A coroner has ruled that neglect contributed to the deaths of five elderly people who died after staying at a care home which has come under fierce criticism.
Penelope Schofield, the West Sussex coroner, said there was "institutionalised abuse" at Orchid View care home in Copthorne.
She said those involved in the neglect of pensioners at the now defunct home should be "ashamed" as it was announced a serious case review has been set up.
A five-week inquest heard how some residents were given wrong doses of medication, left soiled and unattended due to staff shortages and there was a lack of management.
Call bells were also often not answered for long periods or could not be reached by elderly people living at the home, which was deemed "an accident waiting to happen".
Ms Schofield 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", Ms Schofield added.
She went on: "It's a heart-breaking case. We all have parents who will probably need care in the latter part of their lives."
And she said a cause for concern was that many people who worked at Orchid View are still working in the industry.
Speaking outside the inquest, Lisa Martin, who first informed police of the problems at the care home, said she felt she had no choice but to come forward.
"I came forward because I had witnessed too much poor management and care to vulnerable adults and I couldn't live with the with knowledge any longer and felt I had no choice but to tell the police," she said.
"Morally I know I did the right thing but personally I have not worked for two years and the case has had a huge impact on my life.
"However, I wouldn't want to dissuade people from doing the right thing if they see vulnerable elderly people being abused and neglected."
Speaking of her former colleagues, she added: "They shouldn't be allowed to work in the industry."
The coroner said 19 residents at Orchid View suffered "sub-optimal" care. All of those residents died from natural causes, she ruled.
But five of those died from natural causes "which had been attributed to by neglect", Ms Schofield ruled. They were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.
The inquest heard that Mrs Halfpenny was overdosed on the blood thinning drug warfarin while at Orchid View, which had failed to monitor and administer her medication properly.
Whistleblower Lisa Martin, who worked as an administrator at the home, said she was asked to shred forms after Mrs Halfpenny had to be admitted to hospital for bleeding.
Meera Reed, an Orchid View manager, looked at the medication administration record (MAR) brought into the office by a nurse and said: "Shit, we can't send her to hospital with those. They will shut us down."
Blank MAR forms were filled out instead, and Ms Martin said she was asked not to disclose the shredding of the original documents to anyone.
Ms Reed denied asking anyone to dispose of the forms, but the coroner ruled that they had been. Ms Schofield also said she was satisfied Mrs Halfpenny was overdosed on warfarin at Orchid View.
Orchid View, which was run by Southern Cross, was closed down in late 2011 after an investigation by the Care Quality Commission (CQC) found it had failed to meet eight of its essential standards of quality and safety.
In the same year, Sussex Police launched an investigation into alleged neglect at the home, in conjunction with the NHS, West Sussex County Council, the CQC and Ms Schofield.
Five people were arrested, including some on suspicion of manslaughter by gross negligence in relation to Mrs Halfpenny's death, but insufficient evidence existed to support a prosecution and the case was passed to the coroner.
The multimillion-pound home was said to have had a "five-star" feel when it opened in September 2009. Its appearance "seduced" families into believing it was well-run.
But one staff member said: "It was like a car that looked good from the outside but it was knackered."
The inquest heard that residents were treated with a lack of respect and dignity, and there were problems with medication and staffing levels.
Linzi Collings, daughter of Jean Halfpenny, said the care home had failed to provide her mother with the "dignity and compassion" she deserved.
She said: "Whilst my sister and I are pleased with the thoroughness of the inquest and we are grateful to the coroner for investigating, the horrific details that have emerged about Orchi d View are beyond comprehension.
"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.
"Our mum deserved to be treated with dignity and compassion but Orchid View failed to provide her with even a basic level of care, despite being paid a significant amount of money to do so.
"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."
Ms Collings, of Dunstable, Bedfordshire, added that she welcomed a further criminal investigation into the running of Orchid View and called the inquest a "wake-up call" for the industry.
She said: "Southern Cross has closed down and no-one has been prosecuted for the catalogue of errors at the home so otther care homes and providers across the UK have nothing to fear by not meeting targets and Care Quality Commission standards.
"Whilst the inquest has provided some answers, we will not be able to move forward until we know measures hvae been put in place to protect elderly and vulnerable people and prevent the same catalogue of errors being repeated.
" If this inquest hasn't been the wake-up call the industry desperately needs, I dread to think how bad things could get.
"We welcome the criminal case being referred back to the CPS as we still have unanswered questions as to who was responsible for the over-administration of warfarin and the subsequent events leading up to our mum's death."
