Sample policy · Reg 7

Registered manager policy template

Statutory anchor: Regulation 7 (requirements relating to registered managers), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 5 (fit and proper persons: directors) where the registered manager is also a director, and Regulation 19 (fit and proper persons employed) for the Schedule 3 information set. · primary source

Download the PDF

The PDF version of this template is the same content, formatted for adaptation in your document control system. The disclaimer above is repeated on the PDF cover.

Download PDFTalk to a consultant

Verivius pack version v1.2, 2026-07-21

1. What the regulation says

be of good character, (Reg 7(2)(a) (good character))

have the necessary qualifications, competence, skills and experience to manage the carrying on of the regulated activity, (Reg 7(2)(b) (qualifications + competence))

be able by reason of M's health, after reasonable adjustments are made, of doing so, and (Reg 7(2)(c) (health fitness))

be able to supply to the Commission, or arrange for the availability of, the information specified in Schedule 3. (Reg 7(2)(d) (Schedule 3 supply))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/7. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

A registered manager has to be fit to manage the regulated activity. That means good character, the qualifications, competence, skills and experience to manage the activity, sound health (with reasonable adjustments), and being able to supply Schedule 3 information about themselves to CQC.

3. Purpose and scope

This policy sets out how the provider appoints, registers, supports and reviews a Registered Manager, keeps evidence of continuing fitness and manages a planned or unexpected change in management cover.

This policy applies to the Registered Manager position at for every CQC-registered location. It covers the appointment process, the Reg 7 fitness conditions, the Schedule 3 information set for the RM, the day-to-day RM accountability, the handover process when an RM changes, the notification of cessation of RM registration to CQC, and the interim arrangements where an RM cannot continue.

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

(Tenant updates the named role-holders.)

5. Procedure

The RM procedure operationalises the Reg 7 fitness conditions across the lifecycle of an RM at the provider.

  1. Recruitment. When an RM vacancy opens (resignation, retirement, dismissal, end of fixed-term, additional registration), recruitment runs through the standard recruitment process plus the Reg 7-specific fitness checks: good character, qualifications and competence and skills and experience appropriate to manage the regulated activity, sound health with reasonable adjustments, ability to supply Schedule 3 information.
  2. Schedule 3 information. The candidate RM provides the Schedule 3 information set (per the Fit and Proper Persons Employed Policy at safe-recruitment-policy): identity and recent photograph, DBS at the appropriate level for the role, conduct evidence from previous employment in regulated services, qualification evidence, full employment history with explanations of gaps, health declaration. The information is verified by the HR Lead and held in the RM's file.
  3. Fit-and-proper-persons-directors check (where applicable). For corporate-body providers where the RM is also a director, the Reg 5 fit-and-proper-persons-directors test applies in addition. The Reg 5 file (a Schedule 4 information set) is maintained separately.
  4. CQC registration application. The candidate RM applies to CQC for registration as RM for the named regulated activity at the named location through the CQC online portal. The application includes the Schedule 3 information, the application reference, and the timeline.
  5. Interim cover during transition. Where the previous RM has left and the new RM is not yet registered, the provider arranges interim management cover. A formal notification of the situation to CQC is made (per Reg 7 read with the registration framework: the provider should not operate without an RM, but where transition gaps occur, transparency with CQC is the right move). The interim cover arrangement is recorded.
  6. Onboarding the new RM. Once registered, the new RM is on-boarded into the role: handover from the previous RM (where the previous RM is still available), familiarisation with the platform's records, introduction to the team, introduction to any external agencies (commissioners, local authority safeguarding, local infection control team, CQC inspector if assigned).
  7. Day-to-day RM accountability. The RM operates the day-to-day management of the regulated activity: signs off the policies that need RM sign-off, chairs the relevant governance meetings, reads the platform's dashboard, reviews and approves significant decisions, manages the leadership team.
  8. Continuing fitness. The RM's continuing fitness is monitored: appraisal annually, DBS renewal per the role's cadence (typically every 3 years), professional-regulator registration current (where applicable), health declarations refreshed at each appraisal, training matrix current per the role's mandatory training profile.
  9. Cessation of RM registration. When the RM leaves the role (resignation, retirement, dismissal, transfer), the RM submits a notification of cessation of registration to CQC through the CQC online portal. The provider concurrently submits the new RM's registration application. The timing is coordinated to minimise any gap.
  10. No-RM contingency. Where an RM cannot continue and an immediate replacement is not available (sudden resignation, illness, death), the provider notifies CQC immediately, arranges interim cover, and accelerates the recruitment-and-registration of a successor. The contingency plan is documented in this policy's section 5 step 5.

