The country's only kaupapa Maori intellectual disability residential care provider has been strongly criticised by the Health Ministry for being "seriously dysfunctional".
Te Roopu Taurima o Manukau has been under intense investigation since officials were alerted to an increasing number of incidents at some of its sites in late 2010.
They include 14 accusations of assaults on clients, two of abuse, 17 escapes and a fire.
An official report says the problems grew after the death of chief executive Whaea Tui Tenari in 2009.
The ministry says the business has failed to recruit and retain quality staff - and the kaimahi (caregivers) that have been employed are seriously unsuitable for the job, lacking basic knowledge.
But Te Roopu Taurima doesn't get all the blame. The report says disability laws don't do enough to ensure oversight by qualified clinical professionals.
The ministry has appointed an external monitor to the provider's board to ensure it does a better job.
Te Roopu Taurima o Manukau looks after 300 people, with 500 staff in 54 separate whare (residences) in Auckland, Northland, Waikato and Canterbury.
People being cared for have serious mental illness, some have what the ministry calls extremely challenging behaviour, and some may be in secure care facilities by order of the courts.