Fit and Proper Persons under Regulation 5: what directors and nominated individuals miss

Regulation 19 is about fit and proper persons employed. It covers staff, volunteers, contractors, agency and bank workers where they are engaged for the regulated activity. It is the regulation people usually think of when they talk about safer recruitment.

Regulation 5 is different. It applies where the service provider is a body other than a partnership. It is aimed at people with director-level responsibility for quality, safety and meeting the fundamental standards. CQC's guidance covers directors and people performing functions equivalent or similar to a director.

That distinction is important. A staff file is not enough to prove director fitness. A director may not be delivering care personally, but they may control governance, investment, safety culture, escalation and whether the registered manager is actually supported. From a CQC perspective, that can be just as relevant to risk as the competence of a front-line member of staff.

Regulation 6 is also relevant, but it is not the same thing. A provider body must nominate an appropriate individual to supervise the management of the regulated activity. The nominated individual must be of good character, able to perform the role, and have the qualifications, competence, skills and experience needed to supervise the regulated activity. In small providers, the nominated individual may also be a director. In others, they may be a manager or secretary. The point is to map the role correctly, not to treat every senior title as the same legal category, which is the distinction we draw out in registered manager versus nominated individual.

At inspection or registration, the question is not "Do you have a Fit and Proper Persons policy?" The better question is whether the provider can show that senior people were assessed properly, and that their fitness is kept under review. A credible answer usually rests on four things.

A clear role map

Who is a director? Who performs director-equivalent functions? Who is the nominated individual? Who is the registered manager? Who makes decisions about quality and safety? If the structure is informal, document it. Informal does not mean invisible. For the registered manager specifically, CQC assesses fitness directly at registration, which is what the registered manager interview is for.

Evidence of checks

For directors and nominated individuals this may include identity, employment history, qualifications or professional registration where relevant, references, DBS where the role meets the criteria, insolvency or disqualification checks, declarations of interests, and evidence that concerns from previous roles have been considered. The exact evidence depends on the role and current CQC guidance, so the provider should keep its checklist tied to the current source rather than a template copied years ago.

A decision record

The provider should be able to explain why the person is suitable for this role in this service. A CV alone does not answer that. A good record says what was checked, what was considered, who made the decision, and what conditions or follow-ups were set.

Ongoing review

Fitness is not a one-off onboarding event. CQC's Regulation 5 guidance expects providers to assess and regularly review director fitness, with the frequency based on the risk to the business and to people using the service. Annual declarations are a useful baseline, but they are not a substitute for acting when a concern arises.

The common failure pattern is a gap between corporate control and clinical accountability.

In a small healthcare business, the owner or director may control budget, staffing, equipment replacement and the registered manager's authority. If the service is safe, they may feel distant from "CQC compliance" because they are not doing the day-to-day clinical work. But CQC will not see it that way if safety risks are left unresolved because senior leadership did not act.

• A registered manager raises repeated concerns about staffing, but board minutes do not show consideration or action.
• A director responsible for governance has no current evidence file and no annual declaration.
• A nominated individual can describe the business but cannot explain the regulated activity, risk profile or current CQC requirements.
• A provider has a Fit and Proper Persons policy, but no record of how it has been applied to current directors.
• A concern about a senior person's conduct is handled privately, with no governance record of investigation, interim controls or outcome.

These are not just paperwork issues. They suggest weak governance. If CQC sees a pattern where senior people hold authority without visible accountability, the concern will usually land under well-led as well as the specific fitness requirement.

A good Fit and Proper Persons file is not a drawer full of documents. It is a short, current record that helps the provider answer inspection questions quickly. For each relevant person, it should show:

• the role held, and why the person falls within Regulation 5, Regulation 6, or another suitability requirement
• the checks completed, with dates and source
• qualifications, professional registration and experience relevant to the role
• the DBS position where relevant, including why a DBS check was or was not required
• declarations of interests, conflicts, insolvency, disqualification and relevant conduct concerns
• the suitability decision and who approved it
• the review date and evidence of ongoing declarations
• actions taken if new concerns arise

For a nominated individual, the file should also show how the person supervises the management of the regulated activity. A title is not enough. CQC will expect the nominated individual to understand the service, the risks, the regulations and what happens when the registered manager escalates a concern.

For directors, the file should connect to board governance. If the director has responsibility for quality and safety, their fitness record should not live separately from the evidence that they actually discharge that responsibility. Board minutes, quality reports, risk decisions and closed actions all help show that the role is real. In independent secondary care in particular, that join between corporate and clinical governance is something inspectors look for, as we set out in CQC compliance for independent secondary care.

• Do not rely on Companies House as proof of fitness. It proves appointment, not suitability.
• Do not use a generic employment checklist for directors without checking whether it covers Regulation 5 and the current CQC guidance.
• Do not assume a professional registration proves fitness for a governance role. It may be relevant, but CQC will still look for competence, skills and experience for the office or position held.
• Do not let the nominated individual become a name on the registration only. If they cannot explain how they supervise the regulated activity, the provider has a governance problem.

And do not wait for inspection to tidy the file. The value of this evidence is not just in showing CQC something. It is in making sure the provider itself knows who is accountable for what. That is the same trap as why annual-panic compliance fails: evidence assembled the week before an inspection rarely reflects how the service actually runs.

Ask these questions at the next governance meeting:

1. Do we have a current list of directors, director-equivalent roles, the nominated individual and registered manager?
2. For each person, can we show why they are fit for the role they hold?
3. When did we last review that evidence?
4. If a concern arose tomorrow, do we know what process we would follow?
5. Do board minutes show that senior people act on quality and safety risks, not just receive reports?

If the answer to any of those is unclear, the fix is usually straightforward. Create the role map. Check the current CQC guidance. Build a live evidence file. Put review dates into the governance calendar. Record decisions properly. The same discipline pays off when you prepare for a CQC inspection.

The deeper point is this: CQC does not expect small providers to look like large NHS boards. It does expect accountability to be visible. Fit and Proper Persons evidence is one of the ways a provider shows that the people with power over the service are suitable, active and answerable. Verivius keeps fitness checks, declarations, actions and board evidence in one governance record, so you can start a free trial and keep it inspection-ready.