Photo: RNZ / Angus Dreaver
Oranga Tamariki has referred 28 complaints over staff conduct to police since a review into the agency's secure residences began three months ago.
Three people are facing charges stemming from 46 complaints or allegations put to a new Incident Management Team established alongside the review.
Since June, Oranga Tamariki has also removed 22 staff from residences in response to the complaints, which range from inappropriate language and supplying contraband to physical and sexual assaults.
An external Rapid Review of Oranga Tamariki Secure Residences was begun in June after six staff were stood down over allegations of serious misconduct.
Four staff were linked to a video of young people being encouraged to fight in early June and, later in the month, two more were removed from residences after allegations of inappropriate sexual behaviour.
Some of the 46 complaints received over the last three months dated back to 2015.
Oranga Tamariki acting chief executive Phil Grady said the report identified a culture within the residences that stood in the way of complaints being received.
He said it was essential that Oranga Tamariki provided clear pathways for people with grievances to have complaints heard and action followed through.
"Whilst what sits behind the complaints is abhorrent to me, and abhorrent to every staff member that works at Oranga Tamariki, the most important thing is that we're taking action," Grady said.
"This is about the behaviour of a small group of staff that is unacceptable. I expect that as we work through our investigation and as the police work through their investigations that there will be more charges pending."
The findings of the review, headed by former police commissioner Mike Bush, was made public on Thursday.
Bush said the agency had taken on staff who were not a good fit and lacked the skills needed for the job.
Vetting procedures failed to reveal some staff members had gang associations, he said.
"It was almost like they were just recruiting their mates locally. People who weren't qualified.
"We've stopped that. Whether it's gang members, whether it's people of the wrong calibre, that sort of stuff we need to know before we bring people into the organisation," Bush said.
The report outlined a three year road-map to get the agency back on track, he said.
"We own it. We take absolute responsibility. Systemically we let young people down. That's got to change. That's what we're committed to," he said.
He said the majority of Oranga Tamariki staff were hurt and embarrassed by the findings of the report.
It said, despite a theoretical capacity of nearly 180 youth justice placements, residences were only adequately resourced for staff to safely manage a little more than two thirds of that number.
A staff member was quoted in the report as saying the issue was the dilemma that drove all of the agency's problems.
"We just don't have enough beds, and we often can't staff the ones we do have. But the needs of the kids are so great, there's just no way we can ever shut the front door," they said.
It said trends towards more serious youth offending and legislative change were happening at a faster than the agency was capable of adapting for.
It also identified a sense of 'review fatigue' among staff and management.
It said the agency was the subject of multiple and constant reviews resulting in so many internal strategies, plans, projects and working groups that few staff could clearly articulate the Oranga Tamariki vision, purpose and strategy for the homes and residences.
One respondent said the agency only ever reacted to problems "and then generally in an ad hoc and panicked fashion".
"There is no time to embed changes because there is never a considered implementation plan, showing how all the pieces fit together," another said.
Some managers said there were as many as 200 change projects in the pipeline, creating a constant environment of chaos and confusion.
"There are a million [recommendations], but I don't think even managers know what they all amount to. I've just given up. All due respect, but all you guys will do is add to the pile," a staff member said during interviews.
The pressures meant Oranga Tamariki struggled to locate children near their home regions or to separate children from more serious offenders or gang affiliates.
It said management and leadership expertise needed to be lifted and consistent programmes of therapeutic and formal education put in place.
Boredom and disengagement among youth placed in the facilities was increasing the risks of violence in the units.
The report highlighted a 'profound misalignment' between the needs of tamariki and rangatahi in care and the unskilled and unregulated parts of the workforce.
The secure residences themselves were described as 'tired assets' and the report said the agency needed to rethink its existing facilities and planned new builds to ensure better outcomes for the youth they housed.
Oranga Tamariki chief executive Chappie Te Kani said he accepted the report and its findings in full.
He said the agency had begun a 'major change programme' focused on significant improvements to the residences recommended by the report.
As soon as the review was announced Oranga Tamariki had established an Incident Management Team to manage complaints and get urgent work under way, Te Kani said.
He did not want to wait until the review was made public before moving to address problems with the residences.
"I agree that the problems within the residences and homes cannot be addressed in isolation and Oranga Tamariki is in the process of considering all the reports' suggestions," Te Kani said.
He said the agency had taken steps to increase security in residences and had completely refurbished all units in Korowai Maanaki.
New vetting processes for staff had also been put in place and drug and alcohol policies had been reviewed .
"We have new processes for handling medication, use of search powers, prevention of self harm, and responding to incidents involving violence. Whilst the immediate actions we have taken are beginning to address these issues, I recognise there is substantially more work to be done," Te Kani said.
He said head of the review Mike Bush would be kept on as a Transformation Governance Group chair to support the implementation of the organisation's change programme.
In a statement, youth in care advocacy group VOYCE Whakarongo Mai said the report's recommendations were "by no means transformational".
"They are simply the basic standards any service supporting young people would be expected to uphold. Community organisations would have their contracts and funding streams cancelled if they did not have some of these basic operational procedures and systems in place.
"Review after review has made recommendations, but this shows implementation continues to be problematic. There needs to be investment into skilled kaimahi, workforce development, recruitment and training. The next Government must commit to resourcing the system in order to provide effective and meaningful care to the tamariki who present with the most complexities across our communities," the group said.