{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Fit and Proper Persons: Employed Staff Policy

1. Purpose

This policy outlines the steps taken by {{org_field_name}} to ensure that all employees meet the legal and regulatory requirements set by Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The policy ensures that all employed persons are fit and proper to provide care and support to individuals who use our supported living services.

Regulation 19(3) also requires that the information set out in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is obtained and retained for every person employed for the purposes of carrying on a regulated activity and is available for inspection by the Care Quality Commission (CQC) on request.

We are committed to ensuring that only suitable individuals, possessing the necessary character, qualifications, skills, and experience, are employed and retained within our organisation. This policy also sets out our governance processes to ensure ongoing compliance and how we proactively manage potential concerns regarding staff suitability.

2. Scope

This policy applies to:

• All employees, including permanent, temporary, and agency workers who provide direct or indirect care and support.
• Volunteers and contracted professionals working within our services.
• Senior management and leadership teams, including those with oversight of care delivery.
• HR, recruitment, and governance teams responsible for hiring, training, and ongoing compliance.
• The Care Quality Commission (CQC), in relation to our adherence to regulatory standards.

All individuals working within our supported living services must meet the requirements outlined in this policy to ensure the safety, dignity, and well-being of our service users.

For the purposes of Regulation 19, “person employed” is interpreted broadly and includes people engaged under a contract, otherwise than under a contract, agency/bank staff, volunteers and contractors. In practice, Schedule 3 information will be required for the majority of (and potentially all) roles, including those who do not provide direct care, where they are employed for the purposes of carrying on the regulated activity.

3. Legal and Regulatory Framework

This policy aligns with key regulations and legal frameworks, including:

• Regulation 19: Fit and Proper Persons Employed – Ensuring the fitness and suitability of all employees.
• Regulation 18: Staffing – sufficient numbers of suitably qualified, competent, skilled and experienced staff, supported through supervision, training and development.
• Regulation 21: Records – secure, accurate, complete and contemporaneous records, including recruitment checks and evidence.
• Regulation 17: Good governance – systems and audits to monitor compliance with safe recruitment requirements and take action where shortfalls are found.
• Regulation 5: Fit and Proper Persons: Directors – Ensuring senior leaders meet governance requirements.
• Care Act 2014 – Protecting vulnerable adults and ensuring high standards of care.
• Equality Act 2010 – Preventing discrimination in employment and ensuring fair recruitment practices.
• CQC Fundamental Standards – Setting the expectations for quality care and workforce competence.
• CQC Single Assessment Framework (SAF) – particularly the “Safe and effective staffing” quality statement, which expects robust safe recruitment (including DBS), fair recruitment processes, and ongoing supervision, appraisal and development.

Compliance with these frameworks ensures that our organisation only employs individuals who can deliver high-quality, safe, and person-centred care.

4. Recruitment and Selection Process

To ensure that only suitable candidates are appointed, {{org_field_name}} has a rigorous recruitment and selection process, which includes:

• Clearly Defined Job Descriptions and Person Specifications: Each role within the organisation has a clearly defined job description that includes the competencies, values, and qualifications required.
• Comprehensive Interview Process: All candidates undergo structured, competency-based interviews to assess their suitability for the role and their commitment to high-quality care.
• Assessing “good character”: In determining good character, we consider all relevant information available to us, including convictions/cautions (where disclosed/identified), employment conduct, disciplinary history, safeguarding concerns, and any professional regulator findings, and we document the rationale for appointment decisions—particularly where information is identified that may indicate risk.
• Disclosure and Barring Service (DBS) Checks (appropriate level): We obtain the appropriate DBS check for the role and eligibility (standard/enhanced/enhanced with barred list information, as applicable). We record the type of check requested and received, whether barred list information was included (where eligible), the date, and the decision/rationale following review of the outcome and any risk assessment.
• Verification of Professional Qualifications and Registrations: All required qualifications and accreditations are verified before employment commences.
• Employment History and References: A minimum of two references, including from the most recent employer, are obtained and verified.
• Right to Work in the UK Verification: Compliance with immigration laws to ensure all employees have legal employment status.

By implementing these robust recruitment measures, we ensure that only competent and suitable individuals are employed to deliver care.

4.1 Schedule 3 mandatory information

For each person employed for the purposes of carrying on the regulated activity, we obtain and retain the following Schedule 3 information and make it available to CQC on request:

1. Proof of identity, including a recent photograph.
2. DBS certificate information (standard) where required and eligible.
3. Enhanced DBS certificate information where required and eligible, including children’s/vulnerable adults’ suitability information where applicable.
4. Satisfactory evidence of conduct in previous employment relating to health/social care and/or work with children/vulnerable adults.
5. Where previously employed in a role involving children/vulnerable adults, verification (so far as reasonably practicable) of the reason employment ended.
6. Documentary evidence of relevant qualifications (so far as reasonably practicable).
7. Full employment history with a written explanation of any gaps.
8. Information about relevant physical/mental health conditions relating to capability (after reasonable adjustments) to perform intrinsic role tasks.

