A review of abuse allegations in a Co Wicklow intellectual disability service has found "a lack of ownership" of safeguarding practice throughout the organisation.
The report says 11 of the 48 cases, which merited screening by Sunbeam House Services in 2016, were not assessed that year and referred on to the Health Service Executive as required.
It says commitment to safeguarding in the 400-strong workforce "was perhaps limited to senior management and the in-house social work team".
The HSE-commissioned review has been circulated to families of Sunbeam House's 155 residential clients and 250 day-service users.
It was conducted by Tusla's former chief executive Gordon Jeyes, who concluded in a similar review last year that Sunbeam House's complaints procedure was unfit for purpose.
He had studied 231 credible complaints lodged with the HSE about the service over the previous three-and-a-half years.
He has now examined 37 referrals by the charity in 2016 to the HSE Safeguarding and Protection Team, which must be informed once there are reasonable grounds for concern that a disabled person or otherwise vulnerable adult has been abused.
The concerns about possible abuse ranged from 13 in the physical category, a further nine involved neglect, six alleged psychological abuse and five cases alleged sexual abuse.
Reasonable grounds were found in eight cases, while additional information was required in 15.
No grounds were found in 14 cases.
However, the report says an internal audit by the charity identified 11 more incidents giving reasonable grounds for concern that were not screened in 2016.
Four went unattended because of a lack of social workers, while seven were not screened despite meeting the threshold of a safeguarding incident.
The report states that Sunbeam House was primarily focussed on compliance, where it substantially succeeded, rather than on safeguarding in partnership with clients and families with the full understanding and involvement of all staff.
Mr Jeyes says this is perhaps understandable, as 2016 was the first full year of the roll-out of the State's national safeguarding policy.
