The Health and Disability Commissioner has identified shortcomings at a disability care home, where sexual abuse, violence and self-harm occurred.

Deputy Commissioner Rose Wall has found Spectrum Care, a major disability care provider, breached the rights of three residents at one of its homes.

The complaints were lodged in 2021 by family members or guardians of the residents.

One resident, referred to as Mr D, who was in his 20s at the time, had an intellectual disability and foetal alcohol spectrum disorder (FASD).

The report said he had a history of repeated acts of violence, intimidatory and sexualised behaviour aimed at other residents, and a history of self-harm and suicide attempts.

Mr D's father, referred to as Mr C in the report, said he was concerned someone was going to get badly hurt if Spectrum did not step in to safeguard all involved.

He said despite complaints to Spectrum the situation was not addressed adequately, and Spectrum had not communicated adequately about incidents involving his son.

For example, Mr C said that he was not told when Mr D attempted to commit suicide three times.

Mr C does not hold a welfare guardian order for Mr D.

The report said Mr D was quite independent and able to communicate his needs clearly, unless highly anxious, and had said he wanted to advocate for himself.

A complaint was also made by the family of a man known in the report at Mr A.

Mr A was in his 60s at the time, and non-verbal. He had contracted measles as a child and had been diagnosed with developmental delay and an intellectual disability.

Mr A's family said the mix of different disabilities and ages in the facility was inappropriate and unsafe.

They said Mr D had been physically and sexually violent toward Mr A and others in the facility.

Mr A's family said they asked Spectrum to control the situation and safeguard Mr A from Mr D's behaviour, but Spectrum failed to do this.

They said staff at the facility had not reported all the incidents, had failed to tell them about incidents, and had not considered any of the incidents urgent, including sexual assault.

A third resident, Mr F was in his 20s at the time, and had an intellectual disability, foetal alcohol spectrum disorder and oppositional defiant disorder.

Mr F's welfare guardian said that he was not getting the 24/7 care he was entitled to, and the guardian had not been told of serious incidents in a timely manner.

This included when Mr F was moved to another Spectrum facility.

Wall said in her report that Spectrum was in breach of the Code of Health and Disability Services Consumers' Rights.

She said Spectrum did not have an "optimal mix of residents" at the facility, and following a serious incident in April 2021 should have considered relocation of residents a priority.

She recommended Spectrum apologise to the complainants, develop a formal whānau communication strategy and a procedure for consumers who were independent, not under any formal orders and didn't want information shared with their family.

Spectrum accepted the Deputy Commissioner's recommendations, and had made a number of changes.

It said it would now classify each incident of sexualised behaviour as a serious incident, and would complete a serious incident investigation for each.

It had also introduced a new feedback system, brought in a new incident management system, and increased training for staff.

Where to get help:

Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.

Lifeline: 0800 543 354 or text HELP to 4357.

Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.

Depression Helpline: 0800 111 757 or text 4202.

Samaritans: 0800 726 666.

Youthline: 0800 376 633 or text 234 or email [email protected].

What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.

Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.

Rural Support Trust Helpline: 0800 787 254.

Healthline: 0800 611 116.

Rainbow Youth: (09) 376 4155.

OUTLine: 0800 688 5463.