In case you missed them, the (edited) conclusions of the Leas Cross inquiry:
Primary responsibility for maintaining standards of care at Leas Cross nursing home rested with the proprietors and the person in charge of the nursing home.
For nearly two years between 2003 and 2005, standards of care at Leas Cross fell below acceptable levels.
The principal cause of the decline in care standards was the failure of the home to employ sufficient competent staff to provide the necessary standard of nursing care.
The registration in 2002 of 73 additional beds at Leas Cross was granted by the Northern Area Health Board without adequate regard to the wellbeing of the residents.
The Health Board / HSE had in its possession detailed information regarding Leas Cross, covering a number of years, including evidence of recurring problems
For no obviously good reason, the information in the possession of the Health Board / HSE was divided between a number of locations so that no single office or individual had full knowledge of all available information regarding the nursing home. The HSE cannot rely on its administrative arrangements to excuse this failing.
The case raises concerns about the adequacy of the inspection process.