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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Fit and Proper Persons: Directors Policy

1. Introduction

This Fit and Proper Persons: Directors Policy explains how {{org_field_name}} ensures that all individuals who hold director-level responsibilities, or who perform equivalent functions, meet the requirements of Regulation 5 (Fit and proper persons: directors) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended. This regulation applies because {{org_field_name}} is a service provider that is a body other than a partnership. The policy sets out how we prevent the appointment and continued employment of any director who does not meet the fitness and propriety requirements, including those set out in Schedule 4 (Good character and unfit person tests), and how we evidence this to the Care Quality Commission (CQC).

2. Policy Statement

{{org_field_name}} is committed to ensuring that all individuals appointed to director-level roles, including those performing the functions of, or equivalent to, a director, are and remain fit and proper to carry out their duties. In line with Regulation 5, we will not appoint or continue to employ any such individual unless:

• they are of good character;
• they have the necessary qualifications, competence, skills and experience for the role;
• they are able, with any reasonable adjustments, to perform the intrinsic duties of the role by reason of their health;
• they have not been responsible for, privy to, contributed to, or facilitated serious misconduct or mismanagement in the course of carrying on a regulated activity or a similar service; and
• none of the grounds of unfitness in Part 1 of Schedule 4 apply to them.

{{org_field_name}} will ensure that robust recruitment, assessment and ongoing review processes are in place so that all directors continue to meet these requirements throughout their appointment. Where concerns arise, we will act promptly, proportionately and in accordance with this policy, CQC guidance and relevant employment law.

3. Purpose

Under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, a director or equivalent individual must:

• be of good character, having regard to the matters in Part 2 of Schedule 4;
• have the qualifications, competence, skills and experience necessary for the role;
• be able, with reasonable adjustments where required, to perform the intrinsic duties of the role by reason of their physical and mental health;
• not have been responsible for, been privy to, contributed to, or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or a similar service; and
• not meet any of the “unfit person” criteria set out in Part 1 of Schedule 4 (for example, certain insolvency, bankruptcy, barring or prohibition conditions).

Regulation 5 also requires {{org_field_name}} to:

• follow robust processes and gather all available information when assessing a person’s fitness and character;
• ensure that the information specified in Schedule 3, and other relevant information, is available for each director and can be supplied to CQC on request; and
• take necessary and proportionate action, including notifying relevant professional regulators, if a director ceases to meet the fitness and propriety requirements.

4. Regulatory Requirements

Under Regulation 5, a director or equivalent individual must:

• Be of good character.
• Have the necessary qualifications, competence, skills, and experience for the role.
• Be able to perform their tasks effectively, with reasonable adjustments if required.
• Not have been responsible for any serious misconduct or mismanagement.
• Meet the requirements specified in Schedule 4 of the Health and Social Care Act 2008.

5. Recruitment and Appointment Procedures

To ensure that all appointments meet the Fit and Proper Persons criteria, our recruitment process for director-level roles includes the following steps:

5.1 Pre-Recruitment Assessment

• Role Definition: Each director-level position is clearly defined, including key responsibilities and required qualifications, skills, and experience.
• Job Description: Detailed job descriptions and person specifications are developed, ensuring alignment with CQC requirements.

Role definitions and person specifications for director posts explicitly reflect the requirements of Regulation 5 and Schedule 4, including expectations around good character, financial integrity, leadership behaviour and track record in relation to quality, safety and governance.

5.2 Robust Recruitment Process

• Application Review: All applications are screened to ensure candidates meet the required qualifications and experience.
• Interviews: Structured interviews assess the candidate’s competence, character, and suitability for the role.
• Competency Assessment: Candidates are evaluated against the core competencies required for leadership roles in health and social care settings.

5.3 Background Checks

To evidence compliance with Regulation 5 and Schedule 3 and 4 requirements, {{org_field_name}} will undertake the following checks for all prospective directors and, where appropriate, for existing directors:

• Disclosure and Barring Service (DBS) Checks: Enhanced DBS checks will be obtained (including barred list checks where the role involves regulated activity) to identify any criminal history or inclusion on adults’ or children’s barred lists.
• Identity and Right to Work: Verification of identity and legal right to work in the UK.
• Professional Registration and Status: Confirmation of registration with relevant professional bodies (where applicable), and checks for any erasure, suspension, conditions, or fitness to practise concerns.
• Employment History and References: Comprehensive review of at least the previous 10 years’ employment history (or from leaving full-time education), including references that specifically address conduct, integrity, performance in relation to quality and safety, and any involvement in serious misconduct or mismanagement.
• Financial Integrity and Insolvency Checks: Checks for bankruptcy, individual voluntary arrangements, debt relief orders, sequestration, and any disqualification or prohibition from acting as a company director, charity trustee or equivalent position, in line with the Schedule 4 unfit person criteria.
• Other Relevant Checks: Any other checks that may reasonably be required to assess fitness, such as checks with previous regulators, commissioners or oversight bodies where the director has previously held a similar role.

