CQC takes action to protect people at Birmingham care home

Published: 31 January 2024 Page last updated: 31 January 2024

The Care Quality Commission (CQC) has rated Clare Court Care Home in Winson Green, Birmingham, inadequate and placed it into special measures to protect people, following an inspection in September.

Clare Court Care Home, run by Avery Homes (Nelson) Limited, is a residential care home providing accommodation and personal care for people living with dementia. The service provides support for up to 80 people. At the time of this inspection, 61 people were living at the home.

This inspection was prompted in part by potential concerns shared with CQC about the management of risk of falls following an incident involving a person who was using the service.

Following this inspection, the service’s overall rating has dropped from requires improvement to inadequate, as have the ratings for being safe and well-led. It has again been rated requires improvement for being effective. The caring and responsive ratings have dropped from good to requires improvement.

The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made.

Amanda Lyndon, CQC deputy director of operations in the midlands, said:

“When we inspected Clare Court Care Home, we were disappointed to see leaders didn’t understand the issues they faced which resulted in people receiving a poor level of care.

“Our inspectors found serious concerns due to ineffective systems, the inappropriate use of restraints as well as a number of other serious safety concerns.

“We saw that staff didn’t always follow falls prevention processes which is totally unacceptable and puts people at risk of avoidable harm.

“We were also concerned about people’s safety from abuse, as not all injuries had been investigated. One person had suffered a serious injury resulting in fractures; however, staff didn’t know how it had happened and hadn’t followed up to find out. Although we didn’t see any evidence to suggest the person had been the victim of abuse, the failure to investigate meant this was still a possibility.

“Despite being told at their previous inspection about our concerns around people’s food and water intake, their record keeping was still not to the level we would expect. This meant people remained at risk of unhealthy weight loss.

“We have told Clare Court Care Home where we expect to see rapid and widespread improvements and will continue to monitor them closely to keep people safe while this happens. We will return to check on their progress and won’t hesitate to take action if people are not receiving the care they have a right to expect.”

Inspectors found:

  • Risk assessments did not always provide enough guidance to robustly manage risks
  • Staffing levels were not always adequate
  • Care was not always person centred and did not always reflect people’s wishes
  • We saw and heard evidence about examples of both poor and good practice with regard to promoting dignity respect and independence
  • There was not enough activities or entertainment to keep people occupied. This particularly impacted people who were mainly cared for in their rooms
  • People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.


  • We saw significant improvements in medicines management
  • We saw improvements in staff induction training and support.

The report will be published on CQC’s website in the next few days.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.