Monitoring of two Devon care homes where vulnerable residents were abused was “inadequate at best”, a safeguarding review heard.
One family member said life for residents at Vielstone near Bideford, Devon, was a “catalogue of horrors”.
Oversight from watchdogs the Care Quality Commission (CQC) “wasn’t there”, another family member told the review.
The CQC said it “should have responded more quickly to the concerns raised”.
People with autism and learning disabilities at Vielstone were routinely punished by being held in empty rooms without food, heating or a toilet, a court heard in 2017.
Staff imprisoned them in the rooms, often overnight, during 2010 and 2011, as an abusive culture developed.
Bristol Crown Court heard that residents were left in the rooms more than 1,000 times with no furniture or a television for hours at a time.
The incidents took place at both Vielstone and its sister home Gatooma near Holsworthy which were run by Atlas care homes.
As a result all 15 Atlas care homes were closed by the CQC in 2012.
Vielstone manager Jolyon Marshall was jailed for 28 months.
Twelve other people, including other staff members and Marshall’s wife, were convicted.
One family member told the the safeguarding review by Devon Safeguarding Adult Board that inspectors were “lax” and “failed to monitor the quality of the service”.
Deborah Ivanova, the CQC’s deputy chief inspector of adult social care in the South, said “much has changed within CQC since 2011”.
Monitoring and response to concerns had been improved and inspections were “more thorough”.