Family members of residents who died at "Britain's worst care home" have called for a public inquiry after a Serious Case Review (SCR) has made more than 30 recommendations in a bid to prevent a repeat of the "institutionalised abuse" which led to the death of five elderly people.
The SCR was launched following an inquest held last year which found serious failings at the now-defunct Orchid View.
West Sussex coroner Penelope Schofield heavily criticised the quality of care at the Southern Cross-run home in Copthorne and identified failings such as a lack of respect for the dignity of residents, poor nutrition and hydration, mismanagement of medication and a lack of staff, she said.
Call bells were often not answered for long periods or could not be reached, and the home was deemed "an accident waiting to happen", the inquest heard.
Ms Schofield said at the inquest's conclusion: "There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it."
The SCR, commissioned by West Sussex Adult Safeguarding Board, has now made 34 recommendations in its answers to a series of questions asked by the family members of those who died at Orchid View on how care homes and their regulations can be improved.
Russell Tucker, 54, from Oswestry, Staffordshire, whose mother, Margaret Tucker, 77, died at Orchid View, welcomed the SCR but said the recommendations needed to be examined and applied nationally.
He said there had been other SCRs across the country but action needed to be taken by the Government to ensure the same conditions could not be repeated.
He said: "It doesn't go far enough, we know the remit was tight, useful information has come out on a local basis but equally issues have come out that impact nationally that is outside the remit and given that is the case, we think it does warrant a full public inquiry.
"The Government needs to step up to the mark and behave responsibly, The private sector is not the place for the care of the most vulnerable in society and it has failed."
His sister, Theresa Kearsey, 61, from Crawley, Sussex, added: "We are sad and angry because it shouldn't have happened in the first place and we just want to make sure it doesn't happen to anyone else's mum or dad or relative. She didn't deserve to die that way."
One of the main SCR recommendations is that it should be a requirement for care businesses to prove that they can recruit and sustain a trained and skilled workforce and that they can prove this to the Care Quality Commission (CQC) - the care watchdog and regulator.
Another states that relatives should always have a named point of contact within homes and that concerns relating to safeguarding issues should be escalated outside the home if they are not dealt with promptly and properly. And also the emergency services should have named contacts so that they have easier access to care homes, particularly at night.
Other recommendations include a call for care providers to be contractually required to hold open meetings with residents and their relatives on a regular basis to discuss issues of general concern and to make relatives aware of any significant safeguarding concerns in their home. The local authority should be invited to this and the minutes should be shared, the report states.
And it calls for residents to be involved in CQC inspections with opportunities for their relatives to meet and discuss the care home with the inspection team.
Lesley Lincoln, 66, from Copthorne, whose mother Enid Trodden, 86, died at Orchid View, welcomed the recommendation for more consultation with relatives at care homes.
She said: "Possibly it would have solved some problems if you feel there's a direct route to address your concerns. You feel so alone, I feel very guilty, I wrote six letters of complaint and they weren't taken seriously, some of these deaths may not have happened if they had been taken seriously."
She added that a public inquiry could lead to corporate responsibility for organisations such as Southern Cross.
Linzi Collings, 43, from Dunstable, Befordshire, daughter of Orchid View resident Jean Halfpenny, said: "The SCR is certainly thorough in terms of making recommendations in terms of involving all the local agencies, in trying to to get them to work together and build up a picture so this shouldn't happen again.
"But Southern Cross were outside the remit of this review and there's nothing to stop a large organisation setting up and doing what it did at Orchid View. We need all these things joined up nationally and only a public inquiry can do and I do not think any major change will occur otherwise."
The SCR also makes the recommendation that West Sussex Adult Safeguarding Board should develop a threshold for informing the public about significant safeguarding issues and concerns that have been raised at homes. This would help people make informed choices about the homes they choose for their loved ones. The report states that organisations should make it very clear where and how this information can be accessed, known as a duty of candour.
Nick Georgiou, independent chairman of the SCR, said that he supported calls for the independent care home sector to be placed under the same scrutiny as care under the NHS.
Highlighting three main issues, he said: "Firstly, a number of the concerns identified in the recent past with hospital services in the NHS have been echoed at Orchid View and it is right that the scrutiny and demands for improvement in the NHS are also expected from the independent sector.
"As a result of the concerns about the NHS there have been recent government consultations relating to a duty of candour, the fit and proper person test, and a new offence of wilful neglect where people have mental capacity. This Serious Case Review wholeheartedly supports them being applied to independent sector businesses and organisations.
"As the role of independent sector care businesses has grown, the number, frailty and vulnerability of people dependent on their care has increased. It is critically important that these services demonstrate that they can provide the quality of care necessary. In this case the service provider failed. A number of these recommendations are intended to promote strengthened scrutiny of organisations, and the services they provide.
"Secondly, people were making crucial decisions about their care, or that of their relative, and did so without full information about the home, and were largely dependent on the services and self proclaimed quality described in Southern Cross Healthcare's own publicity. They were also ill-informed by the information on the CQC website and unaware of the concerns that the statutory sector had about the home. This was a particular problem for people paying for their own care.
"Thirdly, a great deal of work has gone into building this picture of the care at Orchid View and the volume of problems in the home. With the benefit of hindsight the pattern of safeguarding concerns is now clear, for example in regard to medication, and consistent failures by the people working in the home, and the senior management of Southern Cross Healthcare, to provide positive management and leadership. This was not the case for the social work and nursing staff involved at the time. Firm evidence and information about concerns, and the inability of Southern Cross Healthcare to follow through on remedial actions emerged piecemeal and as the safeguarding investigations ended Orchid View was closed."
