CH03-Requirements for Registered Managers Policy
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{{org_field_name}}
Registration Number: {{org_field_registration_no}}
Requirements for Registered Managers Policy
1. Introduction
This policy explains how {{org_field_name}} appoints, supports and oversees a registered manager for its care home in England. It reflects Regulation 7 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, current Care Quality Commission (CQC) registration guidance and the registered manager’s continuing legal responsibilities. The registered manager and provider share responsibility for compliance with the regulations, although each remains accountable for duties placed upon them as a registered person.
2. Policy statement
{{org_field_name}} will ensure that the person responsible for the day-to-day management of regulated activities is registered with CQC where registration is required, is fit for the role and receives the authority, time, information and resources needed to manage the service safely. The organisation will not treat registration as a one-off recruitment check: suitability, competence, conduct, health-related capability and compliance will be monitored throughout the appointment.
3. Scope
This policy applies to:
• the provider, nominated individual and directors or equivalent office holders;
• the registered manager and any person applying to become registered manager;
• deputy, interim and acting managers;
• senior leaders responsible for supervision or oversight of the manager; and
• staff who support registration, governance, recruitment, notifications and regulatory compliance.
An acting, interim or deputy manager is not automatically a registered manager. The provider will determine whether a CQC application or notification is required and will not describe a person as registered until CQC confirms registration.
4. Legal and regulatory framework
This policy must be read with the current versions of:
• Health and Social Care Act 2008;
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, particularly Regulations 4, 5, 7, 17, 18, 19 and 20 and Schedules 3 and 4;
• Care Quality Commission (Registration) Regulations 2009, including Regulations 12, 14, 15, 16 and 18 as applicable;
• Safeguarding Vulnerable Groups Act 2006 and Protection of Freedoms Act 2012;
• Rehabilitation of Offenders Act 1974 and the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975;
• Equality Act 2010;
• Immigration, Asylum and Nationality Act 2006 and current Home Office right to work guidance;
• Data Protection Act 2018 and UK General Data Protection Regulation; and
• current CQC registration, Regulation 7, assessment and notification guidance.
5. When a registered manager is required
A person must register as manager where they are in charge of the day-to-day running of regulated activities for an organisation or partnership, or for an individual provider who is not personally responsible for day-to-day management. More than one manager may be registered for the same location or activity where the management arrangements require this, including an appropriate job-share arrangement.
The provider will ensure that its registration, statement of purpose, location arrangements and management structure accurately identify who manages each regulated activity. Where there is a vacancy, planned change or temporary arrangement, the provider will promptly assess the registration and notification steps required and will maintain safe management oversight.
6. Regulation 7 fitness requirements
A registered manager must:
• be of good character;
• have the qualifications, competence, skills and experience necessary to manage the regulated activity; and
• be able, by reason of their health and after reasonable adjustments are made, to perform properly the tasks that are intrinsic to the role.
When assessing good character, the matters in Part 2 of Schedule 4 must be considered. These include relevant convictions and whether the person has been responsible for, contributed to, facilitated or been privy to serious misconduct or mismanagement in the course of carrying on a regulated activity. Such information must be assessed fairly and in context; the policy does not create an automatic exclusion unless the law requires one.
The Regulation 7 requirements do not apply to the extent specified in Regulation 7(3) where the registered manager is also the service provider and Regulation 4 applies. Legal advice or CQC guidance will be sought where the correct regulatory route is uncertain.
7. Roles and responsibilities
7.1 Provider and nominated individual
The provider and nominated individual will:
• appoint a suitable person and support a timely, accurate CQC application;
• confirm that all safer recruitment and suitability checks are complete;
• give the manager sufficient authority, resources, staffing information and access to governance systems;
• set clear accountability and escalation arrangements without obstructing the manager’s statutory duties;
• provide supervision, appraisal, wellbeing support and professional development;
• monitor continuing fitness and act promptly on concerns;
• ensure cover and notification arrangements during absence, vacancy or change; and
• maintain effective oversight under Regulation 17 without transferring all provider accountability to the manager.
7.2 Registered manager
The registered manager will:
• manage the regulated activities in accordance with legislation, conditions of registration and the statement of purpose;
• promote safe, effective, caring, responsive and well-led services;
• maintain effective systems for safeguarding, staffing, medicines, infection prevention, complaints, incidents, consent, mental capacity, risk and quality assurance;
• ensure statutory notifications are accurate, complete and submitted within the required timescales;
• co-operate openly with CQC and other lawful investigations;
• escalate risks that cannot be resolved within their authority;
• maintain their own competence, professional registration and continuing fitness; and
• inform the provider and CQC promptly of matters that require notification or may affect registration.
8. Recruitment and appointment
8.1 Role definition and selection
• The job description and person specification will identify the regulated activities, locations, service-user groups, conditions of registration and responsibilities attached to the post.
• Selection will test leadership, relevant management experience, service-specific knowledge, safeguarding, mental capacity, complaints, medicines, workforce, governance and regulatory understanding.
