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CQC report explained · a nursing home, run by Avery

Clare Court Care Home

Clinton Street, Winson Green, Birmingham, B18 4BJ

Requires improvementpublished 28 October 2025, 10 months ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The latest report, explained

What inspectors found, February 2024

Rated Inadequate and placed in special measures; inspectors found people at risk from poor safety systems, staffing concerns and inconsistent care.

This was an unannounced inspection after CQC received information about an incident and possible falls risks. Inspectors visited on 19 and 20 September 2023, spoke with people, relatives and staff, and reviewed care plans, medicines records and other documents.

The home was not consistently safe. Risk assessments, checks on people's wellbeing, falls investigations and staffing arrangements were not reliable. Inspectors also found serious injuries had not always been investigated promptly, and found inappropriate low-level restraint without proper assessment or guidance.

There were some improvements. Medicines were managed much more safely, staff induction and training had improved, and people said they enjoyed the food. However, care was not always personal, respectful or responsive, and quality checks had failed to identify or correct important problems.

The overall rating fell from Requires Improvement to Inadequate. All five areas were rated below Good, with Safe and Well-led rated Inadequate. The home is in special measures, so CQC will keep it under review and usually re-inspect within six months.

What inspectors praised

  • Infection control

    The inspectors were assured that the home had suitable arrangements for preventing and managing infection outbreaks and for using protective equipment.

    “We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report

  • Communication

    Staff understood how to communicate with people living with dementia and adapted their communication to people's needs.

    “People were supported by staff who understood their communication needs.” from the report

  • Consent work

    The home had improved its use of capacity assessments and recorded best-interests decisions. It was no longer in breach of the regulation about consent.

    “Improvement has been made at this inspection and the service is no longer in breach of regulation 11.” from the report

  • People enjoyed the food

    Although food and drink monitoring was not reliable for some people, people told inspectors that they liked the food and were offered meals suitable for their culture.

    “People told us they enjoyed the food.” from the report
What inspectors were concerned about

  • People were at risk of avoidable harm

    serious

    Risk assessments and safety monitoring were not consistently strong enough. Falls and serious injuries were not always investigated promptly, and some people could not reach their call alarm.

    “Systems to assess, monitor and mitigate risk to health, safety and welfare of people using the service were not always effective.” from the report

  • Safeguarding and restraint

    serious

    Some serious injuries were not investigated when they happened. Inspectors also found low-level restraint that had not been properly assessed or explained to staff, and problems with legal authorisations for deprivation of liberty.

    “Systems had failed to safeguard people from the risk of abuse and improper treatment.” from the report

  • Staffing levels

    serious

    People, relatives and most staff reported staffing concerns. On one occasion it took 18 minutes to find a free carer to help someone.

    “Systems to ensure people were supported by appropriately checked and safe numbers of staff were not robust.” from the report

  • Limited activities

    needs fixing

    People, especially those cared for mainly in their rooms, were left without enough to do for long periods. This increased the risk of isolation and poorer mental wellbeing.

    “People were not provided with sufficient means to engage and stimulate them through the day.” from the report

  • Privacy and dignity

    needs fixing

    Inspectors saw staff entering rooms without knocking and some people were not supported in a dignified way. There were also examples of people being ignored or left without clear wellbeing checks.

    “We saw some examples of people's privacy and dignity not being respected.” from the report

  • Weak quality checks

    serious

    The home's monitoring systems did not identify or correct repeated problems with weight loss, choking risks, falls, staffing and the cleanliness of carpets.

    “Quality assurance systems had failed to ensure risks to people were reviewed in a timely manner to prevent further risks.” from the report
Questions to ask them, based on this report
  1. 01What has changed since the inspection to prevent falls and ensure serious injuries are investigated and reported promptly?
  2. 02How many staff are planned for each floor and shift, and how do you check that staffing is enough when people need help?
  3. 03How are call bells, wellbeing checks, weight loss and choking risks now recorded and reviewed?
  4. 04What safeguards are now in place to prevent inappropriate restraint and to keep deprivation of liberty authorisations up to date?
  5. 05What activities are now available, especially for people who spend most of their time in their rooms, and how are complaints followed up?

This was an unannounced comprehensive inspection covering all five key questions, prompted partly by concerns about falls and other risks; the home was also checked for infection prevention and control. This explanation was written from the published report of 3 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Clare Court Care Home

4 rated inspections over 5 years: the service has slipped, from Good to Inadequate.

  1. February 2024Inadequatecurrent ratingdown from Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate

    Read what inspectors found at Clare Court Care Home →

  2. September 2022Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementWell-led: Requires improvement

    We are reading this report · the original is on cqc.org.uk

  3. January 2022Requires improvementdown from Good
    Safe: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. October 2018Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. December 2016

    Registered with the Care Quality Commission on 9 December 2016.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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