He added: "I want to acknowledge the information and understanding I gained from the families of former residents at Orchid View. I hope this report goes some way to addressing the serious and thoughtful questions they put to me based on their direct experience of the poor care their relatives endured.
"Finally, I want to say that it is not possible to say that this report or any other will prevent all future safeguarding alerts. It will not do that, but acting on the recommendations will lessen the risk to other residents in other settings. They also promote actions to support the statutory services and the service provider to respond constructively when there are safeguarding concerns to ensure safe and better quality services for people dependent on nursing care."
Responding to the SCR, Peter Catchpole, West Sussex County Council's cabinet member for adult social care and health, said: "What happened at Orchid View was harrowing. We welcome this report and its recommendations. There is nothing more important than looking after the most vulnerable people in our society and in this respect Southern Cross Healthcare has been judged to have failed. Statutory agencies such as West Sussex County Council had no choice but to take action to investigate and ultimately move people from the home to protect them.
"Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones. I want to offer them my condolences and assure them that we will act on the recommendations made in this report and do all we can to ensure that the other agencies involved in managing and regulating the care of our elderly relatives do the same."
At last year's inquest, the coroner questioned whether a CQC inspection which gave Orchid View a "good" rating in 2010 - a year before it shut - was "fit for purpose".
And the coroner expressed incredulity that many staff were still working in the care industry, and that "there could be another Orchid View operating somewhere else".
The inquest looked at the deaths of 19 pensioners at Orchid View after whistleblower Lisa Martin, an administrator at the home, contacted police to raise concerns about the standard of care.
The coroner ruled that all of these residents suffered "sub-optimal" care. But five of the residents - Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77 - died from natural causes "which had been attributed to neglect".
The multimillion-pound home was said to have had a "five-star" feel when it opened in September 2009 which "seduced" families into believing it was well run.
But one staff member at the £3,000-a-month home said: "It was like a car that looked good from the outside but it was knackered."
Residents were left soiled and unattended due to staff shortages, while in a single night shift staff made 28 drug errors.
It was shut down in late 2011 after an investigation by the CQC. Bereaved relatives called on the Government to usher in "dramatic changes" to improve care standards.
Medical law experts at Irwin Mitchell, representing seven family members, said a SCR was only the first step and are supporting the families' demand for a public inquiry into the regulation of the care industry.
The call follows further high-profile care home exposes including undercover footage of abuse at The Old Deanery Care Home in Essex in April, as well as a CQC report into standards at Francis Court, which re-opened on the same site as Orchid View following its closure, having "serious failures" in staffing levels and resource during an inspection in October 2013.
Laura Barlow, a specialist medical negligence lawyer at Irwin Mitchell, said: "The recommendations in the review are comprehensive and apply to many different organisations both locally and nationally, but for real change to occur they must be delivered and there are questions over who will now drive these improvements and who is ultimately accountable not only for the neglect at Orchid View but at other care homes across the country.
"What is clear is that the independent sector needs to be subject to the same level of scrutiny that the NHS expects. The fact is that we have an ageing population and the number of vulnerable older people is rising significantly and the whole care industry needs to find a way to support them while keeping resident safety at its core.
"We still believe the horrific scale of neglect warrants a completely independent inquiry which would take into account this Review as well as pulling together all the organisations involved in safeguarding care to provide a true blueprint for change in reforming the whole care industry - this must be the lasting legacy of the Orchid View scandal."
Judith Wright, chairwoman of the West Sussex Adult's Safeguarding Board, said: "We welcome this report and its recommendations. We know that, for the families of residents in the home, nothing can bring back the people they loved and lost.
"However we will work with other organisations to ensure that the recommendations outlined in this report are adopted."
Janet Morrison, chief executive of the charity Independent Age, said: "The care home sector is at a crossroads, with public confidence in it worryingly low. Following this and other scandals care home providers must do more to reassure the public that there is zero tolerance of abuse.
"The care business must open itself up to greater scrutiny and ensure staff are properly trained and managed. Relatives must be allowed to be more involved if safeguarding issues are raised to avoid the horrific repeat of 'institutionalised abuse' highlighted at the Orchid View care home."
Mr Georgiou said at a press conference at West Sussex County Council County Hall in Chichester, that he believed a public inquiry looking at the national care industry could have "merit".
He said: "I think there's merit in trying to grasp that broader understanding. In terms of what can be done about what happened at Orchid View we are not going to get much further.
"If you were looking at something further in, it would depend on what the terms of reference were.
"The terms of reference would have to relate to how society as a whole works across the agencies, NHS, local government and the independent sector in how it provides care for older people and the resources it puts into it."
He added that a new law of wilful neglect was needed to provide accountability for what happened at Orchid View.
He said: "It's quite appalling there has been no accountability and I think a law change to wilful neglect would make a difference."
Describing the care at Orchid View, he added: "It was poor care, it was not managed, it was not well-led, it was haphazard.
"There were several instances where people were just left in their room, they didn't want to hear people calling out, there were clearly significant problems with medication, medication wasn't delivered on time and accurately.
"There were some instances where treatment was rough but I have no evidence that people were assaulted in the way that was shown in a recent Panorama programme.
Adrian Hughes, deputy chief inspector adult social care for CQC, said that an ongoing Government review had given it more powers to intervene in cases such as Orchid View.
He said: "We should have stepped in, we should have listened to what people were telling us, brought it together and inspected earlier, we took our eye off the ball.
"We believe there are steps, changes for us as an organisation that have been made, we have got more teeth now than we did and the Government has started to make changes to the regulations."