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.
A raft of changes have been recommended to the way care homes are run in England after five deaths at one home were linked to neglect. A serious case review into the now-closed Orchid View home in West Sussex found that no one did anything to stop the abuse.
Now the families of those who died are demanding a public inquiry.
ITV News Correspondent Lewis Vaughan Jones reports:
Families of those who died at the now defunct Orchid View care home in West Sussex have welcomed the recommendations of the Serious Case Review into the "institutionalised abuse" their relatives suffered, but are calling for a full public inquiry.
Lesley Lincoln, whose mother Enid Trodden died at the Southern Cross run home said she wrote six letters of complaints, all of which were ignored by the company.
"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."
Mrs Lincoln said that a public inquiry could lead to greater responsibility being laid at the hands of companies running the homes.
Publishing the findings of the review, Nick Georgiou said:
"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 Serious Case Review (SCR) into a care home run by Southern Cross has made more than 30 recommendations in a bid to prevent the "institutional abuse" that coroners found contributed to the death of five elderly residents.
The SCR, commissioned by West Sussex Adult Safeguarding Board, made 34 recommendations in its answers to a series of questions asked by the family members of those who died at Orchard View, and how regulations can be improved. Key recommendations include:
It should be a requirement for care businesses to prove they can recruit and sustained skilled staff
Relatives should have a named point of contact within homes
Concerns over safeguarding should be escalated outside the care home, if not dealt with promptly and properly
Emergency services should have named contacts so they can access care home more easily
Care providers should be contractually required to hold open meeting with residents and their relatives on a regular basis - a local authority representative should be invited to this and minutes should be shared
Health and social care inspectorate body the Care Quality Commission said they were "appalled" by the Serious Case Review into the deaths of five residents of Orchard View care home, and admitted they did not act quickly enough.
They were criticised by the coroners report into the death for giving the home a "good" rating a year before shutting it down.
Chief Inspector Andrea Sutcliffe said the blame for the "sub-optimal" care lay with those working in the home.
I was appalled by the descriptions of what had happened at Orchid View. Today’s Serious Case Review once again shows what a truly tragic situation this was and my thoughts remain with the people who suffered such awful care and with their families.
The Serious Case Review shows the primary responsibility for these failings rests with the people providing services at Orchid View, together with their owners Southern Cross.
Ms Sutcliffe admitted the Care Quality Commission missed early warning signs, and did not act quickly or strongly enough. She said:
At CQC we made a commitment to take a long, hard look at our role, make sure lessons were learned - and most importantly - turn those lessons into action.
We know from our own review that we did not fulfil our purpose of making sure Orchid View provided services to people that were safe, compassionate and high quality.
Linzi Collings, whose mother Jean Halfpenny died whilst living at the £3,000-a-month home said she was appalled and baffled by the findings of the coroner's inquest and called for home owners to be more accountable.
Speaking ahead of the Serious Case review into her death due to be published this afternoon, she said:
"How the corporate failings of Southern Cross could create these events and how such terrible standards could go unnoticed by the authorities for so long has left us baffled.
"In this day and age you expect measures to be in place to protect vulnerable members of society from being subjected to such horrendously poor care.
"We believe dramatic changes are needed to the current care system, starting firstly with greater accountability for care home owners if they are found to be making unnecessary mistakes and offering substandard services."
The coroner at the inquest into the deaths last October said all residents suffered "sub-optimal" care, but five people, Wilfred Gardner, Margaret Tucker, Enid Trodden, John Holmes, and Jean Halfpenny, died from natural causes "which had been attributed to by neglect". She said:
There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it.
This, to me, was from the top down. It was completely mismanaged and understaffed and failed to provide a safe environment for residents.
A Serious Case Review (SCR) will be published today into the deaths of five elderly people who died after suffering neglect at a Southern Cross-run care home in Copthorne.
The review into the now-defunct Orchard View care home, will say the home was riddled with "institutionalised abuse".
Following a five-week inquest last October, coroner Penelope Schofield heavily criticised the quality of care at the home, and questioned why the Care Quality Commission inspection a year before it was shut gave it a "good" rating.