By Paul Burnell
BBC Radio 4's File On 4
Tim Thompson was horrified at the state of the care home where his 96-year-old grandmother lived.
Relatives of elderly people in care have criticised CSCI
It was not just the soiled carpets that worried him but his grandmother's rapid deterioration in the Edendale Care Home, Wisbech, Cambs.
He was so desperate he even contemplated "rescuing" her from the home, only to be warned he did not have power of attorney over the dementia patient and would be reported to the police if he removed her.
Mr Thompson hoped reporting the home to the Commission for Social Care Inspection (CSCI) would see an independent investigation improve the care his grandmother and others would receive.
He expected unannounced spot checks - but, to his shock, his three-page letter was sent to the home's temporary manager, who effectively investigated herself and said action had been taken.
"It was unbelievable," Mr Thompson, told a BBC Radio 4's File On 4 programme investigation.
The CSCI decided not to investigate.
Mike Rourke, its business director for inspection, regulation and review, told BBC Radio 4's File On 4 programme: "We don't believe we have the authority to investigate individual complaints."
Mr Thompson had raised concerns with staff at Edendale about an elderly male resident with dementia who had threatened his grandmother. Mr Thompson asked for them to be kept apart.
Tragically for another resident, D-Day veteran Arthur Woods, 86, Mr Thompson's fears proved founded.
An attack by the same resident left Mr Woods unrecognisable, with his face and head just a "mass of blood and bruising", according to his son Andrew.
Called to hospital in the early hours of 22 October 2005, he was warned by nursing staff to prepare for a shock when he went to see his father.
Still wondering how his father received such serious injuries, he was told by the ambulance man, who took the war veteran to hospital, he ought to call the police.
Mr Woods senior died five days later.
The inquest into Mr Woods's death heard that sickness cover was not provided for a staff member on the night of the attack, leaving just two staff to cover more than 25 residents in a home where it was difficult to monitor all parts of the building.
Mr Woods was assaulted out of sight of the staff in the L-shaped building.
It also emerged at the inquest that, after his death, two CSCI inspections found inadequate staffing, especially at night, high levels of staff absenteeism, no monitoring of sickness levels, a lack of supervision and no training in adult protection for care staff.
Yet when Mr Woods later complained to CSCI he was told: "The inspection process looks at rotas to ensure the home is adequately staffed at all times."
The coroner also wrote to the government and the CCSI pointing out the need for minimum staffing levels.
He also said a permanent home manager should have been found sooner.
The lack of a permanent manager was highlighted by the coroner as part of the systems failure that contributed to Mr Woods's death.
The CSCI's Mr Rourke said the agency had recommended changes at the home and the issues had been addressed.
But a group that campaigns on behalf of elderly people in care and their relatives argues the CSCI's overall approach is flawed.
Dr Gillian Dalley, chief executive of the Relatives and Residents Association, said: "There's a real problem with the inspection process, CSCI has undergone huge budget cuts, the number of inspectors has been reduced pretty substantially over the past 18 months."
Dr Dalley added the CSCI did not always enforce recommendations to nursing homes and the same problems seemed to reoccur in the homes.
Ivan Lewis, Minister for Care Services, told the BBC a review of elderly care regulation would be undertaken in the run up to the creation of a new super-regulator Ofcare, which was due to come into effect next year.
He said: "It is a question of whether there needs to be some level of appeal for relatives if you are not satisfied with the way a home has dealt with a complaint."
Mr Lewis said the CSCI's main role was registration and inspection "which is not the same as dealing with complaint".
For more about this issue listen to File On 4 on BBC Radio 4, on Tuesday 18 September 2007 at 2000 BST, repeated on Sunday 23 September 1700 BST.