Professional registration policy
Document control
- Policy owner: People partner
- Corporate lead: Director of people
- Date approved by Joint Negotiating Consultative Forum(JNCF): 12 November 2025
- Date ratified by Trust Leadership team: 17 December 2025
- Date issued: 26 January 2026
- Next review date: April 2028
Executive summary
Professional regulation of clinical staff is intended to protect the public, making sure those who work in regulated roles within the healthcare profession are doing so safely and working within their professional code of practice. This policy applies to all clinical staff, who are required by law and as a condition of their employment with Leeds Community Healthcare NHS Trust (LCH), to hold a current and relevant professional registrations in order to practice in that role.
This policy also covers those clinical and non-clinical staff who require a professional registration for appointment to their post with LCH but where there is not a legal requirement to hold that registration in order to practise in that professional role in the NHS.
This policy applies to all staff required to hold a professional registration, irrespective of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation.
This document sets out Leeds Community Healthcare NHS Trust’s standard professional registration policy and procedures.
This policy applies to staff employed permanently, staff on fixed-term contracts, temporary and bank staff, doctors in training, volunteers, students, trainees, contractors, persons holding honorary agreements and highly mobile staff employed through an agency.
This policy has been drafted to comply with statutory requirements and following professional body guidance and must be read together with other relevant trust policies, procedures and local guidance.
The policy may be reviewed at the request of management or staff side by giving four weeks’ written notice with reasons for the review.
Equality analysis
Leeds Community Healthcare NHS Trust’s vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy.
Table of content
- Introduction
- Aims and objectives
- Definitions
- Responsibilities
- Identification of posts requiring professional registration
- Lapsed registrations
- Referral to professional bodies
- Notification from professional bodies
- Suspension by professional body
- Equality analysis
- Mental Capacity Act
- Risk assessments
- Training needs
- Monitoring compliance and effectiveness
- Ratification and approval process
- Dissemination and implementation
- Review arrangements
- Associated documents
- References
- Appendices
1. Introduction
Regulation of healthcare professionals exists to protect the public ensuring that those who practice as healthcare professionals do so according to their professional codes of practice. Professional registration is the process through which healthcare professionals and identified occupational groups are regulated. Regulation can be statutory or voluntary.
Leeds Community Healthcare NHS Trust (LCH) recognises its legal duty of care to protect the public and will take appropriate measures to verify the registration of employees and other staff covered by this policy, both before appointment and annually thereafter. The trust will have systems in place to ensure Staff know how to raise concerns with regulatory bodies and how to respond to requests and information received from them. It is expected that employees will be responsible for maintaining their own registration.
Instruction of agency staff must be coordinated through Clinical and Support Services (CLaSS) and any external agencies used must be from an approved agency nursing, Commercial Procurement Collaborative (CPC) or Government Procurement
service (GPS). This provides the trust with assurance that employment and registration compliance have been undertaken and agencies are regularly monitored and audited to ensure the workers compliance is maintained. More detail on the framework, audit and checking process for the CPC Framework.
This policy supersedes all other relevant policies under previous terms and conditions of employment held by individuals who have transferred into the Trust from other NHS organisations, and who are required to be registered with a professional body in order to be able to practice.
2. Aims and objectives
This policy will set out the process for ensuring that staff employed in healthcare professions or occupational groups identified as requiring statutory or voluntary regulation have appropriate registration prior to appointment and during their employment. It details the expectations of staff in relation to confirming registration, maintaining registration; and expected actions where registration is compromised. .
This policy takes into consideration legislation and other requirements, including:
- NHS Litigation Authority Risk Management Standard 1.9
- Care Quality Commission outcome 12 and 14
- Health and Social Care Act 2008 (regulated activities) Regulations 2010: Regulations 21 and 23
- Health and Social Care Act 2012
- HSC 2002/008 – Pre and post-employment checks for all persons working in the NHS England; and subsequent guidance from NHS Employers, for example, NHS Employment Check Standards (updated in May 2016)
- NHS Employers’ Guidance on the appointment and employment of NHS locum doctors, June 2012
- NHS Employers Professional registration and qualifications checks, January 2021
- NHS Staffing Procurement Frameworks (see section 10 for full list)
Professional registration is one of the NHS Employers’ six pre-employment check standards. Guidance from NHS Employers states that Trusts must carry out all checks in compliance with the Data Protection Act 1998. Information should only be obtained where it is essential to the recruitment decision and kept in accordance with the Act.
