Why, despite the universalist aspiration of the British welfare state, was institutional care for poor older people so frequently condemned as inferior? This article seeks an answer in the period before 1945, when local government reform might potentially have raised quality. It adopts a regional case study approach, arguing that this permits access to relevant quantitative and qualitative evidence obscured in national sources, and that concentration on urban experience has hitherto produced a distorted picture. It finds that in contrast to the expansive municipal medical services targeted at the broader population, in this area the assumptions, administrative structures and material inheritance of the Poor Law impeded change and constrained resources. © 2012 Copyright Taylor and Francis Group, LLC.