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{{org_field_name}}

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 our organisation complies with Regulation 7 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Registered Manager must be able to demonstrate up-to-date knowledge of relevant legislation, guidance and best practice, and understand the regulatory consequences of non-compliance, including enforcement action. 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, and must be read in conjunction with, the following legislation and CQC requirements (as amended from time to time):

• Health and Social Care Act 2008 – including provisions relating to registration, registered manager conditions and applications for registration as a manager.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – including (but not limited to):
  • Regulation 7 (Requirements relating to registered managers)
  • Regulation 5 (Fit and proper persons: directors)
  • Regulation 19 (Fit and proper persons employed)
  • Regulation 17 (Good governance) and other Fundamental Standards as applicable to the service.
• Care Quality Commission (Registration) Regulations 2009 – including (but not limited to):
  • Regulation 12 (Statement of purpose)
  • Regulation 14 (Notice of absence)
  • Regulation 15 (Notice of changes)
  • Regulation 18 (Notification of other incidents) and Regulation 22A (Form of notifications).
• Care Act 2014 – including safeguarding duties and cooperation with local authorities and partners.
• CQC’s guidance on meeting the regulations (Fundamental Standards) and CQC’s Single Assessment Framework, including the Well-led quality statements, which set expectations for leadership, culture, governance and learning.

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:

1. 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.
2. 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.
3. Regulatory Knowledge and Leadership – The Registered Manager must evidence working knowledge of the Fundamental Standards, the CQC Single Assessment Framework (including Well-led quality statements), statutory notifications, and local safeguarding arrangements, and must lead continuous improvement through effective governance, risk management and learning.
4. 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.
5. Regulatory Compliance and Required Evidence – The Registered Manager must ensure that evidence of their fitness to manage is maintained and available for inspection, including identity checks, right to work, full employment history, qualifications, professional registration (where applicable), references, enhanced DBS status and ongoing suitability, in line with the requirements of the relevant regulations and CQC guidance.

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 RegisteredManager must address any deficiencies promptly.
• CQC Notifications (Statutory Notifications) – The Registered Manager is responsible for ensuring that all statutory notifications are made in accordance with the Care Quality Commission (Registration) Regulations 2009, including Regulation 15 (Notice of changes), Regulation 18 (Notification of other incidents) and Regulation 22A (Form of notifications). Notifications must be submitted promptly, within required timescales, and in the correct format as required by CQC.

6.1 CQC Single Assessment Framework (Well-led) – Registered Manager Expectations

The Registered Manager is accountable for ensuring that the service is Well-led in line with CQC’s Single Assessment Framework. This includes:

• maintaining a clear vision, values and culture that prioritise people’s rights, safety, choice and outcomes;
• ensuring effective governance systems are in place to monitor quality, compliance, risks, incidents, complaints and safeguarding concerns, and to drive learning and improvement;
• ensuring staff feel able to raise concerns (including whistleblowing) and that concerns are investigated, responded to and used to improve the service;
• demonstrating inclusive, capable and compassionate leadership, and ensuring appropriate supervision, support, training and development for staff;
• working openly and transparently with partners (including local authorities, health professionals and safeguarding teams) to deliver safe, coordinated and person-centred care.

6.2 Learning Disability and Autism Training (Code of Practice Compliance)

Where the service supports autistic people and/or people with a learning disability, the Registered Manager must ensure compliance with the statutory learning disability and autism training requirements and associated code of practice. This includes ensuring that training is role-appropriate, completed within required timescales, recorded, refreshed as required, and quality assured. The Registered Manager will ensure that the service adopts the government’s recommended approach to training (including the Oliver McGowan Mandatory Training where appropriate) and will evidence compliance through supervision, audit and training records.

7. Managing Absences and Contingency Planning

Under Regulation 14 (Notice of absence) of the Care Quality Commission (Registration) Regulations 2009, where the Registered Manager proposes to be absent from managing the regulated activity for a continuous period of 28 days or more, the registered person must give notice in writing to CQC of the proposed absence and must also notify CQC where an absence of 28 days or more has occurred without notice.

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.
• Return to Work Notification – Where required, CQC will also be notified of the Registered Manager’s return to duty following an absence covered by Regulation 14.

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 at least annually and immediately following any material change to legislation, CQC regulations, CQC guidance (including the Single Assessment Framework), enforcement learning, or service model changes that may affect registration, leadership capacity, or regulatory compliance.

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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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