The Chancellor must monitor respect for the fundamental rights of individuals held in places of detention. This task arises from the Chancellor of Justice Act under which the Chancellor has been assigned the role of the national preventive mechanism set out in Article 3 of the Optional Protocol to the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). To fulfil this task, the Chancellor’s advisers carry out mostly unannounced visits to places of detention.
Places of detention mean all institutions where persons are or may be deprived of their liberty, either by virtue of an order by a public authority or at its instigation or with its consent or acquiescence. In Estonia, such custodial institutions include prisons, police detention facilities, psychiatric hospitals providing involuntary treatment, closed childcare institutions, social welfare institutions providing 24-hour special care services, etc.
During the reporting period, the Chancellor inspected seven special care institutions: Imastu Residential School, Võisiku Home and Karula Home, the non-profit association Valga County Support Centre, the welfare department of Valga Hospital, Hellenurme Home, and South Lääne County Health and Social Welfare Centre.
The twenty-four-hour special care service financed from the state budget is intended for people with mental disorders or severe or profound disability who are incapacitated for work and in need of daily guidance, counselling, assistance, and supervision due to their mental health condition. As at the end of 2017, Estonia has a total of 43 24-hour special care service institutions, with 2503 residents. During the reporting period, the Chancellor paid closer attention to institutions providing 24-hour special care to people with profound multiple disability.
During inspection of special care institutions, the Chancellor’s advisers reviewed whether residents’ freedom of movement was restricted (e.g. by locking them in rooms, securing them to their beds) and how means of restraint were used. The advisers also assessed the living conditions in these institutions and checked whether staffing was sufficient and whether the staff had received the necessary training to work with people with mental disorders. The advisers also investigated whether residents were offered enough meaningful free-time activities, as well as activities necessary to support maintaining their health. The advisers also monitored how dispensing of medication was organised and whether healthcare services were available. A general practitioner was involved as an expert on all inspection visits.
Special care institutions often lack a sufficient number of competent activity supervisors, in particular in the evening and at night. The work of activity supervisors should be organised so as to enable an individual approach to all residents of a special care institution and, if necessary, to keep an eye on their movements and activities. Staffing should be sufficient so as to enable swift resolution of dangerous situations in a manner that ensures the safety of all patients as well as the safety of the staff themselves. The minimum staffing level laid down in legislation for special care institutions might not always ensure quality service and the fundamental rights of residents. In addition, the specific characteristics of the buildings and residents in a particular institution should be taken into account.
Until 2020, activity supervisors of people with profound multiple disability may also be individuals who have registered for further training required for such work. Many activity supervisors without the necessary training have spent years working with people with profound multiple disabilities. Some have not even received basic training as activity supervisors. The state has established training requirements in view of the specific nature of care and assistance needed by people with mental disorders. Untrained staff might not know how to properly assess situations or choose the right working methods to ensure the safety and well-being of the client. Special care homes must ensure that their staff receive the training required by law as soon as possible.
In several special care institutions, residents’ freedom of movement had been unlawfully restricted. For example, the entrance door to a family house or to a department was locked. People living in locked units should be constantly monitored because of their health. Without a court ruling, a special care home may restrict a resident’s freedom of movement only in exceptional conditions laid down by law, placing a resident in a secure seclusion room for up to three hours.
In some of the special care homes inspected, residents lived in pass-through bedrooms, while the cleanliness of washrooms and toilets was also lacking, and in several buildings moving around in a wheelchair was also difficult.
The Chancellor also inquired how Imastu Residential School and Võisiku Home helped their residents under the reorganisation plan for special care institutions to relocate to smaller social welfare institutions, since those homes are planned to be closed down in a while. Preparations have been carefully considered and thorough. The Chancellor once again reminded care homes that staff should also provide as much information as possible to residents about the reorganisation.
The Chancellor asked the company AS Hoolekandeteenused to ensure that nursing care services are available at least to the statutory minimum extent.
The Chancellor inspected the department for minors placed in Imastu Residential School under a court ruling, the Centre for Infants of the Tallinn Children’s Home and two hospitals providing in-patient psychiatric care for minors: the Children’s Mental Health Centre of Tallinn Children’s Hospital Foundation and the Child and Adolescent Mental Health Centre of the Psychiatry Clinic at the University of Tartu Hospital.
The department for minors in Imastu Residential School is a closed facility for minors in need of individual guidance, even for coping with simpler tasks. It was good to observe that staffing numbers at the department were sufficient during the daytime.
