handrails. A positive development is the partial repair of the joinery and the common sanitary units. In previous years, the Ombudsman made recommendations to the MoH to grant funds for the upgrade of the facilities of the hospitals. It is important to note that capex and energy efficiency funds were granted to most of the hospitals but these are only partial improvements and they cannot address the need of building modern hospitals for psychiatric care. Another recommendation made by the NPM refers to ensuring the required space for patients in hospital rooms in compliance with Ordinance No. 49 on the main requirements for the structure, activities and internal order of inpatient medical establishments and centres for medical and social care. During the inspections in 2019 of Kardzhali SPH (capacity of 320 hospital beds in seven wards) and Karlukovo SPH (capacity of 175 hospital beds in five wards), the NPM found that the patients were placed in rooms with 6 and more beds, which deprived them from their privacy. In several wards in Karlukovo SPH the patients did not have bed sheets and slept on mattresses. The NPM should note that two of the wards in Karlukovo SPH are located in a new building with rooms with 4 beds. The patients have cupboards for personal belongings and the living conditions are good. c) Healthcare. Protection and security for patients The inspected state psychiatric hospitals do not meet the Psychiatry medical standard approved by Ordinance No. 24/2004 of MoH, which establishes the quality of medical care in terms of material and technical conditions and staff. The treatment and diagnostic process in the isolated hospitals is hampered and healthcare is unsatisfactory. For example, for paraclinic tests and consultations with medical specialists the patients of Karlukovo SPH are transported by ambulance (old automobile) to MPHAT Lukovit. The treatment and diagnostic process is conducted only after signing informed consent by a patient or a guardian or a trustee in cases of incapacitated persons. Karlukovo SPH has established a good practice of placement of incapacitated persons without a guardian, with the court sending a copy of the court judgment to Lukovit Municipality for timely appointment of an official guardian of the patient. The psychosocial rehabilitation at state psychiatric hospitals remains unsatisfactory. The NPM found that during the day the patients are not sufficiently engaged in progrmames and activities. In the psychiatric hospitals inspected in 2019, most patients were moving around aimlessly, lying or watching TV. The NPM has repeatedly recommended that an ordinance on labour therapy should be developed as part of the psychosocial rehabilitation of mentally ill people. During the inspections, the NPM found that the status of patients was deteriorating and the staff members were put under extra pressure when patients subject to compulsory treatment were brought to regional courts in accordance with the Health Act. There are good practices, mainly in mental health centres, where the judge conducts on-site court sittings in the medical establishment. d) Continuity of care and deinstitutionalization of psychiatric help This year the NPM again identified cases in which the relatives of patients do not want to take care of them and refuse to take the patients from the state psychiatric hospitals. This makes it impossible to discharge a patient and the period of treatment has to be extended. In these cases the state psychiatric hospital does not deliver treatment to a person with acute psychotic disorder but in practice provides a social service. 40 persons live permanently in 35