- Standards of care at Leas Cross private nursing home fell below acceptable levels for nearly two years from September 2003 until it closed in August 2005.
- The decline in standards of care at the home coincided with a significant increase in the number of frail, high-dependency residents admitted between September 2003 and January 2004, mainly from the publicly run St Ita’s Hospital in Portrane.
- The principal cause of the decline in care standards was the failure of the home to employ sufficient competent staff.
- Extra residents were taken into the home in 2003 after the former Northern Area Health Board allowed it to register an additional 73 beds. It had opened with 38 beds in 1998 and would now have 111 beds. The health board allowed it register these extra beds without adequate regard to residents’ wellbeing or staffing requirements.
- The health board/HSE had detailed information regarding Leas Cross over a number of years, which included evidence of recurring problems. This should have alerted them to impending problems that could have been avoided.
- The health board generally responded efficiently to formal complaints regarding Leas Cross. However, rarely was there adequate follow-up to prevent the recurrence of such problems.
- Staff at Beaumont Hospital did not convey any concerns they may have had about Leas Cross to the health board or the HSE.
- Primary responsibility for maintaining standards of care at the home rested with its proprietor and matron.