The Chancellor found that the closed yard of Imastu Residential School should be developed into a playground suitable for children so as to offer them sufficient activities. Imastu Residential School must also make the route to the seclusion room safer and improve the monitoring possibilities of the seclusion room. The route from the closed department to the seclusion room leads along narrow corridors with several closed doors, clothes racks, etc., which could make escorting a restless child or a young person to the seclusion room dangerous for them as well as for the staff. The door of the seclusion room has an observation window with safety glass, though this did not enable monitoring of the whole room – there was a so-called blind spot.
As a result of inspection of the Centre for Infants of the Tallinn Children’s Home, the Chancellor asked them to improve living conditions and decorate the children’s bedrooms so as to make them more child-friendly. The shelter could have a separate cosy guest room; currently visits take place in the group room or the lobby.
The Chancellor also inspected the Children’s Mental Health Centre of Tallinn Children’s Hospital Foundation and the Child and Adolescent Mental Health Centre of the Psychiatry Clinic at the University of Tartu Hospital as regards provision of psychiatric care to minors.
In hospitals providing psychiatric care to children, patients must be able to lock the door of the toilet. At the same time, medical staff must be able to enter the toilet if a suspicion arises that a child might injure themselves while behind a closed door. Children must be able to communicate with parents and guardians in privacy. Telephone conversations should not take place in the presence of staff.
Both of the hospitals visited use video surveillance, although its implementation in practice differs in some aspects. The Chancellor emphasised that using video surveillance in wards interferes with patient privacy, so that its use must be justified and well-considered in respect of each patient, and not a measure to be applied automatically. Patients under voluntary treatment must consent to using video surveillance in their ward, but patients receiving involuntary treatment must definitely also be informed about the use of video surveillance. If a patient needs constant monitoring, for example due to risk of suicide, the hospital staff must indeed actually carry out such monitoring, as otherwise video surveillance would not serve its purpose − i.e. to protect the life and health of the patient.
The Chancellor emphasised that restraining of patients must be recorded so that the documents always include the reason for applying means of restraint or continuing to apply them. The doctor must provide separate reasoning for continuing the use of restraint; merely repeating the description of the patient’s behaviour prior to restraint is not sufficient.
During in-patient treatment, hospitals must offer children and young people possibilities for spending free time. In the hospitals visited, the patients could watch films, read books, walk in the yard and engage in sports if the patient’s condition so allows. Youth work specialists and activity supervisors helped patients with free-time activities.
The Chancellor inspected Kuressaare, Rapla, Paide, Pärnu and Kärdla police detention centres of the West Prefecture of the Police and Border Guard Board. Deaths of detainees in police facilities were also analysed.
Most cells in the police detention centres visited had insufficient natural light. In Rapla and Paide police detention centres, detainees have no access to the exercise yard at weekends. In Kuressaare and Pärnu police detention centres, detainees can spend no time outdoors at all. In Kuressaare, they can only walk in a cell with an open window.
Use of 24-hour video surveillance in cells at police detention centres presumes a well-considered decision in each case. At Kuressaare police detention centre, hygiene corners in cells should be better partitioned from the rest of the cell, so that a detainee should not be forced to use the toilet while in view of all others present in the cell. In some police detention centres, those placed there for sobering up had no clean drinking vessel.
Documents in relation to detainees are drawn up more carefully than before by police detention centres. The health condition of a person admitted to a police detention centre must still be properly recorded. Potential subsequent legal disputes could be resolved more easily if it were recorded for how long special equipment was used in respect of a detainee. Some documents failed to record whether and with what result a person’s next of kin were notified about their detention.
In a couple of instances, the Chancellor’s advisers found that information on receiving parcels and visits published on the Police and Border Guard Board website and posted in the service hall of a police station differed from the information on the wall of a detainee’s cell. The conflicting information was swiftly corrected.
Plans exist to build a new rescue and police building in Pärnu in the near future. Conditions in the current police detention centre are still poor. Detainees cannot spend time outdoors and short-term visits take place in the corridor, between bars. Access to a toilet is available only in one sobering-up cell. Due to plans for the new building, extensive construction works in the current detention centre are financially questionable. Nonetheless, detainees should not be held in non-compliant conditions.
In 2017, three persons placed in police detention centres for sobering-up died there. Four detainees committed suicide. The Police and Border Guard Board analyses and takes into consideration a detainee’s risk-prone behaviour, including the propensity to suicide. Every suicide incident was immediately investigated. If disciplinary proceedings reveal that a staff member has breached their work duties, a disciplinary sanction can be imposed depending on the nature and level of guilt. Deaths could be avoided by use of more extensive video surveillance in all sobering-up cells and by combining technical supervision with effective and direct visual monitoring.
