A Rainworth care home was found in crisis after carers “neglected” a dementia patient and left a chest infection unchecked, eventually leading to his death.
Now the local government ombudsman is to carry out an investigation into the care of Ronald Steele.
Mr Steele’s family said he was in pain for six weeks before Ashlands Residential Care Home staff called for an ambulance, and had shed stones of weight as his health deteriorated.
Mr Steele died, aged 85, a few weeks after being taken out of the Southwell Road home.
A safeguarding investigation – launched after hospital staff raised concerns – said the home was “in crisis”. And an inspection by the health watchdog Care Quality Commission a few weeks later found it “required improvement”.
The home said it has been transformed since the inspection and was working through an action plan to resolve any problems.
However, following complaints from Mr Steele’s family, the ombudsman is to carry out an investigation.
In a letter to the family, Damien McInerney, from the ombudsman, said: “I have now assessed your complaint and have decided it does warrant further consideration by our investigation unit.
“I cannot say when an Investigator will be allocated your case but it should be in the next four weeks.”
Mr Steele, a former miner from Mansfield, had long suffered chest complaints, and, his family said, they had found him “soaked and soiled”, at the home.
However, it was not until a chest infection went unchecked that Mr Steele was taken to King’s Mill Hospital, Sutton, and his care was flagged with Nottinghamshire County Council.
When Mr Steele arrived in hospital, doctors found he had bed sores and had lost a substantial amount of weight due to poor diet – weighing only eight-and-a-half stones.
Case worker Stuart Roe attended the care home on April 18 and said in his report Mr Steele’s condition would have been noticeable for several days.
Mr Roe said in his report: “This was not identified by anyone or reacted to.”
He had further concerns that after finding discrepancies in Mr Stone’s weight and height records meant his “risks were underplayed” and “the care home are not accuratelyrecording information”.
In a previous incident, staff took weeks to seek medical attention after Mr Steele had a fall.
Mr Roe said: “At Christmas he fell out of bed and complained his arm hurt for quite a while. It is unclear how long he was on the floor. Finally they called the doctor six to seven weeks later and found he has a chipped bone in his arm.”
In conclusion he wrote: “In recent times there has been a lack of leadership and oversight at the home with successive newly appointed managers focusing on putting their mark on the home, failing and leaving.
“There has been suggestion records kept are plain falsehood and I would agree some of the information is either purposely inaccurate or just plain sloppy.
“I feel Ashland’s care home is in a state of crisis and is not meeting the legal duty of care owed to residents.”
After the report, the family decided not to let Mr Steele return to Ashlands. He stayed in another home for several weeks and passed away on May 11.
No one from the home was available for comment.
New manager 'proud' of transformed care home
Following the report branding Ashlands “in crisis”, owners brought in new management and say a number of issues at the home have been rectified.
Sarah Moore, the new manager, joined the team in July, following the CQC inspecition, and said the home has been transformed.
Speaking in August, she said: “What’s happening now is we’ve got a new management team in place.
“We’re arranging family meetings and we’re arranging meetings with myself and my team to sort out any concerns they may have.
“After I read the report, I spoke to the provider who is very supportive and we’re working our way through the action plan and putting in place all the audits that need doing.
“We’re passionate about what we do here. I’d be proud to show anyone around.”