The Victorian Ombudsman Deborah Glass tabled a 116-page investigation in the state Parliament on Thursday.

Ms Glass urged major reform to the system, describing how five "shocking" and "painfully sad" cases had let some of the state's most vulnerable children down.

The first highlighted was that of a child, referred to as Quinn, who was in a Child and Family Services (Cafs) residential care unit in Ballarat from 2008 to 2011.

The report outlines how Quinn, a teenager who was transitioning from a male to a female identity at the time, was placed by child protection staff in with an older teenage boy who had a history of violent outbursts.

"There were many recorded incidents of threatened or actual violence between the pair," the investigation found, with child protection staff aware of the incidents.

"It did not move either child until almost two years later, after the boy reportedly repeatedly punched Quinn to the face and head and was charged by police."

Quinn, who had been diagnosed with various disabilities at the time including an autism spectrum disorder, later said the boy had sexually assaulted her by grabbing her genitals.

Those allegations were not investigated nor were the police informed, the Ombudsman wrote, nor was Quinn referred for counselling.

The report found that Quinn may have been medicated to try to control her behaviour. It noted that while 'chemical restraints' are subject to regulation and oversight in the disability sector, "the investigation identified no such laws or protections for children in residential care."

Quinn was also not allowed to have female clothes or items at the Cafs unit. "Later, her sexual identity and behaviours were apparently deemed a risk to others," the report found.

Now a transgender woman in her 20s, Quinn wrote to the DHHS outlining her experiences in May 2018. The report said her assault allegations were not acknowledged or followed up, and that she approached the Ombudsman the following year.

A response from the Cafs CEO quoted in the report said: "Cafs is sorry for the trauma experienced by [Quinn], and wishes to assure [the Ombudsman] that our knowledge and experience in relation to the issues raised by [Quinn] has expanded since she was in our care, and what we know now is very different to what we knew then."

In a separate written statement to The Courier on Thursday, the CEO of Cafs Wendy Sturgess welcomed the report and its recommendations, saying it shone a light on systemic issues in the residential care system.

"It is very challenging to read the report - these young people deserve so much better," Ms Sturgess said.

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"Cafs is very sorry for the treatment of the young person who was in our care, and we apologise unreservedly. We are acutely conscious there are improvements to be made in the systems and practices of how young people are cared for."

All of the five cases considered in depth in the report involved children aged from 11 to 15, and were all allegedly victims of multiple physical and sexual assaults.

Ms Glass said the experiences described were not "not new or isolated" and that there had been numerous previous warnings about the residential care system.

"Yet despite the numerous critical reports, solid legislative framework and indeed, the good intentions of the many hardworking and dedicated professionals who work in the system, it continues to fail," she wrote in a summary released on Thursday.

She made five recommendations, including converting standard four-bed residential care units "to therapeutic two-bed units with enhanced access for children to services, particularly mental health and education.

She also recommended the government "consider establishing an independent advocate for children in care within the Commission for Children and Young People."

"These are major reforms that will cost money, but as these cases show, doing nothing may well come at a greater cost," she said.

"Nearly a thousand Victorian children lived in residential care at some time in the last year.

"My profound hope is that this is not simply the latest in a long list of critical reports, from which little seems to change."

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Cafs (Child and Family Services Inc.) welcomes the Victorian Ombudsman's report into complaints about the assaults of five young people in Residential Care Program homes, including one overseen by Cafs in Ballarat.

Cafs Chief Executive Officer Wendy Sturgess said she and the Cafs Board acknowledge the events that happened to the young person who was in Cafs' care between 2008 and 2011, and is extremely sorry for the trauma they experienced and still experience.

"It is very challenging to read the report - these young people deserve so much better," Ms Sturgess said.

"Cafs is very sorry for the treatment of the young person who was in our care, and we apologise unreservedly. We are acutely conscious there are improvements to be made in the systems and practices of how young people are cared for."

Ms Sturgess said Cafs' awareness around LGBTIQ+ issues has expanded significantly with Cafs receiving the Rainbow Tick accreditation in 2019 and all Cafs' people undertaking mandatory LGBTIQ+ awareness training. Cafs' Diversity and Inclusion Policy articulates the organisation's commitment to inclusive practice for both staff and clients.

Ms Sturgess said Cafs is continuing to work very closely with the Department of Health and Human Services on the recommendations outlined in the Victorian Government's Roadmap for Reform - Strong Families, Safe Children, and will also work with the department on the Ombudsman's recommendations.

"Cafs welcomes the report as it shines a light on the systemic issues in the out-of-home care system."

Ms Sturgess said Cafs feels very hopeful for the future of Residential Care and is particularly heartened to see the Ombudsman had also recommended moving to a two- bed care home model, something that had also been outlined in the Roadmap for Reform.

"Cafs supports all five recommendations in the report - we support all initiatives that improve the lives of young people."

There is help available. You can phone CASA, Sebastopol on 5320 3933, or free-call the crisis care line 24 hours on 1800 806 292. Or phone Lifeline on 13 11 14, the Blue Knot Foundation on 1300 657 380, or Relationships Australia on 1300 364 277.

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