Information regarding professional registration will be recorded and maintained on the Electronic Staff Record (ESR). This should be the single repository in the trust for information on registration by which compliance with this policy is monitored.
This policy defines the identification of posts which require professional registration either through statutory regulation or through voluntary or best practice regulation. The policy defines the trust stance and escalation process for concerns in relation to practice and defines the responsibilities of individuals in relation to professional registration.
3. Definitions
3.1 Regulation
Regulation sets standards of practice and behaviour expected of healthcare professionals and identified occupational groups. Staff working in regulated roles must be registered with the relevant regulatory body in order to practise.
3.2 Regulatory body
Regulatory bodies can be statutory or voluntary. The Professional Standards Authority oversee the performance of the 10 statutory regulators and hold a list of accredited bodies that provide voluntary regulation.
There are ten statutory regulators:
- General Dental Council
- General Medical Council
- General Optical Council
- General Osteopathic Council
- General Pharmaceutical Council
- Health and Care Professions Council
- Nursing and Midwifery Council
- Pharmaceutical Council of Northern Ireland
- General Chiropractic Council
- Social Work England
3.3 Statutory regulation
Statutory regulation is set in law and regulates certain professions. Where a role falls under a regulated profession, the employee must hold and maintain the relevant registration in order to be able to work in that occupation. Statutory regulatory bodies do four things:
- Set standards of competence and conduct that health and care professionals must meet in order to be registered and practice
- Check the quality of education and training courses to make sure they give students the skills and knowledge to practice safely and competently
- Maintain a register that everyone can search
- Investigate complaints about people on their register and decide if they should be allowed to continue to practice or should be struck off the register, either because of problems with their conduct or their competence.
3.4 Voluntary or best practice registration
Where a role is not legally regulated, the Trust may require staff working in those roles to hold professional registration as an essential criterion of their appointment. Usually this will be an accredited registration overseen by the Professional Standards Authority. Through being on an accredited register, the Professional Body have shown their commitment to good practice, setting standards for best practice and procedures to manage concerns. In certain circumstances, registration with a professional body that follows the standards set by the PSA, but not currently accredited with the PSA, will be considered.
3.5 Registration
Registration is the process by which an individual’s name is included on a regulatory or professional bodies register. Where it is an essential requirement of a post to hold professional registration, it is the responsibility of the post holder to maintain the relevant registration through the re registration processes the regulator has identified.
3.6 Revalidation
Revalidation is a requirement of some regulatory bodies in order to maintain registration. The purpose of revalidation is to ensure registrants remain fit to practise throughout their careers.
4. Responsibilities
All staff employed by LCH must work in concordance with the Leeds Safeguarding Multiagency policies and procedures and local guidelines in relation to any safeguarding concerns they have for children or adults they are in contact with.
Chief executive will ensure that LCH has robust policies and procedures in place for maintaining professional registration. In practice this responsibility is delegated to heads of service, operational managers and clinical leads.
Executive director of Nursing and AHP will ensure that all nursing, AHP and clinical staff not identified below are registered with the appropriate regulatory body and maintain their registration as required. They will maintain oversight of any referrals to NMC, HCPC and any other statutory or voluntary register of staff within their remit. They will support activities required to revalidate or renew registration. They will work with the director or workforce to ensure processes and procedures to achieve this.
Executive medical director will ensure all medical staff have an identified responsible officer (RO) in line with the medical professions (responsible Officer) regulations 2010 (Amended 2013)
Responsible officer is an identified person within the trust with statutory responsibility to:
- ensure processes for medical appraisal and assuring suitability for the job the medic is doing
- ensure process to monitor medical performance
- ensure processes to respond to concerns about a doctor’s performance
- make revalidation recommendations to GMC
- refer concerns to the GMC and monitor compliance with any conditions.
They will work with the director of workforce to ensure processes and procedures support this and align with trust HR policies.
