INSPECTION VISITS
The Chancellor must monitor respect for the fundamental rights of individuals held in general care homes and 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.
A place of detention means a place where persons are or may be deprived of their liberty, either by virtue of an order given by a public authority or at its instigation or with its consent or acquiescence. In Estonia, different places of detention exist: prisons, police detention facilities, psychiatric hospitals providing involuntary treatment, closed childcare institutions, care homes providing 24-hour special care services, etc. During the reporting year, the Chancellor paid more attention to protection of the rights of children in places of detention.
General care homes
A decent life includes the opportunity to receive competent care and assistance when an individual is no longer able to cope on their own at home, due either to poor health or to an unsuitable living environment. Such assistance must be provided to people in general care homes. Most residents in general care homes are elderly people, but younger or middle-aged people may also end up in a care home as a result of illness or injury.
According to data from the Ministry of Social Affairs, 12 368 people received the general care service in 2019. Estonia has over 160 general care homes with slightly fewer than 8400 places.
One of the Chancellor’s tasks is to check the living conditions in care homes and how the rights of people living there are ensured. During the reporting year, the Chancellor’s advisers from the Inspection Visits Department inspected the activities of five care homes providing the general care service. A general practitioner or geriatrician always accompanied the advisers on these inspection visits. The advisers talked to care home residents and staff, inspected the rooms and examined documents.
In comparison to previous years, it may be said that the situation in care homes is slowly improving. The Chancellor is particularly pleased to see people working in care homes who genuinely care about those in their care, are warm-hearted and show empathy.
However, some of the same shortcomings which the Chancellor has pointed out in her previous annual reports can still be found in general care homes. During this reporting year, too, the Chancellor’s advisers found on several occasions that residents in a general care home were locked in their rooms or departments, and in the worst case were secured to a chair or bed. One care home also used a seclusion room for placement of residents with problematic behaviour.
The law prohibits using a seclusion room in general care homes, nor does it allow any other restriction on people’s freedom of movement. If a person’s body posture needs to be fixed in order to avoid falling, devices prescribed for this should be used, such as safety vests or special support belts. A belt of a dress or of a bathrobe or another item happening to be at hand is not suitable to support a person, as even if used for a short period it may cause health problems or death.
The main problem in general care homes is shortage of staff, in particular shortage of staff with the necessary qualifications. This, in turn, causes or exacerbates several other problems: people are not washed with sufficient frequency, no meaningful free-time activities are offered, etc. Under the Social Welfare Act, the operator of a care home must ensure sufficient staff numbers, so that in view of staff preparation and workload it is possible to offer people the necessary care and assistance. However, the law does not determine how many carers should be on duty at any one time round the clock. When determining the necessary staff numbers, the management of a care home must take into account how much assistance and attention the residents of the particular care home require, while also taking into account the specific nature of buildings: whether the service is provided in several separate buildings or in one building, and whether the buildings have a system for summoning help.
Staff who are overburdened do not have sufficient attention for everyone. During inspection visits, the Chancellor’s advisers found that bedpans had not been emptied for a long time, diapers were not changed often enough, etc.
At the beginning of 2020, preparation requirements established for carers in general care homes enter into force (§ 22(3) and (4) of the Social Welfare Act). By the new year, carers must undergo training for care staff or acquire the profession of care worker. According to assessment by the Ministry of Social Affairs, as at May 2019 about 70 per cent of a total of 1780 care workers have the appropriate education and training.
The non-profit associations Baltic Association for the Quality of Social Services and the Advisory Council of the Heads of Social Institutions in Estonia, which unite 54 care homes, expressed concerns in their letter to the Chancellor as to implementation of the preparation requirements for care workers. The petitioners found the new requirements to be excessive, since several establishments (the Social Insurance Board, the Health Board, and others) already supervise provision of the general care home service. In the petitioners’ opinion, the preparation requirements would inevitably lead to an increase in the price of the general care home service, which may impel clients to abandon using the service.
