A centre for people with intellectual disabilities in Co Wicklow has been criticised by the Health Information and Quality Authority for failing to appropriately investigate allegations that residents were harmed.
The watchdog says that some incidents at the centre were either not reported to the person in charge of the facility or were reported retrospectively.
The five-bedroom centre near Greystones, which is run by Sunbeam House Services, accommodates a total of four men and women.
An unannounced HIQA inspection in April was the second such review, but the first since the centre began accepting residents last December.
The centre fully complied with just one of the 12 standards reviewed, substantially complied with another, complied moderately with eight and was seriously non-compliant in two areas.
One of them was the safety or otherwise of the service.
HIQA's inspector's report states that some staff members had reported an incident to the person in charge 17 days after it had occurred on 14 February.
The inspector found that this practice failed to ensure that appropriate measures were put in place to protect residents.
The report states that allegations were not appropriately investigated in accordance with Sunbeam House Services' policy, national guidance and legislation and that this resulted in parents of residents and family members not being informed about allegations.
The person in charge had only learned about the incident less than two days before the inspection.
The inspector says the lapse also resulted in a delay in HIQA being notified of the alleged incidents.
The report records that an allegation of a recent incident of poor care was raised during the review with the person in charge and the inspector.
A newly-appointed employee alleged that a resident's personal care needs were intentionally ignored by a fellow staff member in order to punish the resident.
The report says that because the complainant was going through an induction process at the centre, and had not received any training in reporting procedures regarding abuse allegations, he or she was unaware of such procedures.
Sunbeam House Services told the inspector that a "Trust in Care investigation" was being carried out in relation to the allegation and the latest day for the completion of the process was the end of this year.
The centre was also non-compliant in a major way with statutory regulations on medication management. The inspector found some medications were not marked with the name of the resident for whom they was prescribed.
On the day of inspection, the three members of staff present did not have training in the administration of rescue medication despite the fact that two residents had been prescribed rescue medication for seizures.
The inspector was told that when these residents went out for the day with staff, staff forgot to "sign out" the rescue medication and take it with them.
When the inspector expressed concern, the person in charge said staff would not take this medication with them as they were not trained in administering it.
The inspector did acknowledge that neither resident had experienced a seizure since moving into the designated centre four months earlier.
However, she judged the practice unsafe and contrary to the Sunbeam House Services' policies.
Some staff members the inspector spoke with were not clear in relation to seizure management, a point that was best illustrated when the inspector was informed an automated external defibrillator machine would be used in the event that a resident had a seizure.
The inspector found some of the resident's needs could not be met as some staff members lacked the required training to support them.
The report states that the centre was operating with high levels of relief and agency staff who were needed on 16 of the previous 17 days.
The inspector found this was negatively impacting on residents' lives and that this was evident in findings on medication management, healthcare needs, social care needs, safety, and risk management.
Of the four staff members' records which were inspected, one had received supervision this year and another had not received any since June 2016.
The person in charge had 28 staff members between the centre concerned and another facility.
And the inspector was told that that person provided supervision for 15 staff members while 13 were not receiving any supervision.
In a statement, Sunbeam House Services acknowledged the issues raised in the HIQA report, saying they "fully recognise that the shortcomings highlighted in the report are not acceptable and are fully committed to addressing all issues raised in the report."
They apologised to those affected, saying they "apologise to those who have been adversely affected by our shortcomings and we will seek to do better for all those connected with our services."