New BDJ Team reader panellist Stephanie Boothroyd explains the role of a CQC Registered Manager and how she became one.

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What is a CQC Registered Manager (RM)?

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England and ensures health and social care services including dentistry provide service users with safe, effective, compassionate, high-quality care. They encourage providers to continuously quality check their services for improvements.

All dental practices that are registered with the CQC are required to have a Registered Manager (RM). The only exception is where the service provider (usually the practice principal or the practice owner ie the legal entity) is an individual (ie not part of a partnership and not a limited company) who manages the service that the practice provides on a day-to-day basis and who has the necessary skills and experience to do this.

CQC RMs require an in-depth knowledge of the following guidance and legislation:

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

  • The Care Quality Commission (Registration) Regulations 2009

  • The Health and Social Care Act 2008 (Fundamental Standards)

  • HTM 01-05.

The CQC RM role carries significant legal responsibilities for the individual taking it on. Alongside the business provider they are responsible for the day-to-day management of the practice's regulated activities. One of the visions the CQC wants practices to deliver is ‘encouraging services to constantly improve' and this is the key role of the RM.

What is the process of becoming a Registered Manager?

The Care Quality Commission (CQC) assesses the suitability of an applicant for the role of RM to ensure that people who use the services are safeguarded.

Stage 1 of the application process includes a Disclosure and Barring Service (DBS) check, questions about medical history, work history, and references. The reason for this process is to ensure the applicant is:

  • Of good character

  • Is physically and mentally capable of carrying out the role

  • Has the necessary qualifications, skills and experience to carry out the role

  • Is able to satisfy all CQC requirements in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Stage 2 involves the applicant taking part in an interview to establish ‘fitness' to carry out the role under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Within the interview process the aim is for the CQC to be satisfied that the applicant understands their legal responsibilities, has effective systems and processes in place at their practice and they can demonstrate how these are monitored for quality standards.

Experience, experience, experience for me is the main part of how I got where I am today.

Where it began for me…

Starting 18 years ago as a trainee dental nurse, adding post qualifications to my portfolio upon qualifying which included dental radiographer and assessing/tutoring, I always strived for improvement not just on a personal level, but for my colleagues in the team. I felt empowered encouraging my colleagues to strive for more and to undertake post qualifications. This led me down the path of tutoring and assessing dental nurses, guiding them through their chosen post qualifications as a tutor and mentor.

Experience, experience, experience for me is the main part of how I got where I am today.

For over 17 years I have been working as a dental nurse in a primary health care setting. I have been supported by my practice manager(s) and have been given the encouragement and opportunities to enhance my knowledge and skills over these years. Around seven years ago at New Smile Dental Care, I began supporting my then practice manager, learning about leadership and management, taking on additional responsibilities including policy and procedures updates, auditing, and reviewing our practice working documents to ensure they were fit for use. I learnt to plan and take any action required to improve our services, until I became confident and capable enough to manage these tasks on my own.

Following these years of experience I decided the CQC RM role was one I wanted to pursue. I went on to study to gain a relevant qualification to give me deeper knowledge into the role of the CQC Registered Manager. I embarked upon the Level 5 Diploma for Dental CQC Registered Managers (RQF) with DenTTrack & Glenys Bridges Academy. It enabled me to develop the required knowledge behind the practical side of practice management and to apply for the official role.

It is so important to have a great team, one where team members are engaged, motivated, enthusiastic and feel appreciated for the work they deliver.

What are the CQC RM's responsibilities?

Being a CQC RM I have the responsibility to manage the regulated activities our practice is providing:

  • Regulated activity 1: Diagnostic and screening procedures

  • Regulated activity 2: Treatment of disease, disorder or injury

  • Regulated activity 3: Surgical procedures.

I am responsible for leading my team to deliver high quality care to our patients. As an NHS practice clinical governance is an important part of our quality structure to provide safe and effective care to our patients; it encompasses quality assurance, quality improvements and risk and incident management. NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. I manage the following:

  • Keeping track of compliance - through conducting regular reviews and audits

  • Keeping up to date with any changes to the legislation and regulations

  • Ensuring our policies and procedures are in line with legislation and regulations

  • Carrying out regular staff supervisions, and annual appraisals

  • Ensuring all staff are up to date with mandatory training and carrying out spot checks to ensure staff are compliant.

Talk about compliance and leadership within the team

It is so important to have a great team, one where team members are engaged, motivated, enthusiastic and feel appreciated for the work they deliver. I encourage the nurses at the practice to take on post qualifications which can then lead to extended roles within our practice. I encourage openness with feedback and encourage continuous development in areas of interest, with further training and support. I ensure the team is ‘well-led', which is one of the CQC's key lines of enquiries and which is essential in leadership and management, and feel rewarded to have the support of my team behind me.

To this day I still question how something (even a small change) can have a positive impact in so many ways - to how we work individually, how we work as a team, and the outcomes this can provide through our care to our patients. Initially I viewed this as offering great customer service to our patients but have learnt through knowledge and experience that ‘Total Quality Management' is the key management approach to long term success.

Useful resources

  1. 1.

    Care Quality Commission. Registration under the Health and Social Care Act 2008. Guide to the application process for new registered managers. December 2017. Available at: https://www.cqc.org.uk/sites/default/files/20171218_100743_guidance_to_the_application_process_for_new_registered_managers_v6.pdf (accessed December 2023).

  2. 2.

    Care Quality Commission. Our purpose and role. 5 May 2022. Available at: https://www.cqc.org.uk/about-us/our-purpose-role/who-we-are (accessed December 2023).