The Health Information and Quality Authority has found the "key role" of head of service in a private fostering company was filled by a succession of four people over a 14-month period.
The watchdog's inspectors found that Care Visions Fostering Ireland's assessments of foster carers were poor and that, last year alone, 15 placements had ended, most of them in an unplanned manner.
HIQA also identified serious risks in three cases in the Co Kildare-based service, which arranges the fostering of 22 children on behalf of Tusla, the child and family agency.
Today’s report on last January 's HIQA inspection fails the company on five of the seven standards assessed and finds it moderately non-compliant in the other two.
An inspection 14 months previously, in November 2016, had found that it met just three of the 20 standards reviewed and identified significant risks in the management of child protection and welfare concerns.
A subsequent audit by Tusla found significant deficits in the service and, last July, it stopped accepting new foster children.
But, at the time of this year's inspection, Care Visions Fostering Ireland was placing 22 children and young people in 20 foster care households on behalf of Tusla which had not felt confident enough to sign a service-level agreement with the company.
Today's report says the key role of head of service in Care Visions was filled by a succession of four people over the 14 months between the HIQA inspections (November 2016-January 2018).
It praises the then recent appointment of experienced managers as interim managing director and head of service, but noted that they were both familiarising themselves with the service during January's inspection.
HIQA says significant challenges remained, with an inexperienced social work team, the pool of foster carers available in the service, and the geographic spread of the foster carers in many parts of the country.
The report notes that, while staff showed commitment to making improvements and were committed to the foster carers, the inexperience in the social work team and changes in management disrupted the service.
Inspectors identified serious risks in three cases, including the absence of garda vetting for a serving foster carer's adult children; the absence of a safety plan for a placed child despite the social work team knowing about concerns relating to his or her carers; and the absence of visits by Care Vision to foster carers two months after what is described as "a significant event".
The report says the inspectors escalated the risks to the interim managing director who responded satisfactorily.
The HIQA report says that the chief operations officer of Tusla provided the watchdog with a written response outlining the arrangements he had put in place to ensure appropriate oversight of private foster care services, and to confirm that no requests would be made for placements until Tusla is satisfied that children placed with Care Visions are being provided with safe and quality care.
Care Visions Fostering Ireland said it fully accepts the findings of HIQA's January inspection of its service here.
In a statement, it said that since the inspection, it has put in place an Action Plan to comprehensively address each of the requirements identified by the watchdog.
The company added that its management team has also made significant changes to improve the quality of the service provision and to build confidence in it.
The statement outlines that Care Visions - which was established in 1998 - is an international healthcare company specialising in Children's Residential and Fostering care and in Domiciliary Care - with emphasis on Dementia- for older people.
It operates in Scotland, England, the Republic of Ireland and China.