Where adverse information is identified, {{org_field_name}} will document the details, the assessment undertaken, and clear reasons for any decision to appoint or continue to employ the individual, in line with CQC guidance.

6. Ongoing Monitoring and Reassessment

{{org_field_name}} recognises that ensuring fitness and propriety is an ongoing obligation. Therefore, we implement the following measures:

6.1 Annual Declarations

• Directors are required to complete an annual Fit and Proper Person Declaration, confirming continued compliance with Regulation 5 requirements.
• This declaration includes disclosures related to criminal convictions, professional misconduct, and health issues affecting their ability to perform the role.

Where an annual declaration reveals new information that may affect a director’s fitness (for example, new criminal proceedings, professional sanctions, serious complaints or financial issues), {{org_field_name}} will initiate a formal FPPR review in line with Section 7 of this policy and Regulation 5(6).

6.2 Performance Monitoring

• Regular performance appraisals assess the director’s effectiveness in their role.
• Any concerns identified during appraisals are addressed promptly, with appropriate support or remedial action.

Appraisals will explicitly consider how each director promotes a well-led, open, inclusive and learning culture consistent with the CQC single assessment framework for “Well-led”, including the Nolan principles of public life.

6.3 Whistleblowing and Incident Reporting

• Staff and stakeholders are encouraged to report any concerns regarding the fitness of a director through our Whistleblowing Policy.
• Any reported concerns are investigated promptly and thoroughly.

All FPPR concerns raised through whistleblowing, complaints or incident reporting will be triaged and, where appropriate, investigated under this policy using an evidence-based and fair process. Outcomes and any actions taken will be documented and can be shared with CQC on request.

6.4 Health and Wellbeing

• Reasonable adjustments are made for directors with health conditions to ensure they can perform their duties effectively.
• Occupational health assessments are conducted where necessary.

Decisions about fitness related to health will focus on the director’s ability, with reasonable adjustments, to perform the intrinsic duties of the role, in line with Regulation 5(3)(c) and the Equality Act 2010.

7. Managing Non-Compliance

If concerns arise that a director may no longer meet the Fit and Proper Persons requirements, {{org_field_name}} will:

1. Initiate an Investigation: Promptly commission a fair, thorough and proportionate investigation into the concerns, gathering relevant evidence (for example, complaint outcomes, regulatory findings, employment records).
2. Risk Management: Consider interim measures to protect people using the service and the organisation (for example, temporary restrictions on duties, supervision, or suspension), based on a documented risk assessment.
3. Decision-Making: Convene an appropriately constituted decision-making panel (for example, a sub-committee of the Board) to review the evidence, consider any representations from the individual, and determine whether the Regulation 5 requirements are still met.
4. Support and Remediation: Where appropriate, agree remedial actions (such as further training, mentoring or adjusted duties) and set clear timescales for review, recording reasons where the director is retained despite relevant adverse information.
5. Removal from Role: Where the individual is found not to meet the Regulation 5 requirements and remediation is not possible or appropriate, {{org_field_name}} will remove them from the director role and ensure that the office or position is held by an individual who is fit and proper, in line with Regulation 5(6)(a).
6. Notification of Regulators: Where the director is registered with a professional regulator (for example, NMC, GMC, HCPC, Social Work England), {{org_field_name}} will notify the regulator where required by Regulation 5(6)(b) or relevant professional standards.
7. Notification of CQC and Other Bodies: Where required, we will notify CQC and any other relevant bodies (such as commissioners, funders or Companies House/Charity Commission) of the outcome of FPPR investigations and actions taken.

All FPPR investigations, decisions and actions will be fully documented and retained in line with Section 8 of this policy.

