50 Serious findings led to temporary closure The NPM visited the child welfare institution in Kvammen in January 2018 and discovered extensive unlawful and routine use of coercion that appeared to be an integral part of the institution’s treatment of the young people placed there. On the basis of this visit, the NPM expressed serious concern about whether the institution was being run responsibly, and about its ability to operate in line with child welfare legislation and children’s rights. The severity of the findings was raised with the regional and central authorities.4 As a result, a working group was established charged with following up the NPM’s findings. A new acting head of the unit was appointed and the institution was temporary closed down. Extensive changes were implemented that included a comprehensive evaluation and audit of all the institution’s procedures. A new procedures manual was developed, and steps were taken to ensure that all staff were familiar with the procedures. The NPM was also informed that the institution introduced staff training about child welfare legislation, as well as systematic focus on its institutional culture. Youth placed at Kvammen shall now be able to move freely within as well as out of the institution unless an individual decision provides for restrictions to freedom of movement. Changes were also made to the material conditions at the institution in line with the NPM’s recommendations. The rooms were redecorated to make them more suitable for a child welfare institution, and the NPA has been informed that there should no longer be any rooms at the institution in which the residents are not able to control the lighting, water, temperature and blinds. NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2018 The visit to Kvammen and implementation of all the NPM’s recommendations demonstrates the importance of the prevention mandate. – The NPM must use different measures to enable actual changes to practices that cause concern. – More instruments in the event of inadequate follow-up After its visit to Klokkergården (now Bakkekollektivet) in 2017, the NPM was particularly concerned that the use of forced ‘motivational trips’ as part of the treatment, subjected young people at the institution to inhuman and degrading treatment. The NPM found that several aspects of the institution's practices were not in accordance with the Rights Regulations. Follow-up on the part of the institution did not reflect the severity of the findings. It became clear that the institution lacked the will to change its practices in line with the recommendations. The NPM therefore raised the case with the county governor, the approval authority, and the directorate. This led to a brief pause in admissions to the institution and further follow-up from the responsible sector authorities. The follow-up in this case illustrates that certain matters can be difficult to solve through dialogue with the institution, and that the NPM must use different measures to enable actual changes to practices that cause concern. 4 Regional management of the Office for Children, Youth and Family Affairs (Bufetat) and the management of the Directorate for Children, Youth and Family Affairs (Bufdir).