Dementia sufferers at a Northern Ireland care home suffered a "horrific catalogue of inhuman and degrading treatment", an investigation has found.
Launching a scathing report into standards at Dunmurry Manor Care Home, the Commissioner for Older People for Northern Ireland (COPNI) Eddie Lynch identified "significant failures" in the safeguarding and care of residents.
Mr Lynch, who deployed his investigatory powers after receiving complaints from relatives and former staff, said he found evidence of patients turning on other patients and subjecting them to alleged physical and sexual assaults amid an unsafe environment where such risks were not properly managed.
"When I launched my investigation into Dunmurry Manor nothing prepared me for what I was about to uncover," he said, launching his Home Truths report.
"When a loved one is in a care home we expect them to be provided with good food, adequate drinks, and kept safe from harm, physical and sexual assault.
"It makes me extremely angry that this was certainly not the case for everyone living in Dunmurry Manor.
"I found that some residents who were extremely vulnerable, living with dementia, experienced a horrific catalogue of inhuman and degrading treatment, with many spending their last few months living in appalling circumstances.
"There were significant failures in the safeguarding and care of many residents in Dunmurry Manor, with residents suffering harm through physical and sexual assaults."
Runwood Homes, which owns Dunmurry Manor, said the managing director of the 76-bed facility, Logan Logeswaran, has resigned.
Chief executive officer of Runwood Homes Gordon Sanders apologised for the failures.
"I am truly sorry we failed to deliver the high standards of care our residents at Dunmurry Manor had the right to expect and that, because of those failures, they and their families have had to endure this distressing experience," he said.
"The Board of Directors acknowledge and take full responsibility for these failures and the lack of oversight that could have ensured they did not happen."
He said a new senior management team had been put in place in August 2017, adding: "We have worked hard to put things right at Dunmurry Manor as well as taking strenuous steps to ensure such a situation can never arise at any other Group home."
Mr Lynch made 59 recommendations to the relevant authorities in Northern Ireland focusing on the way care for older people is commissioned, regulated, monitored and delivered.
He highlighted that many of the incidents he flagged happened at a time when inspectors at the RQIA (Regulation and Quality Improvement Authority) were reporting that the home met required care standards.
"Despite the regulator carrying out 23 inspections in a 39-month period, they did not find the extent of the problems experienced by many residents," he said.
"There was a failure by Dunmurry Manor and its parent company, Runwood Homes Ltd, to respond to the concerns identified by staff, relatives, and some inspections.
"This was compounded by a failure of statutory agencies to act to protect the basic human rights of residents and their families."
The commissioner added: "I am angry that this problem is not a new one.
"Over three years ago the previous Commissioner advised Government that a whole-system change to the culture of care provision in care home settings was required.
"Much of that change has still not happened. We have seen the devastating consequence of inaction and lessons must be learnt."
A spokesman from the RQIA said: "RQIA acknowledges the publication of the commissioner's report into Dunmurry Manor Care Home, which we received today.
"We will carefully consider this report and provide a full response in due course.
"This report reflects the experiences of the residents, carers and families who submitted evidence to this investigation, and we recognise the distress they have experienced.
"We accept that only a small number of Dunmurry Manor relatives chose to contact RQIA with their concerns.
"We have taken steps to increase our visibility in care settings, to ensure we hear and take account of these voices.
"The key responsibility for providing safe and effective care in every care setting rests with the service provider.
"Health and social care trusts and the HSC Board also play a key role in the oversight and monitoring of the care they commission in care homes.
"We routinely inspect all care homes, and when problems arise, residents and their families can be assured that RQIA will intervene on their behalf."
A Department of Health spokesman added: "The Department will consider COPNI's report very carefully and provide a formal, comprehensive response.
"COPNI had alerted us during its investigation to areas of concern and we commissioned independent assessments, with a particular focus on the present day standard of care at Dunmurry Manor.
"We published the two independent assessments this week, providing assurance to residents and their families on current care standards.
"The second report detailed the work by RQIA to ensure the implementation of necessary improvements.
"Having secured these assurances on current standards of care, we can concentrate on a detailed examination of COPNI's findings and recommendations."