A HSE report has found that mental health services in Roscommon saw a 'disproportionate focus' on achieving budget savings over an 'adequately staffed and safe service'.
The review of the service was commissioned in 2015.
The inquiry followed claims that sexualised patient behaviour at a unit in Roscommon was mismanaged.
While the review team says it was impressed with the commitment and dedication of staff, it also found that "the culture of the Roscommon Mental Health Service was one in which innovation and drive were stifled."
"Service was marked by control, negativity and a culture of blame," the report notes. "Some senior staff normalised bad behaviour; others perpetrated it."
The review found that many staff were unhappy with aspects of management style, suggesting they felt as if they had to 'comply and accept the prevailing management culture'.
The report lays out 27 recommendations for the service, including a suggestion that the HSE consider delegating budget authority 'further down its organisations that is currently the case' - arguing that it leads to great accountability and ownership for staff.
It calls for a 'rigorous review' of the delivery of day car services, as well as formal mentoring for senior executives.
The report also urges senior leaders in the service to more directly engage with staff, saying "implementation of such a strategy should help focus on the rebuilding of confidence and trust between management and staff".
The Psychiatric Nurses Association says it's shocked by the findings of the report.
In a statement, the association says: "The PNA [calls] for a fuller investigation into how the situation described in today’s Review was allowed to develop and continue for so long despite warnings from PNA, and the obvious impact it was having on the vital mental health services in Roscommon."