Sample policy · Reg 5

Fit and proper persons (directors) policy template

Statutory anchor: Regulation 5 (fit and proper persons: directors), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 6 (requirement where the service provider is a body other than a partnership) and Regulation 19 (fit and proper persons employed). · primary source

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Verivius pack version v1, 2026-06-10

1. What the regulation says

the individual is of good character, (Regulation 5(3)(a))

the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed, (Regulation 5(3)(b))

the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed, (Regulation 5(3)(c))

the individual has not 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 providing a service elsewhere which, if provided in England, would be a regulated activity, (Regulation 5(3)(d))

none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual. (Regulation 5(3)(e))

take such action as is necessary and proportionate to ensure that the office or position in question is held by an individual who meets such requirements, and (Regulation 5(5)(a))

if the individual is a health care professional, social worker or other professional registered with a health care or social care regulator, inform the regulator in question. (Regulation 5(5)(b))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/5. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

If you are a body other than a partnership (a company, charity, NHS trust, etc.), every director or person doing director-equivalent work has to meet the fit-and-proper-persons standard. Good character, the right competence, sound health (with reasonable adjustments), no serious misconduct or mismanagement on their record, and none of the grounds of unfitness in Part 1 of Schedule 4.

3. Scope

This policy applies to every director, trustee, or person performing director-equivalent functions at where the provider is a body other than a partnership. It covers the appointment process for new directors, the continuing fitness of incumbent directors, the Reg 5 grounds-of-unfitness check against Schedule 4 Part 1, the information set held per director (a Reg-5-specific information set distinct from the Reg 19 Schedule 3 employee set), and the cessation arrangements when a director leaves.

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4. Roles and responsibilities

(Tenant updates the named role-holders.)

5. Procedure

The Reg 5 procedure operationalises the fit-and-proper-persons-directors standard.

  1. Appointment process. When a new director is proposed (board appointment, executive appointment, non-executive appointment, trustee appointment for a charity), the FPPR check runs before the appointment is confirmed. The check covers all five Reg 5 conditions.
  2. Good character. Reference checks, online due-diligence search, conflict-of-interest declaration, declaration of any criminal record (subject to spent-convictions rules), declaration of any prior insolvency or disqualification, declaration of any professional-regulator concern.
  3. Qualifications, competence, skills, experience. Documentary evidence of relevant qualifications, work history relevant to the director role, evidence of competence in the specific functions the director will exercise.
  4. Health. Health declaration (with reasonable-adjustment opportunity) covering any physical or mental condition relevant to the director role's intrinsic functions.
  5. No serious misconduct or mismanagement. Conduct evidence from previous roles in regulated services (where relevant), Companies House check for disqualification, Charity Commission check (for charity directors), other regulator check where applicable (FCA, Insolvency Service).
  6. Schedule 4 Part 1 grounds-of-unfitness check. The HR Lead or Company Secretary runs the grounds-of-unfitness check against the eight grounds listed in Schedule 4 Part 1: bankruptcy (within the prescribed period), insolvency-related disqualification, criminal conviction for offences listed, disqualification or suspension by a regulator, the person's previous responsibility for serious misconduct or mismanagement, removal from charity-trustee office, listing on the children's barred list or adults' barred list, any current order under MCA Schedule A1 paragraph 12 or 15.
  7. Information set. The Reg 5 information set is held per director: identity and recent photograph, criminal-record certificate at the appropriate level, qualification evidence, employment history, health information, references, declarations made during the appointment process. The set is updated continuously as new information becomes relevant.
  8. Continuing fitness. Each director undergoes an annual fitness review at the Board's standing agenda. The review re-runs the five Reg 5 conditions against any change in the year. Updated checks (renewed DBS where applicable, refreshed declarations) are added to the information set.
  9. Concern or change-in-circumstances. Where a fitness concern surfaces during the year (a director becomes the subject of a criminal investigation, declares bankruptcy, faces a regulator investigation, has a health condition affecting role), the Board reviews fitness at the earliest opportunity. The outcome is recorded. Where unfitness is established, the director is removed from office through the constitutionally-correct route.
  10. Notification on cessation. When a director leaves the role for any reason, the cessation is recorded against the director's file, and CQC is notified of the director-change through the relevant CQC channel where applicable.

