Walter* was in his 80s when he moved into Marco Polo Aged Care Woonona.
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The elderly man had been cared for full time by his son, but after a stroke increasingly required more care than the family could provide on their own.
"He's paralysed on the right side of his body, he couldn't talk [but] he was cognitive," his son said.
Between the four siblings, someone was in to care for Walter almost every day, but often, they were the only ones providing any care.
"We went in the morning, got him prepared, because staff were so hard to find," a son said.
After moving into the home in 2019, the family started to see a slow deterioration in Walter's condition. At the same time, staff to take care of Walter became harder and harder to find.
One of the sons started taking notes.
"Dad still lying in bed in a soiled nappy. No staff available," one note reads.
"Got into his room @ 10 40am he was still lying in urine soaked sheets with no staff available."
"We went for coffees and came back to his room after 1-1/2 hours and then make his bed up and still had not had any attention from staff that I still couldn't find."
Early one morning in August, one of the sons received a call from staff telling him he had to come now.
Living only minutes away, the son alerted the other relatives and headed over.
On the way, he received another call, telling him that he had to come and asking how far away he was.
By the time he got to his father's room, the nurse there was in tears.
There is one entry in the notes for the next day.
"Room emptied 10.45am."
Last week, the Aged Care Quality and Safety Commission delivered a damning report into Marco Polo Aged Care Woonona that details the conditions Walter and his family were facing.
The report highlights that a lack of staff was a key factor behind the lack of care residents experienced.
However, one former manager at Marco Polo said that staff shortages could be found at any aged care facility in Australia.
"I can walk into Uniting Care across the road and they have all this money and all this funding," the former manager said.
"I'm guaranteeing if I sat in the staff room you're going to hear the same complaints about being short staffed and understaffed."
"You can't keep blaming it on staff if you've got a good number of staff that have a good skill set and a great management team that leads by example."
The manager acknowledged that the additional compliance burden placed on aged care in Australia was significant, but that Marco Polo cut staff and programs to stay afloat.
"Marco Polo has let itself down, because it was doing so well.
"No one wants to stay if the culture of the place is bad, that's why Marco Polo has let itself down."
Seeing the performance report issued on their former workplace, the manager said they were devastated.
"Absolutely devastated. We were a big family, and all work together for a common goal, to be a place where I would want to put my grandparents."
"[Now] I wont ever. I have seen too much and know too much."
Marco Polo management were contacted for comment but no response was received before deadline.
*Name has been changed.
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