The "final straw" for Ms Martin came when she was told by a nurse that they had found 28 drug errors from just one night shift. She called police who arrived the next day.
Summarising Ms Martin's evidence, Ms Schofield said: "Lisa Martin said she couldn't watch it any more and felt no-one was listening."
Lawyers for some of the families called for a public inquiry to be set up, but the coroner said she will await the outcome of the independently-run Serious Case Review first.
During the inquest, Ms Halfpenny's daughter, Louise Halfpenny, spoke of her concerns about the standard of care at Orchid View, which cost more than £3,000 a month.
She described Sadeo Singh, the senior nurse, as "obnoxious, rude and unprofessional" and who was a problem throughout her mother's stay.
She said: "He pulled my mother out of her chair to a standing position even though she had not been on her feet for six months. My mother was terrified."
She also said that Ms Reed was often not there and would be trying to run the home in her absence, the inquest heard.
She said that on one occasion she arrived at 10am to find her mother in bed, hungry, thirsty and with the curtains drawn.
She told the court a social worker who visited her mother in February 2010 found her naked in bed, crying and complaining that she was cold.
Another resident, dementia sufferer Margaret Tucker, suffered a fractured ankle but the injury was only discovered days later, the inquest heard.
Mrs Tucker's daughter, Patricia Newman, said she "had no confidence in the nursing care" and had "completely lost trust in the home" in the run up to her mother's death.
Staff seemed unable to cope with the residents' needs and any complaints she made to the manager were not followed up, she said.
Unexplained bruises were found on her mother, who died at Orchid View aged 77 in July 2011, and she had also been left partially dressed more than once, Mrs Newman said.
On one occasion, Mrs Tucker was left half hanging out of bed for about two hours. And Mrs Newman expressed concern that her mother was not being supervised properly when taking medication.
She said: "I felt I had to go to the home every day as I had no confidence in the care she was being given.'' She believed the carers wanted to do their job but were "stretched to the limit".
Brenda Mulvaney, whose father John Holmes was at Orchid View, said she got the impression that staff levels were being run on "on a budget" and they were "getting away with the minimum they could".
There was no single point of contact for her father and it was often hard to find a member of staff to talk to, she said in a statement to the inquest.
Staff would make her father wear incontinence pads during the day, when he did not need them, and Ms Mulvaney thought this had been done for convenience.
She added that she had seen another resident being locked in her room, and visited her father one day to find he had been put to bed at 5pm.
Ms Mulvaney said: "In hindsight I regret putting dad into Orchid View. The advice I would offer to anyone else is it is the care that matters, not the home.
"The other homes had not been such flashy buildings but the staff loved their jobs. There were not enough good staff at Orchid View to make it work and as a result the residents did not receive adequate care.''
Mr Holmes's son, Jeffrey Holmes, told the court that in the seven weeks his father was at Orchid View he had lost a stone in weight.
He said: "He would wander around unsupervised. On most occasions when I visited there were no staff around. On some visits it was a struggle to find anyone."
Lindsey Ball, whose father Wilfred Gardner died on May 1 2011, broke down in tears while describing the state she had found him in at the home.
Mrs Ball flew over from her home in Australia to clear her father's flat and went to visit him on April 11 2011.
She said: "I was shocked at the way he looked. I just took one look at him and thought ''he looks terrible'. I actually turned to my son and said, 'I will not be coming home with you'.''
Mrs Ball told the court she never saw a care plan and there were several occasions when her father was in a lot of pain but he was not given medication.
When she was told he had to ask for it, she said: "He's got dementia, how would he know what to say?"
Brian Donaghey, whose mother Maureen Donaghey died on July 27 2011, told the inquest that staffing levels failed to keep pace with the increasing number of residents.
He said they had chosen the home because his 87-year-old mother had dementia but he felt many of the staff did not have the right training to deal with this.
The inquest's conclusion came in the same week that a package of proposals were put forward by the health and social care watchdog to prevent abuse and neglect in care homes.
Hidden cameras and "mystery shoppers" reporting back on their experience of services were among the package of measures put forward.
Ian Christian, of Irwin Mitchell solicitors, which represented seven of the families at the inquest, described the case as a "scandal" which should not be allowed to happen again.
He said: "We have been shocked and appalled by the gross failiings at Orchid View. Despite charging huge sums of money, Southern Cross failed to create a safe supervision and management structure, which led to a rotten culture.
"Multiple members of staff let down those elderly people for whom they were responsible and this had fatal consequences for 19 of its residents.
