National Preventive Mechanism agreement in order to offer an evening programme and to be able to delay evening mealtimes which had previously been scheduled much too early. Another control visit showed how negative the effect of changes to those responsible for the home and nursing staff can be. In 2014, Commission 6 visited a privately run nursing home with 132 nursing care places, which overall made a good impression. In 2016, due to complaints received the home was spontaneously reincorporated into the planned visits programme. It became clear in situ that a total of 63 nursing staff had been hired within the space of a year, whilst 55 employees had left the home. In the dementia ward the Commission noticed broken chairs and loose cabling. In the communal area, after breakfast patients with dementia were left to their own devices for hours until lunch, without any activity or verbal interaction. Nursing documentation was comprised of a bundle of text modules. There was no dementia concept or pain assessment; some residents displayed bruising of unclear origin. For 32 residents who had been subject to measures that restrict freedom, it was not apparent whether milder measures had been attempted. Between 2014 and 2016 only induction training was carried out, but no specialist nursing training. Staff objected to mismanagement, harsh treatment, an extremely bad working climate and an unclear allocation of duties. The NPM urgently called for supervisory measures, through to the revocation of the licence. „Anyone who complains gets dismissed“ The nursing home operator was not only active in Lower Austria but also operated two homes for the elderly in Vienna until the end of 2016. Here Commission 4 most recently noted similarly inadequate staff leadership skills, conspicuously high staff turnover and a large number of complaints regarding shortcomings. In the view of Commission 4, neither of these two facilities in Vienna met the quality standards that other Viennese nursing homes have voluntarily undertaken to abide by on the basis of their membership of the Association for Viennese Social Institutions (Dachverband der Wiener Sozialeinrichtungen). In the meantime, the operator has changed, and the NPM will continue to monitor the effects of this. Inadequate staff management skills At a facility in Styria hosting 35 persons with psychiatric diagnoses the entire management team (head of the home and of nursing staff) and 80% of staff changed within a few months. Above all, in view of particular manifestations of diseases, night shifts in the three-storey building were very onerous, with only two nursing staff members present. This led to numerous complications. Eighty falls were documented between the start of the year and the middle of October 2016, mainly during the night, resulting in some cases in severe injury and extended stays in hospital. In the disease progression reports written by Graz Regional Hospital, which were viewed by Commission 3, the home was urgently advised to take measures to prevent falls. However, according to staff from the facility, the purchase of additional auxiliary equipment was rejected on cost grounds. In the meantime, the supervisory authority contacted by the NPM arranged for electronic monitoring systems to be purchased (sensor Management and 80% of staff resign 105