At the request of a prisoner, the Chancellor checked the norms for release on parole and found that the Riigikogu has a wide margin of discretion in establishing the relevant conditions. For example, a person who is released may be required to live at a permanent residence assigned by the court, a ban on consumption of alcohol may be imposed, etc. Release on parole does not relieve a person from serving their sentence. A person who violates their conditions for parole must resume serving their sentence in a custodial institution, and it is only justified for the court to reconsider the possibility of release on parole after a year has passed.
During the reporting year, the Chancellor of Justice inspected two units of the Defence Forces and analysed the organisation of alternative service.
The Chancellor asked Viru Infantry Battalion to ensure that all conscripts can wash with hot water if necessary. In Kalevi Infantry Battalion, the Chancellor did not find any shortcomings needing attention.
On her own initiative, the Chancellor of Justice investigated the organisation of alternative service. Interviews with individuals in alternative service and heads of institutions organising alternative service revealed that most of them were satisfied with the organisation of alternative service. Individuals in alternative service found the duties performed to be interesting and the attitude of the relevant institutions to them was friendly. In the opinion of the heads of institutions, individuals in alternative service are of great assistance. The Chancellor recommended considering the possibility to give individuals in alternative service the right to express their preference for the place of service and let them get acquainted with the place of service in advance. It would also be reasonable if the institution assigned as the place of service could assess the suitability of individuals in alternative service in advance. Better consideration should also be given to the type of training provided to individuals in alternative service in future. Changes to organisation of alternative service are currently being prepared.
The Chancellor of Justice inspected Vao Centre and its Vägeva unit of the Accommodation Centre for Asylum Seekers. Applicants for international protection as well as beneficiaries of international protection live in accommodation centres.
The sympathetic attitude to residents by the staff of accommodation centres and their readiness to swiftly resolve residents’ daily concerns left a very good impression. Residents are ensured healthcare services: an initial health check, the possibility of an appointment with the local general practitioner as well as with specialist doctors. If necessary, an interpreting service can be used during a doctor’s appointment as well as in other situations. Smooth access to necessary medication is ensured.
Children living in the accommodation centre have been provided with free dental care, and all residents of the centre have access to psychological counselling on request. School-age children attend the local school and learn Estonian. Language learning also takes place in the accommodation centres; the centres also organise free-time activities for residents on their premises. Children living in Vao centre can communicate with local children in the centre’s playground.
Children in accommodation centres can play with toys suitable for their age. However, in the Chancellor’s opinion, more of these toys are needed in Vägeva centre. In both centres, children should also be offered regular activities contributing to their development, such as organising hobby groups.
As a rule, children with families are placed in accommodation centres and often live there for more than just a few months for practical reasons. Unfortunately, at the beginning of summer 2018 it was not yet clear how to organise the opportunity for children in the centre to attend kindergarten, even though the Chancellor had already drawn attention to such a need during the previous inspection visit to Vao centre. The Chancellor can note with satisfaction that in autumn 2018 the problem was resolved and now children in the accommodation centre can also attend the local kindergarten. In the Chancellor’s opinion, the kindergarten contributes to integrating children in the centre in Estonian society, facilitates their language learning, better helps them to forge friendships, and enables them to find out about the local culture. This is particularly important for pre-school aged children who will probably cope better at school after having attended kindergarten.
The Chancellor inspected the activities of eight care homes during the reporting year. A healthcare expert (a general practitioner or geriatrician) was involved in all the visits. During the visits, the advisers inspected the rooms, perused documents, and interviewed staff and clients of the care home under inspection.
Particular attention was paid to the accessibility of rooms, as well as whether individuals’ freedom of movement had been restricted (e.g. locking them in their rooms, securing them to their beds), whether people were treated with dignity (e.g. ensuring privacy, living conditions), and whether no risks to their life and health existed (e.g. number and presence of staff, nursing and care, meals, medication, access to healthcare). During the inspection visits, the Chancellor’s advisers also checked how the right to vote of the elderly in social welfare institutions was ensured.
The main problems in care homes relate to ensuring decent living conditions, the number of staff, proper preparation of care plans, unlawful restriction of people’s freedom of movement, and availability of healthcare services.
Inspection of living conditions revealed that people were not ensured privacy during hygiene procedures. In some care homes, high doorsteps, narrow doorways and absence of a lift made it difficult to move around in a wheelchair or a wheeled walking frame. Problems also occurred with using aid devices corresponding to people’s special needs.