Head of medicines management or chief pharmacist will ensure that all pharmacy staff are registered with the General Pharmaceutical Council and maintain their registration as required. They will maintain oversight of any referrals to General Pharmaceutical Council. They will support activities required to revalidate or renew registration. They will work with the director or workforce to ensure processes and procedures to achieve this.
Director responsible for workforce is accountable to the chief executive for the ongoing management of the policy and ensuring systems, processes and procedures are in place to enable the executive director of nursing and AHPs, the executive
medical director or responsible officer and the head of medicines management or chief pharmacist to fulfil their responsibilities of the policy.
Trust board will seek assurance form the organisation on an annual basis that all clinical staff are registered with the appropriate statutory regulator or accredited register and that any lapses in registration or concerns raised with the regulators have been addressed. This will include the statutory requirement in relation to medical revalidation.
Professional bodies and trade union organisations accept the responsibility of working together on issues in good faith and with goodwill with the shared intention of facilitating good working relations.
The workforce directorate will work in partnership with managers, service leads, clinical leads and Employee representatives to ensure employees are treated fairly and consistently within the framework of the policy.
Recruitment are responsible for:
- agreeing with the recruiting manager and clinical lead when and what statutory or voluntary registration is required for a post before it is advertised
- checking that any requirement for statutory or voluntary registration is clear within the person specification and advertisements for posts
- ensuring employees hold the appropriate registration on commencement in post. This includes new starters to the trust both temporary and substantive; staff changing position to a new role within the trust, and staff on secondment.
- ensuring registration details provided during the recruitment and selection process are cross checked with the relevant statutory or voluntary body. The outcome of pre-employment checks will be recorded on the electronic staff record (ESR). For further detail please refer to the trust’s recruitment and selection policy.
Human Resources are responsible for:
- providing advice to managers of options should an employee be managed under this policy
- annually checking the registration status for staff in posts that have been identified as requiring statutory or voluntary registration through monitoring of appraisal documentation, automotive notifications from identified regulators or annual audits
- bringing to the attention of the relevant executive director or responsible officer, service or line manager and clinical lead any lapses in registration notified by the regulator or identified on checking
- annually reporting of data from ESR on professional registration compliance, lapses and referrals to executive medical director, executive director of nursing and allied health professionals (AHPs) or head of medicines management or chief pharmacist as part of the board assurance process.
Workforce Information is responsible for:
Line managers are required to manage and act fairly and consistently in line with Just Culture principles. Management is responsible for ensuring that this policy is disseminated effectively and observed by all relevant employees.
- Managers have a responsibility to ensure that the registration of all professional clinical staff in their area is current as part of the annual appraisal process.
- Where registration has lapsed managers must take action as in section 6 (lapsed registrations) of this policy. Managers must ensure that registration is checked for employees returning from maternity or other long term absences, for examples, sickness, secondment, employment break.
- As part of the recruitment and selection process, the manager will: identify where professional registration is a requirement of the post; ensures that the application form is checked for current registration details including registration number and expiry date. In the event of unsatisfactory registration checks being received prior to employment, the recruiting manager will be informed, enabling them to make a full review of the facts and circumstances and make a decision to recruit or withdraw the job offer.
- Support for the line manager in identifying if professional registration is required is detailed in section 5 below.
- When staff are seconded into the trust, their employer remains the organisation with whom they have a substantive contract. However, the trust will, as a good employer, check the registration via the appropriate website.
- Notifying the responsible officer, executive medical director, executive director of nursing and allied health professionals (AHPs) or head of medicines management or chief pharmacist within LCH of any concerns the trust has about a registrant’s fitness to practise for consideration of referral to the regulatory body. In particular this would include the behaviour or actions of a registrant which has raised concerns about their fitness to practise; if a registrant is dismissed or there is a case of serious misconduct; or there has been a decision taken to downgrade the status of a registrant. In most cases, the regulatory body should be told at the point that the manager decides that there is some evidence of a concern relating to fitness to practise. This is usually when the matter goes forward to the formal disciplinary or capability process. Further guidance on progression of these concerns into a formal process should be sought from the HR department who will be available to provide support and guidance to all parties.
