In the latest in a series looking at care of the elderly in the UK, the Today programme examines the role of the watchdog which inspects care homes in England.
CSCI regulates, inspects and reviews all adult care services in England
"It is a watchdog without any teeth or even a will to act."
John Matthews' condemnation of the Commission for Social Care Inspection (CSCI), which oversees 18,500 care homes in England, is strong.
While complaints about standards of elderly care are not unusual, what makes Mr Matthews' view important is that he is the coroner for the Isle of Wight.
Last year, he recorded a verdict of accidental death contributed by neglect after a 93-year-old man died following a fall.
He was found in a road, half-a-mile away from the care home where he lived. He had a tendency to wander off and on this occasion, he had wandered off unnoticed.
What came to light during the inquest was that eight months prior to his death, a CSCI inspector had discovered there were no risk assessments in residents' files.
This was supposed to be rectified by July 2006 but according to the coroner "nothing was done at all".
Mr Matthews condemned the CSCI as "toothless" and "worse than useless".
"I used those words quite deliberately because it was being dressed up as though there was some institution which had this role when in reality it wasn't doing anything," he said.
If we were to check that every requirement for every inspection has been delivered it would not be feasible given the scale of the task and the resources we've got
Mike Rourke, CSCI
"The public was misled into thinking there was protection which existed which in fact didn't."
In April 2004, the CSCI replaced the National Care Standards Commission, which itself had been formed to take over inspections from local authorities.
"In my view what would have happened in the past is the council or National Care Standards Commission would have inspected the home again shortly after the deadline to make sure it was now in compliance," said Mr Matthews.
Mike Rourke from CSCI said: "Our view is that we made it very clear to the provider what they needed to do and we would look to them to deliver their responsibilities.
"And if we were to check that every requirement for every inspection has been delivered it would not be feasible given the scale of the task and the resources we've got."
Unless they (CSCI) follow up what they have told owners to do, then they don't seem to serve an effective purpose in protecting the most vulnerable members of society
The watchdog says it is now taking action to enforce the law more often. But next year, CSCI will cease to exist.
Following two re-organisations in six years, care home regulation is to be re-organised again. CSCI is to merge with the Healthcare Commission, which inspects hospitals, and the Mental Health Act Commission.
The CSCI's duties include inspecting homes against national minimum standards, set by the government, and publishing a report after each inspection.
It sets out what the home did well and what it needs to improve, and according to the watchdog's website its inspectors will work with the service to make sure improvements happen quickly.
But for the family of Henry Montague, the changes came too late.
In March 2006, Mr Montague was admitted to Eastbourne District General Hospital, south-east England, with severe facial burns.
His face was "grossly swollen" and "beyond recognition" according to a doctor who treated him.
Henry Montague spent 10 months in hospital
Mr Montague, then 80, had fallen out of his bed at the Farmstead Nursing Home, in Hellingly, and onto the hot water pipe which lay exposed on the wall.
It was a risk which the home had been made aware of some three months earlier.
A CSCI inspector had visited in December 2005.
"The hot and cold water pipes in some bathrooms and residents' rooms were not covered. The expectation is that they are boxed in to protect residents," she wrote.
But by March, in Mr Montague's room at least, that had not happened.
His daughter said: "We were shocked that the matter had been brought to the owner's attention and nothing had been done and that nobody had thought it was a sufficiently serious matter to remedy straight away."
The CSCI did not impose a legal requirement for the pipes to be covered and a CSCI spokesman said there would have been "a clear expectation that the provider would have taken action to rectify issues identified in the inspection".
But care home owner Ernie Graham says the CSCI had agreed an "action plan" for the work to be carried out by the end of March. He stressed that the inspector had not seen the specific pipe in Mr Montague's room.
Mr Montague, who suffered from dementia, spent 10 months in hospital and died four months later.
Mr Montague's daughter believes if the CSCI's recommendations had been properly enforced, then their father's accident would not have happened.
She said: "I would have expected CSCI to have told the owners that unless they make sure these matters were remedied immediately, within the next 24 to 48 hours, that the home would not be able to continue operating.
"What you have is a toothless organisation because unless they follow up what they have told owners to do, then they don't seem to serve an effective purpose in protecting the most vulnerable members of society."
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