The report: The report into Leas Cross nursing home has concluded that the level of care provided to residents constituted "institutional abuse".
The report, by consultant geriatrician Prof Des O'Neill, also warns that the problems experienced at Leas Cross could be repeated elsewhere in the State.
The nursing home closed in August 2005.
The report strongly criticises the way that Leas Cross was operated as well as the regulatory process overseen by health authorities.
Prof O'Neill also maintains that policy, legislation and regulations put in place by Government and the health service over many years had failed to adequately address the needs of older Irish people.
He warns that given the lack of engagement by Government and the health system that it would be a major error to presume that the deficits in care shown in Leas Cross represented an isolated incident.
"Rather, given the lack of structure, funding, standards and oversight they are very likely to be replicated to a greater or lesser extent in institutions throughout the long-term care system in the country," the report states.
It points to "inadequate numbers of inadequately trained staff" at Leas Cross.
The report says there was no documentary evidence that management and the clinical leadership "recognised the ensemble of care provision required to meet the needs of residents".
It maintains that there was a deficiency in the regulatory process operated by the health service at all levels in response to the clear deficits uncovered.
"There is no record of senior management in the HSE [ Northern Area] appearing to give due weight to written concerns by senior clinicians about standards of care," it notes.
The overall documentary findings are "consistent with a finding of institutional abuse", it concludes.
Leas Cross was a large nursing home with 111 beds located in Swords, Co Dublin. The report maintains it had a very complex case-mix where the majority of residents had high dependency levels.
Leas Cross deaths
The report notes that people in nursing homes are more likely to die than those in the community.
It maintains that there were 105 deaths detected between 2002 and 2004.
It says there was a steady rise in the one-year mortality rate from 1998 to 2000 and that subsequently it stabilised at 38-39 per cent.
It states that on average patients who died after being transferred from a hospital spent 221 days in Leas Cross.
However, for those transferred from St Ita's Hospital in Portrane, the median time to death was only 77 days.
"This was a particular cause of concern and mirrors concern expressed in strong terms by the consultant psychiatrists in St Ita's Hospital to both the [ then] Northern Area Health Board and the director of St Ita's Hospital," it says.
Care of residents
The report says that case notes reviewed raised "grave concerns" about the care provided.
It says that pressure sores on residents were documented at one stage or another in 33 of 100 available notes.
The report notes that "an alarming number" of residents were noted as being nursed in Buxton chairs.
"The documentation as supplied gives no sense of the application of an informed policy on restraints which reflects the reality that restraints pose a very great hazard to frail older people in nursing homes," it states.
Medical cover for potentially up to 111 residents was almost exclusively provided by a single doctor at any one time, it adds.
It says that in two instances nursing notes indicated difficulty in contacting the doctor, in one case for three days.
Staffing
The report says deficiencies in specialist expertise, nursing numbers and nursing infrastructure were perhaps the single most grievous area of concern.
While individual nurses may have behaved in a professional and appropriate manner, "the ensemble of nursing care as documented left much to be desired".
It says that there was no indication that any recognised measure was used to calculate the required numbers of qualified nursing staff proportional to the number of residents.
"There is no evidence that the proprietor sought senior staff with experience of specialist nursing of older people.
"At senior level, neither of the directors of nursing had any experience of specialist nursing care of older people and neither had any formal specialist qualifications in the nursing of older people," it states.
It also maintains there was no evidence of specific acculturation programmes for nurses from foreign countries to work in the home.
Health service oversight
The report notes that prior to October 2004, there was no designated team assigned specifically to inspect private nursing homes in the Northern Area Health Board.
"Prior to the new format of inspection [introduced at that time], the reports for Leas Cross were relatively brief with a significant focus on physical surroundings," it states.
It says that reports over the 18 months from January 2004 contained a continual refrain of concerns about scanty or poor documentation, inadequate staffing and skill mix and lack of procedures for pressure sores.
It says there was also a recurrent refrain that Leas Cross was working with the then health board to correct the deficits.
The report says that in March 2005 Leas Cross failed an inspection for consideration for a health authority contract for high-dependency beds.
It says that a letter to the assistant chief executive officer of the health board from the former Eastern Regional Health Authority about the standards of care "should have been taken as a warning signal of the gravest import".
The report also highlights a series of concerns raised by consultants at St Ita's Hospital including correspondence circulated to top officials at the health board regarding the deaths of a number of patients transferred to Leas Cross.
The report says that in general the nursing home inspection team had not been set up with clear instructions from health service management in terms of staffing, expertise and in particular empowerment to take significant action to protect residents in long-term care.
"Of particular concern is the lack of documentation that the NAHB/HSE (Northern Area) management responded to the very serious nature of the written concerns expressed by senior clinicians, of the very poor quality of care detected in the review of complaints by families, of the clear expression of concern by the Dublin city coroner over the death of one patient which was in the public domain and of the sustained length of time it took to appreciate that Leas Cross was not going to significantly alter its ways," the report states.
Policy/Funding
Prof O'Neill says there was no evidence that health authorities had moved, in advance of the Leas Cross nursing home controversy, on plans set out in the 2001 health strategy to improve staffing levels and the regulatory system for long-term residential care for older people.
It also described the level of State funding provided as "worryingly low".
