A surgical glove was found in the bowel of a man with severe intellectual and physical disabilities while he was under the care of IDEA Services following a suspected sexual assault.
A report by the Health and Disability Commissioner revealed the 20-year-old man was under the care of IDEA Services between 2013 and 2015.
It said IDEA failed to provide services to the man within reasonable skill and care.
The 20-year-old lived at a IDEA Services residential address with another man who was intellectually disabled.
The other man had issues with exposing himself to others as well as, less frequently, masturbating in front of others.
He was moved to another place of residence after he physically assaulted the 20-year-old.
In 2015 the 20-year-old became unwell and was taken to hospital by ambulance.
He underwent a laparotomy, and a plastic surgical glove was located in his bowel.
"An independent review commissioned by IS could not determine who inserted the glove, or when or where it was inserted, but reached the conclusion that the glove was most likely inserted by a third party as a result of a sexual assault," the report said.
Then later the 20-year-old was taken out of IDEA Services care after he suffered burns as a result of spilling a staff member's hot drink.
IDEA Services "failed to identify risks sufficiently and put in place prevention strategies, failed to ensure that sufficient trained staff were on duty at all times and placed the man with another resident who exhibited inappropriate behaviour towards him", the report said.
"In addition, IS did not have in place policies and training to reinforce to staff that hot liquids should never be left in a manner that could put service users at risk, and IS staff did not manage incident reporting adequately."