Harmful physical restraints and a failure to implement Covid-19 hygiene measures are among concerns raised in a report into Rotorua youth justice residence Te Maioha o Parekarangi.
The Office of the Children's Commissioner inspected the residence last year, and Radio New Zealand obtained its report under the Official Information Act.
Assistant Māori Children's Commissioner Glenis Philip-Barbara said it was troubling to discover restraint use, including holds in which young people end up on the ground, were being used with greater force by staff.
"Restraints are only to be used to prevent eminent harm to a young person when there is no other option available.
"What we've been calling for many years is the need for more nuanced and much greater training and support to help staff meet the challenges that they face" Philip-Barbara said.
The report also found staff behaviour had been unprofessional and insensitive at times.
One young person recalled having a chair pulled out from under them by a staff member as they went to sit down.
Staff practice was not always consistent either, with some adopting a 'safety and security' approach, while others employed more restorative methods.
Philip-Barbara had told the Office of the Children's Commissioner they did not have sufficient training and were overwhelmed by the young people's complex mental health needs.
"Many of them feel that they don't have sufficient training to deal with the complexities of the mental health issues presenting in some of the young people in their care"
"So, when people don't have the skills or the capability to deal with the complexities around mental health, I believe that these are the types of things that we're at risk of seeing" Philip-Barbara said.
Covid-19 personal hygiene measures were not in place, according to the report, even though there had been recent community transmission in Auckland.
Young people were not frequently reminded to wash their hands and there were no visible systems for contact tracing and distancing between units.
The report said each bedroom had a toilet, but no soap.
Philip-Barbara said that was absolutely appalling.
"Kids have a right to be cared for properly and that includes having access to soap where there's a toilet or a bathroom.
"Meanwhile while the rest of the country was washing our hands for the required time and doing all of the things that the public messaging was telling us to do these poor kids didn't have the opportunity to do that" Philip-Barbara said.
The report did find several strengths at Te Maioha o Parekarangi.
It said units were clean and tidy, rangatahi could personalise their rooms, and they had good relationships with experienced staff members.
Staff also supported the young people to get an IRD number, write a CV and prepare to get a driver's license.
Learning modules had also been adapted for the different ages of rangatahi inside, including those not yet able to get a driver's license.
The report said the driver programme covered a range of topics, including drink driving, and staff had found creative ways to make the activities engaging, including using special goggles to mirror the effects of drugs and alcohol on vision.
They also invited guest speakers who had lost loved ones in drunk-driving incidents to speak with the rangatahi.
Philip-Barbara wants to see use of the residences phased out.
"Herding them into a residence and hoping that they might recover, clearly hasn't worked," Philip-Barbara said.
"We believe that moving away from the big institutional model and into the safe secure community-based home, that's going to work better for everyone."
Kingi Snelgar is a barrister who has worked with young people detained in another Youth Justice Residence, Korowai Manaaki, in Auckland.
He said it was common for clients to present with Fetal Alcohol Spectrum Disorder, ADHD or severe learning difficulties.
Snelgar said the residences normalised prisons for those rangatahi, and he also wanted to see them eventually close.
"It's actually not going to help this person by just locking them up," Snelgar said.
"If there are disabilities that are driving the offending it's not going to keep us safer in the long-term.
"What would be, is helping them to cope with the different issues."
In a statement, Oranga Tamariki said staff at times needed to intervene to protect children from harming themselves or others.
Its deputy chief executive youth justice services, Allan Boreham, said staff sometimes had no option but to remove a young person from danger.
He said every use of force was reviewed.
At the time of the visit, Boreham said Te Maioha hand sanitiser and paper towel dispensers had been broken off unit walls and had now been replaced.
Boreham also said unprofessional behaviour of any kind by staff towards young people in care was not acceptable.
"We have established clinical support in each Residence, developed new training and restorative practices, improved the physical environment, added more safeguards and increased leadership on the ground," he said.
"A model of restorative practice 'Whakamana Tangata', was designed and developed by Māori staff from the Te Maioha Residence, mana whenua and experts from Victoria and Canterbury Universities.
"Whakamana Tangata is a new restorative practice approach to improve engagement and build relationships to resolve tension and reduce the need for more physical behaviour management."