Ms Susan Cliffe:

There was a failure to allow for the stress that was on the centre. There was a failure to recognise that stress. There are three floors in that centre with three very different cultures on those floors. The residents with the greatest level of need and higher dependency were all accommodated on one floor. Even relatives who spoke to us said their relative was fine now that they were on the ground floor but that they were not happy when the relative was on the first floor. That was the issue. Those in management lost sight of that. They did not recognise the issue and did not listen to what the staff were telling them. We can see in records of meetings going back to earlier this year that the staff were raising this as an issue but it was not being addressed. That speaks to the immaturity of the management structure that was in place. If you change the person in charge and at the same time change the support structures behind that person, including the assistant director of nursing and clinical nurse manager, you lose organisational knowledge and centre-specific knowledge. You also lose that innate knowledge of the residents. When you do not have that at a management level, it does not transform down through the structures to the nursing staff and carers. That is what happened.