The inquiry into the Leas Cross nursing home in Swords, Co Dublin has said it has not found evidence of a "sustained pattern of inadequate care" but said standards of care "fell below acceptable levels" for a period of nearly two years.
Minister for Health Mary Harney today published the report of the inquiry into the treatment of residents at the home. Leas Cross closed in August 2005 following an undercover RTÉ television Prime Time Investigates programme, which raised concerns over the treatment of people living there.
The home was subsequently sold and opened under new management and with a new name.
The commission said that for a period of nearly two years, dating from September 2003 until the closure of the home in August 2005, the evidence suggested that standards of care at Leas Cross "fell below acceptable levels".
It said the decline in standards of care coincided with a "significant increase in the number of frail, high-dependency residents admitted to the home, between September 2003 and January 2004".
Most of these new residents came from St Ita's Hospital in Portrane and from other general hospitals.
The commission said the evidence before it suggested the principal cause of the decline in standards of care between 2003 and 2005 was "the failure of Leas Cross Nursing Home to employ a sufficient number of competent staff to provide the necessary standard of nursing care".
"In practical terms, the ratio of nursing staff to care attendants was inadequate.
In addition, there is evidence that many care attendants lacked appropriate training."
The report's conclusions raise concerns about the "adequacy of the inspection process", noting a "marked difference" between the findings of a team assigned by the HSE to take over the running of Leas Cross in June 2005 and those of previous nursing home inspections, including one the previous April.
"In particular, it highlights the inability of the inspection system to identify deficiencies in nursing home care without adequate time and resources. An effective inspection process clearly requires significant investment."
In April 2007, Ms Harney commissioned the investigation into the management, operation and supervision of the home. Barrister Diarmuid O'Donovan was the sole member of the commission.
He had been due to publish his report last September, but the Government agreed to extend the deadline to the end of 2008.
Mr O'Donovan's terms of reference included examining the role and responses of the HSE and other bodies in relation to the operation of Leas Cross. He examined the response of the HSE and other bodies to complaints made by residents, former residents or their relatives.
The HSE's role in transferring residents from medical and residential care facilities to the nursing home was also examined.
Ms Harney said she regarded the report's recommendations as "a solid basis to bring improved quality service provision in the future”.
“My thoughts today are first and foremost with the families affected by the events which were the subject of this investigation.
"I am taking this opportunity to extend my deepest sympathy to those families involved. I genuinely hope that this Report will help all the families come to terms with what happened and to take some consolation in the fact that we will use this report to ensure that no other patient or their family face problems like this again.
"I urge all those concerned in any way with residential care for older people to read this report to learn the lessons from it and for its value as a milestone for improved practice and standards."
Responding to the report, the HSE said while it accepted "without equivocation its duty of care responsibilities, it is constrained by nursing home legislation in its ability to exercise duty of care responsibilities in relation to privately owned and operated nursing homes".