Individual registrants are personally responsible for:
- understanding the registration requirements for their profession or occupation. This includes any additional requirements of their profession, for example, revalidation, renewal
- obtaining and maintaining their professional registration. Staff will receive reminders about renewing registration from ESR and their own regulatory body. However, the absence of a reminder will not be accepted as a justifiable reason for failing to maintain registration as it remains a personal responsibility
- notifying their regulatory body should their personal details change, for example, change of address or change of bank account, to avoid any risk of registration being delayed
- renewing and paying for their registration before registration lapses. Providing evidence of such renewal to their manager if requested to do so
- notifying their manager immediately of any lapse in registration, for any reason, and ceasing to work as a registered practitioner until such time as their registration is properly renewed
- notifying their manager immediately of any change in the status of their registration, for example, suspension from the register, limited registration
- maintaining professional registration during periods of sustained leave, for example, maternity and adoption leave, paternity leave, parental leave, shared parental leave, special leave, career break; this is because the employment contract remains in place during these periods and so the individual must remain registered under their contract. Should this not be possible, the Registrant is responsible for making contact and discussing this and how this may affect their return to work, with their line manager at the earliest opportunity
- when staff go on an employment break, they remain an employee of the trust. However, if the Employment Break does not necessitate them maintaining their professional registration, they will not be subject to the conditions within this policy in terms of failing to renew their registration. Once an individual returns to the trust however all conditions or responsibilities within this policy will apply.
- confirming registration details on return from sustained leave
- where a Registered Professional holding an honorary contract for a position within the trust that requires statutory or voluntary registration, chooses not to register or allows their registration to lapse, their honorary contract will be withdrawn.
All staff have a duty to comply with trust policies and procedures. If an employee has any questions or concerns about these they must raise these with their line manager and (or) the Human Resources department
5. Identification of posts requiring professional registration
Where a job is to be advertised or a new post is created, that requires the post holder to undertake independent assessment, diagnosis and formulation of care plans, regulation must be considered. Recruiting managers must refer to the Professional Standards Authority to see which professions are regulated and assess whether the post they are recruiting to requires statutory registration. This requirement must be include in the recruitment documentation.
Where statutory registration is not a requirement of the post, recruiting managers should assess whether voluntary or best practise registration is required within the role and can check accredited registers through the Professional Standards Authority. (Accredited Registers)
Recruiting managers must seek advice from human resources, executive medical director, executive director of nursing and AHPs or head of medicines management or chief pharmacist within the trust if they are unsure whether registrations are applicable.
Pre-employment checks will be carried out by the recruitment department as detailed in the responsibilities above.
On appointment to a new role in the trust, it is essential that professional registration is identified on employees new starter (SW1) form.
5.1 Ongoing registration
Staff on statutory registers have specific guide lines in relation to revalidation or re registration that they must follow. On re registration or revalidation, individual staff have a responsibility to update and maintain their own registration status on ESR. Individual registrants will update their ESR records as soon as their re registration or revalidation is confirmed.
NMC, GMC, GDC and HCPC registers interface with ESR and alert the trust to changes in the employees’ eligibility to practice automatically. Expiry dates are routinely updated.
The workforce directorate will notify managers of staff whose registration has changed or lapsed as soon as it comes to light. Managers will then need to take the actions identified below.
For all other professional bodies this is checked manually by the workforce directorate. Registrants must provide evidence of renewing their registration to their line manager and ensure they update through ESR self service.
6. Lapsed registrations
Staff whose registration has lapsed cannot practice in their professional capacity.
- Where a registration has lapsed, the responsible officer or line manager will establish the reasons why. It is the responsibility of the line manager in consultation with the executive medical director, executive director of nursing and AHPs or head of medicines management or chief pharmacist and their HR business partner, to take prompt action to protect the interests of the public, patients and other staff.
- Employees will usually be suspended with immediate effect if registration is not renewed and the manager must complete an SW2 to notify payroll of the suspension and that it is without pay. In extenuating circumstances, a decision may be authorised by the appropriate Director to allow an individual to work in a non-professional (unregistered) position for an agreed length of time which may be at a lower band than their substantive role. In this case, pay will be adjusted accordingly and with immediate effect.
- The trust regards a situation where registration has lapsed, been revoked or suspended as a serious matter and lapses will be dealt with in accordance with the trust disciplinary procedure. This may include referral to the employee’s
regulatory body. - Anyone found to be practicing whilst unregistered may be subject to prosecution by their professional body and a possible fine of up to £5,000.
