A draft Health Service Executive report of a review of services at the Áras Attracta care home has identified failures at all levels in the system.
The review was established in the wake of an RTÉ Investigates programme that exposed care failings at the Co Mayo facility for people with intellectual disabilities.
Following the programme, the HSE set up an independent review of the facility chaired by Dr Kevin McCoy.
The draft, seen by RTÉ News, highlights failures across the system, including low staff morale; ineffective use of staff resources and weak governance - particularly in Bungalow 3.
Staff at the centre described Bungalow 3 as the 'Forgotten Bungalow', with a culture of bad practices.
They said practices "remained unchallenged by management and certain bad practices became the norm".
The review team was also told there were "fraught relationships" between staff and management.
The draft report is critical of management at the Co Mayo under a number of headings.
The report states that there was "no clear vision for Áras Attracta" and there was a "lack of support and supervision".
The report states that most residents were happy living in Áras Attracta and felt safe.
It also notes sweeping changes were introduced by the HSE in the wake of the 2014 broadcast.
The draft report concludes that people with an intellectual disability be moved out of all large scale homes within the next five years.
The report says the HSE is proposing to move all 90 residents out of Áras Attracta on a phased basis. These proposals are likely to be met with apprehension.
The final report is due to be published on 6 September.