The Chancellor found that the situation in care homes is not as good as the petitioners think. Degrading treatment of residents and violations still occasionally occur regardless of supervision and the awareness-raising that has been carried out. It is in the interests of people and staff in care homes that carers should have the necessary training. Staff with proper qualifications can prevent the occurrence of many problems. Carers with specialist knowledge (including ergonomics of care) are able to avoid work-related injuries and occupational diseases. The general care service cannot become less accessible due to establishing preparation requirements since local authorities are obliged to ensure the general care service to those in need, so that those needing the service do not have to give up their place in a care home.
Living conditions in many care homes need improvement: high doorsills hinder the movement of people with challenged mobility, or rooms are overcrowded. In any case, it would be worthwhile for care homes to consider installing an assistance call system, or if one already exists, then ensuring that the devices are in working order and that everyone can use them. Such a system makes it easier to call for assistance and helps care staff to reach those in need more quickly.
It is important for care homes to pay more attention to free-time activities available for residents. Gradually, some progress has been achieved. Concerts are organised for residents and different performers and speakers are invited to care homes. Despite this, a large number of care home residents spend their days lying in bed, watching television or listening to the radio. Opportunities for hobby groups or dynamic activities are scarce. In this regard, particular attention should be given to people whose ability to move around on their own is limited or who are bedridden. They, too, should be involved in activities provided, physical exercises should be done with them and they should be taken outdoors to get some fresh air.
Special care homes
During the reporting year, the Chancellor inspected six care homes providing 24-hour special care services. The twenty-four-hour special care service is financed from the state budget and is intended for people with mental disorders or severe or profound disability who are incapacitated for work and are in need of daily guidance, counselling, assistance, and supervision due to their mental health condition.
As at the end of 2018, there were 2374 people in 51 locations receiving the special care service. The Chancellor’s advisers carried out an inspection visit to Sillamäe Home of Hoolekandeteenused Ltd (AS HKT) and Valkla Home, to which people are also referred under court orders. These people may pose a danger to themselves or others due to their mental disorder. Narva-Jõesuu Care Home and Lihula Südamekodu also provide the general care home service in addition to the special care service. The Chancellor also inspected Tapa Home and Uuemõisa Home.
Increasingly more care homes are moving from old Soviet-era large buildings to smaller family house-type homes. Among the care institutions inspected in 2019, Tapa Home and Uuemõisa Home are family house-type homes. New buildings are more suitable as care homes, as they have been adapted for the needs of people with challenged mobility and also have a cosier atmosphere.
Unfortunately, the main problems in special care homes are largely the same as in the previous year. The number of activity supervisors hired by care homes may conform to the minimum statutory requirement but is still insufficient. Among care home staff, activity supervisors are those who most often deal directly with people. Particular care and supervision is needed by people with profound multiple disability. Often, in addition to caring for people, activity supervisors also have to cook and clean the rooms. Depending on the health and needs of care home residents and the duties of activity supervisors, the statutory minimum staff number might not be sufficient.
Special training requirements have been established in view of the specific nature of the care and assistance needed by residents of special care homes. Untrained staff might not know how to properly assess situations and cope with agitated people. Trained staff are also able to systematically develop and support people with profound multiple disability who have complicated behaviour, and are able to choose appropriate methods for this. Unfortunately, many activity supervisors dealing with people with profound multiple disability have so far not undergone the relevant training. According to the requirements entering into force at the beginning of 2020, to work as an activity supervisor providing special care it is no longer merely sufficient that the person has registered for training, but the necessary training should also have been completed. Care homes should arrange the necessary further training for their staff as soon as possible.
Under § 107 of the Social Welfare Act, restricting the freedom of movement of a care home resident (i.e. a person who has not been placed to receive the 24-hour special care service by a court ruling) may only be restricted by placing them in a seclusion room complying with the relevant requirements. A person may be placed in such a room for up to three hours and until arrival of an ambulance or the police. However, not all care homes comply with these rules and inadmissibly restrict the residents’ freedom of movement – inter alia, by using a lock on the door of the department operated with a fingerprint reader of a chip card. Some care homes lacked a proper seclusion room, so that agitated persons were taken to calm down in a shower room, their own room or some other room not furnished for this purpose. A seclusion room in Valkla Home providing 24-hour special care service under a court ruling is used frequently due to the particular nature of its residents even though the room is not safe. The Chancellor reminded the care homes that the freedom of movement of a person receiving a 24-hour special care service under a court ruling may only be restricted for a brief period by placement in a seclusion room compatible with requirements.
