More than 30 recommendations have been made in a Serious Case Review (SCR) in a bid to prevent a repeat of the "institutionalised abuse" which led to the death of five elderly people at a scandal-hit care home.
The inquiry was launched following an inquest held last year which found serious failings at the now-defunct Orchid View, labelled "Britain's worst care home".
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.
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.
One of the main 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 easier access to care homes, particularly at night time.
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.