In order to at least spend time together in the dining room on the ground floor, the ladies with limited mobility were carried by the operator up and down the stairs in a wheelchair as there was no barrier-free accessibility. The commissions verified the out-dated condition of the emergency call system and also found the nursing case histories and care planning inadequate and the hygienic conditions very alarming. The operator, who is not subject to the Working Time Act (Arbeitszeitgesetz), had been carrying out all night duty by himself for years; during the day, there was a care aide on site. Continuing observations by the NPM revealed that the supervisory authority had been aware of many problems for years. Numerous requirements, beginning in 2004, had been officially issued without any action being taken as a result of the partial non-compliance. The fact that the operator had inadequately identified the personal habits, resources and deficits of the residents and insufficiently taken them into consideration in his care planning and had poorly documented the care processes was objected to by the commissions as was the complete lack of barrier-free accessibility. In addition to hygienic deficits and the outdated emergency call system, it was emphasised that, under these conditions, a threat to health could not be excluded. If there are indications that persons requiring nursing care could be harmed by unprofessional stationary care, supervisory authorities must promptly make use of their authority. The NPM will closely observe the progress of the official proceedings as well as the changes for the residents that were concretely promised during a hearing of the parties.   When safe care cannot be guaranteed, the residents must be transferred to another facility. Supervisory authorities are called upon to act quickly. 2.1.4 Positive findings During their visits in all institutions and facilities, the commissions pay increased attention to positive practices, which are later on recorded in the reports. A facility which had pursued creative solutions for complaint management and had introduced the concept of “wish messengers” was positively highlighted with the “Good Practice” rating. The reason given was that it is much easier for residents who are dependent on care to express wishes rather than complaints. The “wish messengers”, some of whom are qualified psychologists, worked their way through the facility and, within a period of six months, recorded all the concerns which were then implemented to the greatest extent possible in collaboration with management and staff. 37 Respect is shown by enquiring about residents’ wishes