VISITS TO SOCIAL CARE INSTITUTIONS On the first day, the NPM visited Črnomelj Retirement Home, Novo mesto Retirement Home and Trebnje Retirement Home, and on the second day, Lucija Retirement Home, the Koper Unit of Ptuj Retirement Home, and Cerknica Retirement Home. On the basis of six retirement homes visited and careful examining of fire safety on wards with dementia patients with the help of the external expert, the NPM established that the safety of residents and the staff is generally suitable. The staff on wards are appropriately informed of fire safety rules, the location of fire extinguishers, with which an initial fire can be put out or at least limit its spreading, and particularly escape routes and action taken in the case of fire. Suitable knowledge and training of the staff were evident in the fire which broke out last year in Črnomelj where, because of a prompt response from the staff and exceptionally fast evacuation of immobile residents, the consequences of the fire were not severe. The NPM noted satisfactorily that supervision by competent inspection services was regular, which gave additional confidence in suitable arrangements of fire safety in retirement homes. Irrespective of the aforementioned, we noticed certain deficiencies during the visits which we pointed out explicitly. On this note, we stressed that retirement homes should pay more attention to persons with dementia when dealing with fire safety, particularly regarding their evacuation since residents due to their health condition will not know alone how to act accordingly or they will not be able to ascertain where the fire escape routes are. Furthermore, protection of dementia patients at an evacuation point will need to be defined because they may wander off in fear of what is happening around them and are usually also disoriented in time and space. Due to the aforementioned the evacuation of these persons will, in addition to a limited number of staff and ensuring their protection at the evacuation point, undoubtedly present a special challenge. We highlighted recommendations given in several visited institutions: - On multiple occasions, we recommended supplementing instructions for individuals within fire safety rules, which should provide guidelines for taking action and treatment of dementia patients in the event of a fire; the instructions should also include deaf and blind residents. - It was determined several times that maintenance services do not fully understand the scope of hot works and cases about which expert workers must be informed according to the expert, and we thus recommended that such information be submitted in written form to the maintenance worker. - We advised several times that it be clearly marked in the vicinity of, and in, lifts that it is prohibited to use lifts in the event of a fire. - We also proposed frequently that fire extinguishers be installed at the prescribed height of 80 to 120cm (height of the activation handle). On this note, we particularly mention the recommendation forwarded upon a random activation of the fire alarm in Cerknica Retirement Home. When training and at ward meetings, managements of retirement homes must stress the importance of reacting to fire alarms. The entire fire safety system is meaningless if the staff and, consequently, the residents, act during a fire alarm as if there is no fire. With such reaction, extremely important time is lost in actual danger which enables swift and safe evacuation of residents and prevents consequences occurring due to the fire. On 28 June 2018, we visited Ljubljana Bežigrad Retirement Home. The management explained that there was no secure ward in the sense of point 17 of Article 2 of the Mental Health Act and that persons with various stages of cognitive impairment (dementia) who are usually accommodated on secure wards were staying on various wards in the Home. We wanted to examine whether the right to personal freedom was being restricted for the residents of the Home, particularly dementia patients. Irrespective of their clarifications about the secure ward, we submitted two recommendations, which were accepted in their response to the preliminary report. Among other things, we proposed that in cases when residents do not consent to be accommodated and are unable to leave the institution, the Home immediately proposes to the court to issue a decision as per Article 75 of the Mental Health Act. The management explained in their response that if treatment and measures were required due to a (mental) health condition of a resident which their institution did not provide, other suitable accommodation would be sought with a proposal to the court for ordering accommodation on a secure ward in an institution with necessary facilities. vOn 24 October 2018, we made a control visit to Ljutomer Retirement Home where we checked the realisation of 15 recommendations given during our previous visit in 2017. We determined that the Home had accepted eight recommendations and had also implemented them. These recommendations referred to ventilating rooms and ongoing monitoring of the level of satisfaction of all three target groups, i.e. residents, their relatives and the staff. We were pleased to determine that the home in the case of the Stročja vas Unit observed the NPM recommendation and now complies with the ZDZdr when admitting residents to this Unit. The Home also implemented recommendations relating to the installation of 34 IMPLEMENTATION OF THE DUTIES AND POWERS OF THE NPM IN 2018 NATIONAL PREVENTIVE MECHANISM UNDER THE OPTIONAL PROTOCOL TO THE UN CONVENTION AGAINST TORTURE AND OTHER CRUEL, INHUMAN OR DEGRADING TREATMENT OR PUNISHMENT