The Health Information and Quality Authority has found serious problems with how a high-support unit for teenagers is being run.
The unit, in the Dublin North East region, was subject to an unannounced visit by inspectors in October of last year. At the time, the unit was housing four teenagers.
The teenagers at the unit are not prisoners and were not there for any criminal behaviour, but were there because they were vulnerable and had complex needs.
The inspectors found continuous risk-taking behaviours, which included fire-setting, substance misuse when absent from the unit, and bullying.
Such behaviour, the inspectors found, demonstrated that the systems in place to protect children and keep them safe were not effective.
The report also raises concern about the high number of unauthorised absences from the unit.
There were 134 reported such incidents in the past 12 months.
The report also criticised the rule of doors being locked from 8pm to 8am.
The inspectors said this is authorised and confirmed by the Director of Children and Family Services but was not supported by national policy.
The inspectors found that systems in place to safeguard against the risk of fire were not adequate and fire training was not up-to-date for all staff.
The inspectors did note that there continued to be a good standard of care provided to children in many areas.
The head of the Child and Family Agency has said he considers the unit to be a good and well-run institution that is meticulous in its record-keeping.
Gordon Jeyes said the report highlights an increasing demand for secure places for children.
Mr Jeyes said there is a plan in place to double the number of places by 2016.
He said the main issue that runs through the report shows that the children are safe while in the unit and a danger when outside of it.
Mr Jeyes said it was important to remember that staff are dealing with particularly challenging and vulnerable young people who pose a danger to themselves and others.
He said the fact that does not come through in the report is that progress is made with many of the teenagers who come to the unit.
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