The commission had serious doubts particularly regarding the efficiency of authorities’ supervision and the standards and quality requirements which the facility has had to meet in the past. The facility was unable to show the commission any developmental level assessments, current needs plans or individual care plans. It does not prepare or implement any plans based on current therapeutic approaches. Unfortunately for the residents, there are essentially not enough staff with appropriate qualifications in care and therapeutic methods. In the opinion of the commission, fundamental communication and fundamental stimulation, in particular, are not sufficiently provided. Many of the residents respond to the lack of communication options and the lack of activities with a highly aggressive behaviour and with behavioural abnormalities. Staff responds to such behaviour by taking measures which restrict freedom rather than by offering more specific care or the opportunity to pursue activities. Commission 2 performed random checks regarding reports to the residents’ representatives under the Nursing and Residential Homes Residence Act and in some cases found infringements, due to the fact that milder measures or alternatives to measures which restrict freedom were not discussed at all. The facility had failed to address various criticisms in several court-ordered expert opinions, which had been prepared as part of proceedings under the Nursing and Residential Homes Residence Act aimed at avoiding restrictions on freedom, in which attention was drawn to failures to meet therapeutic standards that would have needed additional staff. No needs plans or care plans, not enough staff A number of residents drew attention to in some cases very serious contractures in their arms, hands and legs. The commission examined the available documentation. It did not appear that skilled contracture prophylaxis or professional positioning techniques were being used. Deficits in provision of care Impermissible restriction of freedom The NPM made it clear to the supervisory authority that minor changes at the facility definitely would not be enough to satisfy requirements regarding the prohibition of torture and violence. All processes will need to be modified so as to comply with UN CRPD, and new building(s) will have to be added.  Protection against inhuman or degrading treatment needs to be swiftly implemented in a comprehensive and effective manner.  Responsibility for the state’s duty to protect must not be shifted to private entities or institutions.  The concept of legal guardianship as such and the associated right to determine an individual’s place of residence conflict with Article 12 UN CRPD. 80