72 persons with disabilities Intervention in mistreatment • The staff had a channel for anonymous feedback and suggestions in use, through which they could suggest improvements to the technical or visual features at the unit. A postbox had been provided for this purpose at the unit. The Ombudsman found this to be a good practice and recommended that the unit introduce a similar whistle-blowing system for suspected mistreatment of residents. The Ombudsman considered it essential that the management communicate to all employees that any incidence of poor treatment must be immediately reported to the management. • It was stated in the self-monitoring plan that inappropriate treatment will be intervened in, following the procedures adopted by the joint authority, but no details of these procedures were provided. The Ombudsman stressed that the self-monitoring plan should include instruction for social services on the correct procedure if they detect or become aware of inappropriate treatment. • As a positive observation, it was noted that the noticeboard of the unit provided instructions by the joint authority on the duty of social services to report any shortcomings or risk of shortcomings that they become aware of in the course of duty. Restrictive measures and the use of restrictive equipment • The residential unit used various devices (e.g. wristbands) to keep track of the movements of residents with memory disorders. The benefit of this equipment is that the movements of other residents need not be restricted and the doors of the unit need not be locked from the inside. • A resident was restrained by his hands to a bed or wheelchair nearly round the clock, as he otherwise harmed himself by tearing and scratching at his ears and eyes. At meal times, the restraints were removed, but the resident’s legs were restrained with Velcro® straps to prevent kicking, and he wore a helmet. As an alternative to restraint, the external expert of the NPM mentioned special observation, in which the resident is continuously accompanied by a nurse, and the use of weighted blankets when nurses are not available for special observation. The Ombudsman drew attention to the provisions of the Act on Special Care for Persons with Intellectual Disabilities, under which a person can be restrained only if other measures prove inadequate. A person may be physically restrained for the necessary period of time only, and for no longer than eight hours in total, continuously or repeatedly, during which time the physician in charge must reassess the criterias for physical restraint at least every two hours. In addition,