4.2 Starting work before DBS clearance (exception only)

As a rule, staff must not work unsupervised until the required DBS clearance is received and assessed. Where an urgent start is considered, this will be exceptional, time-limited, and subject to a documented risk assessment approved by a senior manager. Controls will include (as applicable): direct supervision, restricted duties, no lone working, and obtaining any available safeguarding checks (for example, barred list-related information where eligible) and confirmation of identity and references before any contact with people we support. The rationale and safeguards will be recorded on the person’s recruitment file.

5. Induction and Mandatory Training

Once recruited, all staff must complete a structured induction and training programme to ensure they are fully equipped for their role. This includes:

• Understanding CQC Regulations and Compliance: Training on the CQC Fundamental Standards and how they apply to their responsibilities.
• Safeguarding Training: Ensuring all staff can identify and report abuse in accordance with safeguarding legislation.
• Person-Centred Care Training: Educating staff on how to tailor care plans to individual service user needs.
• Health and Safety Training: Covering risk assessment, infection control, and emergency response procedures.
• Confidentiality, Data Protection, and GDPR Compliance: Training on handling service user information safely and legally.
• Equality, Diversity, and Inclusion Training: Ensuring a workplace free from discrimination and bias.

Staff must complete all induction training before commencing their duties and undertake refresher training annually.

No staff member will work unsupervised until they have been assessed as competent for their role. Where the Care Certificate is applicable, we use it (or an equivalent structured framework) to support and evidence initial competence and ongoing development.

6. Ongoing Compliance and Performance Monitoring

To maintain high standards and regulatory compliance, we implement the following monitoring measures:

• Annual Performance Appraisals: All employees undergo a structured performance review assessing their competence, conduct, and development needs.
• Regular Supervision and Support Meetings: Staff meet with their line managers at least quarterly for guidance and feedback.
• Mandatory Refresher Training: Employees must complete refresher training annually to stay updated with the latest care practices and regulations.
• Professional registration and revalidation monitoring: Where roles require registration (e.g., NMC/HCPC/Social Work England), we verify registration before start, record the evidence, and monitor status/revalidation at agreed intervals (and/or through online checks). Where a registered professional’s fitness, conduct or competence is called into question and regulatory referral thresholds are met, we will notify the relevant professional regulator in line with Regulation 19(5).
• Whistleblowing and Incident Reporting: An open, transparent system for staff to report concerns about their colleagues or work environment.
• Regular Internal and External Audits: Audits assess compliance with legal and organisational standards, ensuring continuous quality improvement.

By monitoring staff performance and compliance, we ensure that all employees remain fit for their role and uphold the highest standards of care.

7. Managing Concerns About Staff Fitness

If concerns arise regarding an employee’s fitness to perform their role, {{org_field_name}} follows a structured process:

• Investigation: A thorough assessment of the concerns, including interviews and evidence collection.
• Risk Assessment: Evaluating the potential impact on service users and the organisation.
• Support and Training Plans: Where possible, additional training, mentoring, or role adjustments are provided to address concerns.
• Disciplinary Action: If an employee continues to pose a risk, disciplinary action may be taken, including suspension or termination.
• External notifications (CQC / safeguarding / professional regulators): Where concerns about a staff member result in, or relate to, an incident that is notifiable to CQC, we will submit a notification without delay in line with Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (Notification of other incidents). Where safeguarding thresholds are met, we will also notify the relevant Local Authority safeguarding team and/or police as required. Where the individual is a registered professional and the concern indicates potential impairment of fitness to practise, we will consider and make a referral to the relevant professional regulator in line with Regulation 19(5).

Our proactive approach ensures that any concerns regarding staff suitability are addressed promptly and effectively.

8. Recruitment Records, Storage and Audit

We maintain a secure recruitment and employment record for each person employed for the purposes of carrying on the regulated activity. This file contains all information required under Regulation 19 and Schedule 3, plus any additional records required by law.

Recruitment files must show a clear audit trail including: what checks were completed, by whom, on what date, what was seen/verified, and the decision made.

We complete routine audits of recruitment files (minimum quarterly) to confirm that Schedule 3 evidence is complete and current, and we take prompt corrective action where gaps are found. Audit outcomes are reviewed through governance meetings and used to improve recruitment processes and reduce risk.

9. Related Policies

This policy should be read in conjunction with:

• Fit and Proper Persons: Directors Policy – Ensuring governance at senior levels.
• Good Governance Policy – Ensuring organisational compliance and oversight.
• Recruitment, Selection, and Retention Policy – Detailing robust hiring processes.
• Safeguarding Adults from Abuse and Improper Treatment Policy – Ensuring the protection of service users.
• Whistleblowing (Speaking Up) Policy – Providing a transparent way for staff to raise concerns.
• Health and Safety at Work Policy – Ensuring a safe working environment.

10. Policy Review

This policy will be reviewed annually or earlier if required due to legislative changes, regulatory updates, or organisational needs. Any amendments will be communicated to staff, stakeholders, and CQC to ensure continued compliance.

---

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.