A care home for autistic people was run by a male "gang" who forced residents to eat raw onion, pay for staff lunches and crawl on all fours, a report found.
Residents at Mendip House regularly suffered physical and mental abuse including being pushed, slapped and laughed at.
Staff "put a ribbon around resident's neck and rode him like a horse" and threw one vulnerable male into a swimming pool repeatedly.
Residents had cake thrown at them, had crayons put in their drinks and were made to eat chillis by staff who also dealt drugs on the premises.
Evidence also found staff turned up late because of tattoo appointments or brought their children into work.
The "laddish" behaviour of a group of male carers included forcing autistic people to walk on all fours and playing on a Playstation instead of fulfilling duties.
An anonymous tip-off eventually led to the care home in Highbridge in Somerset being closed in 2016 and an official report into the home has now been published.
The Care Quaility Commission has admitted it should have responded to allegations made in 2014, two years before an investigation was launched.
The report includes details of horrific abuse against six residents and states all the allegations were investigated and staff sacked or suspended.
But it confirms no one faced criminal prosecution.
A report has now been published by the Safeguarding Somerset Adults Board (SSAB).
Richard Crompton, independent Chair of the SSAB, said: "These reviews are not about apportioning blame.
''They are about making sure lessons are learned and improvements made.
"This happened to be in Somerset, but the weaknesses in the system are nationwide and must be considered at that level.
"That is why some of our key recommendations are addressed to the Department of Health and Social Care and national bodies.
"This board exists to protect vulnerable people and reduce the risk of incidents like those at Mendip House happening again.
"This will have been tremendously upsetting for the victims and their families and the board very much thanks them for the support they gave the investigation.
"I know that the agencies involved it have learned lessons and I hope that they can be learned nationally too.''
The care home run by the National Autistic Society was one of six homes on the same site, Somerset Court, in a 'campus' style facility.
There were six residents living in Mendip House from as far away as London.
After an investigation, residents were reimbursed up to £2,000 each after staff manipulated them into paying for their meals.
One resident, aged in her 20s, vanished from the site without members of staff noticing in 2015, and again the next year.
An anonymous letter to the Care Quaility Commission reported that staff repeatedly threw a resident into a public swimming pool, despite being told not to.
The same resident was said to have been made to eat chillies, and regularly suffered physical abuse including being pushed and slapped, as well as being laughed at.
Six employees were suspended after whistleblowers tipped off inspectors in May 2016.
A man in his 50s, who asked for a biscuit, was instead given a raw onion and sent to his room when he refused to eat it, the shocking report claims.
And when a resident baked a cake, staff members lobbed it at other men and women in their care.
When police were called in for a meeting with safeguarding staff from Somerset County Council in May 2016, it was established that for 18 months Mendip House was dominated by a "gang" of controlling male staff.
By August that year, five members of staff including the manager and the deputy were dismissed, and the manager of the site was suspended, and two final warnings were issued to staff members.
The report detailed "lads messing about" and described staff as "boisterous males", who played on the Playstation rather than taking residents on outings, taunted the people in their care, and sexual discussions at work.
Despite this, in November 2016 police confirmed there was "no likelihood" of a criminal prosecution, although it later emerged that an incorrect address was provided for one of the suspects and that another refused to answer calls.
After the care home closed on October 31 2016, the CQC committed to paying close attention to other care homes run by NAS nationally.
NAS said in the report that there was a "factional, laddish culture at Mendip House", and "there is a general practice of ignoring the mobile phone policy across the whole of the Somerset Court site."
Although the national charity kept records with "critical information about Somerset Court, including poor staff conduct, alleged assaults and drug use or sale" the information was not shared beyond senior managers at Somerset House, who failed to act.
In the wake of the closure of Mendip House, a Safeguarding Adults Review was carried out which made a series of recommendations to national changes to the way care homes were run.
It suggested that the Care Quality Commission (CQC) makes clear in its inspection reports that it will no longer register 'campus' model care arrangements - where a small number of individual residents live in units managed and resourced centrally.
Recommendations were made that the Department of Health and Social Care, NHS England and the Local Government Association carry out a national consultation on steps to regulate of the commissioning of care placements, in order to assign responsibility for monitoring care.
Superintendent Mike Prior, of Avon and Somerset Constabulary, said that despite a police investigation, no charges were pressed due to a lack of evidence.
He said: "We carried out a thorough investigation as a result of concerns raised to the Care Quality Commission.
"The scope extended across agencies but we worked very closely in particular with the CQC.
"As the investigation progressed we encountered some evidential challenges due to the vulnerability of the residents living in Mendip View.
"Allegations of abuse against vulnerable people are always considered against the highest public interest threshold, but on this occasion the evidential test required to bring criminal charges was not met.
"Whist some of the activities could have been criminal if proven, others related more to poor leadership and working practices.
"In light of the lack of evidence we agreed with the CQC that the best route for the victims was via the powers available to the regulator, involving closure of the home and dismissal of staff."
The National Autistic Society (NAS) apologised to the residents of Mendip House.
In a statement in the report, it apologised to "all of the individuals concerned at Mendip House for our poor standards and practice which led to their abuse."
It added: "We take responsibility for the failure of our managers and the failure in this case, of our systems to spot those failures.
"Our responses were slow and lacked coordination. Quality monitoring visits weren't delivering [because] no trends were identified.
"Now, there is much greater emphasis on putting values into practice. Our policies and procedures have been made clear and streamlined. "
Link to original article: https://www.mirror.co.uk/news/uk-news/autism-home-staff-rode-residents-11990547