6. Training requirement

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

7. Audit

Compliance with this policy is monitored by the Nominated Individual (or the Provider where the NI role does not apply):

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

8. Record-keeping

RM records (Schedule 3 information, appraisals, fitness reviews, CQC application and cessation correspondence, RM training records) are held in the provider's HR system for the duration of the RM'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.

Where the RM was also a director, the Reg 5 (fit-and-proper-persons-directors) file is retained for the same period.

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, NI, HR Lead roles. Section 5 expanded to a 10-step procedure covering recruitment, Schedule 3 information, fit-and-proper-persons-directors check (where applicable), CQC registration application, interim cover, onboarding, day-to-day accountability, continuing fitness, cessation, no-RM contingency. Section 6 names training tiers. Section 7 names the audit cadence. Section 8 references the Limitation Act 1980 retention period.
v1, 2026-06-10 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Verbatim Reg 7 quotes with cite labels and the plain-English summary drawn from the /guidance manifest; added the current disclaimer, header block, Sources and further reading, and When to seek further advice sections.
v1.2 2026-07-21 Verivius (sample) Made the operating purpose explicit alongside the policy scope.

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.

A registered manager is the one named person who carries personal accountability for the regulated activity at a location, so the risk this policy carries is not untidy paperwork but a quiet accountability gap: a post left vacant after a resignation, a deputy acting up unregistered for months, or a manager whose Disclosure and Barring Service check, professional registration or health fitness has lapsed with nobody tracking it. When that happens, the decisions that most affect people using the service lose their owner. Whether an incident gets escalated the same day, whether a safeguarding concern is acted on or waits for someone to pick it up, whether tonight's staffing is genuinely safe: each of those needs a named person with the authority and the standing to decide, and each of them drifts when there is not one. A live registration trail, a Schedule 3 file that has been verified rather than taken on trust with next-due dates on the renewable items, and a written fitness review whenever a concern surfaces are what keep that line of accountability unbroken through a handover. Where the manager is also a director at a corporate-body provider, keeping the Regulation 5 fit-and-proper-persons file distinct from the Schedule 3 file matters because the two roles carry different duties, and blurring them hides which test has actually been met. The point of all of it is that the people using the service always have someone who genuinely owns their care, rather than a name on an old certificate.

  1. A registered manager is genuinely registered with CQC for the regulated activity at each location, and any manager change followed the registration route: a planned absence of 28 days or more notified to CQC in advance, an emergency absence notified within the required timescale, and a cessation or replacement handled through the registration process, rather than the service quietly running without a registered manager.

    Strong evidence: The CQC registration application and cessation-of-registration correspondence held in the registered manager's file (procedure steps 4 and 9), plus the interim-cover record and the CQC notification made under the no-registered-manager contingency (procedure steps 5 and 10).

    Weak evidence: The manager's name is on the rota and the organisation chart, but nothing on file from CQC confirms that person is registered as manager for that regulated activity at that location: no application reference, no confirmation of registration, no cessation correspondence for the person they replaced. A previous manager left months ago and a deputy has been acting up unregistered, or a planned absence of 28 days or more was covered internally with no advance notice to CQC and no dated interim-cover record to show for it.

    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.

    Care Quality Commission (Registration) Regulations 2009, reg 14 (notice of absence: 28 days or more, advance notice, emergency route) and reg 15 (notice of changes, including a registered manager ceasing to manage); Health and Social Care Act 2008 s.10 (requirement to be registered)

  2. The registered manager's Schedule 3 information set is complete and verified by the Human Resources (HR) team, not a set of declarations taken on trust: a Disclosure and Barring Service check at the right level, conduct evidence, and a full employment history with gaps explained, so the person accountable for care at that location has actually been checked rather than vouched for.