- If after a maximum period of one month following the expiry of registration the individual has failed to notify the Workforce Information department of their re-registration, there will be a final check after which it will be assumed that the individual has broken their contract and action will be taken to terminate their employment. (appendix 2).
7. Referral to regulatory bodies
Where concerns are raised about the conduct or competence of a member of staff who is on a professional register, the manager to whom the concerns were reported must discuss their concerns with the appropriate responsible officer, executive medical director, executive director of nursing and AHPs or head of medicines management or chief pharmacist within the trust prior to commencing any formal investigation or referral being made to a regulatory body.
Where the decision to make a referral to regulatory body is an outcome of a HR process the appropriate responsible officer, executive medical director, executive director of nursing and AHPs or head of medicines management or chief pharmacist within the trust should be made aware.
Referrals to the GMC must be made through the Responsible Officer. Referrals to other regulators must be made with the knowledge of the executive director of nursing and AHPs or head of medicines management or chief pharmacist within the trust
If it is decided that a referral is appropriate, the employee will be informed of this action before it takes place and will be sent a letter confirming the action taken.
8. Notification from regulatory bodies
Where an employee or manager receives notifications or requests from a regulator or professional body concerning a registrants registration or fitness to practice, they need to inform the responsible officer, executive medical director, executive director of nursing and AHPs or head of medicines management or chief pharmacist as appropriate prior to agree actions necessary.
9. Suspension by a regulatory body
Where an employee has their professional registration suspended by their issuing body or are struck off the register, the trust will have the discretion to suspend the employee without pay whilst taking into consideration the individual circumstances.
10. Equality analysis
The trust expects the same standards of conduct of all employees. Managers should bear in mind the possibility that some employees may need assistance to follow or understand rules or procedures because of language or disability factors, for example. If such assistance is needed or requested, consideration should be given to providing it. LCH aims to design and implement services, policies and measures that meet the diverse needs of its population and workforce, ensuring none are placed at a disadvantage over others.
LCH is subject to the equality duty as set out in the Equality Act 2010 and must pay “due regard” for the need to:
- eliminate unlawful discrimination, harassment and victimisation
- advance equality of opportunity and foster good relations between people who share a protected characteristic and those who do not.
Due regard for advancing equality involves:
- removing or minimising disadvantages suffered by people due to their protected characteristics
- taking steps to meet the needs of people from protected groups where these are different from the needs of other people.
See appendix 4
11. Mental Capacity Act (MCA 2005 Code of Practice)
This Act applies to all persons over the age of 16 who are judged to lack capacity to consent or withhold consent to acts which are considered by health and social care professionals to be in the best interests of their welfare and health.
The Mental Capacity Act 2005 imposes a legal requirement on health and social care professionals to ‘have regard to’ relevant guidance within the Code of Practice when acting or making decisions on behalf of someone who lacks capacity to make the decision for themselves. Furthermore, they should be able to explain how they had regard to the Code when acting or making decisions.
Detailed guidance is available in the Mental Capacity Act 2005 Code of Practice.
12. Risk assessment
The process for checking professional registration for both pre-employment and during employment is robust and provides assurance that all staff (who are required to be registered with a professional body) are registered in order to practise..
There are systems in place to remove any member of staff from the workplace if their registration lapses.
If large numbers of staff within an area fail to re-register with their professional body this may have an impact on service delivery however this is mitigated through the use of business continuity plans.
13. Training needs
All recruiting and line managers must have the ability to check the appropriate website to confirm professional registration status and understand what actions to take if the requirements are not met. This will be achieved through recruitment and selection training and the promotion of this policy.
