A Serious Case Review in to the abuse of patients at a Hambrook care home has criticised the owners, the local NHS and police.
Residents at Winterbourne View which looked after adults with learning difficulties were subjected to both verbal and physical abuse at the hands of eleven members of staff.
The ill treatment only came to light after an undercover report by Panorama showed patients being restrained and assaulted.
A Serious Case Review has criticised those in charge and local authorities for not acting affectively on complaints from patients' families and information from a whistle-blower about what was going on.
The report states that the owners, Castlebeck Ltd, were more interested in the financial rewards of running the home rather than the level of care they provided.
Margret Flynn, the independent chair of the review, said: "This review confirms many of things that we've known for such a long time about the dangers of closed institutions, about the dangers of not having managers in place and about disregarding the voices of people with learning disabilities and autism and about ignoring their families."
Since the abuse was uncovered the home has been closed and the residents moved to other facilities. Efforts have also been made to improve the communication between local authorities.
Head of Avon and Somerset Police CID, Detective Chief Superintendent Louisa Rolfe, said: "Like everyone who watched the Panorama programme we were very shocked at what we saw. No-one should be forced to suffer the appalling and abusive treatment that these victims were subjected to.
"Vulnerable adults deserve the same level of expertise and professional understanding as vulnerable children. As Force Champion it's my job to ensure that we hear their voice and recognise their right to advocacy aside from their immediate carers.
"We take our safeguarding responsibilities very seriously and welcome the independent scrutiny of the Serious Case Review. Comprehensive changes to our safeguarding service over the last year will ensure that the same 'golden thread' principles used in child protection to put the victim at the heart of safeguarding applies in exactly the same way to safeguarding adults."
All eleven members of staff have pleaded guilty to charges of ill-treatment under the Mental Health Act and will be sentenced in a few weeks' time.
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