Portman Healthcare - Courtrai House

Updated 21 February 2019

We carried out this announced inspection on 16 January 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Portman Healthcare – Courtrai House is in Henley on Thames and provides NHS and private treatment to patients of all ages.

There is level access for people who use wheelchairs and those with pushchairs via a ramp at the front of the practice. Car parking spaces, including space for blue badge holders, are available near the practice. We noted bays for disabled patients parking spaces were not marked.

The dental team includes five dentists, one orthodontist, one oral surgeon, four nurses, one decontamination assistant, three dental hygienists, two receptionists, one treatment coordinator and a practice manager from another practice who is supporting the practice while the provider recruits a practice manager. The practice has four treatment rooms.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

At the time of the inspection the practice did not have a registered manager in post. We were advised the provider is in the process of recruiting a manager.

On the day of our inspection we collected eight CQC comment cards filled in by patients and obtained the views of 15 other patients.

During the inspection we spoke with two dentists, a hygienist, decontamination assistant treatment coordinator, nurse, receptionist, the caretaker practice manager and compliance facilitator. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open Monday, and Wednesday 8am to 8pm, Tuesday, Thursday and Friday 8am to 5pm and alternate Saturdays 9am to 1pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk but improvements were required.
• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The practice had staff recruitment procedures but improvements were required.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The practice was providing preventive care and supporting patients to ensure better oral health.
• The appointment system met patients’ needs.
• The practice did not have effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The practice asked staff and patients for feedback about the services they provided.
• The practice dealt with complaints positively but records were not effectively maintained.
• The practice had suitable information governance arrangements.
• Improvements were required to many areas of the practice.

There were areas where the provider could make improvements. They should:

• Review the practice’s system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review the practice's current performance review systems and have an effective process established for the on-going assessment and supervision of all staff.
• Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010. Namely the availability of a hearing loop for hearing aid wearers.
• Review the practice's protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.