The social services watchdog has found that teenagers living in a State-run residential home in Co Kerry have been leaving it frequently to abuse illegal substances.
The Health Information and Quality Authority inspection report reveals that the behaviour has been continuing over a significant period of time despite the home's efforts to address it.
The unnamed centre has the capacity to accommodate five children.
It is located in a two-storey building in ample grounds on the outskirts of a busy town.
When HIQA made its unannounced inspection last July, staff shortages had limited the facility to providing short to medium term care for three boys aged between 13 and 18 years.
Its mission is to give them authoritative parenting and positive behavioural support approaches, alongside the Child and Family Agency-approved approach to crisis intervention.
However, HIQA's inspector did not find that the centre was operated in such a way that the children were always safe and protected from themselves.
It found they had been engaging in serious behaviours outside the centre for a significant time period placing themselves at risk.
The report says this had been a feature of its previous inspections there in 2011 and 2012; that the deficits had been addressed and that there had been a dedicated effort made by all involved to ensure a culture of accountability and safer care practices.
However, the report notes notwithstanding the genuine and dedicated commitment by the manager and staff in caring for the children, the inspector found that the manager struggled to safely manage the residents' risky behaviours and did not have sufficient management oversight to ensure safe outcomes for children.
HIQA says today's report makes a number of findings which the provider of the service, Tusla, the Child and Family Agency, is required to address in an action plan.
It says Tusla provided an incomplete response, promoting HIQA to reissue the plan and request a full response.
However, it was dissatisfied with the revised response, which failed to address all of the actions as requested.
HIQA says this prompted it to publish the action plan.
Tusla accepts findings
Tusla has accepted the concerns expressed in the report. It has also highlighted the report's many positive findings.
In a statement the agency says that since July's inspection, it has implemented a number of reforms to better manage highly challenging and risk-taking behaviours at the home.
These include improving security at the facility, the establishment of an incident management plan and the development of both an action plan to address identified issues and individual plans to manage residents' needs.
Tusla is also performing an ongoing assessment of emerging vulnerabilities and risks affecting the teenage residents.
The agency is reviewing the facility's model of care and its capacity to maintain a safe and effective service.
It is assessing training needs for support staff and evaluating actions taken on foot of the reform programme.
Tusla adds that the home's staff have been proactively contributing both to the review of service delivery and to programme's introduction while receiving ongoing support from management.
The agency emphasises that the report had stated that the children living in the home were well informed and supported by staff in exercising their rights and that there was a good system of communication between staff, children and families.
It underlines that HIQA had also found that children were able to participate in decisions about their care and that care plans were of good quality and regularly reviewed.
The watchdog had also reported that residents had access to specialist services, including a dedicated psychologist and that practices regarding the safety of children were in line with Children First Guidelines.