• The candidate must demonstrate the ability to meet the needs and age ranges of people using the service and to manage the specific regulated activities for which registration is sought.
• Any potential conflict of interest, external commitment or span-of-control concern will be assessed and recorded.
8.2 Pre-appointment checks
Before appointment and application, the provider will obtain, verify and record the checks required by Regulation 19 and Schedule 3, together with CQC application requirements. These include, as applicable:
• Identity: satisfactory proof of identity, including a recent photograph.
• Employment history: a full work history from age 16 for the CQC application and satisfactory written explanations for gaps, including the current CQC requirement to explain gaps exceeding four weeks.
• Conduct and references: satisfactory evidence of conduct in relevant previous employment, including verification with the last employer and appropriate professional or regulatory checks.
• DBS: a current enhanced DBS check that meets CQC’s application requirements and any applicable barred-list eligibility. The provider will not rely on a fixed renewal interval as though DBS certificates had a statutory expiry date.
• Qualifications: original or otherwise verifiable evidence of qualifications and training relevant to the service and role.
• Experience and competence: evidence of relevant management experience, recent regulated-service experience where available, knowledge of the service type and ability to lead safe care.
• Health: role-related information sufficient to assess ability to perform intrinsic duties after reasonable adjustments, obtained and used in accordance with the Equality Act 2010.
• Right to work: a compliant check completed before employment and follow-up monitoring where permission is time limited.
• Professional registration: direct verification of current registration and any conditions, cautions or restrictions where the role or title requires registration.
• Overseas history: proportionate overseas criminal record or good-conduct evidence and further verification where relevant and reasonably obtainable.
Adverse, incomplete or conflicting information will be assessed through a documented, individual risk assessment. Decisions will consider relevance, seriousness, pattern, time elapsed, openness, evidence of rehabilitation, the duties of the role and the safeguards available. A disclosed conviction will not automatically determine the outcome unless a legal prohibition applies.
9. CQC application and registration
• The correct CQC registered-manager application route will be used for the provider’s circumstances.
• The application will be complete, accurate and consistent with the provider application, statement of purpose and regulated activities at the location.
• The applicant will supply the evidence requested by CQC, including GP and last-employer details, qualifications and training information, work history and the DBS evidence specified in current CQC guidance.
• The provider will support the applicant to prepare for CQC’s assessment or interview while ensuring answers reflect the applicant’s own knowledge, judgement and experience.
• The applicant must not provide false or misleading information and must disclose relevant changes while the application is being considered.
• The person will not manage regulated activities as the registered manager until CQC confirms registration. Any interim management arrangement will be lawful, risk assessed, clearly accountable and notified to CQC where required.
• The registration decision, regulated activities, locations and any conditions will be checked and retained before the appointment is treated as confirmed.
10. Qualifications and development
The manager must have, or be able to develop within an agreed and supported timeframe, the qualifications and level of competence appropriate to the service. Current CQC guidance indicates that a Level 5 Diploma in Leadership and Management or equivalent strengthens an application; the current adult social care workforce pathway expects registered managers to hold or work towards relevant Level 5 competence. The provider will not describe a recommended qualification as a universal statutory prerequisite where the law or CQC has not made it one.
A documented development plan will address any gap in qualifications, regulatory knowledge or service-specific competence. It will state the learning required, timescale, supervision, restrictions, evidence of achievement and review arrangements.
11. Induction and handover
The registered manager will receive a structured, service-specific induction and handover covering:
• people’s needs, risks, rights, communication preferences and current safeguarding matters;
• staffing, vacancies, competence, supervision and workforce risks;
• medicines, infection prevention, health and safety and emergency arrangements;
• complaints, incidents, duty of candour, notifications and open investigations;
• Mental Capacity Act 2005, consent, restrictive practices and deprivation of liberty arrangements;
• quality assurance, audits, action plans, provider oversight and CQC history;
• conditions of registration, statement of purpose and local commissioning requirements;
• budgets, resources, business continuity and delegated authority; and
• information governance and access to essential systems and records.
Completion of training alone will not be treated as evidence of competence. Competence will be assessed through discussion, observation, review of decisions and records, and delivery against agreed objectives.
12. Supervision, appraisal and continuing fitness
The provider will monitor and support the manager through arrangements proportionate to the service’s risks and complexity, including:
• planned one-to-one supervision at an agreed frequency and additional supervision after significant events;
• formal appraisal at least annually, with interim objective and development reviews;
• review of leadership, culture, staffing, safeguarding, complaints, incidents, notifications, governance and outcomes for people;
• monitoring of professional registration, right to work and any relevant DBS or suitability information;
• continuing professional development and reflective practice;
• wellbeing, workload, span of control, absence and reasonable-adjustment reviews; and
• documented action plans with named support, timescales and evidence of completion.
13. Statutory notifications and changes
The provider and registered manager will maintain a notifications schedule and clear delegation arrangements. Delegation of administration does not remove the registered person’s legal responsibility to ensure a required notification is made.
