Archived: Queens Court

Updated 8 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 22 June 2017 and was unannounced. We conducted telephone calls with relatives on 22 June, 23 June and 24 June 2017.

This was a focused, responsive inspection. The notification of an incident indicated potential concerns about the management of risks. This prompted the inspection to check the service’s compliance with medicines management and if people were safe.

The inspection team comprised of one adult social care inspector, a pharmacist inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. Our Expert by Experience was familiar with the care of older adults and dementia.

Before the inspection, we did not ask for the submission of a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We reviewed information we already held about the service. This included previous inspection reports and notifications we had received. A notification is information about important events which the service is required to send us by law. We also looked at feedback we received from members of the public, local authorities, the clinical commissioning group (CCG), GPs and the community pharmacy.

During the inspection we spoke with the provider’s operations manager, the quality and compliance manager and the clinical services manager. We also spoke with the service’s clinical lead, deputy manager, two registered nurses, five care workers and the administrator.

We spoke with multiple people who used the service and 16 relatives, friends or visitors. We looked at 11 people’s medicines administration records (MARs), medicines audits, the medicines policy, controlled drugs registers, and other records associated with the safe management of medicines. We asked the provider to send further documents after the inspection and these were included as part of the evidence we collected.

We observed staff that administered medicines as part of our inspection.

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.