A residential centre run by Tusla and caring for four children recorded over 300 unauthorised absences over an eight month period, according to HIQA.
The Health Information and Quality inspectors found that staff had lost control of the centre and that constant changes in management over the six months before the inspection had meant no effective measures were in place to reform the facility.
The HIQA report outlines the results of last December's unannounced inspection of the centre, which is the Dublin-Mid Leinster area and which cares for four children, both male and female.
A HIQA inspection eight months earlier had found that that the residents were well-cared for by staff they had told inspectors that they got on well with their carers.
But it identified that staff were struggling with challenging behaviour.
December's inspection found an increase in the frequency with which residents were using illicit substances in areas which included bedrooms and other places on the Tusla-run property.
Inspectors say management and staff were not adequately addressing the young people's frequent absences and suspected risk-taking behavior.
Inspectors say that staff had lost control of the centre and that since the previous April, had continued to struggle with managing challenging behaviours.
They say six months of constant changes in management meant there were no effective measures in place to bring about any change.
Over the previous eight months, there had been 302 "missing from care incidents" involving residents which gave rise to a significant risk.
Records showed that one young person had been absent from the facility for 13 out of the 14 nights leading up to the inspection.
And during the two-day inspection, two residents were absent without permission for a period of time.
The report recalls that staff told inspectors that they knew where the young people were and had been in contact with them by phone.
It says staff were following a recently updated absence management plan and that some improvements had been made in relation to locating young people before reporting them as missing to gardaí.
The plan stated that staff were to "physically go out looking for" a missing young person.
However staff told inspectors that they could not always do this because the episodes were so frequent and they had to remain in the facility with the other young people.
The centre management had convened strategy meetings with gardaí to co-ordinate the approach to children who repeatedly went missing. But today's report says these had failed to reduce the number of absences.
The high risks and safety concerns for the centre's young residents prompted inspectors to request an urgent meeting with Tusla's regional manager who subsequently gave written assurances and a written plan to mitigate the immediate risks especially over the approaching Christmas holiday period.
The plan promised that:
- no further admissions would be permitted at the centre
- non-sleeping night staff were put in place from the week following the inspection and they were to remain in place until a further review was undertaken
- plans were put in place to support the reduction and or prevention of further absences within the centre
- a Safety Plan was introduced to direct staff on how to manage absences within the centre
- additional staffing was also promised as well as a reduction in the number of young people in the centre
- And an Interim Centre Manager was appointed from Tusla's national panel of centre managers, who commenced duty on 12 February 2018.
The centre prepared an action plan to address the non-compliances identified on inspection. Five were deemed moderate and three were major.
Tusla – the Child and Family Agency has said it has already implemented many of the reforms agreed with HIQA.
In a statement, it said non-sleeping night staff had been operating in the centre since shortly after the inspection in December 2017.
Tusla's National Service Director of Residential Childcare Services, Donal McCormack said the agency was actively implementing other elements of the action plan.
Mr McCormack said HIQA inspection reports were important measurement tools for Tusla which allowed the agency to develop its services so that children and young people received the best possible level of care and support.