6. Training requirement

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the Chair of the Board:

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Director FPPR records are held for the duration of the director's tenure plus a minimum of 6 years after the end of tenure under the Limitation Act 1980, aligned to the standard limitation period for civil claims. Records relating to serious misconduct or mismanagement may be retained longer where the matter could become the subject of future regulatory proceedings.

For company-law purposes, statutory company filings (annual returns, director-change notifications to Companies House, board minutes) follow the Companies Act 2006 retention rules (typically 6 to 10 years for board minutes; longer for the company's underlying records).

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

10. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

11. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

12. Document control

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names the Provider, Board, Chair, NI, HR Lead or Company Secretary roles. Section 5 expanded to a 10-step procedure covering appointment, good character, qualifications, health, misconduct check, Schedule 4 grounds-of-unfitness check, information set, continuing fitness, concern or change-in-circumstances, cessation notification. Section 6 names director training tiers. Section 7 names the audit cadence including the per-appointment FPPR check and annual fitness review per director. Section 8 references the Limitation Act 1980 retention and Companies Act 2006 statutory-records retention.
v1, 2026-06-10 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Verbatim Reg 5(3) and Reg 5(5) blockquotes added with cite labels; engaged Reg 6 and Reg 19 named in the anchor; plain-English summary, Sources and further reading, and When to seek further advice blocks added.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

The risk this policy manages is not a single unsafe act at the bedside but an unfit person holding the levers that decide how safe every act is. A director who is on the children's or adults' barred list, is an undischarged bankrupt, or is prohibited from holding office by a disqualification order can still shape staffing levels, clinical spend and how far a raised concern is allowed to travel, and the people using the service never see who signed those decisions off. That is why the evidence has to sit against each named director rather than as a collective board assurance: a dated insolvency and barred-list result, conduct evidence from previous roles in regulated services, and a record of what the board actually did when a director's circumstances changed part-way through the year. Fitness tested once at appointment and assumed thereafter is the common failure, because a bankruptcy, a barring decision or a professional-regulator investigation almost always arrives after the file was closed. For the person receiving care, well-led begins at this point, in whether the people ultimately accountable for their safety were genuinely tested and kept under test.

  1. Each director has personally been through the Schedule 4 Part 1 grounds-of-unfitness check and the result is evidenced against their name, rather than covered by a general assurance that the board is 'sound'. The Companies House disqualification search, the barred-list results and the insolvency checks sit behind the sign-off, so the people ultimately answerable for the safety of the service have actually been tested.

    Strong evidence: The grounds-of-unfitness check against the eight Schedule 4 Part 1 grounds run by the Human Resources (HR) Lead or Company Secretary (Companies House disqualification, Charity Commission, children's and adults' barred lists, bankruptcy or insolvency) held in the per-director Regulation 5 information set (procedure steps 6 and 7).

    Weak evidence: A single line in the board minutes recording that the board is satisfied every director is fit and proper, with nothing behind it per person. There is no dated Companies House disqualification search, no children's or adults' barred-list result and no bankruptcy or insolvency check held against each named director, so the Schedule 4 Part 1 grounds of unfitness were asserted rather than tested. Regulation 5 requires the information to be available in relation to each individual, so a collective board assurance is the wrong unit of evidence.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 5(3)(e) and Schedule 4 Part 1 (grounds of unfitness), with reg 5(4) requiring the information to be available to the Commission in relation to each such individual

  2. The 'no serious misconduct or mismanagement' condition (Regulation 5(3)(d)) is evidenced from the director's previous roles in regulated services, including a service provided elsewhere which, if provided in England, would be a regulated activity, rather than left as a self-declaration. Conduct history and regulator checks sit behind it, so a director who has been party to mismanagement that harmed people elsewhere is identified before they take office here.

