A shocking report has revealed a 23-year-old autistic man suffered repeated sexual assaults while under the care of a New Zealand disability support service over a two-year period.

Official documents show the disability service, IDEA Services, took "little to no action" despite multiple complaints by the man's mother.

Health and Disability Commission's (HDC) deputy commissioner Rose Wall found its area manager and service manager did not keep the man safe by failing to minimise harm when "many opportunities arose to do so".

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"IDEA Services and its staff were aware of the respective risks and vulnerabilities of [the victim and the assailant]," the HDC report said.

The assailant was another service user, not a carer.

During the weekdays the victim attended a vocational service operated by IDEA Services, where the assaults took place.

The assaults included the man being touched by the assailant indecently in the bathroom. On a separate occasion the assailant also exposed himself while the victim was on the toilet.

"The man's mother (who was also his welfare guardian) had repeatedly raised concerns, and there had been numerous documented serious events, yet little or no action was taken to respond appropriately to those incidents and concerns, and minimise the risk of future harm to the man," the HDC report said.

An internal investigation by IDEA Services, conducted prior to the one by HDC, found that there was "almost a culture and certainly a practice of poor communication within the team and between team and management and across the services".

That investigation concluded the failure of staff to notify management immediately of the incident on June 9, 2017, "significantly impacted" IDEA Services' ability to take remedial actions to prevent and minimise recurrence on June 13, 2017.

IDEA Services said it was "deeply sorry" for what happened to the victim and was determined to learn from this complaint and to ensure that this does not occur again for any other service user in the future, the report said.

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In the HDC report, the victim's mother said the incident reports were withheld from her for a month.

"I spent [my son's] 24th birthday reading incident reports that document two-and-a-half years of sexual abuse, physical abuse and neglect of my son while in the care of IDEA Services."

IDEA Services investigation also found the incident reports lacked critical information including the staff/client comment and recommendations section.

Wall found staff failed to follow policies and procedures or escalate events appropriately, and IDEA Services did not provide adequate training for staff.

"This resulted in a culture where the man's safety was not paramount and staff did not have a zero-tolerance approach to abuse.

"The failures resulted in ongoing acts of sexually inappropriate behaviour by the other service user towards the man, culminating in the two preventable critical events in 2017," Wall said.

The Ministry of Health and the Ministry of Social Development have been alerted to the report and Wall has recommended they update her on the steps they have taken to ensure a zero-tolerance approach to abuse within the disability support services they fund.

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The case has also been referred to the Director of Proceedings to decide whether any legal proceedings should be taken against IDEA Services in the Human Rights Review Tribunal.

As a result of the report, Wall made a number of recommendations to IDEA Services including:

• Implementation of an electronic reporting system.

• Auditing its incident reporting.

• Refresher training to staff including on the prevention and management of abuse

• Seek independent advice on what further improvements could be made to its processes for team meeting, incident reporting and recording of family requests or concerns, and to foster an organisational culture focused on continuous improvement and zero tolerance to abuse.

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In the report, IDEA Services told HDC it expected all staff to be aware of policies and procedures from the day on which they join the organisation and complete their orientation training.

IDEA Services submitted that this case highlighted that senior management was not aware of performance issues arising in respect of service managers or area managers where the general manager was not aware.

The service said it had advised HDC that since the time of these events, it has introduced some key management changes and programmes of work that are designed to improve quality and safety.

IDEA Services reported that in early 2018 it completed a National Quality and Safety Review of Services and began implementing the review's recommendations.

It also restructured its service manager role, which was led by a new chief operating officer. The change in role sees service managers spending more time with service users and their families, to ensure that there is a clear focus on transparency and communications with all stakeholders.

A new training programme for its management team intended to provide an understanding of the concepts of leadership and the role of it has to improve workplace outcomes has also been introduced.

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