Chief Executive / Medical Ensure that policies are in place

Educational Supervisors Monitor trainees on call

Participate in the evaluation of

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Programme Directors/ Year Leads Train trainers in above legislation

Educational Supervisors Trainers maintain awareness of

Chief Executive / Medical Ensure monitoring of posts for

Chief Executive / Medical

Chief Executive / Medical Ensure that PMETB standards are

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Chief Executive / Medical Ensure that the above legislation

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Programme Directors/ Year Leads Each programme must have a

Chief Executive / Medical Ensure that individual with

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Chief Executive / Medical Must support the LTFTW

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Local Tutors 1. Must facilitate such placements

Educational Supervisors Assist in the identification of

Chief Executive / Medical Must be proactive in the

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Educational Supervisors 3. Annual reports to the board on

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Chief Executive / Medical Identify and release of staff for

Level of Responsibility Activities to achieve Sources of evidence Success indicators

3. induction and training for school

4. Work in collaboration with trusts

Chief Executive / Medical Trusts need to be actively involved

Chief Executive / Medical Identify and release of staff for

4.5 Selection panels must include a lay person.

Chief Executive / Medical Trusts need to actively support the

Chief Executive / Medical Must support the need for the

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Local Tutors Ensure that this referred to in the

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Educational Supervisors Maintain registers of attendance at

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Programme Directors/ Year Leads Must ensure that educational

Educational Supervisors Must be familiar with the range of

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Programme Directors/ Year Leads

Local Tutors Ensure the trainees are familiar

Chief Executive / Medical

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Evaluation of training posts 6. Trainer survey

Level of Responsibility Activities to achieve Sources of evidence Success indicators

Local Tutors Ensure that educational 4. Trainee induction programme