    Strong evidence: Conduct evidence from previous roles in regulated services, the Companies House disqualification check, the Charity Commission check for charity directors, and other regulator checks (Financial Conduct Authority, Insolvency Service) where applicable (procedure step 5).

    Weak evidence: A signed self-declaration in the file stating the director has never been involved in serious misconduct or mismanagement, standing in for the check itself. There are no references or conduct evidence from the director's previous roles in regulated services, and no Companies House, Charity Commission, Financial Conduct Authority or Insolvency Service search where that person's history would call for one. Regulation 5(3)(d) reaches conduct in a service provided elsewhere which would be a regulated activity if provided in England, so a director's overseas or non-CQC-regulated history is the gap most often left unexamined.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 5(3)(d)

  3. The fit-and-proper-persons check is completed before each director's appointment is confirmed, and before anyone performing director-equivalent functions begins exercising them, rather than run retrospectively once they are already in post. Nobody carries director-level responsibility for people's care while their disqualification search, barred-list result and conduct history are still outstanding.

    Strong evidence: The end-to-end fit-and-proper-persons check verified at every appointment with the sign-off recorded in the board minutes (procedure step 1, Audit at-every-appointment check).

    Weak evidence: A fitness file whose check dates all fall after the director's start date, or a board minute confirming the appointment with the checks noted as still to follow. The person is already exercising director functions while the disqualification search, barred-list result and conduct history are outstanding. Regulation 5(2) bars appointing or having in place such an individual unless every condition is satisfied, so a check run in hindsight leaves the appointment itself unsupported. The same gap shows up for anyone performing director-equivalent functions without the title, who is frequently never put through the process at all.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.
  4. Each director's fitness is re-run annually against any change in the year, and a mid-year concern (a criminal investigation, a bankruptcy, a regulator investigation, a health condition affecting the role) triggers a recorded board review with an outcome against that director's file, rather than fitness being fixed at appointment. The annual cadence and the Chair sign-off are this policy's own standard rather than a statutory interval. Regulation 5(2) requires a director to remain fit while in place.

    Strong evidence: The annual fitness review per director signed off by the Chair with the file refreshed (procedure step 8, Audit annual review), and the earliest-opportunity board fitness review with a recorded outcome where a concern surfaces (procedure step 9).

    Weak evidence: A file that stops dead at the appointment date: no annual review sign-off by the Chair, declarations and searches years old, and a known mid-year event, a director's bankruptcy or a regulator opening an investigation, discussed informally round the table but never written up as a recorded fitness review with an outcome against that director's file. The annual cadence and the Chair sign-off are this policy's own standard rather than a statutory interval, but Regulation 5(2) requires a director to remain fit while in place, so a file with no refresh after appointment cannot show the duty was met.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.
  5. A director's change in personal circumstances relevant to Regulation 5 is captured and acted on, and where the director is a health care professional, social worker or other professional registered with a health care or social care regulator, that regulator is informed as Regulation 5(5)(b) requires. Informing the professional regulator is a separate duty in its own right and is not discharged by the board handling the matter internally.

    Strong evidence: The director's own notification of any relevant change (criminal conviction, professional-regulator concern, bankruptcy or disqualification, serious-misconduct allegation, health condition) named in Roles and responsibilities, and the recorded action taken under Regulation 5(5), including removal through the constitutionally-correct route where unfitness is established (procedure step 9).

    Weak evidence: A concern that surfaced and was quietly settled in-house: a note of a board conversation but no record of the action taken under Regulation 5(6)(a) to ensure the office is held by someone who meets the conditions, and, where the director is a registered nurse, doctor or social worker, no evidence the relevant professional regulator was informed as Regulation 5(6)(b) requires. Informing the professional regulator is a distinct duty from any Care Quality Commission notification and from any safeguarding referral, so evidence of one is not evidence of the others. Often paired with a director-notification duty that exists only on paper, with no director having ever actually declared a change.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 5(5)(a) and (b)

Last verified 20 July 2026

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Last reviewed 10 June 2026