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Archived: Queens Court Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 July 2017

This inspection took place on 22 June 2017 and was unannounced.

Queens Court is a care home with nursing that is based in Windsor, Berkshire. Queens Court is one of eight care home services the provider currently operates. The service is registered to provide residential and nursing care for up to 62 people. The service is for older adults, some of whom have dementia. At the time of our inspection, 46 people used the service. Queens Court provides care across three floors; two floors accommodate people for nursing care and one floor provides residential care.

The service must have a registered manager.

At the time of the inspection, there was no registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our last inspection was conducted on 12 July, 13 July and 14 July 2016. The key question ‘Is the service safe?’ was rated as ‘requires improvement’ and the overall rating for the service was ‘requires improvement’.

The purpose of this inspection was to examine the safety of people’s medicines management. This inspection looked at only one key question; “Is the service safe?” The rating remains as 'requires improvement’ for this key question. The overall rating has not changed.

The management of medicines at Queens Court was not safe. Medicines were not ordered in time from the GP and the community pharmacy. Records regarding medicines were incomplete, missing or damaged so that accuracy of administration could not be established.

Medicines were stored in appropriate areas, but the storage rooms were frequently beyond the recommended maximum temperature. The service and management had not taken action to ensure medicines rooms were at an appropriate temperature.

Medicines errors were reported by staff. However, an accurate record was not always maintained and investigations were not robust. Learning from medicines incidents to prevent recurrence was not demonstrated.

Relatives told us they did not have enough information provided to them about people’s medicines. They told us they witnessed medicines being given but did not know what the medicines were for.

The disposal of medicines was not always appropriate. We found evidence that medicines were sometimes disposed of incorrectly. Records of medicines disposals and destruction were not robust and checks by management for controlled drugs were lacking.

Staff did receive training about medicines safety and administration. Staff also completed competency assessments to check they could safely deal with people’s medicines.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection areas


Requires improvement

Updated 8 July 2017

The service was not always safe.

People�s medicines were not safely managed.

People received their medicines but records were not clear.

Medicines incidents investigations and audits required improvement to ensure people�s safety.

The disposal of medicines was not always satisfactory.

Relatives told us they did not receive enough information from the service about people�s medicines.


Requires improvement

Updated 8 July 2017



Updated 8 July 2017



Updated 8 July 2017



Updated 8 July 2017