The health watchdog HIQA has sharply criticised two residential centres caring for a total of 65 disabled adults on the Stewarts Care campus in west Dublin.
In both cases supervision of staff was inadequate and inspectors had to intervene to protect some residents and to ensure that a misconduct allegation against a staff member was addressed.
Last July's inspections of both Palmerstown centres were unannounced and HIQA reports that inspectors had to intervene in one sub-unit to ensure a staff member working alone to fully support three adult residents was given assistance.
Inspectors say that at Centre 5 they had to instruct Stewarts Care's management four more times, such was the level of risk found in healthcare and medication management.
They discovered that a distressed resident had not received breakfast by 11.25am and that there was no record of any fluid intake over the previous 14 hours.
Centre staff were unaware of the recommendation in the resident's dietetics plan on how to respond to refusals of diet and fluids.
The report states that another resident became distressed after waiting more than 40 minutes for their meal and that staff breaks coincided with the residents' mealtime.
Centre Three is criticised for failing to take disciplinary action against a staff member who was the subject of a misconduct allegation and for failing to follow up 14 incidents of potential abuse at the facility.
The report says they included peer-to-peer physical abuse, and unexplained bruising and injuries to residents.
Inspectors also observed some residents asking to get out of bed but being told they had to wait there until after the morning "staff handover".
Those who began to wake at 8am and asked for their breakfast were also told to wait. Inspectors noted that some of them got very frustrated and did not get breakfast until 10am.
Two units accommodated a large number of residents but the report says there were not enough staff on duty to support them.
There was a large number of falls by residents in the centre but there was an absence of appropriate follow up to better manage them.
The healthcare plan for one resident with epilepsy failed to outline a typical seizure or to provide any guidance for staff on how to manage it.
One resident's personal savings were found to have been used to build an extension to provide them with a private ensuite bedroom and a separate sitting room area.
The report says that while advocacy services were very much part of this process, it was not clear what arrangements were in place to reimburse the resident in the event of a move to alternative accommodation, or the resident's estate in the event of their passing.
Other residents in the unit concerned had "small bedrooms with very limited space for living and storage".
In one unit, a shower room used by residents was found to be less than one metre wide and staff said that residents frequently required assistance with showering.
The reports also criticises the lack of sufficient toilets and a shower trolley in a unit, which meant the needs of its residents during intimate care were not adequately met.
In a statement, the Board of Stewarts Care said it acknowledged the reports and added that over the past six months the board has "engaged with a significant progress of change in the governance and operation of its services", which are still in progress.
It added: "Stewarts Care has been in active dialogue with its key stakeholders – service users, their families and guardians, staff and the HSE – on the detail of that programme from its outset.
"We recognise and accept the need for change and are fully committed to completing the planned response programme."