Inspectors have written a damning report on a flagship care home in Marlborough. A team from the Care Quality Commission visited Coombe End House in London Road after families complained about the standard of care their elderly relatives were getting.

The inspectors found some residents with dirty fingernails and some women in the dementia unit had greasy hair. Some residents could not reach their call bells to summon assistance or go to the toilet.

One resident was lifted in a hoist to be put in a wheelchair only for the carer to realise no wheelchair was available leaving the resident suspended in the hoist until one was found.

The report said statistics showed that more people have had serious injuries resulting from falls in Coombe End than in other similar homes and the inspection team found that some staff were unaware some residents had a history of falls.

Inspectors heard one woman resident with her arm in a sling cry out in pain when carers used a wrong technique to lift her. Concerns were expressed about residents losing weight and one resident was described as “thin and frail”. However, there was praise for the chef and one carer for the way they encouraged people to eat.

The CQC report said there were “mixed reactions from relatives” but its own inspection team discovered a catalogue of concerns, including residents being called “darling”, “lovey” or “deary” by staff when, said the report: “it is particularly important that people are addressed by their own name”.

But allegations about low staffing levels were not substantiated. The 60-bed home was purpose built in 2006 when the Orders of St John Care Trust took over the former council-run Coombe End House and demolished the original building which no longer complied with health care standards.

The criticism comes just two months after manager Sue Linsley was voted Nurse of the Year for her work with dementia sufferers at the home. Mrs Linsley who has run the home since 2005 was not available to comment and OSJ issued a statement saying: “A recent inspection by the CQC identified shortcomings in certain aspects of care delivery at Coombe End Court.

“This is a disappointment as the previous CQC inspection, in May 2009, awarded the home a three star, ‘excellent’ rating.

“As a charitable care provider we take very seriously the care and well-being of our residents and remedial action plans have already been put in place.

“This was the home’s first inspection under new regulations that came into force in 2010.”