SL03-Requirements for Registered Managers Policy

Registration Number: {{org_field_registration_no}}

Requirements for Registered Managers Policy

1. Purpose

The purpose of this policy is to ensure that our organisation complies with Regulation 7 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This policy outlines the requirements for appointing and maintaining a competent, qualified, and fit Registered Manager to oversee the regulated activities of our supported living service.

This policy ensures that service users receive high-quality, person-centred care through effective leadership and management, promoting safety, dignity, and respect at all times. A well-qualified and experienced Registered Manager ensures that the organisation meets its legal obligations and maintains a safe and effective service.

2. Scope

This policy applies to:

The Registered Manager of {{org_field_name}}, who is responsible for the day-to-day management of regulated activities.
The Nominated Individual, who supervises the management of the regulated activity and ensures compliance.
Directors and senior management involved in the recruitment, selection, and oversight of the Registered Manager.
All staff who report to and work under the direction of the Registered Manager, ensuring that the service operates within legal and regulatory frameworks.

3. Legal and Regulatory Framework

This policy aligns with the following legislation and standards:

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 7 – Requirements for Registered Managers.
Regulation 5: Fit and Proper Persons (Directors) – Ensuring that directors and senior managers responsible for service governance meet suitability standards.
Regulation 19: Fit and Proper Persons (Employed Staff) – Ensuring that all employees, including the Registered Manager, meet suitability criteria.
Care Act 2014 – Ensuring high standards of care and regulatory compliance.
CQC Fundamental Standards, which outline expectations for service delivery and leadership.

4. Appointment and Competency of the Registered Manager

A Registered Manager will be appointed in accordance with Regulation 7 and must demonstrate the following criteria:

Good Character – A thorough background check, including an enhanced Disclosure and Barring Service (DBS) check, must be completed. References from previous employers and regulatory bodies must be obtained and assessed for reliability.
Qualifications, Competence, Skills, and Experience – The Registered Manager must possess leadership qualifications such as the Level 5 Diploma in Leadership for Health and Social Care and Children and Young People’s Services (Adults’ Management Pathway) or an equivalent qualification. In addition, they must demonstrate substantial experience in managing health and social care services, preferably within a supported living setting.
Fitness to Perform the Role – The Registered Manager must be physically and mentally fit to manage the service effectively. Reasonable adjustments will be considered where necessary to support them in performing their duties.
Regulatory Compliance – The Registered Manager must ensure that all CQC requirements are met and that documentation related to their fitness for the role, as outlined in Schedule 3 of the Regulations, is available and up to date.

5. Recruitment and Induction Process

To ensure compliance with Regulation 7, our recruitment process for a Registered Manager includes:

A structured interview process to evaluate leadership capabilities, regulatory knowledge, and alignment with organisational values.
Enhanced DBS checks to identify any criminal history that may impact their suitability for the role.
Verification of professional qualifications and evidence of ongoing professional development.
Reference checks from at least two previous employers within the health and social care sector.
A comprehensive induction programme that includes training on CQC compliance, safeguarding, health and safety, governance, person-centred care, and leadership responsibilities.

6. Ongoing Compliance and Performance Monitoring

To ensure that the Registered Manager continues to meet regulatory and organisational expectations, we implement the following:

Annual Performance Reviews – These assess leadership, service quality, staff management, and regulatory compliance.
Regular Supervision and Support Meetings – The Nominated Individual conducts monthly reviews with the Registered Manager to monitor progress and address any concerns.
Mandatory Training and CPD (Continuing Professional Development) – The Registered Manager must complete ongoing training on key regulatory areas, including safeguarding, health and safety, Mental Capacity Act 2005 compliance, and data protection.
Service Quality Audits – Routine audits ensure that the service remains compliant with legal and operational requirements. The Registered Manager must address any deficiencies promptly.
CQC Notifications – The Registered Manager is responsible for ensuring that all serious incidents, safeguarding concerns, and regulatory notifications are submitted in a timely manner.

7. Managing Absences and Contingency Planning

Under Regulation 14 (Notice of Absence), the organisation must notify CQC when the Registered Manager is absent for 28 days or more. To ensure continuity of service, the following measures will be in place:

Deputy Manager or Interim Cover – A Deputy Manager will be appointed to oversee the service in the Registered Manager’s absence.
CQC Notification and Contingency Plan – The organisation will formally notify CQC of the absence and provide a structured plan detailing how the service will be managed during this period.
Handover Procedures – Detailed handover notes and access to key documentation will be provided to the interim manager.

8. Removal or Replacement of the Registered Manager

If a Registered Manager is deemed unfit for their role due to incompetence, misconduct, or other factors, the organisation will take the following steps:

Risk Assessment and Investigation – A full internal investigation will be conducted to determine the circumstances surrounding the concerns.
Immediate Action if Service User Safety is at Risk – If there is an immediate risk to service users, appropriate safeguards will be implemented, including suspension of duties if necessary.
Regulatory Notification – CQC will be informed if the removal of the Registered Manager is due to safety, competence, or legal concerns.
Recruitment of a New Registered Manager – The organisation will seek a suitable replacement within a reasonable timeframe to ensure continuity of leadership.

9. Related Policies

This policy should be read alongside:

Fit and Proper Persons: Directors Policy – Ensuring the suitability of senior leadership roles.
Fit and Proper Persons: Employed Staff Policy – Ensuring all employees meet fitness standards.
Good Governance Policy – Maintaining regulatory compliance and service quality.
Recruitment, Selection, and Retention Policy – Outlining robust recruitment procedures.
Safeguarding Adults from Abuse and Improper Treatment Policy – Ensuring the safety and dignity of service users.
Notification of Other Incidents Policy – Detailing mandatory reporting requirements.

10. Policy Review

This policy will be reviewed annually or earlier if there are changes in legislation, CQC regulations, or organisational needs. Any updates will be communicated to staff, stakeholders, and CQC to ensure continued compliance and operational efficiency.

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.