8. Record-Keeping and Documentation

{{org_field_name}} will maintain comprehensive and up-to-date FPPR records for all individuals who hold, or are appointed to, director-level roles or equivalent positions. These records will include, as a minimum:

• application forms and CVs;
• role descriptions and person specifications;
• interview notes and competency assessments;
• DBS certificates and barred-list check outcomes (where applicable);
• evidence of identity and right to work in the UK;
• professional registration details and fitness-to-practise status (where applicable);
• full employment history and written references, including specific comments on conduct and performance;
• annual Fit and Proper Person Declarations and any associated investigation reports;
• training, appraisal and supervision records; and
• any other information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that is relevant to the individual.

These records will be stored securely, retained for appropriate periods, and be readily available for inspection by CQC or other regulators on request, in accordance with Regulation 5(5).

9. Training and Awareness

{{org_field_name}} will ensure that:

• all Board members, including executive and non-executive directors, receive induction and periodic refresher training on the Fit and Proper Persons requirements, Schedule 4 criteria, and how these link to our duties under the Health and Social Care Act 2008 and CQC’s fundamental standards;
• staff involved in recruiting, appraising and managing directors receive specific training on safe, values-based and inclusive recruitment, the interpretation of “serious misconduct or mismanagement”, handling FPPR concerns, and documenting decisions;
• FPPR training for directors links to wider leadership development, including the CQC “Well-led” expectations, the Nolan principles of public life and equality, diversity and inclusion responsibilities; and
• training records are maintained and monitored to ensure ongoing compliance.

Training content will be reviewed regularly and updated to reflect any changes in legislation, CQC guidance or best practice.

10. Accountability and Governance

Our Registered Manager and Board of Directors hold overall responsibility for ensuring compliance with this policy. This includes:

• Ensuring robust recruitment and monitoring processes are in place.
• Reviewing compliance as part of our governance and quality assurance framework.
• Reporting any non-compliance to the CQC as required.
• ensuring that FPPR compliance and any FPPR concerns are reported regularly through our governance structure (for example, to the Board or a nominated committee), and that these reports are available as evidence of compliance with Regulation 5 and the CQC Well-led quality statements.

11. Equality and Diversity

Our recruitment and monitoring practices promote equality, diversity, and inclusion. No individual is disadvantaged based on age, disability, gender, race, religion, sexual orientation, or any other protected characteristic.

12. Audit and Review

This policy is reviewed annually or sooner if there are changes to CQC regulations or organisational practices. Regular audits assess the effectiveness of our processes, and findings inform continuous improvement.

Each review of this policy will include a check against the latest version of:

• Regulation 5 and Schedules 3 and 4 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; and
• CQC guidance on Regulation 5 and the single assessment framework for “Well-led”,
  to ensure ongoing compliance with current legislation and regulatory expectations. Any changes will be approved through the governance route described in Section 14.

13. Conclusion

{{org_field_name}} is committed to ensuring that all directors meet the highest standards of conduct, competence, and accountability. This policy reflects our dedication to safeguarding service users, promoting good governance, and maintaining compliance with CQC Regulation 5.

14. Schedule 4 Good Character and Unfit Person Tests

Regulation 5 requires {{org_field_name}} to have regard to the “unfit person” test in Part 1 of Schedule 4 and to consider the “good character” matters in Part 2 of Schedule 4 when assessing directors. In summary:

14.1 Unfit person test (Part 1)
A person will normally be considered unfit to hold a director role if, for example, they:

• are an undischarged bankrupt or subject to certain insolvency or debt-relief restrictions;
• have made arrangements with creditors and not yet been discharged from them;
• are included on the adults’ or children’s barred lists under the Safeguarding Vulnerable Groups Act 2006 or any equivalent list; or
• are prohibited or disqualified from holding the relevant office or position under any enactment (for example, company director or charity trustee disqualification).

14.2 Good character (Part 2)
When assessing whether a person is of good character, {{org_field_name}} will have particular regard to:

• any criminal convictions (in the UK or elsewhere) that would constitute an offence in the UK; and
• whether the person has been erased, removed or struck off from a register of health or social care professionals.

These criteria will be considered alongside other information about a person’s honesty, integrity, reliability, respectfulness and track record in leadership and governance. Where concerns exist but the organisation judges the individual to be suitable, the rationale for this decision will be clearly recorded.

15. Approval and Review

This policy will be reviewed annually. Any updates will be communicated to all relevant staff and stakeholders.

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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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