There are still security problems at an Auckland youth justice residence which two young people escaped from in 2020.
The office of the Children's Commissioner visited Korowai Manaaki this year and published a report, which RNZ obtained under the Official Information Act.
It found many improvements were needed, with staff practice still lacking in some areas.
During the visit, the office said it heard from staff that basic security measures, like ensuring doors were closed, did not always happen.
It highlighted one particular incident where a staff key had gone missing before the visit, and had not been located.
Assistant Māori Commissioner for Children Glenis Philip-Barbara said it was hugely concerning.
"Those are basic things right? Ensuring that doors are properly secured and that keys are properly secured?"
"I mean, if staff are unable to do their basic work properly then of course we are concerned for the extent to which all of the work is being done properly."
The report said physical restraints did not happen often, but could be harmful when used. The young people told inspectors the restraints sometimes hurt them.
Philip-Barbara worried young people were not always coming forward about their treatment.
"We also know, and we are concerned about the fact that young people feel there's no point in telling anyone about their treatment, and that there's a real culture of not telling - or this idea of snitching is a bad thing at Korowai Manaaki."
Insufficient staffing was another sticking point, and at the time of the visit about 40 staff were on special leave. Some had been away since the escape in 2020.
The rangatahi and staff said that meant meals were sometimes delayed, activities cancelled, and some young people were unable to attend medical appointments.
Philip-Barbara said staff had also admitted to feeling poorly trained to deal with complex mental health needs.
"Staff working in places with young people with complex mental health needs deserve to feel trained and properly prepared to work with them, and that includes having the right numbers of staff available to work with these young people in the right way."
In a statement, Youth Justice Services general manager Peter Whitcombe acknowledged the young people who shared their experiences in every monitoring report.
"Our youth justice facilities must keep young people in our care safe while also offering security for the wider community," he said.
"The reports showed that our practice does need to improve in some areas. We acknowledge this and we have a program of change underway that focuses on more therapeutic, preventative, and restorative pathways which we can see is working through the lowering level of assaults on staff members taking place."
Whitcombe said Oranga Tamariki had improved security in the residences and created a senior psychologist role to develop and deliver rehabilitative interventions, while also supporting staff.
"The safety and security of our teenagers and staff is an area we are alert to and always work to improve," he said.
"Staff look for opportunities to role model pro-social behaviour and often build up excellent rapport with the teenagers.
"We have reinforced basics of practice such as staff always having line of site with each other and young people, keeping specific doors closed, not spreading young people and staff across too many areas at once, and staff being with young people at all times."
The report did find several strengths at Korowai Manaaki, including the fact that young people and some staff had good and trusting relationships.
It also said many of the young people got on well with each other, with one saying he liked being in a unit with other boys who were slightly older and more mature.
Philip-Barbara said while that was positive, she wanted to see the use of residences like Korowai Manaaki phased out.
She said young people deserved support to help them become contributing members of society.
"They need our very best, for the fact that we would put them into places where they don't feel it's safe to complain, where they can't even be sure that the doors and the locks are properly secured, this is not good enough."
The office has recommended 21 changes from logistics, to family access, to better incorporating Māori values into the facility.