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CHAPTER 
24
 
CONCLUSIONS
This section of the report contains the conclusions of the Commission in relation toeach aspect of its terms of reference. It also contains some general findings, which theCommission believes arise from those detailed conclusions.It is important to bear in mind that the Commission’s conclusions are based on theinformation made available to it. That information is limited in a number of respects:for example, the Commission was unable to establish contact with all members of staff or families of former residents. There were also deficiencies in certain aspects of record-keeping at the nursing home.The Commission’s general findings, which must be considered in the light of theentire report of the Commission, are as follows:1. Primary responsibility for maintaining standards of care at Leas Cross nursinghome rested with the nursing home proprietors and with the person in chargeof the nursing home. This is acknowledged in the Nursing Homes (Care andWelfare) Regulations 1993.2. Although the Commission has received some evidence of complaints maderegarding care at Leas Cross from its opening in 1998 until the latter half of 2003, the Commission has not found evidence of a sustained pattern of inadequate care at the home during that period.3. However, for a period of nearly two years, dating from September 2003 untilthe closure of the home in August 2005, the evidence before the Commissionsuggests that standards of care at Leas Cross fell below acceptable levels.4. This decline in standards of care coincided with a significant increase in thenumber of frail, high dependency residents admitted to the home, betweenSeptember 2003 and January 2004. Most of these new residents came from StIta’s Hospital, Portrane, and from other general hospitals.5. The evidence before the Commission suggests that the principal cause of thedecline in care standards between 2003 and 2005 was the failure of Leas Cross Nursing Home to employ a sufficient number of competent staff to provide thenecessary standard of nursing care. In practical terms, the ratio of nursing staff to care attendants was inadequate. In addition, there is evidence that many careattendants lacked appropriate training.6. The registration in 2002 of 73 additional beds at Leas Cross was granted bythe Northern Area Health without adequate regard to the wellbeing of theresidents, insofar as it failed to take one or more of the following actions:338
 
(i)Giving detailed consideration to the viability of a nursing home for 111 residents and the likely ability of the nursing home’smanagement to cope with the proposed increase.(ii)Imposing conditions on registration in order to ensure that numbersincreased at a reasonable rate, dependency levels were manageableand staffing was adequate.(iii)Monitoring developments at the nursing home more closely onceregistration had been granted.7. Arising from inspections of the nursing home and the investigation of complaints, the Health Board / H.S.E. had in its possession detailedinformation regarding Leas Cross, covering a number of years, which includedevidence of recurring problems. Taken as a whole, this accumulatedinformation should have alerted the Health Board / H.S.E. to impending problems, which could have been avoided.8. All relevant information relating to a nursing home should at all times beavailable to anybody inspecting, investigating or making a decision in respectof that home. For no obviously good reason, the information in the possessionof the Health Board / H.S.E. was divided between a number of locations sothat no single office or individual within the Health Board had full knowledgeof all available information regarding the nursing home. The H.S.E. cannotrely on its administrative arrangements to excuse this failing.9. The marked difference between the findings of the team assigned by theH.S.E. to take over the running of Leas Cross in June 2005 and those of  previous nursing home inspections, including one in April 2005, gives rise toconcerns regarding the adequacy of the inspection process. In particular, ithighlights the inability of the inspection system to identify deficiencies innursing home care without adequate time and resources. An effectiveinspection process clearly requires significant investment.10. The purpose of investigating a complaint regarding a nursing home is notmerely to vindicate either party but to ensure that all residents receiveadequate care. The Health Board generally responded efficiently to formalcomplaints regarding Leas Cross Nursing Home. Investigations were usuallycarried out within a reasonable time and the findings were communicated tothe complainants. However, rarely was there adequate follow up to preventthe recurrence of such problems.The Commission’s terms of reference required it to examine:“…
the role and responses of such relevant parties as the Commission maydetermine… in relation toa) the establishment, ownership, operation, management, staffing and/or supervision of Leas Cross Nursing Home (hereinafter ‘‘thenursing home’’);
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b) complaints made by or in respect of residents or former residents of the nursing home; and c) the transfer of residents from medical and residential care facilitiesto the nursing home.”
The detailed conclusions of the Commission in relation to each of the headings in theterms of reference are set out below.
Establishment of Leas Cross Nursing HomeProcedure for registering and re-registering nursing homes
•
The Commission is concerned that, from the year 2000 onwards the manner inwhich Northern Area Health Board procedures for the registration of nursinghomes were applied did not ensure adequate consideration of relevant materialat a senior level. The certificates of registration were signed without referenceto reports of previous inspections of the home.
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In registering and re-registering nursing homes, it appears that the NorthernArea Health Board may not have always have given proper consideration tothe possibility of imposing conditions. From the evidence submitted to theCommission, there was some confusion within the N.A.H.B. as to who wasresponsible for considering whether conditions should be imposed.
Initial registration of Leas Cross, 1998
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The application to register Leas Cross as a nursing home clearly indicated thatthe home could cater for maximum dependency residents. Mr Aherne has not provided the Commission with any basis for this assertion on the applicationform, which was repeated on subsequent applications for re-registration andfor the expansion of the nursing home.
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The decision to register Leas Cross Nursing Home in 1998 has been criticisedon the grounds that the building was not entirely suitable for the purpose. Onthe basis of the evidence before it, the Commission finds that the decision of the Northern Area Health Board to grant registration to Leas Cross NursingHome was reasonable.
•
Six residents were admitted to Leas Cross Nursing Home before a formaldecision to register the home had been made and, significantly, before a firesafety certificate had been granted. This was done in spite of the fact that Mr Aherne had been informed by the Nursing Home Section of the Northern AreaHealth Board that this would not be acceptable.
Re-registration of Leas Cross, 2001
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