Children in care, at a residential centre run by Tusla in Co Tipperary, were "exposed to behaviours and situations that were higher risk than the situations they were removed from", according to a report from the Health Information and Quality Authority (Hiqa).
The Hiqa report found some children were returned for access to their homes more frequently to remove them from risk at the Ferryhouse centre in Clonmel.
And children had been paid an allowance to do chores, such as gardening, in the homes of some staff.
Inspectors, who carried out an unannounced inspection over three days beginning at the end of August, found significant risks at the centre and they reported these to senior management in Tusla, the Child and Family Agency.
Over a 12-month period up to August 2016, there were 277 incidents of children being absent from the centre, a marked increase on the previous year when there were only 10 incidents of children being absent.
In total, over the 12 months, there were more than 200 significant events reported by staff at the centre, which is home for up to 15 boys, aged 12 to 16 on admission.
Inspectors found there was an increase in highly inappropriate sexualised behaviours, alcohol and drug use, criminal activities and use of violence and at times the centre was “in crisis”.
One child was subsequently placed under constant supervision while in the centre to reduce risk, though professionals said this was disproportionate and not in the child’s best interests.
One child was remanded to a detention centre, and physical restraint was used on a few occasions, inspectors found.
The report said systems in place for safeguarding and child protection in the centre were not effective in keeping children safe, particularly during crisis periods.
‘Significant risk’
And children working in staff homes were “placed at significant risk,” it found. The activities had not been risk assessed, or included in the children’s care plans and the children’s social workers were unaware of it.
Staff had subsequently been told to stop, the report said.
When crises occurred both on or off campus, safeguarding was “ineffective”, inspectors found.
Records showed though staff followed children, they did not intervene during some “ very serious incidents” and “observed from a distance while children engaged in at risk behaviour”.
There was no policy for the safe use of phones and some children had phones late into the night and could access unsuitable internet content and potentially co-ordinate leaving the centre without permission.
Inspectors also raised concerns about the layout of the campus, which contained other services such as a school for the children and a public swimming pool. Campus grounds also included stables, soccer pitches and a garden.
The inspectors found the layout was unsuitable and not secure, and staff said there were “too many people coming and going”.
When children absconded they frequently went to the river bank on campus, sometimes under the influence of alcohol and parents worried for their safety.
The report found safeguarding during crisis periods was ineffective at the centre.
Over the 12 months prior to inspection, there was a failure to maintain effective management systems to ensure the service was safe.
“This led to a collective failure across several different levels of management to adequately recognise and appropriately respond to children in crisis,” the report said.
Inspectors found significant events were not consistently notified to Tusla and senior managers were not aware of the risks in the centre.
The 49 staff working at the centre were found to be professionally qualified, experienced and appropriately vetted, but their supervision was of poor quality.
Tusla accepted the findings of the inspection report, and said measures have been put in place to address the deficits.
No more children will be admitted until standards have improved and all staff and management are to undergo additional training.