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Registration Number: {{org_field_registration_no}}

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Requirements for Registered Managers Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} employs and maintains competent, qualified, and accountable Registered Managers in compliance with the Care Quality Commission (CQC) Regulations. A Registered Manager (RM) plays a crucial role in ensuring that services meet the highest standards of care quality, safety, governance, and compliance.

This policy outlines the eligibility criteria, responsibilities, training, and monitoring procedures for Registered Managers, ensuring they are fully equipped to lead care services efficiently while maintaining regulatory compliance.

2. Scope

This policy applies to:

• All Registered Managers (RMs) working within our domiciliary care service.
• The Senior Management Team, who oversee the recruitment and supervision of RMs.
• The Care Quality Commission (CQC), ensuring adherence to regulatory requirements.
• Any prospective applicants seeking to become a Registered Manager within the organisation.

It covers:

• Legal requirements and eligibility criteria for Registered Managers.
• Core responsibilities and expectations of an RM.
• Recruitment, appointment, and induction process.
• Mandatory training and continuous professional development (CPD).
• Performance monitoring and compliance assurance.
• Disciplinary measures and managing underperformance.

3. Legal and Regulatory Framework

This policy aligns with the following laws and regulations:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 7 (Requirements relating to Registered Managers).
• Care Quality Commission (CQC) Fundamental Standards – Ensures that care services are safe, effective, and well-led.
• CQC Key Lines of Enquiry (KLOEs) – Defines expectations for leadership and service management.
• The Fit and Proper Persons Requirement (FPPR) – Regulation 5 – Ensures that RMs are competent and suitable for their role.
• Fit and Proper Persons:
  • Regulation 7 (Requirements relating to Registered Managers) – ensures the regulated activity is managed by a person who is of good character, has the necessary qualifications, competence, skills and experience, and is able to meet the requirements of the role.
  • Regulation 5 (Fit and Proper Persons: Directors) applies to directors / equivalent senior leaders of the provider, not to Registered Managers (unless the Registered Manager is also a director).
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended) – including (where relevant to the Registered Manager role) Regulations 9–20A, such as Regulation 17 (Good governance), Regulation 18 (Staffing), Regulation 19 (Fit and proper persons employed) and Regulation 20 (Duty of candour).
• Care Quality Commission (Registration) Regulations 2009 – including duties to maintain an accurate registration and to submit required notifications and information to CQC, including:
  • Regulation 14 – Notice of absence (Registered Manager absence requirements)
  • Regulation 15 – Notice of changes (changes to registered details)
  • Regulation 18 – Notification of other incidents (notifiable events)
• CQC assessment approach / Key Questions – how the service evidences performance against the five Key Questions: Safe, Effective, Caring, Responsive and Well-led, including how leadership and governance evidence is gathered, recorded and presented.
• Data protection and confidentiality – The service will comply with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018, ensuring lawful processing, secure storage, retention and appropriate sharing of information, including records relating to the Registered Manager’s appointment, suitability and ongoing compliance.

 

4. Eligibility Criteria for Registered Managers

To be appointed as a Registered Manager, individuals must meet the following requirements:

• Relevant Qualifications:
  • Hold a Level 5 Diploma in Leadership for Health and Social Care or equivalent.
  • Additional specialist qualifications relevant to care services are advantageous.
• Experience:
  • A minimum of 2 years’ experience in a managerial or supervisory role within the health and social care sector.
  • Demonstrated ability to lead teams, manage resources, and maintain regulatory compliance.
• CQC Registration Requirements:
  • Must be registered with the Care Quality Commission (CQC).
  • Provide evidence of suitability, including enhanced DBS (Disclosure and Barring Service) clearance.
  • Be able to demonstrate an understanding of CQC Key Lines of Enquiry (KLOEs).
• Suitability (Regulation 7 – Registered Managers):
  • Must pass character and competency assessments under the Fit and Proper Persons Requirement (FPPR).
  • Not be disqualified or barred from working with vulnerable adults.

Regulation 7 suitability declaration: The Registered Manager must be able to evidence that they are of good character and have the necessary qualifications, competence, skills and experience to manage the regulated activity. The Registered Manager will provide all required supporting information for the CQC application and ongoing registration requirements, including (as applicable) identity verification, right to work, full employment history, references, enhanced DBS, qualification evidence, and any required declarations relating to suitability.

5. Core Responsibilities of a Registered Manager

A Registered Manager is responsible for:

• Operational Leadership:
  • Ensuring the smooth and effective running of domiciliary care services.
  • Providing strategic direction and decision-making aligned with organisational goals.
• Regulatory Compliance and CQC Liaison:
  • Ensuring compliance with CQC Fundamental Standards and regulatory inspections.
  • Preparing for CQC inspections and responding to improvement recommendations.
• Statutory Notifications, Registration Maintenance and Information Accuracy: The Registered Manager is responsible for ensuring the service meets all notification and registration maintenance requirements under the Care Quality Commission (Registration) Regulations 2009, including timely submission of:
  • Notifiable incidents and events (as required by Regulation 18)
  • Notice of absence from the service where required (Regulation 14)
  • Notice of changes to registered details (Regulation 15)

The Registered Manager must maintain systems to ensure notifications are complete, accurate, submitted within required timescales, and supported by robust records that are retained and auditable.