In several care homes, the numbers of care staff were insufficient, in particular at night. For example, it may be difficult for the residents of a care home to call for assistance if no staff call system exists. Many care homes lacked mandatory care plans, or these were incomplete and not up-to-date. Inspection of several care homes revealed that residents’ freedom of movement had been unlawfully restricted: by locking doors of departments as well as rooms.
Absence of care service suitable for persons with dementia
Freedom of movement was restricted mostly for people with dementia, whose behaviour could be problematic and unpredictable and who have serious memory problems, so as to be difficult for care home staff to handle. The cause of the problem lies in the fact that no care service has been developed corresponding specifically to the needs of people with dementia-related behavioural problems. The Chancellor has already drawn attention to this previously.
A positive development is a Ministry of Social Affairs initiative to set up a dementia competence centre and a plan to support adaptation of rooms for provision of the general care service to the elderly with dementia. Currently, it is difficult for the next of kin as well as for local authorities to find a place providing a service that meets the needs of people with dementia, including offering a suitable environment as well as an opportunity to implement the non-pharmacological approach set out in the treatment guidelines for Alzheimer’s disease. In April, the Chancellor and her advisers visited the De Hogeweyk care centre at Weesp in the Netherlands, which uses a unique concept for care of dementia patients that has attracted worldwide attention.
Healthcare services in care homes
Residents of care homes need regular nursing care but the law does not oblige care homes to provide nursing care services. Primary healthcare in care homes should be ensured through the system of general practitioners and the home nurse service (home visits carried out by general practitioners and their nurses). However, many people live in a care home that is distant from their registered place of residence as well as the service area of their general practitioner.
Inspection visits have revealed that often a patient’s health needs are not assessed by a healthcare professional (doctor or nurse). The need for a healthcare service is also not assessed on a regular basis. As a result, people’s main health concerns may not receive the required attention and problems may deteriorate to the point where often an ambulance has to be called. The Health Board has also indicated in its survey that the number of ambulance calls in care homes has increased significantly and not always are the calls justified.
Due to absence of nursing care, problems have arisen with handling and administering medicines. A critical situation may develop when a doctor has prescribed psychotropic medication to a patient that should be used only in case of need. Only a healthcare professional with medical training can decide on the need to administer this kind of medication. However, there have been cases where a carer or another care home staff member without the necessary education decides on administering medication to be used only in the case of need.
Due to the absence of a nurse, carers often have to perform the tasks of healthcare professionals. In care homes inspected by the Chancellor, there have been cases where medical negligence could be suspected. For example, a care home delayed calling a doctor for an unreasonably long time. Such a situation may also be caused through ignorance because carers without medical knowledge are unable to correctly assess a person’s condition.
Assessment and proper monitoring of a person’s health may also be impeded by the fact that most care homes have no access to the health information system. Often a care home only has the information concerning a person’s health which was submitted to them on paper by their next of kin. Absence of previous health data (including information on previously used medication) may lead to wrong conclusions by a care home in assessing a person’s need for a healthcare service. In turn, if a person’s health status changes, information from the care home does not reach the heath information system, so that general practitioners might lack an overview of the condition and needs of their patient.
Improving the situation of care homes
Improving the quality of the general care service was discussed at the information day organised at the Ministry of Social Affairs, where the Head of the Chancellor’s Inspection Visits Department talked to heads of care homes about problems observed during inspection visits. The Chancellor’s advisers also gave an overview of their work and discussed critical problems in the frame of the development programme for the Social Insurance Board’s supervisory specialists.
In the media, the Chancellor’s advisers have provided comments and clarifications about the care service (e.g. 30 November 2017 Radio 4 programme „Подробности“). The problems of restricting the freedom of movement of people were dealt with in the journal Sotsiaaltöö (see the article „Vabatahtlikkuse põhimõte üldhooldusteenuse osutamisel“ [The principle of voluntarism in providing the general care service]).
Everything begins from mentality
Dignified ageing is often supported by changes that are small and feasible for everyone. One could start with revising the wording of contracts concluded by care homes and remove expressions that refer to people as objects.
For example, contracts often refer to “exclusion of a client from the care home” or the obligation of a “service purchaser” (a person’s next of kin who pays for the service) “to place the service recipient elsewhere in the event of termination of contract”. Finding out the needs and wishes of the elderly is called “cost of care calculation”, which sounds rather like vehicle maintenance terminology. Communication by an elderly person with care home staff is described by a contract provision in the following terms: “disturbing the staff” is prohibited. As regards issues of quality of the care home, “the client is entitled to file a written application to remedy the deficiency”. According to some contracts, care home staff have three days to inform a care home resident’s next of kin about their death.