14. Training needs
14.1 Minimum requirement to be monitored or audited: Duties, both on initial appointment and ongoing thereafter
- Process for monitoring or audit: Recruitment and selection process
- Lead for the monitoring or audit process: Recruitment
- Frequency of monitoring or auditing: On appointment and monthly
- Lead for reviewing results: Executive director of workforce, director of nursing and AHP’s, medical director or head of
medicines management or chief pharmacist - Lead for developing or reviewing action plan: Recruitment
- Lead for monitoring action plan: Quality governance and risk
14.2 Minimum requirement to be monitored or audited: Process for ensuring registration checks are made directly with the relevant professional body, in accordance with their recommendations, in respect of all permanent clinical staff both on initial appointment and ongoing thereafter
- Process for monitoring or audit: Workforce information produce reports about registration and this is checked on relevant websites
- Lead for the monitoring or audit process: Workforce information
- Frequency of monitoring or auditing: Monthly
- Lead for reviewing results: Executive director of workforce, director of nursing and AHP’s, medical director or head of
medicines management or chief pharmacist - Lead for developing or reviewing action plan: Workforce information
- Lead for monitoring action plan: Quality governance and risk
14.3 Minimum requirement to be monitored or audited: Process for monitoring or receiving assurance that registration checks are being carried out by all external agencies (for example, NHS professionals, recruitment agencies) used by the
organisation in respect of all temporary clinical staff
- Process for monitoring or audit: Recruitment and selection process
- Lead for the monitoring or audit process: Recruitment
- Frequency of monitoring or auditing: Monthly
- Lead for reviewing results: Executive director of workforce, director of nursing and AHP’s, medical director or head of
medicines management or chief pharmacist - Lead for developing or reviewing action plan: Recruitment
- Lead for monitoring action plan: Quality governance and risk
14.5 Minimum requirement to be monitored or audited: Process in place for following up these permanent clinical staff
who fail to satisfy the validation of registration process
- Process for monitoring or audit: Workforce information produce reports and non compliance is actioned by manager and HR
- Lead for the monitoring or audit process: Workforce information
- Frequency of monitoring or auditing: Monthly
- Lead for reviewing results: Executive director of workforce, director of nursing and AHP’s, medical director or head of
medicines management or chief pharmacist - Lead for developing or reviewing action plan: Manager and HR
- Lead for monitoring action plan: Quality governance and risk
15. Ratification and approval process
This policy will be approved by JNCF, it will then be ratified by the Remuneration committee.
16. Dissemination and implementation
Professional registration is covered as part of the recruitment process and in the contract of employment.
Dissemination of this policy will be via the Workforce department, line managers and is made available to staff via the trust intranet.
Implementation will require operational directors, general managers and heads of services to ensure that they and their staff understand their responsibilities for maintaining professional registration.
17. Review arrangements
The professional registration policy will be reviewed in line with the timescales for doctors revalidation and responsible officer or sooner if there are any significant changes in requirements of professional bodies.
18. Associated documents
- Contract of Employment
- Codes of Conduct for Professional Bodies
- Recruitment and selection policy and toolkits
19. References
- Nursing and Midwifery (LCH NHS Trust log in number 1003435, Password 2948)
- Doctors
- Dentists
- AHP’s
- Pharmacy
- Professional Standards Authority
20. Appendices
20.1 Appendix 1 Registration dates
1. Nursing & Midwifery Staff are required to register every three years paid by
annual subscription
2. Medical staff are required to register annually
3. Dental staff are required to register annually – 31st December
4. Allied Health Professionals are required to register every two years
|
|
20.2 Appendix 2 Suspension letter
20.3 Appendix 3 Ongoing and monthly processes
| Process | ||
|---|---|---|
| Prior to advertisement | Manager | Checks requirement for statutory or best practice registration |
| Advertisement | Recruitment | Advertise job with requirement for registration clearly identified within advert or associated documents |
| At shortlisting or interview | Manager | Checks candidates holds appropriate registration |
| Pre-employment checks | Recruitment | Verify Registration Input registration information into ESR |
| Monthly | |
|---|---|
| ESR | Automated email to employee advising registration requires renewal prior to expiry |
| ESR | Automated notification to line manager advising professional registrations requiring renewal prior to expiry |
| Line manager | Checks professional registrations approaching renewal or revalidation within team and ensures employee has processes in place for completion |
| Monthly (first working of the month) | |
|---|---|
| WFI | Maintain a report for HR to access detailing registrations which have lapsed according to ESR |
| HR | Contact line managers of lapsed registrants |
| Line manager | Updates registration if they are able to validate. Discusses with HR and professional lead whether suspension is required or if suitable alternative employment can be provided |