• Service User Safety and Well-Being:
  • Implementing and monitoring safeguarding policies to protect service users from harm.
  • Ensuring high-quality, person-centred care is delivered at all times.
• Staff Management and Training:
  • Recruiting, supervising, and supporting care staff.
  • Conducting staff appraisals and performance evaluations.
  • Overseeing mandatory training and continuous professional development.
• Governance and Risk Management:
  • Maintaining effective governance systems that meet Regulation 17 (Good governance), including audit schedules, KPI monitoring, incident/complaint trend analysis, risk registers, action plans and documented learning.
  • Ensuring the service meets Regulation 18 (Staffing) by deploying sufficient numbers of suitably competent staff, supported by robust recruitment, induction, supervision and appraisal arrangements.
  • Ensuring the service meets Regulation 19 (Fit and proper persons employed) through safer recruitment checks, references, DBS, role competencies and ongoing suitability monitoring.

Duty of Candour (Regulation 20): The Registered Manager must ensure effective processes are in place to meet the Duty of Candour, including: identifying notifiable safety incidents, informing the relevant person in a timely way, providing a verbal apology and written follow-up, offering appropriate support, keeping a clear written record of all Duty of Candour actions, and ensuring learning and improvement actions are completed, monitored and embedded.

6. Recruitment, Appointment, and Induction Process

To ensure only competent individuals assume the role of Registered Manager, {{org_field_name}} follows a rigorous selection process:

• Job Advertisement and Shortlisting:
  • Candidates undergo a thorough application screening.
  • Shortlisted applicants complete a pre-interview assessment.
• Interview and Competency Assessment:
  • Structured interviews assess leadership skills, regulatory knowledge, and problem-solving ability.
  • Scenario-based questions test applicants’ responses to CQC compliance issues and safeguarding concerns.
• Background and Reference Checks:
  • Enhanced DBS checks are conducted before employment confirmation.
  • A minimum of two professional references are required.
• CQC Registration Submission:
  • The successful candidate must complete the CQC Registered Manager application process.
  • The organisation supports the applicant through CQC vetting and approval stages.
• Induction and Probation Period:
  • A structured 12-week induction programme ensures the new RM is fully familiar with internal processes.
  • The RM undergoes a six-month probationary review before full confirmation in post.

Registered Manager Compliance Evidence File: Prior to confirmation in post, the organisation will create and maintain a Registered Manager compliance file containing (as a minimum): proof of identity and right to work, verified qualifications, full employment history, interview and competency assessment records, two references, enhanced DBS outcome, training matrix, supervision and appraisal plan, CQC application/registration correspondence, and declarations relating to suitability and good character. This file will be reviewed at least annually and following any material change.

 

7. Mandatory Training and Continuous Professional Development (CPD)

Registered Managers are required to maintain professional competence through:

• Mandatory Training Courses:
  • Safeguarding Adults and Children.
  • Infection Prevention and Control.
  • Mental Capacity Act (MCA) 2005 – including best-interest decision-making, capacity assessments, and lawful restrictions; and where applicable, Deprivation of Liberty Safeguards (DoLS) and any successor framework implemented in law.
  • Health and Safety, Fire Safety, and Risk Management.
  • CQC regulatory framework and notifications (including Registration Regulations: absence, changes and notifiable events)
  • Duty of Candour and incident response
  • Quality governance (audit, risk, KPI oversight, learning culture and improvement planning)
• CPD and Professional Development:
  • Attendance at CQC workshops and leadership training.
  • Engagement in networking events and industry conferences.
  • Access to mentoring and coaching programmes.

8. Performance Monitoring and Compliance Assurance

To ensure continued effectiveness, RMs are subject to:

• Annual Performance Appraisals: Assessing leadership skills, compliance, and service quality.
• Quarterly Compliance Reviews: Ensuring adherence to CQC regulations and internal policies.
• Staff and Service User Feedback: Regular input from employees and service users to identify areas for improvement.

9. Registered Manager Absence and Interim Management Arrangements

Where the Registered Manager will be absent (planned or unplanned), {{org_field_name}} will implement interim management arrangements to ensure continuity of safe, well-led care and ongoing regulatory compliance.

• The Senior Management Team will appoint a suitably competent deputy/interim lead with clear documented delegated responsibilities (including safeguarding decision-making, incident oversight, complaints handling, and quality monitoring).
• Where required, the organisation will submit a Notice of Absence to CQC in line with the Care Quality Commission (Registration) Regulations 2009, and will maintain records of interim cover arrangements, handover notes and oversight actions.
• On return, the Registered Manager will complete a documented handback review, including outstanding incidents/complaints, audit actions and risk register updates.

10. Disciplinary Measures and Managing Underperformance

If an RM fails to meet regulatory or organisational expectations:

• Aperformance improvement plan (PIP) is implemented.
• Continuous non-compliance may result in CQC notification and disciplinary action.
• If required, regulatory bodies such as the DBS or CQC may be informed for further investigation.

11. Policy Review and Updates

This policy is reviewed annually or sooner if:

Significant incidents necessitate policy amendments.

CQC regulations change.

Service improvement plans require updates.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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