The Health Information and Quality Authority has warned that it will move imminently to close a residential centre for people with intellectual disabilities unless there are dramatic improvements in its management.
The centre in Co Wicklow, which is run by Sunbeam House Services, was found by inspectors to pose risks to residents' safety due to a breakdown of governance and management systems.
At the time of last October's unannounced HIQA inspection, the centre in Vevay Close in Bray was home to seven adults with mild to moderate level of needs, who Sunbeam House said should be supported to live as independently as possible.
The report recalls that HIQA had already warned the proprietors last August they would face consequences if they did not bring the facility into line with regulations by November.
But an unsolicited tip-off prompted an earlier than anticipated follow-up inspection.
It confirmed the informant's view that arrangements to keep residents safe and to provide appropriate staffing were inadequate and unsustainable.
Inspectors found there was nobody in charge the morning they arrived and agency staff were piecing together a roster for the day having been left in the dark about their shifts.
The report states that frequently the predominantly agency-sourced staff had voluntarily worked extra hours to ensure residents' needs were met.
The inspectors insisted that the provider give an immediate undertaking to address the situation that was putting residents at an unacceptable risk.
At least four times in the previous couple of months, residents complained to staff that they were fearful of threats from some of their peers and were worried for their safety.
Inspectors were also concerned about Sunbeam House's ability to manage restraint measures in such a way as to ensure that they did not abuse residents.
A group representing hundreds of families of Sunbeam House Services' clients has said many of them are devastated by today's Vevay Close centre report, and by four other reviews of similar facilities run by the charity.
In a statement, the Sunbeam House Services Family Advocacy Group says: "The advocacy group have spoken with some families today who are understandably very upset by these reports."
The group says that after digesting the reports' contents, the families involved will be contacting Minister for Health Simon Harris, who represents Co Wicklow in the Dáil.
The group adds it will ask him and the HSE why the Action Plan developed on foot of a report on Sunbeam's governance failings last year appears to have failed service users.
"We are extremely concerned by the proposal by HIQA to cancel registration of Units of Sunbeam House Services which in effect could render service users homeless," the statement concludes.
Meanwhile, the head of Sunbeam House Services apologised to its clients and their families for the breakdown of governance systems in one of its centres.
The charity's Interim CEO, Hugh Kane, told RTÉ News that the failings identified in the report by HIQA should not be happening in the Vevay Close centre.
Mr Kane began running the Sunbeam House services, which has almost 500 clients, shortly after HIQA's October inspection which prompted today's report.