• A planned absence of a registered person lasting 28 days or more will be notified to CQC at least 28 days before it begins, unless CQC agrees a shorter period.
• An emergency absence of 28 days or more will be notified within five working days of the start of the absence. If the absence was not previously notified when required, CQC will be told without delay.
• CQC will be told of the registered person’s return from a notified absence within seven days.
• The absence notification will explain the reason, expected duration and arrangements for managing the regulated activity safely during the absence.
• Changes affecting the registered manager or the management of a regulated activity will be notified as soon as reasonably practicable and in advance where possible, using the current CQC process.
• A change requiring an amendment to the statement of purpose will be processed and notified within the applicable timescale.
• Other statutory notifications, including deaths, serious injuries, abuse or allegations of abuse, police involvement and events affecting safe operation, will be submitted without delay where the regulations require.
14. Absence, vacancy and succession
• Planned leave and foreseeable absence will be supported by a written handover and named management cover.
• Cover arrangements will identify decision-making authority, on-call support, safeguarding escalation and responsibility for notifications.
• The competence, availability and workload of the person providing cover will be assessed; job title alone is not sufficient assurance.
• Where a manager resigns, is dismissed, becomes unable to act or has registration cancelled, the provider will protect continuity, notify CQC as required and begin recruitment and registration action promptly.
• Succession planning will be maintained so that foreseeable changes do not leave the service without effective leadership.
15. Concerns about fitness, conduct or performance
If information suggests that the registered manager may no longer meet Regulation 7 or cannot manage safely, the provider will:
• assess immediate risk and take proportionate interim action;
• follow safeguarding, disciplinary, capability, sickness absence, grievance and whistleblowing procedures as applicable;
• investigate fairly, preserve evidence and give the manager an opportunity to respond;
• consider reasonable adjustments, support, supervision, training, restrictions or alternative duties where these can manage risk safely;
• notify or refer to CQC, the local authority, police, DBS or a professional regulator where the relevant legal threshold or duty is met;
• continue any necessary investigation and referral assessment if the manager resigns or otherwise leaves; and
• record the evidence, decision, reasons, action, responsible person and review date.
Where registration may need to change or end, the provider and manager will use the appropriate CQC process. Internal removal from post does not itself cancel the person’s CQC registration.
16. Equality, health and reasonable adjustments
• Recruitment and monitoring decisions will comply with the Equality Act 2010 and will focus on ability to perform intrinsic duties after reasonable adjustments.
• Pre-employment health questions will only be asked where lawful. A role-related health assessment will normally follow a conditional offer.
• Disability or a long-term health condition will not, by itself, make a person unfit to be registered.
• Reasonable adjustments will be discussed, recorded, implemented and reviewed while maintaining safe management of the service.
17. Records and confidentiality
The organisation will maintain a complete and auditable record including:
• the job description, person specification, application, interview evidence and appointment decision;
• Schedule 3 and other safer recruitment checks;
• CQC application correspondence, assessment outcome, certificate and conditions of registration;
• qualifications, training, development plan and competence evidence;
• supervision, appraisal, objectives, support and continuing-fitness reviews;
• professional registration, right to work and relevant DBS monitoring;
• absence, cover, change, incident and other notification records;
• governance audits, action plans and provider oversight; and
• concerns, investigations, risk assessments, decisions and external referrals.
Personal and special-category information will be accurate, relevant, securely stored, restricted to authorised persons and retained in accordance with the organisation’s retention schedule, the UK GDPR, the Data Protection Act 2018 and any applicable regulatory requirement.
18. Audit and assurance
At planned intervals, the provider will audit whether:
• the registered manager’s certificate covers the correct location and regulated activities;
• conditions of registration and statement-of-purpose details remain accurate;
• fitness, competence, qualifications and development remain appropriate;
• supervision, appraisal and provider oversight are effective;
• notifications are complete, accurate and timely;
• absence and succession arrangements are safe; and
• governance findings are translated into completed improvements.
Audit findings will be recorded in an action plan with a responsible person, target date and evidence of completion. Significant themes will be reported through the provider’s governance arrangements.
19. Related policies and procedures
• Fit and Proper Persons Employed Staff Policy;
• Fit and Proper Persons Directors Policy;
• Recruitment and Selection Policy;
• Disclosure and Barring Service Policy;
• Safeguarding Adults Policy;
• Governance and Quality Assurance Policy;
• Supervision and Appraisal Policy;
• Training and Development Policy;
• Whistleblowing Policy;
• Disciplinary and Capability Procedures;
• Statutory Notifications Procedure; and
• Business Continuity and Emergency Planning Policy.
20. Approval and review
This policy will be approved through the provider’s governance arrangements and reviewed at least annually. It will be reviewed sooner following a change in legislation or CQC guidance, a change in registration or management arrangements, an audit finding, enforcement action or a significant incident. Approved changes will be communicated to the registered manager and relevant staff.
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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