Fitness to Practice and Professional Registration Policy - Policy document

Sep 16, 2026

Fitness to Practice and Professional Registration Policy sets the Trust-wide framework for protecting patients and the public by ensuring clinicians who require professional registration have verified status. It outlines how fitness to practice concerns are managed in line with Trust procedures and regulatory body codes, and how the Trust provides assurance that qualified clinical employees remain fit to practice. The policy links to specific professional guidance documents and includes monitoring, referral protocols, documentation requirements, and related support mechanisms, timelines, confidentiality, and data protection expectations.

LanguageEnglish

CategoryLetters

FormatPDF

Pages36

Reading Time13 min

AccessFree to download

Introduction

Rationale

Scope

Principles

Policy

Procedure

Checking professional registrations on appointment

Bank/Locum Staff

Regular Checks/Monitoring of clinicians

Professional Registration during periods of absence

Lapsed Registration or Failure to renew Registration

Incidents of Fraud and the Local Counter Fraud Specialist

On-going monitoring, support and development

Dealing with Fitness to Practice concerns in and outside the workplace

Senior reporting of FtP concerns

Regulatory body referral

Documentation of Referral for FtP

CNO Tracker for FtP Referrals

Information Documented on the CNO Tracker

Tracking and Monitoring Process

Timelines for Application of the FtP Process

Support Mechanisms for employees

Confidentiality and Data Protection

Fitness to Practice and Professional Registration Policy | Policy number and category | HR21 | People and Culture | | --- | --- | --- | | Version number and date | 6 | February 2026 | | Ratifying committee or executive director | Transforming Culture and Staff Experience Sub Committee | | | Date ratified | February 2026 | | | Next anticipated review | February 2029 | | | Executive director | Executive Director of Strategy, People and
Partnerships | | | Policy lead | People Partner – Service Delivery | | | Policy author (if different from above) | Graduate Management Trainee | | | Exec Sign off Signature (electronic) | | | | Disclosable under Freedom of Information Act 2000 | Yes | | Policy Context It is a duty of the Trust to ensure that patients and the public are protected and cared for in a safe environment. Professional Registration provides a means of ensuring that health clinicians provide high standards of care through professional standards. Where Fitness to Practice concerns arise, they are dealt with in accordance with Trust procedures and regulatory body codes and protocols. This policy provides an overarching Trust framework under which individual regulatory bodies, codes and protocols sit. It should be read in conjunction with the relevant professional standards and protocols. Policy Requirement Birmingham and Solihull Mental Health NHS Foundation Trust has a duty of care to ensure that employees who provide clinical care and require professional registration to undertake the duties of this role have verification from the professional body. This policy sets out how the Trust is assured that professionally qualified and registered clinical employees are fit to practice and the protocols that are invoked when fitness to practice concerns arise. It is directly linked to each specific professional guidance document. Change Record | Date | Version | Author (Name & Role) | Reasons for review / Changes incorporated | Ratifying Committee | | --- | --- | --- | --- | --- | | May 2025 | 5 | Graduate Management Trainee
People Partner | Three yearly review & merging of two policies (Fitness to Practice & Verification & Monitoring of professional registration) | TCSE | Contents 1. Introduction ............................................................................................................................ 3 1.1. Rationale .................................................................................................................... 3 1.2. Scope ......................................................................................................................... 4 1.3. Principles ................................................................................................................... 4 2. Policy ..................................................................................................................................... 5 3. Procedure .............................................................................................................................. 5 3.1. Checking professional registrations on appointment:.................................................. 5 3.2. Bank/Locum Staff ....................................................................................................... 6 3.3. Regular Checks/Monitoring of clinicians ..................................................................... 6 3.4. Professional Registration during periods of absence .................................................. 6 3.5. Lapsed Registration or Failure to renew Registration ................................................. 6 3.6. Incidents of Fraud and the Local Counter Fraud Specialist......................................... 8 3.7. On-going monitoring, support and development ......................................................... 8 3.8. Dealing with Fitness to Practice concerns in and outside the workplace.....................

FAQs

What is the purpose of this Fitness to Practice and Professional Registration Policy?

It ensures the Trust protects patients and the public by verifying that clinically employed staff who require professional registration hold valid status, and by setting the framework for managing fitness to practice concerns in accordance with applicable codes and protocols.

How does the Trust verify professional registrations at appointment and during employment?

The policy describes procedures for checking registrations on appointment and running regular checks/monitoring of clinicians. It also covers situations involving bank/locum staff and periods of absence.

What happens if fitness to practice concerns arise, including referral and documentation?

Fitness to practice concerns are handled using Trust procedures and invoked protocols, including senior reporting. The policy covers regulatory body referral, required documentation, use of the CNO Tracker, tracking and monitoring processes, and related timelines.

Sep 16, 2026

Upload by Riley West