Living conditions in the family homes seen during inspection visits left a very good impression. These houses have been built keeping in mind the needs of people with challenged mobility. In special care homes operating in older buildings there are also shower rooms in need of repair and overcrowded, bleak or walk-through rooms. In older buildings, it is difficult to move around in a wheelchair or other assistive device.
Care homes still have problems with handling medication. On several occasions it was not clear for whom medication had been prescribed. The Chancellor’s advisers also found medication of patients who had already left the care home, as well as expired medication, even though this must be destroyed properly. The Chancellor explained to the care homes that the strict rules for handling medication have to be complied with. Care homes must also ensure nursing care to the extent required by law.
Healthcare services
During the reporting period, the Chancellor inspected three healthcare institutions: Ahtme Hospital acute care department, department for children and adolescents of the psychiatric clinic of the North Estonia Medical Centre and the tuberculosis department of the psychiatric clinic of Viljandi Hospital.
Ahtme Hospital provides in-patient psychiatric care; some patients also stay at the hospital for involuntary treatment (Mental Health Act § 11). Patients at the tuberculosis department of the psychiatric clinic of Viljandi Hospital are also referred mandatorily under court rulings (Communicable Diseases Prevention and Control Act § 5). Up to five such cases a year occur. The department for children and adolescents of the psychiatric clinic of the North Estonia Medical Centre provides psychiatric care to children.
A good impression was left by the activity room of Ahtme Hospital’s acute care department where patients are instructed by a sports therapist and art therapist. In comparison to the Chancellor’s previous inspection visit in 2015, the hospital is now better ensuring the privacy of patients. However, patients still cannot lock the toilet door. The hospital’s observation rooms (mechanical restraint rooms) do not comply with requirements: in view of their size there may be only one place for a bed, yet each observation room had three beds. A member of the medical staff should always be present beside a mechanically restrained patient.
In the summary of the inspection visit sent to Ahtme Hospital, the Chancellor emphasised that if a doctor does not allow a patient to leave the hospital at will, a decision on involuntary treatment must always be drawn up on this. A patient in voluntary treatment must be able to leave a hospital at will.
The tuberculosis department of Viljandi Hospital has modern equipment to prevent the risk of infection: all wards and common rooms have quartz lamps and a ventilation system. Staff use protective devices to prevent infection and can vaccinate themselves at the expense of the employer. To ensure patient privacy, the Chancellor asked that curtains be placed on the windows of all wards in the department. The department must also put the assistance call system equipment into order.
Doctors at the psychiatric clinic of the North Estonia Medical Centre mentioned the shortage of child psychiatrists and long treatment queues as persistent problems in their field.
It deserves recognition that the staff at the department of the psychiatric clinic of the North Estonia Medical Centre cooperate closely with patients’ parents and guardians. In the Chancellor’s opinion, young people should be included more in making decisions concerning their treatment. If necessary, they need to be explained repeatedly the nature of their disease and given a possibility (if their health condition so allows) to sign their treatment contract themselves. If a child wishes to leave the hospital but, according to the doctor’s assessment, they still need hospital treatment, the hospital must have recourse to the court to apply involuntary treatment.
Patients in the department of children and adolescents at the North Estonia Medical Centre must be able to lock the door of the toilet but, in case of emergency, the medical staff must be able to enter the room. Children must be given an opportunity to communicate in private with parents and guardians. Telephone conversations should not take place in the presence of staff. In addition, chemical restraint should always be properly recorded.
The Chancellor asked hospital staff to pay more attention to opportunities for children to spend free time. For example, better sporting opportunities for them could be created or use of the internet within a limited period could be allowed (e.g. in a study class with computers) Where necessary, access to inappropriate websites and those that might disturb children could be blocked, or access allowed only to designated pages.
Police and Border Guard Board detention facilities
The Chancellor inspected two of the Police and Border Guard Board (PBGB) detention centres: the detention centre of Jõhvi police station in the East Prefecture and the detention centre of Tartu police station in the South Prefecture. An inspection visit was also carried out to the cellblocks of East-Harju, Kesklinna and West-Harju police stations and the sobering-up facility of the law enforcement bureau of the North Prefecture, all used for short-term detention (up to 48 hours).
