Ms Susan Cliffe:

We inspected the entire campus on the evening of 5 June. We did that because we wanted to be sure that what we were seeing in Beneavin Manor was not being supplemented by resources from the other two nursing homes on site. What we found was, in response to the programme, the three registered providers had put increased staff in place in all of those centres. They had a focus on the numbers of staff that were available.

They also had a focus on supervision. If the Leas-Chathaoirleach will recall, very often during the programme we heard "This is not the way to do it", "Close the door" and "We should not be doing this" That was not a failure of knowledge or training. It was a failure of supervision.