Penelope Schofield, the West Sussex coroner, 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.
Ms Schofield said it was "disgraceful" that the home was allowed to be run in the way it was for around two years. She criticised the Care Quality Commission (CQC) which gave Orchid View a "good" rating in 2010 - a year before it shut.
I question how this could be the case and I question whether the inspection that did take place was fit for purpose.
It's a heart-breaking case. We all have parents who will probably need care in the latter part of their lives.
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