"We will not rest until we have uncovered exactly how this was able to happen and we are confident the appropriate steps have been taken to stop this happening again.
"These were vulnerable people who used their life savings, or had their families pay money, so they would be cared for in the final stage of their life.
"They ought to have been in safe hands and provided with a standard of care which gave them dignity in their final days. Sadly this could not have been further from the truth.
"How this could happen in a 21st century care home beggars belief, but it did, and the authorities such as the Care Quality Commission and Government need to consider why this was the case and make vast improvements to the industry to ensure negligence on such a large scale can never, ever happen again.
"The Government has made recent announcements about ways to tackle problems with the care industry, but we are yet to see action and that must be the focus."
Mr Christian said the situation at Orchid View raised questions about the quality of care being provided across the industry.
He said: "Before it closed down, Southern Cross owned 752 care homes across a relatively small area of the UK.
"The evidence revealed in this inquest is deeply concerning as it shows signs of profits being put before the well-being of residents.
"Safety should have been the top priority of any organisation involved in caring for others.
"Questions need to be asked about whether the private care route is safe, appropriate way of caring for our ageing population, which is only going to continue growing.
"We believe urgent action is needed to enforce stricter regulation on those who take responsibility for caring for the elderly and vulnerable.
"The management void within Southern Cross was shocking and how that wasn't picked up by those charged with safeguarding the residents of Orchid View is something that cannot be allowed to happen again.
"Homes cannot be allowed to get to crisis point and for lives to be lost because of failings. This inquest needs to prompt an improvement in accountability to show others in the profession that poor care and taking away people's dignity will not be tolerated by our society.
"Nothing can bring back loved ones to the families we represent and, whilst the details of the failings that have been uncovered have been very upsetting, we will continue to support them in seeking justice for their devastating loss."
Amanda Rogers, director of adult services for West Sussex County Council, said: "This was a shocking example of poor care and West Sussex County Council is pleased that it has been exposed.
"As the inquest has made clear, these were serious cases and families had every reason to expect better.
"However, while there may be isolated examples of poor practice, the public should remain confident about the levels of care in the majority of care homes in West Sussex.
"What's good is that these issues are uncovered and dealt with robustly, as the county council did through its safeguarding role. All possible measures were taken to rectify what happened at Orchid View as soon as we became aware of the severity of the problem.
"We hope that these verdicts will go some way in providing some sort of closure for the families."
Julie Jackson, an activities co-ordinator, said Sellotape was used to secure the dressing of one resident. And one staff member said a nurse told her: "They are old and they are dying, what do you want me to do?"
Following the case, Judith Charatan, whose dementia-suffering mother Doris Fielding died of natural causes, said : "I quickly realised that everything that had appealed to me about Orchid View being a safe place for my mum was just cosmetic, such as the fabric of the building and the brochures that marketed it so well.
"The actual standards of care being given were nothing short of appalling.
"I soon lost confidence in the quality of care being provided and became untrusting of what I was being told by staff. At the time I did not know the scale of problems or what had happened before to other residents.
"Not long after being admitted, mum lost weight and seemed disinterested in everything. She often seemed very anxious and agitated and would often repeat herself saying 'Help me' and 'Something is not right'.
"There was either not enough or a high turnover of staff. Problems kept emerging and agencies like the Care Quality Commission and social services would get called in.
"Sometimes there were attempts to make improvements but in the end staff, it would seem, just became very complacent about this. The main problem was that Orchid View was run as purely a commercial venture to make a profit but compromised care standards as a result.
"My mum and elderly people across the country deserve a good quality of life even if they are in failing health or near the end of their lives.
"The Government keeps talking about using Ofsted-style inspections and appointing 'mystery shoppers' but measures like this won't actually tackle the problem with this country's care industry because they are purely cosmetic."
She added: "The Government needs to wake up and take heed. More funding, resources, better training and increased standards amongst those that work in this industry are the only ways to truly tackle the crisis."
Andrea Sutcliffe, the CQC's chief inspector of adult social care, said: "I am shocked at the descriptions of the care received by residents at Orchid View in 2010 and 2011.
"This was completely unacceptable, and I extend my sympathies to the relatives of everyone who received poor care there.
"We need to learn lessons from what happened at Orchid View, which closed in 2011. I will personally oversee a root-and-branch review of our actions in relation to Orchid View to make sure we learn from it and build any findings into our new way of inspecting.
"This week, I outlined my proposals for changing the way we inspect, monitor and regulate care homes to ensure that these services are safe, caring, effective, well-led and responsive to people's needs."