In all these places of detention (except the sobering-up facility), the hygiene corners were not sufficiently partitioned. Activities in the hygiene corner could be seen by cell-mates as well as police officers. The Chancellor has emphasised in summaries of inspection visits sent to the PBGB that activities in the hygiene corner should not be open to view by other detainees, and while carrying out supervision police officers should not observe a detainee in the hygiene corner without a compelling need (e.g. risk of suicide).
In both police detention centres as well as short-term detention facilities, it is complicated for detained persons to attend to personal hygiene – opportunities to wash oneself, clean one’s cell and dry the laundry are not sufficiently good.
Communication with the next of kin of detained persons is poorly organised. In the detention centre of Tartu police station, detained persons could not always notify their next of kin about their detention. In Jõhvi police detention centre, it was complicated for detainees to communicate with their next of kin by telephone in private.
In the detention centre of Tartu police station, a minor who had no spare clothes or prescription medication had been detained for several weeks. Finding oneself for the first time in a place of detention is a harrowing experience for a child: children are inevitably more vulnerable than adults, and this should be taken into account. Therefore, it is of utmost importance that police detention centre staff enquire from a child about their needs and concerns and will not merely expect the child themselves to seek assistance if necessary. Among other things, a child should be asked whether they have sufficient clothes and an opportunity to call their next of kin.
People detained for more than 24 hours must be given an opportunity to spend time outdoors. Cells must have sufficient natural light and a detainee must have clean bedclothes, access to drinking water and an opportunity to attend to their hygiene.
In line with the Chancellor’s earlier recommendation, the sobering-up facility of the law enforcement bureau of the North Prefecture had installed video surveillance in each cell, which is certainly necessary in view of the health condition of people placed for sobering up. It is positive that, where necessary, the sobering up facility provides a detainee with the necessary clothes. The problem is that sometimes the freedom of movement of an intoxicated person needs to be restricted (to provide healthcare services), so that they need to be temporarily strapped to a bed. Currently, no sufficiently clear and precise regulatory provisions for such restraint exist. The Chancellor asked the Ministry of Social Affairs to find a constitutionally-compliant solution for the situation. The Chancellor also drew attention to the fact that medical staff working in the sobering-up facility should have access to the health information system, so as to have a better overview of a person’s health.
Detention centre
In the spring of 2019, the Chancellor inspected the detention centre, which had moved to a new building at the end of 2018. The centre accommodates aliens subject to expulsion as well as applicants for international protection.
The staff of the detention centre have done a lot to ensure that moving to the new building goes as smoothly as possible. There are also plans to bring computers to the centre, so that persons detained there can access legislation and websites of government agencies. Partition walls will be installed in washrooms and a separate lockable washroom for mothers and children will be created in the department for families. By agreement with the activity supervisor, aliens can also use the exercise yard containing a basketball field.
Some of the so-called ordinary rooms in the detention centre use video surveillance. The Chancellor stressed that it should always be considered whether 24-hour video surveillance is absolutely necessary to monitor a specific person. Hygiene corners in rooms have small windows opening on to the corridor and have a cover with a padlock. The internal rules of the centre must ensure that a hygiene corner is monitored only in very exceptional cases: for example, if a need exists to protect a person’s life and health. If the police develop a reasonable suspicion that a detainee may harm themselves, the detainee should be accommodated in a specially adjusted room or transferred to another establishment.
It would be good if, in the future, the centre finds opportunities to improve the available selection of literature as well as newspapers in foreign languages. Consideration should be given to the possibility to create alternative ways for people to communicate with their next of kin by means of modern technology (e.g. Skype). The Chancellor drew attention to this already during an inspection visit carried out to the previous detention centre. Currently, the centre also lacks a child-friendly room where an alien could meet with their family.
The Chancellor also found shortcomings with regard to catering hygiene and drew attention to the fact that the composition of food must comply with the requirements laid down by legislation. The Chancellor also asked to avoid situations where the staff of the centre or other aliens participate as interpreters in a conversation between patient and doctor, and emphasised that psychological counselling must be available for everyone in the centre. Examination for infectious diseases for a foreigner admitted to the centre should be carried out at the first opportunity.
