According to data from the National Statistical Institute [14], Styria (population: 1.24 million; size: 16,399 km2) and Carinthia (561,293; 9537 km2) collectively accounted for approximately one third of Austria’s geographic size, representing a substantial part of the national population with dementia in 2019. Although both provinces differed with respect to the overall population and land area, the average age of the inhabitants as well as the life expectancy at birth were comparable (see Supplementary Table 3). In both provinces, a higher prevalence of nursing homes in rural areas compared to urban areas was observed.

Between 2017 and 2019 Commission 3 conducted 55 unannounced monitoring visits in 32 nursing homes, covering 24 (11.5%) of the existing facilities in Styria and 8 (10.1%) in Carinthia. The visited facilities, providing care for individuals dependent on caregivers, varied greatly in size (3–165 beds), with average occupancy rates of 97.8% (SD ± 11.7) in Styria and 91.4% (SD ± 16.1) in Carinthia (Table 1). Despite existing human rights norms in accordance with the CRPD, adequate accessibility for persons with disabilities was only partially present. Whereas accessibility with mobility aids such as wheelchairs was sufficient in 86.4% (19 facilities, N = 22 analyzed protocols; Styria) and 87.5% (7 facilities, N = 8 analyzed protocols; Carinthia) of the nursing homes, access for persons with visual or hearing impairments was established solely in 40.0% (4 facilities, N = 10 analyzed protocols; Styria) and 20% (1 facilities, N = 5 analyzed protocols; Carinthia).

Addressing the challenging working conditions in nursing home care, shortages of home helpers were observed in both provinces (Fig. 1). In Styria, the FTE of registered nurses (6.9 ± 4.1) and nursing assistants (16.7 ± 12.1) exceeded the legal requirements set by the provincial government by 2.0 FTE (SD ± 2.9) and 2.9 FTE (SD ± 5.4), respectively. In contrast, an understaffing with home helpers (average staffing: 2.8 FTE, SD ± 3.2; deficit: 1.6 FTE, SD ± 2.0) was observed. In Carinthia, the FTE of registered nurses (6.5 ± 2.7) exceeded the legal requirements by 1.1 FTE (SD ± 1.5). However, an understaffing with nursing assistants (average staffing: 13.9 FTE, SD ± 8.9; deficit: 5.2 FTE, SD ± 4.2) and home helpers (average staffing: 1.0 FTE, SD ± 1.0; deficit: 1.6 FTE, SD ± 1.5) was present. Regarding possible strategies to facilitate the mental well-being of the personnel, only 17.4% (8 facilities, N = 46 analyzed protocols) of the nursing homes implemented a structured supervisory program, even though it provides a useful preventive measure for mediating personal conflicts or unexpected incidents. If available, the staff consistently attended periodical supervision meetings in just 6.5% (3 facilities, N = 46 analyzed protocols) of the monitored institutions. Regarding the training of the nursing home staff in Styria and Carinthia (N = 22 analyzed protocols), no more than 20% of all registered nurses had a specialized education with an emphasis on dementia and neuropsychiatric care.

Average differences between actually existing and legally required full-time equivalents (FTE) of nursing home staff. While staffing of registered nurses and nursing assistants partly exceeded the standards stipulated by the provincial governments, shortages of home helpers were observed in both provinces

While a higher rate of female residents was observed in Styria (59.2%, SD ± 19.0%) and Carinthia (66.0%, SD ± 11.6%), only one nursing home admitted persons formerly treated in forensic psychiatric health services (proportion of forensic residents: 10%). In both provinces, around half of the admitted residents were diagnosed with a psychiatric disorder and 35.7% (SD ± 20.9) received support from an appointed legal guardian to exercise their legal capacity. Furthermore, a substantial proportion of residents necessitated assistance concerning personal hygiene, hearing aids and mobilization. While care levels 3–5 (67.5%, SD ± 13.5) were observed most frequently, higher (> 5; 22.3%, SD ± 11.8) and lower (< 3; 10.5%, SD ± 12.8) care levels occurred less often.

Regarding the living conditions in nursing homes, the majority of residents criticized the daily schedule, in particular the early suppertime around 4:30 p. m. While supper was usually followed by night care provided by the staff before the end of their day duty, only very few facilities provided any form of entertainment in the evening hours. Although personal observations during the visits implied that undetected or untreated hearing impairments could result in reclusive behavior of affected residents, this study revealed no further presumptions related to abuse, neglect and degrading treatment.

Monitoring visits were conducted without prior announcement by at least two members of Commission 3 and, at times, additional external experts. The Commission consisted of a multidisciplinary team of one chairperson and seven members from various backgrounds, including law, medicine, nursing, psychology, education and others. In addition to monitoring nursing homes, further preventive activities of the NPM took place in various areas, such as child and youth welfare facilities, police detention centers, penal institutions and hospitals (see Supplementary Table 4).

In the majority of the cases the visits were conducted due to urgent referrals from other authorities or anonymous complaints (58.1%; 18 visits, N = 31 analyzed protocols). Such ad hoc visits were planned as soon as the NPM received information related to unsatisfactory nursing home care or insufficient capacities (e.g., a particular long waiting time until admission). Occasionally, monitoring visits to individual facilities were conducted multiple times over the years. While a total of 23 (41.8%) follow-up visits took place between 2017 and 2019, potential changes within the visited nursing homes were not evaluated in this study. Further information on the monitoring activity of Commission 3, including the time and duration of the visits, can be found in Table 2.

Noteworthy, the total processing time for the Austrian NPM, reflecting the typical duration from the day of the visit to the official reply by the provincial governments, combined to an average of 312.4 days (SD ± 199.5; median: 255 days, range: 115–1072) (Fig. 2). This suggests room for improvement in the efficiency and functioning of the NPM in handling the respective cases. The time periods referring to the recording of the protocols by Commission 3 (mean handling time: 67.5 days, SD ± 32.3; median: 65 days, 6–161) and processing of the protocols by the AOB (mean: 63.9 days, SD ± 52.2; median: 57 days, 7–235) were comparably short. In contrast, the handling times of the provincial governments were remarkably long (mean: 187.3 days, SD ± 187.3; median: 120 days, 41–1001), with exceptionally lengthy processing periods for multiple outliers (more than 2 years).

Handling times of Commission 3, the Austrian Ombudsman Board (AOB) and the provincial governments. While the handling time of the commission was comparable to the one of the AOB, the handling time of the provincial governments was longer. Remarkably, two individual protocols were processed by the Styrian authorities for more than 800 days