    Strong evidence: The verified Schedule 3 file held in the registered manager's HR record (procedure step 2), refreshed at the annual Schedule 3 review with renewable items (Disclosure and Barring Service check, professional registration) checked against next-due dates (Audit section).

    Weak evidence: The file holds a signed good-character self-declaration but no Disclosure and Barring Service (DBS) certificate, or a basic-level check where the role needed an enhanced one. The employment history has an unexplained gap nobody queried, references confirm only dates of service, and conduct evidence from previous employment in regulated services is missing, so the Schedule 3 information set is taken on trust rather than verified by the Human Resources team.

    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 7(2)(d) and Schedule 3 (paras 2, 4 and 5); reg 19(3)(a)

  3. The registered manager's fitness is monitored across the tenure against the four Regulation 7 conditions rather than fixed at appointment: appraisal, Disclosure and Barring Service renewal, professional-registration currency where the role depends on a professional registration, and the health declaration all in date, so the file shows the manager is fit now and not only on the day they were appointed.

    Strong evidence: The annual registered manager appraisal against the Regulation 7 fitness conditions with its output recorded (Audit section), and the continuing-fitness monitoring of appraisal, Disclosure and Barring Service renewal, professional-registration currency, refreshed health declarations and a current training matrix (procedure step 8).

    Weak evidence: The most recent appraisal is two or three years old, the Disclosure and Barring Service (DBS) certificate is dated at appointment and has never been refreshed, and, where the role depends on it, a professional registration such as with the Nursing and Midwifery Council has lapsed without anyone noticing. The health declaration was signed once on the first day and no next-due dates are tracked anywhere, so the file proves the manager was fit when appointed but offers nothing to show they are fit now.

    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.

  4. A surfaced fitness concern (a complaint, a regulatory issue, a performance issue) actually produced a structured review against the Regulation 7 conditions with a recorded outcome, not an informal conversation that leaves no trail.

    Strong evidence: The per-event Regulation 7 fitness review recorded in the tenant's audit register (Audit section), with registered manager records retained for the tenure plus a minimum of 6 years under the Limitation Act 1980 (Record-keeping section).

    Weak evidence: A serious complaint or performance concern about the manager was talked through in a corridor or on a quick call with the Nominated Individual, but nothing was written down. There is no structured review against the four Regulation 7 fitness conditions and no recorded outcome, so the concern fades from view with nothing on file to show it was ever tested against the manager's continuing fitness.

    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. At a corporate-body provider where the registered manager is also a director, the separate Regulation 5 fit-and-proper-persons file exists alongside the Schedule 3 file rather than being folded into it, because these are two distinct tests and a combined personnel file leaves the Schedule 4 information set assumed rather than evidenced.

    Strong evidence: The Regulation 5 (Schedule 4) fit-and-proper-persons-directors file maintained separately (procedure step 3) and retained for the same period as the registered manager record (Record-keeping section).

    Weak evidence: At a corporate-body provider, a single combined personnel file mixes the Schedule 3 employment information with the Schedule 4 directors' information, so the fit-and-proper-persons-directors items are assumed rather than evidenced: no grounds-of-unfitness check, no separate sign-off. There is no distinct Regulation 5 record, so a reader cannot see which of the two separate tests has actually been met for the director who is also the registered manager.

    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.

Related

Last verified 20 July 2026

Spotted something to improve?

These are sample templates, not the last word. If you would change a wording, or want to help us confirm a detail, tell us and we will look at it.

Related Verivius content

Want help adapting this to your service?

A Verivius consultant can read your adapted policy against the live regulation and your service shape. The work fits inside a Mock Inspection engagement or a shorter consulting brief. A 20-minute conversation is the fastest way to find out whether the fit is right.

Get started free

Free to start, no card. A 14-day trial when you subscribe.

Last reviewed 21 July 2026