Prisons
Estonia has three prisons, the oldest of which is Tartu Prison, opened in 2002. At the end of 2018, Tallinn Prison moved to a newly erected building. In Tartu, Tallinn and Viru Prisons, a total of approximately 2400 people are detained, of whom more than 400 people are remand detainees waiting for a court judgment, while the remainder are convicted prisoners serving a sentence. The prison population includes about a hundred women and approximately ten minors. Convicted prisoners also include 41 persons serving a life sentence.
During the reporting year, the Chancellor’s advisers inspected Viru Prison. Particular attention was paid to the department for young people (those under 21 years old).
Several problems pointed out during previous visits to Viru Prison had unfortunately not been resolved by the time of this inspection: for example, many short-term visits with next of kin still take place so that a prisoner is separated from the visitor by a glass partition.
A major problem that is still unresolved is shortage of prison officers (guards, senior guards, inspector-contact persons). In some departments, almost 25% of guard positions were vacant. Due to overtime, the work of officers is burdensome and this also affects internal security in prison. The Chancellor asked the prison and the Ministry of Justice to continue efforts to fulfil the vacant staff positions.
Based on documents examined in Viru Prison, an impression developed that several prisoners had been introduced to their rights and duties only weeks after they had been admitted to the prison. The Chancellor stressed that prisoners should be given information about legislation from which their rights and duties arise at the latest on the day following their admission to the prison.
In the youth department (third unit), the situation has significantly improved in comparison to the time three years ago. There are fewer violations of rules and prisoners are given more time to move around outside their cell within the accommodation section. Common rooms in the accommodation sections of the R-building of the prison (where minors and young people are staying) should be refurbished and more furnishings procured. Young people themselves could be involved in refurbishing the rooms.
The number of female prisoners who are minors is small in the prison, often no more than one. Therefore, a young person might not have sufficient opportunities for communication and may find herself in isolation, which is not in the best interests of a child. Under § 12 of the Imprisonment Act, minors should be segregated from adults. This is necessary to avoid adults having a bad influence on children. However, the result of segregation should not be total separation from other people, which is not in the best interests of the child. The Chancellor emphasised that restriction of communication of convicted girls with adult prisoners should take into account both aspects and allow a prisoner, under supervision of prison staff, to communicate with those prisoners who do not have a negative influence on the child (e.g. peers who are a year or two older than the child). The prison should also promote a child’s communication with the family and encourage them to establish relationships of trust with staff: if necessary, a child should be referred to an appointment with a specialist.
The Chancellor also dealt with the issue of searching next of kin arriving for a long-term visit with a prisoner. The Chancellor explained to Tallinn Prison that long-term visits are extremely important as they help to maintain a prisoner’s relationship with their close ones. At the same time, in the course of a long-term visit, substances and items endangering prison security may be brought to the prison. Therefore, the prison is entitled to search a person arriving for a visit, as well as their belongings. The manner and extent of a search depends on the situation. If a strip search is absolutely necessary, it should be carried out so that the person searched is at least half clothed. Exceptionally, it may be justified to search a visitor while fully naked. This may be necessary, for example, when a reason exists to suspect that a visitor is trying to bring prohibited items or substances to the prison, and these could not otherwise be detected. Nevertheless, less intense measures (such as scanners) should be preferred to a full strip search.
Defence Forces
The Chancellor inspected the Headquarters Support and Signal Battalion. According to the conscripts in the battalion, the superiors have a friendly attitude towards them and the training is interesting. Some conscripts said that sometimes active servicemen have not allowed them to go to a doctor as they found their health concern to be a minor one. It has also happened that a conscript relieved of training requiring physical effort for health reasons is nevertheless ordered to participate in such training. However, such cases are exceptional. As a rule, superiors do not prevent conscripts from going to a doctor, and the rules on relief from training are also complied with.
The Chancellor asked the commanding officer of the military unit to remind active service personnel involved in training conscripts that conscripts are entitled to medical care and that the regime for relief from training must be observed. This is necessary for protecting the health of conscripts.