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."